Lung Organ Failure Score (LOFS): Probability of severe pulmonary organ failure after multiple injuries including chest trauma

doi:10.1016/j.injury.2010.12.029

Injury

Volume 43, Issue 9, September 2012, Pages 1507-1512

https://doi.org/10.1016/j.injury.2010.12.029 Get rights and content

Abstract

Background

Pulmonary complications are common in multiple trauma patients with chest injury. Factors predisposing these critically ill patients to respiratory organ failure are not fully understood.

Methods

Univariate and multivariate logistic regression analyses were used to assess the prognostic value of clinical and laboratory variables (2002–2008; n = 30,616) from the Trauma Registry of the German Trauma Society (DGU). Data from patients admitted to the ICU with lung contusion/lacerations, an Injury Severity Score ≥16 and age ≥18 were included in the study. Severe pulmonary organ failure was defined as PaO₂/FiO₂ < 200 for ≥3 days and based on the odds ratios (ORs) a simplified Lung Organ Failure Score (LOFS) was developed using integer values.

Results

21.3% (1254) of the 5892 patients analysed developed severe pulmonary organ failure. We identified seven independent predictors with significant correlation: age, gender, head injury, fluid therapy, injury severity, degree of chest trauma and surgical interventions. The highest ORs were observed in cases of Abbreviated Injury Scale (AIS)Thorax = 5 (1.58), surgical intervention (1.71) and multiple surgeries (2.41). We found that patients with simplified score values ≥21 points were at a maximum risk (>30%) for developing severe pulmonary complications.

Conclusion

This scoring method could help trauma surgeons determine which multiple trauma patients are at risk for pulmonary complications after trauma. Efficacy analyses of prophylactic PEEP ventilation or rotational bed therapy in subgroups with comparable risks for respiratory complication could be based on the LOFS.

Introduction

Respiratory complications like Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS) are common occurrences in multiple trauma patients. Mortality rates for ALI after trauma have been described to be around 10%, a figure that is much lower than in septic patients with ALI.¹⁶ Other studies report lower mortality rates in chest trauma patients with ALI/ARDS than when sepsis, pneumonia or aspiration are the underlying causes.6, 15 More recent studies have shown a decrease of approximately 1.1% per year in overall ALI/ARDS mortality,⁴³ indicating improved care.

Multiple trauma patients with chest trauma often have altered post-traumatic inflammation, higher rates of respiratory complications with low PaO₂:FiO₂ ratios, pneumonia and ARDS and poor outcomes.12, 22, 27 The association between parameters such as age, injury pattern and overall injury severity and the development of respiratory complications has not been fully studied in these patients. In a recent article by Ahmad et al.¹ the authors emphasised a need for better scoring systems for patients with blunt chest trauma. Whilst a correlation between decreased oxygenation ratios and increased mortality in critically ill patients has been well established,⁶ it is difficult to draw parallels in cases where indirect lung injury liker sepsis, pneumonia and aspiration are present.

We analysed data from the Trauma Registry of the German Society for Trauma Surgery to identify parameters that predispose multiple trauma patients with chest trauma to pulmonary organ failure.

Section snippets

Trauma Registry of the German Society for Trauma Surgery (DGU)

The Trauma Registry of the German Society for Trauma Surgery (www.traumaregister.de) was founded in 1993 and contains anonymous datasets on patients with multiple trauma, which are prospectively documented and structured into 4 consecutive phases:

1.
Prehospital phase: mechanism of injury, initial physiology, first therapy, neurologic signs, and rescue time.
2.
Emergency room: physiology, laboratory findings, suspected pattern of injury, therapy, time sequence of diagnostics.
3.
Intensive care unit: status

