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The quality and progress of treatment of 4849 multiple trauma patients treated at one institution was reviewed retrospectively. Three periods, 1975-1984 (decade I; n=1469) and 1985-1994 (decade II; n=1937) and 1995-2004 (decade III; n=1443) were compared. 65% of multiple trauma patients had cerebral injuries, 58% thoracic trauma and 81% extremity fractures (37% open injuries). Injury combinations decreased during all decades with head/extremity injuries being the most common combination. Throughout the three decades pre-hospital care became more aggressive with an increase of intravenous fluid resuscitation (I: 80%, II: 97%, III: 98%). Chest tube insertion decreased after an initial increase (I: 41%, II: 83%, III: 27%) as well as intubation (I: 82%, II: 94%, III: 59%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal haemorrhage ultrasound (I: 17%, II: 92%, III: 97%) replaced peritoneal lavage (I: 44%, II: 28%, III: 0%). CT-scans were used more frequently for the initial diagnosis of head injuries and other injuries to the trunk throughout the observation time. With regard to complications, acute renal failure decreased by half (I: 8.4%; II: 3.7%; III: 3.9%), ARDS initially decreased but increased again in the last decade (I: 18.1%, II: 13.4%, III: 15.3%), whereas the rate of multiple organ dysfunction syndrome (MODS) increased continuously (I: 14.2%, II: 18.9%, III: 19.8%) probably due to a decline of the mortality rate from 37% in the first to 22% in the second and 18% in the third decade and parallel increase of the time of death. These treatment results summarise the enormous clinical effort as well as medical progress in polytrauma management over the past 30 years. Further reduction of mortality is desirable, but probably only possible when immediate causal therapy of later posttraumatic organ failure can be established.

The treatment of multiple traumas in children requires knowledge of common injury patterns, incidence, mortality, and the consequences and differences between these injuries in children and adult patients. However, epidemiological studies concerning pediatric multiple trauma are rare. To address this, data were collected and analyzed from 682 multiple trauma patients treated at a Level I trauma center. The patients were divided into four age-related groups (< 6 years, 6-12 years, 13-18 years, and 18-40 years) and were evaluated for trauma mechanism, injury distribution, and cause of death. Children aged 6 to 17 years mostly were injured as pedestrians and cyclists whereas infants, preschoolers, and adults more commonly were injured as car passengers. Pediatric patients suffered a significantly higher mortality than adults, with a threefold increased risk of death when injured as passengers in car accidents. Injuries to the head and the legs were most common. A lower incidence of thoracic (28% versus. 62%), abdominal (20% versus 36%), pelvic (22% versus 35%), and upper limb (32% versus 43%) trauma was observed in children (< 18 years) than in adults (18-40 years). Nevertheless, trauma to the thorax, abdomen, and head were associated with a high risk of death in all groups. Spinal cord injuries, especially in the cervical region, also carried a high risk of mortality (36.8 in the group of patients younger than 18 years and 18.9 in the group of patients 18-40 years). Children younger than 6 years had the most severe head injuries. The data show that there are important differences in incidence, mortality, and injury patterns between pediatric and adult patients with multiple traumas.

Objective: Limb injuries are often underestimated in the diagnostic procedures initiated in the resuscitation room. Missed diagnosis is therefore a frequent consequence in this issue. A systematic analysis of evidence-based procedures was therefore investigated in this paper., Methods: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system)., Results: Following admission of a multiple trauma patient vital functions have to be established in first priority. After stabilization a systematic clinical investigation and consecutive specific radiological procedures should rule out extremity injuries. These are the only evidence-based criteria leading to a complete detection of all limb injuries. All other aspects are only based on clinical experience or the opinion of expert committees., Conclusion: The quality of shock room management is mostly dependent on the experience of the " trauma team" (and especially of the trauma leader). Guidelines and specific trauma algorithms can provide a helpful instrument in this issue.

Objective: The objective of this study was to evaluate the state of rehabilitation in patients with blunt multiple injuries 2 years after their initial injuries, using several standardized scales and a recently described comprehensive scoring system, by means of a prospective clinical multicenter study., Methods: Two years after the initial injury, patients with blunt multiple injuries (Injury Severity Score > or = 16) underwent a clinical follow-up in 5 German Level I trauma centers. The reassessment included a complete head-to-toe examination of the musculoskeletal system and a neurologic examination. The following patient-assessed health status scores were used to determine the quality of life: Short-Form 12, Functional Independence Measurement, and Musculoskeletal Function Assessment. Moreover, a comprehensive scoring system developed in our department (Hannover Score for Polytrauma Outcome [HASPOC]) was used that includes provider-report (physician's examination) and self-report (score systems) criteria., Results: Two hundred fifty-four of 312 patients who had been injured between January 1995 and July 1996 were reexamined between January 1, 1997, and July 1, 1998. Among the remaining 58 patients, 9 had died by the time of follow-up, and 49 patients had not accepted the invitation. The mean age of those patients who underwent reexamination was 36 +/- 13 years, the mean Injury Severity Score was 24 +/- 6, and the mean initial Glasgow Coma Scale score was 11 +/- 4 (Abbreviated Injury Scale (AIS) head score of 3.3 +/- 1.1; AIS face, 1.4 +/- 0.1; AIS chest, 3.0 +/- 0.8; AIS abdomen, 1.7 +/- 0.6; and AIS extremities, 3.4 +/- 0.8). The general outcome (Short-Form 12) was as follows: grade I, 9%; grade II, 25%; grade III, 29%; grade IV, 25%; grade V, 6%; and grade VI, 6%. The outcome of the injured extremity demonstrated moderate or severe restrictions according to the Musculoskeletal Function Assessment in 41% of injuries of the lower extremity and in 16% of injuries of the upper extremity. Among patients with injuries to the lower extremity, 52% experienced pain or impaired ability to walk related to an injury of the foot or ankle, 31% indicated pain after a knee or thigh injury, and 27% indicated pain after a femoral or hip injury. The most severe deficits in the range of motion occurred in the foot and the ankle region (13.4% deficit of range of motion < 20% of normal range, p < 0.05 to other injuries). The results of the outcome obtained by self-report correlated with the clinical examination when a scoring system was used that was described recently, the HASPOC., Conclusion: In a standardized multicenter reexamination of patients with blunt multiple injuries, the general outcome was usually fair or good. Both the complaints and the objective results of specific extremity areas demonstrated that most limitations were because of injuries below the knee. These results were adequately reflected by a comprehensive scoring system, combining self-report and provider report (HASPOC).

Introduction: Previous scoring systems for measurement of the quality of outcome are based on scores regarding injuries to individual body regions. Known scores which describe several organ regions are of no importance for trauma patients. Therefore a new rehabilitation outcome evaluation score was developed at our hospital., Methods: Based on a prospective reinvestigation, a score system was developed that allows a quantitative appraisal of the subjective and objective outcome. A complete physical examination was performed, including ROM, neurologic examination and strength analysis. Part I (113 questions) is to be filled out by the patient; part II (191 questions) focusses on different body regions, physical examination and functional scoring. Included are the MFA, FIM, GCO and Frankel score. A final score (HASPOC) was developed to give a quantitative result of the outcome., Results: The new score has a range from 5 to 411 points. One hundred and fifty patients were re-examined. The mean follow-up time was 2.2 +/- 0.1 years. The SF 12 indicated an outcome more than satisfactory in 63% of cases. The MFA demonstrated moderate or severe restrictions in 41%, in the case of injuries of the lower extremity in 52% of patients. The HASPOC indicated a mean of 44.5 points., Conclusion: This paper describes the development, structure, and the quantitative outcome of rehabilitation in polytrauma patients. This standardized rehabilitation instrument deals with a very heterogeneous patient population and shows the rehabilitation deficits accurately. Implemented recognized evaluations allow comparison of these results with those of other scoring systems.

