Injury, Int. J.

Care Injured (2005) 36, 293302

www.elsevier.com/locate/injury

Management of polytraumatized patients with

associated blunt chest trauma: a comparison
of two European countries
Frank Hildebranda,*, Peter V. Giannoudisb, Martijn van Griensvena,
Boris Zellea, Bastian Ulmera, Christian Kretteka, Mark C. Bellamyb,
Hans-Christoph Papea
a

Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1,

30625 Hannover, Germany
b
Department of Trauma, St. Jamess University Hospital, Leeds, UK

KEYWORDS
Blunt chest trauma;
Abbreviated injury
scale;
Intensive care

Summary
Background: Blunt chest trauma represents one of the most common injuries in
polytrauma patients. Blunt chest injury complicating polytrauma is associated with
significant prolongation of intensive care stay. Further, it has a great impact on the
timing of fixation of skeletal injuries, possibly contributing to adverse outcome.The
purpose of this study is to assess whether there are any differences in the management and outcome of polytrauma patients with blunt chest trauma between trauma
units in two different countries. Detailed information about advantages and disadvantages of these two systems might allow optimising the management of blunt chest
trauma.
Patients and methods: This investigation was performed using the polytrauma
database of the German Trauma Society and the British Trauma Audit Research
Network. After the definition of the inclusion abbreviated injury scale (AISchest  3)
and injury severity score (ISS > 16) and exclusion (AIShead/neck  2, referral from outside
institutions) criteria, patients were recruited solely from these databases.
Results: 188 patients from the German database and 181 patients from the British
database were enrolled in this study. Demographic data and injury pattern of the two
patient populations did not significantly differ. The volume of initial red blood cell
transfusion and length of the intensive care stay were significantly higher in Germany
(p < 0.05). Mortality in the UK was 9% higher than in Germany (p = 0.057). Time to
death in non-survivors was also significantly longer in Germany (p < 0.05).

* Corresponding author. Tel.: +49 511 532 2050; fax: +49 511 532 5877.
E-mail address: Hildebrand.Frank@mh-hannover.de (F. Hildebrand).
00201383/$ see front matter # 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2004.08.012

294

F. Hildebrand et al.

Conclusions: The reasons for the differences regarding survival times and survival
rates seem to be multiple. German patients received more red blood cells, had a
longer hospital stay in intensive care and a better survival rate. The use of kinetic
therapy in Germany, not standard in the UK, may contribute to a more favourable
outcome.
# 2004 Elsevier Ltd. All rights reserved.

Introduction

Patients and methods

Chest trauma ranks as the most important injury in

polytrauma patients with a reported incidence of
4565%. It is usually associated with blunt highenergy trauma and the reported mortality can be
as high as 60%.2 Overall, 2025% of deaths in polytrauma patients are attributed to chest injury.7,12
The degree of chest trauma is usually assessed by
the abbreviated injury scale (AIS). Irrespective of
the severity of injury, blunt chest trauma plays an
important role in the overall management of the
multiply injured patient, from the scene of the
accident to the surgical decision making process.
Multiply injured patients with blunt chest trauma
require significantly longer periods of mechanical
ventilation and a significantly longer stay on intensive care unit compared with trauma patients without a thoracic injury.2 Furthermore, chest injuries
predispose to pneumonia, adult respiratory distress
syndrome (ARDS) and multiple organ dysfunction
syndrome (MODS).22
Management of chest injuries includes urgent
thoracotomy for control of haemorrhage, cavity
decompression by chest tube drainage; and mechanical ventilation in case of respiratory insufficiency.
Factors which may contribute to favourable outcome include kinetic therapy, appropriate fluid
management and avoidance of iatrogenic damage
to the lung by unfavourable mechanical ventilation
techniques.22,24
There has been little agreement over definitions
of chest injury severity. This has led to conflicting
results and created controversy in the management
of polytrauma patients (early total care (ETC) versus
damage control orthopaedics (DCO)).18 One consequence of this lack of consensus is a broad diversity
of practice between units and between European
countries with otherwise similar levels of healthcare
provision.
The purpose of this study was to assess whether
there are differences in management and outcome
of polytrauma patients with blunt chest trauma
between trauma units in two different countries.
Detailed information about advantages and disadvantages of these two systems might allow optimisation of blunt chest trauma management.

