This epidemiological study represents an analysis of the treatment of multiply traumatized patients over the past two decades. The aim of this study was to assess the quality of treatment, to identify factors responsible for mortality, and to define therapeutic methods leading to decreases in mortality.
Was There a Change in Multiple Trauma Patient Characteristics from the First to the Second Decade (Epidemiological Data)?
A striking point of this analysis is that the requirements for the treatment of multiple trauma patients have obviously become continuously more sophisticated. A reason for this is a definite change in the study population towards more complex trauma.
1. Level I trauma centers have to deal with more patients initially treated in other hospitals.  It leads to a significant increase in rescue time, protracted time of resuscitation, and an increased incidence of organ failure, intensive care time, and mortality rate (Table 8).
2. The more frequent use of rescue helicopters leads to shorter rescue time, improved prehospital treatment, and, subsequently, decreases the prehospital mortality rate. More patients with complex trauma reached the hospital alive,  and the overall injury severity increased.
3. The complexity of trauma nowadays is an expression of an increased rate of high-velocity trauma, e.g., severe pelvic and associated injuries, increased incidence of open fractures, and severe soft tissue injury, a higher rate of complex joint fractures, altogether requiring numerous operations to regain adequate function. [10-13] Because the survival rate has increased to more than 80%, the return of organ and extremity function, leading, to private and professional reentry into society in a short time, is nowadays the major focus of treatment. [11,13-15]
4. Especially for ethical and economical reasons, the young age of multiply traumatized patients should be considered. Eighty-one percent of injured motorcyclists were younger than 25, and 49.2% of all injured cyclists were younger than 20 years.
Summarizing these points, the change in the trauma population, the need for fast return to work, and the young age of patients, demands the highest quality treatment and subsequently our analysis of population and current therapy of multiply traumatized patients.
Most of our patients (83%-89%) were injured in motor vehicle crashes (MVCs). Other German-speaking centers report similar statistics. [10,11] The continuous increase of motorcycle crashes and a decrease in automobile crashes corresponds with the number of registered motorcycles, which rose from 374,230 (1972) to 657,541 (1978) in Germany. In 1981, 95,215 persons were involved in MVCs compared to 58,520 in 1972. In 1981, 1918 persons died. Since 1984, the number of injured motorcyclists declined. In 1991, however, 46,792 were injured and 962 died because of MVCs. According to the mechanism of injury, the prognosis was different. In 1991, 31.4% of all deceased were cyclists, 25.8% pedestrians, 23.2% motorcyclists, and 19.6% car passengers.
In Respect to Multiple Trauma which Are Typical Injuries and Injury Combinations We Treat Today?
In contrast to the North American experience, we rarely have to deal with penetrating (gunshot and stabbing) injuries, but more with blunt trauma.  Comparatively this leads to a higher incidence of isolated and extensive soft tissue injuries (open fractures, soft tissue loss, amputations). Because of more high-velocity trauma, the severity and complexity of injuries increased in our population (Figure 5).
The following is concerned with frequency, causes, and prognosis of isolated injuries.
Head injuries are frequent injuries in multiple trauma patients (67% in our population). In our experience, an increase of total injury severity leads to an increase of head injury severity. Isolated severe head injuries are rare.  They lead to a prolongation of intensive care time, rehabilitation (Table 5), and reentry to social life.  The severity of head injury (according to common classifications), however, gives no prediction of the treatment course and outcome.
Thoracic trauma was the third most frequent injury in our population and was often represented in injury combinations. The mechanism in car crashes is a direct impact with the steering wheel or dashboard and in some cases is even found in drivers wearing safety belts. The prognosis of thoracic trauma is related to the severity of parenchymal damage (pulmonary contusion). [7,17,18] We saw more early and late posttraumatic complications (aspiration of blood, pneumothorax/ARDS, pneumonia) with pulmonary contusion than in combination with any other injury. Consequently, ventilation, intensive care, and hospitalization time are longer. Lasting impairment of respiratory function in long-term follow-up is rarely found, however. [19,20]
As in other studies, abdominal injury was found only in one-third of multiple trauma patients,  mostly in combination with thoracic trauma. The mechanism is similar to that of thoracic trauma. Life threatening massive hemorrhage occurs more frequently in this group, however. With this specific injury we saw less posttraumatic complications and no effect on mortality rate and further rehabilitation (Table 5).
