- Email: [email protected]
Fatal outcome after polytrauma: multiple organ failure or cerebral damage?
Resuscitation 36 (1998) 15 – 18
Fatal outcome after polytrauma: multiple organ failure or cerebral damage? Etienne Dereeper, Roberta Ciardelli, Jean-Louis Vincent * Department of Intensi6e Care, Erasme Uni6ersity Hospital, Free Uni6ersity of Brussels, Route de Lennik 808, B-1070 Brussels, Belgium Received 4 April 1997; received in revised form 12 August 1997; accepted 15 September 1997
Abstract To assess the relative importance of multiple organ failure (MOF) and cerebral damage on the mortality rate following trauma we analyzed retrospectively the records from 99 polytrauma patients admitted to a multidisciplinary European intensive care unit in a 2 year period. In all, 93% of the trauma was non-penetrating and 73% was the result of road accidents. 28 patients died giving an overall mortality of 28.3%. The cause of death was cerebral lesions in 19 patients, hemorrhagic shock in eight and multiple organ failure in one patient who had an injury severity score (ISS) of 13. Most deaths (78%) occurred within 24 h of admission, 15 of these were due to extensive cerebral lesions and seven due to hemorrhagic shock. A total of six deaths occurred after 24 h, four due to extensive cerebral lesions, one due to hemorrhagic shock and one due to multiple organ failure. In our experience, cerebral damage was a more common cause of death than MOF following multiple non-penetrating trauma. © 1998 Elsevier Science Ireland Ltd. Keywords: Multiple trauma; Head injury; Organ failure; Non-penetrating trauma
1. Introduction Trauma is the leading cause of death in young people and polytrauma remains a major problem in the intensive care department with high morbidity and mortality rates. Head injury is a common component of severe trauma and is associated with a particularly poor outcome [1] and with increased morbidity as permanent impairment of brain function may lead to persistent vegetative states. Trauma is known to initiate the systemic release of various inflammatory mediators [2,3] which have been implicated in the pathogenesis of multiple organ failure (MOF) and recently the literature has emphasized the importance of MOF as a major factor in the cause of death in post-trauma
* Corresponding author. Tel.: +32 2 5553380; fax: + 32 2 5554555; e-mail: [email protected]
patients [4–8]. Some suggest that the higher incidence of MOF may be due to improvements in early resuscitation, so that patients who previously died now survive to develop MOF. This was stressed by Regel et al. [9], who compared the mortality of trauma patients at their hospital in two 10 year periods, 1972–1981 and 1982– 1991. They observed that the incidence of lethal MOF increased from 13.8 in the first decade to 18.6% in the second decade. A previous study in this hospital [10], revealed that cerebral damage was present in most fatal cases after trauma. Further understanding of the reasons for the high mortality rates following polytrauma will improve our understanding and management of these patients and enable us to focus appropriately attempts to improve outcome. We therefore reviewed polytrauma intensive care unit (ICU) admissions to compare the relative contributions of cerebral lesions and MOF to outcome.
0300-9572/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 0 0 - 9 5 7 2 ( 9 7 ) 0 0 0 8 0 - 4
E. Dereeper et al. / Resuscitation 36 (1998) 15–18
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Table 2 Organ failure in the polytrauma population
2. Patients and methods All records of polytrauma patients admitted to the multidisciplinary 31-bed ICU in the academic hospital (tertiary care facility) of the University of Brussels during 1994 and 1995 were reviewed. From a total of 5000 ICU admissions during these 2 years, 99 (2%) were due to polytrauma. For each patient, age, sex, type of accident, type and severity of lesions, duration of ICU stay and outcome were recorded. The severity of trauma was assessed using the injury severity score (ISS). Organ dysfunction was assessed as follows: acute renal failure was defined as a blood urea nitrogen (BUN) \40 and/or creatinine \ 2 mg/dl; acute respiratory failure by a PaO2/FiO2 ratio B250 mmHg or requirement for mechanical ventilation for \24 h for a respiratory problem; coagulation abnormalities by a platelet countB 100 000/mm3 with either a prothrombin timeB60% of the normal value or an activated partial thromboplastin time \ 80 s; hepatic failure by a bilirubin \ 2 mg/dl or transaminases \ 80 IU/l.
