Pediatric hepatic trauma: does clinical course support intensive care unit stay?

PURPOSE: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. METHODS: A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. RESULTS: Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. CONCLUSIONS: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.     

Longitudinal surveillance of chloroquine resistance of Plasmodium falciparum after cessation of medication in south Yunnan

Despite several large studies, the scoop and run versus field stabilization debate in prehospital trauma care continues. It is unlikely that all trauma patients are best treated by either field stabilization or scoop and run and the most effective form of prehospital care may be dependent upon the type of injuries sustained. Studies suggest that penetrating trauma involving major vascular injury may be best treated by scoop and run since advanced life support (ALS) measures serve only to delay time to definitive surgical treatment. Conversely, patients with head injuries may benefit from rapid ALS performed on scene in order to control airway and breathing problems, and reduce intracranial pressure prior to transport. Between these two groups of patients lie those with blunt trauma in whom scoop and run may be most appropriate if there is major vascular damage or those in whom field stabilization may offer the patient a greater chance of survival if blood loss is not a life-threatening problem.     

Three phenylethanoid glycosides and an iridoid glycoside from Picrorhiza scrophulariiflora

To identify risk factors associated with death in traumatized children, we prospectively studied 507 consecutive patients (7+/-4 yr) admitted to a level I pediatric trauma center over a 3-yr period. Pediatric Trauma Score (PTS), Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS) were calculated. Age, injury mechanism, injury pattern, and initial critical care were recorded. Univariate and multivariate analyses were performed for potential risk factors associated with mortality. Receiver operating characteristic curves were used to determine threshold values of variables identified by univariate analysis. Most children suffered from blunt trauma (99.6%), and head trauma was noted in 85%. Median values (range) of GCS scores, PTS, and ISS were 10 (3-15), 7 (-4 to 12), and 16 (3-75), respectively. The mortality rate was 12%. Using multivariate analysis, death was significantly associated with an ISS > or = 25 (odds ratio [OR] 22.2, 95% confidence interval 2.8-174.9), GCS score < or = 7 (OR 4.77, 1.8-12.7), emergency blood transfusion > or = 20 mL/kg (OR 4.3, 2.1-9.1), and PTS < or = 4 (OR 3.7, 1.4-9.7). An ISS > or = 25, GCS score < or = 7, immediate blood transfusion > or = 20 mL/kg, and PTS < or = 4 were significant and independent risk factors of death in an homogenous population of severely injured children. The probability of traumatic death was therefore 0 (95% confidence interval 0-0.0135) in children with no one of these threshold values in the four predictive factors and 0.63 (95% confidence interval 0.47-0.76) in those children with all the threshold values. IMPLICATIONS: Methods used for evaluating outcome of trauma patients have essentially been derived from adult series, and attempts to apply them to children have usually been inaccurate. Univariate and multivariate analyses were performed to identify risk factors associated with death in severely traumatized children, and Receiver operating characteristic curves were used to determine threshold values.     

Management of blunt liver trauma in children

INTRODUCTION: Management of liver trauma in childhood represents a rare but formidable challenge. METHODS: Clinical presentation, grade of liver injury and Injury Severity Score (ISS) were studied in 11 cases of blunt liver trauma to examine factors influencing outcome. RESULTS: Seven of the 11 children were injured severely and had an ISS greater than 16. Seven who were haemodynamically stable were treated without operation, but four required surgery for grade III, IV and V liver injuries. Two children had primary repair of hepatic lacerations. Perihepatic packing was employed in two other cases (grade IV and V injury) for uncontrollable haemorrhage. Delayed debridement and thrombectomy plus vena cava repair with suturing of liver lacerations in these patients obviated heroic efforts at primary repair. Nine children survived. There were two deaths from head and neck trauma. DISCUSSION: Selected children with liver trauma can be managed non-operatively using established trauma guidelines. Perihepatic packing is recommended in unstable patients with complex injuries, followed by delayed definitive repair.     

