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Vol. 40. Issue 6.
Pages 327-347 (August - September 2016)
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Vol. 40. Issue 6.
Pages 327-347 (August - September 2016)
Original
DOI: 10.1016/j.medine.2015.07.003
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Epidemiology of severe trauma in Spain. Registry of trauma in the ICU (RETRAUCI). Pilot phase
Epidemiología del trauma grave en España. REgistro de TRAuma en UCI (RETRAUCI). Fase piloto
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M. Chico-Fernándeza,
Corresponding author
murgchico@yahoo.es

Corresponding author.
, J.A. Llompart-Poub, F. Guerrero-Lópezc, M. Sánchez-Casadod, I. García-Sáeze, M.D. Mayor-Garcíaf, J. Egea-Guerrerog, J.F. Fernández-Ortegah, A. Bueno-Gonzálezi, J. González-Robledoj, L. Servià-Goixartk, J. Roldán-Ramírezl, M.Á. Ballesteros-Sanzm, E. Tejerina-Alvarezn, C. García-Fuentesa, F. Alberdi-Odriozolae, in representation of the Trauma and Neurointensive Care Working Group of the SEMICYUC
a UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
b Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, Spain
c Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain
d Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, Spain
e Servicio de Medicina Intensiva, Hospital Universitario de Donostia, San Sebastián, Spain
f Servicio de Medicina Intensiva, Complejo Hospitalario de Torrecárdenas, Almería, Spain
g Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
h Servicio de Medicina Intensiva, Hospital Universitario Carlos Haya, Málaga, Spain
i Servicio de Medicina Intensiva, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
j Servicio de Medicina Intensiva, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
k Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Lérida, Spain
l Complejo Hospitalario de Pamplona, Pamplona (Navarra), Spain
m Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain
n Servicio de Medicina Intensiva, Hospital Universitario de Getafe, Getafe (Madrid), Spain
Article information
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Figures (2)
Tables (13)
Table 1. Epidemiological characteristics.
Table 2. First care n (%).
Table 3. Most frequent coded injuries in 1665 patients (%).
Table 4. Complications associated to trauma, n (%).
Table 5. Utilization of resources, n (%).
Table 6. Clinical outcome of the trauma patients admitted to ICU.
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Abstract
Objective

To describe the characteristics and management of severe trauma disease in Spanish Intensive Care Units (ICUs). Registry of trauma in the ICU (RETRAUCI). Pilot phase.

Design

A prospective, multicenter registry.

Setting

Thirteen Spanish ICUs.

Patients

Patients with trauma disease admitted to the ICU.

Interventions

None.

Main variables of interest

Epidemiology, out-of-hospital attention, registry of injuries, resources utilization, complications and outcome were evaluated.

Results

Patients, n=2242. Mean age 47.1±19.02 years. Males 79%. Blunt trauma 93.9%. Injury Severity Score 22.2±12.1, Revised Trauma Score 6.7±1.6. Non-intentional in 84.4% of the cases. The most common causes of trauma were traffic accidents followed by pedestrian and high-energy falls. Up to 12.4% were taking antiplatelet medication or anticoagulants. Almost 28% had a suspected or confirmed toxic influence in trauma. Up to 31.5% required an out-of-hospital artificial airway. The time from trauma to ICU admission was 4.7±5.3h. At ICU admission, 68.5% were hemodynamically stable. Brain and chest injuries predominated. A large number of complications were documented. Mechanical ventilation was used in 69.5% of the patients (mean 8.2±9.9 days), of which 24.9% finally required a tracheostomy. The median duration of stay in the ICU and in hospital was 5 (range 3–13) and 9 (5–19) days, respectively. The ICU mortality rate was 12.3%, while the in-hospital mortality rate was 16.0%.

Conclusions

The pilot phase of the RETRAUCI offers a first impression of the epidemiology and management of trauma disease in Spanish ICUs.

Keywords:
RETRAUCI
Trauma registries
Severe trauma
Intensive care unit
Resumen
Objetivo

Describir las características de la enfermedad traumática grave (ETG) y su atención en las unidades de cuidados intensivos (UCI) españolas.

Diseño

Registro multicéntrico y prospectivo.

Ámbito

Trece UCI españolas.

Pacientes

Pacientes con ETG ingresados en UCI participantes.

Intervenciones

Ninguna.

Variables de interés principales

Aspectos epidemiológicos, atención prehospitalaria, registro de lesiones, consumo de recursos, complicaciones y evolución final.

Resultados

Se incluyó a 2.242 pacientes con 47,1±19,02 años de edad media, 79% hombres. Fue trauma contuso en 93,9%. El Injury Severity Score fue de 22,2±12,1 y el Revised Trauma Score de 6,7±1,6. Fue no intencionado en el 84,4%. Las causas más frecuentes fueron accidentes de tráfico, caídas y precipitaciones. Un 12,4% tomaban antiagregantes o anticoagulantes y en casi un 28% se implicó el consumo de tóxicos. Un 31,5% precisaron una vía aérea artificial en medio prehospitalario. El tiempo medio hasta el ingreso en UCI fue de 4,7±5,3h. Al ingreso en UCI un 68,5% se encontraba estable hemodinámicamente. Predominó el traumatismo craneal y torácico. Hubo un importante número de complicaciones y en el 69,5% de los casos necesidad de ventilación mecánica (media 8,2±9,9 días). De ellos, un 24,9% precisaron traqueotomía. Las estancias en UCI y hospitalarias fueron respectivamente de mediana 5 (3–13) días y 9 (5–19) días. La mortalidad en UCI fue del 12,3% y la hospitalaria del 16%.

Conclusiones

La fase piloto del RETRAUCI muestra una imagen inicial de la epidemiología y atención del paciente con ETG ingresado en las UCI de nuestro país.

