Severe Multiple Trauma Patients Research Articles

Effect of ionized calcium level on short-term prognosis in severe multiple trauma patients: a clinical study

BackgroundHypocalcemia has been reported as an independent predictor of trauma mortality. We investigated the relationship between temporal variations in blood ionized calcium concentration (iCa) and prognosis in severe trauma patients...

Predicting factors associated with in-hospital mortality in severe multiple-trauma patients

Background and Objectives: Traumatic injuries have become a health problem worldwide, especially in low- to middle-income countries. Therefore, this study was conducted to identify predicting factors of death in adult severe multiple trauma patients. Methods: This retrospective cross-sectional study was performed on 1397 adult multiple trauma patients referred to the emergency department (ED) of Poursina Hospital between June 2019 and August 2021. The demographic characteristics, on admission clinical parameters, laboratory tests, the need for packed red blood cell transfusion, and the need for endotracheal intubation were recorded. The revised trauma score (RTS) was calculated according to the physiological variables collected on admission to ED. The primary outcome was 1-day mortality after admission. Results: The mean age of subjects was 37.12 ± 13.61 (18–60) years, and 1250 (89.5%) subjects were male. The 1-day mortality was 339 patients (24.3%). Initial RTS score and the mean Glasgow coma scale (GCS) scores were significantly higher in the survived group than in the nonsurvived group (6.6 ± 1.2 vs. 4.9 ± 1.0, 10.2 ± 3.7 vs. 4.9 ± 2.4, P < 0.001). The multivariate analysis resulted in low GCS (odds ratio [OR] = 1.527, 95%CI 1.434–1625, P < 0.001), low O2 saturation (OR = 1.023, 95%CI 1.003–1.043, P = 0.022), and need for intubation in the ED (OR = 0.696, 95%CI 0.488–0.993, P = 0.046) as predictors of 1-day mortality. The area under the curves receiver operating characteristics of RTS and GCS scores to predict mortality were 0.853 (95% CI: 0.831–0.874) and 0.866 (95% CI: 0.846–0.887), respectively. Conclusion: Multiple factors associated with 1-day mortality were reduced GCS score, decreased oxygen saturation, and need for intubation in the ED. The RTS and GCS scores are good predictors of mortality survival in multiple trauma patients.

Factors associated with the progression of traumatic intracranial hematoma during interventional radiology to establish hemostasis of extracranial hemorrhagic injury in severe multiple trauma patients.

To identify factors affecting the progression of traumatic intracranial hemorrhagic injury (t-ICH) during interventional radiology (IVR) for the hemostasis of extracranial hemorrhagic injury. This was a retrospective comparative study. Fifty-two patients with t-ICH who underwent hemostasis using IVR for extracranial trauma at our institute were included. Clinical and computed tomography scan data were collected to investigate factors associated with t-ICH progression. Fifty-two subjects (36 men/16 women) with a mean age of 70.9±19.2years were analyzed. The mean Injury Severity Score was 34.9±11.2. In 29 patients (55.7%), t-ICH progressed during IVR. Hematoma progression frequently occurred in patients with acute subdural hematoma (56.2%) and traumatic intracerebral hematoma/hemorrhagic brain contusion (66.6%). Factors associated with t-ICH progression included age (P=0.029), consciousness level at admission (P=0.001), Revised Trauma Scale (P=0.036), probability of survival (P=0.043), platelet count (P=0.005), fibrinogen level (P=0.016), hemoglobin level (P=0.003), D-dimer level (P=0.046), and red blood cell transfusion volume (P=0.023). Aggressive correction of anemia, thrombocytopenia, and low fibrinogen levels in severe consciousness disturbance patients with acute subdural hematoma and traumatic intracerebral hematoma/hemorrhagic brain contusion could improve the prognosis after IVR for hemostasis of extracranial hemorrhagic injuries.

