Factors influencing the length of emergency room stay and hospital stay in nonfatal bicycle accidents: A retrospective analysis

Purpose: Lengthy hospitalization places a burden on patients and healthcare resources. However, the factors affecting the length of hospital stay (LHoS) and length of emergency room stay (LERS) in non-fatal bicycle accidents are currently unclear. We investigated these factors to inform efforts to minimize hospitalization. Methods: We performed a retrospective analysis of data from non-fatal injured bicyclists admitted to the Emergency and Critical Care Center at Kyoto Medical Center between January 2012 and December 2016. We measured LHoS, LERS, mechanism of injury, head injury prevalence, polytrauma, operations performed, injury severity score (ISS), abbreviated injury scale (AIS) score, maximum AIS score, and trauma and injury severity score probability of survival. We conducted multiple regression analysis to determine predictors of LHoS and LERS. Results: Within the study period, 82 victims met the inclusion and exclusion criteria and were included. Mean age was (46.0 ± 24.7) years. Overall mean LHoS was (16.8 ± 25.2) days, mean LERS was (10.6 ± 14.7) days, median ISS was 9 (interquartile range (IQR): 3-16), median maximum AIS was 3 (IQR: 1-4), and median trauma and injury severity score probability of survival was 98.0% (IQR: 95.5%-99.6%). Age, maximum AIS, ISS, and prevalence of surgery were significantly greater in long LHoS and LERS group compared with short LHoS and LERS group (p < 0.05). Performance of surgery independently explained LHoS (p = 0.0003) and ISS independently explained LERS (p = 0.0009). Conclusion: Surgery was associated with long hospital stays and ISS was associated with long emergency room stays. To improve the quality life of the bicyclists, preventive measures for reducing injury severity or avoiding injuries needing operation are required.     

Rekombinanter Faktor VIIa in der Hämorrhagiebehandlung des Schwerstverletzten

Background

The aim of the study was to assess whether the use of recombinant factor VIIa (rFVIIa) in trauma patients was associated with improved outcome.

Patients and methods

Patients documented in the TraumaRegistry of the German Society for Trauma Surgery (primary admissions; Injury Severity Score, ISS≥?9) who received rFVIIa in the first 6 hours upon admission (rFVIIa?+) were matched with patients that had not received rFVIIa (rFVIIa?).

Results

The matching comparison yielded two identical groups with 100 patients each (rFVIIa+: average age 40.6±18.5 years, ISS 47.1±16.7 versus rFVIIa─: 40.1±19.1 years, ISS 45.1±15.6). Patients were administered an average of 18.3±13.1 (rFVIIa+) versus 19.5±14.0 (rFVIIa─) red blood cell units (p=0.55) and 15.2±13.7 (rFVIIa+) versus 15.0±13.1 (rFVIIa─) units of fresh frozen plasma (p=0.92). Thromboembolisms occurred in 5% (rFVIIa+) versus 2% (rFVIIa─) (p=0.44), multiple organ failure (MOF) in 82% versus 62% (p=0.003) and hospital mortality was 48% versus 43% (p=0.57), respectively.

Conclusion

The early use of rFVIIa in severely injured patients was not associated with either lower transfusion requirements or with mortality reduction but with increased MOF.     

Hyperglycemia has a stronger relation with outcome in trauma patients than in other critically ill patients

BACKGROUND: Acute hyperglycemia is associated with adverse outcome in critically ill patients. Glucose control with insulin improves outcome in surgical intensive care unit (SICU) patients, but the effect in trauma patients is unknown. We investigated hyperglycemia and outcome in SICU patients with and without trauma. METHODS: A 12-year retrospective study was performed at a 12-bed SICU. We collected the reason for admission, Injury Severity Scores (ISS), and 30-day mortality rates. Glucose measurements were used to calculate the hyperglycemic index (HGI), a measure indicative of overall hyperglycemia during the entire SICU stay. RESULTS: In all, 5234 nontrauma and 865 trauma patients were studied. Trauma patients were younger, more frequently male, and had both lower median admission glucose (123 versus 133 mg/dL) and HGI levels (8.9 vs. 18.4 mg/dL) than nontrauma patients (p < 0.001). Mortality was 12% in both groups.Area under the receiver-operator characteristic for HGI and mortality was 0.76 for trauma patients and 0.58 for nontrauma patients (p < 0.001). In multivariate analysis, HGI correlated better with mortality in trauma patients than in nontrauma patients (p < 0.001). Head-injury and nonhead-injury trauma patients showed similar glucose levels and relation between glucose and mortality. CONCLUSIONS: The relation of hyperglycemia and mortality is more pronounced in trauma patients than in SICU patients admitted for other reasons. The different behavior of hyperglycemia in these patients underscores the need for evaluation of intensive insulin therapy in these patients.     