Pelvic trauma is the only corpus injury (chest, abdomen, pelvis) that showed a significant increase in incidence (21% to 33%) in the past two decades. We saw more complex pelvic trauma often with associated soft tissue injuries.  Mechanisms of injury are high-velocity trauma (47%), MVC victims requiring extrication (39%), and patients with a direct crush injury to the pelvis or abdomen due to overrolling by a motor vehicle (17%). The trauma severity corresponds to the injury mechanism. The prognosis of pelvic trauma is related to the extent of the retroperitoneal hematoma and soft tissue injury, leading to frequent late complications.  Mortality increases significantly in complex and open fractures.
Extremity injuries were the most frequent injuries--76% of patients had fractures. This is consistent with other studies. [11,13] We saw an increase of isolated fractures, and an increase of fracture complexity was also seen and was probably due to high-velocity trauma. Especially open fractures were more frequent, mainly in the lower limb (tibia and foot). Extensive soft tissue injuries and open fractures tend to promote infectious complications, which are important for long-term prognosis. Open fractures with infectious complications result in bad healing and long immobilization. They lead to long hospitalization, long rehabilitation, and increased disability.
Which Criteria Lead to a Reduction of Complications and Mortality Rate?
Two factors in prehospital treatment are important for the course of multiply traumatized patients: (1) duration of initial rescue (interval of no therapy, rescue time), and (2) quality of initial treatment. These requirements were improved, comparing the last two decades. Early and sufficient volume therapy avoids prolonged shock. [6,7,23] Initial intubation and ventilation therapy is felt to be of benefit to patients with multiple trauma, thoracic trauma (lung contusion), or any other respiratory disorder. [12,24] In all patients with thoracic trauma requiring respiratory therapy (positive endexpiratory pressure) thoracic tubes should be inserted. 
Essential in initial resuscitation is the continuous observation of the abdomen. Massive hemorrhage sometimes occurs after a delay during adequate volume therapy. In this case initial treatment should be shortened and continued in the helicopter.  Blood substitution and preparation of staff and equipment should be requested in advance.
Another aspect determining the quality of initial therapy is the early treatment of extremity injuries, including reduction of shaft and joint fractures, sterile dressing, and positioning in air splints. [13,24] This leads to a reduction of further complications.
Initial Clinical Treatment
Diagnostic evaluation: In multiple trauma patients with central or peripheral segmental neurologic deficits as well as in those whose neurologic status it was not possible to judge because of initial ventilation therapy or sedation, initial cranial CT scan is nowadays standard.  For diagnosis of massive abdominal hemorrhage ultrasound is essential today; the accuracy is very high and repeated examinations are easier.  In contrast to North America CT scan of the abdomen is rarely used. It requires the use of more time, staff, and financial resources. These sophisticated methods should not mislead one to underrate the timing of initial diagnostic examination; unnecessary prolongation can cause loss of life.
Operative treatment: Elimination of life-threatening hemorrhage has first priority in initial operative treatment. From our results we know that abdominal massive hemorrhage is most important, mainly related to liver or spleen rupture. In case of liver hemorrhage local control was obtained in most cases, partial resection was only performed exceptionally, and liver transplantation was very rare.  In case of continuous bleeding a packing technique is used. Patients with severe liver ruptures should then be transferred to a level I trauma center. In case of spleen injury, splenectomy needs to be performed at once. Only in multiply traumatized children may organ preservation be considered.