CHANGES IN THE SERUM SEROTONIN LEVEL DURING THE ACUTE PERIOD OF MULTIPLE TRAUMA OF VARYING DEGREES OF SEVERITY

Introduction. The roles of endogenous serotonin such as its effect in the increased permeability of the blood-brain barrier, its effects upon the formation of cerebral edema as well as its participation in early cellular changes are well known and its significance as a marker of severity of traumatic brain injuries is recognized. However, the role of serotonin and its effect on hemodynamics in multiple trauma have not been sufficiently studied yet.Aim. To determine the pathogenetic role of serum serotonin, depending on the initial primary severity of injury in the acute period of multiple trauma with traumatic brain injury.Materials and methods. The study consisted of 40 patients with moderate and severe degrees of multiple trauma which were treated in the Lviv emergency hospital. The average age of the patients was 48.4 ± 5.2 years. In addition to standard laboratory parameters, serum serotonin levels were determined by the improved spectrofluorometry method.Results and discussion. In the group of patients with severe multiple trauma the initial cardiac output (CO) was 4.40 ± 0.07 l / min with a normalization during the first day. The serum serotonin level on admission was 0.075 ± 0.003 мg / cmі and after 24 hours it decreased significantly to 0.043 ± 0.005 мg / cmі. At the end of the 2nd day of treatment, the serotonin levels increased to 0.090 ± 0.008 мg / cmі. In the group of patients with moderate multiple trauma, the initial CO was 4,06 ± 0,10 l / min which was a significantly lower than those of the severe multiple trauma patients. After 6 hours of treatment the CO normalized with a significantly lower volume of infusion. The content of serotonin in the blood serum on admission was significantly lower compared to the group with severe multiple trauma and amounted to 0,055 ± 0,008 мg / cmі, after 24 hours 0,038 ± 0,005 мg / cmі, at the end of the 2 nd day 0,085 ± 0,007 мg / cmі.Conclusion. Serotonin content in the serum of patients with multiple trauma during hospitalization varies significantly depending on the severity of the multiple trauma, which makes it possible to use its as a diagnostic-prognostic bio-marker. A two-phased activation of the sympathetic nervous system during the first two days of treatment was noted, which manifested itself in significant fluctuations in the level of serotonin, regardless of the primary severity of the multiple trauma.

Prognostic value of the dynamic changes in extra vascular lung water index and angiopoietin-2 in severe multiple trauma patients with acute respiratory distress syndrome

To observe the dynamic changes in extra vascular lung water index (EVLWI) and angiopoietin-2 (Ang-2) in severe multiple trauma patients with acute respiratory distress syndrome (ARDS), analyze the risk factor for short-term mortality, and to evaluate their prognostic values for prognosis. A total of 54 severe multiple trauma patients with ARDS admitted to emergency intensive care unit (ICU) of the Affiliated Hospital of Guizhou Medical University from June 2014 to December 2018 were enrolled. The acute physiology and chronic health evaluation II (APACHE II), injury severity score (ISS) and oxygenation index (PaO2/FiO2), EVLWI [pulse-induced contour cardiac output (PiCCO) monitor] and plasma Ang-2 level [enzyme-linked immunosorbent assay (ELISA)] at 0 (immediately), 24, 48 and 72 hours after ICU admission, and the differences in PaO2/FiO2, EVLWI and Ang-2 between 0 hour and 72 hours (ΔPaO2/FiO2, ΔEVLWI, ΔAng-2) were calculated. The 28-day survival of patients was recorded, and the patients were divided into survival group and non-survival group. The differences in above mentioned parameters between the two groups were compared. Multivariate Logistic regression was used to analyze the independent risk factors associated with the prognosis. Receiver operating characteristic (ROC) curve was drawn to evaluate the prognostic values of ΔEVLWI and ΔAng-2 on the prognosis, and the Kaplan-Meier survival curve was plotted. 115 patients were enrolled in the final analysis, 72 survived in 28 days, 43 died, and the mortality rate was 37.4%. The APACHE II and ISS scores of the non-survival group were significantly higher than those of the survival group [APACHE II score: 25.7±2.7 vs. 20.6±2.2, ISS score: 22.1±3.1 vs. 18.1±2.1, both P < 0.05]. EVLWI and Ang-2 showed a gradual downwards tendency with the prolongation of the length of ICU stay in the survival group, but no significant change was found in the non-survival group. Parallel contour test showed that both P < 0.05, indicating that the curves between the two groups had different tendencies and were not parallel. The levels of EVLWI, Ang-2 and PaO2/FiO2 showed no statistical differences from 0 hour to 24 hours between the two groups, but EVLWI and Ang-2 in the non-survival group were significantly higher than those in the survival group from 48 hours on [EVLWI (mL/kg): 15.5±4.2 vs. 10.8±3.2, Ang-2 (ng/L): 352.7±51.2 vs. 237.9±42.8, both P < 0.05], and PaO2/FiO2 was significantly decreased [mmHg (1 mmHg = 0.133 kPa): 126.1±43.7 vs. 211.2±33.8, P < 0.05]. The ΔEVLWI and ΔAng-2 in the non-survival group were significantly lower than those in the survival group [ΔEVLWI (mL/kg): -0.9±6.1 vs. 3.1±6.4, ΔAng-2 (ng/L): -45.3±32.1 vs. 79.8±58.2, both P < 0.05], but ΔPaO2/FiO2 showed no significant difference as compared with the survival group (mmHg: 23.2±24.2 vs. -22.1±22.8, P > 0.05). Multivariate Logistic regression analysis demonstrated that ΔEVLWI [odds ratio (OR) = 2.811, 95% confidence interval (95%CI) = 1.232-3.161, P = 0.001], ΔAng-2 (OR = 2.204, 95%CI = 1.012-3.179, P = 0.001) and APACHE II (OR = 1.206, 95%CI = 1.102-1.683, P = 0.002) were independent risk factors for 28-day mortality of severe multiple trauma patients with ARDS. ROC curve analysis showed that the area under ROC curve (AUC) of ΔEVLWI for predicting 28-day prognosis of severe multiple trauma patients with ARDS was 0.832, which was higher than ΔAng-2 (AUC = 0.790) and APACHE II (AUC = 0.735). When the cut-off value of ΔEVLWI was 2.3 mL/kg, the sensitivity was 79.1%, and the specificity was 81.9%. Kaplan-Meier survival curve showed that the patients with ΔEVLWI > 2.3 mL/kg had a significantly higher 28-day cumulative survival rate as compared with the patients with ΔEVLWI ≤ 2.3 mL/kg (log-rank test: χ2 = 23.385, P = 0.000). ΔEVLWI and ΔAng-2 can be used as independent risk factors for 28-day mortality of severe multiple trauma patients with ARDS, and the predictive value of ΔEVLWI was better than Ang-2 and APACHE II. Dynamic observation of EVLWI could improve the accuracy of death forecasting for severe multiple trauma patients with ARDS.

