Multiorgan failure in the serious trauma patient

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Royo" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Llompart-Pou" "email" => array:2 [ 0 => "juanantonio.llompart@ssib.es" 1 => "ja_llompart@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Talayero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Homar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Royo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:1 [ "colaborador" => "Trauma and Neurointensive Care work group of the SEMICYUC" ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fallo multiorgánico en el paciente con trauma grave" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3077 "Ancho" => 2185 "Tamanyo" => 326072 ] ] "descripcion" => array:1 [ "en" => "Summary of the physiopathology of multiorgan failure following severe trauma." ] ] ] "textoCompleto" => "IntroductionThe development of multiorgan failure (MOF) after severe trauma is one of the leading causes of late mortality in such patients.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> The incidence of MOF varies between 7% and 66%, and despite recent advances in the pre- and in-hospital management of these patients, the disorder is associated to important mortality and prolonged hospital stay.<a class="elsevierStyleCrossRefs" href="#bib0005">1–5</a> Although MOF is recognized to be a dynamic process, agreement is lacking regarding its definition.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The underlying physiopathology is moreover subject to debate, and involves the participation of different components of the immune and inflammatory systems.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a>The present article reviews the current knowledge on the epidemiology and physiopathology of MOF, the scales used to evaluate the disorder, the clinical factors associated to the development of MOF, and the possible treatment options.DefinitionWhile no uniform definition of post-trauma MOF has been established to date,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> a number of scales have been developed for evaluating patient respiratory, cardiovascular, hepatic, renal, neurological and coagulation function–including particularly the Denver, Marshall and Sequential-related Organ Failure Assessment (SOFA) scales. These instruments will be examined further below.Despite the limitations imposed by the lack of a clear definition of MOF, there is agreement in regarding early MOF as multiorgan failure occurring in the first 72h after trauma (this representing approximately 40% of all cases), while late MOF is taken to be multiorgan failure occurring beyond day three post-trauma (60% of all cases).<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Epidemiological aspectsPost-trauma MOF is the leading cause of late mortality in severe trauma, accounting for 50–60% of all deaths in such patients.<a class="elsevierStyleCrossRefs" href="#bib0005">1–6</a> Those individuals that develop post-trauma MOF have a longer stay in the Intensive Care Unit (ICU). The associated mortality rate varies between 27% and 100%, and increases with the number of affected organs.<a class="elsevierStyleCrossRefs" href="#bib0030">6,8,9</a> As early as 1980, Fry et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> showed mortality to increase from 30% in the presence of single-organ dysfunction to 100% in the case of dysfunction affecting four organs. A study conducted in a single reference center for severe trauma in the United States, involving data prospectively collected over a period of 12 years, has found the incidence, duration and mortality of MOF to have decreased in recent years–this being related to advances and new treatment modalities in application to severe trauma patients, and to a decrease in the number of transfusions.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> A recent multicenter study including 1643 trauma patients reported a decrease in incidence of almost 50%–though the related mortality remains very high.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The incidence of MOF is greater in closed trauma patients, and in these cases are associated to greater mortality than in penetrating trauma.<a class="elsevierStyleCrossRefs" href="#bib0005">1,6</a>PhysiopathologyAlthough the physiopathology of MOF in severe trauma is not fully clear and has evolved over the last 30 years, it is currently accepted that the disorder is a bimodal phenomenon with two peaks of presentation, due to an alteration in the balance of the systemic inflammatory response followed by ischemia-reperfusion after hemorrhagic shock. This is in contrast to the early theories which pointed to generalized infection as the sole cause of MOF.<a class="elsevierStyleCrossRefs" href="#bib0030">6,9</a>In this regard, respiratory failure appears to play a key role in early MOF, manifesting in 99% of all cases and usually preceding heart dysfunction by a few hours, and liver and kidney dysfunction by about 5 days.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> In contrast, late MOF occurring beyond 72h after trauma requires a second “hit”,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> usually in the form of infection (mostly of pulmonary origin).<a class="elsevierStyleCrossRef" href="#bib0050">10</a>A number of mediators and effectors can potentially intervene in the physiopathology and development of post-trauma MOF (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>):<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Mediators<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Cytokines: The balance between proinflammatory and antiinflammatory cytokines plays a key role in the maintenance of homeostasis. Following severe trauma there is an overproduction of proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, IL-6 and IL-8 on the part of monocytes and macrophages. This constitutes part of the acute phase response, contributing to initiation and perpetuation of the local and systemic inflammatory response.<a class="elsevierStyleCrossRefs" href="#bib0035">7,11</a> TNF-α increases the production of nitric oxide (NO) and activates cyclooxygenase, resulting in an increased production and release of thromboxanes, prostaglandins and platelet activating factor (PAF)–with a consequent increase in procoagulant activity.<a class="elsevierStyleCrossRefs" href="#bib0035">7,12</a> In turn, IL-6, produced by different cells such as activated monocytes, macrophages, neutrophils and endothelial cells, plays an important role in the acute response, intervening in the production of C-reactive protein, procalcitonin, fibrinogen, α-1-antitrypsin and complement factors.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> In addition, IL-6 regulates the growth and differentiation of lymphocytes and activates natural killer (NK) cells and neutrophils. It is widely agreed that the measurement of IL-6 is a good indicator of trauma severity and outcome.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Interleukin-8 participates in leukocyte recruitment, and facilitates the activation of these cells at the damage site. The levels of IL-8 are correlated to the development of acute respiratory distress syndrome (ARDS) following severe trauma.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Of the different antiinflammatory cytokines, mention must be made of IL-10, which is synthesized by lymphocytes and monocytes. This cytokine fundamentally inhibits the production of TNF-α, IL-6 and IL-8.<a class="elsevierStyleCrossRef" href="#bib0035">7</a></li><li class="elsevierStyleListItem" id="lsti0010">-Complement system: Activation of the complement system can occur after severe trauma via any of the known pathways (alternative, classical, lectin), generating biologically active peptides that play a key role through different mechanisms<a class="elsevierStyleCrossRefs" href="#bib0035">7,14</a>: the elimination of invasive pathogens via opsonization and phagocytosis (C3b, C4b), leukocyte chemotaxis (C3a, C5a), and pathogen destruction through the membrane attack complex (C5b-9). In addition, the anaphylotoxins C3a, C4a and C5a attract phagocytes and polymorphonuclear cells (PMNs) toward the damage site<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> and induce the degranulation of mast cells, basophils and eosinophils.<a class="elsevierStyleCrossRefs" href="#bib0035">7,14</a> Experimental and clinical studies have demonstrated that complement activation takes place both locally at the damage site and systemically after trauma.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The plasma C3 levels are correlated to the severity of trauma and to the infectious complications and mortality after trauma.<a class="elsevierStyleCrossRef" href="#bib0080">16</a></li><li class="elsevierStyleListItem" id="lsti0015">-Pathogen-associated molecular patterns (PAMPs), damage-associated molecular patterns (DAMPs) and alarmins: PAMPs are inflammatory molecules related to activation of the innate immune system in cases of infection, while the alarmins constitute their equivalents in the absence of infection and in the presence of tissue damage.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Such molecules include the heat-shock proteins, annexins, defensins, HMGB1 and S100. Both families have been grouped into a larger family known as DAMPs, which are recognized by the immune system through multiligand receptors such as the toll-like receptors (TLRs).<a class="elsevierStyleCrossRef" href="#bib0085">17</a> However, their precise role in the development of MOF remains to be fully clarified.<a class="elsevierStyleCrossRef" href="#bib0070">14</a></li></ul>Effectors<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">-Neutrophils: Polymorphonuclear cells, monocytes, macrophages, dendritic cells and natural killer cells play a relevant role in the cellular immune response after trauma.<a class="elsevierStyleCrossRefs" href="#bib0030">6–9,18</a> Neutrophils are attracted to the damage site by cytokines such as IL-8, and participate in the defense and debridement of the damaged tissue. In addition, these cells participate in the activation of molecules such as TNF-α, IL-8, platelet activating factor and anaphylotoxin (C5a), leading to hyper-inflammation and PMN activation and recruitment, and contributing to the development of systemic inflammatory response syndrome and MOF.<a class="elsevierStyleCrossRefs" href="#bib0030">6–8,19</a> This mobilization of PMNs results in neutrophilia three hours after injury, which represents a “vulnerability window” during which a second “hit” can give rise to MOF.<a class="elsevierStyleCrossRefs" href="#bib0030">6,20</a> In those patients that develop MOF, neutrophilia is followed by neutropenia 6–12h after trauma.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Moreover, the PMNs induce endothelial and epithelial damage through the overregulation of adhesion molecules in the cells, and this situation results in permeability changes and cellular edema, with cellular dysfunction.<a class="elsevierStyleCrossRef" href="#bib0035">7</a></li><li class="elsevierStyleListItem" id="lsti0025">-Ischemia-reperfusion: This phenomenon develops in two phases following trauma: a first phase is characterized by the temporary privation of nutrients and oxygen due to the lack of blood supply, resulting in a switch from aerobic to anaerobic metabolism at cellular level. The second phase is characterized by the restoration of blood flow and oxygenation to the ischemic tissue.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> In the ischemic phase, hypoxemia implies a low production and high consumption of adenosine triphosphate, which is degraded to adenosine diphosphate. This in turn is degraded to inosine and hypoxanthine,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> triggering alterations in permeability with an increase in intracellular sodium that causes cell edema and membrane disruption.<a class="elsevierStyleCrossRefs" href="#bib0035">7,22</a> In addition, the depletion of adenosine triphosphate causes cell damage mediated by alterations in the concentrations of cytosolic calcium.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> The reperfusion phase is of greater importance in relation to tissue damage and MOF than the ischemia phase. In the reperfusion phase, hypoxanthine is degraded to xanthine and finally to uric acid through the mediation of xanthine oxidase, with the production of superoxide anions (O2+−) from the available oxygen. Such anions are moreover reduced to hydrogen peroxide (H2O2) and to hydroxyl ions (OH2+−) through the mediation of superoxide dismutase. These free radicals enhance the alterations in intracellular calcium homeostasis and induce lipid peroxidation, membrane disintegration and deoxyribonucleic acid alterations – with apoptosis and cell necrosis as the end result.<a class="elsevierStyleCrossRef" href="#bib0110">22</a></li><li class="elsevierStyleListItem" id="lsti0030">-Intestinal hypothesis: The alterations in the structure and permeability of the intestinal mucosa play a key role as a source of bacterial products and antiinflammatory mediators that penetrate the systemic circulation and damage different organs. Two basic factors may contribute to this phenomenon: intestinal stasis allowing bacterial overgrowth, and ischemia-reperfusion, which increases intestinal permeability. However, the precise mechanisms involved have not been well established.<a class="elsevierStyleCrossRef" href="#bib0030">6</a></li></ul>Clinical manifestations and assessment scalesAs has been mentioned, there is no uniform definition of post-trauma MOF.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> However, a number of scales have been developed for evaluating patient respiratory, cardiovascular, hepatic, renal, neurological and coagulation function. The most widely used scales are summarized below.Sequential-related Organ Failure Assessment (SOFA)The SOFA was developed in 1994 under the auspices of the European Society of Intensive Care Medicine as an objective tool for quantitatively assessing organ dysfunction or failure over time, and thus also for evaluating patient response to treatment.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> The SOFA scores 6 organs from 0 to 4 according to the degree of dysfunction in each of them (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Multiorgan failure is defined as the alteration of two or more organs with a score of ≥3.