Severe Multiple Injuries Research Articles

Returning to Work After Severe Multiple Injuries: Multidimensional Functioning and the Trajectory From Injury to Work at 5 Years

The process of returning to work (RTW) after multiple injuries is lengthy. Prospective studies with follow-up times of up to 5 years are necessary but lacking. The aim of this study was to describe the trajectory of RTW and to examine the factors that predicted RTW over 5 years for patients with multiple injuries using a prospective cohort design. One-hundred one patients aged 18 years to 67 years who had been admitted to a trauma referral center with a New Injury Severity Score >15 starting January 2002 through June 2003 were included. The follow-up rate at 5 years was 79%. Outcomes were assessed 6 weeks after discharge and at 1 year, 2 years, and 5 years postinjury. The instruments used to assess patient status were the Short Form 36, the World Health Organization Disability Assessment Schedule II cognitive subscale, a Cognitive Function Scale, and the Brief Approach/Avoidance Coping Questionnaire. Repeated measures analyses of categorical correlated data were applied. Patient's mean age was 34.5 years (SD, 13.5); 83% were men and 25% had a university or college education; 66% were blue-collar workers. Mean New Injury Severity Score was 35.1 (SD, 12.7). RTW rates were 28% at 1 year, 43% at 2 years, and 49% at 5 years postinjury. There were differences among patients in RTW status, and personal factors and physical and psychosocial functioning. Predictors of RTW were as follows: measurement occasion, education (high/low), coping, and physical and cognitive functioning. The proportion of unexplained variation between subjects in the models was 31% to 55%. Of the patients included in this study, 49% achieved RTW, and 23% received full disability benefits. Higher education; better physical, social, and cognitive functioning; and coping strategies all predicted RTW.

Circulating Levels of Clara Cell Protein 16 But Not Surfactant Protein D Identify and Quantify Lung Damage in Patients With Multiple Injuries

Almost 60% of all patients with severe multiple injuries sustain severe chest trauma with aggravating effect on morbidity and mortality. Diagnosis of lung contusion is performed by early posttraumatic multislice computed tomography. Because this diagnostic procedure requires time, resources, and exposure to radiation, a noninvasive approach with easy follow-up measurements is warranted. Serum levels of Clara cell protein 16 (CC16) and surfactant protein D as lung-specific biomarkers were obtained on admission from 104 patients with multiple injuries using enzyme-linked immunosorbent assay technique. Patients were divided into those with severe lung injury ([LI]; n = 68) and without LI (NLI; n = 36). Nonsmoking healthy volunteers served as controls. In addition, volume of lung contusions were calculated planimetrically on serial multislice computed tomography scans obtained after admission. Factors influencing CC16 serum levels were determined in uni- and multivariate analyses, and Spearman rank coefficients were calculated for correlations. Patients with LI showed a significant (p < 0.05) elevation of median CC16 levels (10.2 ng/mL) compared with NLI patients (5.4 ng/mL) and controls (5.2 ng/mL). Serum CC16 levels correlated with the volume of lung contusions (r = 0.78, p < 0.0001) and were not influenced by overall injury severity, age, gender, or preclinical ventilation. In contrast, circulating surfactant protein D levels were not associated with the presence of LI or the extent of lung contusions. Our results advocate CC16 as a potential biomarker for LI in severely injured patients because of its high correlation with the volume of contused lung parenchyma. Therefore, this parameter may allow a specified initial treatment of patients with multiple injuries.

Specific Abbreviated Injury Scale Values Are Responsible for the Underestimation of Mortality in Penetrating Trauma Patients by the Injury Severity Score

