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Traumatic brain injury (TBI) and hemorrhagic shock due to uncontrolled bleeding are the major causes of death after severe trauma. Mortality rates are threefold higher in patients suffering from multiple injuries and additionally TBI. Factors known to impair outcome after TBI, namely hypotension, hypoxia, hypercapnia, acidosis, coagulopathy and hypothermia are aggravated by the extent and severity of extracerebral injuries. The mainstays of TBI intensive care may be, at least temporarily, contradictory to the trauma care concept for multiple trauma patients. In particular, achieving normotension in uncontrolled bleeding situations, maintenance of normocapnia in traumatic lung injury and thromboembolic prophylaxis are prone to discussion. Due to an ongoing uncertainty about the definition of normotensive blood pressure values, a cerebral perfusion pressure-guided cardiovascular management is of key importance. In contrast, there is no doubt that early goal directed coagulation management improves outcome in patients with TBI and multiple trauma. The timing of subsequent surgical interventions must be based on the development of TBI pathology; therefore, intensive care of multiple trauma patients with TBI requires an ongoing and close cooperation between intensivists and trauma surgeons in order to individualize patient care.

Background: The monitoring of intracranial pressure (ICP) represents a cornerstone in the intensive care of patients with traumatic brain injury (TBI) and the industry provides various technical solutions to this end. Decompressive craniectomy can be an option if conservative measures fail to reduce excessive ICP., Objective: To examine the pathophysiology of ICP in trauma, the management of polytrauma involving TBI, and the indications for decompressive craniectomy; and to compare the different monitoring systems and their complications., Material and Methods: A retrospective analysis of TBI patients between 2010 and 2016 was performed. Relevant publications are discussed, particularly those relating to the indications for monitoring and its influence on polytrauma management., Results: Between 2010 and 2016, 106 patients with closed TBI and a mean age of 65.9 years received a total of 120 ICP monitors, most of which were parenchyma devices (111/120), followed by intraventricular catheters (8/120), and one combined system (1/120). Of these patients, 27.4% had sustained polytrauma, whilst 33% regularly used anticoagulants. ICP monitors were removed after 8.5 days on an average and the mean ICU stay was 20 days. Probe insertion was combined with craniectomy in 69.8% patients. Probe-related complications, most commonly involving malfunction, were seen in 6.6%. The duration of monitoring was significantly related to polytrauma (p ≤ 0.001) and age <60 (p = 0.03). ICU stay was also significantly related to polytrauma (p = 0.02) and monitoring complications (p ≤ 0.001). Mortality was related to anticoagulant medication (p = 0.01) and age <60 (p = 0.03)., Conclusions: ICP monitoring is one of the most important tools in TBI treatment. The course and outcome of these severe injuries is affected by polytrauma, age, and the use of anticoagulants.

Accidental hypothermia is a common complication in severely injured patients. Risk factors include environmental exposure of the patient at the accident site or in the clinic, infusion of cold fluids, hemorrhagic shock and anesthetics which influence thermoregulation. In contrast to animal studies, human studies and clinical experiences have identified accidental hypothermia of the severely injured patient to be associated with increased complication and mortality rates. As a consequence, hypothermia together with acidosis and coagulopathy, have been coined the lethal triad in severely injured patients. On a cellular level hypothermia reduces cellular activity and metabolism resulting in reduced oxygen consumption, which is therapeutically used in patients following cardiac arrest. However, the activity of important enzymes, such as those of the coagulation pathway, is simultaneously down regulated. Hypothermia-induced coagulopathy, which is refractory to substitution of coagulation factors, is a major complication of hypothermia in traumatized patients. Therefore, hypothermic trauma patients with hemodynamic instability require aggressive rewarming.

Multiple trauma patients frequently demonstrate a hypothermic core temperature, defined as a temperature below 35 degrees C, already at admission in the emergency room. As a drop of the core temperature below 34 degrees C has been shown to be associated with a significant increase in post-traumatic complications, this limit is considered to be critical in these patients. Multiple trauma patients with hypothermia demonstrate a markedly increased mortality rate compared to normothermic patients with the same injury severity. Therefore effective rewarming measures are essential for adequate bleeding control and successful resuscitation. If and to what extent the induction of controlled hypothermia in the early phase of treatment on the intensive care unit after resuscitation and operative bleeding control can contribute to an improved post-traumatic outcome, has to be clarified in further experimental and clinical studies.