Resuscitative endovascular balloon occlusion of the aorta may increase the bleeding of minor thoracic injury in severe multiple trauma patients: a case report

BackgroundThe resuscitative endovascular balloon occlusion of the aorta, because of its efficacy and feasibility, has been widely used in treating patients with severe torso trauma. However, complications developing around the site proximal to the occlusion by resuscitative endovascular balloon occlusion of the aorta have almost never been studied.Case presentationA 50-year-old Japanese woman fell from a height of approximately 10 m. At initial arrival, her respiratory rate was 24 breaths/minute, her blood oxygen saturation was 95% under 10 L/minute oxygenation, her pulse rate was 90 beats per minute, and her blood pressure was 180/120 mmHg. Mild lung contusion, hemopneumothorax, unstable pelvic fracture, and retroperitoneal bleeding with extravasation of contrast media were observed in initial computed tomography. As her vital signs had deteriorated during computed tomography, a 7-French aortic occlusion catheter (RESCUE BALLOON®, Tokai Medical Products, Aichi, Japan) was inserted and inflated for aortic occlusion at the first lumbar vertebra level and transcatheter arterial embolization was performed for the pelvic fracture. Her bilateral internal iliac arteries were embolized with a gelatin sponge; however, the embolized sites presented recanalization as coagulopathy appeared. Her bilateral internal iliac arteries were re-embolized by n-butyl-2-cyanoacrylate. The balloon was deflated 18 minutes later. After embolization, repeat computed tomography was performed and a massive hemothorax, which had not been captured on arrival, had appeared in her left pleural cavity. Thoracotomy hemostasis was performed and a hemothorax of approximately 2500 ml was aspirated to search for the source of bleeding. However, clear active bleeding was not captured; resuscitative endovascular balloon occlusion of the aorta may have been the cause of the increased bleeding of the thoracic injury at the proximal site of the aorta occlusion.ConclusionsIt is necessary to note that the use of resuscitative endovascular balloon occlusion of the aorta may increase bleeding in sites proximal to occlusions, even in the case of minor injuries without active bleeding at the initial diagnosis.

Application of ISS and CRAMS score for the assessment of the prognosis of patients with multiple trauma