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Although the initial aim of the scale was to evaluate morbidity, a good correlation has been observed between the maximum score obtained and mortality. In this regard, the mortality rate is over 90% in those patients presenting a total score of over 15 (with a specificity of almost 99%).<a class="elsevierStyleCrossRef" href="#bib0120">24</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Antonelli et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> evaluated the SOFA in trauma patients and found non-survivors to have poorer respiratory, cardiovascular and neurological scores, particularly during the first 5 days of admission. In this context, neurological function is the most complicated dimension to evaluate in certain cases, due to both the potential interferences of sedating drugs and the presence of traumatic brain injury. The SOFA has recently been used by a German group in the largest series of trauma patients published to date, with the assessment of MOF in 31,154 patients.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> The authors recorded an incidence of MOF of 32%, which suggests that the SOFA may overestimate the incidence of post-trauma MOF. The scale, developed at European level, is used in the Spanish national trauma registry (RETRAUCI) for assessing the incidence of MOF.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>Denver scaleIn 1987, the Denver group for the first time developed a scale for assessing MOF.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> This instrument evaluates four systems, each of which are scored from 0 to 3 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Organ failure is defined by a score of over 0, while MOF is defined as the failure of two or more organs, with a total score of ≥4 as determined 48h after trauma.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> The Denver scale has been revised on several occasions since its introduction, and some of the original parameters have received modifications–fundamentally in relation to the respiratory and cardiovascular dimensions. The current version of the scale evaluates the parameters described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Marshall scaleIn the 1990s, Marshall et al. presented a new scale for assessing MOF.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> The authors evaluated 6 systems, each of which were scored from 0 to 4 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The parameters are always recorded at the same time of day (the first value in the morning). The Marshall scale does not consider specific values as indicators of MOF as such; rather, it establishes degrees of severity defined by the observed mortality. Thus, no mortality is observed in patients with a score of 0, while the mortality rate is 25% in those with a score of 9–12; 50% in those with a score of 13–16; 75% in those with a score of 17–20; and 100% in the case of a score of over 20. A good correlation is observed between the score and hospital stay. In the same way as the SOFA, the Marshall scale evaluates neurological status. In this case, a Glasgow coma score of 15 is assumed in sedated patients. On the other hand, because of the difficulty of defining the optimum parameter for assessing patient hemodynamics, a new variable was introduced in the updated version of 1995: the pressure adjusted heart rate (PAR). This variable is the ratio between the product of heart rate and central venous pressure, and the mean blood pressure (PAR=HR×CVP/MBP).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Some studies have compared the different scales described above. A German study analyzing the performance of the Goris, Marshall and Denver scales found the latter instrument to offer the best performance, with a sensitivity of 81% and a specificity of 88%.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> The authors highlighted that the Denver scale does not include more complex evaluations such as aspartate transaminase levels (GOT) or PAR, which had a scant impact upon the calculations made. Some years later, the Denver group compared their scale with the Marshall scale in patients of their severe trauma database and excluding pure traumatic brain injury cases and patients with an extracranial Abbreviated Injury Score of under 2. The receiver operator characteristic (ROC)-based analysis yielded similar results for both scales, though the Denver scale had greater specificity and a greater capacity to evaluate patient response to treatment.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> Different studies in turn have compared the SOFA with the Marshall scale, though not in specific trauma patient groups.A new scale has recently been developed: the Denver Emergency Department Trauma Organ Failure Score (Denver ED TOF Score).<a class="elsevierStyleCrossRef" href="#bib0160">32</a> This is the first scale designed to allow early prediction (within the first 4h after trauma) of the development of MOF in the first 7 days of admission. The instrument includes pre-hospital variables and parameters collected during first care in the emergency room (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). The score ranges from 0 to 9, and an increased risk of MOF is associated to higher scores, with excellent calibration and discrimination. The Denver ED TOF Score could be useful not only in identifying patients in early stages of MOF but also as a screening tool for patient transfer to a reference center. Its main limitation is lesser patient severity (median Injury Severity Score [ISS] 9, with an interquartile range of 4–16), since it was developed from secondary analysis of a database not designed for this purpose, and the lack of external validation.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Predictors of severe multiorgan failure after traumaDifferent parameters have been associated to an increased risk of developing MOF after trauma. Those most frequently cited in the literature are commented below:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">-Age: In recent years there has been an increase in the age of patients with trauma. A number of studies have identified patient age as an independent risk factor for the development of MOF, with the definition of different cutoff points–generally 55 or 65 years of age.<a class="elsevierStyleCrossRefs" href="#bib0005">1,5,26,33</a></li><li class="elsevierStyleListItem" id="lsti0040">-Gender: Previous studies had not considered the male gender to be a risk factor for the development of post-trauma MOF. However, in the recent German registry, the male gender (73.1% of all patients) was identified as a risk factor in the multivariate analysis.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> This observation could be mediated by the existence of higher IL-6 levels in males following severe trauma.<a class="elsevierStyleCrossRef" href="#bib0170">34</a></li><li class="elsevierStyleListItem" id="lsti0045">-Severity of trauma: The severity of trauma as assessed by the ISS has consistently been cited as a risk factor<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,4,26,33</a>–the most widely used cutoff point being a score of 24. However, some authors believe that the ISS has lost usefulness as a predictor of MOF, since it may underestimate severity in patients with several injuries in a given anatomical area. In fact, the ISS has been compared with the New Injury Severity Score (NISS) as a predictor of the development of MOF in a limited population of patients,<a class="elsevierStyleCrossRef" href="#bib0175">35</a> with the NISS being found to offer superior performance. However, while this new scale is attractive, its use has not become widespread in the major trauma registries.</li><li class="elsevierStyleListItem" id="lsti0050">-Traumatic brain injury: Among the different body regions analyzed in the ISS, a score for the head on the Abbreviated Injury Scale of ≥3 is related to an increased risk of developing MOF,<a class="elsevierStyleCrossRefs" href="#bib0135">27,34</a> in the same way as an initial Glasgow coma score of ≤8.<a class="elsevierStyleCrossRef" href="#bib0130">26</a></li><li class="elsevierStyleListItem" id="lsti0055">-Blood products: It is well known that blood products contain abundant mediators that act as immune modulators. As a result, their use is associated to an increased incidence of nosocomial infections, MOF and mortality. Many studies have shown that the transfusion of more then 6 red cell concentrate units in the first hours is an independent risk factor for the development of MOF.<a class="elsevierStyleCrossRefs" href="#bib0005">1,26,33</a> Moreover, the age of the concentrates is also associated to an increased risk of MOF.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> The transfusion of fresh frozen plasma likewise constitutes a risk factor for the development of acute respiratory distress syndrome and MOF,<a class="elsevierStyleCrossRef" href="#bib0185">37</a> though not so the transfusion of platelets.</li><li class="elsevierStyleListItem" id="lsti0060">-Coagulation disorders and thrombocytopenia: Coagulation disorders and platelet count are well known to play a prognostic role in relation to post-trauma MOF. The platelet count in the first hours following admission has recently been established as an independent predictor of MOF using different cutoff points and times after trauma: counts below 80,000/μl to 150,000/μl between admission and the first 24h have been evaluated. Furthermore, those patients who continue to present low platelet counts after several days have a poorer prognosis.<a class="elsevierStyleCrossRef" href="#bib0190">38</a></li><li class="elsevierStyleListItem" id="lsti0065">-Hemodynamic status and lactate: The hemodynamic situation upon admission, evaluated on the basis of shock parameters such as systolic blood pressure (≤90mmHg), and base deficit or lactate concentration have also been identified as risk factors.<a class="elsevierStyleCrossRefs" href="#bib0005">1,26</a> Not only the initial concentration is of prognostic importance in the case of lactate, but also the time elapsed until the concentration normalizes (assuming the levels do return to normal).<a class="elsevierStyleCrossRef" href="#bib0195">39</a></li><li class="elsevierStyleListItem" id="lsti0070">-Other factors that have been proposed as possible predictors of the development of MOF are the minimum bilirubin levels or the peak creatinine concentrations in the first 24h. Obesity might also play a role. However, the evidence supporting these factors is much more limited.</li></ul>TreatmentAlthough there is no specific treatment for MOF once it has become established, the incidence of the disorder is considered to have decreased in recent years thanks to advances in the general management of critical trauma patients and the early correction of shock.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,6,26</a> Considering the results recently published by the German group, it seems less clear whether the associated mortality rate has also decreased in recent years.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Some strategies referred to the early management of these patients appear to contribute to avoid the development of MOF.<a class="elsevierStyleCrossRefs" href="#bib0005">1,6</a> Such strategies include the following:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0075">-Cardiorespiratory support: Initially, the recommendations for the management of patients with traumatic shock focused on obtaining parameters indicative of supranormal oxygen transport. However, in recent years there have been changes in the general approach to the treatment of these patients, oriented toward permissive hypotension and the correction of hypothermia, coagulopathy and acidosis.<a class="elsevierStyleCrossRefs" href="#bib0200">40,41</a> In this way the use of crystalloids is reduced and the incidence of abdominal compartmental syndrome, MOF and death is lowered.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> It should be mentioned that the presence of traumatic brain injury obliges us to seek higher arterial pressure levels.</li><li class="elsevierStyleListItem" id="lsti0080">-Damage control surgery and debridement of infected tissues: The first concern is to control the bleeding, avoiding prolonged interventions, in an attempt to not worsen the acidosis and coagulopathy. In addition, this helps limit the release of inflammatory mediators in the acute phase.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Likewise, the debridement of infectious foci, with the removal of non-viable tissue, the use of vacuum systems and second-step interventions contribute to reduce the infectious complications which play a very important role in late MOF.</li><li class="elsevierStyleListItem" id="lsti0085">-Volume replacement and blood products: This issue remains subject to controversy, though the current tendency is to administer lesser crystalloid volumes. Furthermore, since it is known that the transfusion of blood products is significantly associated to the development of MOF,<a class="elsevierStyleCrossRefs" href="#bib0005">1,26,33</a> a more restrictive approach is advised in order to avoid unnecessary transfusions. However, as has been mentioned, this subject remains open to debate.</li><li class="elsevierStyleListItem" id="lsti0090">-Others: Different treatment measures used in critical patients in general, such as protective mechanical ventilation, adequate nutritional support, the management of hyperglycemia with insulin or adrenal gland replacement therapy, while controversial in the general population of patients in the ICU, could play a role in lowering the incidence of post-trauma MOF.</li></ul>ConclusionsTo summarize, post-trauma MOF remains an important cause of morbidity-mortality in severe trauma patients. Because of the different definitions used, the true incidence of MOF remains unclear. The RETRAUCI registry, auspiced by the Trauma and Neurointensive Care work group of the SEMICYUC, will help define the incidence in our setting. The prognosis of MOF has improved in recent years, probably as a result of advances in the general management of critical trauma patients. While certain non-modifiable factors such as age and comorbidities among trauma patients imply a poorer prognosis, the application of uniform protocols referred to resuscitation, damage control, sedation and volume replacement appears to have mitigated their negative effects.