Article

Negative Factors Influencing Multiple-Trauma Patients

Mihaela Anghele 1 , Virginia Marina 2, * , Aurelian-Dumitrache Anghele 3 , Cosmina-Alina Moscu 4
and Liliana Dragomir 1

1 Clinical-Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University,

47 Str. Domnească, 800201 Galati, Romania; [email protected] (M.A.);
[email protected] (L.D.)
2 Medical Department of Occupational Health, Faculty of Medicine and Pharmacy, “Dunărea de Jos”
University, 47 Str. Domnească, 800201 Galati, Romania
3 Department of General Surgery, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University,
47 Str. Domnească, 800201 Galati, Romania; [email protected]
4 Emergency Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, 47 Str. Domnească,
800201 Galati, Romania; [email protected]
* Correspondence: [email protected]; Tel.: +40-770-89-82-74

Abstract: Background and objectives: This study aimed to assess the impact and predicted outcomes
of patients with multiple trauma by identifying the prevalence of trauma sustained and associated
complications. Materials and Methods: This retrospective cohort study focused on individual
characteristics of patients with multiple trauma admitted to our County Emergency Hospital. The
final table centralized the characteristics of 352 subjects aged between 3 and 93 years who presented
with multiple trauma from 2015 to 2021. Inclusion criteria for this study were the presence of multiple
trauma, intervention times, mentioned subjects’ ages, and types of multiple trauma. Results: Patients
with multiple trauma face an increased risk of mortality due to the underlying pathophysiological
response. Factors that can influence the outcomes of multiple-trauma patients include the severity of
the initial injury, the number of injuries sustained, and the location of injuries. Conclusion: The first
60 min after trauma, known as the “golden hour,” is crucial in determining patient outcomes. Injuries
to the head, neck, and spine are particularly serious and can result in life-threatening complications.

Citation: Anghele, M.; Marina, V.;

Keywords: multiple trauma; Injury Severity Score; intracranial hemorrhage; hematoma
Anghele, A.-D.; Moscu, C.-A.;
Dragomir, L. Negative Factors
Influencing Multiple-Trauma Patients.
Clin. Pract. 2024, 14, 1562–1570. 1. Introduction
https://doi.org/10.3390/ The term “multiple trauma” is commonly found in the literature referring to injuries
clinpract14040126 involving more than two anatomical segments or organs, with at least one being potentially
Academic Editor: Francesco Massoni life-threatening. According to the new Berlin definitions, multiple trauma is defined as an
ISS greater than 16 and an AIS greater than 3 for at least two segments. However, an ISS of
Received: 11 July 2024 6 for only one segment is incompatible with life and produces a total ISS of 75 points [1].
Revised: 3 August 2024
The management of multiple trauma has significantly improved in recent years. De-
Accepted: 8 August 2024
spite these advancements, multiple trauma remains the leading cause of death in individu-
Published: 13 August 2024
als under 40 years of age [2–4]. The primary causes of traumatic death worldwide are road
traffic accidents, followed by suicide and homicide [5].
Immediate and early trauma-related deaths are often due to severe primary brain
Copyright: © 2024 by the authors.
injury or massive hemorrhage (hemorrhagic shock). Late mortality can result from sec-
Licensee MDPI, Basel, Switzerland. ondary brain injury and systemic organ failure [6]. Tissue injuries, such as lacerations and
This article is an open access article contusions, can lead to local tissue hypoxia and hypotension, triggering local and systemic
distributed under the terms and host responses [7]. These responses can cause a systemic inflammatory reaction, which
conditions of the Creative Commons can be exacerbated by secondary trauma like ischemia or reperfusion injury, surgery, or
Attribution (CC BY) license (https:// infection [7,8].
creativecommons.org/licenses/by/ The first 60 min after trauma, known as the “golden hour”, are crucial in determining
4.0/). patient outcomes. Definitive trauma care with resuscitation should be initiated during

Clin. Pract. 2024, 14, 1562–1570. https://doi.org/10.3390/clinpract14040126 https://www.mdpi.com/journal/clinpract