Objective To compare the clinical value of injury severity score (ISS) and CRAMS (circulation, respiration, abdomen, motor, speech) score in the prognosis of patients with severe multiple trauma in emergency department. Methods A total of 93 severe multiple trauma patients with 69 male and 24 female and age ranged from 21 to78 years with mean age (43.4 ±14) years admitted in the emergency department from March 20l4 to December 20l5 were enrolled into this study. All of them were evaluated by using ISS and CRAMS score respectively and their survival during hospitalization was observed. Then, the predictive capabilities of ISS and CRAMS score for the mortality of patients were assessed by using receiver operator characteristic (ROC) curves. Results The mean ISS was (25.59±5.37) and mean CRAMS score was (6.75±1.26) in 93 patients with severe multiple trauma. Compared with the survival group (n=75), the ISS in the death group (n=18) was significantly higher (t=7.13, P 0.05). When the death was chosen as the prediction target, the optimal cut-off point for ISS was 27 and CRAMS score was 6, respectively. Conclusions CRAMS score in comparison with ISS score has the likewise predictive value for the prognosis of severe multiple trauma patients in emergency department. However, the CRAMS score is simple and easy in practice. The changes of CRAMS score demonstrate the severity of trauma timely and reliably, which is in favor of the diagnosis and treatment of hospitalized trauma patients in early stage. Key words: Injury severity score; CRAMS Score; Emergency; Multiple trauma; Prognosis assessment

Extracorporeal Life Support in Multiple Trauma Patients with Refractory Cardiopulmonary Failure: Predictors of Procedural Suitability and Success Rate

Background: Major trauma is a leading cause of death, particularly amongst young patients. New strategies in management are needed to improve the poor outcome of severe trauma. We report our initial experience with extracorporeal life support (ECLS) as a rescue therapy in severe multiple trauma patients with refractory cardiopulmonary failure. Objectives: The purpose of this study was to identify the pre-ECLS patient characteristics predicting appropriateness ECLS treatment. Methods: From December 2008 to May 2013, 420 multiple trauma patients were treated at our tertiary level referral trauma center. Our ECLS team was alerted on 35 and applied ECLS in 20 adult trauma patients. In 16 patients with cardiopulmonary failure with refractory shock, we adopted a veno-arterial ECLS; in 4 patients with isolated refractory acute respiratory failure, we used venovenous ECLS. Results: ECLS was initiated at a mean of 324.15 ± 197.8 (110 - 950) min from initial trauma. In 4 patients, ECLS treatment failed due to an incapability to maintain adequate ECLS flow and patient perfusion. In the other 16 patients efficiently supported by ECLS, the Cardiac Index, mean arterial pressure, lactate concentration, PaO2, PaCO2, and pH showed significant improvement with normal values reached at 3.2 ± 1.5 hours. Seven (43.7%) patients in the ECLS-Success Group donated organs, 2 patients (22.2%) died due to septic multi organ failure (MOF), and 7 (77.7%) patients were discharged from the hospital. ECLS was suitable and successful in patients with a significantly lower injury severity score, lower blood lactate level, lower number of blood units given, and significantly higher pH and Hb. Conclusions: From our data, ECLS seems to be a valuable option to resuscitate severe trauma patients when conventional therapies are insufficient: it is safe, feasible and effective in providing hemodynamic support and blood gas exchange. Our data permitted us to identify strong predictors of ECLS non-suitability and success in multiple trauma patients; these might be helpful in deciding whether ECLS should be used or not. Future improvements in materials and techniques are expected to make ECLS even easier and safer to manage, leading to a further extension of its use in disastrously injured patients

A retrospective analysis of severe multiple trauma with secondary thrombocytosis

Objective To estimate the clinic features of severe multiple trauma with secondary thrombocytosis as a factor influencing the prognosis. Methods A retrospective single-center study was carried out in 680 patients with severe multiple trauma survived longer than 72 hours in Chongqing Emergency Medical Center from March 2010 through March 2013. The variables including age, gender, ISS (injury severity score) , APACHE Ⅱ score, splenectomy and the usages of vasopressors, blood products transfusion, hematopoietic medicines and anticoagulant were analyzed. The prognosis indices including total in-hospital mortality after 72 hours, length of hospital stay and morbidity of thrombo-embolism were explored. The clinic characteristics and prognosis of severe multiple trauma with secondary thrombocytosis (platelet count more than 450 ×109L-1) were evaluated. T test or rank sum test was used for comparison between measurement data and Chi-square test or Fisher's exact test was used for comparison between enumeration data. Results Thrombocytosis was identified in 99 (14.56%) patients and it occurred one week after injury with median time of 27 days (ranged from 8 days to 304 days) , and maintained for (18.62 ±4.38) d. The median of platelet count was 584 × 109L-1 (lowest 478 × 109L-1, highest 1 072 ×109L-1) in severe multiple trauma patients with thrombocytosis. The proportions of splenectomy, prolonged use of vasopressors and employment of hematopoietic medicines or anticoagulant were significantly higher in patients with thrombocytosis than those in patients without thrombocytosis (14.14% vs.7.06% , P =0.03; 62.63% vs.39.07%, P <0.01; 28.28% vs.6.71%, P <0.01; 90.91% vs.19.45% , P< 0.01) . The highest D-Dimer level presenting in patients with thrombocytosis during the time of platelet increasing was significantly more common than that in patients of non-thrombocytosis group 7 days after trauma [(11.68 ±11.90) vs. (5.05 ±5.11) , P =0.004]. However, the mortality, length of hospital stay and morbidity of thrombo-embolism were not significantly increased in patients with thrombocytosis compared with patients without thrombocytosis [8.08% vs.8.78% , P =0.82; 34 d (28.5, 54.5) d vs. 45 d (23, 67) d, P =0.41; 10.10% vs.10.50% , P =0.91]. Conclusion There was a higher rate of secondary thrombocytosis in severe multiple trauma patients. The factors such as splenectomy, vasopressors, hematopoietic medicines and so on might induce the reactive thrombocytosis in trauma patients. Thrombocytosis might increase the incidence of thromboembolism in severe multiple trauma patients without appropriate prophylactic anticoagulation. For the sake of prophylaxis, employment of anti-platelet agent might be the appropriately therapeutic strategy for patients suffering from severe multiple trauma with secondary thrombocytosis accompanying risk factors of arterial thrombo-embolism. Key words: Multiple trauma; Thrombocytosis; Thromboembolism; Anticoagulation; Prognosis