Outcome and management of blunt liver injuries in multiple trauma patients

Background: In Germany, abdominal trauma in multiple- trauma patients can be observed in about 25–35% of all cases. Due to major bleeding complications, the initial treatment of blunt abdominal trauma in multiple-trauma patients has high priority. The aim of this study was to discuss management, treatment and outcome of blunt liver injury in multiple-trauma patients treated in our department. Methods: The clinical records of 1192 multiple-trauma patients [injury severity score (ISS) 3–18] treated at the Surgical Department of the University Clinic of Essen from January 1975 to February 1998 were reviewed. Seventy-five patients with an ISS above 18 operated on due to a blunt liver injury could be included. The mean age was 29.82±1.80 years (60 males and 15 females). The degree of injury in this group was high (ISS 37.12±1.06). Results: Twenty-three of the 75 (30.6%) patients died during their hospital stay. Deceased patients were older (27±2 years versus 37±4 years; P<0.01) and had a higher ISS (ISS=34.5±1 versus 43.2±2; P<0.01). In nine cases, death was strongly related to liver injury. Operational blood loss was higher in the group of multiply injured patients with liver injury and in those patients who did not survive (P<0.05). An increased mortality could be seen in this selected patient group when compared with our large collective of multiply injured patients. The age of the patients, the ISS and operative blood loss were the significant factors that influenced the operative mortality after blunt hepatic injuries in our study. Received: 28 October 1998 Accepted: 22 April 1999     

Effect of early enteral nutrition on outcomes of trauma patients requiring intensive care

Purpose: To investigate the effect of early enteral nutrition on outcomes of trauma patients in the intensive care unit (ICU). Methods: Clinical data of trauma patients in the ICU of Daping Hospital, China from January 2012 to December 2017 was retrospectively analyzed, including patient age, gender, injury mechanism, injury severity score (ISS), nutritional treatment, postoperative complications (wound infection, abdominal abscess, anastomotic rupture, pneumonia), mortality, and adverse events (nausea, vomiting, abdominal distention). Only adult trauma patients who developed bloodstream infection after surgery for damage control were included. Patients were divided into early enteral nutrition group (<48 h) and delayed enteral nutrition group (control group, >48 h). Data of all trauma patients were collected by the same investigator. Data were expressed as frequency (percentage), mean ± standard deviation (normal distribution), or median (Q1, Q3) (non-normal distribution) and analyzed by Chi-square test, Student''s t-test, or rank-sum test accordingly. Multiple logistic regression analysis was further adopted to investigate the significant variables with enteral nutrition. Results: Altogether 876 patients were assessed and 110 were eligible for this study, including 93 males and 17 females, with the mean age of (50.0 ± 15.4) years. Traffic accidents (46 cases, 41.8%) and fall from height (31 cases, 28.2%) were the dominant injury mechanism. There were 68 cases in the early enteral nutrition group and 42 cases in the control group. Comparison of general variables between early enteral nutrition group and control group revealed significant difference regarding surgeries of enterectomy (1.5%vs. 19.0%, p = 0.01), ileum/transverse colon/sigmoid colostomy (4.4% vs. 16.3%, p = 0.01) and operation time (h) (3.2 (1.9, 6.1) vs. 4.2 (1.8, 8.8), p = 0.02). Other variables like ISS (p = 0.31), acute physiology and chronic health evaluation20 (p = 0.79), etc. had no obvious difference. Chi-square test showed a much better result in early enteral nutrition group than in control group regarding morality (0 vs. 11.9%, p = 0.03), length of hospital stay (days) (76.8 ± 41.4 vs. 81.4 ± 44.7, p = 0.01) and wound infection (10.3% vs. 26.2%, p = 0.03). Logistic regression analysis showed that the incidence of wound infection was related to the duration required to achieve the enteral nutrition standard (OR = 1.095, p = 0.002). Seventy-six patients (69.1%) achieved the nutritional goal within a week and 105 patients (95.5%) in the end. Trauma patients unable to reach the enteral nutrition target within one week were often combined with abdominal infection, peritonitis, bowel resection, intestinal necrosis, intestinal fistula, or septic shock. Conclusion: Early enteral nutrition for trauma patients in the ICU is correlated with less wound infection, lower mortality, and shorter hospital stay.     