The Injury Severity Score (ISS) is widely used as a method for rating severity of injury. The ISS is the sum of the squares of the three worst Abbreviated Injury Scale (AIS) values from three body regions. Patients with penetrating injuries tend to have higher mortality rates for a given ISS than patients with blunt injuries. This is thought to be secondary to the increased prevalence of multiple severe injuries in the same body region in patients with penetrating injuries, which the ISS does not account for. We hypothesized that the mechanism-based difference in mortality could be attributed to certain ISS ranges and specific AIS values by body region. Outcome and injury scoring data were obtained from transfused patients admitted to 23 Level I trauma centers. ISS values were grouped into categories, and a logistic regression model was created. Mortality for each ISS category was determined and compared with the ISS 1 to 15 group. An interaction term was added to evaluate the effect of mechanism. Additional logistic regression models were created to examine each AIS category individually. There were 2,292 patients in the cohort. An overall interaction between ISS and mechanism was observed (p = 0.049). Mortality rates between blunt and penetrating patients with an ISS between 25 and 40 were significantly different (23.6 vs. 36.1%; p = 0.022). Within this range, the magnitude of the difference in mortality was far higher for penetrating patients with head injuries (75% vs. 37% for blunt) than truncal injuries (26% vs. 17% for blunt). Penetrating trauma patients with an AIS head of 4 or 5, AIS abdomen of 3, or AIS extremity of 3 all had adjusted mortality rates higher than blunt trauma patients with those values. Significant differences in mortality between blunt and penetrating trauma patients exist at certain ISS and AIS category values. The mortality difference is greatest for head injured patients.

Application of damage control orthopedics in treatment of severe multiple injuries combined with fractures

Objective To probe the feasibility, indications and efficacy of damage control orthopedics (DCO) in treating severe multiple injuries combined with fractures. Methods A retrospective analysis was done on the clinical data of 31 patients with severe multiple injuries combined with fractures treated by DCO from 1998 to 2008. Results Of all patients, 18 patients were combined with pelvic fractures and hemorrhage. Bilateralis hypogastric artery ligation was performed early in 17 patients and nonage pelvis external fixation was performed in 12. Eleven multiple trauma patients combined with femoral fractures received primary debridement and temporal external fixation for further definitive internal fixation. Two patients with spinal fractures combined with spinal cord compression received primary simple decompression. All patients received resuscitation in ICU for average 4.3 days (1-11 days). There was one death due to hemorrhagic shock. Conclusions DCO well conforms to pathophysiological character of the wounded. Early DCO and later integrated treatment are key to enhancement of the survival rate of the multiple trauma patients. Key words: Multiple trauma; Damage control orthopedics; Fractures

Multiple blunt trauma after suicidal attempt: an analysis of 4,754 multiple severely injured patients

The suicidal attempt is a significant cause for multiple severe injuries in Germany. The aim of the present study was to obtain information regarding injury patterns, clinical treatment, and outcome. We analyzed the data of 4,754 patients of the Trauma Registry of the German Trauma Society (1993-2007) with an Injury Severity Score (ISS) ≥9 after a suicidal jump from a height (SUICIDE) and after an accidental fall from a height (ACCIDENT). Comparing the data of 3,682 patients with accidental fall versus those with intentional fall/jump (n=1,072), we found that male patients were predominant in the ACCIDENT group (84.9 vs. 52.2%). The SUICIDE group had more severe injuries (ISS: 31.8 vs. 26.4). The ACCIDENT group suffered more severe head injuries (51.1 vs. 36.6%). Mortality (21.4 vs. 14.2%), length of stay in hospital (29.5 vs. 26.5days), and costs (€34,833 vs. €24,701) were higher in the SUICIDE group. Falls from a height are a common cause of injury among severely injured patients. The resulting trauma composes a particular form of blunt trauma with severe and multiple injuries, which depends on the fact of whether the free fall from a height was caused by an accident or as a result of a suicidal attempt. Taking the injury severity into consideration, there is no difference in the prognosis of the patients.

Diagnostic Value of the Glasgow Coma Scale for Traumatic Brain Injury in 18,002 Patients with Severe Multiple Injuries

Although patients with severe multiple injuries may have other reasons for unconsciousness, traumatic brain injury (TBI) in these patients is frequently defined by the Glasgow Coma Scale (GCS). Nevertheless, the diagnostic value of GCS for severe TBI in the multiple-injured patient is unknown. Therefore, we investigated the diagnostic value of GCS to identify severe TBI in multiple-injured patients. The records of 18,002 severely injured adult (ISS >16) patients from the Trauma Register of the German Society for Trauma Surgery were analyzed and initial GCS and Abbreviated Injury Scale (head) (AIS(head)) were recorded. A severe TBI was defined by an AIS(head) ≥ 3. On the other hand, unconsciousness was defined by an initial GCS ≤ 8. By these criteria, 6546 patients (36.3%) were unconscious, and 8746 patients (48.6%) had severe TBI. Nine percent of all cases (n=1643) had a GCS ≤ 8 without severe TBI. Only 56.1% of patients with severe TBI (n=4903) had been unconscious. Decreasing levels of unconsciousness (as defined by GCS) showed consistent rising prevalence of severe TBI (correlation coefficient r=-0.52). Approximately 20% of all multiple-injured patients arriving in the emergency department with an initial GCS of 15 had severe TBI (AIS(head) ≥ 3). The diagnostic value of GCS ≤ 8 for severe TBI in patients with multiple injuries has low sensitivity (56.1%) but higher specificity (82.2%). Our study indicates that the GCS (as defined ≤ 8) in unconsciousness patients with multiple injuries shows only a moderate correlation with the diagnosis of severe TBI. Nevertheless, the main reason for unconsciousness in patients with multiple injuries is TBI, since only 9% of these patients had another reason for unconsciousness. However, due to the poor sensitivity of GCS, we suggest the use of the anatomical scoring system with AIS(head) ≥ 3 to define severe TBI in patients with multiple injuries.

