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Treatment Results of Patients with Multiple Trauma: An Analysis of 3406 Cases Treated between 1972 and 1991 at a German Level I Trauma Center

Regel, G. MD; Lobenhoffer, P. MD; Grotz, M. MD; Pape, H.C. MD; Lehmann, U. MD; Tscherne, H. Professor of Surgery

The Journal of Trauma: Injury, Infection, and Critical Care: January 1995 - Volume 38 - Issue 1 - p 70-78
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The quality and progress of treatment for 3406 multiple trauma patients was reviewed retrospectively. Two periods (1972 to 1981, the first decade, and 1982 to 1991, the second decade) were compared.

Sixty-nine percent of patients with multiple trauma had cerebral injuries, 62% thoracic trauma, and 86% fractures (40% open fractures).

Concerning injury combinations, there was an increase of head/extremity injuries and thoracic/extremity injuries, whereas all combinations with abdominal injuries decreased. The relation between severity of injury as well as number of injured body regions and the mortality rate was significant.

In the second decade prehospital care became more aggressive with an increase in use of intravenous fluid resuscitation (from 80% to 98%), intubation (from 84% to 91%), and chest tube insertion (from 37% to 76%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal hemorrhage, ultrasound (89%) nearly replaced peritoneal lavage (10%) and led to earlier surgical approach. For diagnosis of head injury, CT scan was used more frequently.

Primary stabilization of long bone fractures, especially of the lower limb, is recommended. Concerning complications, the change in volume therapy helped to nearly eliminate acute renal failure (from 8.4% to 3.7%), the modification of respirator treatment led to a decrease of pulmonary insufficiency (ARDS; from 18.2% to 12.0%), whereas the rate of multiple organ failure increased.

The mortality rate declined from 37% in the first decade to 22% in the second decade. The incidence of lethal multiple organ failure increased from 13.8% in the first decade to 18.6% in the second decade, whereas the mortality rate of ARDS decreased from 32.4% to 15.9%. Further reduction of incidents of death is only possible with causal therapy of posttraumatic organ failure immediately after injury.

From the Department of Trauma Surgery, Hannover Medical School, Hannover, Germany.

Address for reprints: G. Regel, MD, Department of Trauma Surgery, Hannover Medical School, Konstanty-Gutschow-Str. 6-8, 30625 Hannover, Germany.

Care of patients with multiple trauma requires maximal diagnostic and therapeutic efforts. [1,2] A critical evaluation of treatment results is impeded by a heterogeneous patient population, low number of cases, and different therapy regimens over the past years. For predictive figures complete documentation of diagnoses, therapy, course, and complications is necessary.

The quality of specific treatment regimens for patients with multiple trauma should be analyzed by an evaluation of the total population. We compared our populations of patients with multiple trauma from 1972 to 1981 (first decade) and 1982 to 1991 (second decade) and asked the following questions:

1. Was there a change in the characteristics of patients with multiple trauma from the first to the second decade as shown by epidemiological data?

2. In respect to multiple trauma, which are typical injuries and injury combinations we treat today?

3. Which criteria lead to a reduction of complications and mortality rate?

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STUDY POPULATION AND METHODS

This study includes all patients with multiple trauma treated initially at the Hannover Medical School or after transfer from another hospital. Multiple trauma was defined according to Tscherne et al. as at least three preexisting injuries which in combination are life threatening. [2] All patients had to score more than 20 points on the Injury Severity Score (ISS scale). [3] Not included are patients with isolated, severe, potentially life-threatening injuries; for example, isolated head or abdominal injuries. Data were classified into seven sections: Patient-specific data (age, sex, weight, height); type and time of accident; type, location, and severity of injuries; prehospital and initial clinical treatment; intensive care treatment and course; and posttraumatic complications and mortality. Type and time of accident as well as prehospital treatment were taken from ambulance records.

Rescue intervals were defined as follows: Interval of no therapy--time between accident and arrival of ambulance or emergency physician car (EPA); Rescue time--time between accident and arrival at the hospital for initial treatment; and Intubation time--time between accident and intubation of patient.