Objective: The ventilation mode clearly influences the course of patients with multiple trauma on the ICU. Ventilation according the "open lung" approach rapidly opens up atelectatic lung regions. Generation of an adequate intrinsic PEEP enables to keep the lung open. We studied the consequences of the "open lung" approach on the lung function and monitored its side effects on patients with multiple trauma., Methods: 18 consecutive patients with multiple trauma and additional thoracic trauma were routinely ventilated according the "open lung" approach between May and November 1999. We were mainly interested in data of lung mechanics, oxygenation and ventilation. Side effects on other organ systems and consequence for the infection rate were monitored., Results: Ventilation according the "open lung" approach enables early sufficient oxygenation and ventilation of patients with severe multiple trauma and accompanying thoracic trauma. The ventilation mode helps to prevent baro-, volu- and atelectrauma and thus fulfils the requirements for a present-day ventilation mode. An immediate complete healing of the lung damages was not found. Nevertheless, as a trend the length of ventilation support seems short. Even extensive osteosynthesis at multiple fractures was possible without delay. Side effects of the high opening pressure on the lung or other organs as well as sequels of the high intrinsic PEEP on liver, kidney or intestine were not found. The infection rate was low, therapeutic doses of antibiotics were necessary only in less than half of the ICU-stay., Conclusion: Ventilation according the "open lung" approach is a very effective and safe way to ventilate patients after severe multiple trauma with accompanying thoracic trauma.

Objective: To describe the long term results in patients with multiple injuries including severe head injury., Design: Retrospective and prospective clinical study., Setting: Level I trauma centre, Germany., Patients: Patients aged 16-60 years who had been injured more than 2 years before, whose Injury Severity Score was over 20 and whose cranial Abbreviated Injury Score (AIS) was over 3., Main Outcome Measures: Glasgow Outcome Scale (GOS), functional, neuropsychological, vocational and social outcomes., Results: 58 patients, median age 24 (range 16-53, interquartile range (IQR) 21-32) years were investigated 5 (3-9; IQR 4-7) years after their injury. Median ISS was 34 (21-57; IQR 26-41) and GCS 6 (3-8; IQR 4-7). Duration of coma was 10 (2-51; IQR 7-22) days and neurological rehabilitation lasted 169 (10-830; IQR 80-300) days. Movements of the elbow and ankle was most impaired by injury. All psychometric tests showed deficits, particularly in speed of processing, concentration, recent memory, and learning performance. The social environment had been changed in half and vocational rehabilitation was dependent on age. 24 (42%) returned to their former profession, 18 (31%) were retrained to another profession, 16 (27%) were unemployed or retired on a pension. 31 (53%) made a good recovery with moderate disability, 19 (33%) had severe disability, and 8 (14%) remained in a persistent vegetative state assessed by the GOS., Conclusion: Early and concentrated rehabilitation facilitates functional, social, and neuropsychological reintegration.

Primary stabilization of major fractures in polytrauma patients is known to represent an important principle of treatment and has been shown to reduce the incidence of posttraumatic complications and of organ failure. However, in critically injured patients it has been discussed that extensive primary definitive treatment may also cause adverse effects due to its systemic burden by blood loss, loss of temperature etc. Patients who deteriorated unexpectedly following primary surgery have been named "borderline patients". In these patients it appears necessary to limit the amount of operative procedures, e. g. by performing temporary fixation of major fractures primarily. The threshold beyond which surgical procedures may cause more harm than good has not been well defined. This holds true especially for the duration of primary surgery. We investigated the clinical outcome in a large number of prospectively documented multiple trauma patients with respect of the duration of primary fracture stabilization. If a primary surgical procedure exceeded 6 hours in multiple trauma patients with an ISS of 25 points, patients demonstrated a significantly elevated ventilation time, an increased mortality, and a higher incidence of death from MOF in comparison with patients that were injured comparably, but were submitted to shorter primary operative procedures.

Objective: The purpose of this retrospective analysis was to evaluate whether systemic parameters that are used to characterize multiple organ dysfunction could also be used to predict the optimal time for amputation in patients failing limb salvage surgery following severe extremity injury., Methods: The principal criterion for the study group was a lower limb amputation following a type IIIb or IIIc open tibial shaft fracture in multiply traumatized patients. This group was then divided into one group of primary amputation (group A) and one group of secondary amputation (group B). Beside these groups a third group of total traumatic lower limb amputation was recruited (group C). Data analysis included demographics, injury severity according to the ISS, evaluation of the limb injury by three different salvage scores (HFS, MESS and NISSSA) and organ function monitoring by the Denver MOD Score over a 14-day period posttrauma or up to 7 days after secondary amputation., Results: Within the period 1987-1997 a total of 15 patients were recruited for group A (primary amputation), 10 patients for group B (secondary amputation) and nine patients for group C (traumatic amputation). The MOD score was only positive for pulmonary dysfunction, also reflected by the Horovitz quotient, in those patients that died later in either group. Mortality was higher in group A (three out of 15) compared with group B (one out of 10), which may be due to a higher ISS in group A (mean ISS 28.2 vs. 21.0 of group B). Although the MOD score of all recovered patients revealed no significant difference between group A and B, secondary amputation resulted in significantly longer demand of mechanical ventilation. According to our results secondary amputation may lead to transiently decreased pulmonary function but does not necessarily end in multiple organ dysfunction. The need for amputation in failed limb salvage was not indicated by systemic parameters., Conclusion: The right time for secondary amputation in order to prevent subsequent pulmonary dysfunction cannot be predicted by parameters otherwise indicating organ dysfunction. As the risk of secondary amputation for developing pulmonary dysfunction apparently cannot be estimated the decision for amputation or limb salvage should be made initially after trauma and should be the definite one.