Posterolateral corner injuries of the knee

We retrospectively reviewed the hospital records of 68 patients who had been referred with an injury to the posterolateral corner of the knee to a specialist knee surgeon between 2005 and 2009. These injuries were diagnosed based on a combination of clinical testing and imaging and arthroscopy when available. In all, 51 patients (75%) presented within 24 hours of their injury with a mean presentation at eight days (0 to 20) after the injury. A total of 63 patients (93%) had instability of the knee at presentation. There was a mean delay to the diagnosis of injury to the posterolateral corner of 30 months (0 to 420) from the time of injury. In all, the injuries in 49 patients (72%) were not identified at the time of the initial presentation, with the injury to the posterolateral corner only recognised in those patients who had severe multiple ligamentous injuries. The correct diagnosis, including injury to the posterolateral corner, had only been made in 34 patients (50%) at time of referral to a specialist knee clinic. MRI correctly identified 14 of 15 injuries when performed acutely (within 12 weeks of injury), but this was the case in only four of 15 patients in whom it was performed more than 12 weeks after the injury. Our study highlights a need for greater diligence in the examination and investigation of acute ligamentous injuries at the knee with symptoms of instability, in order to avoid failure to identify the true extent of the injury at the time when anatomical repair is most straightforward.

A case of severe multiple injuries due to a traffic accident with an intracerebral hemorrhage possibly caused by the rupture of an angiographically occult arteriovenous malformation

交通外傷で搬送された重症多発外傷例で，angiographically occult arteriovenous malformation（AOAVM）が脳内出血の原因と考えられた症例を経験した。症例は24歳女性。自家用車を運転中に交差点での単独事故で受傷した。近医へ救急搬送されたが高エネルギー外傷のため当院へ紹介された。来院時の脳CTで脳挫傷を伴わない右被殻出血を認めた。またinjury severity scoreは48点であった。IIIa型腎損傷に対してtranscatheter arterial embolizationを施行した。右大腿骨骨折に対して鋼線牽引を施行した。外傷性播種性血管内凝固症候群を呈しており新鮮凍結血漿を含めた大量輸血を要した。3時間後の経過観察CTで脳内出血の増大を認めたため，AVMが原因と推察し脳血管撮影を施行したが，明らかな異常血管を認めなかった。来院6時間後のCTで切迫脳ヘルニアが出現し緊急開頭血腫除去術を施行した。術中所見では血腫の中に異常血管が認められ，病理組織検査でAVMと診断した。若年発症例や高血圧が併存しない脳内出血症例の場合，鑑別診断にAOAVMを考慮すべきである。

Damage control of severe limb(finger) with multiple injuries

Objective To explore the strategy of damage control in clinic treatment of severe limb (finger) with multiple injuries.Methods Severe multiple injuries patients with ISS evaluation more than 16 points were chosen for this study.Simple replatations of severed limb(finger) were perfored in 40 patients while their multiple injuries were actively treated.Results Among the 40 cases, all cases survived.1-3 years follow-up showed that the results were excellet in 8, good in 21, middle in 7, and poor in 4, with an excellent or good rate of 72.5 percent.Conclusion Multiple specialties cooperation, early treatment of multiple injuries and experienced microsurgery operation are the keys to improve success rate of replantation of severed limb(linger) with multiple injuries. Key words: Severed limb(finger) replantation; Multiple injuries; Microsurgery; Damage control orthopetics

