Technology and Health Care 23 (2015) 63–73 DOI 10.3233/THC-140869 IOS Press

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Kinetic therapy in multiple trauma patients with severe blunt chest trauma: An analysis at a level-1 trauma center C. Zeckeya , K. Wendta , P. Mommsena,∗, M. Winkelmanna, C. Frömkeb , J. Weidemannc , T. Stübiga , C. Kretteka and F. Hildebrandd a Trauma

Department, Hannover Medical School, Hannover, Germany of Biostatistics, Hannover Medical School, Hannover, Germany c Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany d Department of Orthopedic Trauma, University Hospital Aachen, Aachen, Germany b Institute

Received 18 September 2014 Accepted 14 October 2014 Abstract. BACKGROUND AND OBJECTIVES: Chest trauma is a relevant risk factor for mortality after multiple trauma. Kinetic therapy (KT) represents a potential treatment option in order to restore pulmonary function. Decision criteria for performing kinetic therapy are not fully elucidated. The purpose of this study was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort. METHODS: A retrospective analysis (2000–2009) of polytrauma patients (age > 16 years, ISS  16) with severe chest trauma (AISChest  3) was performed. Patients with AISHead  3 were excluded. Patients receiving either kinetic (KT+) or lung protective ventilation strategy (KT-) were compared. Chest trauma was classified according to the AISChest , Pulmonary Contusion Score (PCS), Wagner Jamieson Score and Thoracic Trauma Severity Score (TTS). There were multiple outcome parameters investigated included mortality, posttraumatic complications and clinical data. A multivariate regression analysis was performed. RESULTS: Two hundred and eighty-three patients were included (KT+: n = 160; KT-: n = 123). AISChest , age and gender were comparable in both groups. There were significant higher values of the ISS, PCS, Wagner Jamieson Score and TTS in group KT+. The incidence of posttraumatic complications and mortality was increased compared to group KT- (p < 0.05). Despite that, kinetic therapy failed to be an independent risk factor for mortality in multivariate logistic regression analysis. CONCLUSIONS: Kinetic therapy is an option in severely injured patients with severe chest trauma. Decision making is not only based on anatomical aspects such as the AISChest , but on overall injury severity, pulmonary contusions and physiological deterioration. It could be assumed that the increased mortality in patients receiving KT is primarily caused by these factors and does not reflect an independent adverse effect of KT. Furthermore, KT was not shown to be an independent risk factor for mortality. Keywords: Multiple trauma, blunt chest trauma, kinetic therapy, posttraumatic complications, outcome

∗ Corresponding author: Philipp Mommsen, Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625 Hannover, Germany. E-mail: [email protected].

c 2015 – IOS Press and the authors. All rights reserved 0928-7329/15/$35.00 

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Fig. 1. Kinetic therapy in a severely injured patients with chest trauma. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/THC-140869)

1. Background and objectives Severe blunt chest trauma is frequently observed in multiple trauma patients and it is widely accepted that it considerably contributes to posttraumatic complications, such as the Multiple Organ Dysfunction Syndrome (MODS). Failure of the lung (Acute Respiratory Distress Syndrome has been proven to be one of the first components within the development of MODS and has been associated with increased ventilation time as well as an increased mortality [1,2]. There is an ongoing discussion about therapeutic strategies for patients suffering from severe chest trauma and ARDS, including the type of ventilation and positioning of the patient. With regard to positioning, prone positioning has been reported to be effective in order to improve oxygenation in patients suffering from ARDS [3]. Apart from prone positioning, kinetic therapy has also been described as an effective therapeutic option in trauma and surgical patients to improve oxygenation and lessen the occurrence of atelectasis and pneumonia [4,5]. Kinetic therapy is defined as the use of a bed that turns continuously and slowly over an angle wider than 40◦ along its longitudinal axis [6] (Fig. 1). Pape and co-workers recommended an early application of kinetic therapy in multiple trauma patients with severe chest trauma or high overall injury severity. The authors argued that kinetic therapy applied when ARDS is already established, may not be as effective as the early application [7]. These findings are in line with studies published by other authors [8,9]. However, the cohorts analyzed in these studies were either small or heterogeneous. When considering the beneficial effects of kinetic therapy, the negative side effects should not be forgotten. A study of Mahlke et al. pointed to possible negative side effects such as even prolonged ventilation time and increased ventilator associated morbidities [10]. Also, according to clinical experience, a number of multiple trauma patients with chest trauma who were not selected for kinetic therapy due to various reasons, nevertheless showed a satisfying outcome. Therefore, the identification of patients requiring kinetic therapy seems to be crucial in order to achieve optimal results for the individual patient.