Background: The major pathophysiologic role of cytokines such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-1, and IL-6, as well as of the (soluble) adhesion molecules ICAM-1 and E-selectin, has been identified using different experimental models of ischemia/reperfusion injury. Moreover, in intensive care management, evaluation of these agents as diagnostic or prognostic tools is of great interest in ischemia/reperfusion injury caused by surgical or accidental trauma. For this reason, inflammatory mediators including those mentioned above were investigated in three different groups of surgical patients., Methods: The first group (A, n = 13) comprised patients undergoing elective limb surgery without a tourniquet. The second group (B, n = 36) included patients subjected to limb surgery with a tourniquet. The third group (C, n = 30) was composed of accidental trauma patients who were retrospectively divided into those with and without multiple organ dysfunction (+MOD and -MOD, respectively) as defined by the Denver Score. Serial blood samples were taken during a 5-day (elective surgery) or 14-day (accidental trauma) observation period for monitoring of cytokines and soluble adhesion molecules. The clinical course and the degree of MOD were recorded daily., Results: Only when a tourniquet was applied for a mean time of 105 minutes did elective limb surgery result in significantly increased serum levels of IL-6, IL,-1ra, and IL-10 but not TNF-RII. Yet, the increase in cytokine levels was not sufficient to cause an enhanced shedding of adhesion molecules, and both soluble ICAM-1 and soluble E-selectin remained unchanged in groups A and B throughout the 5-day observation period. In patients with multiple injuries (group C), all parameters increased early after trauma up to 10- to 20-fold in comparison with the elective limb surgery patients in groups A and B. When the accidental trauma patients were divided according to the Denver Score for +MOD (n = 8, mean Injury Severity Score = 33.8) and -MOD (n = 22, mean Injury Severity Score = 31.2), a clear difference became evident in serum IL-6 and IL-1ra levels within the first 4 days and in serum IL-10 levels for the first 2 days after trauma, with cytokine levels being significantly higher in the +MOD patients 3 to 4 days before the onset of MOD. Although highly elevated, TNF-RII levels did not differentiate between +MOD and -MOD at any time. The increase in serum cytokine levels was associated with a remarkable expression and shedding of ICAM-1 and E-selectin made obvious by significantly increased soluble serum ICAM-1 levels in +MOD patients compared with the -MOD group between days 3 and 5 after trauma and increased soluble serum E-selectin levels between days 2 and 4 after trauma., Conclusion: The release of cytokines and soluble adhesion molecules into the circulation correlates well with the degree of trauma (elective surgery vs. accidental multiple trauma), depending on the extent of the associated ischemia/reperfusion injury. Both groups of mediators are also clearly related to the development of MOD in patients with multiple injuries with generalized ischemia/reperfusion injury caused by hemorrhagic shock. They may be predictive of patients at risk for MOD when measured early in the posttraumatic period.

Numerous epidemiological studies about multiple trauma patients do not include an analysis of patients under the age of 18. To study this, the data of 682 patients with multiple traumata, treated between 1981 and 1991 at Hannover Medical School, Germany, were retrospectively analyzed. The patients were divided into four age-related groups: preschool age (< 6 years), school age (< 13 years), teenagers (< 18 years) and adults (> or = 18 years). Analyzed were the cause of trauma, localization of injuries and the cause of death. Children were less often injured as passengers in cars, but more often injured as pedestrians and bicyclists than adults. However, children showed a significant higher mortality than adults, with threefold increased risk of death when they injured as passengers in car accidents. In all groups injuries to the head and the legs were most common. Children showed a lower incidence of trauma to the thorax, abdomen, hip and arms than the adult group. Nevertheless, trauma to the thorax, abdomen and head was associated with the highest risk of death in all groups. Spinal cord injuries, especially injuries to the neck, also showed a high risk of death. Children younger than 6 years had the most severe head injuries. Safety improvements for children in cars, helmet usage on bicycles and early training in traffic safety for children might decrease the lethality in this group of trauma patients.

Body positioning (kinetic therapy) is known to improve oxygenation in patients with impaired pulmonary function and ARDS. We have used body positioning prophylactically in trauma patients whose injury and pattern predispose to ARDS. This retrospective study reports the effects of early prophylactic (group P) versus late (group L) axial rotation on pulmonary function and the incidence of ARDS. Both groups were comparable in age, injury severity and the degree of thoracic injury. Systemic oxygenation was significantly better and the incidence of ARDS significantly lower in group P (group P: 34.3 per cent, group T: 74.1 per cent, P < 0.05). There was a tendency towards a lower incidence of pneumonia and a better survival in group P, which did not reach statistical significance. The duration of kinetic therapy and of ventilation was comparable in both groups. In this retrospective evaluation early prophylactic kinetic therapy was associated with a significantly lower incidence of ARDS compared with that instigated later.

Quality control in preclinical medical care has become a matter of concern in recent years. In order to evaluate the quality of treatment one has to set standards. Most of the current standards were defined by different preclinical care organisations and are also accepted in the unique emergency medical care protocol used in the Federal Republic of Germany. Considering these standards, we retrospectively analyzed the preclinical treatment of all multiple trauma patients admitted to our department between 1985 and 1996. The major issues of this analysis were the diagnoses, the indications for invasive measures and the performance. Regarding the triage, for example, it was noted that 28% of patients who should have been admitted to a level I trauma center considering the severity of their injury were first admitted to a level III hospital and needed to be transferred later. In 7% of patients two additional mistakes and in 4% of patients more than two mistakes in the triage were noted. On the other hand, there are records of patients who were considered to be only slightly injured but received invasive treatment. Preclinical intubation and mechanical ventilation was not performed in 16.5% although the severity of injury clearly demanded it. A thoracic drain tube was not positioned in 38% of patients suffering from severe thoracic trauma (AISThorax > or = 4). Insufficient application of resuscitation volume (< 2500 ml on admission) was evident in 17% of all documented patients. According to our results, the initial evaluation of severity of injury is still a major problem and leads to wrong decisions for treatment. Although the qualification of ambulance physicians has been standardized for some years, there are still clear deficits in the preclinical management of trauma patients that need to be targeted.

Within the last decade understanding of the pathogenetic consequences of trauma has been improved significantly. An additional reduction of lethality has been achieved that in part is related to increasing discrimination of complex injury patterns. Accordingly, additional staging in fracture management of these injuries has been developed. An overview of the current status of fracture management in polytrauma is given and certain regimens that are still controversially are discussed. The principles determined are based on the treatment experience of 4003 multiply injured patients within the past 23 years. The most important principles within the first hours after trauma represent adequate hemorrhage control. In fracture treatment the primary goal remains to perform primary stable osteosynthesis. In severe polytrauma with severe injuries to the extremities, the first decision is whether limb salvage can be achieved without risk of deterioration of the patient's condition. If this is the case, open fractures Grades III b and c usually can be stabilized primarily by unreamed intramedullary nailing or percutaneous plating. The priority pattern in multiple closed fractures is as follows: (1) tibia; (2) femur; (3) pelvis; (4) spine; and (5) upper extremity. Exceptions may ensue if severe head or thoracic trauma is present. Delayed treatment is performed for complex joint reconstruction, definitive treatment of maxillofacial injuries, and soft tissue reconstruction.

Previous studies in critically ill patients have shown the beneficial effects of early enteral nutrition supplemented with arginine, omega-3 fatty acids and nucleotides (Impact) on immunological response, infection rate and length of stay in hospital. No specific data exist for patients with severe multiple injury, who represent a high risk group for systemic inflammatory response syndrome (SIRS), septic complications and multiple organ failure (MOF). In this prospective, randomized, double-blind controlled clinical study on patients after severe trauma (ISS ca. 40) the primary study endpoints were incidence of SIRS and MOF [definitions according to Am Soc Crit Care Med (5) and Goris (23), Sauaia (43)]. Thirty-two patients enrolled in the study, and 29 were eligible for analysis: test (Impact) (n = 16), control (n = 13). Both groups were comparable according to age, body mass index and severity of trauma (PTS-test: 38.8 +/- 12.5, PTS-control: 40.8 +/- 15.5, ISS-test: 39.6 +/- 11.4, ISS-control: 40.5 +/- 9.2). Patients were randomized to receive either Impact (test) or an isonitrogenous isocaloric diet (control). Feeding was started on the 2nd day after trauma via endoscopically placed nasoduodenal or jejunal feeding tubes. The experimental diet was safe and well tolerated. During the 1st week the enteral feeding amount was about 2000 ml without significant difference. Test-fed patients developed SIRS significantly less frequently between day 1 and day 28 (8 vs 13.3; P < 0.05) and especially between day 8 and day 14 (3 vs 6.2; P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16 and 17 and the Sauaia score on days 8, 9, 10 and 11 (P < 0.05; P < 0.01). Mortality rate did not significantly differ (test 2/16, control 4/13), nor did length of ICU or hospital stay. With regard to the acute-phase response, C-reactive protein was significantly lower on day 4 in the test group (test: 131 +/- 67 mg/l, control: 221 +/- 110 mg/l) as was fibrinogen on day 12 (6.6 +/- 1.4 vs 7.5 +/- 1.4 g/l) and day 14 (7.1 +/- 1.3 vs 7.8 +/- 0.8 g/l). No significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin (II)-2-receptor- and II-6 level. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the test group (P < 0.05). According to the results, arginine, omega-3 fatty acids and nucleotides-enriched diet during early enteral feeding leads to reduction of SIRS after severe multiple injury. There is evidence for improvement of post-traumatic immunological response which helps to overcome the immunological depression after trauma.