Databases
All data were obtained from the polytrauma database at the Department of Trauma & Orthopedics at
St. Jamess University Hospital, Leeds and the polytrauma database at the Department of Trauma Surgery at Hannover Medical School. The database of
the former contributes to the Trauma Audit
Research Network (TARN) ongoing study into the
epidemiology of trauma in the United Kingdom,
whereas the latter is part of the German Trauma
Society, documenting polytrauma patients.
Both databases were developed in the early
1990s. Since that time, every polytrauma patient
treated in one of the participating trauma centers
has been documented prospectively in these databases.
Trauma Audit Research Network
The British database includes all patients that have
been treated on an intensive care unit (ICU) or a high
dependency unit (HDU) within the first 72 h after
their injury. Besides the demographic data, clinical
data including mechanism of injury, Glasgow coma
scale (GCS), heart rate, blood pressure, ventilation
rate, protective head gear and details of initial
resuscitation (time, location and nature (fluid/
blood)) and pre-hospital treatment are documented. The documentation of the hospital course
includes details about any inter-hospital transfer
and surgery (nature of procedure performed, seniority of the operating surgeon and assistant). Moreover, all injuries are documented, and they are
classified according the abbreviated injury scale
(AIS),5 and the injury severity score (ISS) is calculated.1 The duration of hospital stay, complications
and mortality are recorded. During the ICU/HDU
course, organ function scores, clinical and physiological data are documented daily.
Database of the German Trauma Society
The database of the German Trauma Society is
divided into five parts. The first sheet documents
patient status at the accident scene. Mechanism of
injury, vital signs (heart rate, blood pressure, ventilation rate, GCS), mechanism of injury, and initial

Chest trauma in Europe

therapy are documented. The second sheet documents the patients status in the trauma bay including vital signs, laboratory results, diagnostic and
therapeutic procedures. Injuries are classified
according to the AIS, and the ISS is calculated.
The third sheet documents status at ICU admission
including vital signs and laboratory results. The
fourth sheet documents status at ICU discharge
including complications and duration of mechanical
ventilation. The fifth sheet is a complete survey of
all injuries, surgery and complications until discharge (Table 1).
Definitions of ARDS and multiple organ
dysfunction syndrome (MODS)
In the British database, ARDS is defined according to
the criteria of the AmericanEuropean Consensus
Conference (Table 2).3 In the German data, ARDS
was defined according to the lung failure definition
of Goris et al. (Table 3).9 In both databases, MODS is
defined according to the criteria of Goris et al.
(Table 3).9

295

Classification of injury severity

Injury severity was classified according to the
abbreviated injury scale and the injury severity
score.1,5
Inclusion and exclusion criteria
The inclusion criteria for this study were as follows:
 AISchest  3.
 ISS  16.
The exclusion criteria for this study were as
follows:
 AIShead/neck  2.
 Referrals from outside institutions.
Patients with severe head trauma were excluded
as they have an intrinsically prolonged intensive
care requirement. Referrals from other institutions
were excluded because of lack of uniformity of
documentation.

Table 1 Documented parameters: comparison between German and British database

Database of the German Trauma Society

Trauma research network

Identification number
Date and time of injury
Anonymous
Date of birth
Gender
Injury mechanism
Initial diagnosis at the accident scene
Vital signs at accident scene
Glasgow coma scale
Neurological status at the accident scene
Intravenous infusions
RBC transfusions
Prehospital care
Treatment in trauma bay
Initial lab results
Classification of injuries according to AO and AIS
Injuries
Vital signs at admission to ICU
Lab results at admission to ICU
Surgeries
Dates of surgeries
ISS
Length of intensive care
Not documented
Length of hospital stay
Length of mechanical ventilation
Survived/deceased
Lab results from ICU
MOF/ARDS/sepsis
Not documented
Past medical history
Rehab

Identification number
Date of injury
Name
Date of birth
Gender
Injury mechanism
Not documented
Vital signs at accident scene
Glasgow coma scale
Not documented
Intravenous infusions
RBC transfusions
Prehospital care
Not documented
Not documented
Classification of injuries according to AIS
Injuries
Vital signs at admission to ICU
Not documented
Surgeries
Dates of surgeries
ISS
Length of intensive care
Length of HDU
Length of hospital stay
Documentation by time of intensive care
Survived/deceased
Lab results from ICU
MOF/ARDS/sepsis
Security devices (helmets, seat-belts, etc.)
Not documented
Not documented

