Changes in the temporal distribution of in-hospital mortality in severely injured patients—An analysis of the TraumaRegister DGU (original) (raw)
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Epidemiology of in-hospital trauma deaths
European Journal of Trauma and Emergency Surgery, 2011
Purpose About half of all trauma-related deaths occur after hospital admission. The present study tries to characterize trauma deaths according to the time of death, and, thereby, contributes to the discussion about factors considered as the cause of death. Methods Data from two large European trauma registries (Trauma Registry of the German Society of Trauma Surgery, TR-DGU, and the Trauma Audit and Research Network, TARN) were analyzed in parallel. All hospital deaths with Injury Severity Score (ISS) [ 9 documented between 2000 and 2010 were considered. Patients were categorized into five subgroups according to the time to death (0-6 h; 7-24 h; day 1-6; day 7-30; beyond day 30). Surviving patients from the same time period served as a control group. Results In total, 6,685 and 6,867 non-survivors were included from the TR-DGU and TARN, respectively. The hospital mortality rate was between 15 and 17%. About half of all deaths occurred within the first 24 h after admission (TR-DGU: 54%; TARN: 45%). The earliest subgroup of trauma deaths showed the highest mean ISS and the highest rate of mass transfusions. Severe head injury was most frequently observed in the subgroup of day 1-6. Late deaths are associated with higher age and more complications (sepsis, multiple organ failure). Conclusions The time to death after severe trauma does not follow a trimodal distribution but shows a constantly decreasing incidence.
Predicting factors associated with in-hospital mortality in severe multiple-trauma patients
Archives of Trauma Research
Original Article intROductiOn Trauma is the leading cause of death under the age of 40 years [1] and one of the most important causes of death and disability at all ages. [1,2] According to the world health organization report entitled Road Traffic Injuries, released in February 2020, approximately 1.35 million people die each year due to road accidents alone. According to these reports, 93% of road deaths occur in low-to middle-income countries (Iran is in the middle-income group); however, only 60% of the world's vehicles are in these countries. [2] In addition, trauma is one of the four leading causes of death in middle-income countries such as Iran. [3] Trauma has different causes; road accidents, followed by falls from heights, are the most common causes of trauma. [3-8] Previous studies have shown that these two mechanisms alone account for about 80% of trauma cases. [1,3,5,6] This number Background and Objectives: Traumatic injuries have become a health problem worldwide, especially in low-to middle-income countries. Therefore, this study was conducted to identify predicting factors of death in adult severe multiple trauma patients. Methods: This retrospective cross-sectional study was performed on 1397 adult multiple trauma patients referred to the emergency department (ED) of Poursina Hospital between June 2019 and August 2021. The demographic characteristics, on admission clinical parameters, laboratory tests, the need for packed red blood cell transfusion, and the need for endotracheal intubation were recorded. The revised trauma score (RTS) was calculated according to the physiological variables collected on admission to ED. The primary outcome was 1-day mortality after admission. Results: The mean age of subjects was 37.12 ± 13.61 (18-60) years, and 1250 (89.5%) subjects were male. The 1-day mortality was 339 patients (24.3%). Initial RTS score and the mean Glasgow coma scale (GCS) scores were significantly higher in the survived group than in the nonsurvived group (6.6 ± 1.2 vs. 4.9 ± 1.0, 10.2 ± 3.7 vs. 4.9 ± 2.4, P < 0.001). The multivariate analysis resulted in low GCS (odds ratio [OR] = 1.527, 95%CI 1.434-1625, P < 0.001), low O 2 saturation (OR = 1.023, 95%CI 1.003-1.043, P = 0.022), and need for intubation in the ED (OR = 0.696, 95%CI 0.488-0.993, P = 0.046) as predictors of 1-day mortality. The area under the curves receiver operating characteristics of RTS and GCS scores to predict mortality were 0.853 (95% CI: 0.831-0.874) and 0.866 (95% CI: 0.846-0.887), respectively. Conclusion: Multiple factors associated with 1-day mortality were reduced GCS score, decreased oxygen saturation, and need for intubation in the ED. The RTS and GCS scores are good predictors of mortality survival in multiple trauma patients.