Univariate analyses

A total of 5892 patients, consisting primarily of middle-aged males suffering from blunt trauma made up the study population. Of these 1254 (21.3%) had severe pulmonary organ failure (Fig. 1) and were more severely injured (ISS 37.4 vs. 31.8 pts.) with more concomitant injuries to the head, extremities and abdomen. Correspondingly time on mechanical ventilation and length of ICU stay were prolonged as well as in-hospital mortality was increased. Additionally, more organ failure patients had

Discussion

In the present study we identified and quantified predictors for severe pulmonary organ failure after chest trauma in multiple injured patients using retrospective data from a large multi-country trauma registry. The data used for the selected population of more than 6000 patients was 93% complete for the primary endpoints. We therefore believe that, since only few patients were excluded, our results are representative of this population of patients in western countries. Our data confirmed the

Conflict of interest

There are no conflicts of interest.

Acknowledgements

The Trauma Registry of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie) was partly funded by the Deutsche Forschungsgemeinschaft Ne 385/5 and by a grant from Novo Nordisk A/S, Bagsvaerd, Denmark.

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We included adult patients that were admitted to our level 1 trauma centre from 2010-2014 and presented with severe thoracic injuries (AISThorax ≥3) within 24 h after the injury and required at least 72 h of mechanical ventilation. Patients were either treated with manual turning every 2–4 h or CLRT. To ensure comparable injury severity and a similar risk for posttraumatic respiratory complications, we matched for thoracic injury severity, age, additional injuries (head, abdomen, extremities) and need for massive transfusion.
A total of 22 pairs (n = 44 patients) were successfully matched and analysed. The use of CLRT did not have a statistically significant impact on respiratory function, gas exchange, duration of mechanical ventilation, ICU or hospital length of stay, or overall patient outcomes (e.g. pneumonia, sepsis, ARDS, mortality). During active rotation the level of sedation was lower compared to manual turning (Richmond Agitation Sedation Scale; manual turning: −3.6; CLRT: −4.0; p = 0.01). Patient agitation was noticed more frequently in the CLRT group (manual turning: n = 2 (9%); CLRT: n = 9 (41%); p = 0.02).
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Several harmful factors can subsequently lead to the occurrence or aggravation of ARDS in the days after the initial chest trauma. Pulmonary oedema results from extravascular diffusion because of increased capillary permeability, and decrease in oncotic pressure [33]. Limitation of capillary pressure by fluid restriction has been shown in favour of a decreasing of lung oedema [34].
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In severely injured patients severe thoracic trauma is common and can significantly influence the outcome of these critically ill patients by increased rates of mainly pulmonary complications. Furthermore, patients who sustained thoracic trauma are at increased risk for Acute Lung Injury (ALI) or Adult Respiratory Distress Syndrome (ARDS). Therapeutic options are limited, basically consisting of prophylactic antibiotic therapy and changing patient’s positions. It is known, that ALI and ARDS differ clinically and pathobiologically from ALI/ARDS caused by other reasons, but the exact pathology remains elusive. Due to that no reliable predictive or surveillance biomarkers could be established for clinical diagnosis and identification of patients at high risk for acute traumatic lung injury. Nevertheless, there are plenty of promising markers that need to be further elucidated in larger case numbers and multicenter studies. This article sums up the recent status of those promising clinical biomarkers.
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However, selection bias was low because only a few patients were excluded for lack of data. Fluid therapy and sequencing of surgical intervention were not standardised in our centre during the study period, although they are well known to be associated with the occurrence of ARDS [23,24]. Ventilatory strategies are not detailed in our series.
Pulmonary contusion is a major risk factor of acute respiratory distress syndrome (ARDS) in trauma patients. As this complication may appear after a free interval of 24–48 h, detection of patients at risk is essential. The main objective of this study was to assess the performance of the Thoracic Trauma Severity (TTS) score upon admission in predicting delayed ARDS in blunt trauma patients with pulmonary contusion.