Injuries due to falls from a considerable height. A comparative analysis from injuries and clinical course after international or accidental fall

Summary The aim of this study was to compare the outcome and clinical course of multiple trauma patients with accidental or intentional (suicide related) fall from heights > 4 m. 211 patients with an injury severity score (ISS) > 17 were assigned to the following groups: I: intentional fall, n = 94; A: accidental fall, n = 117) and ISS (I: 28 ± 1; A: 30 ± 1), ventilation time (I: 16 ± 2; A: 15 ± 1) were not different. Significant differences were found in sex (m/f: I: 56/44; A: 73/27 %), fractures of lumbarspine (I: 34; A: 15 %), pelvis (I: 51; A: 38 %), lower leg (I: 47; A: 20 %), pilon (I: 15; A: 5 %), and os calcis (I: 17; A: 9 %). Liver lacerations occured more often after intentional fall (I: 16; A: 6 %). Single or multiple organ failure (MOF) was diagnosed significantly more often in group A (I: 1; A: 8 %). Main cause of death in both groups was single or multiple organ failure (MOF: I: 47; A: 69 %) or related to brain-injuries (I: 35; A: 19 %). Prognosis and rehabilitation of multiple trauma patients after intentional fall is related to brain-injuries, spine-fractures and the functional outcome of the injured lower leg. Prognosis of patients after accidental fall is related to the development of MOF during the ICU-course.      

Injuries due to falls from a considerable height. A comparative analysis from injuries and clinical course after international or accidental fall Eine vergleichende Analyse von Verletzungsmuster und Verlauf nach suizidalem und akzidentellem Absturztrauma

The aim of this study was to compare the outcome and clinical course of multiple trauma patients with accidental or intentional (suicide related) fall from heights > 4 m. 211 patients with an injury severity score (ISS) > 17 were assigned to the following groups: I: intentional fall, n = 94; A: accidental fall, n = 117) and ISS (I: 28 ± 1; A: 30 ± 1), ventilation time (I: 16 ± 2; A: 15 ± 1) were not different. Significant differences were found in sex (m/f: I: 56/44; A: 73/27 %), fractures of lumbarspine (I: 34; A: 15 %), pelvis (I: 51; A: 38 %), lower leg (I: 47; A: 20 %), pilon (I: 15; A: 5 %), and os calcis (I: 17; A: 9 %). Liver lacerations occured more often after intentional fall (I: 16; A: 6 %). Single or multiple organ failure (MOF) was diagnosed significantly more often in group A (I: 1; A: 8 %). Main cause of death in both groups was single or multiple organ failure (MOF: I: 47; A: 69 %) or related to brain-injuries (I: 35; A: 19 %). Prognosis and rehabilitation of multiple trauma patients after intentional fall is related to brain-injuries, spine-fractures and the functional outcome of the injured lower leg. Prognosis of patients after accidental fall is related to the development of MOF during the ICU-course.     

Abbruch der Schockraumdiagnostik und Notfalloperation beim Polytrauma – Inzidenz und klinische Relevanz

Background

Life-threatening situations after multiple trauma which require interruption of the diagnostic algorithm and immediate surgical treatment after admission are a challenge for the multidisciplinary trauma team. The purpose of this study was to evaluate the incidence, causes, implications and relevance of life-threatening situations for major trauma patients after admission to trauma centers.