Risk factors for death of trauma patients admitted to an Intensive Care Unit
Revista Latino-Americana de Enfermagem, 2020
Objective: To analyze the risk factors for death of trauma patients admitted to the intensive care unit (ICU). Method: Retrospective cohort study with data from medical records of adults hospitalized for trauma in a general intensive care unit. We included patients 18 years of age and older and admitted for injuries. The variables were grouped into levels in a hierarchical manner. The distal level included sociodemographic variables, hospitalization, cause of trauma and comorbidities; the intermediate, the characteristics of trauma and prehospital care; the proximal, the variables of prognostic indices, intensive admission, procedures and complications. Multiple logistic regression analysis was performed. Results: The risk factors associated with death at the distal level were age 60 years or older and comorbidities; at intermediate level, severity of trauma and proximal level, severe circulatory complications, vasoactive drug use, mechanical ventilation, renal dysfunction, failure ...
Mortality after acute trauma: progressive decreasing rather than a trimodal distribution
Journal of Acute Disease, 2015
Retrospective study of major trauma patients admitted in a Level I trauma center, during the latest 5 years was conducted. Selection criteria included (1) injury severity score (ISS) > 16 and (2) in-Objective: To characterize the pattern of mortality for major trauma patients. Methods: Retrospective study of major trauma patients admitted in a Level I trauma center, during the latest 5 years was conducted. Selection criteria included (1) injury severity score (ISS) > 16 and (2) in-hospital death. Results: There were 47 patients, with a mean age of 37.2 ± 19.9 years. The mean ISS was 37.6 ± 12.7 and the mean revised trauma score was 4.5 ± 2.2. Computed tomography scan on admission was done in 18 (38%) patients, 20% being hemodynamically unstable (P = 0.001). The diagnostic peritoneal lavage was performed in 10 (22%) cases, 23.3% being hemodynamically unstable (P > 0.05). The mean number of intraabdominal injuries was 3. The need for transfusion was 8.2 ± 6.7 units. The mean time to death was 4.9 days. Early death was secondary to hemorrhagic shock (HS) (ISS = 35.2 ± 15.9, P > 0.05, revised trauma score = 3.74 ± 2.70, P = 0.008) and multiple organ failure (ISS = 36.6 ± 14.1, P > 0.05, revised trauma score = 5.94 ± 1.34, P = 0.008) was the cause for later mortality. Combined liver and splenic injuries were found in 13 cases, with secondary death through HS in 5 and multiple system organ failure (MSOF) in 8 cases. Combined liver, splenic and kidney injuries were found in 5 cases (cause of death: HS 2 cases, MSOF 3 cases). A total of 14 patients had associated head, thorax, abdomen and extremity trauma (cause of death: cerebral trauma 6 cases, MSOF 5 cases, HS 2 cases); 5 patients had thorax and abdomen trauma (cause of death: HS 5 cases); 8 patients had thorax, abdomen and extremity trauma (cause of death: MSOF 5 cases, HS 3 cases); 3 patients had abdomen and extremity trauma (HS 2 cases). We did not find a trimodal time distribution for mortality. Conclusions: The trimodal time distribution of mortality remains a milestone in trauma education and research. Nevertheless, it must be questioned in the modern and very efficcient trauma systems, but still very actual for developing trauma care systems. In conclusion, the pattern of mortality due to major trauma seems decreasing continuously with time rather than presenting high peaks of frequency at some moments.