Clin. Pract. 2024, 14 1563

this early window, as it has been emphasized, taught, and practiced globally for over four
decades. The primary steps in early trauma management include primary assessment,
simultaneous resuscitation, a reassessment of airway, breathing, and circulation, and
secondary assessment. Primary assessment provides essential baseline data for patient
survival when life or limb is at risk. Resuscitation should begin simultaneously with the
primary assessment whenever instability is detected. Secondary assessment should follow
the completion of primary assessment and resuscitation [9].
Individuals with multiple trauma require ongoing support and care to address the
long-term effects of their injuries on their mental health [10].
The management of multiple trauma requires well-defined protocols, such as ALS
(advanced life support), a universal protocol that includes both the assessment and man-
agement of trauma patients. ALS includes primary, secondary, and tertiary assessment [11].
The primary purpose of primary assessment is to identify and immediately treat
potentially life-threatening conditions. Imaging plays an active role in diagnosing multiple-
trauma patients. Computer tomography is preferred since it brings crucial information in
a short amount of time. Magnetic resonance imaging is less feasible in multiple-trauma
patients because it is a lengthy process and due to other extrinsic limiting factors [12].
The first and most important step in the ALS protocol is airway assessment and
management, including managing the cervical spine for protection. In patients with apnea,
a GCS (of less than or equal to 8), orotracheal intubation, and mechanical ventilation are
required [13].
The second step includes the assessment of breathing and ventilation, where respi-
ratory rate and efficiency are evaluated. Chest assessment is also necessary to identify
potentially life-threatening trauma. Critical conditions requiring immediate management,
which may be complicated by hypoxia, hypovolemia, a low heart rate, and even “exitus
letalis”, include tension pneumothorax, massive closed hemothorax, cardiac tamponade,
and open hemothorax rib flap [14].
One of the most common complications encountered in multiple trauma is massive
hemorrhage, with the most common reason for shock in these patients being hypovolemic
shock resulting from massive hemorrhage. Hemorrhagic shock is characterized by tachy-
cardia, hypotension, increased capillary refill time, increased respiratory rate, and altered
mental status [15].
In the case of multiple-trauma patients, it is necessary to remove clothing at the scene
of the accident to conduct a comprehensive assessment. Therefore, another important
step in managing these patients is to minimize environmental exposure and consequently
minimize heat loss [16].
The early identification of life-threatening injuries that require immediate management
and other injuries that may become life-threatening if not properly managed are primary
steps in minimizing the negative impact on patients with multiple trauma.

2. Materials and Methods

This retrospective cohort study followed the individual characteristics of patients with
multiple trauma admitted to the Galati County Emergency Hospital. The final database
was developed using information collected from observation sheets of patients who met
the inclusion criteria for this study.
The centralized table included data on 352 subjects, aged between 3 and 93 years, who
experienced multiple trauma between 2015 and 2021. This table was created and formatted
using Microsoft Excel 2019 and then exported to SPSS v26 software.
The final statistical analysis included graphical and descriptive elements, as well as
specific statistical measures like mean, standard deviation, minimum/maximum values,
kurtosis index, and skewness index.
The study aimed to identify factors that could negatively impact the outcome of
patients with multiple trauma.
Clin. Pract. 2024, 14 1564

Inclusion criteria involved the presence of multiple trauma, documented intervention

times, subject age, and types of multiple trauma.
The exclusion criteria for the study included patients and their families who refused to
participate, as well as patients with isolated traumas that posed a minimal or non-existent
risk of complications.

3. Results
In the first instance, the objective was to assess the sociodemographic distribution of
the group to compare their results with those in the existing literature. After evaluating
the age distribution, it was found that the mean age of the group was 29.94 years, with a
standard deviation of 14.266. The youngest member was 3 years old, while the oldest was
93. The skewness index was 1.016, indicating a positive skew in the group’s distribution.
Other sociodemographic factors examined included gender and the year of patient
registration. Frequency analysis revealed a higher prevalence of males (72.7%) than females
(27.3%).
Regarding registration years, the prevalence of multiple trauma in the group by gender
and year of case registration is represented in Table 1.