Outcome of Blunt Diaphragmatic Rupture. Analysis of 44 Cases

To determine the predictors of outcome after blunt diaphragmatic rupture, the records of 44 patients aged 15-70 years (84.1% male) who underwent diaphragm repair between 1998 and 2007 were reviewed. There were 38 (86.4%) cases of acute diaphragmatic rupture and 6 (13.6%) of post-traumatic diaphragmatic hernia. The injury was left-sided in 30 (68.2%) patients, right-sided in 12 (27.3%), and bilateral in 2 (4.5%). The diagnosis of acute diaphragmatic rupture was made preoperatively in 28 (73.7%) patients and intraoperatively in 10 (26.3%). Repair was carried out through a thoracotomy in 31 cases, laparotomy in 4, and thoracolaparotomy in 3. The mortality rate after diaphragmatic rupture was 13.2% (5/38). The 33 survivors had a significantly younger mean age (37 vs. 57 years) and lower incidences of multiple injuries (36.4% vs. 100%) and shock (24.2% vs. 100%). Repair of diaphragmatic hernia was performed through a thoracotomy in all cases, with no mortality. It was concluded that age, associated severe multiple injuries, and clinical status were predictors of mortality after blunt diaphragmatic rupture.

(i) The response of children to trauma

Abstract Children differ markedly from adults in their response to trauma. They sustain predictable injuries from typical mechanisms based upon their age and activity profile. They have been shown to have different patterns of injury when sustaining single bone trauma, pelvic fractures and spinal injuries. The microscopic structure of a child's bone is different creating an environment for unique fracture types including those of the physis. The biological healing response differs and children often have the capacity for significant remodelling. Due to the unique anatomy and physiology of a child, the management of severe trauma and multiple injuries is different to that of an adult. Continuing growth and development always need to be taken into account and will have a bearing on the management plan. The long-term outcome, from both a functional and psychological standpoint, is of great concern as these patients have potentially so much time ahead of them. It is important to be aware of all these differences to ensure that assessment, diagnosis, initial and definitive management, rehabilitation and follow up are optimal for each injured child.

(iv) The response of children to trauma

Children differ markedly from adults in their response to trauma. They sustain predictable injuries from typical mechanisms based upon their age and activity profile. They have been shown to have different patterns of injury when sustaining single bone trauma, pelvic fractures and spinal injuries. The microscopic structure of a child's bone is different creating an environment for unique fracture types including those of the physis. The biological healing response differs and children often have the capacity for significant remodelling. Due to the unique anatomy and physiology of a child, the management of severe trauma and multiple injuries is different to that of an adult. Continuing growth and development always needs to be taken into account and will have a bearing on the management plan. The long-term outcome, from both a functional and psychological standpoint, is of great concern as these patients have potentially so much time ahead of them. It is important to be aware of all these differences to ensure that assessment, diagnosis, initial and definitive management, rehabilitation and follow up are optimal for each injured child.

Unaufgebohrte Marknagelung

Reaming and non-reaming of intramedullary nails in long bone fractures was a controversial and even emotional topic in recent decades. This article gives an historical overview of the development in this field and presents the background to the need for unreamed nailing. Furthermore, the current state of knowledge is illustrated by describing the results of a series of randomised controlled trials. Before the year 2000 nearly all German handbooks on orthopaedic and trauma surgery recommended unreamed intramedullary nailing as a more "biological" treatment that causes less harm to vascularity with equal or even better results. Unreamed nailing was in particular advocated for the treatment of open fractures. The tide turned as randomised controlled trials conducted since 2000 gave evidence that unreamed nailing leads to a higher rate of delayed or non-union, while the advantages to blood supply and infection rate could not be proven. According to evidence based medicine isolated femur and tibia fractures should be nailed in a reamed procedure. In a severe multiple injury setting it is safer to stabilize long bone fractures with external fixators, as adverse events are described for reamed and unreamed nailing.