296

F. Hildebrand et al.

Table 2 Definition of adult respiratory distress syndrome (ARDS) according to the AmericanEuropean Consensus
Conference

ARDS-criteria

Onset

Oxygenation

Chest X-ray

Pulmonary capillary
wedge pressure (PCWP)

Acute

Horovitz-ratio <200 mmHg

Bilateral, diffuse infiltrates

PCWP <18 mmHg

Statistics
Both databases were processed using SPSS (SPSS
10.0, Chicago, IL). The statistical analysis was performed with the same software. Data was first
analysed by analysis of variance (ANOVA) and thereafter subjected to Students t-test for comparisons
between groups. Statistical significance was
assumed at p < 0.05. Categorical data such as
mortality or the outcome scale were subjected to
the x2-test. Data are presented graphically as mean
 standard error of the mean (S.E.M.).

Results
Patients and mechanisms of injury
The German patient population included 188
patients; the British patient population included
181 patients. The average age at time of injury
was 38.5  17.7 years in Germany and 39.1 
20.0 years in the UK. The male to female ratio
was M:F = 3:1 in both populations. In the British
patient population, the number of pedestrians was
significantly higher than in the German patient
population. By contrast, the number of automobile
and motorcycle accidents tended to be higher in the
German population (Table 4).

Initial vital signs, GCS, and infusions

The systolic blood pressure as measured at the
accident scene was 114.4  33.8 mmHg in Germany
and 119.7  42.9 mmHg in the UK. This difference
was not significant. The initial heart rate did not
significantly differ in these two patient populations.
The initial GCS did not significantly differ between

the German patient population (11.9  4.1) and the

British patient population (10.9  5.4). The total
fluid infused from the time of injury until leaving the
trauma bay was not significantly different in these
two groups. However, the total amount of transfused red blood cell units (RBC) was almost twice as
high in the German patient population (7.9  4.9
units versus 4.9  2.1 units). This difference was
significant (p < 0.01) (Table 5).

Injury pattern
The severity of chest trauma did not significantly
differ between the German patient population
(AISchest = 3.6  0.7) and the British patient population (AISchest = 3.7  0.7). The AISchest was the
highest component compared with other body
regions. The incidence of other injuries was evenly
distributed in both patient populations. In both
patient populations the abdomen was the second
most severely injured body region (AISabdomen = 3.2
 0.9 in Germany; AISabdomen = 2.8  0.6 in the UK).
The injury severity of remaining body regions did not
demonstrate any significant differences between
patient populations (Table 6).
The most common associated injuries were injuries to the extremities (60.1% in Germany; and 55.3%
in the UK), followed by abdominal injuries, injuries
to the head and neck, and injuries to the face
(Fig. 1).
The distribution of associated injuries was independent of the injury severity of the thoracic component. Injuries to the extremities were the most
common associated injuries for AISchest 3, AISchest 4,
and AISchest 5. However, the incidence of injuries to
the extremities decreased with increasing severity
of chest injury.

Table 3 Definition of multi organ dysfunction syndrome (MODS) according to Goris et al.9
Organ

Dysfunction

Lung failure
Cardiovascular failure
Renal failure
Hepatic failure
Gastro-intestinal tract failure

Mechanical ventilation; PEEP >10 cm H2O and FiO2 > 0.4

Systolic blood pressure <100 mmHg and/or dopamine >10 mg/(kg min)
Dialysis
Bilirubine >6 mg/dl and/or GOT 50 U/l
Perforation of gall bladder and/or bleeding ulcer and/or necrotic enterocolitis

Chest trauma in Europe

297

Table 4 Demographic data and injury mechanism

Number of patients
Age (years)
Gender (M:F)
Mechanism of injury
(1) Automobile
(2) Motorcycle
(3) Pedestrian
(4) Others

Germany

UK

Significance (p)

188
38.5  17.7
143:45

181
39.1  20.1
134:47

n.s.
n.s.

86
32
12
58

69
28
43
41

n.s.
n.s.
<0.05
n.s.

Comparison of German and British (UK) study population.

ISS did not significantly differ between the German patient population (26.5  6.8) and the British
patient population (28.7  10.7). ISS increased with
increasing AISchest (Table 7).