Multiple organ failure is with an incidence of 10-25% and a mortality of 50-70% the most severe complication after severe trauma. Intestinal ischemia and a corresponding impaired gut barrier function is thought to have a high impact on the development of multiple organ failure after severe trauma. Under normal conditions the intestinal wall is a sufficient barrier against bacteria and their products. Gut ischemia is followed by mucosal lesions, the intestinal permeability is increased. Translocating bacteria and bacterial products (endotoxin, peptidoglykan) can lead to a local and/or systemic immun-inflammatory response, which is made responsible for the development of multiple organ failure. Tonometry as a possibility of monitoring intestinal ischemia as well as a tool to estimate the prognosis of multiple trauma patients is still discussed controversially. Dopexamin, which directly influences intestinal ischemia (goal directed therapy) might be a successful treatment option, however until now no clinical study about beneficial effects of dopexamine in severely injured patients is available. Selective gut decontamination showed no clinical benefits in multiple trauma patients. Early enteral nutrition especially with immunomodulating ingredients ("immunonutrition") decreases posttraumatic complications as well as the incidence of MOF. However a reduction of mortality could not be described in severely injured patients so far.

In this prospective, randomized, double-blind controlled clinical study, 29 patients after severe trauma (ISS about 40) were randomized to receive either IMPACT (Test) or an isonitrogenous isocaloric diet (Control). The primary study endopoints were the incidence of SIRS and MOF (definitions according to Bone, Goris and Sauaia). Test-fed patients developed significantly less SIRS between days 1 and 28 (8 vs 13.3, P < 0.05) and especially between days 8 and 14 (3 vs 6.2, P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16, 17 and the Sauaia score on days 8, 9, 10, 11 (P < 0.05, P < 0.01). According to the results, an arginine, omega-3-fatty acids and nucleotide-enriched diet during early enteral feeding leads to reduction of SIRS and MOF scores after severe multiple injury.

The complex injury is characterized by a fracture and/or dislocation of the elbow in association with a serial injury of the upper extremity, or a severe soft tissue trauma, or a prolonged ischemia caused by vascular injury or compartment syndrome. They are defined as complex injuries because their treatment differs from that of a simple fracture implying that standardized concepts usually cannot be employed. The results of primary treatment show a high rate of complications. They are accompanied by functional deficits including pseudarthrosis and ankylosis. As a consequence, ulnar neuropathy may occur. Inadequate treatment leads to delayed rehabilitation and several secondary operations. The main goal points at the reconstruction of the elbow joint to restore function. Therefore, the logistical pathway of individual therapy is the key for success. The operation has to include fracture stabilisation of all injuries of the upper extremity. Only stable osteosynthesis makes early mobilisation possible. Transfixation of the elbow joint should be reserved for exceptional cases. The principals of AO have proven to be practical both for the distal humerus and the proximal forearm. Successful reconstruction of the elbow joint often demands extended approaches. ORIF of the proximal ulna can be achieved by indirect reposition techniques. Dynamic stabilisation should be established by conservation of the radial head and coronoid process. For treatment of soft tissue injury it is necessary to undertake local reconstructive measures. Operative treatment is widely indicated for forearm compartment syndrome. Diagnosis and therapy of possible accompanying vascular injury should be made early to avoid prolonged ischemia. Operative treatment of nerve injury is only indicated in case of sharp dissection of the nerve. Otherwise the reconstruction should be performed, but not earlier than three months. Rehabilitation outcome depends on primary therapy. Sufficient functional results are only achieved after early mobilisation and intensive physiotherapy. If necessary, arthrolysis is planned early and combined with removal of implants at 6 months post injury.

A total of 208 multiple trauma patients with head injury (HI) were investigated who had been treated in the period from 1990 to 1995. The average age was 35.2 +/- 17.7 years; the injury severity according to ISS was 30.2 +/- 8.6 points; 20.5% died as a result of the HI; the mortality of all patients was 26.5%. The Glasgow Coma Scale (GCS) was determined at an average of 22 min after trauma (8.0 +/- 4.3 points) at the scene of accident. The patients were classified according to GCS into minor HI (group 1: 14-15 points), moderate HI (group 2: 9-13 points) and severe HI (group 3: 3-8 points). Patient outcome was assessed by the Glasgow Outcome Scale (GOS) and was classified as good (GOS 4 and 5) and poor (GOS 1, 2 and 3) outcome. At the latest, 2 h after trauma, a CT scan of the head (CCT) was done. The HI groups are compared regarding frequency of types of injury. In all HI groups the fractures of the bony face occurred at the same frequency (36.0-38.9%). The frequency of calotte fractures (Kal-Fx) increased from group 1 (8.0%) to 2 (19.2%) and 3 (25.6%); fractures of the skull base significantly differed between group 1 (16.0%), 2 (7.8%) and 3 (33.4%). Epidural hemorrhage (EDB) appeared only in group 2 (7.8%) and 3 (6.7); subdural hemorrhage was found in group 1 (2.7%), 2 (7.8%) and 3 (10.0%). Subarachnoid hemorrhage (SAB) was significantly more frequently seen, dependent on HI severity, in group 3 (26.7%) compared to group 2 (11.7%) and 1 (8.0%). Intracerebral contusion (ICK) significantly increased from group 1 (12.0%) to 2 (27.3) and 3 (45.6%). Brain swelling (BS) also significantly increased from group 1 (8.0%) to 2 (19.5%) and 3 (49.0%) and lesions of ventricles (VL) from group 1 (2.7%) to 2 (11.7%) and 3 (20.0%). Midline shift (13.4%) and signs of herniation (4.5%) only occurred in group 3. The analysis of correlation/regression and receiver operating characteristics was able to predict 79% of patients' outcome accurately using GCS (r 0.54; P < 0.0001) alone, using CCT (r 0.65; P < 0.0001) 87% were correctly predicted with significant variables Cal-Fx, EDB, SAB and BS. CCT with GCS (r 0.74; P < 0.0001) were able to predict 88% accurately with significant variables Cal-Fx, EDB, BS and GCS. The combination of CCT with GCS, age and ISS (r 0.78; P < 0.0001) was able to predict only 87% correctly, although the r value was the highest; significant variable were Kal-Fx, EDB, BS, VL, GCS, age and ISS.