Pathophysiology of multiple trauma is characterized by different trauma-associated repercussions like organ destruction, haemorrhage, immune cell activation by foreign antigen, for example. The length of time while such impairments take hold of the organism substantially impacts the extent of the post trauma secondary injury. Short interruptions in microcirculation can mostly be compensated, whereas elongated ischemic periods definitely cause structural cell damage up to death. The current review highlights the importance of the time duration of posttrauma second hits on the pathophysiology of systemic inflammation and multiple organ failure. The quick termination of such secondary impairments by immediate therapeutic intervention mainly impacts the patients' prognosis.

Purpose: Is the measurement of continuous cardiac output useful for the management of polytrauma patients?, Methods: In a prospective non randomized study (ethic commission file 43/96) we evaluated the diagnostic and therapeutic impact of the CCO (continuous cardiac output measurement) for polytrauma patients on the ICU. The Baxter Vigilance System was used for measuring the continuous cardiac output. The CCO values were controlled once a day by the conventional "cold" thermodilution technique., Results: All values are given as mean +/- standard deviation. The Patients were scored on the first day for ISS (injury severity score) (47 +/- 17) and APACHE II (15 +/- 5). The CCO was used no later than 12 hours after the initial treatment in 20 polytrauma patients. As clinical outcome parameters were chosen: days on ventilation (23 +/- 23 days), days on the ICU (31 +/- 26 days) and mortality (20%). The treating ICU physicians were asked in a standardized questionnaire, whether or not there was an impact of the CCO measurement on their therapy. Seven different surgeons were working with the system., Conclusion: The unique opinion was that the CCO device had an impact on their decision making in the fluid and drug management of the study patients. Our first experience, however, suggests that this device may become an important improvement in the management of haemodynamics in the early trauma phases. Before a wide-spread application of this method on the ICU an evidence based prospective randomized trial should be performed.

Isolated severe head trauma (SHT) or SHT in combination with multiple injuries are important factors for the prognosis of morbidity and mortality in patients suffering from the consequences of accidents. The prognosis mainly depends on the presence of primary mechanic brain injury and the development of secondary brain damage. Causes for the development of secondary brain damage are the intracranial space demand after traumatic injury and edema formation which may result in iscemia, as well as inflammatory processes. Both isolated SHT and polytrauma with or without brain damage may result in a systemic inflammatory response syndrome (SIRS) due to the synthesis of cytokines and other inflammatory mediators which may cause a single or multiple organ failure (MOF). Often the organism is able to survive isolated traumatic injuries and functional disturbances, but in combination or cumulation they may be lethal. The hypermetabolism after SHT is often regarded as an interaction between the central nervous system and the whole organism by the activation of the neuroendocrine axis. In contrast to the consequences of SHT for the whole organism, multiple injuries after polytrauma may affect brain functions, such as the shock dependent disturbance of the brain perfusion accompanied by brain hypoxia which may lead to an aggravated prognosis. Moreover, coagulation, metabolism and fracture healing are influenced by the onset of SIRS as well. Our knowledge about the bidirectional inflammatory interaction between brain and whole organism is still limited. In this context, the effects of secondary surgical interventions which may additionally, stress a traumatized body have to be considered and are the subject for actual clinical discussions and experimental studies. This article tries to summarize some important aspects on this topic.

The benefit of early operative stabilization of femoral fractures is established in patients with multiple injuries. In the last few years the unreamed femoral nail is favoured for internal fixation of femoral fractures despite pathophysiological concerns. The foremost advantage of femoral nails compared with plate fixation is the possibility of early full weight bearing. The aim of this retrospective study was to investigate, under consideration of the severity of injury, the extent of injury, and the clinical course, if multiple injured patients with concomitant femoral fractures benefit from the preferred intramedullary nailing with early weight bearing. Three hundred and two (23.8%) out of 1271 multiple injured patients (ISS > 17) had a concomitant femoral fracture. Fourty-seven out of 302 patients were children under 16 years of age, remaining 255 patients. Eighteen out of 255 patients died within the first 21 days after trauma and 66 patients required mechanical ventilation for more than three weeks (171/255). Thirty patients suffered from severe head injury (AIS-head > 3) and seven from severe pulmonary contusion with concomitant abdominal injury (134/255). Two patients had grade III open femoral fractures with vascular injury. Ipsilateral unstable pelvic fractures were seen in 11 patients, seven patients had ipsilateral intraarticular femoral fractures, and ipsilateral intraarticular fractures of the lower leg or foot were observed in 40 patients (74/255). The results demonstrate, that only 74 (29%) out of 255 multiple injured patients (> 16 years of age) had a theoretical benefit of early weight bearing. Seventy percent of the patients did not benefit from intramedullary nailing considering full weight bearing. With regard to pathophysiological concerns alternative methods of fracture fixation should be discussed for these patients. Primary fracture fixation with external fixators and secondary internal fixation proved to be a save alternative method. The complication rate of plating is comparable to intramedullary nailing but associated with less severe systemic risks. Primary plating of femoral fractures would not delay mobilization of most multiple injured patients.