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A recently published study analyzed treatment modalities including kinetic therapy in severely injured patients with relevant chest trauma in Germany. Criteria to initiate kinetic therapy were provided only by 18.8% which potentially reflects some uncertainty about patient characteristics who undergo kinetic therapy. Finally, the majority of the participating hospitals declared that additional research and more detailed information are required [11]. The purpose of the present study was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort. In addition, we attempt to evaluate potential beneficial effects or even adverse effects of kinetic therapy in multiple trauma patients with severe chest trauma. 2. Methods The present study was approved by the local ethical committee of Hannover Medical School, Hannover, Germany. The study followed the guidelines of the revised UN declaration of Helsinki in 1975 and its latest amendment in 1996 (42nd general meeting). 2.1. Inclusion/exclusion criteria In this retrospective study multiple trauma patients (ISS  16, age > 16 years) with associated severe chest trauma (AISChest  3) admitted to our level 1 trauma center between 2000 and 2009 were included. Further inclusion criteria consisted of: primary admission within 6 h after trauma, plain radiographs of the chest at admission and 24 h thereafter, CT of the head, spine, chest, abdomen and pelvis. Exclusion criteria were penetrating thoracic trauma, AISHead > 2, steroidal and non-steroidal anti-inflammatory medication, hormone replacement, chronic diseases of the lungs, liver or kidneys and vascular obstruction. 2.2. Definitions Overall injury severity was classified according to the Injury Severity Score (ISS), based on the Abbreviated Injury Scale (AIS) [12]. Diagnosis of SIRS and sepsis was made according to the criteria of the Consensus Conference of the American College of Chest Physicians and Society of Critical Care Medicine [ACCP/SCCM] [13,14], the Multiple Organ Dysfunction Syndrome (MODS) was defined according to Marshall et al. [15]. ARDS was diagnosed according to the criteria of the American-European Consensus Conference on ARDS [16]. To calculate the expected mortality, the Trauma Score and ISS (TRISS) method was used according to Boyd and colleagues [17]. 2.3. Blunt chest trauma scores In order to analyze the grade of chest trauma, we used the AISChest [18], the Pulmonary Contusion Score (PCS) [19], the Wagner Jamieson Score [20], and the Thoracic Trauma Severity Score [21]. The PCS is based on plain radiographs of the chest at the time of admission and 24 h thereafter. The lung is virtually divided in an upper, middle and lower third and pulmonary contusion in every third is assessed and assigned a value between 1 and 3. The score is defined as the sum of these values and classifies contusion in mild (score of 1 or 2), moderate (score of 3–9) and severe (score of 10–18) [19]. Wagner and Jamieson developed a thoracic trauma score based on findings in computed tomography (CT) [20]. Depending on the extension of pulmonary lesions the severity of thoracic trauma is divided

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C. Zeckey et al. / Kinetic therapy in multiple trauma patients with severe blunt chest trauma Table 1 Calculation of the anatomical/physiological thoracic trauma severity score

Grade 0 I II

PO2 /FiO2 > 400 300–400 200–300

Rib fractures 0 1–3 unilateral 4–6 unilateral

III

150–200

> 3 bilateral

Pulmonary contusion None 1 lobe unilateral 1 lobe bilateral or 2 lobes unilateral < 2 lobes bilateral

IV

< 150

Flail chest

 2 lobes bilateral

Pleural lesion None Pneumothorax Hemothorax/ Hemopneumothorax unilateral Hemothorax/ Hemopneumothorax bilateral Tension pneumothorax

Age (years) < 30 30–40 41–54

Points 0 1 2

55–70

3

> 70

5

Fig. 2. Pulmonary proportions to calculate the Wagner Jamieson Score [20].