In our study population we found an increase in pelvic trauma. The only indication for urgent stabilization of the pelvis is massive pelvic hemorrhage, mostly related to the sacral venous plexus.  In the past years we used the pelvic C-clamp leading to external compression of the dorsal pelvic ring and subsequently to a tamponade of hemorrhage. Additional treatment is performed secondarily. MAST trousers are not recommended in multiply traumatized patients, because of complications described by others. 
Another basic principle after elimination of life-threatening massive hemorrhage and further diagnostics (e.g., cranial CT scan) is the initial stabilization of long bone fractures. [10-12,27-29] This is especially recommended with femur fractures. Early operation is desired since increasing soft tissue trauma and prolonged immobilization can lead to pulmonary complications. [27-29] The only exception is in association with pulmonary contusion. There the reaming procedure can be hazardous for the contused lung.  We nowadays exclusively use an unreamed, solid nailing technique.  Considering the operative time required for complex fractures (comminuted and intra-articular fractures), these should be stabilized with transarticular external fixation initially. Definite operative treatment is performed secondarily. In case of severe open fractures and traumatic amputation injuries, replantation possibility or amputation necessity should be decided initially, considering not only isolated extremity injury but total injury severity. Prolonged reconstruction attempts can considerably endanger survival rate.
Intensive care course and treatment: Intensive care treatment is an important aspect in the therapy of multiply traumatized patients. Considerable technical and medical progress has led to a decrease of ventilation time, posttraumatic complications, and mortality rate. From all therapeutic regimens only the main aspects in comparing both decades were considered in this study.
There was an essential change in volume therapy in the past 20 years. In the seventies volume replacement with colloids was recommended. Experimental and clinical studies have proven that, in traumatic-hemorrhagic shock, crystalloids are advantageous from the pathophysiological point of view. [6,23] We changed volume therapy to crystalloids in 1978 and saw a decrease of posttraumatic organ failure, especially kidney failure. [32,33] Since then the necessity of dialysis is rare. Advantageous effects on the lung with reduction of ARDS incidence have also been proven.
In ventilation therapy we saw with the introduction of continuous positive airway pressure (CPAP) in 1978 at first a significant decrease of weaning time. The duration of controlled ventilation however showed only little change when we analyzed this time period. We changed our ventilation philosophy: reducing sedation, sitting patients up in bed, and forcing early mobilization. This leads to a reduction of post-traumatic complications, especially ARDS. [13,27,29] An important aspect in this issue was also the introduction of continuous kinetic therapy.  Since then the overall ventilation time could not be significantly reduced, because with the reduction of mortality the frequency of prolonged but not lethal MOF increased.
In our population the mortality rate declined from 37% in the first to 22% in the second decade. There was a significant relation between the mortality rate and the type (e.g., thoracic injury) as well as severity of injury and the age of the patients. Development of posttraumatic organ failure is bad for prognosis, the number of failed organs being related to mortality probability. [1,7] For this reason organ failure should be treated aggressively by means of: (1) Treatment of traumatic shock in an early stage: Decrease of rescue time is advantageous as well as ``aggressive'' volume therapy and initial intubation in cases where indicated. (2) Avoidance of prolonged shock: Reduction of resuscitation time with rapid diagnostic examinations (ultrasound) and immediate treatment of life-threatening massive hemorrhage (mostly spleen and liver). This also helps to shorten the initial clinical treatment time in order to start intensive care treatment (optimal ventilation therapy, extended monitoring) as early as possible. The longer intensive care time and higher mortality rates of secondarily transferred patients must be related mainly to prolonged initial treatment. Most of these patients were in prolonged shock and showed a higher incidence of MOF. (3) Limiting continuing trauma helps to avoid pathogenetic mechanisms leading to MOF. Early stabilization of long bone fractures, radical debridement of necrotic tissue, and control of continuous occult hemorrhage and infection is important. Considering these principles a further reduction of organ failure and consequently of mortality rates can be anticipated.
The authors thank David H. Wisner, MD, Associate Professor of Trauma, University of California, Davis, for his editorial assistance.
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