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres373975" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec353023" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres373976" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec353024" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Definition" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Epidemiological aspects" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Physiopathology" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Mediators" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Effectors" ] ] ] 8 => array:3 [ "identificador" => "sec0035" "titulo" => "Clinical manifestations and assessment scales" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Sequential-related Organ Failure Assessment (SOFA)" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Denver scale" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Marshall scale" ] ] ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Predictors of severe multiorgan failure after trauma" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Treatment" ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-07" "fechaAceptado" => "2014-05-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec353023" "palabras" => array:3 [ 0 => "Severe trauma" 1 => "Multiorgan failure" 2 => "Clinical scales" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec353024" "palabras" => array:3 [ 0 => "Trauma grave" 1 => "Fallo multiorgánico" 2 => "Escalas clínicas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Multiorgan failure remains one of the leading causes of late morbidity and mortality after severe trauma. In the early phase, it is related with an uncontrolled hyper-inflammation state, whereas in the late phase (>72h), septic complications play a major role. We review the underlying pathophysiology, the evaluation with different scales and the clinical factors associated with multiorgan failure, as well as potential treatment options." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El fallo multiorgánico tras el trauma grave constituye una de las principales causas de morbimortalidad tardía en este grupo de pacientes. En su fase precoz, es consecuencia de un estado de hiperinflamación no controlado, mientras que en su presentación tardía (>72h) se relaciona principalmente con las complicaciones infecciosas. Se resumen los mecanismos fisiopatológicos implicados en su desarrollo, la valoración mediante diferentes escalas y los factores clínicos asociados, además de las potenciales opciones de tratamiento." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Llompart-Pou JA, Talayero M, Homar J, Royo C, grupo de trabajo de Trauma y Neurointensivismo de SEMICYUC. Fallo multiorgánico en el paciente con trauma grave. Med Intensiva. 2014;38:455–462." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3077 "Ancho" => 2185 "Tamanyo" => 326072 ] ] "descripcion" => array:1 [ "en" => "Summary of the physiopathology of multiorgan failure following severe trauma." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Glasgow: Glasgow coma score; MBP: mean blood pressure; CNS: central nervous system." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SOFA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory: PaO2/FiO2 (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤ 400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤200 with ventilatory support \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤100 with ventilatory support \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coagulation: Platelets ×103/μl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>150 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤ 150 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liver: Bilirubin (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2–1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2–5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6–11.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular: Hypotension (μg/kg/min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MBP<70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dopamine ≤5μg/kg/min or dobutamine (any dose) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dopamine >5μg/kg/min or adrenalin or noradrenalin ≤0.1μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dopamine >15μg/kg/min or adrenalin or noradrenalin >0.1μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CNS Glasgow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13–14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal: Creatinine (mg/dl) or diuresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2–1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2–3.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.5–4.9<500ml/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>5<200ml/day \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab565994.png" ] ] ] ] "descripcion" => array:1 [ "en" => "SOFA scale." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "CI: cardiac index." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Denver \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory: PaO2/FiO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>250 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">250–200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">199–100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal: Creatinine (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9–2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6–5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liver: Bilirubin (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.1–4.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1–8.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No inotropic drugs and CI>3l/min/m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A low-dose inotropic drug or CI<3l/min/m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Any inotropic drug at moderate doses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Any inotropic drug at high doses \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab565993.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Denver scale." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "HR: heart rate; Glasgow: Glasgow coma score; MBP: mean blood pressure; PAR: pressure adjusted heart rate; CVP: central venous pressure; CNS: central nervous system.PAR=HR×CVP/MBP.Bilirubin conversion factor: 1mg/dl=17.1μmol/l.Creatinine conversion factor: 1mg/dl=88.4μmol/l." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Marshall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory: PaO2/FiO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">226–300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">151–225 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76–150 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coagulation: Platelets ×103/μl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81–120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51–80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21–50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liver: Bilirubin (μmol/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21–60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61–120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">121–240 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>240 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular (PAR) version 1995 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.1–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.1–20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.1–30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal: Creatinine (μmol/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">101–200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">201–350 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">351–500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>500 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CNS Glasgow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13–14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab565995.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Marshall scale." ] ] 4 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "SBP: systolic blood pressure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age ≥65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prehospital intubation or intubation during first care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hematocrit</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥20% and <35% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SBP <90mmHg at first care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urea ≥30mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leukocytes ≥20.000/μl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab565996.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Denver Emergency Department Trauma Organ Failure Score." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A 12-year prospective study of postinjury multiple organ failure: has anything changed?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.J. Ciesla" 1 => "E.E. Moore" 2 => "J.L. Johnson" 3 => "J.M. Burch" 4 => "C.C. Cothren" 5 => "A. Sauaia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archsurg.140.5.432" "Revista" => array:6 [ "tituloSerie" => "Arch Surg" "fecha" => "2005" "volumen" => "140" "paginaInicial" => "432" "paginaFinal" => "438" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15897438" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Temporal trends of postinjury multiple-organ failure: still resource intensive, morbid, and lethal" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Sauaia" 1 => "E.E. Moore" 2 => "J.L. Johnson" 3 => "T.L. Chin" 4 => "A. Banerjee" 5 => "J.L. Sperry" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0000000000000147" "Revista" => array:6 [ "tituloSerie" => "J Trauma Acute Care Surg" "fecha" => "2014" "volumen" => "76" "paginaInicial" => "582" "paginaFinal" => "592" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24553523" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Epidemiological profile of late mortality in severe polytraumatisms]" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Proyecto Poliguitania" "etal" => true "autores" => array:6 [ 0 => "F. Alberdi" 1 => "F. Azaldegui" 2 => "M. Zabarte" 3 => "I. García" 4 => "L. Atutxa" 5 => "J. Santacana" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2012.07.001" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2013" "volumen" => "37" "paginaInicial" => "383" "paginaFinal" => "390" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22999375" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multiple organ failure in trauma patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.M. Durham" 1 => "J.J. Moran" 2 => "J.E. Mazuski" 3 => "M.J. Shapiro" 4 => "A.E. Baue" 5 => "L.M. Flint" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.TA.0000092378.10660.D1" "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "2003" "volumen" => "55" "paginaInicial" => "608" "paginaFinal" => "616" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14566110" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changes in the epidemiology and prediction of multiple-organ failure after injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.C. Dewar" 1 => "S.M. Tarrant" 2 => "K.L. King" 3 => "Z.J. Balogh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0b013e31827a6e69" "Revista" => array:6 [ "tituloSerie" => "J Trauma Acute Care Surg" "fecha" => "2013" "volumen" => "74" "paginaInicial" => "774" "paginaFinal" => "779" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23425734" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postinjury multiple organ failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Dewar" 1 => "F.A. Moore" 2 => "E.E. Moore" 3 => "Z. Balogh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.injury.2009.05.024" "Revista" => array:6 [ "tituloSerie" => "Injury" "fecha" => "2009" "volumen" => "40" "paginaInicial" => "912" "paginaFinal" => "918" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19541301" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current theories on the pathophysiology of multiple organ failure after trauma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Tsukamoto" 1 => "R.S. Chanthaphavong" 2 => "H.C. Pape" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.injury.2009.07.010" "Revista" => array:6 [ "tituloSerie" => "Injury" "fecha" => "2010" "volumen" => "41" "paginaInicial" => "21" "paginaFinal" => "26" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19729158" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multiple system organ failure. The role of uncontrolled infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.E. Fry" 1 => "L. Pearlstein" 2 => "R.L. Fulton" 3 => "H.C. Polk Jr." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Surg" "fecha" => "1980" "volumen" => "115" "paginaInicial" => "136" "paginaFinal" => "140" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6965449" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postinjury multiple organ failure: a bimodal phenomenon" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F.A. Moore" 1 => "A. Sauaia" 2 => "E.E. Moore" 3 => "J.B. Haenel" 4 => "J.M. Burch" 5 => "D.C. Lezotte" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "1996" "volumen" => "40" "paginaInicial" => "501" "paginaFinal" => "510" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8614027" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of the lung in postinjury multiple organ failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.J. Ciesla" 1 => "E.E. Moore" 2 => "J.L. Johnson" 3 => "J.M. Burch" 4 => "C.C. Cothren" 5 => "A. Sauaia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.surg.2005.07.020" "Revista" => array:6 [ "tituloSerie" => "Surgery" "fecha" => "2005" "volumen" => "138" "paginaInicial" => "749" "paginaFinal" => "757" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16269305" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cytokine levels (IL-4, IL-6 IL-8 and TGFb) as potential biomarkers of systemic inflammatory response in trauma patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Volpin" 1 => "M. Cohen" 2 => "M. Assaf" 3 => "T. Meir" 4 => "R. Katz" 5 => "S. Pollack" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00264-013-2261-2" "Revista" => array:6 [ "tituloSerie" => "Int Orthop" "fecha" => "2014" "volumen" => "38" "paginaInicial" => "1303" "paginaFinal" => "1309" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24402554" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Inflammatory responses and mediators" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.K. Kim" 1 => "C.S. Deutschman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Surg Clin North Am" "fecha" => "2000" "volumen" => "80" "paginaInicial" => "885" "paginaFinal" => "894" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10897267" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessment of the clinical course with inflammatory parameters" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H.C. Pape" 1 => "T. Tsukamoto" 2 => "P. Kobbe" 3 => "I. Tarkin" 4 => "S. Katsoulis" 5 => "A. Peitzman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.injury.2007.09.026" "Revista" => array:6 [ "tituloSerie" => "Injury" "fecha" => "2007" "volumen" => "38" "paginaInicial" => "1358" "paginaFinal" => "1364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18048038" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of biological modifiers regulating the immune response after trauma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.F. Stahel" 1 => "W.R. Smith" 2 => "E.E. Moore" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.injury.2007.09.023" "Revista" => array:6 [ "tituloSerie" => "Injury" "fecha" => "2007" "volumen" => "38" "paginaInicial" => "1409" "paginaFinal" => "1422" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18048034" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of C5a in inflammatory responses" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.F. Guo" 1 => "P.A. Ward" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1146/annurev.immunol.23.021704.115835" "Revista" => array:6 [ "tituloSerie" => "Annu Rev Immunol" "fecha" => "2005" "volumen" => "23" "paginaInicial" => "821" "paginaFinal" => "852" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15771587" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Circulating complement proteins in multiple trauma patients – correlation with injury severity, development of sepsis, and outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Hecke" 1 => "U. Schmidt" 2 => "A. Kola" 3 => "W. Bautsch" 4 => "A. Klos" 5 => "J. Köhl" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "1997" "volumen" => "25" "paginaInicial" => "2015" "paginaFinal" => "2024" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9403752" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Inflammatory response to trauma: Implications for coagulation and resuscitation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Pierce" 1 => "J.F. Pittet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ACO.0000000000000047" "Revista" => array:7 [ "tituloSerie" => "Curr Opin Anaesthesiol" "fecha" => "2014" "volumen" => "27" "paginaInicial" => "246" "paginaFinal" => "252" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24419158" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0033833810002493" "estado" => "S300" "issn" => "00338338" ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The systemic inflammatory response induced by trauma is reflected by multiple phenotypes of blood neutrophils" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Pillay" 1 => "F. Hietbrink" 2 => "L. Koenderman" 3 => "L.P. Leenen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.injury.2007.09.016" "Revista" => array:6 [ "tituloSerie" => "Injury" "fecha" => "2007" "volumen" => "38" "paginaInicial" => "1365" "paginaFinal" => "1372" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18061190" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postinjury neutrophil priming and activation: an early vulnerable window" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.J. Botha" 1 => "F.A. Moore" 2 => "E.E. Moore" 3 => "F.J. Kim" 4 => "A. Banerjee" 5 => "V.M. Peterson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Surgery" "fecha" => "1995" "volumen" => "118" "paginaInicial" => "358" "paginaFinal" => "364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7638753" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The two-event construct of postinjury multiple organ failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E.E. Moore" 1 => "F.A. Moore" 2 => "A.H. Harken" 3 => "J.L. Johnson" 4 => "D. Ciesla" 5 => "A. Banerjee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Shock" "fecha" => "2005" "volumen" => "24" "numero" => "Suppl. 1" "paginaInicial" => "71" "paginaFinal" => "74" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16374376" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Application of heme oxygenase-1, carbon monoxide and biliverdin for the prevention of intestinal ischemia/reperfusion injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Nakao" 1 => "D.J. Kaczorowski" 2 => "R. Sugimoto" 3 => "T.R. Billiar" 4 => "K.R. McCurry" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3164/jcbn.2008013" "Revista" => array:6 [ "tituloSerie" => "J Clin Biochem Nutr" "fecha" => "2008" "volumen" => "42" "paginaInicial" => "78" "paginaFinal" => "88" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18385824" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathophysiology of polytrauma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Keel" 1 => "O. Trentz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.injury.2004.12.037" "Revista" => array:7 [ "tituloSerie" => "Injury" "fecha" => "2005" "volumen" => "36" "paginaInicial" => "691" "paginaFinal" => "709" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15910820" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0033833811001007" "estado" => "S300" "issn" => "00338338" ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The SOFA (sepsis-related organ failure assesment) score to describe organ dysfunction/failures. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.L. Vincent" 1 => "R. Moreno" 2 => "J. Takala" 3 => "S. Willats" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "1996" "volumen" => "22" "paginaInicial" => "707" "paginaFinal" => "710" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8844239" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on «sepsis-related problems» of the European Society of Intensive Care Medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.L. Vincent" 1 => "A. de Mendonça" 2 => "F. Cantraine" 3 => "R. Moreno" 4 => "J. Takala" 5 => "P.M. Suter" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Crit Care Med" "fecha" => "1998" "volumen" => "26" "paginaInicial" => "1793" "paginaFinal" => "1800" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9824069" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109709012169" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Application of SOFA score to trauma patients. Sequential Organ Failure Assessment" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Antonelli" 1 => "R. Moreno" 2 => "J.L. Vincent" 3 => "C.L. Sprung" 4 => "A. Mendoça" 5 => "M. Passariello" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "1999" "volumen" => "25" "paginaInicial" => "389" "paginaFinal" => "394" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10342513" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology and risk factors of multiple-organ failure after multiple trauma: An analysis of 31,154 patients from the TraumaRegister DGU" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS)" "etal" => true "autores" => array:6 [ 0 => "M. Fröhlich" 1 => "R. Lefering" 2 => "C. Probst" 3 => "T. Paffrath" 4 => "M.M. Schneider" 5 => "M. Maegele" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0000000000000199" "Revista" => array:7 [ "tituloSerie" => "J Trauma Acute Care Surg" "fecha" => "2014" "volumen" => "76" "paginaInicial" => "921" "paginaFinal" => "928" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24662853" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109709002289" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Registros de trauma: una prioridad sanitaria, un proyecto estratégico para la SEMICYUC" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Chico Fernández" 1 => "C. García Fuentes" 2 => "F. Guerrero López" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2013.01.010" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2013" "volumen" => "37" "paginaInicial" => "284" "paginaFinal" => "289" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23507334" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gut bacterial translocation via the portal vein: a clinical perspective with major torso trauma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.A. Moore" 1 => "E.E. Moore" 2 => "R. Poggetti" 3 => "O.J. McAnena" 4 => "V.M. Peterson" 5 => "C.M. Abernathy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "1991" "volumen" => "31" "paginaInicial" => "629" "paginaFinal" => "636" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2030509" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.C. Marshall" 1 => "D.J. Cook" 2 => "N.V. Christou" 3 => "G.R. Bernard" 4 => "C.L. Sprung" 5 => "W.J. Sibbald" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "1995" "volumen" => "23" "paginaInicial" => "1638" "paginaFinal" => "1652" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7587228" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Scoring multiple organ failure after severe trauma. Comparison of the Goris, Marshall and Moore scores]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Grotz" 1 => "M. von Griensven" 2 => "M. Stalp" 3 => "U. Kaufmann" 4 => "F. Hildebrand" 5 => "H.C. Pape" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chirurg" "fecha" => "2001" "volumen" => "72" "paginaInicial" => "723" "paginaFinal" => "730" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11469095" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Validation of postinjury multiple organ failure scores" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Sauaia" 1 => "E.E. Moore" 2 => "J.L. Johnson" 3 => "D.J. Ciesla" 4 => "W.L. Biffl" 5 => "A. Banerjee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SHK.0b013e31818ba4c6" "Revista" => array:6 [ "tituloSerie" => "Shock" "fecha" => "2009" "volumen" => "31" "paginaInicial" => "438" "paginaFinal" => "447" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18838942" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prediction of postinjury multiple-organ failure in the emergency department: development of the Denver Emergency Department Trauma Organ Failure score" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Vogel" 1 => "M.M. Liao" 2 => "E. Hopkins" 3 => "N. Seleno" 4 => "R.L. Byyny" 5 => "E.E. Moore" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0b013e3182a99da4" "Revista" => array:6 [ "tituloSerie" => "J Trauma Acute Care Surg" "fecha" => "2014" "volumen" => "76" "paginaInicial" => "140" "paginaFinal" => "145" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24368369" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early predictors of morbidity and mortality in trauma patients treated in the intensive care unit" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "O. Brattström" 1 => "F. Granath" 2 => "P. Rossi" 3 => "A. Oldner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1399-6576.2010.02266.x" "Revista" => array:7 [ "tituloSerie" => "Acta Anaesthesiol Scand" "fecha" => "2010" "volumen" => "54" "paginaInicial" => "1007" "paginaFinal" => "1017" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20626360" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109705005279" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Male gender is associated with excessive IL-6 expression following severe injury" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Inflammation and the host response to injury investigators" "etal" => true "autores" => array:6 [ 0 => "J.L. Sperry" 1 => "R.S. Friese" 2 => "H.L. Frankel" 3 => "M.A. West" 4 => "J. Cuschieri" 5 => "E.E. Moore" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0b013e3181650fdf" "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "2008" "volumen" => "64" "paginaInicial" => "572" "paginaFinal" => "578" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18332795" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "NISS predicts postinjury multiple organ failure better than the ISS" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Z. Balogh" 1 => "P.J. Offner" 2 => "E.E. Moore" 3 => "W.L. Biffl" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "2000" "volumen" => "48" "paginaInicial" => "624" "paginaFinal" => "627" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10780593" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Age of transfused blood is an independent risk factor for postinjury multiple organ failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Zallen" 1 => "P.J. Offner" 2 => "E.E. Moore" 3 => "J. Blackwell" 4 => "D.J. Ciesla" 5 => "J. Gabriel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "1999" "volumen" => "178" "paginaInicial" => "570" "paginaFinal" => "572" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10670874" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Inflammation and Host Response to Injury Investigators" "etal" => true "autores" => array:6 [ 0 => "G.A. Watson" 1 => "J.L. Sperry" 2 => "M.R. Rosengart" 3 => "J.P. Minei" 4 => "B.G. Harbrecht" 5 => "E.E. Moore" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0b013e3181ad5957" "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "2009" "volumen" => "67" "paginaInicial" => "221" "paginaFinal" => "227" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19667872" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Refractory postinjury thrombocytopenia is associated with multiple organ failure and adverse outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.L. Nydam" 1 => "J.L. Kashuk" 2 => "E.E. Moore" 3 => "J.L. Johnson" 4 => "C.C. Burlew" 5 => "W.L. 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Update in Intensive Care

Multiorgan failure in the serious trauma patient

Fallo multiorgánico en el paciente con trauma grave

J.A. Llompart-Poua,

Corresponding author

juanantonio.llompart@ssib.es
ja_llompart@hotmail.com

Corresponding author.

