Trauma remains the leading cause of mortality and disability in individuals younger than 35 years,1–4 with a significant increase in those above 65 years.5,6 Globally, there are epidemiological and clinical differences between blunt and penetrating trauma depending on the social context.1,7–9 However, these differences are not welldefined in our setting.

To date, we have limited data on penetrating trauma in Spain, obtained from local retrospective registries10 and hospital records (using ICD-9-MC coding).11,12

An initial snapshot of data, obtained through RETRAUCI, can help provide more information about the epidemiology, clinical characteristics of penetrating trauma, its contributing factors, and its differences vs blunt trauma. Additionally, understanding the epidemiology of penetrating trauma and its impact can help establish potential lines of action and prevention according to the ecological model established by the World Health Organization.13

Therefore, the primary endpoint of this study is to describe the epidemiology of penetrating trauma, the factors associated with mortality, and its management in Spanish intensive care units (ICUs). Secondary endpoints include resource utilization analysis, clinical outcomes (organ support in ICUs), while comparing these with a cohort of patients with blunt trauma.

RETRAUCI is an observational, prospective, and multicenter registry sponsored by the Neurointensivism and Trauma Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Currently, it includes 61 national hospitals with the collaboration of 198 investigators who enter updated data on traumatic disease on the platform http://www.retrauci.org. It has been approved by Hospital Universitario 12 de Octubre Ethics Committee (registration code 12/209).

This study analyzes a cohort of patients with severe traumatic injury from June 2015 through June 2022. Data on trauma epidemiology, severity indices, prehospital management, resource utilization, and clinical outcomes have been recorded. Follow-up is conducted until hospital discharge.

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for observational studies has been used.14

Two patient cohorts are established based on the variable "type of trauma": blunt trauma and penetrating trauma, designated by the investigator coding the patient in the registry based on the predominant mechanism. Three categories of penetrating trauma are established based on the mechanism of action: penetrating trauma by sharp weapon, firearm, and other.

Data obtained from the Revised Trauma Score (RTS) are based on physiological variables from the first medical attention. The Injury Severity Score (ISS) is calculated prospectively by intensivists based on the 2008 update of the Abbreviated Injury Scale (AIS). The New Injury Severity Score (NISS) is the modification of the ISS, which consists of the sum of the squares of the 3 most severe injuries, regardless of the body region injured. Its calculation is performed prospectively based on the coded injury pattern. The probability of survival is calculated using Trauma and Injury Severity Score (TRISS) methodology. Expected mortality is the result of the sum of individual probabilities. Hemodynamic stability is considered when systolic blood pressure is >90 mmHg during initial care. If systolic blood pressure is <90 mmHg but requires only volume administration to recover, the patient is considered unstable yet responsive to volume. Shock is defined as the presentation of blood pressure <90 mmHg requiring only the administration of volume and vasopressor support to normalize. Refractory shock is defined as hypotension refractory to volume administration, vasopressor support, and activation of the massive hemorrhage protocol during initial care. Coagulopathy is defined as prolongation of prothrombin and activated partial thromboplastin times to >1.5 times the control, fibrinogen <150 mg/dL, or thrombocytopenia (<100,000/mcl) in the determination within the first 24 h after admission. Massive transfusion is defined as the need to activate the massive hemorrhage protocol by the clinician. Multiple organ dysfunction syndrome (MODS) is defined as the involvement of ≥2 organs with a score ≥3 on the Sequential Organ Failure Assessment (SOFA) scale.

Quantitative variables are expressed as mean ± standard deviation (SD) or as median with interquartile range (IQR) based on their distribution. Categorial variables are expressed as absolute values (percentages). Categorical variables were analyzed using the chi-square test or Fisher's exact test. The normality of continuous data was assessed using the Shapiro-Wilk test. For the evaluation of variables showing a non-normal distribution, the non-parametric Wilcoxon Mann–Whitney test was used. For the analysis of causes of mortality and predictive factors, patients managed as intensive care to facilitate organ donation were excluded. Logistic regression was used to determine risk factors for ICU mortality. In the maximum model, variables were included based on their significance (p < 0.05) and clinical relevance. The variables shock (shock and refractory shock), presence of TBI (MAIS head ≥ 3), and prior anticoagulant/antiplatelet use were dichotomized for analysis based on their absence or presence. p values < 0.05 were considered statistically significant. All statistical analyses were performed using RStudio version 2023.3.1. For the design of the figures, the BioRender® tool with a publication license was used.