Palabras clave:
RETRAUCI
Registros de trauma
Trauma grave
Unidad de Cuidados Intensivos
Full Text
Introduction

Severe trauma disease (STD) is a worldwide pandemic and one of the leading causes of death and disability, particularly in young adults.1 The prognosis of STD depends on a number of factors, such as the severity and energy of trauma, the physiological reserve of the patient, and the quality and promptness of the provided care. The latter are the modifiable factors.2 However, modification is only feasible if the reality of healthcare is adequately monitored, and this inevitably implies the existence a trauma registry (TR).2,3

Trauma registries can fully monitor the STD care process, and among other aspects their advantages include the monitoring of epidemiological trends, the promotion of public health and scientific production, the designing of individualized intervention plans, and the optimization of resources as functions related to the accreditation and elaboration of different scales related to trauma disease.4,5 The methodology used in the different registries is by no means uniform, however.6,7

Despite the above, and although there have been different regional initiatives in Spain,8–12 to date no registry has afforded national coverage of the patients admitted to Intensive Care Units (ICUs). The Trauma and Neurointensive Care Working Group (WG) of the Spanish Society of Intensive Care Medicine and Coronary Units (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias [SEMICYUC]) has dedicated effort to the development of a severe TR that may serve as a vehicle for improving the documentation, care and investigation of STD in Spain.2 The RETRAUCI (Trauma Registry in the ICU [Registry TRAuma en UCI]) was started as a registry pilot initiative in a series of hospitals with a particular interest in severe trauma.

The aim of this study is to describe the characteristics of STD and its management in Spanish ICUs, based on the first results of the RETRAUCI pilot initiative.

Material and methods

The registry was identified as a need in the course of the meetings of the Trauma and Neurointensive Care Working Group of the SEMICYUC. Finally, and after several preliminary meetings, data collection was started on 23 November 2012 in some selected centers. During this pilot phase, the data were entered by the supervising investigator in each center using a Microsoft Access spreadsheet. At the time of submission of this study, the online tool had already been activated (www.retrauci.org).13 Approval was obtained from the corresponding Ethics Committees.

Inclusion criteria

The study included all patients admitted to an adult patients ICU due to STD during the study period, with a stay of over 24h. Cases involving shorter stays with a fatal outcome were also included.

Data collection

The following data were collected:

  • -

    Epidemiological information, including age, gender, date and time of trauma and of admission to the ICU, intentionality, mechanism and type of trauma, previous use of antiplatelet or anticoagulant medication, and potential implication of different drugs of abuse.

  • -

    Aspects related to out-hospital care, including the type of initial medical care and the need for lung isolation measures.

  • -

    Registry of trauma injuries according to the Abbreviated Injury Scale (AIS),14 and calculation of different severity scores based on physiological (Revised Trauma Score [RTS])15 and anatomical aspects (Injury Severity Score [ISS]).16

  • -

    Complications during admission to the ICU, including the hemodynamic condition upon admission, the existence of coagulopathy, rhabdomyolysis, respiratory dysfunction, multiorgan failure syndrome, intracranial hypertension, renal failure and nosocomial infection. The definitions are described in Annex 1.

  • -

    Resource utilization, including blood product transfusions, number of urgent surgeries in the first 24h, and number of non-urgent surgeries, days on mechanical ventilation, pneumological monitoring, tracheotomy (percutaneous or surgical), arteriography for hemostasis and neuromonitoring techniques (ICP, SjO2, PtiO2 and NIRS).

  • -

    Evolution and final destination of the patients in ICU.

Coding of injuries

In 7 of the 13 centers that participated in the pilot phase (Annex 2), the injuries were coded with the 7 digits of the AIS in its updated version corresponding to the year 2008.17 In those centers where no complete coding with the 7 digits was made, a customized abridged version was used (Annex 3) for calculating the ISS.

Statistical analysis

The normal distribution of the variables was assessed using the Kolmogorov–Smirnov test. The quantitative variables followed a normal distribution, and were therefore reported as the mean±standard deviation. Categorical variables were reported as number (percentage).

The bivariate analysis (differences between 2 groups) of the categorical variables was based on the chi-squared test, using the Fisher exact test if the expected frequency of a variable was less than 5 in 2×2 tables. The Student's t-test was used in the case of quantitative variables. Analysis of variance (ANOVA) was used when comparing more than two variables. The SPSS version 20 statistical package (IBM Corporation, 2011) was used throughout. Statistical significance was considered for p<0.05.

Results

Between 23 November 2012 and 31 January 2015 we included a total of 2242 patients admitted to the participating ICUs due to STD. The distribution of patients per participating center in the pilot phase is shown in Annex A. The characteristics of the patients included in the registry are summarized in Table 1. Of the included patients, 20.6% were over 65 years of age. Trauma was unintentional in 1890 cases (84.4%), intentional in 13.9% and unknown in 1.7%. Injury occurred in the context of a working accident in 154 patients (6.9%), a sports accident in 126 patients (5.6%), physical assault in 149 patients (6.7%), and attempted suicide in 162 patients (7.2%). Traffic accidents considered globally regardless of the type of vehicle, and falls, were the most frequent causes of trauma.

Table 1.

Epidemiological characteristics.

Age (years)  47.1±19.02 
Gender (M/F) as %  79/21 
Type (contusive/penetrating) as %  93.9/6.1 
Injury Severity Score  22.2±12.1 
Revised Trauma Score  6.7±1.6 
Origin n (%)
Out-hospital  816 (36.9) 
Emergency care  784 (35.4) 
Operating room  137 (6.2) 
Other hospital  475 (21.5) 
Mechanism n (%)
Accidental fall  465 (20.8) 
Fall from a height  358 (16.0) 
Automobile  352 (15.3) 
Motorcycle  321 (14.3) 
Run over by vehicle  191 (8.5) 
Bicycle  110 (4.9) 
Struck with an object  96 (4.3) 
Knife  73 (3.3) 
Other vehicles  66 (3.0) 
Crushing  29 (1.3) 
Firearm  28 (1.3) 
Explosion  16 (0.7) 
Unknown  43 (1.9) 
Others  99 (4.4) 

The percentage of patients with ISS>15 and RTS<6 was 72.7% and 26%, respectively.

A total of 12.4% of the subjects presented coagulopathy prior to trauma, 6.8% received antiplatelet medication, and 5.6% anticoagulant treatment. In 27.9% of the cases substance abuse was clinically suspected or confirmed by the laboratory tests.

The type of initial out-hospital care, the need for orotracheal intubation or in situ alternative airway, the hemodynamic situation upon admission to the ICU, and the evaluation of brain injury based on the radiological data are summarized in Table 2.

Table 2.

First care n (%).

