PURPOSE: The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients. METHODS: In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room. RESULTS: We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention. CONCLUSION Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.
Accidents ; classification ; Adult ; Age Factors ; Blood Transfusion ; Data Analysis ; Emergency Medical Services ; Female ; Fluid Therapy ; Germany ; epidemiology ; Hemoglobins ; Humans ; International Normalized Ratio ; Intubation ; statistics & numerical data ; Male ; Matched-Pair Analysis ; Multiple Organ Failure ; Registries ; Sex Factors ; Survival Rate ; Trauma Severity Indices ; Wounds and Injuries ; mortality

OBJECTIVE: A massive transfusion (MT) of 10 or more units of packed red blood cells (PRCs) focuses on the summation volumes over 24 hours. This traditional concept promotes survivor bias and fails to identify the “massively” transfused patient. The critical administration threshold (≥3 units of PRCs per hour, CAT+) has been proposed as a new definition of MT that includes the volume and rate of blood transfusion. This study examined the CAT in predicting mortality in adult patients with severe trauma, compared to MT. METHODS: Retrospective data of adult major trauma patients (age≥15 years, Injury Severity Score [ISS]≥16) from a regional trauma center collected between May 2016 and June 2017 were used to identify the factors associated with trauma-related death. Univariate associations were calculated, and multiple logistic regression analysis was performed to determine the parameters associated with in-hospital mortality. RESULTS: A total of 540 patients were analyzed. The median ISS was 22, and the hospital mortality rate was 30.9% (n=92). Forty-two (7.8%) and 23 (4.3%) patients were CAT+ and traditional MT+, respectively. Severe brain injury, CAT+, acidosis, and elderly age were significant variables in multivariate analysis. CAT+ was associated with a fourfold increased risk of death (odds ratio, 4.427; 95% confidence interval, 1.040–18.849), but MT+ was not associated (odds, 1.837; 95% confidence interval, 0.376–8.979). CONCLUSION: The new concept of CAT for transfusion was a more useful validation concept of mortality in adult severe trauma patients on admission than traditional MT. Encompassing both the rate and volume of transfusion, CAT is a more sensitive tool than common MT definitions.
Acidosis ; Adult* ; Aged ; Animals ; Bias (Epidemiology) ; Blood Transfusion ; Brain Injuries ; Cats ; Erythrocytes ; Hospital Mortality ; Humans ; Injury Severity Score ; Logistic Models ; Mortality* ; Multiple Trauma ; Multivariate Analysis ; Retrospective Studies ; Survivors ; Trauma Centers

OBJECTIVE: The purpose of this study was to evaluate whether or not the d-dimer level indicating hyperfibrinolysis could be a predictor of early poor outcome (massive transfusion, death within 24 hours) associated with trauma-induced coagulopathy in blunt trauma without significant brain injury. METHODS: This study was a retrospective observational study using 516 blunt trauma patients without significant brain injury. The poor outcome group, including patients receiving massive transfusion and those who died within 24 hours, consisted of 33 patients (6.4%). The variables were compared between the poor outcome group and good outcome group, and logistic regression analysis was performed using statistically significant variables. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the poor outcome prediction ability of the initial d-dimer level. RESULTS: The poor outcome group showed more serious anatomical, physiological, and laboratory data than the good outcome group. In the ROC curve analysis for evaluation of the poor outcome prediction of the d-dimer level, the area under the curve value was 0.87 (95% confidence interval [CI], 0.84–0.90) while the cut-off value was 27.35 mg/L. In the logistic regression analysis, the high d-dimer level was shown to be an independent predictor of poor outcome (adjusted odds ratio, 14.87; 95% CI, 2.96–74.67). CONCLUSION: The high d-dimer level (>27.35 mg/L) can be used as a predictor for the poor outcome of patients with blunt trauma without significant brain injury.
Blood Transfusion ; Brain Injuries* ; Brain* ; Humans ; Logistic Models ; Multiple Trauma ; Observational Study ; Odds Ratio ; Retrospective Studies ; ROC Curve ; Wounds, Nonpenetrating