Length of intensive care, mechanical

ventilation, and hospital stay
To obtain the length of intensive care for the British
population, the days on the intensive care unit and
the high dependency unit were added (i.e. level 2
dependency and above). The length of intensive
care in the German patient population was 15.8 
4.7 days compared to 5.4  3.7 days (ICU: 3.9  2.7
days; HDU: 1.6  1.2 days) in the British patient
population. This difference was significant (p <
0.0005). In both countries, the length of intensive
care increased with a higher AISchest (Table 8).
The duration of mechanical ventilation was significantly longer in the German population (11.1 
7.9 days versus 3.9  2.7 days). The length of
mechanical ventilation increased with an increasing
AISchest (Table 8).
Hospital stay was 36.2  24.2 days in Germany
compared to 24.4  21.3 days in the UK. This
difference however was not significant (Table 8).

developed ARDS had an average AISchest of 3.6  0.9;

the British patients who developed ARDS had an
average AISchest of 3.5  0.5. This difference was
not significant. The average ISS was not significantly
different between the two patient populations
(GER: 25.1  7.7; GB: 27.2  9.1). The length of
intensive care was differed significantly between
German patients with ARDS (35.4  14.2 days)
and the British patients with ARDS (12.3  6.4 days).
In both patient populations, the length of intensive
care and the length of mechanical ventilation were
significantly longer in patients with ARDS as compared to patients without ARDS. In Germany 14 out
of 17 patients with ARDS survived whereas in the UK
3 out of 6 patients with ARDS survived (Table 9).

Incidence of multiple organ dysfunction

syndrome and sepsis
The incidence of sepsis or MODS was not significantly
different between the German and the British
patient population. In Germany, 27 out of 188
patients (14.4%) developed a multiple organ failure
or a sepsis; in the UK 25 out of 181 patients (13.8%)
developed a multiple organ failure or a sepsis.

Mortality
Complications
ARDS
The number of patients diagnosed as having ARDS
was significantly higher in Germany (n = 17) than in
the UK (n = 6) (p = 0.03). German patients who

In the German patient population 21 out of 188

patients died, whereas in the British patient population 33 out of 181 patients died (p = 0.056). The
mortality for the different AIS values is illustrated in
Table 10. The average age of the deceased patients

Table 5 Initial vital signs and amounts of infusions (fluid/blood)

Germany
Systolic blood pressure at the accident scene (mmHg)
Heart rate at the accident scene (beats/min)
GCS at the accident scene
Infusion volumes (accident scene and trauma bay (ml))
Number of RBC units
Comparison of German and British (UK) study population.

114.4
104
11.9
3400
7.9







33.8
20
4.1
578
4.9

UK
119.7
108
10.9
3600
4.9

Significance (p)






42.9
25
5.4
987
2.1

n.s.
n.s.
n.s.
n.s.
<0.03

298

F. Hildebrand et al.

Table 6 Injury pattern according to the abbreviated

injury scale (AIS)
AISchest
AIShead/neck
AISface
AISabdomen
AISextremities

Germany

UK







3.7
1.9
1.5
2.8
2.8

3.6
1.5
2.2
3.2
3.0

0.7
0.4
0.8
0.9
0.6

Significance






0.7
0.6
0.2
0.6
0.7

n.s.
n.s.
n.s.
n.s.
n.s.

Comparison of German and British (UK) study population.

was similar in both patient populations (44 years).

The average ISS of the deceased patients was three
points higher in the British population (not significant). In the German patient population, the average survival time of the deceased patients was twice
as long as in the British patient population. We also
calculated the length of intensive care and hospital
stay for those patients who finally survived their
injury (excluding non-survivors from this calculation). The length of intensive care of survivors
was significantly higher in the German patient population (16.2  6.7 days in Germany versus 4.5  3.6
days in the UK, p < 0.05). Hospital stay was marginally longer in the German population (39.4  30.1
days in Germany versus 29.1  24.6 days in the UK)
(not statistically significant).

Discussion
The database of the German Trauma Society and the
Trauma Audit Research Network are not specifically

Figure 1

Table 7 Abbreviated injury scale (AIS)chest distribution and injury severity score (ISS)
Germany
Distribution
of AISchest
AISchest 3 (%) 52.8
AISchest 4 (%) 35.1
AISchest 5 (%) 12.1
ISS
AISchest 3
AISchest 4
AISchest 5
Total

21.7
29.2
43.6
26.5






1.5
1.8
1.4
6.8

UK

Significance

46.4
35.9
17.7

n.s.
n.s.
n.s.