3. Results The records of the 99 polytrauma patients were analyzed. The male:female ratio was 76:23 and the mean age was 35 years. Of these patients 12 were children (age 2–15 years) and the rest were aged 16–82 years. The trauma was the result of a road accident in 72 patients (73%), of falls or assault in 24 (24%) and of gun-shot injury in 3 (3%). Only 7% of the injuries were penetrating. The mean ISS was 20 (range 2 – 50). The type of injury incurred is represented in Table 1. 74 patients (75%) suffered head trauma. Other injuries, in decreasing order of occurrence, involved the thorax, the limbs, the abdomen and the spine. Of the 99 patients, 71 survived and 28 (28%) died during their ICU stay. Of the discharged patients, three needed to be re-admitted to the ICU. All three survived. There were no significant differences in the type of trauma sustained between the survivors and non-survivors. Two children died, in both cases the death was due to extensive cerebral lesions. Among the adult Table 1 Area of injury in the polytrauma population
Head Thorax Limbs Abdomen Spine
Survivors (n =71)
Non-survivors (n=28)
Total (n = 99)
52 44 45 25 17
22 19 13 2 4
74 63 58 27 21
(73.2%) (62.0%) (63.4%) (35.2%) (23.9%)
(78.6%) (67.9%) (46.4%) (7.1%) (14.2%)
(74.7%) (63.6%) (58.6%) (27.3%) (21.2%)
Renal failure Coagulation abnormalities Respiratory failure Alteration of hepatic function Multiple organ failure
Survivors (n =71)
Non-survivors (n =28)
Total (n = 99)
10 (14%) 8 (11%)
1 (4%) 0 (0%)
11 (11%) 8 (8%)
7 (10%) 6 (8%)
1 (4%) 0 (0%)
8 (8%) 6 (6%)
9 (13%)
1 (4%)
10 (10%)
patients, of 26 deaths, 21 (78%) occurred within 24 h of admission. Fourteen of these were due to extensive cerebral lesions and seven due to hemorrhagic shock. Five deaths occurred after 24 h, three due to extensive cerebral lesions, one due to hemorrhagic shock and 1 due to MOF. The latter patient suffered acute lung injury secondary to multiple rib fractures and had an ISS of only 13. During their ICU stay, acute renal failure was observed in 11 patients, coagulation abnormalities and acute respiratory failure in eight and altered liver function in six. All of these patients survived except one who developed renal and respiratory failure. MOF was more common in the survivors than in the non-survivors (Table 2). A total of 63 patients had an ISS score \ 16 (mean of 25). 24 (38%) of these patients died, 20 (83%) of them during the first 24 h; 16 (67%) of these deaths were due to extensive cerebral lesions and 8 (33%) to hemorrhagic shock.