Driveway crush injuries in young children: a highly lethal, devastating, and potentially preventable event

BACKGROUND/PURPOSE: The aim of this study was to investigate driveway-related injuries in children, identify associated risk factors, and evaluate outcome compared with other mechanisms of blunt trauma. METHODS: A 6-year review (1991 to 1996) of pediatric (age less than 18 years) pedestrian injuries treated at two urban trauma centers was conducted: one regional pediatric trauma center and one level I trauma center with pediatric commitment. Five hundred twenty-seven children injured in pedestrian accidents were identified from the trauma registry; 51 children (10%) sustained traumatic injuries as a result of being struck in their driveway. Data are reported as mean +/- SEM. RESULTS: Children less than 5 years of age (n = 41) had an injury severity score (ISS) of 12.3+/-2.3, 15 (37%) sustained closed head injury, 13 (37%) had torso trauma, 19 (46%) skeletal trauma, and eight (20%) died. Children > or = 5 years old (n = 10) had an ISS of 10.7+/-2.4, three (30%) sustained closed head injury, four (40%) torso trauma, six (60%) skeletal trauma, and none died. In contrast, all other pediatric pedestrian accidents analyzed over the same time period had a mortality rate of only 2% (11 of 476). CONCLUSIONS: Pediatric driveway trauma carries a significant risk of head injury and a 10-fold increase in mortality in children under 5 years of age when compared with all other pediatric pedestrian accidents. More emphasis must be placed on injury prevention and public education to prevent this devastating mechanism of injury in these young, vulnerable children.     

Basic life support versus advanced life support for injured patients with an injury severity score of 10 or more

To study the value of advanced life support (ALS) compared with basic life support (BLS) for penetrating and motor vehicle crash (MVC) patients, data were collected from eight hospitals over 24 months on 781 consecutive patients with Injury Severity Scores > or = 10 as well as on a subset of 219 hypotensive patients. Initial prehospital Revised Trauma Scores (RTSs) were compared with initial emergency department RTSs. Scene times, total prehospital times, and the use of a pneumatic antishock garment (PASG), intravenous fluids, and endotracheal intubation were also documented. A modified TRISS method was used to compare mortality rates. The MVC ALS patients showed improvement in mean RTSs between prehospital and the emergency department while MVC BLS patients did not. Mean changes in blood pressure (BP) and the percentage of patients with improved BP were significantly higher among patients who received ALS; ALS was associated with increased use of PASGs and IV fluids. There were no differences between groups with respect to observed versus predicted mortality. Similar results were found in the hypotensive subset of patients. No benefit from the use of ALS for trauma patients with total prehospital times of less than 35 minutes was documented.     

Review of liver trauma management in Tasmania: an analysis of risk factors for mortality and morbidity

A review of liver trauma treated by the major trauma care facilities of Tasmania in the 5 year period between 1989 and 1993 is presented. The aim of this retrospective review was to provide an audit of the management of liver trauma in the island of Tasmania and to analyse the risk factors contributing to mortality and major morbidity. Thirty-seven patients were treated with a median Injury Severity Score (ISS) of 14 (range 9-34). The overall mortality rate of this series was 5.8%. Age, mechanism of injury (blunt or penetrating), delay prior to hospital presentation and modality of treatment (operative or non-operative) were not significant risk factors for mortality and morbidity; however, transfusion requirement of over 10 units of blood (P < 0.005), ISS score of over 20 (P < 0.0005), haemodynamic instability at presentation (P < 0.05) and a Hepatic Injury Score (HIS) grade of 3 or more (P < 0.05) were statistically significant risk factors.     

Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma

A recent retrospective analysis of femur fractures concluded that early surgical fixation in patients who have sustained blunt thoracic trauma (AIS score for Thorax > or = 2) was a risk factor for postoperative pulmonary failure. We conducted a review of all femur fractures admitted to a level I trauma center from November, 1988 to May, 1993. Inclusion criteria were ISS > or = 18, mid-shaft femur fractures treated with reamed intramedullary fixation, and no mortalities secondary to head trauma or hemorrhagic shock. One hundred thirty-eight patients met these criteria. Four patient groups were created: N1--no thoracic trauma (AIS score for thorax < 2), and early surgical fixation (< 24 hours after injury, n = 49); N2--no thoracic trauma and delayed fixation (> or = 24 hours, n = 8); T1--thoracic trauma (AIS score for Thorax > or = 2) and early fixation (n = 56); T2--thoracic trauma and delayed fixation (n = 25). There were no significant differences in age, Injury Severity Score, or Glasgow Coma Scale score between the four groups. Mortality rate, length of stay (LOS), LOS in the TICU, and duration of mechanical ventilation tended to be greater in patients with delayed fracture fixation, however, this was not statistically significant. The N2 patients had a pneumonia rate of 38% compared with 10% in group N1 (p = 0.07). The T2 patients had a pneumonia rate of 48% compared with 14% in group T1 (p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)     