The free functional muscle transfer (FFMT) is the surgical procedure aimed at reconstructing defective or deteriorated muscle function by grafting free muscles including blood vessels and nerves. Since the free gracilis transfer in the facial paralysis was introduced in 1976, there have been many studies and clinical applications of the FFMT in various donor and recipient sites in brachial plexus injury, muscle ischemic contracture, muscle defect after tumor resection, congenital muscular deficit, multiple trauma. When the reconstruction of the nerve is delayed for 9 months to 1 year after the brachial plexus injury, voluntary muscle contracture is impossible even after the nerve regeneration by the irreversible degeneration of the muscles. And it is difficult to obtain adequate function even if nerve transfer or nerve transplantation is performed because the distance to be regenerated is too long. In these cases, the FFMT has been improved the functions of the upper limb in flexion or extension of the elbow, fingers. Many good clinical results of the FFMT have been reported, so the FFMT gets much interests and attentions. The essential things for the successful outcome of the surgery are the anatomical knowledge, the skilled surgical technique and the choice of patients who can meet the indications and receive long-term rehabilitation. Recent advances in surgical techniques will result in improved results of the FFMT.
Attention ; Blood Vessels ; Brachial Plexus* ; Contracture ; Elbow ; Facial Paralysis ; Fingers ; Humans ; Ischemic Contracture ; Multiple Trauma ; Muscle, Skeletal ; Muscles ; Nerve Regeneration ; Nerve Transfer ; Rehabilitation ; Tissue Donors ; Transplants ; Upper Extremity

It is not a common case for neurosurgery department and the other departments to perform joint operation at the same time. Patients with severe head injury are a condition in which vital signs are unstable due to severe brain swelling and increased intracranial pressure, and emergency surgery is required. A 44-year-old man visited the trauma center with a motorcycle accident. The Glasgow Coma Scale score at the time of emergency department was 3 points, and the pupil was fixed at 6 mm on both sides. His medical history was unknown. His vital signs including blood pressure (BP), heart rate, respiratory rate and oxygen saturation were stable. Associated injuries included multiple fractures of whole body. Brain computed tomography revealed subarachnoid hemorrhage, intraventricular hemorrhage and severe cerebral edema. During the preparation of the craniectomy, abdominal ultrasonography performed because of decreased BP resulted in a large amount of hemoperitoneum. The bi-coronal craniectomy and splenectomy were performed simultaneously for about 4 hours. After fifty days of treatment, he was discharged with Glasgow Outcome Scale-extended 4 points and is undergoing rehabilitation. In severe polytrauma patients, active concurrent surgery is a good method to save their lives.
Adult ; Blood Pressure ; Brain ; Brain Edema ; Craniocerebral Trauma* ; Emergencies ; Emergency Service, Hospital ; Fractures, Multiple ; Glasgow Coma Scale ; Head* ; Heart Rate ; Hemoperitoneum ; Hemorrhage ; Humans ; Intracranial Pressure ; Joints ; Methods ; Motorcycles ; Multiple Trauma ; Neurosurgery ; Oxygen ; Pupil ; Rehabilitation ; Respiratory Rate ; Splenectomy* ; Subarachnoid Hemorrhage ; Trauma Centers ; Ultrasonography ; Vital Signs