Pre-hospital care
None  192 (8.6) 
Non-medicalized  229 (10.3) 
Mobile ICU  1551 (69.7) 
Helicopter  207 (9.3) 
Unknown  46 (2.1) 
Pre-hospital OTI
No  1518 (68.5) 
Yes  630 (28.4) 
Alternative airway  68 (3.1) 
Hemodynamics upon admission to the ICU
Stable  1389 (64.4) 
Unstable, recovers with volume replacement  326 (15.1) 
Shock  323 (15,0) 
Refractory shock  119 (5.5) 
TBI Marshalla
DI type I  156 (19.7) 
DI type II  351 (44.4) 
DI type III  45 (5.7) 
DI type IV  25 (3.2) 
Evacuated mass  139 (17.6) 
Non-evacuated mass  74 (9.4) 

OTI: orotracheal intubation; DI: diffuse injury; TBI: traumatic brain injury; ICU: Intensive Care Unit.

a

Only in patients with injuries in coded head areas.25

The mean time from trauma to admission to the ICU was 4.7±5.3h. There were significant differences in the time from trauma to admission to the ICU according to the type of first medical care provided: no pre-hospital care (7.3±4.5h), non-medicalized care (5.8±3.4h), mobile ICU (4.2±5.6h), helicopter (4.3±3.4h) and unknown (7.6±4.8h) (p<0.0001). The post hoc analysis found the mobile ICU to show significant differences versus no pre-hospital care, non-medicalized care and unknown care, while helicopter transfer showed significant differences in the post hoc analysis versus no pre-hospital care and unknown care. Regarding the time of admission, 24.2% of the patients were admitted in the course of the morning shift (08:01–15:00h), 39.5% in the afternoon (15:01–22:00h), and 36.2% during the night shift (22:01–08:00h).

A total of 9890 injuries in 1665 patients were coded. The most commonly coded injuries according to the AIS are shown in Table 3, and the percentage injuries in each body region are indicated in Fig. 1. The percentage patients with each type of complication are shown in Table 4, while resource utilization on the part of the patients in the study sample is reported in Table 5.

Table 3.

Most frequent coded injuries in 1665 patients (%).

450203.3: Fracture ≥ 3 ribs without flail chest (17.1) 
650620.2: Lumbar transverse process (14.9) 
140695.3: Subarachnoid hemorrhage with coma >6h (13.7) 
150202.3: Fracture of the skull base without cerebrospinal fluid loss (12.1) 
150402.2: Uncomplicated fracture of the skull dome (11.5) 
442202.2: Pneumothorax (10.7) 
140694.2: Subarachnoid hemorrhage without coma >6h (10.4) 
140651.3: Small subdural hematoma <6mm in thickness (8.6) 
650420.2: Dorsal transverse process (8.4) 
441407.2: Minor unilateral pulmonary contusion (7.7) 
Figure 1.

Percentage of injuries coded according to the different areas contemplated by the Abbreviated Injury Scale.

(0.13MB).
Table 4.

Complications associated to trauma, n (%).

Coagulopathy trauma  497 (23.1) 
Rhabdomyolysis  237 (11.1) 
Intracranial hypertensiona
No  145 (34.2) 
First-level measures required  144 (34) 
Second-level measures required  135 (31.8) 
MOFS
Early  231 (10.9) 
Lateb  234 (15.7) 
ARDS  501 (23.4) 
Renal failure  312 (14.7) 
Nosocomial infectionc  455 (32.3) 

MOFS: multiorgan failure syndrome; ARDS: acute respiratory distress syndrome.

a

Considering only the patients in which intracranial pressure has been measured (n=424).

b

Considering only the patients with ICU stay >3 days (n=1407).

c

Considering only the patients with ICU stay ≥3 days (n=1804).

Table 5.

Utilization of resources, n (%).

Transfused patients 6h  596 (26.6) 
Volume RCC transfused
0–600ml  1868 (83.3) 
601–2000ml  289 (12.9) 
>2000ml  85 (3.8) 
Arteriography bleeding  88 (3.9) 
Urgent surgery patients  833 (37.2) 
Non-urgent surgery patients  407 (24.1) 
Monitoring of ICP  424 (21) 
Days of monitoring of ICPa  6.6±4.8 
Other neuromonitoring
SjO2  20 (1) 
PtiO2  84 (4.2) 
NIRS  23 (1.1) 
Patients on mechanical ventilation  1363 (69.5) 
Days of mechanical ventilationb  8.2±9.9 
Tracheotomized patientsb  340 (24.9) 
Percutaneous  248 (73) 
Surgical  92 (27) 

RCC: red cell concentrates; NIRS: near-infrared spectroscopy; ICP: intracranial pressure; PtiO2: tissue oxygen pressure; SjO2: jugular bulb oxygen saturation.

a

Considering only the patients with intracranial pressure monitoring (n=424).

b

Considering only the patients with mechanical ventilation (n=1363).

The in-ICU mortality rate was 12.3%, while the in-hospital mortality rate was 16%. The days of ICU stay and of post-ICU hospital stay, together with in-ICU mortality and post-ICU hospital mortality are reported in Table 6. A significant association was observed between the ISS score and mortality (p<0.0001) (Fig. 2). Of the survivors, 11.6% were transferred to another ICU after discharge, while 21.1% were moved to another hospital center.

Table 6.

Clinical outcome of the trauma patients admitted to ICU.

ICY stay (days)a  5 (3–13) 
Post-ICU hospital stay (days)a  9 (5–19) 
ICU mortality  273 (12.3%) 
Post-ICU hospital mortality  53 (3.7%) 
a

Median and interquartile range.

Figure 2.

Distribution of cases according to the Injury Severity Score and associated mortality in each group.

(0.06MB).

Limitation of life support measures was applied to one degree or other in 6.9% of the overall patient sample. Specifically, limitation of life support was implemented in 55.1% of the 273 patients that died (156 patients). A total of 27.5% of those who died became organ donors.

Discussion

The data presented in this study offer a first impression of the epidemiology and management of patients with STD admitted to the ICUs in Spain. The findings suggest that the introduction of a national TR is feasible, and may result in improved knowledge of STD in our setting and better patient care in the future.

The standard patient with STD in our setting is a middle-aged male with unintentional contusion injuries caused by a traffic accident or fall, and initially attended by a mobile ICU in the out-hospital setting, without the need for in situ orotracheal intubation in 70% of the cases. The patient is hemodynamically stable at the time of first care and mainly suffers brain (type II diffuse injury) and chest trauma. Three out of every four patients are admitted to the ICU in the course of the afternoon or night shift, and are therefore attended by less experienced personnel on duty. One out of every three patients require urgent intervention, while a similar proportion receive deferred care. These typical patients are associated to important resource utilization, and most of them receive mechanical ventilation during admission to intensive care, and suffer different complications. Intracranial hypertension is frequent in patients with brain injuries. Other neuromonitoring techniques are very little used. One out of every four patients on mechanical ventilation require a tracheotomy (preferentially percutaneous). The mortality rate is relatively low, though the stay in the ICU and in hospital is long.