Type and location of injuries were taken from patient's records. Injury severity was classified according to the ISS scale. [3] Initial clinical treatment consisted of resuscitation, diagnostic evaluation, and primary operative treatment (when indicated) until transfer to the intensive care unit (ICU).

Treatment intervals were defined as follows: Resuscitation time--time between arrival in the first hospital and initial operative treatment or admission to the ICU if operative treatment was not performed; and Operation time--duration of initial operative treatment.

During initial and intensive care treatment, fluid balance, hemodynamic and respiratory parameters, temperature, laboratory parameters, medications, and surgical treatment were documented. Organ failure was defined according to Goris. [4]

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STATISTICS

For comparison of the different time periods a two-tailed t test for paired data was used. In all instances, the null hypothesis was rejected at the p < 0.05 level, significance (p < 0.05) was marked by asterisks (*). Data in the tables and figures are presented as means +/- standard error of the mean (SEM).

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RESULTS

A total of 3406 patients with multiple trauma were either treated initially or were transferred to Hannover Medical School between 1972 and 1991. The rate of patients secondarily transferred increased from an initial 22.6% to 40.2% in 1991. Considering all patients, time between injury and arrival at Hannover Medical School ranged from less than 1 hour to more than 3 days.

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Patient-specific Data

The majority of patients were male (73.7%). There was no significant difference in age distribution between the first and second decade (Figure 1). During the past decade the average age decreased from 34 +/- 18 years in 1982 to 31 +/- 16 years in 1991.

Figure 1

Figure 1

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Type of Accident

Most of our patients (83%-89%) were injured in motor vehicle crashes (MVCs). Only 4% suffered penetrating trauma (2.7% gunshot wounds, 1.3% stab wounds). Comparing both decades, car crashes declined from 54% to 42%, whereas cycle accidents showed a significant increase (Figure 2). In 1972 there were seldom bicyclists and only 9% motorcyclists in the study population, in 1981 11% were bicyclists and 17% motorcyclists, and in 1991 there were 15% bicycle and 21% motorcycle accidents. Other causes of injury (pedestrian, falls, suicide) decreased in the past 20 years (Figure 2).

Figure 2

Figure 2

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Location and Severity of Injury

Multiple trauma patients treated at our hospital had an average of 7.6 injuries. Eighty-six percent had fractures of the extremities, 69% head injuries or skull fractures and 62% thoracic trauma. Intra-abdominal lesions (36%), pelvic injuries (28%), and spine injuries (14%) were less frequent (Figure 3). Comparing both decades, the injury pattern showed no significant difference. Only in the last few years was an increase in pelvic and extremity injuries apparent.

Figure 3

Figure 3

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Specific injuries

Sixty-nine percent of multiple trauma patients suffered head injury, 42.8% with an initial Glasgow Coma Scale score of 11 to 15, 27.4% with a score of 6 to 10, and 29.8% with a score of 3 to 5. The importance of head injury in the intensive care period and the effect on mortality rate is discussed in a separate section below. Sixty-two percent of all patients sustained blunt thoracic trauma. Lung contusion occurred more frequently (72.6%) in the last decade. Thirty-six and two-tenths percent of the study population suffered abdominal trauma requiring laparotomy, 38% because of splenic rupture and 32% because of liver rupture. The incidence of renal injuries (4.5% to 15.2%) showed a significant increase. Rupture of the diaphragm was only present in 1.7%, half of these patients had other abdominal or thoracic injuries.

Pelvic injuries were diagnosed in 27% of multiple trauma patients. Eighty-seven and six-tenths percent were fractures of the pelvic ring, 38.8% were associated with acetabulum fractures. Isolated acetabulum fractures were found in 11.7%, complex fractures (i.e., including severe soft tissue trauma, and/or injuries of the pelvic organs) in 14.7% and complex open fractures in 3%. There was an increase of pelvic trauma from 74 in the first decade to 85 cases a year in the second decade.

Eighty-six percent of all patients had injuries of the extremities, mostly lower limb fractures. Femur fractures were found in 27.6%, tibia fractures in 21.3%, and injuries of the foot and ankle in 20.3% (Table 1). Comparing both decades, extremity injuries became more frequent (80% to 92%).