European Journal of Trauma and Emergency Surgery, 2013
Objective The classical trimodal distribution of trauma deaths describes three peaks of deaths following trauma: immediate, early and late deaths. The aim of this study was to evaluate whether further maturation of the trauma centre and the improvement of survival have had an effect on the time of death distribution and resulted in a shift in causes of death. Methods All trauma patients from 1999 to 2010 who died after arrival in the emergency room and prior to discharge from the hospital were included. Deaths caused by drowning, poisoning and overdose were excluded. Results A total of 16,421 trauma patients were admitted to our hospital. 772 (4.7 %) patients died, of which 720 were included in this study. The trauma mechanism was predominantly blunt (94.7 %). 530 patients (73.6 %) had Injury Severity Score (ISS) C25. The most frequent causes of death were central nervous system (CNS) injury (59.9 %), exsanguinations (12.9 %) and pneumonia/respiratory insufficiency (8.5 %). The first peak of death was seen in the first hour after arrival at the emergency department; subsequently, a rapid decline was observed and no further peaks were seen. Over the years, we observed a general decrease in deaths due to exsanguination (p = 0.035) and a general increase in deaths due to CNS injury (p = 0.004). Conclusion The temporal distribution of trauma deaths in our hospital changed as maturation of the trauma centre occurred. There is one peak of trauma deaths in the first hour after admission, followed by a rapid decline; no trimodal distribution was observed. Over time, there was a decrease in exsanguinations and an increase of deaths due to CNS injury.
Medicine, 2017
The aim of this study was to compare septic shock directly associated-mortality between severe trauma patients and nontrauma patients to assess the role of comorbidities and age. We conducted a retrospective study in an intensive care unit (ICU) (15 beds) of a university hospital (928 beds). From January 2009 to May 2015, we reviewed 2 anonymized databases including severe trauma patients and nontrauma patients. We selected the patients with a septic shock episode. Among 385 patients (318 nontrauma patients and 67 severe trauma patients), the ICU death rate was 43%. Septic shock was directly responsible for death among 35% of our cohort, representing 123 (39%) nontrauma patients and 10 (15%) trauma patients (P < 0.0). A sequential organ failure assessment score above 12 (odds ratio [OR]: 6.8; 95% confident interval (CI) [1.3-37], P = 0.025) was independently associated with septic shock associated-mortality, whereas severe trauma was a protective factor (OR: 0.26; 95% CI [0.08-0....
Analysis of Hospital Mortality and Epidemiology in Trauma Patients: A Multi-Center Study
Journal of Current Surgery, 2011
Background: This study evaluated the clinical characteristics of trauma patients in the southeastern coastal area of Turkey and investigated the factors influencing mortality. Methods: Patients admitted with trauma to the emergency departments of Harran and Gaziantep Medical Schools and to the emergency services of hospitals in Sanlıurfa between June 2008 and December 2008 were enrolled retrospectively in this study. All medical records and follow-up data were reviewed for each patient. Results: The study evaluated 15,120 trauma patients. The causes of trauma were motor vehicle accidents (38.7%), falls from heights (36.8%), burns (7.8%), knife wounds and gun shots (8.1%), homicides (6.5%), and workplace-related accidents (2.1%). The overall patient mortality rate was 3.8%. The mean patient ages were 47.8 ± 0.9 and 29.7 ± 0.4 among those who died and among those who survived, respectively (P < 0.01). The median times to arrival were 130 minutes and 42 minutes among those who died and among those who survived, respectively (P < 0.01). Whereas 79.9% of patients were discharged after treatment in the emergency departments, 16.3% were referred to various departments for hospitalization, and 3.8% were admitted to the intensive care unit (ICU). The mean score on the Glasgow Coma Scale was 7.5 ± 0.3 among who died and 12.8 ± 0.6 among those who survived (P < 0.05), and the mean Revised Trauma Scores were 8.7 ± 0.5 among those who died and 11.5 ± 0.7 among those who survived (P < 0.05). Intubation or cardiopulmonary resuscitation was initiated in 88% of those who died and 43.5% of those who survived (P < 0.05). Of those who died, 84% had cranial injuries and 43.5% had thoracic injuries. Conclusions: Frequent causes of trauma in our region are motor vehicle accidents and falls from heights. Type of trauma, rapid arrival at the hospital, hospital procedures and interventions, age, sex, and trauma scores were predictors of mortality in trauma patients.