, M. Talayerob, J. Homara, C. Royoa, Trauma and Neurointensive Care work group of the SEMICYUC

a Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma de Mallorca, Spain

b Unidad de Cuidados Intensivos de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain

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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Summary of the physiopathology of multiorgan failure following severe trauma&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The development of multiorgan failure &#40;MOF&#41; after severe trauma is one of the leading causes of late mortality in such patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The incidence of MOF varies between 7&#37; and 66&#37;&#44; and despite recent advances in the pre- and in-hospital management of these patients&#44; the disorder is associated to important mortality and prolonged hospital stay&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a> Although MOF is recognized to be a dynamic process&#44; agreement is lacking regarding its definition&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The underlying physiopathology is moreover subject to debate&#44; and involves the participation of different components of the immune and inflammatory systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The present article reviews the current knowledge on the epidemiology and physiopathology of MOF&#44; the scales used to evaluate the disorder&#44; the clinical factors associated to the development of MOF&#44; and the possible treatment options&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition</span><p id="par0015" class="elsevierStylePara elsevierViewall">While no uniform definition of post-trauma MOF has been established to date&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> a number of scales have been developed for evaluating patient respiratory&#44; cardiovascular&#44; hepatic&#44; renal&#44; neurological and coagulation function&#8211;including particularly the Denver&#44; Marshall and Sequential-related Organ Failure Assessment &#40;SOFA&#41; scales&#46; These instruments will be examined further below&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the limitations imposed by the lack of a clear definition of MOF&#44; there is agreement in regarding early MOF as multiorgan failure occurring in the first 72<span class="elsevierStyleHsp" style=""></span>h after trauma &#40;this representing approximately 40&#37; of all cases&#41;&#44; while late MOF is taken to be multiorgan failure occurring beyond day three post-trauma &#40;60&#37; of all cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiological aspects</span><p id="par0025" class="elsevierStylePara elsevierViewall">Post-trauma MOF is the leading cause of late mortality in severe trauma&#44; accounting for 50&#8211;60&#37; of all deaths in such patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6</span></a> Those individuals that develop post-trauma MOF have a longer stay in the Intensive Care Unit &#40;ICU&#41;&#46; The associated mortality rate varies between 27&#37; and 100&#37;&#44; and increases with the number of affected organs&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;9</span></a> As early as 1980&#44; Fry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> showed mortality to increase from 30&#37; in the presence of single-organ dysfunction to 100&#37; in the case of dysfunction affecting four organs&#46; A study conducted in a single reference center for severe trauma in the United States&#44; involving data prospectively collected over a period of 12 years&#44; has found the incidence&#44; duration and mortality of MOF to have decreased in recent years&#8211;this being related to advances and new treatment modalities in application to severe trauma patients&#44; and to a decrease in the number of transfusions&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A recent multicenter study including 1643 trauma patients reported a decrease in incidence of almost 50&#37;&#8211;though the related mortality remains very high&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidence of MOF is greater in closed trauma patients&#44; and in these cases are associated to greater mortality than in penetrating trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Physiopathology</span><p id="par0035" class="elsevierStylePara elsevierViewall">Although the physiopathology of MOF in severe trauma is not fully clear and has evolved over the last 30 years&#44; it is currently accepted that the disorder is a bimodal phenomenon with two peaks of presentation&#44; due to an alteration in the balance of the systemic inflammatory response followed by ischemia-reperfusion after hemorrhagic shock&#46; This is in contrast to the early theories which pointed to generalized infection as the sole cause of MOF&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In this regard&#44; respiratory failure appears to play a key role in early MOF&#44; manifesting in 99&#37; of all cases and usually preceding heart dysfunction by a few hours&#44; and liver and kidney dysfunction by about 5 days&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In contrast&#44; late MOF occurring beyond 72<span class="elsevierStyleHsp" style=""></span>h after trauma requires a second &#8220;hit&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> usually in the form of infection &#40;mostly of pulmonary origin&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A number of mediators and effectors can potentially intervene in the physiopathology and development of post-trauma MOF &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#58;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Mediators</span><p id="par0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Cytokines&#58; The balance between proinflammatory and antiinflammatory cytokines plays a key role in the maintenance of homeostasis&#46; Following severe trauma there is an overproduction of proinflammatory cytokines such as tumor necrosis factor-alpha &#40;TNF-&#945;&#41;&#44; interleukin &#40;IL&#41;-1&#946;&#44; IL-6 and IL-8 on the part of monocytes and macrophages&#46; This constitutes part of the acute phase response&#44; contributing to initiation and perpetuation of the local and systemic inflammatory response&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11</span></a> TNF-&#945; increases the production of nitric oxide &#40;NO&#41; and activates cyclooxygenase&#44; resulting in an increased production and release of thromboxanes&#44; prostaglandins and platelet activating factor &#40;PAF&#41;&#8211;with a consequent increase in procoagulant activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;12</span></a> In turn&#44; IL-6&#44; produced by different cells such as activated monocytes&#44; macrophages&#44; neutrophils and endothelial cells&#44; plays an important role in the acute response&#44; intervening in the production of C-reactive protein&#44; procalcitonin&#44; fibrinogen&#44; &#945;-1-antitrypsin and complement factors&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In addition&#44; IL-6 regulates the growth and differentiation of lymphocytes and activates natural killer &#40;NK&#41; cells and neutrophils&#46; It is widely agreed that the measurement of IL-6 is a good indicator of trauma severity and outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Interleukin-8 participates in leukocyte recruitment&#44; and facilitates the activation of these cells at the damage site&#46; The levels of IL-8 are correlated to the development of acute respiratory distress syndrome &#40;ARDS&#41; following severe trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Of the different antiinflammatory cytokines&#44; mention must be made of IL-10&#44; which is synthesized by lymphocytes and monocytes&#46; This cytokine fundamentally inhibits the production of TNF-&#945;&#44; IL-6 and IL-8&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Complement system&#58; Activation of the complement system can occur after severe trauma via any of the known pathways &#40;alternative&#44; classical&#44; lectin&#41;&#44; generating biologically active peptides that play a key role through different mechanisms<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;14</span></a>&#58; the elimination of invasive pathogens via opsonization and phagocytosis &#40;C3b&#44; C4b&#41;&#44; leukocyte chemotaxis &#40;C3a&#44; C5a&#41;&#44; and pathogen destruction through the membrane attack complex &#40;C5b-9&#41;&#46; In addition&#44; the anaphylotoxins C3a&#44; C4a and C5a attract phagocytes and polymorphonuclear cells &#40;PMNs&#41; toward the damage site<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> and induce the degranulation of mast cells&#44; basophils and eosinophils&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;14</span></a> Experimental and clinical studies have demonstrated that complement activation takes place both locally at the damage site and systemically after trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The plasma C3 levels are correlated to the severity of trauma and to the infectious complications and mortality after trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Pathogen-associated molecular patterns &#40;PAMPs&#41;&#44; damage-associated molecular patterns &#40;DAMPs&#41; and alarmins&#58; PAMPs are inflammatory molecules related to activation of the innate immune system in cases of infection&#44; while the alarmins constitute their equivalents in the absence of infection and in the presence of tissue damage&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Such molecules include the heat-shock proteins&#44; annexins&#44; defensins&#44; HMGB1 and S100&#46; Both families have been grouped into a larger family known as DAMPs&#44; which are recognized by the immune system through multiligand receptors such as the toll-like receptors &#40;TLRs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However&#44; their precise role in the development of MOF remains to be fully clarified&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Effectors</span><p id="par0070" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Neutrophils&#58; Polymorphonuclear cells&#44; monocytes&#44; macrophages&#44; dendritic cells and natural killer cells play a relevant role in the cellular immune response after trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;9&#44;18</span></a> Neutrophils are attracted to the damage site by cytokines such as IL-8&#44; and participate in the defense and debridement of the damaged tissue&#46; In addition&#44; these cells participate in the activation of molecules such as TNF-&#945;&#44; IL-8&#44; platelet activating factor and anaphylotoxin &#40;C5a&#41;&#44; leading to hyper-inflammation and PMN activation and recruitment&#44; and contributing to the development of systemic inflammatory response syndrome and MOF&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8&#44;19</span></a> This mobilization of PMNs results in neutrophilia three hours after injury&#44; which represents a &#8220;vulnerability window&#8221; during which a second &#8220;hit&#8221; can give rise to MOF&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20</span></a> In those patients that develop MOF&#44; neutrophilia is followed by neutropenia 6&#8211;12<span class="elsevierStyleHsp" style=""></span>h after trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Moreover&#44; the PMNs induce endothelial and epithelial damage through the overregulation of adhesion molecules in the cells&#44; and this situation results in permeability changes and cellular edema&#44; with cellular dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Ischemia-reperfusion&#58; This phenomenon develops in two phases following trauma&#58; a first phase is characterized by the temporary privation of nutrients and oxygen due to the lack of blood supply&#44; resulting in a switch from aerobic to anaerobic metabolism at cellular level&#46; The second phase is characterized by the restoration of blood flow and oxygenation to the ischemic tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In the ischemic phase&#44; hypoxemia implies a low production and high consumption of adenosine triphosphate&#44; which is degraded to adenosine diphosphate&#46; This in turn is degraded to inosine and hypoxanthine&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> triggering alterations in permeability with an increase in intracellular sodium that causes cell edema and membrane disruption&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;22</span></a> In addition&#44; the depletion of adenosine triphosphate causes cell damage mediated by alterations in the concentrations of cytosolic calcium&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> The reperfusion phase is of greater importance in relation to tissue damage and MOF than the ischemia phase&#46; In the reperfusion phase&#44; hypoxanthine is degraded to xanthine and finally to uric acid through the mediation of xanthine oxidase&#44; with the production of superoxide anions &#40;O2&#43;&#8722;&#41; from the available oxygen&#46; Such anions are moreover reduced to hydrogen peroxide &#40;H<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleInf">2</span>&#41; and to hydroxyl ions &#40;OH2&#43;&#8722;&#41; through the mediation of superoxide dismutase&#46; These free radicals enhance the alterations in intracellular calcium homeostasis and induce lipid peroxidation&#44; membrane disintegration and deoxyribonucleic acid alterations &#8211; with apoptosis and cell necrosis as the end result&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Intestinal hypothesis&#58; The alterations in the structure and permeability of the intestinal mucosa play a key role as a source of bacterial products and antiinflammatory mediators that penetrate the systemic circulation and damage different organs&#46; Two basic factors may contribute to this phenomenon&#58; intestinal stasis allowing bacterial overgrowth&#44; and ischemia-reperfusion&#44; which increases intestinal permeability&#46; However&#44; the precise mechanisms involved have not been well established&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></li></ul></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinical manifestations and assessment scales</span><p id="par0090" class="elsevierStylePara elsevierViewall">As has been mentioned&#44; there is no uniform definition of post-trauma MOF&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However&#44; a number of scales have been developed for evaluating patient respiratory&#44; cardiovascular&#44; hepatic&#44; renal&#44; neurological and coagulation function&#46; The most widely used scales are summarized below&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Sequential-related Organ Failure Assessment &#40;SOFA&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The SOFA was developed in 1994 under the auspices of the European Society of Intensive Care Medicine as an objective tool for quantitatively assessing organ dysfunction or failure over time&#44; and thus also for evaluating patient response to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The SOFA scores 6 organs from 0 to 4 according to the degree of dysfunction in each of them &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Multiorgan failure is defined as the alteration of two or more organs with a score of &#8805;3&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Although the initial aim of the scale was to evaluate morbidity&#44; a good correlation has been observed between the maximum score obtained and mortality&#46; In this regard&#44; the mortality rate is over 90&#37; in those patients presenting a total score of over 15 &#40;with a specificity of almost 99&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Antonelli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> evaluated the SOFA in trauma patients and found non-survivors to have poorer respiratory&#44; cardiovascular and neurological scores&#44; particularly during the first 5 days of admission&#46; In this context&#44; neurological function is the most complicated dimension to evaluate in certain cases&#44; due to both the potential interferences of sedating drugs and the presence of traumatic brain injury&#46; The SOFA has recently been used by a German group in the largest series of trauma patients published to date&#44; with the assessment of MOF in 31&#44;154 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The authors recorded an incidence of MOF of 32&#37;&#44; which suggests that the SOFA may overestimate the incidence of post-trauma MOF&#46; The scale&#44; developed at European level&#44; is used in the Spanish national trauma registry &#40;RETRAUCI&#41; for assessing the incidence of MOF&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Denver scale</span><p id="par0105" class="elsevierStylePara elsevierViewall">In 1987&#44; the Denver group for the first time developed a scale for assessing MOF&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> This instrument evaluates four systems&#44; each of which are scored from 0 to 3 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Organ failure is defined by a score of over 0&#44; while MOF is defined as the failure of two or more organs&#44; with a total score of &#8805;4 as determined 48<span class="elsevierStyleHsp" style=""></span>h after trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> The Denver scale has been revised on