4. Discussion It is well known that early death after trauma is primarily due to extensive brain lesions or to hemorrhagic shock [11,12]. Recent studies on trauma patients have suggested that whilst early deaths may be due to these factors, later deaths are due to multiple organ failure [5,13,14,3]. This has not been our experience. Deaths later than 24 h after trauma were in fact quite rare, representing less than 5% of our study population. Shackford et al. [11] reported a similarly low incidence of late deaths following trauma, with 92% of deaths occurring within 7 days of ICU admission. A number of patients developed organ dysfunction during their ICU stay, but in our study only one patient died from MOF. This study represents the particular experience of a European center where, with a few exceptions, trauma patients are not generally concentrated in trauma centers, as is often the case in the US. In our large, urban, university hospital, only 2% of all ICU admissions were
E. Dereeper et al. / Resuscitation 36 (1998) 15–18
due to polytrauma. We also had a low incidence of penetrating trauma with only three patients being admitted with gunshot wounds and no patient with stab wounds. This is comparable with figures from other European centers [4,15,7], but is in contrast to American hospitals which see a much higher incidence of penetrating injuries, particularly gunshot wounds and stab injuries [11,12,16 – 18]. In European centers these latter are very rare and when they do occur do not usually result in polytrauma. The overall mortality rate of 28% that we observed is comparable to that reported in other studies [15,19,10]. In our population, extensive cerebral lesions were the most common cause of death (68%), with only one patient dying from multiple organ failure. The higher incidence of deaths due to extensive cerebral lesions that we observed was obviously due to the high numbers of patients presenting with head trauma. Some studies have related the incidence of MOF to the severity of trauma as defined by the ISS score [6] but in our study the one patient who died from MOF had an ISS of just 13. Excluding patients with an ISS scoreB 16 did not influence the results and the severity of injury is therefore unlikely to be an important factor in this issue. The reported incidence of MOF following polytrauma varies widely and indeed comparison of such figures from different studies and different centers is difficult. The type and severity of trauma encountered, as well as the definition of organ failure used, may influence results and comparisons. Our experience is similar to that in two other European centers. van der Sluis et al. [20] found 2.2% of deaths were due to MOF and 76% due to cerebral damage and similar results were obtained by Frutiger et al. [19] who found 91% of deaths in trauma patients were due to head injury and again only one patient in 43 (2%) died from MOF. However, other European studies have observed larger percentages of trauma patients dying from MOF. Faist et al. [7] reported 49% of deaths were from cerebral lesions and 24% from MOF, while Nuytinck et al. [2] reported MOF to be the cause of death in 31% of the polytrauma patients in their study. In 163 consecutive trauma patients Smail et al. [21] reported a higher mortality from MOF than from other causes. Regel et al. [9] in their comparison of mortality rates in two 10 year periods reported 32% mortality from brain damage and 13.8% from MOF in 1972 – 1981 and 28% from brain damage and 18.6% from MOF in 1982 –1991. Some American centers though have recorded similar results to ours, with Shackford et al. [22] reporting 2.5% of deaths due to MOF compared with 40% due to cerebral injury. Hence the differences between studies is not simply a question of differences in patient populations and trauma management between the US and Europe. We suspect that some of the observed differ-
17
ences are due to a problem of definition. Patients with severe head trauma may well have a degree of multiple organ failure, which without their cerebral damage they would probably survive. Deaths in these patients may have been attributed to MOF by some authors while they are in fact primarily a result of severe cerebral damage. Very few deaths in our study occurred more than 24 h after the trauma and this may also account for the low incidence of lethal MOF. Regel et al. [5] observed that mortality due to MOF occurred a mean of 17 days after trauma, whereas death due to other causes occurred a mean of 9 days after trauma. However, in our study four of the five late deaths were due to persistent cranial injury. Recently Moore et al. [6] reported a 15% incidence of MOF in 457 polytrauma patients, occurring in a bimodal fashion with an early and delayed peak. The overall mortality rate was 8%, 66% of deaths were due to MOF. This study had a much higher incidence of penetrating wounds than ours (28%) and excluded deaths occurring within the first 48 h, which may explain some of the large discrepancy between their figures and ours. Interestingly, in the study by Moore et al. [6], patients with predominant head injury had a lower incidence of MOF than those with abdominal trauma. 75% of our patients had cerebral trauma and this may therefore also contribute to the low incidence of MOF in our study population. In conclusion, our experience with a particular population of polytrauma patients presenting primarily with non-penetrating head trauma shows that late deaths are rare and when they do occur, they are primarily related to persistent and extensive brain damage. Multiple organ failure is a rare cause of death in this population. Efforts to improve the management of head trauma should be a priority for increasing survival rates in these patients.