The blood loss during the acute period after complex pelvic trauma is finally responsible for the high mortality associated with this specific type of injury. Several protocols have been published for optimized management, but up to now comparable data are not available as no exact definitions exist judging the severity of trauma and blood loss. As part of a prospective study 19 patients after unstable pelvic injuries with unstable circulation underwent emergency stabilization by the pelvic C-clamp. Beside standard clinical parameter the initial hemoglobin value was converted into a "blood volume equivalent". 18 of the 19 patients had an injury severity according to group III and IV of the Hannover Polytrauma Score (PTS). Concommitant abdominal injuries were seen in 12 cases (23 injuries), concommitant urological injuries in 12 cases (14 injuries). In 13 cases the pelvis was the major source of bleeding in 9 cases an additional intraabdominal hemorrhage was observed. 11 patients died due to sequelae of their injury, 8 patients survived. Although the initial blood loss was comparable both in the group of the deceased patients and the survivors, a 44% higher subsequent blood substitution (= 10089 ml) was observed in the nonsurvivor group. In conclusion the data proofed that early control of hemorrhage is fundamental for the prognoses after complex pelvic trauma. The estimation of the blood loss may help in indicating aggressive emergency procedures like emergency stabilisation, pelvic clamps, surgical exploration and tamponade. This calculation may be a basis for a more detailed analyses of this devastating injury and judging the benefit of different management protocols.

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.

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.

The objective of this study was to evaluate and compare the derangement of body homeostatis and the inflammatory response after different types of traumatological operations in patients with multiple injuries. These were determined in a total of 60 operations. The procedures comprised osteosynthesis of the femur (n = 28), the pelvic girdle (n = 11) the spine (n = 8), and facial and basal skull reconstructions (n = 13). Specific and unspecific parameters of the inflammatory response were determined on the morning of the operation, immediately after the procedure, every 6 h on the 1st day and 48 h after the end of surgery. After all types of operations (pelvis, femur, spine, face/basal skull) significant alterations were observed for neutrophil elastase, C-reactive protein, interleukin 6, interleukin 8, antithrombin III, partial thromboplastin time and other parameters. The degree of postoperative changes differed significantly (Kruskal-Wallis test, P < 0.05) among the four types of operations for lactate, heart rate, PO2/FiO2 ratio and nitrogen excretion and showed a strong discriminating tendency for neutrophil elastase and C-reactive protein. The changes were most pronounced after operations on the pelvic girdle, followed by procedures in the femoral, spinal, and facial/basal skull regions. We conclude that a considerable inflammatory response and pronounced disturbance of body homeostasis follow traumatological operative procedures, varying in severity with the type of surgery. Several parameters allow quantitation of the surgical trauma and differentiation between different operations/regions. Further research should focus on the interrelationship between pre-existing preoperative inflammation and the additional trauma inflicted by surgery in patients with severe injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

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 influence of intermittent prone positioning on pulmonary gas exchange and parenchymal densities was investigated in ten patients. Three patients fulfilled the criteria of "severe ARDS"; seven patients had moderate lung injury as documented by the "lung injury score" (LIS). Nine out of ten were trauma patients and had an average injury severity score of 32.3. The oxygenation index (paO2/FiO2) improved in all patients after prone positioning, showing an increase of 81 +/- 47 (20-197) mmHg (MV +/- SD). Total static lung compliance showed an increase of 7.6 (0-16) ml/mbar. Patients with ARDS benefitted especially from intermittent prone positioning, resulting in a substantial improvement of the LIS of 0.91 (0.75-1.0) points. In moderate lung injury the LIS improved 0.5 (0.25-1.0) points. In lung computerized tomography, we observed the disappearance of posterobasal densities. Repeated prone positioning may therefore be used in ARDS patients as well as in patients with moderate lung injury.

Posttraumatic adult respiratory distress syndrome (ARDS) still involves significant mortality, despite progress in management concepts. Current therapeutic strategies are briefly described, including kinetic therapy, high-frequency jet ventilation and extracorporeal membrane oxygenation. In addition, a spectacular case of the first successful lung transplantation for posttraumatic ARDS after failed ECMO (extracorporeal membrane oxygenation) support is reported. This young man with severe posttraumatic ARDS developed a potentially lethal bilateral pulmonary hemorrhage under treatment with ECMO, and on the basis of this bilateral pulmonary transplantation was considered to be indicated. The patient is alive and well 2 years after the procedure.