The keeping of a TR is associated to improved knowledge of the epidemiology, processes and outcomes of the management of patients with STD,2–7 and over time the documentation of such information is associated to lesser mortality and disability in patients with STD.18 At this point it is still too early to assess this latter aspect in our registry. A controversial issue in relation to TRs is what parameters should be recorded and how optimum data collection can be ensured. In this regard, a recent Scandinavian study involving 783 patients from different geographical areas19 has found that certain physiological and time-related variables pose compilation difficulties.

In our case, this pilot phase has allowed us to modify the way in which certain variables are collected and to add some others that may be of interest. Such flexibility is necessary, since a TR must be adaptable to the setting in which it is kept and modifiable according to the results obtained and the variations in scientific evidence over time.7 Accordingly, and in comparison with the pilot phase presented herein, the latest version of the online access base contemplates among other modifications the time elapsed from the moment of trauma to hospital admission and from hospital admission to admission to the ICU; intoxication due to drugs and psychotropic agents of chronic use; the administration of new antiplatelet agents and anticoagulant drugs; pupil status and the performing of decompressive craniotomy; documentation of the patients admitted to the ICU as potential organ donors; the total red cell concentrate units transfused in the first 24h instead of the number of milliliters transfused in the first 6h; the number of fresh plasma bags and massive transfusions; the use of continuous renal replacement therapies; the introduction of a new definition of acute respiratory distress syndrome based on the Berlin criterion; and neurological assessment at discharge from the ICU. Furthermore, we will be able to gain more complete information referred to different trauma severity scores, with automatic calculation of the ISS and the New ISS, and of survival probability.20

The pilot phase of the RETRAUCI has allowed us to detect errors and opportunities for improvement in the documentation and follow-up of trauma patients in Spain, and has shown that starting the initiative is feasible. On the other hand, it has given us an initial impression of the epidemiology and management of patients with STD admitted to the ICUs in our country.

In future, and ideally, an analysis of the quality of life of patients with STD also should be contemplated,21 though the optimum timing of such an analysis is not clear,22 and moreover it will require a great effort on the part of the investigators – particularly on considering the usual structure of Spanish ICUs.

The RETRAUCI was created as a project of the Trauma and Neurointensive Care Working Group of the SEMICYUC, with the intention of continuing over time and of having an impact upon the evolution of patients with STD, in the same way as with other Working Groups of the SEMICYUC in patients with ischemic heart disease or sepsis, through the ARIAM and ENVIN registries. At the time of drafting of this article, and with the online tool already active, several additional centers have announced their participation. From this article we wish to invite all Spanish ICUs that attend trauma cases to participate in the RETRAUCI through the mentioned online tool, since doing so will undoubtedly contribute to improve survival, increase volume and quality, and positively affect the health of these patients. The data obtained by means of the RETRAUCI can afford reliable information for public and political institutions with legislative intent, as well as optimize the use of resources and social awareness.7,23

We must take note of the limitations of this study in particular, and of registries in general. Firstly, the information presented herein arises from a voluntary TR in which the participating centers have expressed interest in joining the initiative. Coverage is therefore limited, and this may lead to bias in evaluating the results, since the registry documents information from particularly motivated centers.2 Furthermore, this TR only contemplates those patients that are effectively admitted to the ICU. As such, it is not representative of STD in general, since it does not contemplate patients who die before reaching hospital, and which represent most of the fatalities due to severe trauma (mainly as a result of bleeding),1,24 or minor traumatisms that do not require admission to the ICU.

In sum, the pilot phase of the RETRAUCI offers a first impression of patients with STD admitted to ICUs in Spain, and represents the first initiative of this kind. The consolidation of a national TR is feasible and in future may contribute to reduce mortality and disability among such patients.

Authorship/collaborators

Luis Terceros-Almanza (Hospital Universitario 12 de Octubre), Ruth Salaberria-Udabe (Hospital Universitario de Donostia), Javier Homar-Ramírez (Hospital Universitari Son Espases), Francisca Inmaculada Pino-Sánchez (Hospital Universitario Virgen de las Nieves), Cecilia Carbayo-Górriz (Complejo Hospitalario de Torrecárdenas), Carmen Corcobado-Márquez (Hospital General Universitario de Ciudad Real), Javier Trujillano-Cabello (Hospital Universitari Arnau de Vilanova), Eduardo Miñambres-García (Hospital Universitario Marqués de Valdecilla), Amanda Lesmes-González (Hospital Universitario de Getafe).

Financial support

The registry receives financial support from the Fundación Mutua Madrileña during three years for the development of an online data collection tool, assigned to the principal investigator of the project (Dr. Chico-Fernandez, reference no. AP117892013), in representation of the Trauma and Neurointensive Care Working Group of the SEMICYUC.

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgements

The authors of this study wish to express their profound gratitude to Vicente Gómez-Tello (coordinator of the Working Groups of the SEMICYUC, Hospital Moncloa, Madrid) and Andrés J. Chacón (project manager, Xferic) for their collaboration in developing the registry, and to Miguel Ferrero-Fernández (computing science engineer of the Computing Department, SEMICYUC) for his work in developing the online tool of the RETRAUCI.

Annex A
Distribution of patients in the centers participating in the pilot phase

Center  Patients n  Patients (%) 
Hospital Universitario 12 de Octubre, Madrida  549  24.5 
Hospital Universitario de Donostia, San Sebastiána  310  13.8 
Hospital Universitari Son Espases, Palma de Mallorcaa  261  11.6 
Hospital Universitario Virgen de las Nieves, Granadaa  223  9.9 
Hospital Torrecárdenas, Almería  200  8.9 
Hospital Universitario Virgen del Rocío, Sevilla  153  6.8 
Hospital Universitario Carlos Haya, Málaga  128  5.7 
Hospital General Universitario de Ciudad Real, Ciudad Reala  122  5.4 
Complejo Asistencial Universitario de Salamanca, Salamancaa  96  4.3 
Hospital Universitari Arnau de Vilanova, Léridaa  94  4.2 
Complejo Hospitalario de Navarra, Pamplona  60  2.7 
Hospital Universitario Marqués de Valdecilla, Santander  24  1.1 
Hospital Universitario de Getafe, Madrid  22  1.0 
a

Centers in which the injuries are coded with all the digits of the Abbreviated Injury Scale.