Variation and significance of NKT cell and its subset in patients with severe multiple injuries

To observe the variation and significance of natural killer T (NKT) cells in patients with severe multiple injuries. Peripheral blood was drawn from 30 patients with severe multiple injuries and 20 healthy individuals. NKT cells and the subsets of NKT cells were stained and analyzed on fluorescence activated cell sorter (FACS) using Cellquest software. The level of IL-4 and IFN-gamma in blood serum was detected by ELISA. The proportion of NKT cells was significantly increased. CD4+ NKT cells was increased (t equal to -3.11, P less than 0.01) and CD4+CD8+NKT (double negative NKT, DN NKT) cells decreased in patients with severe multiple injuries compared with healthy controls (t equal to 2.99, P less than 0.01). There was a positive correlation between the proportion of NKT cells and injury severity score (ISS) by Spearman correlation analysis (r equal to 0.70, P less than 0. 01). The level of IFN-gamma was significantly decreased and the level of IL-4 significantly increased in patients with severe multiple injuries. We demonstrate that human NKT cells are increased in trauma patients. Most significantly, there is an association between ISS and NKT cells. The increased CD4+NKT cells may contribute to the reduction of Th1 cytokine production and the growth of Th2 cytokine production, leading to the suppression of immunity after injury.

Pro- and Synbiotics to Control Inflammation and Infection in Patients With Multiple Injuries

A recent randomized clinical trial of our group disclosed considerable reduction of the infective sequelae after administration of a synbiotic formula, namely Synbiotic 2000FORTE, in patients with multiple injuries, the latter being a preparation of four probiotics. The mechanism of action of synbiotics was studied. A total of 72 patients with severe multiple injuries were allocated to a 15-day administration of either placebo or the synbiotic formula. The association of bloodstream infections, ventilator-associated pneumonia (VAP), serum levels of C-reactive protein (CRP), and endotoxins (LPS) were studied. Sepsis in the field of bacteremia occurred in 13 patients treated with placebo (36.1%) compared with 5 patients treated with Synbiotic 2000FORTE (13.9%, p = 0.028 between groups). The time to progression to primary bacteremia was longer among patients treated with Synbiotic 2000FORTE compared with placebo (p = 0.0237 between groups). Twelve (33.3%) and five (13.9%) placebo-treated and probiotic-treated patients, respectively, developed ventilator-associated pneumonia with Acinetobacter baumannii as a bacterial cause (p = 0.047 between groups). Treatment with synbiotics was accompanied by reduction of white blood cell counts and LPS and CRP levels in either patients who did or did not develop sepsis. Synbiotics contained in the studied formula decrease significantly the risk for sepsis by bloodstream infections and the occurrence of VAP by A. baumannii. The mechanisms of action might involve direct immunomodulatory effect, prevention of bacterial translocation, or most likely a combination of both.

Application of integrative treatment model and damage control theory in management of severe multiple injury

Objective To investigate the clinical therapeutic effect of integrative treatment model and damage control theory in treatment of severe multiple injury. Methods A retrospective study was done on 116 patients with severe multiple injuries who were divided into integrative treatment plus damage control group, integrative treatment group and conventional treatment group. The relationship of correlative factors with mortality rate among three groups was compared before operation, during operation and after operation. Results All the indices in integrative treatment plus damage control group were better than other two groups before operation, during operation and after operation, with lower mortality rate (P<0.05). Conclusions Early use of integrative treatment model and damage control theory can obviously decrease complications, improve prognosis and decrease mortality rate for patients with severe multiple injury. Key words: Multiple trauma; First aid; Integrative treatment model

Relationship between disseminated intravascular coagulation and levels of plasma thrombinogen segment 1+2, D-dimer, and thrombomodulin in patients with multiple injuries

To explore the relationship between disseminated intravascular coagulation (DIC) and levels of plasma thrombinogen segment 1+2 (F1+2), D-dimer (D-D), and thrombomodulin (TM) in patients with severe multiple injuries. In this study, 66 patients (49 males and 17 females, aged 15-74 years, mean=38.4 years) with multiple injuries, who were admitted to our hospital within 24 hours after injury with no personal or family history of hematopathy or coagulopathy, were divided into a minor injury group (ISS<16, n=21) and a major injury group (ISS>or=16, n=45) according to the injury severity. The patients in the major injury group were divided into a subgroup complicated with DIC (DIC subgroup, n=12) and a subgroup complicated with no DIC (non-DIC subgroup, n=33). Ten healthy people (7 males and 3 females, aged 22-61 years, mean=36.5 years+/-9.0 years), who received somatoscopy and diagnosed as healthy, served as the control group. Venous blood samples were collected once in the control group and 1, 3 and 7 days after trauma in the injury groups. The F1+2 and TM concentrations were determined by enzyme linked immunosorbent assay (ELISA), and D-D concentrations were measured by automated latex enhanced immunoassay. F1+2, D-D and TM levels were higher in the minor and major injury groups than in the control group. They were markedly higher in the major injury group than in the minor injury group. In the non-DIC subgroup, F1+2 levels declined gradually while D-D and TM levels declined continuously. In the DIC subgroup, F1+2 and D-D levels remained elevated while TM levels exhibited an early rise and subsequent decrease. Plasma F1+2, D-D and TM levels were higher in the DIC patients than in the non-DIC patients. Injury-induced increases in F1+2, D-D and TM plasma levels had significant positive correlation with each other at each time point. Besides being related to trauma severity, F1+2, D-D and TM levels correlate closely with the occurrence of posttraumatic DIC. Therefore, changes in plasma F1+2, D-D and TM levels may predict the occurrence of DIC.