Patient and methods

Data of 12,971 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) >16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to patients where the diagnostic algorithm in the resuscitation room was interrupted to perform emergency surgery (group Notop, n=713, 5.5%) and patients who received early surgical care after completed diagnostics (group Frühop, n=5,515, 42.5%). Comparative parameters were the pattern and severity of injury, physiological state and clinical outcome.

Results

Patients receiving emergency surgery showed an average ISS score of 39±15 points, whereas patients receiving early surgery showed an average ISS of 31±12 points. On admission patients in the emergency surgery group (44%) suffered from hemodynamic shock considerably more often than patients in the early surgery care group (15%, p <0.001). This was indicated by the significant differences in systolic blood pressure on admission, amount of preclinical substituted volume, base excess on admission and substituted erythrocyte concentrates in early clinical course. Mortality was 46% in the emergency surgery group and 13% in the early surgical care group (p <0.001). Severe injuries (AIS ≥4) of the thorax, abdomen and extremities (including the pelvis) were encountered considerably more often in the emergency surgery group. There was no statistical difference in occurrence of severe head injuries between the groups. Emergency surgery consisted of 50.5% laparatomy, 19.8% craniotomy, 10.0% thoracotomy and 9.3% pelvic surgery.

Conclusion

Life-threatening situations after major trauma which require immediate surgical intervention in the resuscitation room rarely occur in Germany. Nevertheless, they are associated with a high mortality and prolonged and complex clinical course if primarily survived. Indications and decision-making processes of these challenging situations have to be practiced with standardized algorithms and should be considered for the future education of orthopedic surgeons in Germany.     

In-house trauma surgeons do not decrease mortality in a level I trauma center

BACKGROUND: The value of an in-house trauma surgeon is debated. Previous studies focus on comparing in-house and on-call surgeons at different institutions or different periods in time. The purpose of this study was to simultaneously evaluate in-house and on-call trauma surgeons in a single Level I trauma center and to determine the impact of in-house trauma surgeons on the mortality of severely injured patients. METHODS: All records were reviewed for patients classified as major resuscitations from July 1997 through November 1999. Multiple logistic regression was performed to determine predictors of mortality on the basis of trauma surgeon status (in-house vs. on-call) and response time, while controlling for Injury Severity Score (ISS) and Revised Trauma Score. RESULTS: Of the 4,278 admissions, 537 were trauma codes. Mean ISS was 20.16 +/- 11.59. There was no difference between groups admitted by in-house surgeons versus on-call surgeons with respect to ISS or Revised Trauma Score. Mortality for the group was 24.8% (133 of 537); no statistical difference existed between observed and expected mortality by TRISS. The average response time was 3.96 minutes for the in-house group and 14.70 minutes for the on-call group (p < 0.001). Neither the call status nor the response time of the trauma surgeon significantly decreased emergency department or hospital mortality. There was a trend for improved outcome in those patients cared for by an in-house surgeon who were upgraded to a code, transferred into the institution, admitted during the night, or neurologically impaired. This trend did not reach statistical significance. CONCLUSION: When the trauma surgeon was rapidly available (< 15 minutes), there was no difference in emergency department or hospital mortality between in-house and on-call trauma surgeons. Selected subgroups of severely injured patients may benefit from an in-house trauma surgeon. If trauma surgeons are not readily available in an institution, an in-house call policy may be necessary for the prompt resuscitation of critically ill patients.     

Influence of primary plate-osteosynthesis of femur fractures on complications in multiple trauma patients with or without thoracic injuries