References [1] Gennarelli TA, Champion HR, Copes WS, Sacco WJ. Comparison of mortality, morbidity and severity of 59 713 head injured patients with 114 447 patients with extracranial injuries. J Trauma 1994;37:962. [2] Nuytinck JK, Goris JA, Redl H, Schlag G, Van Munster PJ. Posttraumatic complications and inflammatory mediators. Arch Surg 1986;121:886 – 90. [3] Waydhas C, Nast-Kolb D, Jochum M, et al. Inflammatory mediators, infection, sepsis and multiple organ failure after severe trauma. Arch Surg 1992;127:460 – 7. [4] Tran DD, Cuesta MA, van Leeuwen PAM, Nauta JJ, Wesdorp RI. Risk factors for multiple organ system failure and death in critically injured patients. Surgery 1993;114:21 – 30. [5] Regel G, Grotz M, Weltner T, Sturm JA, Tscherne H. Pattern of organ failure following severe trauma. World J Surg 1996;20:422 – 9. [6] Moore FA, Sauaia A, Moore EE, Haenel JB, Burch JM, Lezotte DC. Postinjury multiple organ failure: a bimodal phenomenon. J Trauma 1996;40:501 – 10.
E. Dereeper et al. / Resuscitation 36 (1998) 15–18
18
[7] Faist E, Baue A, Ditmer H, Heberer G. Multiple organ failure in polytrauma patients. J Trauma 1983;23:775–87. [8] Goris RJA, Boekhorst TPA. Multiple-organ failure: generalized autodestructive inflammation. Arch Surg 1985;120:1109– 15. [9] Regel G, Lobenhoffer P, Grotz M, Pape HC, Lehmann U, Tscherne H. Treatment results of patients with multiple trauma: an analysis of 3406 cases treated between 1972 and 1991 at a German level 1 trauma center. J Trauma 1995;38:70–8. [10] Manikis P, Jankowski S, Zhang H, Kahn RJ, Vincent JL. Correlation of serial blood lactate levels to organ failure and mortality after trauma. Am J Emerg Med 1995;13:619–22. [11] Shackford SP, Mackersie RC, Davis JW, Wolf PL, Hoyt DB. Epidemiology and pathology of traumatic deaths occurring at a level 1 trauma center in a regionalized system: The importance of secondary brain injury. J Trauma 1989;29:1392–7. [12] Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epidemiology of trauma deaths. Am J Surg 1980;140:144 – 9. [13] Goris RJA, Draaisma J. Causes of death after blunt trauma. J Trauma 1982;22:141–6. [14] DeCamp MM, Demling RH. Posttraumatic multisystem organ failure. J Am Med Assoc 1988;260:530–4. [15] Lauwers L, Rosseel P, Roelants A, Beeckman C, Baute L. A
.
.
[16]
[17] [18]
[19] [20] [21]
[22]
retrospective study of 130 consecutive multiple trauma patients in an intensive care unit. Intensive Care Med 1986;12:296–301. Rixen D, Siegel JH, Friedman HP. ‘Sepsis/SIRS’, physiologic classification, severity stratification, relation to cytokine elaboration and outcome prediction in posttrauma critical illness. J Trauma 1996;41:581 – 98. Cummings P. Cause of death in an emergency department. Am J Emerg Med 1990;8:379 – 84. Champion H, Copes W, Sacco W, et al. The major trauma outcome study: establishing national norms for trauma care. J Trauma 1990;30:1356 – 65. Frutiger A, Ryf C, Bilat C, et al. Five year follow-up of severely injured ICU patients. J Trauma 1991;31:1216 – 26. van der Sluis CK, ten Duis HJ, Geertzen JHB. Multiple injuries: an overview of the outcome. J Trauma 1995;38:681 – 6. Smail N, Messiah A, Edouard A, et al. Role of systemic inflammatory response syndrome and infection in the occurrence of early multiple organ dysfunction syndrome following severe trauma. Intensive Care Med 1995;21:813 – 6. Shackford SP, Mackersie RC, Holbrook TL, Davis JW, Hollingsworth-Fridlund P, Hoyt DB, Wolf PL. The epidemiology of traumatic death: a population based analysis. Arch Surg 1993;128:571 – 5.