Annex B
B.1
Head–neck–cervical spine

 
Cranium
Whole area  Erosion/contusion/superficial lacerationa  Laceration >10cma
Avulsion >100cm2a 
Laceration/avulsion bleeding >20%
Superficial penetrating injury ≤2cm 
  Deep penetrating injury >2cm  Crush with massive destruction 
Vessels      Thrombosis vertebral art./ant./post. cerebral art./other distal art.
Aneurysm int. carotid art./cerebral art./vertebral/other distal art.
Venous thrombosis 
Laceration other distal art.
Thrombosis int. carotid art./middle cerebral art.
Thrombosis (bilateral) vertebral art./ant./post. cerebral art.
Laceration of venous sinus
Thrombosis of venous sinus
Carotid-cavernous fistula
Venous laceration 
Laceration int. carotid art./cerebral art./vertebral/basilar art.
Thrombosis (bilateral) int. carotid art./middle cerebral art.
Traumatic aneurysm basilar art.
Laceration with ext. bleeding of venous sinus
Thrombosis (bilateral) of sinuses 
Laceration (bilateral) vertebral art./int. carotid art.
Laceration with ext. bleeding of sigmoid/transverse sinuses (bilateral) 
Nerves    Contusion/laceration of cranial nerve  Laceration (bilateral) of cranial nerve VII/VIII       
Internal organs
Brainstem and cerebellum    Epidural/subdural ≤0.6cm
SAH 
Contusion ≤15 cc
Superficial penetrating injury <2cm
Swelling/infarction 
Hematoma ≤15 cc
Contusion/epidural/subdural ≤30 cc 
Contusion/infarction of brainstem
Contusion/hematoma/epidural/subdural extensive >30 cc, >1cm
Deep penetrating injury >2cm 
Crush/laceration of brainstem 
Brain  Mild contusion/amnesia/GCS 9–14  Petechiae <1cm diameter
Epidural small <0.6cm thickness
Intraventricular hemorrhage/SAH without coma
Loss of consciousness <1h 
Superficial penetrating laceration ≤2cm
Contusions small ≤30 cc
Subdural small <0.6cm thickness
Swelling/edema mild (ventric. compression)
Infarction/ischemia without coma
SAH with coma. Pneumoencephalus
Loss of consciousness 1–6h 
Contusions large 30–50cc. Hematoma ≤30cc
Confirmed white matter diffuse axonal injury
Epidural/subdural moderate ≤50cc, 0.6–1cm
Swelling/edema moderate (ventricle/cistern compression)
Intraventricular hemorrhage with coma >6h
Loss of consciousness 6–24h 
Deep penetrating laceration >2cm
Extensive contusion >50 cc. Hematoma >30 cc
Diffuse axonal injury with involvement of corpus callosum
Epidural/subdural extensive >50cc, >1cm thickness
Epidural moderate (bilateral), ≤50cc, 0.6–1cm
Swelling/edema severe (absent ventricle/cistern)
Infarction/ischemia with coma 
 
Bones    Linear simple dome fracture  Skull base fracture
Dome fracture comminuted/depressed ≤2cm 
Complex skull base or dome fracture with brain exposure Depressed dome fracture >2cm     
Neck
Whole area  Mild penetrating injury
Erosion/contusion/laceration superf.a 
Penetrating injury >25cm2
Laceration >10cma
Avulsion >25cm2a 
Penetrating injury with hemorrhage >20%
Laceration/avulsion bleeding >20% 
    Decapitation 
Vessels  Minor injury/laceration ext. jugular bleeding <20%  Laceration ext. carotid/vertebral bleeding <20%
Thrombosis ext. carotid
Laceration int. jugular bleeding <20% 
Minor laceration carotid/vertebral bleeding <20%
Thrombosis carotid/vertebral without neurological defect
Laceration ext. carotid bleeding >20%
Laceration jugular bleeding >20% 
Major laceration carotid bleeding >20%
Injury/laceration/thrombosis carotid/vertebral with neurological defect 
Major laceration carotid with neurological defect
Laceration/thrombosis vertebral art. (bilateral) with neurological defect 
 
Nerves  Vagus nerve damage  Phrenic nerve damage    Phrenic nerve damage (bilateral)     
Internal organs  Contusion thyroid gland  Contusion/hematoma of esophagus/larynx/pharynx/trachea
Incomplete perforation of larynx/trachea
Laceration thyroid/cord 
Incomplete perforation of esophagus/pharynx
Perforation of entire wall of larynx/trachea. Tracheal fracture
Contusion/hematoma >75% of lumen
Vocal cord damage (bilateral)
Salivary gland duct transection 
Complete perforation of wall of esophagus/pharynx
Perforation of entire wall of larynx with involvement of vocal cords
Avulsion/massive damage to trachea
Laryngo-tracheal separation 
Avulsion/massive injury of esophagus/larynx/pharynx   
Bones    Hyoid fracture         
Cervical spine
Nerves    Contusion/laceration/incomplete avulsion brachial plexus
Contusion/laceration nerve root 
Contusion/laceration/complete avulsion brachial plexus
Laceration/avulsion multiple roots 
Complete injury (bilateral) brachial plexus     
Spinal cord      Spinal cord damage with transient symptoms  Incomplete cervical spinal cord damage  Complete spinal cord damage between C7 and C4  Complete spinal cord damage at level C3 or higher 
Bones    Disk herniation without radiculopathy
Joint luxation (unilateral)
Simple/multiple vertebral fracture 
Disk herniation with radiculopathy
Luxation occipito-C1/C1-C2/art. (bilateral) Vertebral collapse >20% height
Odontoid fracture 
     
a

Code in skin.