into different sections. Pulmonary lesions in < 19% of total air space are classified as grade 1, in 19%– 27% as grade 2, and in > 28% as grade 3 (Fig. 2). In order to combine anatomical and physiological parameters, Pape and co-workers developed the Thoracic Trauma Severity Score (TTS) [21]. The TTS is based on five anatomical and physiological parameters: paO2 /FiO2 , rib fractures, pulmonary contusion, pleural lesion, and age. Each parameter is assigned a value of 0–5, these are subsequently added. The TTS score ranges from 0 to 25. See Table 1 for calculation details. The retrospective examination of all chest images (plain radiography, computer tomography) and the classification according to the different scoring systems were performed in cooperation with a consultant of the Institute of Diagnostic Radiology, Hanover Medical School. The radiologist was blinded with respect to the clinical outcome. 2.4. Patient care and treatment algorithms Initial treatment and diagnostics of multiple trauma patients were performed according to ATLS principles. Initial diagnostics included X-rays (chest, pelvis, cervical spine and extremities) and a CT scan of the head, spine, chest, abdomen, and pelvis. Depending on the status of the patient and injury pattern, we followed the principles of early total care or damage control orthopedics as described earlier [22,23]. Kinetic therapy (KT+) was individually allocated based on the responsible senior physician depending on the extend of chest trauma, overall injury severity, transfusion requirement and physiological parameters. In case of kinetic therapy, a continuous 5 to 7 day therapy with 62◦ rotation to each side was applied [7]. Independent of kinetic therapy, lung protective ventilator presettings according to the ARDS

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Table 2 Demographic data and injury characteristics of the study population Patients (n) Male (%) Age (years) AISHead AISChest AISAbdominal AISExtremities AISExternal ISS Pulmonary Contusion Score Wagner Jamieson-Score Thoracic Trauma Severity Score

KT+ 160 76.3 43.3 ± 16.9 0.6 ± 0.8 3.6 ± 0.7 1.7 ± 1.8 2.5 ± 1.1 1.8 ± 1.1 30.4 ± 9.9 4.2 ± 3.2 1.9 ± 0.8 8.3 ± 3.6

KT− 123 69.1 42 ± 17.2 0.6 ± 0.8 3.5 ± 0.6 1.4 ± 1.6 2.3 ± 1.2 1.5 ± 1.0 27.2 ± 8.4 2.5 ± 3.0 1.4 ± 0.7 6.6 ± 3.8

P-value 0.18 0.52 0.93 0.06 0.12 0.22 0.04 0.005 0.001 0.001 0.001

AIS: Abbreviated Injury Scale. ISS: Injury Severity Score. KT: Kinetic therapy.

Network recommendations were chosen, using increased positive end-exspiratory pressure (PEEP) of 5–15 mmH2 0 and a tidal volume of 6–8 ml per kg/bodyweight [24]. FiO2 and breath frequency were adapted according to blood gas analysis. Physiological measurements were attempted, however, in case of ALI or ARDS permissive hypercapnemia or/and permissive hypoxemia (lowest paO2 75 mmHg) were tolerated in order to reduce barotrauma. During the stay on the trauma ICU, routine examinations every morning and evening were performed; blood samples for laboratory parameters were taken repetitively. Blood replacement therapy using packed red blood cells (PRBC), fresh frozen plasma (FFP) or platelet-rich plasma (PRP) was used depending on whether or not coagulopathy existed and based on the patients’ overall status. In case of mass transfusion, a 1:1 ratio (PRBC: FFP) was implemented. Standard protocols for microbiological assessments (twice weekly and screening) were used. Empiric antibiotic treatment was performed and adapted according to microbiological findings. 2.5. Clinical course/clinical parameters The clinical course was recorded on a daily basis and included demographics, total in-hospital stay (days), duration of ICU treatment (days), hours of ventilation (VT), mortality and the transfusion of blood products. For laboratory analysis, blood samples were taken three times daily during the first three days, and at 7 a.m. daily afterwards for routine and blood gas measurements. 2.6. Statistics Differences in demography and clinical interventions were compared with t-test, Mann-Whitney Utest and χ2 -test. The observed mortality rate was compared to the expected rate (TRISS) with a binomial test. Significance was set to p  0.05. To evaluate the impact of additional kinetic therapy on the dichotomous outcomes mortality, ARDS, MODS, ALI, SIRS and sepsis, univariate and multivariate logistic regression models were computed. While the treatment variable (KT+ vs. KT-) was included in all models, the number of prognostic variables in the model was reduced using a stepwise variable selection. These results are presented listing the odds ratios, their corresponding two-sided 95%-confidence interval and the two-sided p-value. For some variables, information was incomplete (worst case: 7%). The influence of imputed values on the results was analyzed in sensitivity analyses. Data analyses were performed using SPSS (Version 18, SPSS Inc., Chicago, IL) and SAS (Version 9.2, SAS Institute Inc., Cary, NC).