Regional audit of pedestrian accident care

In all, 160 serious pedestrian accidents (ISS > 15 or death), were recorded during a 12-month prospective study of all trauma in a population of 3.2 million. Of these, 35 died at scene, 125 arrived at hospital alive and 68 (54 per cent) subsequently died. There were 35 (22 per cent) children, and 62 per cent (39) were more than 60 years of age. Prehospital care significantly delayed transfer to hospital. In the accident and emergency department, only 38 per cent of those unconscious had a cervical collar applied, and only 67 per cent were intubated. Of those transferred for neurosurgical care, 34 per cent were not intubated. The Median Injury Severity Score for each outcome group was similar between age groups. The Revised Trauma Score and APACHE II score showed significant differences between those who lived and died. TRISS analysis revealed that 32 per cent of deaths and 12 per cent of survivors were unexpected. ATLS treatment protocols should be instituted for prehospital care and in all accident and emergency departments (A&E).     

Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development

BACKGROUND: Whereas organized trauma care systems have decreased trauma mortality in the United States, trauma system design has not been well addressed in developing nations. We sought to determine areas in greatest need of improvement in the trauma systems of developing nations. METHODS: We compared outcome of all seriously injured (Injury Severity Score > or = 9 or dead), nontransferred, adults managed over 1 year in three cities in nations at different economic levels: (1) Kumasi, Ghana: low income, gross national product (GNP) per capita of $310, no emergency medical service (EMS); (2) Monterrey, Mexico: middle income, GNP $3,900, basic EMS; and (3) Seattle, Washington: high income, GNP $25,000, advanced EMS. Each city had one main trauma hospital, from which hospital data were obtained. Annual budgets (in US$) per bed for these hospitals were as follows: Kumasi, $4,100; Monterrey, $68,000; and Seattle, $606,000. Data on prehospital deaths were obtained from vital statistics registries in Monterrey and Seattle, and by an epidemiologic survey in Kumasi. RESULTS: Mean age (34 years) and injury mechanisms (79% blunt) were similar in all locations. Mortality declined with increased economic level: Kumasi (63% of all seriously injured persons died), Monterrey (55%), and Seattle (35%). This decline was primarily due to decreases in prehospital deaths. In Kumasi, 51% of all seriously injured persons died in the field; in Monterrey, 40%; and in Seattle, 21%. Mean prehospital time declined progressively: Kumasi (102 +/- 126 minutes) > Monterrey (73 +/- 38 minutes) > Seattle (31 +/- 10 minutes). Percent of trauma patients dying in the emergency room was higher for Monterrey (11%) than for either Kumasi (3%) or Seattle (6%). CONCLUSIONS: The majority of deaths occur in the prehospital setting, indicating the importance of injury prevention in nations at all economic levels. Additional efforts for trauma care improvement in both low-income and middle-income developing nations should focus on prehospital and emergency room care. Improved emergency room care is especially important in middle-income nations which have already established a basic EMS.     

Acute and long-term outcomes of extremely injured blunt trauma victims

Long-term outcomes after blunt trauma remain poorly defined. The purpose of this study was to document such outcomes in extremely injured adults (Injury Severity Score > or = 50). From April 1990 to June 1993, 76 patients (5% of all trauma victims) had an ISS > or = 50 at a single trauma center. Thirty-five (46%) survived to hospital discharge. The mean duration of hospital stay was longer for survivors than for nonsurvivors (92 days versus 16 days, p < 0.001). Of the 35 survivors, 26% were discharged directly home, 60% to a rehabilitation hospital, 8% to a chronic care facility, and 6% to an acute care hospital. After a mean follow-up of 27 months, 6% had died, 9% refused participation, and the remaining 30 patients (91% of long-term survivors) demonstrated significant residual disabilities in physical, emotional, and mental health status. We suggest that extremely injured patients comprise a small proportion of blunt trauma victims, consume substantial acute care hospital resources, often survive, and yet frequently have residual disability. A reduction in this long-term disability may represent the greatest challenge in modern trauma care.     