Summary Primary intramedullary nailing of femoral fractures is well known to increase the risk of pulmonary complications, especially in multiple-trauma patients with severe thoracic injuries. Aim of this study was to investigate the influence of primary plate ostesynthesis of femur fractures on maior complications after trauma. This retrospective study based on the records of 325 multiple trauma patients (Injury severity score ISS > 18, no letal brain injury, age 16–65). According to the abbreviated injury scale of the Thorax (AIS T) patients were divided in groups without (AIS T < 3, “N”) or with relevant thoracic injury (AIS T > = 3, “T”). Both groups were additionally divided in subgroups without severe trauma to the extremities (AIS E< 3, “0”) or primary plate-osteosynthesis of femur fractures (< 24 h, “I”). 4 groups were performed: N0 (n = 39, ISS 25 ± 1, pneumonia 10 %, ARDS 5 %, lethality 10 %); NI (n = 55, ISS 27 ± 1, pneumonia 4 %, ARDS 5 %, lethality 4 %); T0 (n = 137, ISS 28 ± 1, pneumonia 21 %, ARDS 15 %, lethality 16 %); TI (n = 94, ISS 31 ± 1, pneumonia 21 %, ARDS 17 %, lethality 15 %). Primary plate-osteosynthesis of femur fractures did not increase lethality or incidence of pulmonary complications in patients with or without severe thoracic injuries. Also complication rate after primary plate-osteosynthesis was less compared to published results after intramedullary nailing. For this, primary plate-osteosynthesis is recommendable in case of multiple trauma with thoracic injuries.      

Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting

OBJECTIVE: To determine the characteristics and outcome of transferred trauma patients in a rural setting. METHODS: We conducted a case-control study of all trauma admissions to a rural Level I trauma center to examine a 3.5-year (1993-1996) comparison of trauma patients admitted directly with those transferred (RTTP) after being initially stabilized at an outlying hospital. We used prehospital times, Injury Severity Score (ISS), LD50ISS (the ISS at which 50% of patients died), Revised Trauma Score, probability of survival, Acute Physiology and Chronic Health Evaluation II, and observed survival as main outcome measures. RESULTS: RTTPs (39.4%) spent an average of 182+/-139 minutes at the outlying hospital and 72+/-42 minutes in transport to the trauma center. Proportionately more head/neck and patients with multiple injuries composed the RTTP group. The RTTP were more severely injured (ISS 11.1+/-8.5; Acute Physiology and Chronic Health Evaluation II 16.2+/-5.8; Revised Trauma Score 7.44+/-1.1) than the trauma patients admitted directly (ISS 7.9+/-5.3; Acute Physiology and Chronic Health Evaluation II 13.1+/-6.3; Revised Trauma Score 7.8+/-0.4; p < 0.05). However, both groups had the same LD50ISS (ISS = 35). When logistic regression was applied with death as the dependent variable, both ISS and age contributed significantly (p = 0.0001) but transfer status did not (p = 0.473). CONCLUSION: Rural trauma centers admit a high percentage of RTTP. These RTTP have a higher injury severity and acuity than their trauma patients admitted directly counterparts. Trauma care in rural areas that involves initial stabilization at outlying hospitals does not adversely affect mortality.     

The emergency department length of stay: Is the time running out?

Purpose: To examine the relationships between emergency department length of stay (EDLOS) with hospital length of stay (HLOS) and clinical outcome in hemodynamically stable trauma patients. Methods: Prospective data collected for 2 years from consecutive trauma patients admitted to the trauma resuscitation bay. Only stable blunt trauma patients with appropriate trauma triage criteria requiring trauma team activation were included in the study. EDLOS was determined short if patient spent less than 2 h in the emergency department (ER) and long for more than 2 h. Results: A total of 248 patients were enrolled in the study. The mean total EDLOS was 125 min (range 78-180). Injury severity score (ISS) were significantly higher in the long EDLOS group (17 ± 13 versus 11 ± 9, p < 0.001). However, when leveled according to ISS, there were no differences in mean in diagnostic workup, admission rate to intensive care unit (ICU) or HLOS between the short and long EDLOS groups. Conclusion: EDLOS is not a significant parameter for HLOS in stable trauma patients.     

Hypothermie bei Traumapatienten

Coincidental hypothermia after trauma can aggravate the severity of injury and it therefore makes sense to monitor the body temperature in the preclinical setting. In a prospective study, incidence and degree of severity of hypothermia were analysed as a function of injury pattern and preclinical care. A main factor of hypothermia was severity of injury measured by the injury severity score (ISS 24.0±15.5 versus 8.3±7.8) and the revised trauma score (RTS 5.6±1.8 versus 7.3±1.1). Of the patients with multiple trauma, 88.2% were hypothermic when administered to hospital, but no reason was found concerning the rescue methods (e.g. rescue time, whole duration, weather). An increase in the rate of hypothermia was seen only after long lasting incarceration. A multivariate data analysis showed, that in addition to ISS and RTS patient age (p=0.014) was primarily responsible for hypothermia after trauma, whereas no dependency was demonstrated for other factors. Thus, parts of this analysis are in contrast with other studies. Overall approximately 50% of trauma patients in the emergency unit suffer from hypothermia, but at this time point changes in physiological control mechanisms are not yet detectable. Nevertheless prevention of hypothermia is very important in the preclinical setting.     