several occasions since its introduction&#44; and some of the original parameters have received modifications&#8211;fundamentally in relation to the respiratory and cardiovascular dimensions&#46; The current version of the scale evaluates the parameters described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Marshall scale</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the 1990s&#44; Marshall et al&#46; presented a new scale for assessing MOF&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The authors evaluated 6 systems&#44; each of which were scored from 0 to 4 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The parameters are always recorded at the same time of day &#40;the first value in the morning&#41;&#46; The Marshall scale does not consider specific values as indicators of MOF as such&#59; rather&#44; it establishes degrees of severity defined by the observed mortality&#46; Thus&#44; no mortality is observed in patients with a score of 0&#44; while the mortality rate is 25&#37; in those with a score of 9&#8211;12&#59; 50&#37; in those with a score of 13&#8211;16&#59; 75&#37; in those with a score of 17&#8211;20&#59; and 100&#37; in the case of a score of over 20&#46; A good correlation is observed between the score and hospital stay&#46; In the same way as the SOFA&#44; the Marshall scale evaluates neurological status&#46; In this case&#44; a Glasgow coma score of 15 is assumed in sedated patients&#46; On the other hand&#44; because of the difficulty of defining the optimum parameter for assessing patient hemodynamics&#44; a new variable was introduced in the updated version of 1995&#58; the pressure adjusted heart rate &#40;PAR&#41;&#46; This variable is the ratio between the product of heart rate and central venous pressure&#44; and the mean blood pressure &#40;PAR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>HR<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>CVP&#47;MBP&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Some studies have compared the different scales described above&#46; A German study analyzing the performance of the Goris&#44; Marshall and Denver scales found the latter instrument to offer the best performance&#44; with a sensitivity of 81&#37; and a specificity of 88&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The authors highlighted that the Denver scale does not include more complex evaluations such as aspartate transaminase levels &#40;GOT&#41; or PAR&#44; which had a scant impact upon the calculations made&#46; Some years later&#44; the Denver group compared their scale with the Marshall scale in patients of their severe trauma database and excluding pure traumatic brain injury cases and patients with an extracranial Abbreviated Injury Score of under 2&#46; The receiver operator characteristic &#40;ROC&#41;-based analysis yielded similar results for both scales&#44; though the Denver scale had greater specificity and a greater capacity to evaluate patient response to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Different studies in turn have compared the SOFA with the Marshall scale&#44; though not in specific trauma patient groups&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A new scale has recently been developed&#58; the Denver Emergency Department Trauma Organ Failure Score &#40;Denver ED TOF Score&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> This is the first scale designed to allow early prediction &#40;within the first 4<span class="elsevierStyleHsp" style=""></span>h after trauma&#41; of the development of MOF in the first 7 days of admission&#46; The instrument includes pre-hospital variables and parameters collected during first care in the emergency room &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The score ranges from 0 to 9&#44; and an increased risk of MOF is associated to higher scores&#44; with excellent calibration and discrimination&#46; The Denver ED TOF Score could be useful not only in identifying patients in early stages of MOF but also as a screening tool for patient transfer to a reference center&#46; Its main limitation is lesser patient severity &#40;median Injury Severity Score &#91;ISS&#93; 9&#44; with an interquartile range of 4&#8211;16&#41;&#44; since it was developed from secondary analysis of a database not designed for this purpose&#44; and the lack of external validation&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Predictors of severe multiorgan failure after trauma</span><p id="par0125" class="elsevierStylePara elsevierViewall">Different parameters have been associated to an increased risk of developing MOF after trauma&#46; Those most frequently cited in the literature are commented below&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Age&#58; In recent years there has been an increase in the age of patients with trauma&#46; A number of studies have identified patient age as an independent risk factor for the development of MOF&#44; with the definition of different cutoff points&#8211;generally 55 or 65 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#44;26&#44;33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Gender&#58; Previous studies had not considered the male gender to be a risk factor for the development of post-trauma MOF&#46; However&#44; in the recent German registry&#44; the male gender &#40;73&#46;1&#37; of all patients&#41; was identified as a risk factor in the multivariate analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> This observation could be mediated by the existence of higher IL-6 levels in males following severe trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Severity of trauma&#58; The severity of trauma as assessed by the ISS has consistently been cited as a risk factor<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;26&#44;33</span></a>&#8211;the most widely used cutoff point being a score of 24&#46; However&#44; some authors believe that the ISS has lost usefulness as a predictor of MOF&#44; since it may underestimate severity in patients with several injuries in a given anatomical area&#46; In fact&#44; the ISS has been compared with the New Injury Severity Score &#40;NISS&#41; as a predictor of the development of MOF in a limited population of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> with the NISS being found to offer superior performance&#46; However&#44; while this new scale is attractive&#44; its use has not become widespread in the major trauma registries&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Traumatic brain injury&#58; Among the different body regions analyzed in the ISS&#44; a score for the head on the Abbreviated Injury Scale of &#8805;3 is related to an increased risk of developing MOF&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;34</span></a> in the same way as an initial Glasgow coma score of &#8804;8&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0150" class="elsevierStylePara elsevierViewall">Blood products&#58; It is well known that blood products contain abundant mediators that act as immune modulators&#46; As a result&#44; their use is associated to an increased incidence of nosocomial infections&#44; MOF and mortality&#46; Many studies have shown that the transfusion of more then 6 red cell concentrate units in the first hours is an independent risk factor for the development of MOF&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;26&#44;33</span></a> Moreover&#44; the age of the concentrates is also associated to an increased risk of MOF&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> The transfusion of fresh frozen plasma likewise constitutes a risk factor for the development of acute respiratory distress syndrome and MOF&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> though not so the transfusion of platelets&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">-</span></span><p id="par0155" class="elsevierStylePara elsevierViewall">Coagulation disorders and thrombocytopenia&#58; Coagulation disorders and platelet count are well known to play a prognostic role in relation to post-trauma MOF&#46; The platelet count in the first hours following admission has recently been established as an independent predictor of MOF using different cutoff points and times after trauma&#58; counts below 80&#44;000&#47;&#956;l to 150&#44;000&#47;&#956;l between admission and the first 24<span class="elsevierStyleHsp" style=""></span>h have been evaluated&#46; Furthermore&#44; those patients who continue to present low platelet counts after several days have a poorer prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Hemodynamic status and lactate&#58; The hemodynamic situation upon admission&#44; evaluated on the basis of shock parameters such as systolic blood pressure &#40;&#8804;90<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; and base deficit or lactate concentration have also been identified as risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;26</span></a> Not only the initial concentration is of prognostic importance in the case of lactate&#44; but also the time elapsed until the concentration normalizes &#40;assuming the levels do return to normal&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Other factors that have been proposed as possible predictors of the development of MOF are the minimum bilirubin levels or the peak creatinine concentrations in the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; Obesity might also play a role&#46; However&#44; the evidence supporting these factors is much more limited&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Treatment</span><p id="par0170" class="elsevierStylePara elsevierViewall">Although there is no specific treatment for MOF once it has become established&#44; the incidence of the disorder is considered to have decreased in recent years thanks to advances in the general management of critical trauma patients and the early correction of shock&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;6&#44;26</span></a> Considering the results recently published by the German group&#44; it seems less clear whether the associated mortality rate has also decreased in recent years&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Some strategies referred to the early management of these patients appear to contribute to avoid the development of MOF&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a> Such strategies include the following&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Cardiorespiratory support&#58; Initially&#44; the recommendations for the management of patients with traumatic shock focused on obtaining parameters indicative of supranormal oxygen transport&#46; However&#44; in recent years there have been changes in the general approach to the treatment of these patients&#44; oriented toward permissive hypotension and the correction of hypothermia&#44; coagulopathy and acidosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a> In this way the use of crystalloids is reduced and the incidence of abdominal compartmental syndrome&#44; MOF and death is lowered&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> It should be mentioned that the presence of traumatic brain injury obliges us to seek higher arterial pressure levels&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Damage control surgery and debridement of infected tissues&#58; The first concern is to control the bleeding&#44; avoiding prolonged interventions&#44; in an attempt to not worsen the acidosis and coagulopathy&#46; In addition&#44; this helps limit the release of inflammatory mediators in the acute phase&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Likewise&#44; the debridement of infectious foci&#44; with the removal of non-viable tissue&#44; the use of vacuum systems and second-step interventions contribute to reduce the infectious complications which play a very important role in late MOF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">Volume replacement and blood products&#58; This issue remains subject to controversy&#44; though the current tendency is to administer lesser crystalloid volumes&#46; Furthermore&#44; since it is known that the transfusion of blood products is significantly associated to the development of MOF&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;26&#44;33</span></a> a more restrictive approach is advised in order to avoid unnecessary transfusions&#46; However&#44; as has been mentioned&#44; this subject remains open to debate&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">Others&#58; Different treatment measures used in critical patients in general&#44; such as protective mechanical ventilation&#44; adequate nutritional support&#44; the management of hyperglycemia with insulin or adrenal gland replacement therapy&#44; while controversial in the general population of patients in the ICU&#44; could play a role in lowering the incidence of post-trauma MOF&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0195" class="elsevierStylePara elsevierViewall">To summarize&#44; post-trauma MOF remains an important cause of morbidity-mortality in severe trauma patients&#46; Because of the different definitions used&#44; the true incidence of MOF remains unclear&#46; The RETRAUCI registry&#44; auspiced by the Trauma and Neurointensive Care work group of the SEMICYUC&#44; will help define the incidence in our setting&#46; The prognosis of MOF has improved in recent years&#44; probably as a result of advances in the general management of critical trauma patients&#46; While certain non-modifiable factors such as age and comorbidities among trauma patients imply a poorer prognosis&#44; the application of uniform protocols referred to resuscitation&#44; damage control&#44; sedation and volume replacement appears to have mitigated their negative effects&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Definition"
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          "identificador" => "sec0015"
          "titulo" => "Epidemiological aspects"
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          "titulo" => "Physiopathology"
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              "titulo" => "Mediators"
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          "titulo" => "Clinical manifestations and assessment scales"
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              "titulo" => "Sequential-related Organ Failure Assessment &#40;SOFA&#41;"
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              "identificador" => "sec0045"
              "titulo" => "Denver scale"
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            2 => array:2 [
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              "titulo" => "Marshall scale"
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        9 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Predictors of severe multiorgan failure after trauma"
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          "titulo" => "Treatment"
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        11 => array:2 [
          "identificador" => "sec0065"
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    "fechaRecibido" => "2014-04-07"
    "fechaAceptado" => "2014-05-07"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Severe trauma"
            1 => "Multiorgan failure"
            2 => "Clinical scales"
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        0 => array:4 [
          "clase" => "keyword"
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            0 => "Trauma grave"
            1 => "Fallo multiorg&#225;nico"
            2 => "Escalas cl&#237;nicas"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Multiorgan failure remains one of the leading causes of late morbidity and mortality after severe trauma&#46; In the early phase&#44; it is related with an uncontrolled hyper-inflammation state&#44; whereas in the late phase &#40;&#62;72<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; septic complications play a major role&#46; We review the underlying pathophysiology&#44; the evaluation with different scales and the clinical factors associated with multiorgan failure&#44; as well as potential treatment options&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El fallo multiorg&#225;nico tras el trauma grave constituye una de las principales causas de morbimortalidad tard&#237;a en este grupo de pacientes&#46; En su fase precoz&#44; es consecuencia de un estado de hiperinflamaci&#243;n no controlado&#44; mientras que en su presentaci&#243;n tard&#237;a &#40;&#62;72<span class="elsevierStyleHsp" style=""></span>h&#41; se relaciona principalmente con las complicaciones infecciosas&#46; Se resumen los mecanismos fisiopatol&#243;gicos implicados en su desarrollo&#44; la valoraci&#243;n mediante diferentes escalas y los factores cl&#237;nicos asociados&#44; adem&#225;s de las potenciales opciones de tratamiento&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Llompart-Pou JA&#44; Talayero M&#44; Homar J&#44; Royo C&#44; grupo de trabajo de Trauma y Neurointensivismo de SEMICYUC&#46; Fallo multiorg&#225;nico en el paciente con trauma grave&#46; Med Intensiva&#46; 2014&#59;38&#58;455&#8211;462&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Summary of the physiopathology of multiorgan failure following severe trauma&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Glasgow&#58; Glasgow coma score&#59; MBP&#58; mean blood pressure&#59; CNS&#58; central nervous system&#46;</p>"