PURPOSE: Occult injuries are diagnosed using computed tomography (CT), often with intravenous (IV) contrast CT, in major trauma patients. The contrast dye is known to be potentially nephrotoxic. Thus, we measured the incidence and risk factors for contrast-induced nephropathy (CIN) in major trauma patients. METHODS: A retrospective review was performed on 247 patients who were treated by the activated trauma team between June 2012 and July 2014. The exclusion criteria were underlying renal failure, no IV contrast CT administered, and no creatinine (Cr) follow-up within 72 hours. We examined age, gender, initial vital signs, the Glasgow Coma Scale (GCS), initial Cr levels, Cr level within 72 hours after admission, the IV contrast CT number, Injury Severity Score (ISS). CIN was defined as 25% relative or 0.5 mg/dL absolute increase in serum Cr within 72 hours of presentation. RESULTS: One hundred forty-three patients were included in this study. CIN manifested in 12 patients (8.4%). The injury severity was associated with CIN (ISS≥16, p=0.003; GCS≤8, p<0.001; death, p<0.001). Initial Cr levels, elderly patients, and initial hypotension were not statistically significant (p=0.065, 0.176, and 0.402, respectively). The number of IV contrast CTs administered was also not associated with the occurrence of CIN (p=0.331). CONCLUSION: We found an 8.4% incidence of CIN in multiple trauma patients exposed to IV contrast. The number of IV contrasts, age, initial systolic blood pressure, and initial Cr levels were not associated with CIN. Only injury severity was associated with CIN occurrence; therefore, physicians should pay more attention to severely-injured patients.
Aged ; Blood Pressure ; Creatinine ; Follow-Up Studies ; Glasgow Coma Scale ; Humans ; Hypotension ; Incidence ; Injury Severity Score ; Multiple Trauma ; Renal Insufficiency ; Retrospective Studies ; Risk Factors ; Vital Signs

BACKGROUND: It is important that proper protocols are in place for trauma patients who require massive transfusion upon arrival at the emergency department. This study is a preliminary analysis of massive transfusion cases at the emergency department of our institution aimed to review the characteristics and situations in which massive transfusion occurs in an effort to better manage trauma patients receiving massive transfusion in the emergency department. METHODS: This study was conducted at the Department of Emergency Medicine in the Korea University Guro Hospital. We retrospectively reviewed the medical charts of trauma-related patients who required massive blood transfusions between January 2013 and December 2015. The inclusion criteria were as follows: patients who were over the age of 18 years and received more than 4 packed RBC (pRBC) units per hour, or 10 or more pRBC units during a period of 24-hours. RESULTS: A total of 669 patients were included in the study. There were significant differences of initial systolic blood pressure (P<0.0001), diastolic blood pressure (P<0.0001), and Injury Severity Score (P<0.0001) between those who survived and those who expired. CONCLUSION: Proper initial resuscitation is essential for the improvement of outcome in trauma patients that require a massive transfusion. The findings from this study may serve as preliminary data in developing proper transfusion protocols for massive transfusion among trauma patients.
Blood Pressure ; Blood Transfusion ; Emergencies* ; Emergency Medicine ; Emergency Service, Hospital* ; Humans ; Injury Severity Score ; Korea ; Multiple Trauma ; Resuscitation ; Retrospective Studies ; Transfusion Reaction

PURPOSE: Early assessment of injury severity is important in management of major trauma patients. In general, hypotensive major trauma patients show more severe outcomes from injuries compared with normotensive major trauma patients. In this study, we analyzed the clinical features of severe trauma patients with initial hypotension and attempted to determine the prognostic factors of mortality in these patients. METHODS: A retrospective study was conducted within our hospital. Review of trauma registry data identified 679 major trauma patients (Injury severity score, ISS>15). From January 2011 to December 2013, all major trauma patients with initial systolic blood pressure lower than 90 mmHg were included (N=77). The patients were divided into two groups - those who survived and those who expired - and the differences in initial and final values were compared between the two groups. RESULTS: Out of a total of 77 patients, 55 patients survived and 22 patients died. The data showed almost no difference in heart rate between the two groups. The expired group showed low Glasgow Coma Scale (GCS) score, systolic blood pressure, revised trauma score, initial pH, and follow-up pH, as well as higher age, ISS, initial lactate, prothrombin time (PT), international normalized ration (INR), and follow-up lactate, compared with the survived group. In multivariate logistic analysis, age (p=0.034, OR 1.071), GCS (p=0.006, OR 0.61), initial base excess (p=0.042, OR 0.57), and follow-up base excess (p=0.041, OR 0.799) were independently associated with mortality. CONCLUSION: The patient's age, initial GCS, initial base excess and follow-up values of base excess were good prognostic factors for mortality in the expired major trauma patients with initial hypotension.
Blood Pressure ; Emergency Service, Hospital* ; Follow-Up Studies ; Glasgow Coma Scale ; Heart Rate ; Humans ; Hydrogen-Ion Concentration ; Hypotension* ; Lactic Acid ; Mortality* ; Multiple Trauma ; Prothrombin Time ; Retrospective Studies

OBJECTIVETo investigate clinical effects of damage contral resuscitation (DCR) in rescue multiple fracture with hemorrhagic shock.