B.2
Face

Face
Whole area  Abrasion/contusion/minor lacerationa  Penetrating trauma damage >25cm2
Major laceration >10cma
Major avulsion >25cm2a 
Penetrating trauma with bleeding >20%
Laceration/avulsion with bleeding >20% 
Penetrating trauma with massive facial destruction (including both eyes)   
Vessels  Minor laceration of external carotid    Major laceration of external carotid with bleeding >20%     
Nerves    Contusion (uni-/bilateral) optic nerve
Laceration/avulsion of optic nerve 
Laceration/avulsion (bilateral) of optic nerve     
Internal organs
Ear  Middle/inner ear damage (unilateral)
Bone chain luxation (unilateral)
Eardrum rupture. Vestibular damage 
Bone chain luxation (bilateral)
Laceration middle/inner ear (bilateral) 
     
Eye  Laceration lacrimal canal
Conjunctival damage
Abrasion/contusion/laceration cornea
Foreign body in ant./post. chamber
Uveal/vitreous damage 
Avulsion/enucleation (unilateral)  Avulsion/enucleation (unilateral)     
Moth  Laceration of mouth/palate/gums         
Tongue  Minor, superficial laceration  Major, deep laceration       
Osteoarticular  Simple mandibular fracture
Simple nasal fracture
Luxation/fracture/avulsion tooth/teeth
Zygomatic arch fracture 
Temporo-mandibular luxation
Dental alveolar fracture
Open/displaced/comminuted mandibular fracture
Maxillary fracture: sinus/LeFort I/LeFort II
Open/displaced/comminuted nasal fracture
Orbital fracture
Complex zygomatic arch fracture 
LeFort III
Panfacial fracture 
LeFort III with bleeding >20%
Panfacial fracture with bleeding >20% 
 
a

Code in skin.

B.3
Thorax

 
Thorax
Whole area  Abrasion/contusion/minor lacerationa  Penetrating trauma damage >100cm2 Major laceration >20cma
Major avulsion >100cm2a 
Penetrating trauma with bleeding >20%
Laceration/avulsion with bleeding >20% 
Sucking chest wound    Thoracic crush with massive destruction 
Vessels    Minor lacerationa of other minor art./veins (bronchial, esophageal, intercostal, int. mammary, etc.Minor lacerationa of pulmonary art./brachiocephalic trunk/subclavian art./innominate vein/pulmonary vein/vena cava/Subclavian vein
Major lacerationc of other minor art./veins (bronchial, esophageal, intercostal, int. mammary, etc.
Minor laceration Aortic damage
Major laceration 2 brachiocephalic trunk/subclavian art./innominate vein/vena cava/subclavian vein 
Major lacerationb of aorta/pulmonary art./pulmonary vein
Intimal laceration with aortic valve involvement
Laceration of coronary artery
Major lacerationc superior vena cava/innominate vein with air embolism 
Major lacerationb Aortic damage with bleeding confined to mediastinum
Major lacerationc
Pulmonary art./vein (bilateral) 
Nerves  Vagus nerve damage           
Internal organs
Bronchi  Contusion/hematoma  Contusion/hematoma of distal bronchus
Laceration without perforation of distal bronchus 
Laceration without perforation of principal bronchus
Laceration with perforation of distal bronchus 
Laceration with complete perforation of principal bronchus
Complex laceration, transection, avulsion of distal bronchus 
Complex laceration, transection, avulsion of principal bronchus   
Diaphragm    Contusion/hematoma of diaphragm  Ruptured diaphragm ≤10cm  Ruptured diaphragm with herniation
Ruptured diaphragm >10 cm 
   
Esophagus    Contusion/hematoma of esophagus  Partial laceration <50% circumference
Ingestion of caustic agents with partial necrosis 
Laceration with perforation >50% circumference of esophagus
Ingestion of caustic agents with complete necrosis 
Complex laceration, transection, avulsion of esophagus   
Heart  Minor contusion (without acute dysfunction)  Laceration/puncture of pericardium  Laceration without perforation of chambers
Laceration of pericardium with hemopericardium (without tamponade or heart damage) 
Major contusion (acute dysfunction)
Laceration of pericardium with tamponade (without heart damage) 
Atrial rupture/burst
Ventricular/atrial perforation
Valve/septal/chord rupture
Laceration of pericardium with herniation 
Cardiac avulsion
Laceration with
Ventricular burst 
Lungs    Minor pulmonary contusion (unilateral)d
Inhalation damage without erythema, edema, bronchorrhea or obstruction 
Mild pulmonary blast
Minor pulmonary laceration (unilateral)d
Minor pulmonary contusion (bilateral)d
Major pulmonary contusion (unilateral)e
Inhalation damage with mild erythema 
Blast (uni-/bilateral) with alveolar hemorrhage
Minor pulmonary laceration (bilateral)d
Major pulmonary laceration (unilateral)e
Major pulmonary contusion (bilateral)d
Inhalation damage, erythema, bronchorrhea 
Severe pulmonary blast injury (bilateral)
Major pulmonary lacerationd (bilateral)
Inhalation damage with severe inflammation, obstruction and hypoxemia 
Inhalation damage with necrosis, detachment and obliteration at bronchial level 
Thoracic cavity    Pneumothorax
Hemo-/pneumomediastinum
Laceration of the thoracic duct 
Hemothorax/hemo-pneumothorax
Pneumomediastinum with tamponade 
Pneumothorax >50% or persistent leakage
Hemothorax >1000cc 
Tension pneumothorax Air embolism   
Trachea      Tracheal contusion/hematoma
Laceration without tracheal perforation 
Laceration with complete tracheal perforation  Complex laceration, transection, avulsion of trachea   
Osteoarticular  Costal/sternal contusion. Rib fracture  Fracture of 2 ribs
Sternal fracture 
Unstable thorax (unilateral) 3–5 ribs
Fracture of ≥3 ribs 
Unstable thorax (unilateral) >5 ribs  Unstable thorax (bilateral)   
Dorsal spine
Nerves  Contusion/avulsion of a nerve  Laceration/avulsion of multiple nerve roots         
Spinal cord      Spinal cord damage with transient symptoms  Incomplete spinal cord damage  Complete spinal cord damage   
Bones    Disk herniation without radiculopathy
Joint luxation (unilateral)
Simple/multiple vertebral fracture 
Disk herniation with radiculopathy
Joint luxation (bilateral)
Vertebral collapse >20% height 
     
a

Code in skin.

b

Minor vascular laceration: superficial/intimal, without affecting entire circumference and with bleeding <20%.

c

Major vascular laceration: rupture of entire circumference, complete transection and with bleeding >20%.

d

Minor lung contusion/laceration: involvement of less than one lobe, without increase in O2 (A-a) gradient.

e

Major lung contusion/laceration: involvement of one or more lobes, or hypoxemia, or increase in increase in O2 (A-a) gradient.