Pattern of maxillofacial fractures in severe multiple trauma patients: a 7-year prospective study.

The incidence of facial trauma is high. This study has the primary objective of documenting and cataloging maxillofacial fractures in polytrauma patients. From a total of 1229 multiple trauma cases treated at the Emergency Room of the Santo Antonio Hospital - Oporto Hospital Center, Portugal, between August 2001 and December 2007, 251 patients had facial wounds and 209 had maxillofacial fractures. Aged ranged form 13 to 86 years. The applied selective method was based on the presence of facial wound with Abbreviated Injury Scale ≥1. Men had a higher incidence of maxillofacial fractures among multiple trauma patients (86.6%) and road traffic accidents were the primary cause of injuries (69.38%). Nasoorbitoethmoid complex was the most affected region (67.46%) followed by the maxilla (57.42%). The pattern and presentation of maxillofacial fractures had been studied in many parts of the world with varying results. Severe multiple trauma patients had different patterns of maxillofacial injuries. The number of maxillofacial trauma is on the rise worldwide as well as the incidence of associated sequelae. Maxillofacial fractures on multiple trauma patients were more frequent among males and in road traffic crashes. Knowing such data is elementary. The society should have a key role in the awareness of individuals and in prevention of road traffic accidents.

Role of intensive care unit in treatment of severe multiple trauma

Objective To investigate the criteria and significance for management of severe multiple trauma in the intensive care unit (ICU).Methods Data of 64 patients with non-fatal severe multi-trauma (ISS≥20) treated in the First Aid Center for Traffic Injuries in 117th Hospital of PLA between 2006-2012 documented in China Trauma Database were analyzed.Differences in trauma scoring,complications,functional prognosis and medical cost were analyzed between ICU and non-ICU patients.Results There were statistical differences for GCS and revised trauma score (RTS) between ICU patients and non-ICU patients (P ＜ 0.05),but the differences were insignificant for ISS and new ISS (NISS).Likewise,the differences were significant for complication incidence and functional independence measure (FIM) on discharge (P ＜ 0.05),but not in the length of hospital stay and medical cost.Complication incidence of non-ICU patients was 2.96 times that of ICU patients.FIM of ICU patients scored 10.11 ± 2.10,far higher than that of non-ICU patients (P ＜ 0.05).Conclusion For severe multiple trauma patients with ISS≥20,the admission to the ICU is helpful for reduction of the complication rate. Key words: Multiple trauma; Database; Intensive care unit

The outcomes of 1120 severe multiple trauma patients with hemorrhagic shock in an emergency department: a retrospective study

ObjectiveUncontrolled hemorrhagic shock is a significant factor in death of severe multiple trauma patients. The acute management of injured bleeding in emergency department (ED) may improve patient outcomes. The medical records of severe multiple trauma patients with hemorrhagic shock in our ED were reviewed to summarize an evidence-based approach to the management of critically injured bleeding trauma patients.MethodsA retrospective study was carried out from January 2002 to December 2011 in a Chinese tertiary hospital. Clinical data from major trauma patients with hemorrhagic shock admitted to ED were evaluated. The patients were stratified based on the characteristics of traumatic condition and resuscitation strategies. The medical treatments and the outcomes of these severe multiple trauma patients were described.ResultsA total of 1120 major trauma patients, consisting of 832 males and 288 females, were enrolled. 906 of the patients (80.9%) were injured in traffic accidents, 104 (9.3%) from falling, and 100 from other reasons. The number of injured sites varied from 2 to 6, 616(55.0%) more than 3. 902 (80.5%) trauma patients have recovered and been discharged from hospital.ConclusionsUncontrolled hemorrhagic shock is a main reason of trauma patients’ death. The resuscitation strategy should center upon permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy. The current approach to the management of critically injured bleeding trauma patients is able to improve patient outcomes.