During the study period, 12,833 patients were included in RETRAUCI, 12,806 of whom were eligible. 821 (6.4%) suffered penetrating trauma. 418 of these traumas (50.9%) were due to bladed weapons, 93 (11.3%) to firearms, and 310 (37.8%) to other penetrating objects (Fig. 1). The rate of penetrating trauma is significant, although blunt trauma still accounts for more than 90% of all patients with traumatic injury admitted to participaiting ICUs.

Figure 1.

Identification of the cohort.

Table 1 describes the study population and compares the variables of interest with blunt trauma. Broken down by age intervals, a higher rate of trauma by both mechanisms was observed in the 45–55 age group, although penetrating trauma was more incident at younger ages (23.6% vs 12.9% in patients aged 16–25 and 22.4% vs 13.8% in patients aged 26–35). The most common cause of injury was assault (47.7%) vs blunt trauma, which was accidental.

The mean ISS was 15.2 ± 10.6 in penetrating trauma and 19.8 ± 11.9 in blunt trauma (p < 0.001). Based on the AIS classification, the most frequently affected body areas in penetrating trauma were 33.5% in the chest and 23% in the abdomen, accounting for 56.3% of injuries with AIS ≥3 in the torso. Other affected areas were extremities (22.5%), head and neck (18.3%), and face (3.7%). In contrast, the body areas most frequently injured in blunt trauma were head and neck (45.9%) and chest (39.2%), followed by extremities (20.1%) and abdomen (14.1%) (Fig. 2).

Figure 2.

Lesion pattern (percentage of patients with AIS lesion ≥3) in patients with blunt (n = 11,985) and penetrating trauma (n = 821) according to RETRAUCI.

The chances of survival calculated using TRISS methodology was 84.2 ± 27.6 in penetrating trauma and 81.3 ± 26.9 in blunt trauma (p = 0.003). The observed ICU mortality in the sample was 7.8% vs. 11.7% in blunt trauma. Regarding the timeframe distribution of death, blunt trauma tends to have a trimodal distribution (39% within the first 24 h, 36% within the first week, and 25% after day 7) vs. penetrating trauma, where death within the first 24 h remains more frequent (64% vs. 39% in blunt trauma) (Fig. 3).

Figure 3.

Time distribution of mortality by type of trauma.

The main cause of death in penetrating trauma was intracranial hypertension (42.1% vs. 19.3% in blunt trauma). After excluding patients admitted for intensive care to facilitate organ donation, the distribution of causes of mortality in penetrating trauma was exsanguinating hemorrhage (28.2%), intracranial hypertension (17.9%), and multiple organ dysfunction (17.9%) (p = 0.278) (Supplementary data 1 and 2).

In the multivariate analysis, independent factors associated with mortality in penetrating trauma were female sex, prior antithrombotic use, age, higher NISS score, and the presence of traumatic brain injury or shock (Table 2).

This study provides an initial description of the characteristics of penetrating trauma in Spain. Although blunt trauma remains prevails in our setting, penetrating trauma is a condition with significant prevalence in Spain. Most European registries report incidence rates of penetrating trauma of around 4% or less (including patients with penetrating trauma regardless of ICU admission). In relation to these figures, and, in light of the presented results, Spain could be among the European countries with the highest rates of severe penetrating trauma15–17 (Fig. 4). However, worldwide, South Africa and the United States are the countries with the highest incidence rate of recorded penetrating trauma at 23%.18–20

Figure 4.

Comparison of the overall incidence rate of penetrating trauma. Figures expressed as percentages based on national records (15–20).

The incidence rate of this type of trauma has historically been associated with the percentage of interpersonal violence underlying social inequalities.21,22 Additionally, in times of crisis, the increase in inequalities and, consequently, violence, is more evident. This social context is also reflected in the epidemiology of trauma in our setting, transcending the hospitalization episode and becoming a chronic and recurrent disease, with higher chronic mortality.3,22,23 Although the most common cause for injury is assault, the percentage of patients who suffer penetrating trauma with suicidal ideation is worth highlighting. In the subgroup of patients older than 65 years who die from a firearm wound, 100% do so with suicidal ideation. This trend is evident in other European registries published in the literature.24,25

Considering the presented results, penetrating trauma entails a higher use of advanced prehospital resources, as well as greater utilization of hospital resources such as blood products, with higher percentages of massive hemorrhage protocol activation vs blunt trauma. In our setting, the need for surgery within the first 24 h, being more than double that of blunt trauma, stands out. These data are similar to those coming from other European registries, even with lower overall mortality rates.15,16