All blunt thoracic trauma patients admitted consecutively to our trauma centre between January 2005 and December 2009 were retrospectively included if they presented a pulmonary contusion on the admission chest computed tomography scan. Main outcome measure was the presence of moderate or severe ARDS (PaO₂/FiO₂ ratio ≤ 200) for 48 h or more. The global ability of the TTS score to predict ARDS was studied by ROC curves with a threshold analysis using a grey zone approach.
Of 329 patients studied (75% men, mean age 36.9 years [SD 17.8 years], mean Injury Severity Score 21.7 [SD 16.0]), 82 (25%) presented with ARDS (mean lowest PaO₂/FiO₂ ratio of 131 [SD 34]). The area under the ROC curves for the TTS score in predicting ARDS was 0.82 (95% CI 0.78–0.86) in the overall population. TTS scores between 8 and 12 belonged to the inconclusive grey zone. A TTS score of 13–25 was found to be independent risk factors of ARDS (OR 25.8 [95% CI 6.7–99.6] P < 0.001).
An extreme TTS score on admission accurately predicts the occurrence of delayed ARDS in blunt thoracic trauma patients affected by pulmonary contusion. This simple score could guide early decision making and management for a non-negligible proportion of this specific population.
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The consecutive reaction is characterised by local and systemic release of pro-inflammatory cytokines,7–9,36 which often results in a systemic inflammatory response syndrome (SIRS). Trauma therefore acts as a trigger for a complex cascade of post-traumatic events that lead to multifocal pathophysiological processes.37–45 In addition, “second hits”, such as surgical interventions, ischaemia/reperfusion injuries or infections, can worsen this systemic inflammation leading to the development of multiple organ dysfunction syndrome (MODS) or multiple organ failure (MOF), and death.
Hand and wrist lesions are relatively common in polytraumatised patients. These subjects sustain a wide range of potential life-threatening conditions and hand and wrist injuries incurred are often not diagnosed or are insufficiently treated. Closed lesions are the most frequently missed diagnosis, but even severe open lesions may be incorrectly treated. Most of these hand and wrist injuries can have a strong negative impact on long-term quality of life, particularly when treatment of these injuries is poor or delayed. Orthopaedic and hand surgeons should be vigilant in their assessment and treatment of patients with multiple injuries and a global approach, based on the advanced trauma life support (ATLS)-protocol, must be applied. The very common association of head, chest, abdomen, bone and soft-tissue lesions in the polytraumatised patient requires a multidisciplinary team approach from the beginning. The energy of trauma in these patients often causes complex injuries to the wrist and hand; these require correct treatment in terms of both timing and techniques. It is not possible to create a practical, useful guideline with a “one lesion-one solution” approach, because every case is different; therefore, this paper describes a spectrum of indications and techniques that may be useful in managing hand and wrist injuries, particularly in polytraumatised patients.

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¹: German Trauma Society, participating centers: http://www.traumaregister.de.

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Lung Organ Failure Score (LOFS): Probability of severe pulmonary organ failure after multiple injuries including chest trauma

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Trauma Registry of the German Society for Trauma Surgery (DGU)

Univariate analyses

Discussion

Conflict of interest

Acknowledgements

Chest

Injury

Injury

Injury

Chest

Injury

Chest

Chest

Assessment of severity of chest trauma: Is there an ideal scoring system?

Injury

Effect of kinetic therapy on pulmonary complications

Am J Crit Care

The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care

J Trauma

Report of the American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes and clinical trial coordination. The Consensus Committee

Intensive Care Med

Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study

Intensive Care Med

Gender differences in acute response to trauma-hemorrhage

Shock

Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications

J Trauma

Guidelines for prehospital fluid resuscitation in the injured patient

J Trauma

Identification of early predictors for post-traumatic pneumonia

Am Surg

Prone ventilation in trauma or surgical patients with acute lung injury and adult respiratory distress syndrome: is it beneficial?

J Trauma

The prognostic significance of pulmonary contusions on initial chest radiographs in blunt trauma patients

Eur J Trauma Emerg Surg

Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997–2008

J Trauma