Traumatic Tracheobronchial Injury: Delayed Diagnosis and Treatment Outcome

BackgroundMost traumatic tracheobronchial injuries are fatal and result in death. Some milder cases are not life threatening and are often missed at the initial presentation. Tracheobronchial rupture is difficult to diagnose in the evaluation of severe multiple trauma patients. We reviewed the traumatic tracheobronchial injuries at Konyang University and Eulji University Hospital and analyzed the clinical results.Materials and MethodsFrom January 2001 to December 2011, 23 consecutive cases of traumatic tracheobronchial injury after blunt trauma were reviewed retrospectively. We divided them into two groups by the time to diagnosis: group I was defined as the patients who were diagnosed within 48 hours from trauma and group II was the patients who diagnosed 48 hours after trauma. We compared the clinical parameters of the two groups.ResultsThere was no difference in the age and gender between the two groups. The most common cause was traffic accidents (56.5%). The Injury Severity Score (ISS) was 19.6 in group I and 27.5 in group II (p=0.06), respectively. Although the difference in the ISS was not statistically significant, group II tended toward more severe injuries than group I. Computed tomography was performed in 22 cases and tracheobronchial injury was diagnosed in 5 in group I and 6 in group II, respectively (p=0.09). Eighteen patients underwent surgical treatment and all four cases of lung resection were exclusively performed in group II (p=0.03). There were two mortality cases, and the cause of death was shock and sepsis.ConclusionWe believe that close clinical observation with suspicion and rigorous bronchoscopic evaluation are necessary to perform diagnosis earlier and preserve lung parenchyma in tracheobronchial injuries from blunt trauma.

The “Coagulation Box” and a New Hemoglobin-Driven Algorithm for Bleeding Control in Patients With Severe Multiple Traumas

BackgroundExtensive hemorrhage is the leading cause of death in the first few hours following multiple traumas. Therefore, early and aggressive treatment of clotting disorders could reduce mortality. Unfortunately, the availability of results from commonly performed blood coagulation studies are often delayed whereas hemoglobin (Hb) levels are quickly available.ObjectivesIn this study, we evaluated the use of initial hemoglobin (Hb) levels as a guide line for the initial treatment of clotting disorders in multiple trauma patients.Patients and MethodsWe have developed an Hb-driven algorithm to initiate the initial clotting therapy. The algorithm contains three different steps for aggressive clotting therapy depending on the first Hb value measured in the shock trauma room, (SR) and utilizes fibrinogen, prothrombin complex concentrate (PCC), factor VIIa, tranexamic acid and desmopressin. The above-mentioned drugs were stored in a special “coagulation box” in the hospital pharmacy, and this box could be immediately brought to the SR or operating room (OR) upon request. Despite the use of clotting factors, transfusions using red blood cells (RBC) and fresh frozen plasma (FFP) were performed at an RBC-to-FFP ratio of 2:1 to 1:1.ResultsOver a 12-month investigation period, 123 severe multiple trauma patients needing intensive care therapy were admitted to our trauma center (mean age 48 years, mean ISS (injury severity score) 30). Fourteen (11%) patients died; 25 (mean age 51.5 years, mean ISS 53) of the 123 patients were treated using the “coagulation box,” and 17 patients required massive transfusions. Patients treated with the “coagulation box” required an average dose of 16.3 RBC and 12.9 FFP, whereas 17 of the 25 patients required an average dose of 3.6 platelet packs. According to the algorithm, 25 patients received fibrinogen (average dose of 8.25 g), 24 (96%) received PCC (3000 IU.), 14 (56%) received desmopressin (36.6 µg), 13 (52%) received tranexamic acid (2.88 g), and 11 (44%) received factor VIIa (3.7 mg). The clotting parameters markedly improved between SR admission and ICU admission. Of the 25 patients, 16 (64%) survived. The revised injury severity classification (RISC) predicted a survival rate of 41%, which corresponds to a standardized mortality ratio (SMR) of 0.62, which implies a higher survival rate than predicted.ConclusionsAn Hb-driven algorithm, in combination with the “coagulation box” and the early use of clotting factors, could be a simple and effective tool for improving coagulopathy in multiple trauma patients.