Table 1. Prevalence of multiple trauma in the group by gender and year of case registration.

Number of Cases Percent

Gender
Male 256 72.7%
Female 93 27.3%
Year
2015 60 17.0%
2016 48 13.6%
2017 50 14.2%
2018 44 12.5%
2019 93 26.4%
2020 29 8.2%
2021 28 8.0%

Further analysis identified the prevalence of different types of multiple trauma in the
study group. Road traffic accidents were the most common (68.09% of patients), followed
by falls from heights (15.50% of patients). Other injuries and their prevalence are listed in
Table 2.

Table 2. Type of identified multiple trauma mechanisms in the group.

Type of Multiple Trauma Mechanisms Number of Patients Percentage

Multiple trauma by aggression 24 7.29%
Multiple trauma by falling from height 51 15.50%
Multiple trauma by falling from the cart 6 1.82%
Multiple trauma by explosion/projection 6 1.82%
Multiple trauma incarcerated 0.61%
Multiple trauma by railway accident 0.61%
Multiple trauma by crushing 11 3.34%,
Multiple trauma by road traffic accident 224 64.09%
Multiple trauma by road traffic accident as pedestrian 3 0.91%

To assess the impact and predicted outcomes of patients with multiple trauma, this
study identified the prevalence of trauma sustained and associated complications. The
most common traumas in this group were traumatic brain injury and traumatic facial injury.
The distribution of these traumas, categorized by severity in relation to the total number
of patients, was as follows: 13.4% had grade 0 minor acute TBI, 7.1% had grade 1 minor
Clin. Pract. 2024, 14 1565

acute TBI, 1. 4% had grade 2 minor acute TBI, 2% had moderate TBI, 20.2% had severe
acute TBI, 9.9% had TBI, 5.1% had craniofacial trauma (CFT), and 1.1% had TBI and CFT.
Additionally, subarachnoid hemorrhage (SAH) was predominantly traumatic, with only
6.8% of patients having SAH (Table 3).

Table 3. Diagnoses and complications associated with multiple trauma in the studied group.

Number of Number of
Diagnose Percentage Complications Percentage
Patients Patients
TBI/CFT Hematoma
Minor acute TBI, grade 0 47 13.4% Epicranial 5 1.4%
Minor acute TBI, grade 1 25 7.1% Subdural 17 4.8%
Minor acute TBI, grade 2 5 1.4% Extradural 8 2.3%
Medium acute TBI 7 2.0% Paraspinal 1 0.3%
Severe acute TBI 71 20.2% Intraparenchymal 1 0.3%
TBI 35 9.9% No 320 90.9%
CFT 18 5.1% Coma
TBI and CFT 4 1.1% Yes 40 11.4%
No 140 39.8% No 312 88.6%
OTI/MV Epistaxis
Yes 26 7.4% Yes 4 1.1%
No 326 92.6% No 348 98.9%
Ethanol
SAH
intoxication
Yes 24 6.8% Yes 15 4.3%
No 328 93.2% No 337 95.7%
SCR Pneumothorax
Nonresponsive to CPA 11 3.1% Yes 30 8.5%
Resuscitated 6 1.7% No 322 91.5%
Absent 335 95.2% Pneumomediastinum
Shock type Yes 2 0.6%
Traumatic 12 3.4% No 350 99.4%
Hemorrhagic 9 2.6% Hemopneumothorax
Traumatic and hemorrhagic 3 0.9% Yes 9 2.6%
Cardiogenic 1 0.3% No 343 97.4%
Hypovolemic 2 0.6% Hemoperitoneum
No 325 92.3% Yes 12 3.4%
Organ rupture No 340 96.6%
Spleen 12 3.4%
Liver 2 0.6%
Liver and spleen 1 0.3%
No 337 95.7%