Air transportation over-utilization in pediatric trauma patients

BackgroundAir transportation can be a life-saving transfer modality for trauma patients. However, it is also costly and carries risk for air-crews and patients. We sought to examine the incidence of air transportation among pediatric trauma patients as well as the rate of over-triage in utilizing this intervention.MethodsWe conducted a single-institution retrospective review of all pediatric trauma patients who utilized air transportation, either from scene to hospital or hospital to hospital Emergency Department (ED) transfers, between 2013 and 2018.ResultsThere were 348 pediatric trauma patients who utilized air transport. More than half of all patients (n = 186, 55.9%) were discharged from the hospital within 48 h, 121 (36.3%) were discharged within 24 h, and 34 (10.2%) were discharged home from the ED. The mean ISS was 11.2 ± 0.5 while only 31% had an ISS ≥ 15. There were 97 patients (27.9%) with elevated age adjusted shock index, and 101 patients (29.0%) who required time sensitive interventions.More than half of patients (59.3%) were initially taken to an outside hospital (OSH) and were then transferred to our facility by air while 40.4% were transported directly from scene to our institution by air. Patients who were transferred from an OSH were younger (6.8 ± 0.4 vs 11.2 ± 0.4, p < 0.01) and had a higher incidence of an elevated age-adjusted shock index (32.4% vs 19.1%, p = 0.006) as well as mortality (6.3% vs 1.4%, p = 0.03). However, ultimately there were no differences in ISS, rates of operative intervention, PICU utilization, or time sensitive intervention. Both groups had similarly high rates of discharge within 48 h, 24 h, and from the ED.ConclusionsAir transportation among pediatric trauma patients from scene to hospital and hospital to hospital is over-utilized based on multiple metrics including low rates of ISS ≥ 15, elevated age-adjusted shock indexes, low rates of time sensitive intervention, as well as high rates of discharge within 24 and 48 h.Level of EvidenceIIIType of StudyClinical Research-retrospective review.     

Variations of p38 MAPK and sICAM-1 with therapeutic effect of different resuscitation fluids on severe traumatic patients

OBJECTIVE: To investigate the dynamic variation and action mechanism of sICAM-1 and p38 mitogen-activated protein kinases (MAPK) signal transduction in human severe trauma and resuscitation, as well as the effect of lactated Ringer's solution(LR), 7.5% sodium chloride solution(HS) and 20% albumin injection(ALB) on the incidence and mortality of multiple organ dysfunction syndrome (MODS). METHODS: Seventy-two severe trauma patients (ISS score 16-43) were divided into ISS < or = 25 and ISS > 25 groups (each group was subdivided into LR, HS and ALB groups). ELISA was used to measure the concentration of sICAM-1. Western blot was used to measure the expression of p38 MAPK. RESULTS: Compared with LR group, the transfusion volume needed for maintaining systolic blood pressure > or = 90 mm Hg was significantly decreased in HS and ALB groups (P < 0.05). Compared with the control group, the concentration of blood sICAM-1 and the expression of p38 MAPK was elevated from 4 to 48 hours after trauma in all experimental groups (P < 0.05-0.01). At 4, 12, and 24 hours, there was significant correlation between the expression of p38 MAPK and sICAM-1 (P < 0.01). Compared with LR group, sICAM-1 and p38 MAPK in HS and ALB groups were decreased (P < 0.05). sICAM-1 and p38 MAPK were significantly higher in the group of ISS > 25 than that of ISS < or = 25 (P < 0.05). MODS incidence and mortality were significantly higher in the group of ISS > 25 than that of ISS < or = 25 (P < 0.05). MODS incidence and mortality were lower in HS and ALB groups than LR group (P < 0.05). CONCLUSIONS: The up-regulation of polymorphonuclear neutrophil-endotheliocytes (PMN-EC) adhesion may be due to the increased sICAM-1 expression during severe trauma. The up-regulation of sICAM-1 expression is correlated with the activation of p38 MAPK. During severe trauma, the levels of sICAM-1 and p38 MAPK, as well as the incidence and mortality of MODS are lower when HS and ALB are used than single lactated LR solution is used.     

