Impact of the establishment of a trauma center on blunt traumatic spleen injury treatment: Comparison between pre-traumatic center and trauma center periods.

BACKGROUND: The spleen is a commonly injured intra-abdominal organ from blunt trauma. In cases of traumatic blunt spleen injury, immediate treatment is often required. This study aimed to investigate the prognostic impact of the establishment of a trauma center on the treatment of patients with blunt trauma injury to the spleen. METHODS: We retrospectively reviewed 235 patients who visited our center from 2012 to 2019 for blunt trauma injury to the spleen. The study period was divided into two groups: January 2012 to September 2015 was the pre-center period (PCP), and September 2015 to December 2019 was the trauma center period (TCP). In each period, there were three treatment groups: Surgical group, embolization group, and conservative treatment group. The primary outcome was mortality, and the secondary outcomes were patient characteristics, such as injury severity score and abbreviated injury scale score, time from admission to intervention (both surgery and angiography embolization), and rate of spleen-preserving surgery. RESULTS: In the conservative treatment group, the Hb and hct values were relatively low in the TCP than in the PCP (p=0.007, p=0.008, respectively). The intensive care unit admission rate was relatively high in the TCP (72.9% vs. 90.6%, p=0.031). The ISS was relatively low in the TCP (18 vs. 17, p=0.001). In the surgical group, the time taken to transfer patients to the operating room after admission was greatly reduced in the TCP (151 min vs. 107 min, p=0.028). In the embolization group, the patient's age and SBP were lower in the PCP than in the TCP (p=0.003, p=0.049, respectively); three patients had undergone embolization with CPR in the PCP, and no patient underwent CPR in the TCP. There were three deaths in PCP and none in the TCP (p=0.05). CONCLUSION: The establishment of a trauma center has led to improvements in the treatment quality and prognosis of patients with blunt trauma injury to the spleen receiving either of the three treatments.

Antiphospholipid syndrome with renal and splenic infarction after blunt trauma: A case report.

BACKGROUND: In trauma patients, bleeding is an immediate major concern. At the same time, there are few cases of acute vascular occlusion after blunt trauma, and it is unclear what assessment and diagnosis should be considered for these cases. Herein, we describe a patient diagnosed with antiphospholipid syndrome after a hypercoagulable workup for acute renal and splenic vascular occlusion due to blunt trauma. CASE SUMMARY: A 20-year-old man was admitted to the emergency department with abdominal pain after hitting a tree while riding a sled 10 h ago. He had no medical history. Radiological investigations revealed occlusion of the left renal artery with global infarction of the left kidney and occlusion of branches of the splenic artery with infarction of the central portion of the spleen. Attempted revascularization of the left renal artery occlusion through percutaneous transluminal angioplasty failed due to difficulty in passing the wire through the total occlusion. Considering the presence of acute multivascular occlusions in a young man with low cardiovascular risk, additional laboratory tests were performed to evaluate hypercoagulability. The results suggested a high possibility of antiphospholipid syndrome. Treatment with a subcutaneous injection of enoxaparin was started and changed to oral warfarin after two weeks. The diagnosis was confirmed, and he continued to visit the rheumatology outpatient clinic while taking warfarin. CONCLUSION: A hypercoagulable workup can be considered in trauma patients with acute multivascular occlusion, especially in young patients with low cardiovascular risk.

Time from Injury to Initial Operation May Be the Sole Risk Factor for Postoperative Leakage in AAST-OIS 2 and 3 Traumatic Duodenal Injury: A Retrospective Cohort Study.

Background and Objectives: Traumatic duodenal injury is a rare disease with limited evidence. We aimed to evaluate the risk factors for postoperative leakage and outcomes of pyloric exclusion after duodenal grade 2 and 3 injury. Materials and Methods: We reviewed a prospectively collected trauma database for the period January 2004-December 2020. Patients with grade 2 and 3 traumatic duodenal injury were included. To identify the risk factors for postoperative leakage, we used a stepwise multivariable logistic regression model and a least absolute shrinkage and selection operator (LASSO) logistic model. We constructed a receiver operator characteristic (ROC) curve to predict risk factors for postoperative leakage. Results: During the 17-year period, 179,887 trauma patients were admitted to a regional trauma center in Korea. Of these patients, 74 (0.04%) had duodenal injuries. A total of 49 consecutive patients had grade 2 and 3 traumatic duodenal injuries and underwent laparotomy. The incidence of postoperative leakage was 32.6% (16/49). Overall mortality was 18.4% (9/49). A stepwise multivariable logistic regression and LASSO logistic regression model showed that time from injury to initial operation was the sole statistically significant risk factor. The ROC curve at the optimal threshold of 15.77 h showed the following: area under ROC curve, 0.782; sensitivity, 68.8%; specificity, 87.9%; positive predictive value, 73.3%; and negative predictive value, 85.3%. There was no significant difference in outcomes between primary repair alone and pyloric exclusion. Conclusions: Time from injury to initial operation may be the sole significant risk factor for postoperative duodenal leakage. Pyloric exclusion may not be able to prevent postoperative leakage.