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C. Zeckey et al. / Kinetic therapy in multiple trauma patients with severe blunt chest trauma Table 3 Clinical parameters of the study population. PRBC: Packed red blood cells Ventilation time (h) ICU treatment (days) In-hospital time (days) PRBC (n) FFP (n) PRP (n) SIRS Sepsis MODS Mortality

KT+ (n = 160) 532.1 ± 320.7 25.7 ± 13.4 38.4 ± 21.1 22.9 ± 26.6 16.6 ± 20.9 2.6 ± 5.7 65% 53.1% 21.3% 12.5%

KT− (n = 123) 135.8 ± 245.8 9.1 ± 11.0 24.4 ± 17.6 10.5 ± 14.1 7.0 ± 11.4 0.9 ± 2.1 34% 19.5% 2.4% 5.7%

P-value < 0.0001 < 0.0001 < 0.0001 < 0.01 0.01 0.01 0.001 0.001 0.001 0.044

FFP: Fresh frozen plasma. PRP: Platelet-rich plasma. KT: Kinetic therapy. Table 4 Multivariate logistic regression analysis for clinical factors on mortality Kinetic therapy Age (16–40;  40 years) Thoracic Trauma Severity Score (0–9;  10) Requirement of PRP (0; 1)

Odds ratio [95%-CI] 0.96 [0.34; 2.74] 2.71 [0.88; 8.41] 4.47 [1.68; 11.91] 9.86 [3.04; 31.94]

P-value > 0.05 > 0.05 0.0027 0.0001

3. Results 3.1. Demographic data In total, we included 283 patients in this study (Group KT+: n = 160 vs. KT-: n = 123). There was a predominance of male gender in both groups (Group KT+: 76.3% vs. Group KT-: 69.1%). Moreover, there were significantly higher scores of ISS, PCS, Wagner Jamieson Score and TTS in group KT+. However, no differences were found for the AISChest comparing both groups (Table 2). 3.2. Clinical data, posttraumatic complications and outcome Patients in the KT+ group had significantly increased ventilation time, prolonged duration on ICU and total in-hospital time and an increased need for blood replacement compared to group KT-. The incidence of SIRS, sepsis, MODS and mortality was increased in group KT+ (Table 3). 3.3. Multivariate logistic regression analysis For the logistic regression, all factors were dichotomized. The full multivariate model consisted of the dependent variable mortality and the independent factors kinetic therapy (levels: no; yes), gender (female; male), age (16–40;  41), Injury Severity Score (16–32;  33), duration of initial operation (0– 74;  75 min), requirement of FFP (0–6;  7), requirement of PRBC (0–10;  11), requirement of PRP (0;  1), Thoracic Trauma Severity Score (0–9;  10) and the Horowitz score (0–299;  300). After the backward selection, the independent factors kinetic therapy, age, requirement of transfusions and TTS remained in the model. In this model, an increased risk for mortality in patients who underwent kinetic therapy cannot be shown. However, mortality was associated with the TTS and amount of transfused PRP (Table 4).