Fatal outcome after polytrauma: multiple organ failure or cerebral damage? Etienne Dereeper, Roberta Ciardelli, Jean-Louis Vincent * Department of Intensi6e Care, Erasme Uni6ersity Hospital, Free Uni6ersity of Brussels, Route de Lennik 808, B-1070 Brussels, Belgium Received 4 April 1997; received in revised form 12 August 1997; accepted 15 September 1997
Abstract To assess the relative importance of multiple organ failure (MOF) and cerebral damage on the mortality rate following trauma we analyzed retrospectively the records from 99 polytrauma patients admitted to a multidisciplinary European intensive care unit in a 2 year period. In all, 93% of the trauma was non-penetrating and 73% was the result of road accidents. 28 patients died giving an overall mortality of 28.3%. The cause of death was cerebral lesions in 19 patients, hemorrhagic shock in eight and multiple organ failure in one patient who had an injury severity score (ISS) of 13. Most deaths (78%) occurred within 24 h of admission, 15 of these were due to extensive cerebral lesions and seven due to hemorrhagic shock. A total of six deaths occurred after 24 h, four due to extensive cerebral lesions, one due to hemorrhagic shock and one due to multiple organ failure. In our experience, cerebral damage was a more common cause of death than MOF following multiple non-penetrating trauma. © 1998 Elsevier Science Ireland Ltd. Keywords: Multiple trauma; Head injury; Organ failure; Non-penetrating trauma
1. Introduction Trauma is the leading cause of death in young people and polytrauma remains a major problem in the intensive care department with high morbidity and mortality rates. Head injury is a common component of severe trauma and is associated with a particularly poor outcome [1] and with increased morbidity as permanent impairment of brain function may lead to persistent vegetative states. Trauma is known to initiate the systemic release of various inflammatory mediators [2,3] which have been implicated in the pathogenesis of multiple organ failure (MOF) and recently the literature has emphasized the importance of MOF as a major factor in the cause of death in post-trauma
* Corresponding author. Tel.: +32 2 5553380; fax: + 32 2 5554555; e-mail: [email protected]
patients [4–8]. Some suggest that the higher incidence of MOF may be due to improvements in early resuscitation, so that patients who previously died now survive to develop MOF. This was stressed by Regel et al. [9], who compared the mortality of trauma patients at their hospital in two 10 year periods, 1972–1981 and 1982– 1991. They observed that the incidence of lethal MOF increased from 13.8 in the first decade to 18.6% in the second decade. A previous study in this hospital [10], revealed that cerebral damage was present in most fatal cases after trauma. Further understanding of the reasons for the high mortality rates following polytrauma will improve our understanding and management of these patients and enable us to focus appropriately attempts to improve outcome. We therefore reviewed polytrauma intensive care unit (ICU) admissions to compare the relative contributions of cerebral lesions and MOF to outcome.
0300-9572/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 0 0 - 9 5 7 2 ( 9 7 ) 0 0 0 8 0 - 4
E. Dereeper et al. / Resuscitation 36 (1998) 15–18
16
Table 2 Organ failure in the polytrauma population
2. Patients and methods All records of polytrauma patients admitted to the multidisciplinary 31-bed ICU in the academic hospital (tertiary care facility) of the University of Brussels during 1994 and 1995 were reviewed. From a total of 5000 ICU admissions during these 2 years, 99 (2%) were due to polytrauma. For each patient, age, sex, type of accident, type and severity of lesions, duration of ICU stay and outcome were recorded. The severity of trauma was assessed using the injury severity score (ISS). Organ dysfunction was assessed as follows: acute renal failure was defined as a blood urea nitrogen (BUN) \40 and/or creatinine \ 2 mg/dl; acute respiratory failure by a PaO2/FiO2 ratio B250 mmHg or requirement for mechanical ventilation for \24 h for a respiratory problem; coagulation abnormalities by a platelet countB 100 000/mm3 with either a prothrombin timeB60% of the normal value or an activated partial thromboplastin time \ 80 s; hepatic failure by a bilirubin \ 2 mg/dl or transaminases \ 80 IU/l.