Results of treatment of multiple trauma in 130 children

Trauma remains the leading cause of death in the pediatric age group, despite recent advances in prevention and treatment. We retrospectively analyzed 130 cases of multiple trauma among 725 pediatric patients with injuries treated here during 1988-1989. Road accidents and falls from heights were the most common causes of injury. Mean age was 7 years (range 0.5-15) and the male to female ratio 2.7:1.0. Overall mortality was 9.2%. 57 patients (44%) did not get any prehospital medical care and 5 of them with injury severity scores (ISS) greater than 25 died. In contrast 11/18 (61%) of patients with ISS greater than 25 who were treated by medical teams survived. On arrival at the emergency room, 15% were hypothermic ( < 34 degrees C), and 6 were in hypovolemic shock--5 of whom died. Most common injuries were head trauma (91), limb injuries (69), abdominal trauma (34) and thoracic trauma (34). In 39 injury was severe, with pediatric trauma score (PTS) 6 or less, 12 of whom died. All deaths except 1 were associated with severe head injury and with ISS more than 25. There was no mortality in those with PTS more than 7 or ISS less than 25. Thus, the prehospital care of pediatric patients with head injury is associated with high mortality. Absence of mortality in patients with PTS of more than 7 emphasizes the importance of designated trauma centers for these patients.     

Epidemiology of immediate and early trauma deaths at an urban Level I trauma center

The objective of this study is to identify and differentiate the injury patterns and causes of death among patients who died within the 1st hour and those in the period between 1 and 48 hours after hospital admission. Information was collected from the 1994 to 1996 trauma data base at an urban Level I trauma center. The records of 155 trauma patients who died within the 1st hour (immediate trauma death, ITD) and between 1 and 48 hours (early trauma death, ETD) were examined retrospectively. Total and constituent Injury Severity Score (ISS), Trauma Score (TS), and Glasgow Coma Score were analyzed. ITDs constituted 49 per cent of all deaths within 48 hours. Blunt mechanisms accounted for 37 per cent of ITDs and 40 per cent of ETDs (not significant), whereas penetrating trauma accounted for 59 per cent of ITDs and 56 per cent of ETDs (not significant). Exsanguination most commonly caused death among ITDs (54%) and head injury (51%) among ETDs (P < 0.01). Patients who died within the 1st hour had higher ISS (42.6 +/- 23.2, P < 0.03), lower TS (1.7 +/- 1.9, P < 0.0001), and lower Glasgow Coma Score (3.1 +/- 1.1, P < 0.0001) than those who died after the 1st hour. Patients with ITD had a significantly worse chest ISS than those with ETD (47.4 +/- 28.6 vs 19.0 +/- 19.1, P < 0.0001). We conclude that 1) ITD is caused primarily by exsanguination, whereas ETD is largely due to the sequelae of severe neurologic injury; 2) ITD has a significantly lower TS and higher ISS than ETD; and 3) thoracic injuries are more severe among patients with ITDs than among those with ETDs. The severity of thoracic injury among ITDs suggests that rapid surgical intervention is critical during the resuscitation of these severely injured patients.     

Modeling injury outcomes using time-to-event methods

BACKGROUND: Mortality is an important measurement of injury outcomes, but measurements reflecting disability or cost are also important. Hospital length of stay (LOS) has been used as an outcome variable, but reduced LOS could be achieved either by improved care or by increased mortality. A solution to this statistical problem of "competing risks" would enable injury outcomes based on LOS to be modeled using time-to-event methods. METHODS: Time-to-event methodology was applied to 2,106 cases with complete data from the 1991-1994 registry of a regional trauma center. LOS was used as the outcome variable, modified by assigning an arbitrarily long LOS to any fatal case. A combination of proportional hazards and logistic regression models was used to explore the effects of potential predictive variables, including Trauma Score (TS), Injury Severity Score (ISS), components of TS or ISS, age, sex, alcohol use, and whether a patient was transferred. RESULTS: The "TRISS" combination of TS, ISS, and age previously shown to predict mortality also predicted "modified LOS" (Wald p value less than 0.001 for each variable). Models using only age and certain components of ISS or TS fit our data even better, with fewer parameters. Other variables were not predictive. Modified Kaplan-Meier plots provided easily interpreted graphical results, combining both mortality and LOS information. CONCLUSIONS: With a simple modification to allow for competing risks, time-to-event methods enable more informative modeling of injury outcomes than binary (lived/died) methods alone. Such models may be useful for describing and comparing groups of hospitalized trauma patients.     

