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PubMed1987

Mortality and morbidity related to severe intrapulmonary shunting in multiple trauma patients.

Of 210 multiple trauma patients admitted to our Intensive Care Unit (ICU), 12 (5%) presented with severe hypoxemic respiratory failure needing mechanical ventilation with an FIO2 of 1.0 because of severe intrapulmonary shunting (IS). Five (42%) of these patients survived and two (17%) died because of their underlying respiratory failure. We found a mean of three etiologic factors in each patient to account for their IS. Nonsurvivors had a lower cardiac index than survivors when they first needed FIO2 of 1.0 and ARDS was more frequent among this group. All patients who survived were in severe hypoxemic respiratory failure in the first 5 days post-trauma; all patients who needed FIO2 of 1.0 later than 5 days post-trauma died. Data collected for patients with similar degree of respiratory failure in coronary care ICU (n = 18), in medical ICU (n = 19), and surgical ICU (n = 21) demonstrated that multiple trauma patients with severe hypoxemic respiratory failure were younger and were hospitalized and ventilated for longer periods of time. In multiple trauma patients, as for patients with cardiogenic pulmonary edema, death was seldom related to respiratory failure itself. We concluded that severe hypoxemic respiratory failure in trauma patients is usually of mixed etiologies. It is a serious cause of morbidity in these patients; however, mortality is seldom directly related to this condition. Severe IS occurring shortly after trauma is of better prognosis than late IS.

Adult↗
PubMed1989

The frequency and significance of thoracic injuries detected on abdominal CT scans of multiple trauma patients.

Of 174 multiple trauma patients undergoing abdominal CT examination for suspected abdominal trauma, 65 patients had 109 chest injuries detected by abdominal CT, chest film, or both examinations. Forty-one patients had 55 chest injuries at the base of the thorax which were not detected on the initial chest film. The most frequent chest injuries detected only by CT were pneumothroax, fracture (rib, thoracic spine, and sternum), lung contusion, aspiration pneumonia, hemothorax, and post-traumatic atelectasis. Seven patients whose chest injury initially was seen only at abdominal CT required treatment of the injury, suggesting that a variety of chest injuries which may vitally affect patients can be detected early in multiple trauma patients by abdominal CT, and that all abdominal trauma CT scans should be scrutinized for signs of a chest injury.

False Positive Reactions↗
PubMed1991

Fibrinolytic (rt-PA) therapy for superior vena cava thrombosis in a multiple trauma patient.

An adult multiple trauma patient (head injury with coma, blunt chest trauma, bone and pelvis fractures) developed superior vena cava thrombosis which extended to the right atrium as a complication of central venous catheterism. Since a four day heparin therapy was unsuccessful, the patient was treated with recombinant tissue-type plasminogen activator (rt-PA), 100 mg over three hours. Thrombolysis with rt-PA was not associated with cutaneous or internal bleeding and was partially effective (improvement of the clinical picture, disappearance of the right atrium thrombus, superior vena cava still occluded). Although our patient could have benefited from an additional administration of rt-PA, we did not start a second course because the risk of major hemorrhage increases over 100 mg. For its relative clot-selectivity rt-PA could be indicated when fibrinolytic treatment is required in multiple trauma patient, but safe and more efficacious regimens have still to be defined.

Adult↗
PubMed1981

Effect of multiple trauma on outcome of pediatric patients with neurologic injuries.

In a 3-year period, 95 patients with severe head injury (unconsciousness greater than 6h duration) were treated at our institution. Of these, 46 patients (48%) had isolated head injury and 49 (52%) had head injury plus severe multiple trauma. Multiple trauma was scored using the Modified Injury Severity Scale. All patients in the multiple trauma group had at least one additional area of severe injury. Severity of head injury, judged by Glasgow Coma Score, presence of mass lesions, abnormal posturing or flaccidity, impaired or absent oculocephalic reflexes, and fixed, dilated pupils, was much greater in the isolated head injury group. In spite of this, poor outcome (death or vegetative/severe disability) was 2 1/2 times as frequent in the multiple trauma group. Shock, refractory hypoxemia and sepsis were contributing factors in this increased morbidity and mortality. Increasing Modified Injury Severity Scale scores were associated with increased morbidity and mortality.