3. Results The records of the 99 polytrauma patients were analyzed. The male:female ratio was 76:23 and the mean age was 35 years. Of these patients 12 were children (age 2–15 years) and the rest were aged 16–82 years. The trauma was the result of a road accident in 72 patients (73%), of falls or assault in 24 (24%) and of gun-shot injury in 3 (3%). Only 7% of the injuries were penetrating. The mean ISS was 20 (range 2 – 50). The type of injury incurred is represented in Table 1. 74 patients (75%) suffered head trauma. Other injuries, in decreasing order of occurrence, involved the thorax, the limbs, the abdomen and the spine. Of the 99 patients, 71 survived and 28 (28%) died during their ICU stay. Of the discharged patients, three needed to be re-admitted to the ICU. All three survived. There were no significant differences in the type of trauma sustained between the survivors and non-survivors. Two children died, in both cases the death was due to extensive cerebral lesions. Among the adult Table 1 Area of injury in the polytrauma population
Head Thorax Limbs Abdomen Spine
Survivors (n =71)
Non-survivors (n=28)
Total (n = 99)
52 44 45 25 17
22 19 13 2 4
74 63 58 27 21
(73.2%) (62.0%) (63.4%) (35.2%) (23.9%)
(78.6%) (67.9%) (46.4%) (7.1%) (14.2%)
(74.7%) (63.6%) (58.6%) (27.3%) (21.2%)
Renal failure Coagulation abnormalities Respiratory failure Alteration of hepatic function Multiple organ failure
Survivors (n =71)
Non-survivors (n =28)
Total (n = 99)
10 (14%) 8 (11%)
1 (4%) 0 (0%)
11 (11%) 8 (8%)
7 (10%) 6 (8%)
1 (4%) 0 (0%)
8 (8%) 6 (6%)
9 (13%)
1 (4%)
10 (10%)
patients, of 26 deaths, 21 (78%) occurred within 24 h of admission. Fourteen of these were due to extensive cerebral lesions and seven due to hemorrhagic shock. Five deaths occurred after 24 h, three due to extensive cerebral lesions, one due to hemorrhagic shock and 1 due to MOF. The latter patient suffered acute lung injury secondary to multiple rib fractures and had an ISS of only 13. During their ICU stay, acute renal failure was observed in 11 patients, coagulation abnormalities and acute respiratory failure in eight and altered liver function in six. All of these patients survived except one who developed renal and respiratory failure. MOF was more common in the survivors than in the non-survivors (Table 2). A total of 63 patients had an ISS score \ 16 (mean of 25). 24 (38%) of these patients died, 20 (83%) of them during the first 24 h; 16 (67%) of these deaths were due to extensive cerebral lesions and 8 (33%) to hemorrhagic shock.