Value of critical care medicine scoring systems and procalcitonin in evaluation of severe multiple trauma

Objective To compare the value of acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ),sequential organ failure assessment (SOFA) and procalcitonin (PCT) in assessment of severe multiple trauma. Methods A retrospective study was carried out on clinical data of patients with severe multiple trauma who were admitted to ICU from July 1 st 2010 to October 31 st 2011.PCT detection,APECHE Ⅱ and SOFA scoring were routinely performed for all the patients within 24 hours,and were performed again one week later for the patients who were complicated with sepsis within one week.Results The score of APACHE Ⅱ and SOFA in septic shock group was higher than that in severe septic and septic groups (P ＜0.01 ),while PCT level among septic,severe septic and septic shock groups had no statistical difference (P ＞ 0.05).To determine the predicting accuracy of APECHE Ⅱ score,SOFA score and PCT,receiver operating characteristic curve (ROC) was constructed.The areas under the curve (AUC) for APECHE Ⅱ score,SOFA score and PCT in predicting the emergence of sepsis on admission was 0.615,0.663 and 0.160 respectively.AUC for APECHE Ⅱ score,SOFA score and PCT in predicting the occurrence of death among the severe multiple trauma patients on admission was 0.576,0.571 and 0.619 respectively.AUC for APECHE Ⅱ,SOFA and PCT in predicting the death of patients complicated with sepsis at one week after admission was 0.746,0.837 and 0.600 respectively. Conclusions Among the APACHE Ⅱ score,SOFA score and PCT,APACHE Ⅱ and SOFA score are better than PCT in assessing the infection severity of sepsis.SOFA score is the best in predicting the occurrence of sepsis,while PCT is the worst.PCT is the best in predicting the occurrence of death of severe multiple trauma patients,while SOFA score is the worst.SOFA score is better than APACHE Ⅱ score and PCT in predicting the occurrence of death of the patients complicated with sepsis. Key words: Multiple trauma; Sepsis; Research design; Calcitonin

Analysis of emergency treatment on severe multiple trauma patients

Objective To study the method of first aid for severe multiple trauma.Methods The emergency data of 236 case of severe multiple trauma were retrospectively analyzed.Results 223 cases were successful rescued and 13 cases died.Conclusions Scientific judgments and rescued of mortal wound were needed for emergency of severe multiple trauma.Patients that were in different serious degree should be prioritized,intensively observed and given effective treatments.Standardized emergency method with strict process could save time for successful first aid and become solid foundation for later treatment and rehabilitation. Key words: Multiple trauma; Emergency; Surgery

The clinical application of damage control orthopaedics strategy in treatment of multiple traumas combing with bone injuries.

Objective To evaluate the feasibility and safety of the damage control orthopedics (DCO) strategy in the treatment of multiple traumas combine with bone injuries. Methods Forty-seven se-vere multiple injuries patients were treated by DCO strategy in our center. There were 35 males, 12 females, with a mean age of 32.8 years (17-55 years). There were 28 for open fractures, and 19 for close fractures. Other system injuries mainly include: brain injury 15 cases, breast injury 20 cases, abdominal injury 17 cases. Mean injury severity score was 33.4, mean glasgow coma score was 11.4, mean systemic inflammatory response syndrome score was 2.9. After the early resuscitation and one-stage of damage control surgery, all patients were send to ICU for a profound resuscitation. Two -stage definitive osteosynthesis were executed when the patients were stabilization. The data of time spend, blood loss, and complications of operations were recorded to evaluation. Results In the one-stage procedure, the mean time spend on bone injury for each patients was 65 min, blood loss during the operation was 185 ml. The two-stage definitive osteosynthesis were performed average 7 days after the one-stage procedure, and the time spend and blood loss during the oper-ation were (142±29) min and (420±70) ml, respectively. Three patients died from the deteriorate after one-stage procedure. Six cases development complications after the operation. Fat embolism, deep vein thrombus and others deteriorate associate with the one-stage procedure were not found. Four patients were all obtained neurologic improvement who has spinal fractures combined with spinal cord injuries. 39 cases were followed up for a mean time of 9 months (range, 3-14 months). No long-term complications were found, and the frac-tures got a satisfactory healing. Conclusion DCO appears to reduce the extent of second-hit, control the in-crease of systematic inflammatory response, deduce the risk of the operation for those severe multiple trauma patients, and have a satisfactory clinical outcome, is a safe, effective, feasible treatment strategy. Key words: Multiple trauma; Fractures; Surgical procedures, operative