Splenic injury in children: a 10 year experience

The aim of this report was to review retrospectively the management of splenic trauma at a major Australian tertiary referral centre (Westmead Hospital) over a 10 year period. Forty-nine patients (0-15 years of age) with documented blunt splenic trauma were identified. The causes of splenic injury were road trauma (73%) and falls (27%). There were 22 minor injuries (Injury severity score [ISS] < 16) and 27 severe injuries (ISS > or = 16). All nine deaths were related to road trauma (mean ISS = 59). The investigation most commonly used was CT scanning (47%). Peritoneal lavage was performed in six patients (12%). Management involved non-operative care in 29 patients (57%), exploratory laparotomy alone in 5 (10%), splenic salvage in 2 (4%) and splenectomy in 13 (26%). This experience supports the view that non-operative management of splenic injury in haemodynamically stable children is safe and is the preferred treatment. Experienced assessment and meticulous observation is necessary. Laparotomy is indicated if there is continuing haemodynamic instability despite resuscitation. Operative management is aimed at splenic salvage with splenectomy being reserved for uncontrolled haemorrhage.     

In-house board-certified surgeons improve outcome for severely injured patients: a comparison of two university centers

The benefit derived from in-house board-certified attending surgeons (IHBCS) staffing trauma centers has recently been questioned. We compared the outcomes and provider-related complications of patients with severe injuries who were treated at two university trauma centers, one with IHBCS, and one with PGY-4 or PGY-5 residents in house (RIH). The RIH center had a significantly longer resuscitation time (160 vs. 58.8 minutes; p < 0.01). Except in cases of vascular injury, the odds ratio of dying at the RIH institution was significantly greater in all groups when the variables of transport time, Revised Trauma Score, and ISS were controlled. Errors in judgment were significantly more likely to have been made at the RIH institution in all groups. It is concluded that the management and ultimate outcome are significantly improved when IHBCS are involved with the resuscitation and early care of specific cohorts of severely injured patients.     

A method to reduce response times in prehospital care: the motorcycle experience

This study compared the response times of a motorcycle and a standard ambulance in a congested urban emergency medical services (EMS) setting. The study was performed in Taipei, Taiwan, a densely populated urban area. A basic life support (BLS) motorcycle (without defibrillation capability) and an advanced life support (ALS) ambulance were based at three study hospitals and simultaneously dispatched when there was a perceived need for ALS ambulance transport. Over a 3-month period, prehospital personnel evaluated 307 medical and trauma emergencies. Time data were insufficient for analysis in 33 cases, leaving a study population of 274. Response times of the motorcycle and the ambulance were prospectively assessed and compared. During rush hours, the response times of the motorcycle and ambulance were 4.9+/-3.0 minutes and 6.3+/-3.4 minutes (P < .05), respectively, and in non-rush hours, 4.2+/-2.1 minutes and 5.1+/-2.5 minutes (P < .05), respectively. Using motorcycles to transport EMTs to the emergency scene significantly reduced response time compared with a standard ambulance in a congested urban setting. Large prospective studies are required to determine the impact on patient outcome of shorter EMS response times using motorcycles. EMS motorcycles appear feasible and deserve consideration to help expedite prehospital care in other systems in densely populated cities.     