Most subjects in this study group had no hematomas (90.9%). The types of hematomas
identified and their prevalence were as follows: 1.4% had epicranial hematomas, 4.8% had
subdural hematomas, 2.3% had extradural hematomas, 0.3% had paravertebral hematomas,
and 0.3% had intraparenchymal hematomas. Additionally, 1.1% of subjects had epistaxis,
and 4.3% had ethanolic intoxication (Table 3).
Out of the 352 subjects, 11.4% experienced coma, while 7.4% underwent orotracheal
intubation and mechanical ventilation. Furthermore, 17 patients had negative outcomes
related to cardiorespiratory arrest, with 3.1% being unresponsive to resuscitation maneuvers
and 7.7% being responsive (Table 3).
Chest trauma is often associated with rib fractures, both with and without displace-
ment. According to the literature, common complications include pneumothorax and
hemopneumothorax. In our group, the prevalence of these complications was 8.5% of
patients with pneumothorax and 2.6% of patients with hemopneumothorax (Table 3).
Clin. Pract. 2024, 14 1566

Abdominal trauma can also be complicated by pneumomediastinum (the presence of

air in the mediastinum—the space located between the two lungs) or hemoperitoneum (free
blood accumulated in the peritoneal cavity). In this study, we identified a low prevalence
of these complications: 0.6% of patients had pneumomediastinum, and 3.4% had hemoperi-
toneum. Additionally, these injuries can be associated with visceral, often life-threatening,
injuries such as ruptured spleen. The visceral injuries associated with organ ruptures
identified in this group were spleen rupture in 3.44% of patients, liver rupture in 0.6% of
patients, and liver and splenic rupture in 0.3% of patients (Table 3).
Furthermore, within this group, a significant number of subjects experienced traumatic
shock (3.4% of patients), while 0.3% of patients experienced cardiogenic shock, and 0.6% of
patients experienced hypovolemic shock. Additionally, 2.6% of patients experienced hem-
orrhagic shock, and 0.9% of patients experienced both traumatic shock and hemorrhagic
shock (Table 3).
The odds ratio (OR) measures how strongly an event is associated with exposure. The
odds ratio is a ratio of two sets of odds: events occurring in an exposed group versus those
occurring in an unexposed group. In this study, to assess factors with a negative impact
on multiple-trauma patients, we evaluated the probability of coma induction based on the
presence of subarachnoid hemorrhage (SAH), pneumothorax, and hemopneumothorax.
The probability of presenting with subarachnoid hemorrhage (SAH) was 2.203 times
higher in comatose patients than in non-comatose patients. Additionally, in patients who
experienced SAH, the relative risk of coma induction was 2.053 compared to patients who
did not experience SAH (0.932).
The probability of presenting with pneumothorax in comatose patients was 0.856
higher than in non-comatose patients. The relative risk of coma induction was 0.867 in
patients who presented with pneumothorax compared to 1.013 in patients who did not
(Table 4).

Table 4. Estimated risk by associated pathologies of the group.

95% Confidence Interval

Coma/SAH * p Value
Lower Upper
Odds Ratio for Coma (Yes/No) 2.203 0.774% 6.268%
For Cohort SAH = Yes 2.053 0.811% 5.195%
For Cohort SAH = No 0.932 0.826% 1.051%
Number of Valid Cases 352
95% Confidence Interval
Coma/Pneumothorax p Value
Lower Upper
Odds Ratio for Coma (Yes/No) 0.856 0.247% 2.960%
For Cohort Pneumothorax = Yes 0.867 0.275% 2.727%
For Cohort Pneumothorax = No 1.013 0.921% 1.113%
Number of Valid Cases 352
95% Confidence Interval
Coma/Hemopneumothorax p Value
Lower Upper
Odds Ratio for Coma (Yes/No) 2.293 0.460% 11.441%
For Cohort Hemopneumothorax = Yes 2.229 0.479% 10.360%
For Cohort Hemopneumothorax = No 0.972 0.903% 1.045%
Number of Valid Cases 352
SAH *—Subarachnoid hemorrhage.