Adolescent↗
PubMed2004

[Personnel and structural requirements for the shock trauma room management of multiple trauma. A systematic review of the literature].

The aim of the study was the description of personal and structural preconditions essential for adequate diagnostic requirements and treatment in severely injured patients. Herein we give detailed information regarding both the composition and qualification of the trauma team and the activation criteria as well as instructions for the design of the emergency room and technical requirements. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The trauma team should consist of (trauma) surgeons, anesthesiologists, radiologists, and one to two nursing staff members of each department. The attending physician should be present within 20 min. Trauma team activation criteria are among others: high energy/velocity trauma, penetrating injuries, GCS < or =14, and intubation. The emergency room should be integrated in the emergency department with all technical equipment being permanently available for optimal diagnostic and therapeutic management. A CT scanner should be positioned nearby.Adequate management of severely injured patients requires optimal personal and structural conditions. High costs and additional personnel are justified by improved quality of treatment.

Emergency Medical Services↗
PubMed1990

[Diagnostic problems of multiple trauma and technical means].

Multiple trauma requires immediate and combined resuscitation and surgery. For resuscitation, the neurological condition must be assessed prior to any sedation, as well as the respiratory and hemodynamic condition, in order to carry out first aid (tubing, ventilation, infusion...). The surgeon who is present must contribute in the quick clinical assessment of the lesions, perform temporary hemostasis as well as hemostatic and anti-infectious dressing, find out associated vascular complications and possible injuries to the spine and cord. Various blood samples must be taken before setting up the venous pathways (peripheral and central), and the various parameters will be followed up. Thoracic aspiration will sometimes be essential for better ventilation. Radiographs of the chest and of the pelvis will be taken with the injured person on the stretcher, without displacing him/her. The rest of the assessment will be performed only when the person with multiple trauma has been resuscitated and is hemodynamically stable, and it will include various radiographs, ultrasound and CT studies, and even angiograms, of the skeleton and of the cranial contents, of the thorax and of the abdomen. However, all these explorations are somewhat time-consuming, and involve a risk of neurological, hemodynamic or ventilatory aggravation. Therefore they must be organized into a hierarchy, and only those that are essential will be performed to avoid delaying the treatment. Neither must the effectiveness of resuscitation be too reassuring, as the morbidity of the lesions increases with the number of units of transfused blood. The vital prognosis is often worsened when a lesion is not recognized or when complications occur.

Brain↗
PubMed2026

Online-delivered eye movement desensitization and reprocessing treatment for adults with post-traumatic stress disorder due to multiple traumas: a non-concurrent multiple baseline design.

Background: No controlled studies incorporating randomization have been conducted to investigate the effectiveness of online eye movement desensitization and reprocessing (EMDR) treatment, despite its use in clinical practice.Objective: This study evaluated the effect of online EMDR treatment in adults aged 18-65&#xa0;years with post-traumatic stress disorder (PTSD) resulting from multiple traumas.Method: A multiple baseline single-case experimental design (n&#x2009;=&#x2009;21) was employed. Participants were patients with PTSD due to multiple traumas, recruited from a mental healthcare institution in the Netherlands. They were randomly assigned to baseline phases of 2, 3.5, or 5.5 weeks. After this, participants received 10 weekly online EMDR sessions. The primary outcome was the total score on an adapted version of the PTSD Checklist for DSM-5 (PCL-5), which was administered twice a week during baseline and intervention phases, and once 12 weeks after the end of the intervention phase. We performed visual analysis and calculated the improvement rate difference (IRD) for each individual separately to determine whether online EMDR was effective. We also performed a paired t-test and calculated Cohen's d for pretreatment and post-treatment comparisons, and pretreatment versus follow-up to evaluate effects at the group level.Results: Visual analysis and IRD scores showed that the treatment was effective for 15 participants, with effect sizes ranging from small to very large. The mean scores on the PCL-5 at group level decreased significantly over time between pretreatment and post-treatment (Mdiff&#x2009;=&#x2009;23.6, Cohen's d&#x2009;=&#x2009;1.34, 95% CI 0.74-1.93), as well as between pretreatment and follow-up (Mdiff&#x2009;=&#x2009;27.2, Cohen's d&#x2009;=&#x2009;1.62, 95% CI 0.95-2.27).Conclusion: Most participants showed a reduction in symptoms following the start of the online EMDR. Furthermore, at the group level there was a significant and clinically relevant reduction in symptoms over time. This provides preliminary evidence for the effectiveness of online EMDR treatment.