Stimulating effect of sera from severe trauma patients on NF-kappaB activity in macrophage and its relationship with patients prognosis

To investigate the stimulating effect of sera from severe multiple trauma patients within 24 h post trauma on nuclear factor-kappaB (NF-kappaB) activity in macrophage and their relationship with patients prognosis. Peripheral blood of 47 patients with multiple traumas with injury severity score (ISS) > or = 16 and 24 healthy volunteers were obtained, and sera samples were isolated. And 24 h after transfection of the recombinant NF-kappaB plasmid containing luciferase reporter gene into the mouse macrophage line (RAW 264.7), the cells were stimulated by sera from different patients for 6 h, then stimulating effect of sera on NF-kappaB was assessed by luciferase activity. The concentrations of interleukin-1 beta, tumor necrosis factor alpha, interleukin-10, interleukin-1 receptor antagonist, and soluble tumor necrosis factor receptor I were detected with ELISA kits. The stimulating activity of sera from trauma patients on NF-kappaB was increased significantly, and it was higher in MODS group, non-survivor group than that in non-MODS, survivor group respectively. The level of activity was correlated positively with APACHE II score, while it did not have relationship to the cytokine or endogenous antagonist levels. The area under the receiver operating characteristic curve (ROC) of NF-kappaB activity for predicting MODS and mortality was significantly higher than that of APACHE II score. Early measurement of NF-kappaB stimulating activity of sera from severe multiple trauma patients may have the value to predict occurrence of MODS and mortality.

Comparison of Mortality Due to Severe Multiple Trauma in Two Comprehensive Models of Emergency Care: Atlantic Pyrenees (France) and Navarra (Spain)

Background: Injury due to external causes is an important health problem in our society today. Emergency care systems based on the concept of “comprehensive care” can prevent deaths and disabilities as well as limit the severity and pain caused by trauma. Objective: To investigate the frequency and characteristics of different mechanisms of injury and to estimate mortality, comparing two comprehensive emergency systems: Atlantic Pyrenees (AP) in France and Navarra (NA) in Spain. Material and Methods: A prospective cohort study of severe multiple-injury patients attended to by the comprehensive emergency care systems of AP and NA from April 1, 2001 to March 31, 2002. Data were collected from personal patient data, the emergency coordination center “112,” pre-hospital and hospital health care levels, and discharge data. Bivariate statistical analysis and multivariate logistic regression models were employed for statistical management. Results: There were 614 severe multiple trauma patients recorded, 278 in AP and 336 in NA. Significant differences were observed in arrival time, pre-hospitalization care, pre-hospital Revised Trauma Score (RTS), Injury Severity Score (ISS) at the intensive care unit, and procedures used (intubation, administration of fluids, immobilization, and diagnostic methods). Logistic regression showed significant differences in patient death, age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01–1.03), penetrating or accidental injuries, (OR 3.85, 95% CI 1.1–13.1), RTS (OR 0.58, 95% CI 0.5–0.7), and ISS score (OR 1.05, 95% CI 1.0–1.1). Conclusion: Despite a more aggressive approach and employment of greater resources, the French comprehensive trauma system does not show greater survival rates among injured patients compared to Navarra, even when controlling for confounding factors like age, injury mechanism, RTS, ISS, and others.

The Impact of Clinical Risk Factors in the Conversion from Acute Lung Injury to Acute Respiratory Distress Syndrome in Severe Multiple Trauma Patients

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are different stages of the same disease, the aggravated stage of ALI leading to ARDS. Patients with ARDS have higher hospital mortality rates and reduced long-term pulmonary function and quality of life. It is, therefore, important to prevent ALI converting to ARDS. This study evaluated 17 risk factors potentially associated with the conversion from ALI to ARDS in severe multiple trauma. The results indicate that the impact of pulmonary contusion, APACHE II score, gastrointestinal haemorrhage and disseminated intravascular coagulation may help to predict conversion from ALI to ARDS in the early phase after multiple-trauma injury. Trauma duration, in particular, strongly impacted the short- and long-term development of ALI. Being elderly (aged > or = 65 years) and undergoing multiple blood transfusions in the early phase were independent risk factors correlated with secondary sepsis, deterioration of pulmonary function and transfusion-related acute lung injury due to early multiple fluid resuscitation.