Variation of T regulatory cells and its relation with injury severity and sepsis in patients with se-vere multiple injury

Objective To observe change of T regulatory cells (Tregs) and its relation with in-jury severity and sepsis following severe muhiple injury. Methods A total of 60 patients were em-ployed in the study and divided into severe group (30 patients) and critical group (30 patients) based on ISS scores and into sepsis group (22 patients) and non-sepsis group (38 patients) based on complication of sepsis. The proportion of Tregs in peripheral blood in different groups was detected by flow cytometry at days 1,3,5 and 8 after injury. Results The proportion of Tregs was significantly increased at day 5 postinjury, with statistical difference compared with that at day 3 postinjury (P < 0.01). The proportion of Tregs remained increasing at day 8 pestinjury (P < 0.05). At day 8 postinjury, the proportion of Tregs in critical group was significantly higher than that in severe group (P < 0.01). At the same time, the proportion of Tregs in sepsis group was significantly higher than that in non-sepsis group (P < 0.05). Spearman correlation analysis showed a positive correlation of Tregs proportion with ISS score (rs =0.654, P < 0.01). Conclusions Tregs play an important role in suppression of T cell-mediated im-munity after severe injury. The variation of Tregs can help evaluate prognosis and predict the risk of com-plicating sepsis in patients with severe multiple injury. Key words: Multiple injury; Injury severity score; Sepsis; Regulatory T cells

Intramedulläre Stabilisierung beidseitiger Femurfrakturen bei Polytrauma mit primärer Lungenembolie

This is a case report of a 31-year-old motorcyclist who was admitted to our emergency department with severe multiple injuries and an ISS score of 38 points.There were bone injuries on all 4 extremities, fractures of both proximal femurs, both radii, a great soft tissue injury of the lower limb, stable fractures of the spine and a blunt thoracic injury. A bone fragment compressed femoral vein and artery on the right side with consecutive thrombus in the inferior caval vein and thrombembolism of the central lung artery. The proximal femur fractures were treated initialy with gamma-nails after implanting a cava-filter because of the high-risk constellation for further thrombembolism. Operation was monitored with transesophageal echocardiography.The cava filter could be delivered on 2nd postoperative day without complication. The patient was ventilated for 1 day, stayed on ICU for 9 days and left hospital in a good condition after 28 days. It was the strategic and logistic great achievement of an interdisciplinary trauma center to implant cava filter and decide for intramedullar osteosythesis without delay.

Frequency, risk stratification and therapeutic management of acute post‐traumatic coagulopathy

Uncontrolled haemorrhage is still responsible for more than 50% of all trauma-related deaths within the first 48 h after hospital admission. Clinical observations together with recent research resulted in a new appreciation of the central role of coagulopathy in acute trauma care. A synopsis of different analyses based on datasets from severely multiple-injured patients derived from the TR-DGU database (Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie (DGU)/German Society of Trauma Surgery) with respect to incidence, risk stratification and therapeutic management of acute post-traumatic coagulopathy is presented. Retrospective analyses based on datasets from severely multiple-injured patients derived from the TR-DGU database and development/validation of a scoring system (TASH score = trauma-associated severe haemorrhage) that allows an early and reliable estimation for the probability of massive transfusion as a surrogate for life-threatening haemorrhage after severe multiple injuries. There is a high frequency of acute post-traumatic coagulopathy already present upon ER admission which is associated with significant morbidity and mortality in multiple-injured patients. The TASH score is recognized as an easy-to-calculate and valid scoring system to predict the individual's probability for massive transfusion and thus ongoing life-threatening haemorrhage at a very early stage after severe multiple injuries. An early aggressive management of acute post-traumatic coagulopathy including a more balanced administration of blood products to favour improved outcome is advocated.