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                  \t\t\t\t">&#60;1&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;2&#8211;1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#8211;5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#8211;11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiovascular&#58; Hypotension &#40;&#956;g&#47;kg&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MBP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dopamine &#8804;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min or dobutamine &#40;any dose&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dopamine &#62;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min or adrenalin or noradrenalin &#8804;0&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dopamine &#62;15<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min or adrenalin or noradrenalin &#62;0&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CNS Glasgow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#8211;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#8211;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Renal&#58; Creatinine &#40;mg&#47;dl&#41; or diuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;1&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;2&#8211;1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#8211;3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;5&#8211;4&#46;9&#60;500<span class="elsevierStyleHsp" style=""></span>ml&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;5&#60;200<span class="elsevierStyleHsp" style=""></span>ml&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab565994.png"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SOFA scale&#46;</p>"
        ]
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        "etiqueta" => "Table 2"
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        "mostrarFloat" => true
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CI&#58; cardiac index&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Denver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Respiratory&#58; PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;250&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">250&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">199&#8211;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Renal&#58; Creatinine &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;9&#8211;2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;6&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liver&#58; Bilirubin &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;1&#8211;4&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;1&#8211;8&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiovascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No inotropic drugs and CI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A low-dose inotropic drug or CI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Any inotropic drug at moderate doses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Any inotropic drug at high doses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Denver scale&#46;</p>"
        ]
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      3 => array:7 [
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">HR&#58; heart rate&#59; Glasgow&#58; Glasgow coma score&#59; MBP&#58; mean blood pressure&#59; PAR&#58; pressure adjusted heart rate&#59; CVP&#58; central venous pressure&#59; CNS&#58; central nervous system&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PAR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>HR<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>CVP&#47;MBP&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Bilirubin conversion factor&#58; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;l&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Creatinine conversion factor&#58; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>88&#46;4<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;l&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Marshall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Respiratory&#58; PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">226&#8211;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">151&#8211;225&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#8211;150&nbsp;\t\t\t\t\t\t\n
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                        "paginaInicial" => "774"
                        "paginaFinal" => "779"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23425734"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Postinjury multiple organ failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46; Dewar"
                            1 => "F&#46;A&#46; Moore"
                            2 => "E&#46;E&#46; Moore"
                            3 => "Z&#46; Balogh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.injury.2009.05.024"
                      "Revista" => array:6 [
                        "tituloSerie" => "Injury"
                        "fecha" => "2009"
                        "volumen" => "40"
                        "paginaInicial" => "912"
                        "paginaFinal" => "918"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19541301"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current theories on the pathophysiology of multiple organ failure after trauma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46; Tsukamoto"
                            1 => "R&#46;S&#46; Chanthaphavong"
                            2 => "H&#46;C&#46; Pape"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.injury.2009.07.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Injury"
                        "fecha" => "2010"
                        "volumen" => "41"
                        "paginaInicial" => "21"
                        "paginaFinal" => "26"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19729158"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multiple system organ failure&#46; The role of uncontrolled infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46;E&#46; Fry"
                            1 => "L&#46; Pearlstein"
                            2 => "R&#46;L&#46; Fulton"
                            3 => "H&#46;C&#46; Polk Jr&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Surg"
                        "fecha" => "1980"
                        "volumen" => "115"
                        "paginaInicial" => "136"
                        "paginaFinal" => "140"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6965449"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Postinjury multiple organ failure&#58; a bimodal phenomenon"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46;A&#46; Moore"
                            1 => "A&#46; Sauaia"
                            2 => "E&#46;E&#46; Moore"
                            3 => "J&#46;B&#46; Haenel"
                            4 => "J&#46;M&#46; Burch"
                            5 => "D&#46;C&#46; Lezotte"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "1996"
                        "volumen" => "40"
                        "paginaInicial" => "501"
                        "paginaFinal" => "510"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8614027"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of the lung in postinjury multiple organ failure"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D&#46;J&#46; Ciesla"
                            1 => "E&#46;E&#46; Moore"
                            2 => "J&#46;L&#46; Johnson"
                            3 => "J&#46;M&#46; Burch"
                            4 => "C&#46;C&#46; Cothren"
                            5 => "A&#46; Sauaia"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.surg.2005.07.020"
                      "Revista" => array:6 [
                        "tituloSerie" => "Surgery"
                        "fecha" => "2005"
                        "volumen" => "138"
                        "paginaInicial" => "749"
                        "paginaFinal" => "757"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16269305"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cytokine levels &#40;IL-4&#44; IL-6 IL-8 and TGFb&#41; as potential biomarkers of systemic inflammatory response in trauma patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46; Volpin"
                            1 => "M&#46; Cohen"
                            2 => "M&#46; Assaf"
                            3 => "T&#46; Meir"
                            4 => "R&#46; Katz"
                            5 => "S&#46; Pollack"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00264-013-2261-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int Orthop"
                        "fecha" => "2014"
                        "volumen" => "38"
                        "paginaInicial" => "1303"
                        "paginaFinal" => "1309"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24402554"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Inflammatory responses and mediators"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46;K&#46; Kim"
                            1 => "C&#46;S&#46; Deutschman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Surg Clin North Am"
                        "fecha" => "2000"
                        "volumen" => "80"
                        "paginaInicial" => "885"
                        "paginaFinal" => "894"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10897267"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessment of the clinical course with inflammatory parameters"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "H&#46;C&#46; Pape"
                            1 => "T&#46; Tsukamoto"
                            2 => "P&#46; Kobbe"
                            3 => "I&#46; Tarkin"
                            4 => "S&#46; Katsoulis"
                            5 => "A&#46; Peitzman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.injury.2007.09.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "Injury"
                        "fecha" => "2007"
                        "volumen" => "38"
                        "paginaInicial" => "1358"
                        "paginaFinal" => "1364"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18048038"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Role of biological modifiers regulating the immune response after trauma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46;F&#46; Stahel"
                            1 => "W&#46;R&#46; Smith"
                            2 => "E&#46;E&#46; Moore"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.injury.2007.09.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "Injury"
                        "fecha" => "2007"
                        "volumen" => "38"
                        "paginaInicial" => "1409"
                        "paginaFinal" => "1422"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18048034"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Role of C5a in inflammatory responses"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;F&#46; Guo"
                            1 => "P&#46;A&#46; Ward"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1146/annurev.immunol.23.021704.115835"
                      "Revista" => array:6 [
                        "tituloSerie" => "Annu Rev Immunol"
                        "fecha" => "2005"
                        "volumen" => "23"
                        "paginaInicial" => "821"
                        "paginaFinal" => "852"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15771587"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Circulating complement proteins in multiple trauma patients &#8211; correlation with injury severity&#44; development of sepsis&#44; and outcome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46; Hecke"
                            1 => "U&#46; Schmidt"
                            2 => "A&#46; Kola"
                            3 => "W&#46; Bautsch"
                            4 => "A&#46; Klos"
                            5 => "J&#46; K&#246;hl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "1997"
                        "volumen" => "25"
                        "paginaInicial" => "2015"
                        "paginaFinal" => "2024"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9403752"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Inflammatory response to trauma&#58; Implications for coagulation and resuscitation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Pierce"
                            1 => "J&#46;F&#46; Pittet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ACO.0000000000000047"
                      "Revista" => array:7 [
                        "tituloSerie" => "Curr Opin Anaesthesiol"
                        "fecha" => "2014"
                        "volumen" => "27"
                        "paginaInicial" => "246"
                        "paginaFinal" => "252"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24419158"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0033833810002493"
                          "estado" => "S300"
                          "issn" => "00338338"
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                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The systemic inflammatory response induced by trauma is reflected by multiple phenotypes of blood neutrophils"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Pillay"
                            1 => "F&#46; Hietbrink"
                            2 => "L&#46; Koenderman"
                            3 => "L&#46;P&#46; Leenen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.injury.2007.09.016"
                      "Revista" => array:6 [
                        "tituloSerie" => "Injury"
                        "fecha" => "2007"
                        "volumen" => "38"
                        "paginaInicial" => "1365"
                        "paginaFinal" => "1372"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18061190"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Postinjury neutrophil priming and activation&#58; an early vulnerable window"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46;J&#46; Botha"
                            1 => "F&#46;A&#46; Moore"
                            2 => "E&#46;E&#46; Moore"
                            3 => "F&#46;J&#46; Kim"
                            4 => "A&#46; Banerjee"
                            5 => "V&#46;M&#46; Peterson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Surgery"
                        "fecha" => "1995"
                        "volumen" => "118"
                        "paginaInicial" => "358"
                        "paginaFinal" => "364"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7638753"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The two-event construct of postinjury multiple organ failure"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;E&#46; Moore"
                            1 => "F&#46;A&#46; Moore"
                            2 => "A&#46;H&#46; Harken"
                            3 => "J&#46;L&#46; Johnson"
                            4 => "D&#46; Ciesla"
                            5 => "A&#46; Banerjee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Shock"
                        "fecha" => "2005"
                        "volumen" => "24"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "71"
                        "paginaFinal" => "74"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16374376"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Application of heme oxygenase-1&#44; carbon monoxide and biliverdin for the prevention of intestinal ischemia&#47;reperfusion injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Nakao"
                            1 => "D&#46;J&#46; Kaczorowski"
                            2 => "R&#46; Sugimoto"
                            3 => "T&#46;R&#46; Billiar"
                            4 => "K&#46;R&#46; McCurry"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3164/jcbn.2008013"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Biochem Nutr"
                        "fecha" => "2008"
                        "volumen" => "42"
                        "paginaInicial" => "78"
                        "paginaFinal" => "88"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18385824"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pathophysiology of polytrauma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Keel"
                            1 => "O&#46; Trentz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.injury.2004.12.037"
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                        "tituloSerie" => "Injury"
                        "fecha" => "2005"
                        "volumen" => "36"
                        "paginaInicial" => "691"
                        "paginaFinal" => "709"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15910820"
                            "web" => "Medline"
                          ]
                        ]
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                          "pii" => "S0033833811001007"
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                          "issn" => "00338338"
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                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The SOFA &#40;sepsis-related organ failure assesment&#41; score to describe organ dysfunction&#47;failures&#46; On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;L&#46; Vincent"