We present a technique to measure pulmonary microvascular permeability for albumin in patients with multiple trauma by means of bronchoalveolar lavage (BAL). Routine laboratory tests for the analysis of BAL fluids are used. The results were clinically validated in 10 healthy volunteers and 12 patients with multiple trauma in a first prospective study. Additionally, another 11 severely traumatized and 24 less traumatized patients were evaluated in a second prospective study. Normal values (> 0.09 +/- 0.02), posttraumatic physiological ranges (< 0.35), and a "high risk" range (> 0.5) for pulmonary microvascular permeability for albumin were developed. There was a high correlation between the first posttraumatic values of pulmonary microvascular permeability and the required duration of intensive care treatment (r = 0.81), the duration of continuous mandatory ventilation (r = 0.78) and the mean lung injury score by Murray (r = 0.76). We conclude that the presented method is harmless and useful to describe the post-traumatic course of pulmonary microvascular permeability.

We investigated the effects of primary (< 24 h) intramedullary femoral nailing on lung function and pulmonary hemodynamics in multiple trauma patients. The standard procedure following reaming of the medullary canal (AFN) was compared with a new procedure using a small, solid nail without prior reaming (UFN). Pulmonary hemodynamics were determined using a pulmonary artery catheter. Global lung function was assessed by means of the oxygenation ratio (PaO2/FiO2). Concentrations of elastase and the platelet count as a general parameter of the clinical course were determined from central venous blood during and 3 days after surgery. The lung function was stable in UFN patients (n = 6), but decreased significantly in AFN patients (n = 10) from 353 +/- 24 (PaO2/FiO2 preoperative) to 260 +/- 28 (PaO2/FiO2 postoperative) and did not improve until 48 h later. Pulmonary artery pressure (Pap) remained within normal limits in UFN patients, whereas in AFN patients Pap increased from 27.4 +/- 3 mm Hg (preoperative) to 37 +/- 3 mm Hg during reaming and did not normalize until 1 h after insertion of the nail. The platelet count remained unchanged in UFN patients and dropped in AFN patients from 143 +/- 25 x 1000 cells/ml blood (preoperative) to 87.5 +/- 15 x 1000 cells/ml blood 2 days after surgery. Our measurements did not show an increase in central venous triglycerides in the AFN group, probably because bone marrow does not become immediately soluble. There was no significant difference between the increase of elactase levels in the two groups. The femoral nailing procedure with reaming in multiple trauma patients involves a potential risk to the lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple organ failure (MOF) is presently recognized as the most severe, and often lethal, complication after multiple trauma. Causal factors and pathomechanisms remain unclear, however. Generalized inflammatory cell tissue injury with a subsequent increase in permeability in all organs has been suggested. For this reason, 38 polytraumatized patients were examined in a prospective study. Organ function was analyzed, and specific clinical and histological studies were performed to check for generalized cell tissue damage and increased respiratory permeability. In all organs we found signs of tissue damage immediately after trauma. Disturbances of organ function were seen consistently, starting precisely from day 4. It was not possible to confirm an influence of blunt organ trauma on organ function during follow-up. The severity of injury (especially intrathoracic and intraabdominal) and massive bleeding increases the risk of MOF. MOF was not always associated with the onset of sepsis, and no temporal dependence could be shown. Histological studies demonstrated an inflammatory change in organ tissues, which is probably the result of toxic substances (endotoxin, TNF, oxygen radicals, proteases and eicanosoids) released into the blood circulation after trauma. Insufficient neutralization of these toxic metabolites leads to generalized permeability damage and consequently to progressive organ failure. Therefore, even with optimized initial treatment of multiple trauma patients, MOV and mortality can only be reduced with a causal approach to therapy.

The data recorded in 10 multitrauma patients who died of respiratory insufficiency (ARDS) were retrospectively compared with corresponding data recorded in 10 patients with similar injury scores who survived. All 20 patients had had respirator therapy from the 1st day onward. The criteria for ARDS were: (1) death in respiratory insufficiency after trauma. (2) chest X-rays showing signs of ARDS, (3) continuous decrease in the Horowitz quotient, and (4) autopsy (50% of the patients). The goal was to find out which variables give the first indication that ARDS is developing. Leukocyte and serum fibrinogen levels proved to have no discriminatory value. The inspiratory oxygen concentration needed (FiO2) and the Horowitz quotient differed in a highly significant manner beginning on the 1st day after trauma. None of the survivors needed an FiO2 of over 0.28 by the 2nd posttraumatic day, while none of the ARDS patients needed less than 0.35. In survivors the Horowitz quotient increased up to physiological values on the 2nd day. A significantly higher PEEP from the 3rd posttraumatic day onward was needed in ARDS patients. The respiratory peak-pressure increased significantly from the 2nd posttraumatic day.