4. Discussion It is well known that early death after trauma is primarily due to extensive brain lesions or to hemorrhagic shock [11,12]. Recent studies on trauma patients have suggested that whilst early deaths may be due to these factors, later deaths are due to multiple organ failure [5,13,14,3]. This has not been our experience. Deaths later than 24 h after trauma were in fact quite rare, representing less than 5% of our study population. Shackford et al. [11] reported a similarly low incidence of late deaths following trauma, with 92% of deaths occurring within 7 days of ICU admission. A number of patients developed organ dysfunction during their ICU stay, but in our study only one patient died from MOF. This study represents the particular experience of a European center where, with a few exceptions, trauma patients are not generally concentrated in trauma centers, as is often the case in the US. In our large, urban, university hospital, only 2% of all ICU admissions were
E. Dereeper et al. / Resuscitation 36 (1998) 15–18
due to polytrauma. We also had a low incidence of penetrating trauma with only three patients being admitted with gunshot wounds and no patient with stab wounds. This is comparable with figures from other European centers [4,15,7], but is in contrast to American hospitals which see a much higher incidence of penetrating injuries, particularly gunshot wounds and stab injuries [11,12,16 – 18]. In European centers these latter are very rare and when they do occur do not usually result in polytrauma. The overall mortality rate of 28% that we observed is comparable to that reported in other studies [15,19,10]. In our population, extensive cerebral lesions were the most common cause of death (68%), with only one patient dying from multiple organ failure. The higher incidence of deaths due to extensive cerebral lesions that we observed was obviously due to the high numbers of patients presenting with head trauma. Some studies have related the incidence of MOF to the severity of trauma as defined by the ISS score [6] but in our study the one patient who died from MOF had an ISS of just 13. Excluding patients with an ISS scoreB 16 did not influence the results and the severity of injury is therefore unlikely to be an important factor in this issue. The reported incidence of MOF following polytrauma varies widely and indeed comparison of such figures from different studies and different centers is difficult. The type and severity of trauma encountered, as well as the definition of organ failure used, may influence results and comparisons. Our experience is similar to that in two other European centers. van der Sluis et al. [20] found 2.2% of deaths were due to MOF and 76% due to cerebral damage and similar results were obtained by Frutiger et al. [19] who found 91% of deaths in trauma patients were due to head injury and again only one patient in 43 (2%) died from MOF. However, other European studies have observed larger percentages of trauma patients dying from MOF. Faist et al. [7] reported 49% of deaths were from cerebral lesions and 24% from MOF, while Nuytinck et al. [2] reported MOF to be the cause of death in 31% of the polytrauma patients in their study. In 163 consecutive trauma patients Smail et al. [21] reported a higher mortality from MOF than from other causes. Regel et al. [9] in their comparison of mortality rates in two 10 year periods reported 32% mortality from brain damage and 13.8% from MOF in 1972 – 1981 and 28% from brain damage and 18.6% from MOF in 1982 –1991. Some American centers though have recorded similar results to ours, with Shackford et al. [22] reporting 2.5% of deaths due to MOF compared with 40% due to cerebral injury. Hence the differences between studies is not simply a question of differences in patient populations and trauma management between the US and Europe. We suspect that some of the observed differ-
17
ences are due to a problem of definition. Patients with severe head trauma may well have a degree of multiple organ failure, which without their cerebral damage they would probably survive. Deaths in these patients may have been attributed to MOF by some authors while they are in fact primarily a result of severe cerebral damage. Very few deaths in our study occurred more than 24 h after the trauma and this may also account for the low incidence of lethal MOF. Regel et al. [5] observed that mortality due to MOF occurred a mean of 17 days after trauma, whereas death due to other causes occurred a mean of 9 days after trauma. However, in our study four of the five late deaths were due to persistent cranial injury. Recently Moore et al. [6] reported a 15% incidence of MOF in 457 polytrauma patients, occurring in a bimodal fashion with an early and delayed peak. The overall mortality rate was 8%, 66% of deaths were due to MOF. This study had a much higher incidence of penetrating wounds than ours (28%) and excluded deaths occurring within the first 48 h, which may explain some of the large discrepancy between their figures and ours. Interestingly, in the study by Moore et al. [6], patients with predominant head injury had a lower incidence of MOF than those with abdominal trauma. 75% of our patients had cerebral trauma and this may therefore also contribute to the low incidence of MOF in our study population. In conclusion, our experience with a particular population of polytrauma patients presenting primarily with non-penetrating head trauma shows that late deaths are rare and when they do occur, they are primarily related to persistent and extensive brain damage. Multiple organ failure is a rare cause of death in this population. Efforts to improve the management of head trauma should be a priority for increasing survival rates in these patients.