                            1 => "R&#46; Moreno"
                            2 => "J&#46; Takala"
                            3 => "S&#46; Willats"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "1996"
                        "volumen" => "22"
                        "paginaInicial" => "707"
                        "paginaFinal" => "710"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8844239"
                            "web" => "Medline"
                          ]
                        ]
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                    ]
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                ]
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            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Use of the SOFA score to assess the incidence of organ dysfunction&#47;failure in intensive care units&#58; results of a multicenter&#44; prospective study&#46; Working group on &#171;sepsis-related problems&#187; of the European Society of Intensive Care Medicine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;L&#46; Vincent"
                            1 => "A&#46; de Mendon&#231;a"
                            2 => "F&#46; Cantraine"
                            3 => "R&#46; Moreno"
                            4 => "J&#46; Takala"
                            5 => "P&#46;M&#46; Suter"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "1998"
                        "volumen" => "26"
                        "paginaInicial" => "1793"
                        "paginaFinal" => "1800"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9824069"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0125"
              "etiqueta" => "25"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Application of SOFA score to trauma patients&#46; Sequential Organ Failure Assessment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Antonelli"
                            1 => "R&#46; Moreno"
                            2 => "J&#46;L&#46; Vincent"
                            3 => "C&#46;L&#46; Sprung"
                            4 => "A&#46; Mendo&#231;a"
                            5 => "M&#46; Passariello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "1999"
                        "volumen" => "25"
                        "paginaInicial" => "389"
                        "paginaFinal" => "394"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10342513"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology and risk factors of multiple-organ failure after multiple trauma&#58; An analysis of 31&#44;154 patients from the TraumaRegister DGU"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Committee on Emergency Medicine&#44; Intensive Care and Trauma Management of the German Trauma Society &#40;Sektion NIS&#41;"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Fr&#246;hlich"
                            1 => "R&#46; Lefering"
                            2 => "C&#46; Probst"
                            3 => "T&#46; Paffrath"
                            4 => "M&#46;M&#46; Schneider"
                            5 => "M&#46; Maegele"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TA.0000000000000199"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Trauma Acute Care Surg"
                        "fecha" => "2014"
                        "volumen" => "76"
                        "paginaInicial" => "921"
                        "paginaFinal" => "928"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24662853"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0735109709002289"
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                          "issn" => "07351097"
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                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Registros de trauma&#58; una prioridad sanitaria&#44; un proyecto estrat&#233;gico para la SEMICYUC"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Chico Fern&#225;ndez"
                            1 => "C&#46; Garc&#237;a Fuentes"
                            2 => "F&#46; Guerrero L&#243;pez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2013.01.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2013"
                        "volumen" => "37"
                        "paginaInicial" => "284"
                        "paginaFinal" => "289"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23507334"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gut bacterial translocation via the portal vein&#58; a clinical perspective with major torso trauma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46;A&#46; Moore"
                            1 => "E&#46;E&#46; Moore"
                            2 => "R&#46; Poggetti"
                            3 => "O&#46;J&#46; McAnena"
                            4 => "V&#46;M&#46; Peterson"
                            5 => "C&#46;M&#46; Abernathy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "1991"
                        "volumen" => "31"
                        "paginaInicial" => "629"
                        "paginaFinal" => "636"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2030509"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multiple organ dysfunction score&#58; a reliable descriptor of a complex clinical outcome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;C&#46; Marshall"
                            1 => "D&#46;J&#46; Cook"
                            2 => "N&#46;V&#46; Christou"
                            3 => "G&#46;R&#46; Bernard"
                            4 => "C&#46;L&#46; Sprung"
                            5 => "W&#46;J&#46; Sibbald"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "1995"
                        "volumen" => "23"
                        "paginaInicial" => "1638"
                        "paginaFinal" => "1652"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7587228"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0150"
              "etiqueta" => "30"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Scoring multiple organ failure after severe trauma&#46; Comparison of the Goris&#44; Marshall and Moore scores&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Grotz"
                            1 => "M&#46; von Griensven"
                            2 => "M&#46; Stalp"
                            3 => "U&#46; Kaufmann"
                            4 => "F&#46; Hildebrand"
                            5 => "H&#46;C&#46; Pape"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chirurg"
                        "fecha" => "2001"
                        "volumen" => "72"
                        "paginaInicial" => "723"
                        "paginaFinal" => "730"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11469095"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Validation of postinjury multiple organ failure scores"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Sauaia"
                            1 => "E&#46;E&#46; Moore"
                            2 => "J&#46;L&#46; Johnson"
                            3 => "D&#46;J&#46; Ciesla"
                            4 => "W&#46;L&#46; Biffl"
                            5 => "A&#46; Banerjee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/SHK.0b013e31818ba4c6"
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                        "tituloSerie" => "Shock"
                        "fecha" => "2009"
                        "volumen" => "31"
                        "paginaInicial" => "438"
                        "paginaFinal" => "447"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18838942"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0160"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prediction of postinjury multiple-organ failure in the emergency department&#58; development of the Denver Emergency Department Trauma Organ Failure score"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "M&#46;M&#46; Liao"
                            2 => "E&#46; Hopkins"
                            3 => "N&#46; Seleno"
                            4 => "R&#46;L&#46; Byyny"
                            5 => "E&#46;E&#46; Moore"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1097/TA.0b013e3182a99da4"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma Acute Care Surg"
                        "fecha" => "2014"
                        "volumen" => "76"
                        "paginaInicial" => "140"
                        "paginaFinal" => "145"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24368369"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
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            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Early predictors of morbidity and mortality in trauma patients treated in the intensive care unit"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                            3 => "A&#46; Oldner"
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                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1399-6576.2010.02266.x"
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                        "tituloSerie" => "Acta Anaesthesiol Scand"
                        "fecha" => "2010"
                        "volumen" => "54"
                        "paginaInicial" => "1007"
                        "paginaFinal" => "1017"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20626360"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Male gender is associated with excessive IL-6 expression following severe injury"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Inflammation and the host response to injury investigators"
                          "etal" => true
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                            1 => "R&#46;S&#46; Friese"
                            2 => "H&#46;L&#46; Frankel"
                            3 => "M&#46;A&#46; West"
                            4 => "J&#46; Cuschieri"
                            5 => "E&#46;E&#46; Moore"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                        "tituloSerie" => "J Trauma"
                        "fecha" => "2008"
                        "volumen" => "64"
                        "paginaInicial" => "572"
                        "paginaFinal" => "578"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18332795"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "NISS predicts postinjury multiple organ failure better than the ISS"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Z&#46; Balogh"
                            1 => "P&#46;J&#46; Offner"
                            2 => "E&#46;E&#46; Moore"
                            3 => "W&#46;L&#46; Biffl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "2000"
                        "volumen" => "48"
                        "paginaInicial" => "624"
                        "paginaFinal" => "627"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10780593"
                            "web" => "Medline"
                          ]
                        ]
                      ]
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                  ]
                ]
              ]
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              "identificador" => "bib0180"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Age of transfused blood is an independent risk factor for postinjury multiple organ failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Zallen"
                            1 => "P&#46;J&#46; Offner"
                            2 => "E&#46;E&#46; Moore"
                            3 => "J&#46; Blackwell"
                            4 => "D&#46;J&#46; Ciesla"
                            5 => "J&#46; Gabriel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Surg"
                        "fecha" => "1999"
                        "volumen" => "178"
                        "paginaInicial" => "570"
                        "paginaFinal" => "572"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10670874"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Inflammation and Host Response to Injury Investigators"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46;A&#46; Watson"
                            1 => "J&#46;L&#46; Sperry"
                            2 => "M&#46;R&#46; Rosengart"
                            3 => "J&#46;P&#46; Minei"
                            4 => "B&#46;G&#46; Harbrecht"
                            5 => "E&#46;E&#46; Moore"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TA.0b013e3181ad5957"
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                        "tituloSerie" => "J Trauma"
                        "fecha" => "2009"
                        "volumen" => "67"
                        "paginaInicial" => "221"
                        "paginaFinal" => "227"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19667872"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Refractory postinjury thrombocytopenia is associated with multiple organ failure and adverse outcomes"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46;L&#46; Nydam"
                            1 => "J&#46;L&#46; Kashuk"
                            2 => "E&#46;E&#46; Moore"
                            3 => "J&#46;L&#46; Johnson"
                            4 => "C&#46;C&#46; Burlew"
                            5 => "W&#46;L&#46; Biffl"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TA.0b013e31820b5c85"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "2011"
                        "volumen" => "70"
                        "paginaInicial" => "401"
                        "paginaFinal" => "406"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21307741"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Measurement of lactic acid in multiple injury patients and its usefulness as a predictor of multiorgan failure and mortality&#93;"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
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                            1 => "S&#46; Navarro Soto"
                            2 => "P&#46; Rebasa Cladera"
                            3 => "A&#46; Luna Aufroy"
                            4 => "C&#46; G&#243;mez D&#237;az"
                            5 => "H&#46; Llaquet Bayo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ciresp.2011.07.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cir Esp"
                        "fecha" => "2012"
                        "volumen" => "90"
                        "paginaInicial" => "107"
                        "paginaFinal" => "113"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22206654"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "What&#39;s new in resuscitation strategies for the patient with multiple trauma&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "N&#46; Curry"
                            1 => "P&#46;W&#46; Davis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.injury.2012.03.014"
                      "Revista" => array:7 [
                        "tituloSerie" => "Injury"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2014.05.002

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	23	17	40
2024 October	228	94	322
2024 September	206	68	274
2024 August	224	96	320
2024 July	178	63	241
2024 June	169	67	236
2024 May	242	49	291
2024 April	196	65	261
2024 March	189	60	249
2024 February	222	69	291
2024 January	189	45	234
2023 December	223	85	308
2023 November	266	75	341
2023 October	351	59	410
2023 September	203	55	258
2023 August	196	33	229
2023 July	193	38	231
2023 June	199	37	236
2023 May	225	46	271
2023 April	331	41	372
2023 March	356	51	407
2023 February	352	47	399
2023 January	324	35	359
2022 December	274	60	334
2022 November	249	50	299
2022 October	338	62	400
2022 September	322	51	373
2022 August	240	66	306
2022 July	193	47	240
2022 June	279	62	341
2022 May	314	92	406
2022 April	222	56	278
2022 March	241	49	290
2022 February	246	62	308
2022 January	329	56	385
2021 December	240	84	324
2021 November	300	96	396
2021 October	391	90	481
2021 September	206	66	272
2021 August	247	83	330
2021 July	205	81	286
2021 June	348	61	409
2021 May	359	97	456
2021 April	770	135	905
2021 March	529	58	587
2021 February	360	39	399
2021 January	451	55	506
2020 December	369	33	402
2020 November	324	57	381
2020 October	171	52	223
2020 September	245	42	287
2020 August	187	36	223
2020 July	216	29	245
2020 June	210	36	246
2020 May	208	44	252
2020 April	298	42	340
2020 March	224	21	245
2020 February	504	78	582
2020 January	360	51	411
2019 December	361	39	400
2019 November	575	60	635
2019 October	556	61	617
2019 September	307	40	347
2019 August	256	45	301
2019 July	248	48	296
2019 June	226	38	264
2019 May	268	50	318
2019 April	196	40	236
2019 March	199	47	246
2019 February	166	51	217
2019 January	213	49	262
2018 December	221	52	273
2018 November	389	87	476
2018 October	219	35	254
2018 September	115	12	127
2018 August	85	11	96
2018 July	48	5	53
2018 June	35	8	43
2018 May	23	3	26
2018 April	49	15	64
2018 March	33	10	43
2018 February	35	6	41
2018 January	54	9	63
2017 December	40	8	48
2017 November	52	8	60
2017 October	76	6	82
2017 September	52	10	62
2017 August	47	7	54
2017 July	38	7	45
2017 June	39	19	58
2017 May	39	9	48
2017 April	47	15	62
2017 March	44	5	49
2017 February	45	3	48
2017 January	24	4	28
2016 December	60	11	71
2016 November	78	27	105
2016 October	77	32	109
2016 September	87	13	100
2016 August	41	6	47
2016 July	24	10	34

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