Humans↗
PubMed2000

[Cost analysis of the treatment of patients with multiple trauma].

Current clinical management after multiple trauma is expensive. The aim of the present study was to quantify the actual costs of inpatient treatment after multiple trauma in a German university hospital, to compare the actual costs with the reimbursement rates, and to identify important determinants of costs. Routine documentation of hospital costs at a patient level was not available. Therefore a method for calculating the costs of resource utilization during clinical treatment of patients was developed. The concept was based on financial and utilization data provided by the hospital administration and patient-specific data. The average costs per case in the study group (mean ISS = 37) were 73.613 DM, maximal costs were up to 292.490 DM. The most costly components were intensive care, accounting for 60%, followed by procedures in the operating room (24%). A comparison with the reimbursement rates resulted in an average loss of 23.211 DM per case. Factors significantly associated with the costs of acute care hospitalization were outcome, injury severity, pattern of injury, blood volume replacement, length of mechanical ventilation, and number of operations. Whereas patient age, CNS state, mechanism of injury, pre-hospital care, and time between accident and hospital admission revealed no effect. Given the current reimbursement rates, multiple trauma care clearly belongs to those categories of care which have to be subsidized within the hospital. Any challenge to the optimal level of care resulting from this should be avoided.

Acute Disease↗
PubMed1984

The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients.

122 multiple trauma patients staying in the ICU for 5 or more days and needing mechanical ventilation were investigated to determine the effect of selective decontamination of the digestive tract on prevention of infection. The (retrospectively studied) control group of 59 patients received no antibiotic prophylaxis. The infection rate during ICU-stay was 81%. Most infections were caused by potentially pathogenic microorganisms (PPM) from the oral cavity or the intestines (i.e. endogenous infections). The oropharynx and the intestines were rapidly colonised with ICU-associated gram-negative bacilli. After 2 weeks more than 80% of patients were found colonised. This secondary colonisation of the digestive tract is a very important stage in the pathogenesis of infections. Sixty-three patients were selectively decontaminated with nonabsorbable antibiotics, administered through the gastric tube even if peristalsis was absent. Emphasis was laid on the selective decontamination of the oral cavity, using topical application of an antibiotic paste. With this technique the oral cavity was free of PPM within 3 days in most patients. No secondary colonisation was found. Rectal colonisation decreased significantly after 5 days. Secondary colonisation occurred in 9 patients with PPM sensitive to the antibiotics used. The prophylactic regimen included systemic cefotaxim, directed against early endogenous infection. The suppression and after some time the absence of the endogenous source of PPM resulted in a significant reduction of colonisation and infection. The total infection rate decreased to 16%.

Administration, Topical↗
PubMed2004

[Preclinical management of multiple trauma].

Approximately 8000 patients with multiple trauma are admitted annually to an emergency room in Germany. The prognosis of these severely injured patients is influenced in particular by concomitant craniocerebral injury, an abdominal wound, or thoracic trauma. Hypoxia and hypotension subsequent to shock induced by hemorrhagic-traumatic effects are of prime importance. Preclinical management thus includes examining the injured patient, immobilizing the spine, ensuring airway patency, stabilizing cardiovascular status suitting the approach to the injury pattern, commensurate care of partial injuries, pain therapy, as well as rapid and careful transportation to the nearest qualified trauma center. Management of patients with multiple trauma poses a particular challenge to the responding team. This article in the continuing education series deals with current algorithms for preclinical management of patients with multiple injuries with particular focus on the significant factor of time.

Blood Transfusion↗
PubMed1998

Serum Gc-globulin in the early course of multiple trauma.