METHODSFrom January 2009 to May 2013, clinical data of 24 patients suffered from multiple fracture with hemorrhagic shock were retrospectively reviewed. Among them, 18 cases were male and 6 cases were female, aged from 21 to 48 years old with an average of (32.5 +/- 4.5). Small capacity of balanced salt solution were used to maintain systolic, pressure (80-90) mmHg before operation. After control of bleeding with operation, sufficient amount of liquid were rapidly use, and plasma were supplied according to proportion of plasma and red cell suspension (1 U:2 U-1 U:1 U). After remedy of shock, fluid infusion were sustained negative balance slightly and keep acid-base equilibrium of electrolyte. Dosage of balanced salt solution and blood transfusion before remedy shock were recorded, removal time of lactic acid, coagulation function, incidence and case fatality of DIC were observed.

RESULTSFour patients were died after 6-18 h into hospital (2 cases died for acute respiratory distress syndrome and 2 cases for irreversible shock). Twenty patients with shock were corrected at 2-6 h after injury. Dosage of balanced salt solution was(4,259 +/- 268) ml,red cell suspension was (14 +/- 2) U, fresh frozen plasma was (800-1,600) ml (FFP: 1 U = 100 ml) averaged (900 + 300) ml, blood platelet was 4-6 U. Coagulation function and electrolyte were normal. Lactic acid was less than 2 mmol/L within 24 h,the success rate of recovery was 83.3% (20/24).

CONCLUSIONPerforming DCR can obvious improve success rate of remedy serious fracture combined with uncontrolled hemorrhagic shock. Supplementing FFP when correcting coagulation function should be carry out promptly in fluid resuscitation.

Adult ; Blood Transfusion ; Female ; Humans ; Male ; Middle Aged ; Multiple Trauma ; therapy ; Resuscitation ; Retrospective Studies ; Shock, Hemorrhagic ; therapy ; Young Adult

PURPOSE: Simulation-based medical education allows medical students to experience scenarios that are otherwise rare to encounter during on-site training. The purpose of our study is to assess the performance of a medical student training program using a realistic, patient simulation for activities including initial evaluation and management, situational judgment, and decision making associated with patients with multiple trauma. METHODS: After a slide lecture and patient simulation training, 46 medical students in their sixth-year were trained using a multiple-trauma patient simulation scenario. The performance assessment checklist included possibilities for both appropriate and inappropriate actions. After debriefing, the students filled out a questionnaire and participated in a feedback session. Two specialists in emergency medicine evaluated the completed checklists. Inter-rater reliability was established for the results. RESULTS: The appropriate action checklist items for obtainment of blood for type and crossmatch, initiation of emergency blood transfusion, and resuscitation with vigorous fluid therapy, resulted in low mean numbers. The inappropriate action checklist items for delay in recognition of tension pneumothorax, blood ordering type and crossmatch, and ordering blood transfusion, resulted in high mean numbers. The inter-rater reliability of these results were 0.90. Students responded in the questionnaire that they appreciated the opportunity to have this training before graduation and that they had learned more about multiple trauma treatment through this training. CONCLUSION: We suggest that this training program, using a realistic patient simulation, can be highly effective for teaching medical students about initial evaluation and management, situational judgment, and decision making in patients suffering with multiple traumas. We also demonstrated the efficacy of simulation as a trauma performance assessment tool for evaluating medical students.
Blood Transfusion ; Checklist ; Computer Simulation ; Decision Making ; Education, Medical ; Educational Measurement ; Emergencies ; Emergency Medicine ; Fluid Therapy ; Humans ; Judgment ; Multiple Trauma ; Patient Simulation ; Pneumothorax ; Surveys and Questionnaires ; Resuscitation ; Specialization ; Stress, Psychological ; Students, Medical