Efficacy and Safety of Laparoscopy for Mild and Moderate Pediatric Abdominal Trauma: A Systematic Review and Meta-Analysis.

In this systematic review and meta-analysis, we aimed to investigate the efficacy and safety of laparoscopy for pediatric patients with abdominal trauma. Relevant articles were obtained by searching the MEDLINE PubMed, EMBASE, and Cochrane databases until 7 December 2021. Meta-analyses were performed using odds ratio (OR) for binary outcomes, standardized mean differences (SMDs) for continuous outcome measures, and overall proportion for single proportional outcomes. Nine studies examining 12,492 patients were included in our meta-analysis. Our meta-analysis showed younger age (SMD -0.47, 95% confidence interval (CI) -0.52 to -0.42), lower injury severity score (SMD -0.62, 95% CI -0.67 to -0.57), shorter hospital stay (SMD -0.55, 95% CI -0.60 to -0.50), less complications (OR 0.375, 95% CI 0.309 to 0.455), and lower mortality rate (OR 0.055, 95% CI 0.0.28 to 0.109) in the laparoscopy group compared to the laparotomy group. The majority of patients were able to avoid laparotomy (0.816, 95% CI 0.800 to 0.833). There were no missed injuries during the laparoscopic procedures in seven eligible studies. Laparoscopy for stable pediatric patients showed favorable outcomes in terms of morbidity and mortality. There were no missed injuries, and laparotomy could be avoided for the majority of patients.

Altered distribution, activation and increased IL-17 production of mucosal-associated invariant T cells in patients with acute respiratory distress syndrome.

OBJECTIVE: Mucosal-associated invariant T (MAIT) cells are a subset of innate-like T cells that are engaged in a number of diseases, but their roles in acute respiratory distress syndrome (ARDS) are not fully examined yet. This study aimed to examine levels and functions of MAIT cells in patients with ARDS. METHODS: Peripheral blood samples from patients with ARDS (n=50) and healthy controls (HCs, n=50) were collected. Levels of MAIT cells, cytokines, CD69, programmed cell death-1 (PD-1) and lymphocyte-activation gene 3 (LAG-3) were measured by flow cytometry. RESULTS: Circulating MAIT cell levels were significantly reduced in patients with ARDS than in HCs. MAIT cell levels were inversely correlated with disease severity and mortality. Cytokine production profiles in MAIT cells showed that percentages of interleukin (IL)-17 producing MAIT cell were significantly higher in patients with ARDS than in HCs. Patients with ARDS exhibited higher expression levels of CD69, PD-1 and LAG-3 in circulating MAIT cells. Moreover, levels of MAIT cells and expression levels of CD69, PD-1 and IL-17 in MAIT cells were higher in bronchoalveolar lavage fluid samples than in peripheral blood samples. Our in vitro experiments showed that MAIT cells triggered macrophages to produce proinflammatory cytokines such as tumour necrosis factor-α, IL-1ß and IL-8. CONCLUSIONS: This study demonstrates that circulating MAIT cells are numerically deficient in patients with ARDS. In addition, MAIT cells were found to be activated, migrate into lung, secrete IL-17 and then stimulate macrophages. These findings suggest that MAIT cells contribute to the worsening of inflammation in the lung of patients with ARDS.

Circulating Plasmacytoid and Conventional Dendritic Cells Are Numerically and Functionally Deficient in Patients With Scrub Typhus.