The aim of this study was to identify, in (pre-) clinically obtained data, parameters predicting the outcome of patients with multiple trauma and severe head injury. Fifty-eight patients aged 27 +/- 10 years were investigated an average of 5.8 years after the accident. The Hanover Polytrauma Score was 34 +/- 11 points, the initially assessed Glasgow Coma Scale (GCS) was 6.2 +/- 3.2 points; and the duration of coma was 15.4 +/- 14.4 days. The primary length of stay in hospital averaged 33.4 days, including 22.9 days in the intensive care unit and 20.2 days of ventilation. For a further 223 days the patients were treated at the Neurologic Clinic of Hessisch Oldendorf. Besides different neurologic deficiency symptoms, the psychometric tests showed deficits in all areas. In particular, information processing speed, concentration, recent memory and learning performance were impaired. There was free mobility of all joints in 33% of the patients. Due to injury the elbow and ankle joint developed the worst restriction. Central paralysis and heterotopic ossification also caused a restriction in joint mobility. Half of the patients were confronted with different social changes. The rate of return to work was dependent on age. Some 42% of all patients had taken up their former profession, 5% were still in training or at college, 32% were retrained to other professions, 16% were unemployed and 5% were completely retired on pension. Age, injury severity, GCS, duration of coma and duration of weaning were suitable predictors in correlation- and regression analysis. The Glasgow Outcome Scale showed good recovery and moderate disability in 53%, severe disability in 33% and persistent vegetative state in 14% of the patients.

Background: Multiple organ failure is regarded to be the major complication of trauma victims treated in the intensive care unit. Long-term rehabilitation results of this special group of patients have not been analyzed so far., Methods: Fifty patients with multiple injuries and multiple organ failure (Injury Severity Score > or = 36.8) were followed-up 4.9 +/- 0.3 years after the trauma. To show any organotopic sequelae, laboratory tests for the function of lungs, liver, kidney, and the hematologic system were performed. Additionally their functional (locomotion and neurologic system) and occupational rehabilitation results were investigated., Results: The laboratory tests showed entirely normal results. The only pathologic values could be found in the lung function tests. Nineteen percent of the patients showed nonphysiologic results in either spirometry, body plethysmography, or diffusion capacity of carbon monoxide. In more than 25% of the patients, permanently decreased range of motion (limitation of more than 30% of the entire range of motion) of the elbow, hip, knee, or ankle joint were found. In 40% of the patients, permanent motoric nerve lesions were identified; in 50% of the patients, permanent sensoric nerve lesions could be verified. The return to work rate was 60%., Conclusions: Patients with multiple injuries, who survived multiple organ failure during their long-term intensive care treatment, show an excellent functional and occupational rehabilitation result. They show no major sequelae in their organ function even years after the trauma. Although often these patients suffer from permanent central or peripheral paralysis and decreased range of motion, this finding does not correlate with the patients' ability to return to work.

We report on the case of a pneumonia caused by Bacillus cereus in a patient who sustained severe thoracic trauma, fractures of ribs 3-12, left lung contusion and haematopneumothorax. Bronchoscopic alveolar lavage (BAL) performed on ICU day four helped identifying the underlying cause of pneumonia. Inspite of early diagnosis and antibiotic treatment with clindamycin, cefotaxim and tobramycin, which rapidly eliminated the bacteria from the patient's lungs, the patient eventually died from the severe underlying injuries. However, this case emphasises that early performed BAL and rapid microbiological staining techniques can help diagnose pneumonia in critically ill patients. We also review the literature on pulmonary infections caused by Bacillus cereus.

The improvement of rescue systems and on-scene therapy has lead to a significant reduction of early posttraumatic death. It was the goal of this study to critically analyse the value of prehospital care in respect to early but also to delayed complications (single = SOF or multiple organ failure = MOF) In a retrospective analysis 1223 polytraumatized patients treated during 1984 and 1994, with an injury severity of more than 20 points according to the Injury Severity Score = ISS, on-scene therapy ("field stabilization") was evaluated. We could show that a sufficient preclinical airway management has major influence on late prognosis (MOF). We therefore definitely recommend early intubation at the scene in these patients. The intravenous access at the emergency place is always necessary independent whether the patient is in hemorrhagic shock or not. Loss of time can increase shock mechanisms making intravenous access even more difficult. If there is already a peripheral vasoconstriction and the localisation of an peripheral vein renders more difficult, one possibility is a venae section to get safe access. Concerning the amount of preclinical infusion controverse opinions exist. Our evaluation could not give an satisfactory statement because of a differing high incidence of mass bleeding in the groups with low (< 1000 ml) and high (> 2000 ml) preclinical infusion. The improvement of rescue systems and on-scene therapy has lead to a significant reduction of early posttraumatic death. Especially in those injuries, that are directly associated with the development of early death, i.e. intracranial bleeding, massive hemorrhage from thoracic and intraabdominal lesions these regimens on scene improved survival significantly (Fig 1) (Trunkey 1983). Nevertheless it is still discussed whether a longer rescue time is then justified to intensify on scene therapy. Recent publications demonstrate for instance that infusion therapy beginning on scene is not always necessary and sometimes especially in severe hemorrhagic shock can even aggrevate bleeding (Bickell 1989, Bickell 1991, Bickell 1993, Crawford 1991, Gross 1988, Stern 1993). On the other hand the value of on scene intubation and ventilation and chest tubing in these patients is critically discussed (Mattox 1989). Most of these studies however have their origin in the USA and are related exclusively to penetrating trauma (knife and gunshot wounds), which is completely different from underlying pathomechanisms (pure hemorrhagic shock). Only one reports of the same experience with blunt trauma (Barone 1986). Thus for severe blunt trauma the question is still open: "field stabilization" or "load and go" (Krausz 1992). A decision that always has to be related to the definite rescue time (Smith 1985). It was the goal of this study to critically analyse the value of prehospital care in respect to early but also to delayed complications (single = SOF or multiple organ failure = MOF).

Early enteral nutrition is widely accepted for its support of organ structure and function ("gut injury hypothesis") and reduction of infectious complications and hypermetabolism in critically ill postoperative or postinjury patients. Nineteen severely injured patients (Injury Severity Score 40.3 +/- 11.6) were studied for the feasibility of early enteral nutrition via a duodenal feeding tube. Despite maxillary fractures, rhinoliquorrhea and blunt abdominal trauma the enteral feeding was mostly started immediately after trauma. Intermittent diarrhea or constipation resolved after reduction of the feeding rate within 1 or 2 days. Total enteral nutrition could not be realized in all cases; a central venous line was always additionally necessary. However, the goal was not complete enteral nutrition but a continuous enteral supply to maintain the integrity of the gut. The study has shown that early enteral nutrition via a duodenal feeding tube is also feasible in severely injured patients. The expenditure to overcome the technical and organizational problems seems to be justified. Enterally fed patients may have a better outcome that those in whom only parenteral is employed.

Multiple organ failure (MOF) is considered to be the leading cause of death after severe trauma. Although there is extensive literature on MOF, little is known about the pattern, sequence, and onset of this clinical syndrome. The first goal of this clinical study was to define MOF; the second was to assess the typical onset, sequence, and pattern of MOF; and the third was to define certain risk factors for the development of MOF in 342 multiple trauma patients. Patients with an Injury Severity Score (ISS): > 20 (mean 35.7) were included. Three well established MOF scoring methods were used to give strict definitions of MOF: 11.4% of the total patient population developed MOF, and 88.6% did not. Respiratory failure was most frequent in patients developing MOF (74.4%), and these patients had the highest mortality rate (65.5%) compared to patients with failure of other organ systems (liver, cardiovascular system). Generally, the lung is the first organ to fail after injury (failure after 3.7 +/- 2.8 days). Significant renal failure and the need for dialysis decreased to < 5%; other signs of organ dysfunction (gastric, central nervous system) are difficult to verify. Typical risk factors for the development of MOF after severe trauma are the severity, type, and distribution of injury as well as the indicators of prolonged hemorrhagic shock (elevated lactate levels). The main therapeutic efforts, therefore, should be the effective treatment of traumatic hemorrhagic shock during the initial phase, adequate resuscitation, optimal oxygenation, and early surgical treatment.

