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.

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.

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.

The following data were collected:

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  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.

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

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  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

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  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.

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  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).

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  Evolution and final destination of the patients in ICU.

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.

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.

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.

Figure 1.

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

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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.

Figure 2.

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

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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.

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.

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).

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.

The authors declare that they have no conflict of interest.