The course of extravascular lung water in severely injured patients in intensive care with and without thoracic trauma

In patients with multiple injuries, the development of permeability edema can be assumed. However, no uniform shape of this fluid accumulation can be found even in the presence of severe injuries. Based on the first clinical observations, our aim was to search for correlations between the development of extravascular lung water (EVLW) and the individual injury pattern in severely traumatized ICU patients. PATIENTS and METHODS. Our investigations were performed in 48 artificially ventilated ICU patients. According to the prevailing injury pattern patients were divided into three groups: group A: 18 patients (mean age: 32 years, mean Injury Severity Score (ISS) = 29) with isolated thoracic trauma; group B: 10 patients (mean age: 27 years, mean ISS = 42) with severe multiple trauma but without any thoracic injury; group C: 20 patients (mean age: 33 years, mean ISS = 43) with severe multiple trauma and concomitant thoracic trauma. In all patients (group A, B, C), EVLW was determined by means of a double indicator method on a daily basis from the patient's admission to the ICU (day of trauma) until day 10. Additionally, the hemodynamic parameters (heart rate, mean arterial pressure, mean pulmonary arterial pressure, pulmonary capillary wedge pressure and cardiac index) were determined at the same time. RESULTS. As shown in Fig 1, EVLW was slightly elevated on day 1. However, on day 2 EVLW decreased within normal values and remained in that range until the end of the observation period. On day 3 a slight and fleeting increase of EVLW, but within normal range, can be seen. In group B (Fig.2), EVLW can be observed within normal range within a period of 4 days. Starting from day 5 until day 7 a marked increase (p greater than 0.01) in EVLW can be seen. From that maximum point EVLW development reverses slightly until day 10--however, without returning to the normal range. In group C, a marked biphasic pattern can be seen due to EVLW maximum values on post-traumatic days 3 and 7. However, in this group the EVLW was in the pathological range during the whole observation period. No statistically significant differences could be seen, when looking at hemodynamic variables. CONCLUSION. Isolated thoracic trauma will not lead to a marked pathological elevation of EVLW within the lungs. Moreover, EVLW decreases rapidly within a short time period. Based on our results, it seems that severe extrathoracic injuries will intensify microvascular injury in the initial period, as shown in our patients in group C. Increase of EVLW at a later time (day 7), as observed in groups B and C, is possibly the expression of a mediator and activator-induced "septiformal" injury of the microvascular endothelium. This may be caused by the underlying massive peripheral soft-tissue trauma. Specific elevations of EVLW subsequent to the individual injury pattern can indicate that that process has begun and is responsible for the origin of the microvascular injuries.     

Prognoseabschätzung des Schwerverletzten – Eine Analyse von 2069 Patienten des Traumaregisters der DGU

On hospital admission numerous variables are documented from multiple trauma patients. The value of these variables to predict outcome are discussed controversially. The aim was the ability to initially determine the probability of death of multiple trauma patients. Thus, a multivariate probability model was developed based on data obtained from the trauma registry of the Deutsche Gesellschaft für Unfallchirurgie (DGU). Patients and methods. On hospital admission the DGU trauma registry collects more than 30 variables prospectively. In the first step of analysis those variables were selected, that were assumed to be clinical predictors for outcome from literature. In a second step a univariate analysis of these variables was performed. For all primary variables with univariate significance in outcome prediction a multivariate logistic regression was performed in the third step and a multivariate prognostic model was developed. Results. 2069 patients from 20 hospitals were prospectively included in the trauma registry from 01.01.1993–31.12.1997 (age 39±19 years; 70.0% males; ISS 22±13; 18.6% lethality). From more than 30 initially documented variables, the age, the GCS, the ISS, the base excess (BE) and the prothrombin time were the most important prognostic factors to predict the probability of death (P_(death)). The following prognostic model was developed: P_(death)=1/1+e^{{?[k+β1(age)+β2(GCS)+β3(ISS)+β4(BE)+β5(prothrombin time)]}} where: k=minus;0.1551, β1=0.0438 with p<0.0001, β2=?0.2067 with p<0.0001, β3=0.0252 with p=0.0071, β4=?0.0840 with p<0.0001 and β5=?0.0359 with p<0.0001. Each of the five variables contributed significantly to the multifactorial model. Conclusions. These data show that the age, GCS, ISS, base excess and prothrombin time are potentially important predictors to initially identify multiple trauma patients with a high risk of lethality. With the base excess and prothrombin time value, as only variables of this multifactorial model that can be therapeutically influenced, it might be possible to better guide early and aggressive therapy.     

