Severity-dependent differences in early management of thoracic trauma in severely injured patients - Analysis based on the TraumaRegister DGU®

Abstract

BackgroundMajor trauma is associated with chest injuries in nearly 50% of multiple injuries. Thoracic trauma is a relevant source of comorbidity throughout the period of multiply-injured patient care and may require swift and well-thought-out interventions in order to avert a deleterious outcome. In this epidemiological study we seek to characterize groups of different thoracic trauma severity in severely injured patients and identify related differences in prehospital and early clinical management. This may help to anticipate necessary treatment for chest injuries.MethodsPatients documented between 2002 and 2012 in the TraumaRegister DGU®, aged ≥ 16 years, determined Injury Severity Score ≥ 16, and documentation from European trauma centers were analyzed. Isolated brain injury and severe head injury (Abbreviated Injury ScaleHead ≥ 4) led to patient exclusion. Patient subgroups were formed according to the Abbreviated Injury ScaleThorax as Controls, AIS-2, AIS-3, AIS-4, and AIS-5/6. Demographic and clinical characteristics comparing the aforementioned groups were evaluated using descriptive statistics.ResultsTwenty two thousand five hundred sixty five predominantly male (74%) patients, mean age 45.7 years (SD 19.3), suffering from blunt trauma (95%), and presenting a mean Injury Severity Score of 25.6 (SD 9.6) were analyzed. Higher thoracic injury severity was associated with more different thoracic injuries. The highest rate of prehospital intubation (58%) occurred in AISThorax-5/6. The worse the chest trauma, the more chest tubes were placed prehospitally, peaking at 22% in AISThorax-5/6. Out-of-hospital cardiopulmonary resuscitation was successfully performed in 11% in AISThorax-5/6 compared to 1%–3% in lesser thoracic trauma severity. Massive transfusion and emergency surgery was highest in AISThorax-5/6 compared to lesser thoracic injury (12% vs. 5%–7% and 17% vs. 3%–7%) and both were independently associated with thoracic injuries in patients with AISThorax ≥ 4.ConclusionsWe provide epidemiological data on trauma mechanism, concomitant injuries, frequencies of emergency interventions and outcome associated with different thoracic trauma severity. Prehospital and early clinical management is more complex when AISThorax is ≥ 4. Severely injured patients with critical thoracic trauma are most challenging to take care of with highest rates in prehospital intubation, cardiopulmonary resuscitation, chest tube placements, blood transfusions as well as emergency surgery.

Surgical Stabilization of Clavicle Fractures Reduces Organ Failure Rates in Multiply-injured Patients with Thoracic Trauma: An Analysis Based on the TraumaRegister DGU®.

“…Similar to previously published data on thoracic trauma, motorcycle crashes could be identi ed as the most frequent injury mechanism for developing a severe thoracic trauma with a clavicle fracture [11,14,29,30].…”

The role of whole-body computed tomography in the diagnosis of thoracic injuries in severely injured patients – a retrospective multi-centre study based on the trauma registry of the German trauma society (TraumaRegister DGU®)

“…Mean and upper and lower limits of the 95% confidence intervals (CI) are given. Where appropiate, the median as well as the interquartile range (IQR) are given too Parameter Pre-WBCT group ( n = 5002) WBCT group ( n = 8559) Trauma room Intubation in the trauma room [%] mean (95% CI) 55.6 [54.2–57.0] 49.3 [48.3–50.4] Chest drain in the trauma room [%] mean (95% CI) 20,0% [ 1 , 9 – 21 ] 18,5% [ 3 , 7 – 19 ] Time spent in the trauma room [minutes] mean (95% CI) median (IQR) 78 [76–79] 68 (51–87) 64 [63–65] 55 (40–77) Chest radiography [%] mean (95% CI) 85.2 [84.3–86.2] 59.8 [58.7–60.8] Trauma scan [%] mean (95% CI) 10.0 [9.2–10.8] 80.1 [79.3–81.0] Time to trauma scan [minutes] mean (95% CI) median (IQR) 31.3 [29.8–32.9] 29 (20–38) 23.6 [23.3–24.0] 21 (15–30) Discontinuation of trauma room management because of emergency surgery [%] mean (95% CI) 6.5 [5.8–7.2] 5.6 [5.0–6.1] Surgery before ICU stay [%] mean (95% CI) 44.0 [42.5–45.5] 40.5 [39.3–41.7] Further management Length of ICU stay [days] mean (95% CI) median (IQR) 10.8 [10.5–11.2] 8 (3–18) 9.7 [9.4–10.0] 6 (2–15) Length of intubation/ventilation [days] mean (95% CI) median (IQR) 6.9 [6.6–7.2] 3 (1–13) 5.6 [5.4–5.8] 2 (0–9) Length of hospital stay [days] mean (95% CI) median (IQR) 26.2 [25.8–26.9] 23 (11–37) 23.3 [22.7–23.8] 17 (9–30) Ventilator-free days [days] mean (95% CI) median (IQR) 19.8 [19.4–20.1] 24 (2–29) 20.8 [2...…”

“…Thoracic injuries account for 25% of deaths in polytrauma patients and are thus a common cause of death among these patients [ 1 , 2 ]. In recent years, a trauma room algorithm has become widely accepted in Germany which is based on Advanced Trauma Life Support (ATLS ® ) and the European Trauma Course [ 3 – 5 ].…”

Thoracic trauma severity contributes to differences in intensive care therapy and mortality of severely injured patients: analysis based on the TraumaRegister DGU®

“…Only a minority of patients with thoracic trauma tends to develop respiratory failure requiring intubation and ventilator support to correct hypoxia and hypercapnia [ 3 ]. On the other hand, 35 to 58% of severely injured patients require prehospital intubation, depending on the severity of concomitant chest injury [ 4 , 5 ]. While severely injured patients usually require intensive care therapy irrespective of accompanying thoracic injuries, organ dysfunction and multiple organ failure (MOF) are known to develop more often in patients with severe thoracic trauma [ 6 ].…”

“…Taking care of a severely injured patient is demanding. Differences in prehospital and early clinical trauma management have been reported that depends on the severity of an accompanying chest trauma [ 5 ]. Multiply-injured patients with blunt chest trauma require significantly longer periods of mechanical ventilation and a significantly longer stay in the ICU than trauma patients without a thoracic injury [ 2 ].…”