B.4
Abdomen

 
Abdomen
Whole area  Abrasion/contusion/minor lacerationa  Penetrating trauma damage >100cm2
Major laceration >20cma
Major avulsion >100cm2a
Rupture of rectus abdominalis muscle 
Penetrating trauma with bleeding >20%
Laceration/avulsion with bleeding >20% 
    Transection of trunk 
Vessels      Minor lacerationb of iliac art. (common, internal or external)/sup. mesenteric art./common iliac vein/vena cava/other minor art. or veins (renal, hepatic, splenic)
Celiac trunk intimal damage 
Minor lacerationb of aorta/celiac trunk
Major lacerationc iliac artery (common, internal or external)/sup. Mesenteric art./common iliac vein/vena cava/other minor art. or veins (renal, hepatic, splenic, etc.)
Common iliac artery damage (bilateral) 
Major lacerationc of aorta/celiac trunk   
Nerves  Vagus nerve damage           
Internal organs
Adrenal glands  Contusion/minor laceration  Contusion/major laceration >2cm  Massive damage, destruction >50%       
Anus  Contusion/hematoma  Partial laceration (without perforation)  Perforation of full thickness  Massive laceration, avulsion     
Bladder, ureter, perineal region  Bladder contusion
Contusion/minor laceration of perineal region 
Extraperitoneal laceration ≤2cm
Laceration without perforation bladder/ureter
Major laceration perineal region. Ureteral contusion 
Intra-/extraperitoneal rupture >2cm
Perforation, rupture of ureter
Massive laceration, avulsion of perineal region 
Massive bladder laceration, avulsion affecting trigone or neck     
Colon, rectum    Contusion/laceration without perforation of the rectum/colon  Laceration with perforation <50% circumference, of the rectum, >50% circumference of the colon  Laceration with perforation >50% circumference, with extension to perineal region
Laceration with transection of colon 
Massive laceration, avulsion of rectum   
Duodenum    Disruption <50% circumference
Contusion/laceration without perforation 
Disruption 50–75% circumference of portion D2
Disruption >50% of portion D1, D3 or D4 
Laceration with disruption >75% circumference D2 (affecting ampoule or distal portion of choledochus)  Massive laceration, avulsion, devascularization   
Gallbladder    Contusion/laceration without affecting cystic duct  Massive laceration+cystic duct  Massive laceration+cystic+(choledochus/hepatic)     
Small bowel    Contusion/laceration without perforation  Laceration with perforation of full thickness  Massive laceration, avulsion, devascularization     
Kidney    Laceration ≤1cm of cortex
Subcapsular contusion ≤50% 
Laceration >1cm of cortex (not collector system)
Subcapsular contusion >50% 
Laceration cortex+medulla+collector system+vessels
Renal rupture 
Total avulsion of renal hilum   
Mesenterium    Contusion/minor laceration  Major laceration with bleeding >20%  Massive laceration, avulsion of mesenterium     
Uterus, ovary  Contusion/laceration ≤5cm of ovary  Contusion/laceration ≤1cm of uterus
Laceration >5cm of ovary 
Laceration >1cm. Abruptio placentae ≤50%  Major laceration+uterine art. Abruptio placentae >50%  Rupture, avulsion. Abruptio placentae   
Urethra, testes,
Prostate, penis, 
Contusion/minor laceration penis/testes
Prostate gland contusion 
Laceration without perforation urethra/prostate
Major laceration penis/testes/scrotum/perineal region. Urethral contusion 
Laceration prostate without urethral involvement
Laceration with transection of urethra >2cm 
     
Spleen    Superficial laceration ≤2cm
Subcapsular contusion ≤50%/parenchyma ≤5cm 
Laceration >3cm without vascular/segmental damage
Subcapsular contusion >50%/parenchyma >5cm 
Major laceration with vascular involvement and devascularization >25%  Massive laceration, avulsion, hilar destruction, devascularization   
Liver    Laceration ≤3cm depth/≤10cm length
Subcapsular contusion ≤50%/parenchyma ≤10cm 
Laceration >3cm depth/major duct involvement
Subcapsular contusion >50%/parenchyma >10cm 
Parenchymal laceration ≤75% of one/multiple lobes laceration >3cm in depth/Hepatic rupture  Parenchymal laceration >75% of 1 lobe/
>3 segments (Couinaud classification) of 1 lobe/involvement of vena cava or hepatic veins 
Hepatic avulsion 
Stomach    Contusion/laceration without perforation  Laceration with perforation of full thickness  Massive laceration, avulsion, devascularization     
Vagina, vulva  Contusion/superficial laceration  Deep laceration extending to muscle  Massive laceration, avulsion of vagina/vulva       
Lumbar spine
Nerves  Contusion/avulsion of a nerve  Laceration/avulsion multiple nerve roots         
Spinal cord      Spinal cord damage with transient symptoms  Incomplete spinal cord damage  Complete spinal cord damage   
Bones    Disk herniation without radiculopathy
Joint luxation (unilateral)
Simple/multiple vertebral fracture 
Disk herniation with radiculopathy
Joint luxation (bilateral)
Vertebral collapse >20% height 
     
a

Code in skin.

b

Minor vascular laceration: superficial/intimal, without affecting entire circumference and with bleeding <20%.

c

Major vascular laceration: rupture of entire circumference, complete transection and with bleeding >20%.