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3.4. Trauma score – injury severity score (TRISS) To analyze the expected mortality rates in our cohort, we used the TRISS. There were no significant differences between the observed and the expected mortality (Group KT+: Mortality 12.2% vs. Expected mortality 11.3%, p = 0.73; Group KT-: Mortality 5.8% vs. Expected mortality 9.6%, p = 0.16). 4. Discussion Kinetic therapy is described as an option in order to prevent or to treat pulmonary failure in multiple trauma patients with severe chest trauma. In a former study, an early begin of kinetic therapy was favored in patients with severe chest trauma or high overall injury severity to achieve best possible results for the patients [7]. Although these results were confirmed also by other studies, a general guideline or recommendation is missing [8,9]. This comes true especially for decision making to initiate kinetic therapy. In this context, Wyen and colleagues recently investigated the treatment concepts in multiple trauma patients with severe chest trauma using a nationwide online-survey in Germany [11]. Only 63.6% of the participating centers indicated the capability and capacity to apply kinetic therapy. The majority of level 1 trauma centers provide kinetic therapy; however, only 50% of level 3 trauma centers are able to do so. Also, treatment modalities show great diversity amongst the participating centers. Criteria to initiate kinetic therapy was provided only by 18.8% of the participating hospitals which were “radiological findings” and “impaired pulmonary function”. In conclusion, 72.8% of the participants declared that more information and additional studies are “urgently needed” or “necessary”. In addition, some authors are aware about potential negative side effects of kinetic therapy itself such as prolonged ventilation time and increased ventilator associated morbidities [10]. Also, according to clinical experience, a number of multiple trauma patients with chest trauma who were not selected for kinetic therapy due to various reasons, nevertheless showed a satisfying outcome. Therefore, the identification of patients requiring kinetic therapy seems to be crucial in order to achieve optimal results for the individual patient. The purpose of the study at hand was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort. In addition, we attempt to evaluate potential beneficial effects or even adverse effects of kinetic therapy in multiple trauma patients with severe chest trauma. In our study, we were able to demonstrate that high risk patients for posttraumatic complications are treated by kinetic therapy at our department. Risk factors included significant pulmonary contusions and high injury severity with related need for blood replacement according to Pape et al. [7,22]. We were able to demonstrate an increased incidence of posttraumatic complications such as ALI and ARDS in group KT+ which emphasizes the remarkable effect of severe chest trauma and the associated pulmonary contusion on the posttraumatic course. In contrast to the AISChest , the additionally analyzed chest trauma scores including the PCS, TTS and the Wagner Jamieson Score were significantly increased in group KT+. These scores more precisely differentiate between fractures and lung contusions compared to the AISChest . Obviously, decision making was more based on pulmonary contusions rather than on rib fractures. Moreover, the combined anatomical/physiological TTS was significantly increased in group KT+. We therefore conclude that decision making to initiate kinetic therapy is mainly based on pulmonary contusions, physiological status, transfusion requirement and overall injury severity. The AISChest therefore seems to be of limited relevance in the decision making process. Söderlund et al. were able to demonstrate that not the number of rib fractures are associated with mortality in patients with chest trauma but other clinical parameters such as base excess and coagulation status which underlines our

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results [25]. Although until now not routinely used in daily practice, the described chest trauma scores should be used to help in the decision making process in order to generate comparable data particularly to evaluate pulmonary contusions. In addition, the combined physiological/anatomical TTS was found to be an independent predictor of death. In this context, we recently published that the TTS, the PCS and the Wagner Jamieson Score are independent predictors of ventilation time, length of ICU stay, and the development of post-traumatic ARDS and MODS [26]. Keeping in mind that a Thoracic Trauma Severity Score > 9 predicts mortality, this information should be taken into account during decision making concerning kinetic therapy in the future. Especially for the unexperienced user of the anatomical AIS, the described anatomical/physiological scores might help with choosing the appropriate therapeutic concept in the future. As mechanical ventilation itself represents a well known risk factor for complications with associated mortality, some authors provide more restrictive mechanical ventilation protocols than in earlier times [27]. For some patients not in need of, but having received several days of kinetic therapy due to early decision making, early extubation would have possibly been beneficial instead of deep anesthesia and prolonged prophylactic ventilation. In addition to ventilator associated infections, one may argue that ICU treatment is prolonged and so are its consequences including the resulting invasive procedures such as tracheotomies, central lines, chest tubes, artificial nutrition and even mortality. Moreover, therapeutic costs have to be taken into account. Therefore, there has been a noticeable tendency towards shorter ventilation strategies even in severely injured patients. The early weaning of the respirator, supported by non-invasive ventilation strategies and intensive physiotherapeutic interventions has shown some interesting results [27]. In this context, Mahlke et al. investigated the effect of early extubation in a multiple trauma cohort with severe chest trauma as classified by an AISChest > 3 on ventilation time and questioned the routine use of prophylactic kinetic therapy [10]. The mean ventilation time for all patients was 98.4 hours (4.1 days); in patients without TBI ventilation time was as low as 71.3 hours (2.96 days). However, 18% of these patients needed to be re-intubated due to respiratory failure. This data presents the potential role of early extubation even in multiple trauma patients with severe chest trauma. However, the re-intubation rate needs to be reduced by further analysis of the influencing factors. In the study at hand, there was an increased mortality in patients of group KT+, moreover, posttraumatic complications such as ARDS, SIRS, sepsis and MODS were increased. However, multivariate regression analyses demonstrated that kinetic therapy itself does not have a negative influence on mortality. We assume that the increased incidence of posttraumatic outcome is related to the increased overall injury severity and the more relevant chest trauma. Analyzing the TRISS, the described mortality rates in our study cohort are in line with the expected rates and are slightly lower than in published reports. Fueglistaler and coworkers analyzed the prognostic value of different outcome scores in a multiple trauma cohort. In total, they were able to recruit 237 patients showing a hospital mortality of 23.2%, ICU days (6.2 ± 9.6) were slightly lower than in our report [28]. Another study by Veysi et al. analyzed the prevalence and influence of chest trauma on various clinical parameters [29]. While overall mortality of 18.7% was higher compared to our report, the authors described a mean ICU stay of 5.5 days which is clearly shorter than in our cohort. Besides, mortality rates up to 40% are described in patients suffering from thoracic injury [26]. This emphasizes the profound influence of these injuries on outcome. Voggenreiter and co-workers investigated the influence of the prone position compared to supine position in multiple trauma patients with established ALI or ARDS in a prospective randomized trial. Although the authors were able to demonstrate improved oxygenation and a reduced prevalence of ARDS in the prone group, ventilation time and mortality were comparable. However, patient size was small (n = 40) and patients with TBI were included which may potentially have influenced the results [30].