References [1] Gennarelli TA, Champion HR, Copes WS, Sacco WJ. Comparison of mortality, morbidity and severity of 59 713 head injured patients with 114 447 patients with extracranial injuries. J Trauma 1994;37:962. [2] Nuytinck JK, Goris JA, Redl H, Schlag G, Van Munster PJ. Posttraumatic complications and inflammatory mediators. Arch Surg 1986;121:886 – 90. [3] Waydhas C, Nast-Kolb D, Jochum M, et al. Inflammatory mediators, infection, sepsis and multiple organ failure after severe trauma. Arch Surg 1992;127:460 – 7. [4] Tran DD, Cuesta MA, van Leeuwen PAM, Nauta JJ, Wesdorp RI. Risk factors for multiple organ system failure and death in critically injured patients. Surgery 1993;114:21 – 30. [5] Regel G, Grotz M, Weltner T, Sturm JA, Tscherne H. Pattern of organ failure following severe trauma. World J Surg 1996;20:422 – 9. [6] Moore FA, Sauaia A, Moore EE, Haenel JB, Burch JM, Lezotte DC. Postinjury multiple organ failure: a bimodal phenomenon. J Trauma 1996;40:501 – 10.
E. Dereeper et al. / Resuscitation 36 (1998) 15–18
18
[7] Faist E, Baue A, Ditmer H, Heberer G. Multiple organ failure in polytrauma patients. J Trauma 1983;23:775–87. [8] Goris RJA, Boekhorst TPA. Multiple-organ failure: generalized autodestructive inflammation. Arch Surg 1985;120:1109– 15. [9] Regel G, Lobenhoffer P, Grotz M, Pape HC, Lehmann U, Tscherne H. Treatment results of patients with multiple trauma: an analysis of 3406 cases treated between 1972 and 1991 at a German level 1 trauma center. J Trauma 1995;38:70–8. [10] Manikis P, Jankowski S, Zhang H, Kahn RJ, Vincent JL. Correlation of serial blood lactate levels to organ failure and mortality after trauma. Am J Emerg Med 1995;13:619–22. [11] Shackford SP, Mackersie RC, Davis JW, Wolf PL, Hoyt DB. Epidemiology and pathology of traumatic deaths occurring at a level 1 trauma center in a regionalized system: The importance of secondary brain injury. J Trauma 1989;29:1392–7. [12] Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epidemiology of trauma deaths. Am J Surg 1980;140:144 – 9. [13] Goris RJA, Draaisma J. Causes of death after blunt trauma. J Trauma 1982;22:141–6. [14] DeCamp MM, Demling RH. Posttraumatic multisystem organ failure. J Am Med Assoc 1988;260:530–4. [15] Lauwers L, Rosseel P, Roelants A, Beeckman C, Baute L. A
.
.
[16]
[17] [18]
[19] [20] [21]
[22]
retrospective study of 130 consecutive multiple trauma patients in an intensive care unit. Intensive Care Med 1986;12:296–301. Rixen D, Siegel JH, Friedman HP. ‘Sepsis/SIRS’, physiologic classification, severity stratification, relation to cytokine elaboration and outcome prediction in posttrauma critical illness. J Trauma 1996;41:581 – 98. Cummings P. Cause of death in an emergency department. Am J Emerg Med 1990;8:379 – 84. Champion H, Copes W, Sacco W, et al. The major trauma outcome study: establishing national norms for trauma care. J Trauma 1990;30:1356 – 65. Frutiger A, Ryf C, Bilat C, et al. Five year follow-up of severely injured ICU patients. J Trauma 1991;31:1216 – 26. van der Sluis CK, ten Duis HJ, Geertzen JHB. Multiple injuries: an overview of the outcome. J Trauma 1995;38:681 – 6. Smail N, Messiah A, Edouard A, et al. Role of systemic inflammatory response syndrome and infection in the occurrence of early multiple organ dysfunction syndrome following severe trauma. Intensive Care Med 1995;21:813 – 6. Shackford SP, Mackersie RC, Holbrook TL, Davis JW, Hollingsworth-Fridlund P, Hoyt DB, Wolf PL. The epidemiology of traumatic death: a population based analysis. Arch Surg 1993;128:571 – 5.