21.4
30.7
43.8
28.7






4.0
6.4
12.1
10.7

n.s.
n.s.
n.s.
n.s.

Comparison of German and British (UK) study population.

designed for the documentation of patients with

chest trauma, but rather for the documentation
of polytrauma patients in general.
We only included patients with an AISchest 3 or
above to exclude patients with minor or clinically
insignificant chest injuries who did not require
intensive care because of their chest injury. Patients
who died at the accident scene were similarly
excluded. Previous studies have shown that polytrauma patients with chest and head injuries require
prolonged intensive care stay and mechanical ventilation.11 Therefore, patients with severe head
injuries were also excluded from this study. This
resulted in a relatively high GCS (>11) in both
patient populations. The demographic data and
associated injuries of both patient populations were
comparable and are unlikely to account for the

Incidence of chest trauma associated injuries. Comparison of German and British (UK) study population.

Chest trauma in Europe

299

Table 8 Duration of intensive care, mechanical ventilation and hospital stay

Germany

UK

Significance (p)

ICU+HDU

HDU

4.9
5.5
6.7
5.4






3.3
3.4
4.1
3.7

1.1
2.1
1.8
1.6

Mechanical ventilation (days)

8.8  4.4
AISchest 3
AISchest 4
13.3  11.3
AISchest 5
16.7  13.8
Total
11.0  7.9

3.4
3.8
5.0
3.9






2.1
2.8
3.3
2.7

Hospital stay (days)

AISchest 3
AISchest 4
AISchest 5
Total

28.6
20.9
21.0
24.4

Intensive care (days)

AISchest 3
AISchest 4
AISchest 5
Total

12.8
18.5
22.8
15.8

37.8
34.3
33.6
36.2











3.1
4.8
6.4
4.7

29.1
27.9
26.8
28.2











0.8
1.7
1.1
1.2

0.001
<0.0005
0.004
<0.0005
<0.05
<0.05
<0.05
<0.05

23.1
18.1
18.9
21.3

n.s.
n.s.
n.s.
n.s.

Comparison of German and British (UK) study population. Intensive care in UK: stay on intensive care unit (ICU) + stay on high
dependency unit (HDU).

differences in hospital course and outcome. Tertiary

referral patients were excluded since the documentation of these cases was likely to be incomplete.
The mechanisms of injury and the injury patterns in
our series are comparable to previous studies about
the chest trauma.20 Overall, we believe that the
quality of the presented data is very high since bias
was minimised, the patient populations are representative of patients with severe chest trauma, and
the patient groups match well for demographics and
injury pattern.
Analysis of vital signs at the accident scene
demonstrated comparable values for German and
British patients. This rules out the possibility that
initial status accounted for differences between
groups. Our data demonstrate that fluid infusion
volumes did not differ between the two patient
populations. However, German patients received a
significantly higher volume of red blood cell

(RBC) transfusions, although the injury pattern

and the injury severity were similar. In the literature, the effect of RBC transfusion on critical care
outcomes is controversial. It may be that in the
German patient population transfusion of RBC units
contributed to the higher survival rate by improving
the peripheral oxygen delivery in line with goal
directed approaches.21 However, this is at variance
with recent evidence suggesting a restrictive transfusion strategy is associated with better outcomes in
critical illness.10 Further, blood resuscitation prior
to surgery in other patient populations, e.g. aneurysm surgery, is also associated with worse outcome.
It is tempting to speculate whether the German
outcomes would have been even better had blood
transfusion been restricted early on. A clinical prospective study in trauma patients demonstrated,
that fluid restriction results in improved gas
exchange and compliance of the lung and reduces

Table 9 Distribution and clinical variables of patients with adult respiratory distress syndrome (ARDS) in the clinical
course
Germany

UK

ARDS

All patients

Total
with AISchest 3
with AISchest 4
with AISchest 5

17
7
9
1

188
103
66
19

Average ISS
Intensive care (days)
Mechanical ventilation (days)

25.1  7.7
35.4  14.2
25.4  12.6

Comparison of German and British (UK) study population.