Background: Dendritic cells (DCs) are specialized antigen-presenting cells known to bridge innate and adaptive immune reactions. However, the relationship between circulating DCs and Orientia tsutsugamushi infection is unclear. Therefore, this study aimed to examine the level and function of plasmacytoid DCs (pDCs) and conventional DCs (cDCs), two subsets of circulating DCs, in scrub typhus patients. Methods: The study included 35 scrub typhus patients and 35 healthy controls (HCs). pDC and cDC levels, CD86 and CD274 expression, and cytokine levels were measured using flow cytometry. Results: Circulating pDC and cDC levels were found to be significantly reduced in scrub typhus patients, which were correlated with disease severity. The patients displayed increased percentages of CD86+ pDCs, CD274+ pDCs, and CD274+ cDCs in the peripheral blood. The alterations in the levels and surface phenotypes of pDCs and cDCs were recovered in the remission state. In addition, the production of interferon (IFN)-α and tumor necrosis factor (TNF)-α by circulating pDCs, and interleukin (IL)-12 and TNF-α by circulating cDCs was reduced in scrub typhus patients. Interestingly, our in vitro experiments showed that the percentages of CD86+ pDCs, CD274+ pDCs, and CD274+ cDCs were increased in cultures treated with cytokines including IFN-γ, IL-12, and TNF-α. Conclusions: This study demonstrates that circulating pDCs and cDCs are numerically deficient and functionally impaired in scrub typhus patients. In addition, alterations in the expression levels of surface phenotypes of pDCs and cDCs could be affected by pro-inflammatory cytokines.

Stent Graft Placement in the Top-Down Direction for Treating Traumatic Intra-Abdominal Suprahepatic Inferior Vena Cava Rupture: A Case Report.

PURPOSE: The treatment of suprahepatic inferior vena cava (IVC) ruptures results in high mortality rates due to difficulty in performing the surgical procedure. Here, we present a case of successful endovascular management of a life-threatening suprahepatic IVC rupture with top-down placement of a stent graft. CASE REPORT: A 33-year-old woman was involved in a traffic accident and presented to our emergency department due to unstable hemodynamics after blunt abdominal wall trauma. Computed tomography (CT) revealed massive extravasation of contrast agent from the suprahepatic IVC, which suggested traumatic suprahepatic IVC rupture. To seal the IVC, to salvage major hepatic veins, and to prevent migration of the stent graft into the right side of the heart after placement, an aortic cuff with a proximal hook was introduced in a top-down direction via the right internal jugular vein. After closure of the injured IVC, the patient's hemodynamics improved, and additional laparotomy was performed. After 3 months of trauma care, the patient recovered and was discharged. Follow-up CT after 58 months showed a patent stent graft within the IVC. CONCLUSION: Endovascular management with top-down placement of a stent graft is a viable option for emergent damage control in patients with life-threatening hemorrhage from IVC rupture.

The Efficacy and Safety of Laparoscopy for Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis.

The efficacy and safety of laparoscopy for blunt trauma remain controversial. This systemic review and meta-analysis aimed to evaluate the usefulness of laparoscopy in blunt trauma. The PubMed, EMBASE, and Cochrane databases were searched up to 23 February 2021. Meta-analyses were performed using odds ratios (ORs), standardized mean differences (SMDs), and overall proportions. Overall, 19 studies with a total of 1520 patients were included. All patients were hemodynamically stable. In the laparoscopy group, meta-analysis showed lesser blood loss (SMD -0.28, 95% confidence interval (CI) -0.51 to -0.05, I2 = 62%) and shorter hospital stay (SMD -0.67, 95% CI -0.90 to -0.43, I2 = 47%) compared with the laparotomy group. Pooled prevalence of missed injury (0.003 (95% CI 0 to 0.023), I2 = 0%), nontherapeutic laparotomy (0.004 (95% CI 0.001 to 0.026), I2 = 0%), and mortality (0.021 (95% CI 0.010 to 0.043), I2 = 0%) were very low in blunt trauma. In subgroup analysis, recently published studies (2011-present) showed lesser conversion rate (0.115 (95% CI 0.067 to 0.190) vs. 0.391 (95% CI 0.247 to 0.556), test for subgroup difference: p < 0.01). This meta-analysis suggests that laparoscopy is a safe and feasible option in hemodynamic stable patients with blunt abdominal trauma.

Failed angioembolization of a ruptured liver hemangioma complicated by iatrogenic injury of subclavian vein during catheter insertion.

In this study, we report a case of failed angioembolization of a ruptured liver hemangioma complicated by iatrogenic injury of the subclavian vein during catheter insertion. A 30-year-old woman experienced blunt trauma upon falling from her bed. Laceration of a seemingly preexisting hepatic hemangioma was diagnosed. No other injury was detected during a preoperative diagnostic workup. Subclavian vein catheterization was performed, followed by angioembolization to control bleeding due to the ruptured hemangioma. After angioembolization, the patient's systolic blood pressure and hemoglobin levels were 70 mmHg and 5.3 g/dL, respectively. She underwent emergency laparotomy. During the surgery, a large volume of blood in the abdominal cavity due to profuse bleeding from the ruptured hemangioma was observed. Because of a hemothorax found on chest radiography, we performed thoracoscopy, which revealed a large volume of blood in the right thoracic cavity and perforation of the subclavian vein by the catheter. After the damage-control surgery, the patient recovered safely. In this case, ruptured liver hemangioma complicated by subclavian vein catheter-related injury was treated safely using damage-control surgery. The catheter-related injury could be identified and treated using thoracoscopy.