Table 1

Table 1

Open injuries were seen in 23.9% of all fractures. They occurred mainly at the elbow (30.8%) and the lower leg (34.5%). The incidence for other shaft fractures was lower (22-27%) (Table 1).

The most frequent injury combination was that of head and extremity injuries (63%), followed by thoracic trauma combined with extremity injuries (63%), followed by thoracic trauma combined with extremity injuries (52%) (Figure 4). Comparing both decades, there was an increase of these two combinations, whereas all combinations with abdominal injuries decreased.

Figure 4

Figure 4

A score describing injury severity of multiply traumatized patients is necessary to compare patient groups and possibly to indicate a prognosis. We used the ISS, and there was an increase of patients with an ISS between 25 and 40 points in the last decade (Figure 5). The relation of injury severity according to the ISS and the mortality rate was significant.

Figure 5

Figure 5

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Prehospital Treatment

Methods of Rescue

Both transport systems (helicopter and ambulance) based at our hospital carry a physician trained on the treatment of multiple trauma patients. The rescue helicopter was introduced in 1972. Only in the first time period (1972 to 1976) the ambulance was used more frequently than the helicopter (Figure 6). In 1991 74.2% of our study population were transported by helicopter, only 25.8% by ambulance. The interval of no therapy and the intubation time were shortened significantly (p < 0.05) (Table 2). In the last decade time of rescue was less than one hour in 75% of patients treated initially at Hannover Medical School.

Figure 6

Figure 6

Table 2

Table 2

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Prehospital Treatment

In association with the increased use of the helicopter, specific therapeutical regimens have been developed for the multiple trauma victim. There was an increase in prehospital treatment, e.g., infusion therapy from 80% in the first to 98% in the second decade, initial intubation from 84% to 91%, prophylactic chest tube insertion from 37% to 76%, as well as fracture reduction and splinting at the scene from 75% to 83% (Figure 7). In intravenous infusion therapy there was a change from colloids to crystalloids (Table 3).

Figure 7

Figure 7

Table 3

Table 3

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Initial Clinical Treatment

Diagnostic Procedures

CT scan and ultrasound were introduced during the last two decades (Figure 8). Since 1977, CT scan has become increasingly important in the initial diagnostic evaluation of head injuries (Figure 8). Additionally, CT scan was used in thoracic, abdominal, and pelvic injuries more frequently. Since its introduction in 1982, ultrasound has nearly completely replaced peritoneal lavage for acute diagnostic evaluation of blunt abdominal trauma (Figure 8). [5] The duration of initial diagnostic procedures was 45.6 minutes on average.

Figure 8

Figure 8

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Initial Operative Treatment

Primary operative treatment was desired in all cases. Only patients with severe respiratory or hemodynamic deficits were transferred directly to the ICU. Head injury: Only 4.2% needed craniotomy, 2% because of epidural hematoma, and 1.5% because of subdural hematoma. Thoracic trauma: Thoracotomy (n = 177, 5.2% of all patients) was required mainly because of intrathoracic hemorrhage (n = 116, 65.5% of all thoracotomies). In 39 cases (22%) segmental resection of lung, and in 19 cases (10.7%) an acute operation was performed, because of aortic injury. No change in frequency was found comparing both decades. Abdominal trauma: Laparotomy was done in 763 cases (22.4% of all patients). Sixty-five and seven-tenths percent of all laparotomies were to control active hemorrhage (coagulation, ligature, etc.), in 38.8% from the liver, in 65.3% from the spleen (splenectomy in 359 cases). Control of massive life threatening hemorrhage had absolute priority. When the spleen was the *Illegible Text* of bleeding this was possible in 53.9% of cases within the first hour after the injury and in 81.4% within the second hour. Pelvic trauma: An initial operation was required in 20.5% of all pelvic trauma cases because of associated injuries, e.g., urogenital (8.8%), bowel injury (5.1%), or severe intrapelvic hemorrhage (9.2%). Spine injury: Emergency operations were very rare and were only performed in patients with signs of spine instability or progressive neurologic symptoms. Extremity injury: The rate of acute operative treatment depended on injury location. In case of operation primary treatment was performed in femoral (84%), tibia (78%), elbow (83%), and forearm (64%) fractures. Intra-articular fractures of wrist, distal femur, tibial head, and foot were treated secondarily after preoperative planning and further diagnostic procedures (tomography).