26.5  6.8
15.8  4.7
11.0  7.9

ARDS
6
4
1
1
27.2  9.1
12.3  6.4
8.9  6.0

Significance (p)
All patients
181
84
65
32
28.7  10.7
5.4  3.7
3.9  2.7

n.s.
<0.05
<0.05

300

F. Hildebrand et al.

Table 10 Distribution and clinical variables of deceased patients

Germany
Total
with AISchest 3 (%)
with AISchest 4 (%)
with AISchest 5 (%)

UK

21
28.6
52.4
19.1

Significance (p)
33
24.2
51.5
24.3

0.056
n.s.
n.s.
n.s.

3.5
4.6
3.5
2.1






2.3
2.6
2.3
2.1

3.1
4.0
2.9
2.8






2.7
2.0
2.6
2.4

n.s.
n.s.
n.s.
n.s.

Average ISS (all patients)

with AISchest 3
with AISchest 4
with AISchest 5

29.6
22.5
29.0
42.0






6.8
1.2
1.0
1.2

32.5
21.6
30.9
45.4






12.0
4.4
7.3
11.6

n.s.
n.s.
n.s.
n.s.

Age (all patients), (years)

with AISchest 3
with AISchest 4
with AISchest 5

44.0
53.3
40.8
38.8






20.6
21.4
19.9
22.2

44.0
45.1
44.8
41.1






25.4
27.1
27.4
21.9

n.s.
n.s.
n.s.
n.s.

RTS (all patients)

with AISchest 3
with AISchest 4
with AISchest 5

Gender (all patients), (M:F)

with AISchest 3
with AISchest 4
with AISchest 5
Survival time (all patients), (days)
with AISchest 3
with AISchest 4
with AISchest 5

17:4
4:2
10:1
3:1
11.0
14.2
9.3
10.8

18:15
5:3
9:8
4:4





6.8
9.1
6.5
7.8

5.5
8.0
4.3
5.4

n.s.
n.s.
n.s.
n.s.





3.3
3.5
3.3
3.8

<0.05
<0.05
<0.05
<0.05

Comparison of German and British (UK) study population.

the length of mechanical ventilation.14 This practice

is limited by the hemodynamic instability and the
decreased renal perfusion of trauma patients. However, the massive application of RBC units has several disadvantages that have been widely described
in the literature.25 A massive transfusion may result
in microaggregation and pulmonary complications.
Furthermore, acidbase disturbances and disturbances in the electrolyte balance (hyperkalemia
and hypocalcemia) may appear and result in hemodynamic disturbances with secondary pulmonary
dysfunction. Additionally, massive transfusion of
RBC may cause an increased left-ventricular enddiastolic pressure with secondary pulmonary
oedema. The transfusion-associated acute lung
injury (TRALI) is generated by an immunologic
reaction. The clinical picture may resemble ARDS.
These issues highlight the important role of initial
fluid and transfusion therapy (including invasive
monitoring) in the management of the polytrauma
patient.
AISchest was highest compared to AIS for other
body regions. Therefore, it was assumed for both
patient populations that chest trauma was the most
significant injury. The average AISchest was comparable in both groups so could not account for the

differences in outcome. Injuries to the extremities

were the most common associated injuries, and the
abdomen was the second most severely injured body
region as determined by the AIS value. These associated injury patterns are similar to those in previous studies.11 The overall injury severity as
determined by the ISS was also comparable in both
populations.
An average AISextremities > 3 is associated with a
high likelihood of operative treatment.16 There are
at present different schools of thought regarding
timing of surgery. Following the principles of early
total care, immediate and definitive operative care
of all fractures should be performed within 24 h
after the trauma.8 However, certain exceptions
have been discussed in the past few years, where
the principle of early total care may not be beneficial (head and chest trauma, high ISS predisposing
to
posttraumatic
complications,
borderline
patients).15 In these patients, the surgical burden
may even increase the risk of postoperative complications.19 For these patients, the concept of
initial temporary fixation and secondary conversion
to a definitive procedure has recently been advocated (Damage Control Orthopaedics).17 In the UK
trauma unit, the principle of ETC currently repre-