OBJECTIVES: In patients with multiple trauma, actin released from damaged cells may cause severe circulatory disturbance due to thrombi formation. The aim of this study was to evaluate serum concentrations of the actin scavenger, Gc-globulin, in relation to the severity of injury and outcome. DESIGN: Prospective, longitudinal, observational study. SETTING: Trauma center at a university hospital. PATIENTS: Twelve patients with multiple trauma, consecutively included, according to defined criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Serum Gc-globulin concentrations were measured at the time of admission and daily thereafter for 1 wk or until death. In all patients, the Gc-globulin concentration was significantly low (p < .0001), and the proportion of Gc-globulin bound to actin was already increased compared with normal values (p < .0001) by the time of hospital arrival. There was an inverse correlation between the mean concentration of serum Gc-globulin in the first week after trauma and the Injury Severity Score (r = -0.72, p < .05). Surviving patients had a significantly (p < .05) higher concentration of serum Gc-globulin in the first week after trauma compared with nonsurvivors. CONCLUSIONS: Serum concentrations of Gc-globulin were significantly low in trauma patients. The reduction took place within 60 mins after injury. Because the normal half-life of Gc-globulin is almost 48 hrs, our observations suggest a marked consumption of Gc-globulin immediately after the trauma. This finding could be the first clinical evidence that Gc-globulin plays a role in the systemic inflammatory response syndrome after trauma. This result is supported by the finding that lack of Gc-globulin was related to nonsurvival and the severity of the trauma.

Actins↗
PubMed1992

Diagnosis and treatment of retroperitoneal hematoma in multiple trauma patients.

From 1984 to 1991 20 multiple trauma patients with pelvic fractures and retroperitoneal bleeding from pelvic vessels underwent angiographic localization and embolization of massively bleeding arterial vessels. Nine patients survived (multiple trauma index grade III, Hanover polytrauma index), three patients with very severe injuries died immediately (multiple trauma index grade IV). After successful control of bleeding by embolization, three other patients died from severe brain injuries and five patients from septic multiorgan failure. The interval to definite localization and treatment of the bleeding source was three times shorter in the group of survivors, and the amount of transfusions needed was less by a factor of three. This underlines the importance of early angiography in multiple trauma patients with pelvic fractures and persisting hemorrhage. Embolization has proven to be effective in the treatment of such injuries.

Adolescent↗
PubMed2006

Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma.

INTRODUCTION: Early detection of pneumothorax in multiple trauma patients is critically important. It can be argued that the efficacy of ultrasonography (US) for detection of pneumothorax is enhanced if it is performed and interpreted directly by the clinician in charge of the patients. The aim of this study was to assess the ability of emergency department clinicians to perform bedside US to detect and assess the size of the pneumothorax in patients with multiple trauma. METHODS: Over a 14 month period, patients with multiple trauma treated in the emergency department were enrolled in this prospective study. Bedside US was performed by emergency department clinicians in charge of the patients. Portable supine chest radiography (CXR) and computed tomography (CT) were obtained within an interval of three hours. Using CT and chest drain as the gold standard, the diagnostic efficacy of US and CXR for the detection of pneumothorax, defined as rapidity and accuracy (sensitivity, specificity, positive predictive value, negative predictive value), were compared. The size of the pneumothorax (small, medium and large) determined by US was also compared to that determined by CT. RESULTS: Of 135 patients (injury severity score = 29.1 +/- 12.4) included in the study, 83 received mechanical ventilation. The time needed for diagnosis of pneumothorax was significantly shorter with US compared to CXR (2.3 +/- 2.9 versus 19.9 +/- 10.3 minutes, p < 0.001). CT and chest drain confirmed 29 cases of pneumothorax (21.5%). The diagnostic sensitivity, specificity, positive and negative predictive values and accuracy for US and radiography were 86.2% versus 27.6% (p < 0.001), 97.2% versus 100% (not significant), 89.3% versus 100% (not significant), 96.3% versus 83.5% (p = 0.002), and 94.8% versus 84.4% (p = 0.005), respectively. US was highly consistent with CT in determining the size of pneumothorax (Kappa = 0.669, p < 0.001). CONCLUSION: Bedside clinician-performed US provides a reliable tool and has the advantages of being simple and rapid and having higher sensitivity and accuracy compared to chest radiography for the detection of pneumothorax in patients with multiple trauma.

Adult↗
PubMed1994

Extracorporeal life support for respiratory failure after multiple trauma.