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Intensive Care Therapy and Course

Comparing both decades there was a change in volume therapy from colloids to crystalloids (Table 2). Considering even volume efficiency total fluid amount increased significantly (6). Comparing the first and second decade, there was a slight increase in ventilation time; however, with CPAP-weaning (1978) it decreased and thereby shortened the intubation time (12.0 to 8.2 days) (Table 4). In the second decade we noticed an increase in controlled ventilation time (CMV), which let the intubation time increase as well. The intensive care time showed a similar course and has today an average of 13.7 days. The duration of intensive care treatment is related to type and severity of injury. Coexistant thoracic trauma and pulmonary contusion may extend ventilation and ICU time (Table 5) (7). The relation between duration of intensive care treatment and the ISS was significant. ICU time of patients secondarily transferred was longer than that of prehospitals initially treated at Hannover Medical School, which was not specifically related to longer ventilation times. Only nonsignificant reduction of the hospitalization time was found in the past two decades (from 35.4 to 31.0 days).

Table 4

Table 4

Table 5

Table 5

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Posttraumatic Complications and Mortality

Complications

In this study only complications that were not related to a specific injury or, on the other hand, could not be eliminated by a single therapeutic intervention were regarded as post-traumatic. Comparing both decades, we saw a significant decrease in renal failure and subsequently the rate of dialysis (from 8.4% to 3.7%) as well as in acute respiratory distress syndrome (ARDS) (from 18.2% to 12.0%), whereas the rate of MOF increased. Significant changes of infections were not evident. Patients secondarily transmitted to our hospital showed a significant higher incidence of complications, especially of MOF (28.2%), compared to those primarily treated at our hospital.

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Mortality

The mortality rate of multiple trauma patients treated at our hospital decreased from 37% in the first to 22% in the second decade (Figure 9). In the same time the treatment period of nonsurvivors increased from 13.6 to 22.4 days (Figure 9). There was a significant correlation between the mortality rate and the age of patients, the ISS, as well as the number of affected regions (Table 6). The prognosis of multiple trauma patients worsens with specific injuries (head, thorax, extremities) (Table 5).

Figure 9

Figure 9

Table 6

Table 6

In the first decade ARDS, besides brain death and cardiovascular failure, showed the highest mortality rate; in the second decade MOF apart from the others was the leading cause of death (Table 7). Comparing both decades, there is a significant increase in the mortality rate of MOF from 13.8% to 18.6% (p < 0.05), whereas the mortality rate of ARDS decreased from 32.4% to 15.9%. The mortality rate due to hemorrhagic shock showed a significant decrease from 16.6% in the first to 5.8% in the second decade (p < 0.05) (Table 7). Patients secondarily transmitted to our hospital showed a higher mortality rate in the last decade (Table 8).

Table 7

Table 7

Table 8

Table 8

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DISCUSSION

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.

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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. [8] 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, [9] 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.

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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. [8] 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. [16] They lead to a prolongation of intensive care time, rehabilitation (Table 5), and reentry to social life. [16] 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, [21] 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. [22] 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. [22] 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.

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Which Criteria Lead to a Reduction of Complications and Mortality Rate?

Prehospital Treatment

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. [24]

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. [24] 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.

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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. [16] For diagnosis of massive abdominal hemorrhage ultrasound is essential today; the accuracy is very high and repeated examinations are easier. [5] 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. [25] 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. [22] 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. [26]

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. [30] We nowadays exclusively use an unreamed, solid nailing technique. [31] 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. [34] 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.

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Acknowledgment

The authors thank David H. Wisner, MD, Associate Professor of Trauma, University of California, Davis, for his editorial assistance.

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