Patient volume per surgeon does not predict survival in adult level I trauma centers

BACKGROUND: The 1999 American College of Surgeons resources for optimal care document added the requirement that Level I trauma centers admit over 240 patients with Injury Severity Score (ISS) > 15 per year or that trauma surgeons care for at least 35 patients per year. The purpose of this study was to test the hypothesis that high volume of patients with ISS > 15 per individual trauma surgeon is associated with improved outcome. METHODS: Data were obtained from the trauma registry of the five American College of Surgeons-verified adult Level I trauma centers in our mature trauma system between January 1, 1998, and March 31, 1999. Data abstracted included age, sex, Glasgow Coma Scale (GCS) score, intensive care unit length of stay, hospital length of stay, probability of survival (Ps), mechanism of injury, number of patients per each trauma surgeon and institution, and mortality. Multiple logistic regression was performed to select independent variables for modeling of survival. RESULTS: From the five Level I centers there were 11,932 trauma patients in this time interval; of these, 1,754 patients (14.7%) with ISS > 15 were identified and used for analysis. Patients with ISS > 15 varied from 173 to 625 per institution; trauma surgeons varied from 8 to 25 per institution; per-surgeon patient volume varied from 0.8 to 96 per year. Logistic regression analysis revealed that the best independent predictors of survival were Ps, GCS score, age, mechanism of injury, and institutional volume (p < 0.01). Age and institutional volume correlated negatively with survival. Analysis of per-surgeon patient caseload added no additional predictive value (p = 0.44). CONCLUSION: The significant independent predictors of survival in severely injured trauma patients are Ps, GCS score, age, mechanism of injury, and institutional volume. We found no statistically meaningful contribution to the prediction of survival on the basis of per-surgeon patient volume. Since this volume criterion for surgeon enpanelment and trauma center designation would not be expected to improve outcome, such a requirement should be justified by other measures or abandoned.     

Kostenanalyse von Schockraumpatienten im DRG-System

Background

Since the implementation of the diagnosis-related system there has been a continuous lack of finances in the treatment of multiple injured patients. The current investigation summarizes consecutive patients from a level I trauma centre and tests the hypothesis that an injury severity score (ISS) based reimbursement would be an improvement in the cost-effectiveness of this patient population.

Methods

The study is based on multiple injured patients admitted to the emergency department in 2009. The ISS, intensive care unit (ICU) stay and cost data were recorded for every patient and two subgroups were formed: group I ISS?Results A total of 442 patients with an average age of 40.5?±?9.1 years (ISS 12) were included. The average amount of coverage during an average length of stay of 13.15?±?6.3 was ?2,752 € per patient. Patients in group I (n?=?296, ISS 6.3) showed a value of ?1,163 € with an average length of stay of 8?±?4.6 days. In group II (n?=?146, ISS 23.6) the average amount of coverage was ?5,973 € during an average hospital stay of 23?±?8.7 days.

Conclusion

Improvements have been made with the recent adjustment of the reimbursement within the last year. Nevertheless, several factors identified in this study require additional adjustment: the ISS, the requirement of blood transfusion and the presence of additional chest trauma should be weighted in the calculation of reimbursement.     

Elderly trauma patients with rib fractures are at greater risk of death and pneumonia

BACKGROUND: The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality. METHODS: Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry. RESULTS: Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old. CONCLUSION: Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.