Patients with penetrating trauma predominantly die within the first 24 h, with the most frequent cause in our series being intracranial hypertension (42.1% vs. 19.3%). These data contrast with those presented in the literature, where the main cause of death is exsanguinating hemorrhage.24–26 However, when conducting an adjusted analysis of the causes of mortality, excluding patients admitted for intensive care to facilitate organ donation, it was observed that the predominant cause of death in penetrating trauma was exsanguinating hemorrhage, followed by a non-negligible percentage of patients who die from intracranial hypertension. The presence of variables that could influence this outcome, such as secondary brain injury, traumatic arrest, or cervical vascular involvement, are not recorded in the registry. Regarding the expected mortality in penetrating trauma calculated by the TRISS methodology (15.8%), the observed mortality is less than half (ICU mortality rate: 7.8%).

Most factors associated with higher mortality in penetrating trauma also reflect its severity (higher NISS score, presence of shock, traumatic brain injury, and elder population under antiplatelet or anticoagulation therapy). Although the most common injury pattern in penetrating trauma is torso involvement (with implication of 1 or 2 cavities), the presence of TBI is independently associated with higher mortality rates. Of note, mortality rate is higher in women (OR, 3.8; 95%CI, 1.38–10.44). A gender-adjusted deeper analysis on aspects related to injury pattern, age, cause of injury, and other social determinants is required. The presence of gender-based violence is a variable that is not usually identified in major trauma registries (only a comparable variable is found in the Victorian State Trauma Registry (VSTORM)27–31 and can help put the problem into perspective.

The 2021 Delphi Consensus on the definition of severe trauma defined it as "a traumatic event that results in fatal damage or significant damage with high physiological impact and requires a high level of intervention".32 The higher resource consumption and associated mortality of penetrating trauma, mainly within the first 24 h, involves a greater need for trauma intervention, which in turn defines the complexity and severity of this disease.33

This study provides a global perspective of penetrating trauma in Spain; however, it has limitations, such as being a retrospective analysis of a national registry. Although it has a high implementation rate across the country, its voluntary participation and the inclusion only of patients requiring ICU admission are limitations for data collection. Similarly, patients who die during prehospital care are excluded. The percentage of patients with mixed trauma could influence the evaluation of clinical variables, so it is necessary to redefine the "mechanism" variable when including patients in the registry (16% are included in the "other mechanisms" category).

Clinical outcomes depend on multiple factors within the care chain, from prehospital care to hospital arrival and subsequent ICU admission, the analysis of which exceeds the objective of this study and requires a deeper process perspective. In Spain, trauma care is not homogeneous. The trauma code is not present in all regions, with variable prehospital care and transfer times depending on geographical dispersion, as well as variable care upon hospital arrival.34

Being a low-prevalence condition in our setting, but associated with high complexity and impact on patients, it is necessary to focus on homogeneous action protocols and clinical practice guidelines, as well as on the training of involved personnel. Traumatic injury is the disease associated with the greatest decrement in quality of life in the critical patient population,35 which is why its mid- and long-term evaluation and rate of recurrence should be endpoints of future studies. Similarly, a systemic vision is necessary to address both violence and inequalities.

The average rate of penetrating trauma requiring ICU admission in Spain is 6.4%. One in two patients is unstable, requiring higher consumption of prehospital and hospital resources with greater transfusion of blood components. The ICU mortality rate in our series is < 8%, predominantly within the first 24 h. Given the significant prevalence of penetrating trauma in Spain, it is necessary to emphasize the importance of recording related data and analyzing the process, also focusing on the training of personnel involved in the care of these patients and the search for possible preventive activities.

• 1

  Judit Gutiérrez-Gutiérrez: Study design, data collection, drafting of the first and final draft, approved the final version.

• 2

  Jesús Abelardo Barea-Mendoza: Study design, data collection, statistical analysis, critical review, approved the final version.

• 3

  Carlos García-Fuentes: Data collection, approved the final version.

• 4

  Juan Antonio Llompart-Pou and Mario Chico-Fernández: Data collection, critical review, approved the final version.

• 5

  Begoña Guardiola-Grau, Mikel Durán-Suquía, María Ángeles Ballesteros-Sanz, Javier González-Robledo, Lluís Serviá-Goixart, Cristina Méndez-Benegassi Cid, and Jose Maria Toboso Casado: Data collection, approved the final version.

None declared.