In this study a group of 104 multiply injured patients (mean ISS = 34) was examined for physical status and social reintegration. Essentially it was noted that 76 per cent of all patients were able to return back to work, although this appears to be age dependent. Open fractures of the leg seem to be the dominating prognostic factor for reintegration resulting in a disability rate of between 20 and 50 per cent. Disability of more than 80 per cent was only due to major head injury. Apparently reintegration is linked to the pattern of injury and is less related to the overall injury severity. We conclude that trauma care is economically cost effective but also needs further standardization and subsequent outcome analysis.

Hypothermia is a frequent event in trauma patients and appears to be related to posttraumatic organ dysfunction, although in elective surgery hypothermia is known to prevent ischemia reperfusion injury. Retrospectively, we analyzed data of 641 trauma patients treated in our institution between 1988 and 1993. At hospital admission the core temperature (cT) was > 34 degrees C in the majority (64%) of all patients, < 34 degrees C in 23.6% and < 32 degrees C in 12.4%. At 24 99% had cT of > 34 degrees C. Lethality was twice as high (53%) in patients with cT < 32 degrees C as in patients with cT > 34 degrees C (28%). Analysis of correlation revealed that hypothermia was paralleled by a longer rescue time, greater severity of limb injury, and hypoxia. It also appeared that hypothermia is not an independent prognostic factor for posttraumatic lethality. The different effects of hypothermia in trauma and elective surgery may be due to a lack of energy-storing phosphates such as adenosine triphosphate (ATP). Ongoing investigations will identify the role of ATP in trauma-related hypothermia.

High-velocity trauma now often results in complex injuries to the upper extremity, and especially the elbow joint. These can lead to both an enormous reduction in the range of motion of the shoulder, elbow and wrist joints, in severe cases with complete loss of upper extremity function. A complex injury is defined as a fracture and/or dislocation of the elbow in association with (1) a serial injury of the upper extremity, (2) a severe soft tissue trauma, or (3) concomitant injury to vessels or nerves. Serial fractures, in particular can lead to enormous problems with treatment and are often associated with special complications. A standardized operative approach therefore seems essential. An analysis of our patient populations was made to compare the frequency of different injury types, develop specific treatment regimens, and document the clinical course. We made a retrospective analysis of patients admitted to our facility between 1981 and 1992, with particular reference to cause of accident, severity of injury (ISS), type of fracture of the upper extremity (according to the AO classification), extent of soft tissue trauma and whether closed or open, and the concomitant injuries (vascular, compartment and nerve lesions). Type and sequence of therapy and any complications were noted, and the clinical course up to consolidation was recorded. The functional result (i.e., ROM, neurology) was observed at primary discharge and 12 weeks, 6 months and 2 years later. In the time period mentioned 224 complex injuries of the elbow region were noted. Often MVAs were the cause of the complex trauma (39% car/30% motorcycle). The average injury severity was scored as 32 (ISS) in these, mostly polytraumatized, patients (68%). The most frequent fracture combination at the elbow region was combined with C2/C3 fractures of the distal humerus (57%) and proximal ulna (43%). A very commonly seen complex injury was the Monteggia equivalent, with fracture dislocation of the proximal ulna. Most (82%) of the injuries at the elbow region were open, and open lesions were similarly frequently seen at the forearm shaft. The most frequent concomitant injuries was were to the nerves (63.5%) and the plexus. A compartment syndrome developed in 23.8%. This complication was frequently seen in multiple trauma patients after primary resuscitation (extensive volume therapy) and in serial fractures with more than three associated lesions. In 67% of these complex injuries a definitive operation was performed as primary treatment (in the first 24 h after injury). Debridement of open fractures and fasciotomy in compartment syndrome of the forearm are standard techniques in the initial care. In serial fractures all concomitant (humerus, forearm, wrist, etc.) fractures were operated on primarily. This primary treatment included ORIF of humeral and forearm fractures in 76%. In patients with multiple injuries (ISS > 30) primary treatment was not possible in 37%, and in these cases transfixation of the elbow joint was performed. Other indications for transfixation were severe comminution of the elbow joint, impossibility of achieving complete stability after ORIF, extensive soft tissue injuries, with healing dependent on short-term immobilization, and finally status following extensive ligamentous reconstruction. The most frequent permanent disturbance was a persisting nerve lesion in our patients. A significantly reduced range of motion (30% deficit flexion/extension) was mostly seen at the elbow (17%), most frequently associated with serial fractures (> 3 associated injuries) and with severe semicircular soft tissue trauma. The most severe injury in combined trauma of the upper extremity is a serial fracture in the elbow region. Such fractures are often associated with vascular and nerve lesions. Even with primary fracture stabilization and early soft tissue management these often end with significant functional deficits.(ABSTRACT TRUNCATED)

In this study multiple trauma patients with severe head injury showed a different functional, neuropsychological and social outcome depending on several clinical parameters. In a stepwise regression analysis age, injury severity, Glasgow Coma Scale, length of coma and weaning time were proved to be suitable predictors. During the intensive care stay an early prognosis on severe head injury patients is possible.

The prognostic value of a dynamic liver-function test, based on the hepatic conversion of lidocaine to monoethylglycinexylidide (MEGX), in predicting multiple organ failure (MOF) was prospectively investigated in 28 critically ill patients after multiple trauma. The MEGX test and conventional static liver tests (bilirubin, aspartate aminotransferase, glutamate dehydrogenase and factor V) were performed on days 1, 3, 5, and 7 after trauma and patients were classified by a modified MOF score into a group without (n = 18) and a group with the MOF syndrome (n = 9). All patients who subsequently developed MOF, however, displayed a sharp decrease in their MEGX values between days 1 and 3.

The aim of this study was to investigate criteria in the preclinical and early clinical treatment which contribute to the development of posttraumatic multiple organ failure (MOV). In a retrospective study, 1112 primarily treated patients with multiple trauma and an injury severity > 20 on the Hanover Polytrauma Score (PTS) were investigated. The patients were classified according to Goris into groups with MOV (+MOV; 16.8%) and without MOV (-MOV). Patients with MOV had a significantly higher injury severity score (39.1 vs 33.7). A significantly higher proportion of +MOV patients had severe trunk injuries: thorax (85.2% vs 68.9%), abdomen (37.0% vs 26.1%) and pelvis (49.4% vs 35.6%). -MOV patients had significantly more injuries of the extremities (83.6% vs 72.8%). Differences in preclinical management were seen. The proportion of helicopter transports was significantly higher in the -MOV group (67.9% vs 57.8%). A positive effect was seen for early preclinical intubation. Patients who were intubated before arrival at the hospital had the same rate of MOV incidence as late intubated patients, but they had significantly higher (trunk) injury severity. +MOV patients received a significantly higher quantity of fluid replacement. In particular, more blood units and fresh frozen plasma were given in the first 24 h after trauma, possibly in association with the trunk injuries and the consequently increased hemorrhage. The mortality for all patients was 27.2%, in the +MOV group 60.4%. Posttraumatic MOV was the most frequent cause of death (37.5%), and the mean time of death after MOV was 16.7 days.