Hemopneumothorax was 2.293 times more likely to develop in comatose patients

than in non-comatose patients. In addition, the relative risk supported these results.
Specifically, the relative risk of coma induction was 2.229 times higher in patients with
hemopneumothorax than in those without this complication (0.972) (Table 4) [17].
Clin. Pract. 2024, 14 1567

4. Discussion
There are no standard threshold values for multiple trauma, but mortality ranges from
10% in patients with an Injury Severity Score (ISS) of 15 to 20% in those with an ISS of >25.
This results in 1 in 3 cases of severe multiple trauma resulting in severe disability, and the
morbidity arising from such injuries is considerable [17,18].
There is a high incidence of multiple trauma in developing countries, and it continues
to be one of the main causes of death among young people aged 10–40 years. In this
study, the mean age of the subjects was 29.94 years, similar to other values found in the
literature [19,20].
Trauma patients in rural areas are usually older, less severely injured, and more likely
to die at the scene than urban patients. The rate of fatal accidents is more than twice as
high in rural areas than in urban areas [21,22]. The most common mode of multiple trauma
identified in this group was road traffic accidents, with a prevalence of 68.09%.
The outcome of patients with multiple trauma often depends on the severity of head
injuries, affecting both short-term survival and long-term outcomes. Gennarelli demon-
strated a continuous, progressive, inverse-proportional relationship between mortality
following traumatic brain injury and GCS score. Specifically, they observed that the mor-
tality rate increases as the GCS score decreases [23]. These results are supported by other
studies in the literature [24]. The mean GCS score recorded in this group was 11.2, with
most subjects presenting a GCS higher than 8 points.
Massive hemorrhages are the main cause of death in multiple-trauma patients. Ac-
cording to studies in the literature, one-third of trauma patients with major bleeding and
almost half of all patients with massive bleeding will die [25]. Hemostasis requires a
balance between coagulation and fibrinolysis, which allows the control of bleeding and the
prevention of intravascular thrombosis. Major hemorrhage disrupts coagulum fibrinolysis,
leading to altered hemostatic response and worsening blood loss [26]. In this study, we
identified 2.6% of patients with hemorrhagic shock.
Normally, cellular and molecular interactions contribute to restoring tissue home-
ostasis and reducing acute inflammation [27]. Severe trauma is associated with systemic
inflammatory syndrome. The endothelium activated by exposure to inflammatory cy-
tokines becomes more porous, allowing mediators of tissue injury to access the intercellular
space. This leads to a vicious circle of inflammation and immune pheresis, resulting in
inflammation-associated sepsis and an increased risk of developing multi-organ dysfunc-
tion syndrome [23,28–30]. The first inflammatory response occurs immediately after injury,
precipitating organ dysfunction in the days and weeks that follow [31,32]. The patient
becomes vulnerable, and tissue hypoxia and hypovolemia set in, facilitating the onset
of infection. The nature of the medical and surgical interventions required defines the
second inflammatory moment. In this study, we identified a varied prevalence of different
types of shock. Traumatic shock was found in 3.4% of subjects, whereas 0.3% of patients
experienced cardiogenic shock, and 0.6% experienced hypovolemic shock. In addition,
0.9% of patients experienced both traumatic and hemorrhagic shock.
If early and adequate resuscitation following a major trauma fails, three key physiolog-
ical disorders are found: hypothermia, coagulopathy, and acidosis. These are recognized
in the literature as the “lethal triad” [1,31,33,34]. They exhibit a continuous effect on each
other, ultimately resulting in patient death if not individually treated.
Multiple trauma is generally used to describe trauma patients whose injuries involve
more than one region of the body, compromise the patient’s physiology, and may cause
the dysfunction of uninjured organs [35]. Patients with multiple trauma are at increased
risk of mortality due to the underlying pathophysiological response. According to the
literature, head and brain injury and chest trauma are major risk factors in trauma pa-
tients, and the concomitant occurrence of these factors leads to an exponential increase in
mortality [17,36,37]. Additionally, pulmonary contusions can cause decreased pulmonary
reserve, leading to hypoventilation and hypoxia, subsequently causing secondary brain
injury. Studies have also identified a significant correlation between early intubation and
Clin. Pract. 2024, 14 1568