B.5
Extremities

 
Upper extremities
Whole area  Amputation/crush finger/s 2–5
Minor/superficial penetrating trauma
Abrasion/erosion/minor lacerationa
Avulsion <25cm2 hand/<100cm2 rest of extremitya 
Amputation/crush hand/finger 1. Compartmental syndrome
Degloving of a part of the extremity
Penetrating trauma injury >25cm2, without bleeding >20%
Laceration >10cm in hand/>20cm rest of extremitya
Avulsion >25cm2 hand/>100cm2 rest of extremitya 
Amputation/crush between wrist and elbow
Degloving of the entire extremity
Penetrating trauma above elbow and bleeding >20%
Laceration/avulsion with bleeding >20% 
Amputation/crush above elbow   
Vessels  Minor lacerationb brachial vein/other art./veins with bleeding <20%  Minor lacerationb axillary/brachial art./axillary vein bleeding <20%  Major lacerationc art./vein with bleeding >20%     
Nerves  Contusion median/radial/cubital  Laceration/avulsion of median/radial/ulnar       
Muscles, tendons, ligaments  Damage of muscle/tendon/ligament         
Joints  Luxation carpal/metacarpophalangeal/interphalangeal Spraining/subluxations  Luxation sternoclavicular/acromioclavicular/shoulder/wrist/open head of radius       
Bones  Phalangeal fracture  Clavicular/scapular/humeral/ulnar/radial/carpal/metacarpal fracture  Open fracture+(comminuted/articular) of humerus/ulna/radius     
Lower extremities
Whole area  Minor/superficial penetrating trauma
Abrasion/erosion/minor lacerationa
Avulsion <100cm2a 
Amputation/crush of foot (total or partial)
Compartmental syndrome without muscle necrosis
Degloving of a part of the extremity
Penetrating trauma injury >25cm2, bleeding <20%
Laceration >20cm/avulsion >100cm2, bleeding <20%a 
Amputation/crush between ankle and knee
Degloving of the entire extremity
Penetrating trauma above knee with bleeding >20%
Laceration/avulsion with bleeding >20%
Compartmental syndrome with muscle necrosis 
Amputation/crush above knee   
Vessels  Minor lacerationb of other art./veins distal to knee  Minor lacerationb of popliteal art./popliteal/femoral vein  Major lacerationc art./vein with bleeding >20%
Minor lacerationb of femoral art. 
Major lacerationc femoral art. with bleeding >20%   
Nerves  Contusion/laceration of digital nerve  Contusion sciatic/popliteal/tibial/fibular nerve
Laceration popliteal/tibial/fibular nerve 
Laceration of sciatic nerve (complete or incomplete)     
Muscles, tendons, ligaments  Partial muscle disruption  Laceration tendon/ligament
Complete muscle disruption 
     
Joints  Luxations of the foot. Subluxations/spraining  Luxation of hip/knee/ankle       
Bones  Phalangeal fracture  Pelvic fracture without posterior ring involvement
Closed acetabular fracture. Closed tibial fracture
Fibular fracture. Patellar/astragalar/calcaneal/navicular/wedge/cuboid/metatarsal fracture 
Open pelvic fracture (stable ring)
Open acetabular fracture. Femoral fracture
Open tibial fracture. Open, bi-malleolar fibular fracture 
Pelvic ring fracture (complete or incomplete) with bleeding <20%  Pelvic ring fracture (complete or incomplete) with bleeding >20% 
a

Code in skin and soft tissues:

- Isolated skin damage (without underlying disease) is counted for calculation of the ISS in the region of the skin and soft tissues.

- Skin damage occurring associated to other injuries is coded in the corresponding region, except open fractures, which are coded in the corresponding region and skin damage in the region of the skin and soft tissues.

b

Minor vascular laceration: superficial/intimal, without affecting entire circumference and with bleeding <20%.

c

Major vascular laceration: rupture of entire circumference, complete transection and with bleeding >20%.

B.6
Skin and soft tissues

 
Skin  Abrasion/contusion/laceration/avulsion           
Freezing  1st grade, superficial  Deep, full skin thickness  Deep, full skin thickness, multiple locations       
Burns  1st grade any affected body surface area
2nd grade <10%
3rd grade <100cm2 (face ≤25cm2
2nd or 3rd grade of 10–19% affected body surface area
3rd grade >100cm2 to ≤10% (face >25 cm2
2nd or 3rd grade of 20–29% affected body surface area  2nd or 3rd grade of 30–39% affected body surface area  2nd or 3rd grade of 40–89% affected body surface area  2nd or 3rd grade ≥90% affected body surface area 
Asphyxia      Without neurological defect  With neurological defect  With cardiac arrest documented by medical personnel   
Drowning      Near-drowning without neurological defect  Near-drowning with neurological defect  With cardiac arrest documented by medical personnel   
Electrical injury (high voltage)      With muscle necrosis    With cardiac arrest documented by medical personnel   

In addition to the injuries described here, code in skin and soft tissues:

- Isolated skin damage (without underlying disease) is counted for calculation of the ISS in the region of the skin and soft tissues.

- Skin damage occurring associated to other injuries is coded in the corresponding region, except open fractures, which are coded in the corresponding region and skin damage in the region of the skin and soft tissues.

Annex C
Definition of complications upon admission and during stay in the Intensive Care Unit.

  • Hemodynamic situation upon admission

  • Stable: systolic blood pressure >90mmHg during initial trauma care.

  • Unstable, restored with volume replacement: presentation of systolic blood pressure <90mmHg, requiring only volume replacement (crystalloids or colloids) for normalization.

  • Shock: presentation of blood pressure <90mmHg requiring volume replacement, blood products and vasoactive drug support for normalization.

  • Refractory shock: presentation of hypotension refractory to volume replacement measures (crystalloids or colloids), blood products or vasoactive drug support. Activation of massive bleeding protocol at time of initial care.

  • Coagulopathy: Prolongation of the prothrombin and activated partial thromboplastin times to over 1.5 times the control values, or fibrinogen <150mg/dl or thrombocytopenia (<100,000) at determination in the first 24h after admission.

  • Rhabdomyolysis: laboratory test determination of CPK >5000U/l.

  • Respiratory dysfunction: presence of PO2/FiO2 during admission <300.

  • Early multiorgan failure syndrome: defined as involvement of two or more organs with score of ≥3 on the Sequential-related Organ Failure Assessment (SOFA) scale in the first 72h after trauma.

  • Late multiorgan failure syndrome: defined as involvement of two or more organs with score of ≥3 on the SOFA scale beyond the first 72h after trauma.

  • Intracranial hypertension: intracranial pressure increase of >20mmHg, maintained for at least 5min, and requiring guided management.

  • Renal failure: creatinine elevation of ≥1.5 times the initial value, reduction of glomerular filtration rate by 25% or more, and lowering of urine flow to under 0.5ml/kg/h during 6h or more.

  • Nosocomial infection: infection acquired in hospital, with the development of symptoms beyond 48h of admission.

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Please cite this article as: Chico-Fernández M, Llompart-Pou JA, Guerrero-López F, Sánchez-Casado M, García-Sáez I, Mayor-García MD, et al. Epidemiología del trauma grave en España. REgistro de TRAuma en UCI (RETRAUCI). Fase piloto. Med Intensiva. 2016;40:327–347.

Part of the information contained in this article was presented as a communication at the X Congreso Panamericano e Ibérico de Medicina Crítica y Terapia Intensiva (Madrid, Spain) and at the XXVII Annual Congress of the European Society of Intensive Care Medicine (Barcelona, Spain).

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