Respiratory failure may complicate multiple trauma and can add significant morbidity, mortality, and cost to the care of such patients. We used extracorporeal life support (ECLS) to treat 24 patients with multiple trauma who, after their injury, developed respiratory failure refractory to conventional ventilatory management. Injuries in these patients were the result of motor vehicle crashes (16 patients), pedestrian versus car collisions (3 patients), gunshots (2 patients), stabs (1 patient), and a recreational vehicle crash (1 patient). Patients were placed on venovenous or venoarterial ECLS, using continuous systemic anticoagulation with heparin, and percutaneous cannulation where possible. Average time on ECLS was 287 +/- 43 hours (12 +/- 1.8 days). The major complication was bleeding, which occurred in 75% of patients. Fifteen patients survived to be discharged from the hospital (63% survival). Early intervention (mechanical ventilation < or = 5 days prior to ECLS) was associated with good outcome. Despite risks of anticoagulation in patients with multiple injuries, ECLS can be life-saving in cases of respiratory failure refractory to conventional mechanical ventilation.

Adult↗
PubMed1992

Platelet activation during acute phase after multiple trauma.

The acute phase after multiple trauma is associated with both thrombotic phenomena and a bleeding diathesis. To evaluate the activation of platelets, beta-thromboglobulin (BTG) in plasma and serum and thromboxane B2 (TxB2) in serum were measured in 14 patients with multiple trauma. BTG in plasma was significantly increased on days 1, 2 and 10 to 14 after the trauma. The highest median value 90 micrograms/l was measured on day 1. BTG in serum was significantly reduced 1 to 7 days after the trauma (median levels 4450-9100 micrograms/l). TxB2 was significantly reduced (median levels 18-97 ng/l) on days 1 to 14. The increased plasma levels of BTG is due to the posttraumatic activation of platelets in vivo. The reduced levels of serum BTG and TxB2 reflect the deficient functional capacity of circulating platelets to respond to extreme stress. Therefore, platelet count alone may correlate poorly with the haemostatic potential and may underestimate the need of platelet transfusions.

Acute-Phase Reaction↗
PubMed1998

[Radiologic emergency management in multiple trauma cases].

The management of multiple trauma patients has improved recently. Surgeons' education, preclinical rescue structures, initial clinical survey and therapeutic strategies, as well as diagnostic imaging, have progressed. Plain film imaging is increasingly being abandoned in favor of CT. Fast imaging techniques (spiral CT) have led to the inclusion of CT in the primary survey. To minimize the risk to the patient during prolonged diagnostic time, algorithms have to be defined concerning structures, emergency room equipment and quality. Basics, state of the art and suggestions concerning management of multiple trauma patients are presented and discussed from the radiologist's point of view.

Emergencies↗
PubMed2003

Serum S 100 B: a marker of brain damage in traumatic brain injury with and without multiple trauma.

This prospective clinical study was conducted to determine whether S 100 B is a reliable serum marker for traumatic brain injury (TBI) with and without multiple trauma. Fifty-five trauma patients (Injury Severity Score [ISS] > or = 24 and Glasgow Coma Score [GCS] < or = 8) were classified by radiography, computer tomography, ultrasound, and neurology as TBI without multiple trauma (n = 23), TBI with multiple trauma (n = 23), or multiple trauma without TBI (n = 9). S 100 B was measured initially after trauma and daily for a maximum of 21 days. Both survivors and nonsurvivors had markedly increased S 100 B initially. All survivors returned to normal or moderately increased S 100 B levels within the first 48 h after trauma. In contrast, all nonsurvivors of isolated TBI had S 100 B values that either increased consistently or dropped and then increased again 48 h after the initial increase after trauma. There was no relationship between localization, extent, or severity of TBI and S 100 B. According to receiver operating characteristic curve analysis and calculation of the area under the curve (AUC), S 100 B is equally accurate for mortality prediction at 24, 48, and 72 h after trauma and is most accurate >84 h after trauma. Sensitivity/specificity for mortality prediction are more accurate in TBI without multiple trauma (AUC 0.802-0.971) than in TBI with multiple trauma (AUC 0.693-0.783). Thus, though S 100 B may be a reliable marker of brain damage in TBI without multiple trauma 24 h after trauma and thereafter, it appears to be less reliable in TBI with multiple trauma.

Adult↗