Expression of inducible nitric oxide synthase in the brains of scrapie-infected mice

Thoracic trauma in the elderly population constitutes a major challenge for both thoracic and trauma surgeons as their presentation and outcomes differ from the adult population in addition to their high morbidity and mortality. One hundred and one patients, 60 years of age or older, with thoracic trauma were treated at Dicle University School of Medicine during a 6-year period. Eighty-five per cent were male and 15% were female with a mean age of 64.5 years. The cause of thoracic injury was blunt in 77.2% and penetrating in 22.8% of the patients. Sixty-two patients (61.4%) had isolated thoracic injuries. The median Injury Severity Score (ISS) was 23. The morbidity rate was 23.8%. The mortality rate was 16.8%. Seven of 10 patients (70%) who had an ISS greater than 25 died, whereas six of 24 (25%) patients with an ISS between 17 and 25, and four of 67 (5.9%) patients with an ISS less than 16 died. In the elderly the morbidity and mortality rates were higher for blunt trauma compared with penetrating trauma. For ISS greater than 25 the mortality rate was 71.4% for blunt and 66.6% for penetrating trauma. As the morbidity and mortality rate are significantly higher in the elderly patients the approach to these patients should include recognition of their high risk for morbidity and mortality, especially for those who had an ISS greater than 25.     

Retinal detachment with vitreous hemorrhage

The aim of this study was to assess the influence of prehospital advanced life support (PALS) on the survival of victims of severe trauma in our hospital. During a period of 24 months, 46 patients with severe trauma were admitted to our Emergency Department after receiving PALS; this included endotracheal intubation and ventilatory support (IVS) in 35 cases, and cardiopulmonary resuscitation (CPR) in 11. The severity of the trauma in this group of patients was confirmed by assessing the clinical condition on admission and the Glasgow Coma Scale score (mean = 4.0, median = 3), the Revised Trauma score (mean = 4.1, median = 4) and the Injury Severity Score (mean = 44.5 and median = 41 in blunt trauma; mean = 58.3 and median = 75 in penetrating trauma). The overall survival was 41%. The survival rate was 48% in patients with prehospital IVS rate and 18% in those receiving CPR. We conclude that PALS in severe trauma was able to save the lives of many patients at high risk of dying before reaching hospital.     

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definitions of the systemic inflammatory response syndrome and allied disorders in relation to critically injured patients

OBJECTIVES: To determine the frequency of the proposed definitions for the systemic inflammatory response syndrome (SIRS), sepsis and septic shock, and to further define severe SIRS and sterile shock as determined at 24 hrs of admission to an intensive care unit (ICU) in critically ill trauma patients without head injury, and their relationships to mechanism of injury, Acute Physiology and Chronic Health Evaluation (APACHE) II score, risk of death, Injury Severity Score (ISS), number of organ failures, and mortality rate. DESIGN: Prospective, inception cohort analysis. SETTING: Sixteen-bed surgical ICU in a teaching hospital. PATIENTS: Four hundred fifty critically injured patients without associated head trauma. Penetrating trauma accounted for 70% (gunshot 202; stab 113) and nonpenetrating trauma for 30% (motor vehicle collision 103; blunt 32) of admissions. Three hundred ninety-four (88%) patients underwent surgical procedures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Infective and noninfective insults were distinguished by the need for therapeutic or prophylactic antibiotics, respectively, based on an established antibiotic policy. Three hundred ninety-five (87.8%) patients fulfilled a definition of the SIRS criteria. The frequency of the definitive categories was SIRS 21.8%, sepsis 14.4%, severe SIRS 8.4%, severe sepsis 13.6%, sterile shock 9.3%, and septic shock 20.2%. Patients with penetrating trauma had a significantly higher frequency of sepsis, severe sepsis, and septic shock (p < .01). The APACHE II score, risk of death, and number of organ failures increased significantly in both infective and noninfective groups with increasing severity of the inflammatory response. Sterile shock was associated with a significantly higher APACHE II score (p < .02), risk of death (p < .01), and number of organ failures (p = .03) compared with septic shock. Only sterile shock was associated with a significantly higher ISS (p < .01). Organ system failure was significantly (p < .001) higher in nonsurvivors compared with survivors in all categories. The only significant (p < .001) difference in mortality rate was found between patients in shock and all other categories. CONCLUSIONS: The current definitions of SIRS, sepsis, and related disorders in critically injured patients without head trauma show a significant association with physiologic deterioration and increasing organ dysfunction. The only significant association with mortality, however, is the presence of shock. The definitions require refinement, with the possible inclusion of more objective gradations of organ system failure, if they are to be used for stratifying severity of illness in seriously injured patients.