Chest trauma in Europe

sent standard care, whereas in the Germany trauma

unit the concept of damage control orthopaedics is
widely used. These two approaches may influence
the differences in outcome observed in the present
study. The length of intensive care and mechanical
ventilation may be reduced by the principle of
ETC.4,13 However, ETC has been reported to be
associated with a higher postoperative complication
rate (i.e. ARDS).19 Although the demographics,
initial vital signs, injury pattern, and injury severity
were similar in the German and the British patient
population, the time of intensive care was significantly longer in the German patient population. In
our series, the average length of mechanical ventilation in the German patient population was 11
days, and the average length of intensive care in
the German patient population was 15 days. These
results are consistent with a previous German study
(9 days of mechanical ventilation and 12 days of
intensive care).22 This study also reported the severity of the chest trauma to be associated with the
length of mechanical ventilation and intensive care.
In accordance, the length of intensive care and
mechanical ventilation were also associated with
increasing AISchest values in our study.
These differences between German and British
patient populations may be explained by differing
indications for critical care admission and discharge
in the two countries. A careful review of the data
revealed that in Germany non-intubated patients
with bilateral lung contusions and chest tubes are
usually monitored on the ICU. In the United Kingdom, the same patient is usually monitored on the
HDU or a regular ward. These different principles
seem to be essential for the significant difference
regarding the ICU-stay between the German and the
British patient population. In this context, medical
and economical aspects have to be analysed and
discussed very carefully. Moreover, it is debatable
whether intermediate care units should be recommended for use in Germany. It has to assumed that
many German patients with chest trauma who are
managed on intensive care units can be adequately
treated on intermediate care units: our data support
the view that many patients with an AISchest 3 can be
successfully treated on high dependency units (level
2 care).
A major reason for the significant higher length of
intensive care in Germany is the duration of
mechanical ventilation. A careful analysis of the
mechanical ventilation in Germany shows an
increase of mechanical ventilation for an increasing
injury severity of chest trauma. This may be due
to the fact that in the UK for many injuries with
an AISchest of 5 a conservative treatment is performed. In Germany, however, most patients with

301

an AISchest  4 receive mechanical ventilation.

Extended mechanical ventilation may predispose
to complications like ARDS or ventilator-associated
pneumonia (VAP).25 Therefore, the risks and benefits of a mechanical ventilation should always be
discussed in detail. Likewise, some of the differences could relate to the presence of specialist
intensivists in UK critical care units.
Despite comparable values for the ISS and the
AISchest, the incidence of an ARDS is significantly
higher in Germany. These data are difficult to interpret, both because the absolute numbers are relatively small, and because the databases used
different definitions for ARDS, so subtly different
patient populations may have been selected. The
higher incidence of ARDS in the German patients is
genuine, then this could help account for the prolonged mechanical ventilation and intensive care
stay seen in Germany. Possible reasons for the higher
incidence of an ARDS in Germany are the higher
amount of RBC transfusions and longer periods of
mechanical ventilation and secondary ventilatorassociated pneumonia.
In contrast to the higher incidence of ARDS, the
mortality was apparently lower in Germany than in
the British patient population (18% versus 50%). In
UK however, there may be a trend to underdiagnose
ARDS (i.e. only most severe cases are included). This
could also account for apparently higher mortality.
Kinetic therapy is widely used in Germany but less
so in the United Kingdom. Kinetic therapy is used to
reduce the incidence and extent of posttraumatic
respiratory complications by reducing dorsal lung
atelectasis.23 Kinetic therapy can be used prophylactically in the early phase after trauma. Kinetic
therapy with prone positioning has been shown to be
effective in patients who have developed posttraumatic dorsal lung atelectasis.6
In contrast to the incidence of the ARDS, the
incidence of MODS is comparable for both countries
(approximately 14%). It is well known that 80% of the
cases with MODS start with lung failure.11 These
numbers were reproduced in the German population
(out of 27 patients with MODS, 17 patients had an
ARDS). In the UK, however, 25 cases with MODS
and only 6 cases with ARDS were described. Other
organ systems seem to play a major role for MOF in
the UK.
In the UK, the mortality ratio was 9% higher than
in Germany. Moreover, the time to death in the nonsurvivors was twice as long in Germany. We can
speculate that the higher amount of RBC transfusions and the routine use of the kinetic therapy are
possible reasons for the better prognosis in the
German patient population. Additionally, it can be
assumed that for some British patients who are

302

managed on the HDU a treatment on the ICU could

be more beneficial.
This study supports the view that therapy of chest
trauma leads to a better outcome in the German
patient population, but it has higher financial implications. Further prospective studies are required to
elucidate the apparent outcome differences. One
approach would be to attempt a prospective study in
the two centres with more standardised aspects
of care.

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