In the past various attempts have been made to develop a standardized animal model of multiple organ failure (MOF). Until now there has been no large animal model, that imitates the clinical situation of multiple trauma patients up to MOF. In a manner similar to the pathophysiological sequence in multiple trauma patients, the combination of damaging mechanisms in the early phase (hemorrhagic shock, operating trauma, application of endotoxin (ET; 0.75 microgram/kg body weight) and zymosan-activated plasma (ZAP; 20 ml) every 12 h on days 1-5) leads to sequential irreversible damage to several organs in the late phase (> day 6) in sheep (n = 10). In this animal model representative organ parameters showed a similar course to that in MOF after multiple trauma in humans. The cardiac index increased significantly in the late phase (day 1: 6.47 +/- 0.41 ml/min x m2; day 10: 10.36 +/- 0.79 ml/min x m2), arterial oxygen pressure declined significantly (day 1: 103.1 +/- 1.6 mmHg; day 10: 89.8 +/- 4.2 mmHg). Liver function was impaired, bilirubin levels showed a significant increase (day 1: 2.94 +/- 0.34 mumol/l; day 10: 7.19 +/- 0.91 mumol/l). Creatinine clearance was low on day 1 (54.3 +/- 7.4 ml/min), increased up to day 5 and deteriorated again significantly in the late phase over the entire period (day 2: 104.3 +/- 26.8 ml/min; day 10: 53.1 +/- 17.6 ml/min).

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.

In multiple trauma patients with lung contusion, pulmonary complications have been reported that were attributed to intramedullary stabilization of the femur. The reaming procedure of the medullary canal is thought to play a major role. We investigated whether different types of reamers might exert different amounts of fat mobilization into the vascular system and different degrees of pulmonary dysfunction. Adult female Merino sheep were submitted to hemorrhagic shock (2 h, 50 mm Hg) and a unilateral lung contusion; in addition, a lung lymph fistula was created. Pulmonary capillary permeability, central venous triglyceride levels, 11-dehydro-thromboxane B2 (dh-TXB2) levels, and pulmonary artery pressure were determined. After recovery, animals were randomly assigned to intramedullary femoral nailing using several types of reamers: group A, AO reamer (n = 8); group B, Biomet reamer (n = 7); group H, Howmedica reamer (n = 6); group C, controls, no reaming (n = 4). Intramedullary reaming caused a significant (p < 0.05) increase in pulmonary artery pressure in groups A and B; dh-TXB2 levels increased in all groups. Statistically significant (p < 0.05) pulmonary capillary permeability damage was measured in group A only. Intramedullary femoral nailing can cause transient pulmonary hemodynamic and mediator effects as well as increased pulmonary capillary permeability. In the present study, this effect was evident in group A reamer systems only, which may be due to reamer construction.

Gut permeability was studied in multiply injured patients with respect to the development of multiple organ failure (MOF). Two groups were defined according to MOF score (threshold 10 points) as to whether MOF developed (group 1; n = 11, four deaths) or did not (group 2; n = 21, no death). Gut permeability was determined from the ratio of urinary excretion of enterally administered lactulose and mannitol. Serum elastase concentrations were also determined. Mean(s.e.m.) gut permeability was abnormal during the entire study (day 1: group 1--5.1(2.1) versus group 2--10.6(4.1) (P not significant; P < 0.001 versus normal volunteers, 0.56(0.24)). An increase on days 3 and 5 correlated with serum elastase levels only in patients in group 1 (rs = 0.71, P < 0.01). Severe injury leads to increased intestinal permeability, which is related to a systemic inflammatory response.

Scoring systems are nowadays said to be helpful in decision-making in preclinical and early clinical treatment of multiple trauma patients. To evaluate the importance of these scores in daily routine, we analysed the scores routinely used in our department at the Hannover Medical School. We present three scoring systems: the Polytrauma Score, the Pelvis Score, and the Hannover Fracture Scale. All of these have certain qualities relevant to the aspects of decision-making and prognostic value. The evaluation demonstrates that these scoring systems are genuinely helpful, especially for the inexperienced.

A random group of multiple traumatized patients (n = 50) was compared from the aspects of physical rehabilitation and social reintegration with a group of multiple traumatized patients (n = 54) all of whom had serial fracture of the lower extremity. In both groups automobile accidents were the main reason for the injury (in 62%). Motorcycle accidents were responsible in 29% of cases but resulted in twice as many extremity injuries as car accidents, in addition to which the treatment of patients with serial extremity injury lasted twice as long as that of those patients with only single extremity injury. In 40% of the first group more than two secondary hospital treatments were necessary. Two years after trauma working capacity was reduced by less than 20% in only 28.8% of patients with serial injuries as against 69.2% in the randomized group. Reduction of working capacity by more than 80% was observed in only 9% of patients in both groups. In these cases reduction of working capacity was mainly due to severe head injuries and not to limb fractures. Return to work was achieved only after retraining in most such cases, while in others a transfer within the same company made it possible. When patients were asked for their own opinions on the final results of treatment, 75% said they were satisfied. Our results underscore the importance of reestablishing normal function and of reintegration after extremity injuries but also the problems involved.

In the treatment of adult respiratory distress syndrome (ARDS) no breakthrough has been achieved so far. In several cases of severe ARDS in multiply injured patients we have seen improvements of lung function by means of continuous body positioning. We therefore compared the effect of kinetic positioning (KIN) on lung function and haemodynamics in ARDS patients with conventional (CON) supine positioning. Pulmonary and systemic haemodynamics were determined on the basis of pulmonary artery catheter measurements. On a daily basis oxygenation ratio (PaO2/FiO2) and pulmonary shunt (Os/Ot. per cent) were calculated. Extravascular lung water (EVLW, ml/kg BW) was determined by the double indicator thermodilution technique. Twenty-two patients were included: KIN, N = 11, CON, N = 11. Mortality from ARDS in KIN patients was 18.2 per cent (N = 2): in CON patients it was 63.6 per cent (N = 7). The oxygenation ratio (PaO2/FiO2) increased significantly in KIN patients from 140 + 45 (day 0) to 237 + 40 (P < 0.05) (day 5); in CON patients no improvement was seen (143 + 48 (day 0). 133 + 44 (day 5); n.s. between groups at day 0: P < 0.05 between groups at day 5). Pulmonary shunt decreased significantly from 26.6 + 4 per cent (day 0) to 12.5 + 2 per cent (day 5) (P < 0.05) in KIN patients and was 36.6 + 6 per cent at day 0 and 31.4 + 2 per cent at day 5 in CON patients (P < 0.05 between groups at day 5).(ABSTRACT TRUNCATED AT 250 WORDS)