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Pape and co-workers investigated the effect of kinetic therapy on multiple trauma patients. They compared patients with a suspected risk for pulmonary failure (e.g. ISS > 25, AISChest > 3) with those with already impaired pulmonary function. In summary, the investigators were able to demonstrate some potential benefits of the early application of kinetic therapy in terms of a decreased incidence of ARDS. However, no difference concerning the mortality in patients suffering from ARDS was shown. As discussed by the authors, some influencing factors might not have been recognized, and multivariate analysis was missing. However, apart from a reduced incidence of ARDS, the authors were able to show that early kinetic therapy improved response to the therapy, leading to improved oxygenation. Therefore, early kinetic therapy has been favored instead of waiting until the respiratory system fails [7]. Another study investigated the effect of kinetic therapy on pulmonary function in 111 multiple trauma patients. The investigators compared patients with primary poor oxygenation (ARDS) to those suffering from acute lung injury (ALI) and those with an ISS > 15 but no pulmonary dysfunction (reference group) [9]. In that study, oxygenation was improved in ARDS patients and those of group ALI, however, no effect was shown in the reference group. Patients of the reference group showed a relatively high ISS of 37, however, mortality was notable with 0%. The investigators found a protective effect of kinetic therapy, demonstrated by lower mortality than calculated, in all groups. However, most of the patients of the reference group suffered from severe traumatic brain injury, which explains the relatively high ISS in that group. Since we excluded all patients with significant TBI due to the known deleterious effect on posttraumatic complications and outcome we believe that reproducibility to our cohort is limited. Our study presents data of a homogenous multiple trauma cohort at a single center institution. Our strict exclusion criteria lead to the exclusion of a number of patients mainly due to the presence of TBI. TBI is known to influence the posttraumatic course including the development of MODS and associated complications. Most of the available studies included patients with TBI, leading to increased injury severity and therefore to a possible bias. Treatment strategies such as damage control orthopaedics (DCO) and treatment algorithms on ICU were comparable during the study period at our department, thus underlining a consistent therapeutic regime and, therefore, a comparable study population during the observation period. The retrospective design of the study is a drawback. As in any retrospective study, we are aware that some bias or other unknown influencing factors might exist. During the final statistical stages, we were able to eliminate most of the known influencing factors on outcome such as age, injury severity and gender by multivariate analysis using stepwise variable selection. One of the most important questions which came up is to identify those patients most likely to benefit from early kinetic therapy. Although we performed considerable analysis with the available data, we were not able to answer this question fully. Therefore, a prospective study to further analyze the effect of kinetic therapy with the additional information out of the present study should be performed. Acknowledgement This study was part of the doctoral thesis of Kristina Wendt. The authors thank Ms. Penelope Stiefel for editing of this article. Conflict of interest There are no conflicts of interest in the manuscript, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest. No funding was received for this study.

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Parts of the data were presented at the European Congress of Emergency and Trauma Surgery, Basel, Switzerland 2012 and at the German congress of Orthopaedic and Trauma Surgery, Berlin, Germany 2011.

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Kinetic therapy in multiple trauma patients with severe blunt chest trauma: an analysis at a level-1 trauma center.

Chest trauma is a relevant risk factor for mortality after multiple trauma. Kinetic therapy (KT) represents a potential treatment option in order to r...
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