Surgical Infections, 2013
Background: Post-traumatic sepsis is a significant cause of in-hospital death. However, socio-demographic and clinical characteristics that may predict sepsis in injured patients are not well known. The objective of this study was to identify risk factors that may be associated with post-traumatic sepsis. Methods: Retrospective analysis of patients in the National Trauma Data Bank for 2007-2008. Patients older than 16 years of age with an Injury Severity Score (ISS) ‡ 9 points were included. Multivariable logistic regression was used to determine association of sepsis with patient (age, gender, ethnicity, and insurance status), injury (mechanism, ISS, injury type, hypotension), and clinical (major surgical procedure, intensive care unit admission) characteristics. Results: Of a total of 1.3 million patients, 373,370 met the study criteria, and 1.4% developed sepsis, with an associated mortality rate of approximately 20%. Age, male gender, African-American race, hypotension on emergency department presentation, and motor vehicle crash as the injury mechanism were independently associated with post-traumatic sepsis. Conclusions: Socio-demographic and injury factors, such as age, race, hypotension on admission, and severity and mechanism of injury predict post-traumatic sepsis significantly. Further exploration to explain why these patient groups are at increased risk is warranted in order to understand better and potentially prevent this lifethreatening complication. W ith an estimated 750,000 cases annually, severe sepsis is the tenth leading cause of death overall in the United States [1-3]. Sepsis is the principal cause of in-hospital death outside of coronary intensive care units (ICUs), and surgical patients account for one-third of all diagnosed cases [4]. Physiology of sepsis in surgical patients is believed to be distinct because of immune modulation associated with surgery and trauma [5]. Current literature suggests a mortality rate of 17%-23% in patients who develop post-traumatic sepsis during their hospital stays [6-8]. Knowledge of patient-and injury-specific characteristics associated with its development may help in early identification of this complication and timely intervention to improve clinical outcomes. However, our understanding of the relation between patient and injury characteristics and predisposition to post-traumatic sepsis is limited [6,7]. The primary objective of this study was to identify the role of socio-demographic and injury characteristics in predisposition to post-traumatic sepsis in moderately to severely injured patients. This study also explored associations between these characteristics and death in patients who developed sepsis. Patients and Methods Data source This study retrospectively analyzed adult patients entered in the National Trauma Data Bank (NTDB) between 2007 and 2008. The NTDB is maintained by the American College of Surgeons and contains data contributed by more than 900 trauma centers in the United States and its territories. Data reporting to the NTDB is voluntary, and some institutions do not submit complication and demographics information. Patients from facilities that did not submit data on complications and insurance status were therefore excluded. We calculated the percentage of missing information for the complications field for each facility and included only patients from facilities
European Journal of Trauma, 2004
Background and Purpose: The Injury Severity Score (ISS) is a widely used trauma scoring system which, based on the Hospital Trauma Index (HTI), categorizes injury into six different organ systems. A possible limitation is the equal weight given to each body region, although this equal qualification is not appropriate when predicting mortality. This study was undertaken to determine the impact on mortality of equal injury severity in different body regions. Patients and Methods: All consecutive multiply injured patients (HTI-ISS ≥ 18) treated over a 4-year period in the University Medical Center Utrecht, the Netherlands, were reviewed. The prognostic value of the HTI-ISS concerning mortality was assessed, before and after incorporating the presence of relevant injury (HTI ≥ 3) in each separate organ system, with receiver operating characteristics and logistic regression modeling. Results: The HTI-ISS proved to be a good predictor of mortality. In the highest quintile, 55% of the patients died. The area under the curve (AUC) was 0.83 (95% confidence interval [CI] 0.79-0.87). The risk of dying increased 13 times (hazard ratio [HR] 13.2 [6.5-26.8]) once relevant head injury was present. After incorporation of head injury, the prognostic value of the HTI-ISS increased to 0.87 (95% CI 0.84-0.91). Injury in any of the other organ systems did not significantly increase the prognostic value of the HTI-ISS for mortality. Conclusion: The prognostic value of the HTI-ISS for mortality is fairly good. If the weight of head injury in the HTI-ISS is doubled, the predicted probability rises significantly to an AUC of 0.87. It is too far-fetched to change the calculation of the HTI-ISS based on one study, but one should be aware of the impact of relevant injuries to the head. This study confirms the expert opinion that relevant to severe head injury is a special and dominant predictor of mortality in multiply injured patients.