In the treatment of posttraumatic adult respiratory distress syndrome (ARDS) so far no breakthrough has been achieved. In several cases of severe ARDS we have seen improvements of lung function by means of continuous body positioning. We therefore compared the effect of kinetic positioning (KIN) on lung function and hemodynamics in ARDS patients to conventional (KON) supine positioning. 22 ARDS patients with multiple trauma treated by supportive continuous body positioning (KIN) (KCI-Mediscus) and without continuous positioning (KON) were investigated daily. Pulmonary and systemic hemodynamics were determined on the basis of pulmonary artery catheter measurements. Oxygenation ratio (PaO2/FiO2) and pulmonary shunt (Qs/Qt,%) were calculated. Extravascular lung water (EVLW, ml/kg body weight) was determined by double indicator thermodilution technique. Total injury severity by injury severity score (ISS) was 29.6 +/- 6 points (KIN) and 31.6 +/- 5 points (KON). The oxygenation ratio (PaO2/FiO2) increased significantly from 140 +/- 45 (day 0) to 237 +/- 40 (p < 0.05) [day 5] (KIN), in KON patients no improvement (143 +/- 48 [day 0], 133 +/- 44 [ay 5]) was seen (p < 0.05 between groups). There were no significant changes of systemic hemodynamics between the groups or compared to day 0. Pulmonary shunt decreased significantly from 26.6 +/- 4% (day 0) to 12.5 +/- 2% (day 5) (p < 0.05) in KIN patients and was 36.6 +/- 6% at day 0 and 31.4 +/- 2% at day 5 in KON patients (p < 0.05 between groups). EVLW was 11.1 +/- 2 ml/kg body weight at day 0 and 9.4 +/- 1 ml/kg body weight at day 5 (KIN)-EVLW was 12.9 +/- 2 ml/kg body weight at day 0 and 17.4 +/- 3 ml/kg body weight at day 5 (KON) (not significant). We found no hemodynamic side effects from continuous body positioning. In ARDS-patients submitted to body positioning oxygenation and pulmonary shunt improved significantly and were significantly better compared to those with conventional supine positioning. Continuous body positioning appears to represent a promising supportive treatment regimen in posttraumatic ARDS.

We investigated the effects of primary (< or = 24 h) intramedullary femoral nailing on lung function and pulmonary hemodynamics in patients with multiple trauma. Two groups were separated: the group with primary femoral nailing with reaming (group RFN) was submitted to femoral nailing after reaming of the medullary canal; in the group with unreamed femoral nailing (group UFN) a small-diameter solid nail was inserted without reaming. Lung function was assessed by oxygenation ratio (PaO2/FIO2), and pulmonary hemodynamics by intraoperative pulmonary artery catheter measurements. Central venous blood concentrations of elastase and the platelet count were determined during and 3 days after surgery. Lung function was stable in UFN patients (n = 14), but deteriorated in RFN patients (n = 17) from 353 +/- 24 (PaO2/FIO2 preoperatively) to 260 +/- 28 (PaO2/FIO2 postoperatively) (p < 0.05) and improved only after 48 hours. Pulmonary artery pressure (PAP) did not change during surgery in UFN patients; in RFN patients PAP increased from 27.2 +/- 3.1 mm Hg (preoperatively) to 36.3 +/- 4.1 mm Hg (p < 0.05) upon reaming and normalized 1 hour after insertion of the nail. Femoral nailing after reaming represents a potential risk with respect to lung function disturbances. This might trigger the development of adult respiratory distress syndrome (ARDS), especially in patients at extra risk of this complication (additional lung contusion, "borderline patient"). In these cases unreamed femoral nailing might offer an alternative by allowing primary intramedullary stabilization without the risk of adverse effects to the lung.

The treatment data on 3,406 patients with multiple injuries were analyzed retrospectively from the viewpoint of quality control. The diagnosis, therapy, complications and course were documented and the treatment results of two decades (1972-1981 and 1982-1991) compared. Young people with an average age of 31 years were mostly affected: 86% had fractures (40% open injuries), 69% head injuries and 62% thoracic trauma. Head injury together with thoracic trauma was the most frequent injury combination and affected the duration of ventilation therapy and the intensive care course. The relationship between the kind and severity of injury [categorized according to the Hannover Polytrauma Score (PTS)] and the lethality rate was significant. Preclinical treatment (infusion, intubation, thoracic tube) has increased in the past decade, and rescue time has been shortened. For the initial clinical diagnosis, ultrasound and the CT scan have been used more frequently. In patient treatment the elimination of massive hemorrhage still has first priority. Primary stabilization of long tubular bones, mostly of the lower limb, is aspired for. Volume therapy has changed over the last decade, so the risk of acute renal failure has been nearly eliminated. Nowadays late complications, e.g., multiorgan failure, are well in the foreground. Today at Hannover Medical School the average intensive care time is 13.7 days and the hospitalization time 31 days. When the two decades were compared, mortality was seen to have declined from 40% to 18%. In the future if the mortality rate is to be reduced further, this can only be done by treating the cause of post-traumatic organ failure.

In this randomized study we attempt to verify treatment results, rehabilitation and social reintegration of multiple trauma patients. Two to 4 years after the accident a clinical follow-up examination was carried out on 104 multiple trauma patients with an average age of 29.5 years who had 7.7 single injuries. Patients with injuries of the central nervous system still showed neurological disorders in 32%. The initially determined Glasgow Coma Scale did not correlate with the long-term prognosis of neurological disorders. Only 4 of 38 thoracic injuries had functional disorders-these patients had required long-term ventilation therapy (> 3 weeks). Former abdominal injuries showed no objective disorders in the follow-up. Most of the injuries to the extremities (79.7%) healed without functional disorder. Only patients with lower limb injuries still had complaints. At the time of the checkup 6.7% had still not been able to work (for more than 24 months) and 26.9% for more than 12 months. The disability rate was less than 20% in 64.3%, 7.2% more than 50% and 9.6% more than 80%. Most of these patients had severe head injuries. There was a relationship between reintegration at work and the age of the patients: 49.2% of patients younger than 25 years were working in their previous profession, 26.9% had here re-educated, and only 7.9% were unemployed. However, in the age group older than 25 years, only 29.2% worked in their previous profession and 12.2% had been re-educated. This follow-up study shows that in multiple trauma patients reintegration at work and in social life is possible.(ABSTRACT TRUNCATED AT 250 WORDS)

We investigated whether primary (< 24 hours) intramedullary stabilization of femoral shaft fractures in multiple trauma patients with severe thoracic injury might be associated with an increased incidence of adult respiratory distress syndrome (ARDS). A total of 766 patients with multiple trauma admitted to Hannover Medical School between January 1, 1982, and December 31, 1991, were investigated retrospectively. Of these, 106 patients met the inclusion criteria: Injury Severity Score > 18, femoral midshaft fracture treated by intramedullary nailing, primary admission or referral within 8 hours after injury, and no death from head injury or hemorrhagic shock. Two groups were differentiated according to the presence or absence of chest trauma (severe chest trauma = AIS thorax > or =, group T; no severe chest trauma = AIS thorax < 2, group N). Selection of subgroups according to the time of femur stabilization was group I < 24 hours after trauma, group II > 24 hours after trauma. Injury Severity Scores in the four groups were TI: 29.4 (n = 24); TII 31.4 (n = 26); NI 20.1 (n = 33); NII 25.4 (n = 23). In patients without thoracic trauma the ICU time (NI: 7.3 days; NII: 18.0 days) and intubation time (NI: 5.5 days; NII: 11.0 days) were lower in the patients treated primarily (p < 0.05). In patients with severe chest trauma there was a higher incidence of posttraumatic ARDS (33% versus 7.7%) and mortality (21% versus 4%) when early intramedullary femoral nailing was done. In the absence of severe chest trauma primary intramedullary femoral nailing is beneficial.(ABSTRACT TRUNCATED AT 250 WORDS)