brain damage in patients with multiple trauma [38]. In our study, we identified that 11.4%
of patients were in a coma, 7.4% of patients required OTI + MV, 3.1% of patients had an
unresponsive CRA to resuscitation maneuvers, and 7.7% of patients were responsive to
resuscitation maneuvers.
Injury to the abdomen can change nutritional balance and increase bacterial transloca-
tion from the gastrointestinal tract [39,40]. Increased levels of post-traumatic endotoxemia
have also been reported in the literature [41].
The severity of injury, relevant pathophysiological changes, and physiological changes
can be used for mortality prediction [35]. In addition, disorders produced in the post-
traumatic immune system pose one of the greatest threats to life [42,43].
Severe multiple trauma often comes with traumatic intracranial hemorrhagic lesions.
According to the literature, mortality rates increase about eightfold in cases involving
both intracranial and extracranial hemorrhagic trauma (such as massive hemothorax, intra-
abdominal organ injury, and pelvic fracture) compared to situations with just head trauma.
In our study, we found a prevalence of 6.8% for SAH, 8.5% for pneumothorax, and 2.6% for
hemopneumothorax. The severity of abdominal trauma was also evaluated based on the
types of visceral injuries found in the group. We observed a prevalence of 3.44% for spleen
rupture and 0.6% for liver rupture, with 0.3% of patients having both liver and spleen
rupture [36]. In addition, the relative risk of inducting a coma was 2.053 times higher in
patients with SAH, 0.867 times higher in patients with pneumothorax, and 2.229 times
higher in patients with hemopneumothorax.
Head trauma is still a big problem worldwide. The rapid and comprehensive assess-
ment of head injuries is crucial in managing each case because primary and secondary
lesions can be threatening [44].
The prognosis largely depends on the time of presentation to the doctor but also on
the patient’s comorbidities [45].
The goals of pharmacotherapy are to reduce morbidity, prevent complications, im-
prove symptoms and quality of life, decrease hospitalizations, and improve mortality. The
goal of pharmacologic therapy is to control symptoms and initiate and escalate drugs that
reduce mortality and morbidity in multiple-trauma patients [46].

5. Conclusions
Factors that may influence the outcome of multiple-trauma patients include the sever-
ity of the initial injury, the number of injuries sustained, and the location of the injuries.
Patients with more severe injuries are at a higher risk of experiencing worse outcomes.
Additionally, patients with multiple injuries are also more likely to have worse outcomes.
Injuries to the head, neck, and spine are particularly serious and can result in life-
threatening complications.

Author Contributions: Conceptualization and writing—original draft preparation M.A.; method-

ology, C.-A.M.; software, A.-D.A. and M.A.; validation, M.A., V.M. and L.D.; formal analysis, L.D.;
investigation, M.A.; data curation, C.-A.M.; writing—review and editing, V.M.; visualization, V.M.
and M.A.; supervision, V.M.; project administration M.A. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki, and the protocol was approved by the Ethics Committee of the Clinical Emergency
Hospital, Galati, Romania (project identification code: 3613/12/2021).
Informed Consent Statement: All subjects provided informed consent for inclusion before they
participated in the study. Informed consent was obtained from all subjects involved in the manuscript
(project identification code: 3613/12/2021).
Data Availability Statement: Data is unavailable due to privacy or ethical restrictions, a statement is
still required.
Clin. Pract. 2024, 14 1569

Conflicts of Interest: The authors declare no conflicts of interest.

Abbreviations

AIS Abbreviated Injury Scale

ATLS advanced trauma life support
CPA cardiopulmonary arrest
CFT craniofacial trauma
IIP increased intracranial pressure
ISS Injury Severity Score
GCS Glasgow Coma Scale
Max maximum
MV mechanical ventilation
OTI orotracheal intubation
SAH subarachnoid hemorrhage
SD standard deviation
TBI traumatic brain injury

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