Natural Killer T Cells Are Numerically and Functionally Deficient in Patients with Trauma.

Natural killer T (NKT) cells rapidly produce Th1 and Th2 cytokines such as interferon-γ (IFN-γ) and interleukin (IL)-4. This study examined the frequency and function of NKT cells in trauma patients. Frequencies, proliferative responses to α-galactosylceramide (α-GalCer), and Th1/Th2 cytokine secretion levels of NKT cells in peripheral blood mononuclear cells from trauma patients and healthy controls (HC) were measured by flow cytometry. Circulating NKT cell levels were significantly reduced in trauma patients. Proliferation and IFN-γ production of circulating NKT cells in response to α-GalCer were markedly decreased in trauma patients. CD69 expression levels produced by NKT cells were significantly upregulated in trauma patients compared to those in HC. In addition, annexin V+ NKT cells were profoundly increased in trauma patients after α-GalCer stimulation. Trauma patients had higher plasma levels of IL-6, IL-8, and TNF-α compared to HC. In particular, the proliferative response of NKT cells to α-GalCer was significantly decreased in the presence of these cytokines. Such decrease was partially recovered after treatment with blocking antibodies against these cytokines. This study demonstrates that circulating NKT cells are numerically deficient and functionally impaired in IFN-γ production in trauma patients. These findings provide an important insight into the trauma-related innate immune response.

Laparotomy following cardiopulmonary resuscitation after traumatic cardiac arrest: is it futile?

PURPOSE: The outcome of cardiopulmonary resuscitation (CPR) after traumatic cardiac arrest is very poor. Moreover, some consider laparotomy for abdominal trauma after CPR futile. This study aimed to investigate the outcomes of trauma patients who were pulseless and received CPR followed by laparotomy. METHOD: We conducted a retrospective review of 28,255 trauma patients from our hospital from January 2009 to November 2017. Patient demographics, injury severity scores, duration of CPR, operative data, and mortality of patients with laparotomy after CPR were collected and analyzed. RESULT: We identified 120 trauma patients (0.42%) who underwent CPR at admission. Twenty-three patients (0.08%) underwent laparotomy following CPR. Of these, 19 patients (82.6%) died after laparotomy. Of four survivors after laparotomy, three (13.0%) survived with a good neurologic outcome. One survivor required rehabilitation due to poor neurologic outcome. All patients had suffered a blunt injury. CONCLUSION: The survival rate for laparotomy following CPR after traumatic cardiac arrest was very poor. However, laparotomy following CPR is not always futile.

Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center.

BACKGROUND: Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center. METHOD: The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality. RESULT: Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80 min, p = 0.022), time from admission to operation (125 vs. 112 min, p = 0.010), time from admission to first treatment (119 vs. 99 min, p = 0.004), and time from admission to first transfusion (70 vs. 52 min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24 h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period. CONCLUSION: After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.

Activation and Impaired Tumor Necrosis Factor-α Production of Circulating Mucosal-Associated Invariant T Cells in Patients with Trauma.

Mucosal-associated invariant T (MAIT) cells rapidly produce proinflammatory cytokines in an innate-like manner and play an important role in controlling the host immune response. This study examined the function of MAIT cells in trauma patients. The expression of cytokines in peripheral blood MAIT cells was measured by flow cytometry. MAIT cells in trauma patients displayed impaired tumor necrosis factor (TNF)-α production, together with elevated CD69 expression. The expression of CD69 was negatively correlated with MAIT cell frequency. These patients had higher plasma levels of interleukin (IL)-12 and IL-18. In particular, CD69 expression of MAIT cells was increased by stimulation with IL-18 in synergy with other proinflammatory cytokines or plasma of trauma patients. The production of TNF-α by MAIT cells was characterized by an initial burst and rapid decline, in contrast to delayed and sustained production of interferon (IFN)-γ. Activated MAIT cells showed a functional defect in the production of TNF-α upon restimulation. This study demonstrates that circulating MAIT cells are activated and functionally impaired in TNF-α production in patients with trauma. The activation and dysfunction of MAIT cells was mediated by proinflammatory cytokines. These findings provide important information underlying the innate immune response of patients with trauma.

Gamma probe-guided confirmation of balloon placement in endovascular procedures.

BACKGROUND: Gamma probes can provide real-time information on lesion location and allow radioguided surgery in many diseases. The purpose of this study was to determine whether a gamma probe could be used to confirm balloon location in resuscitative endovascular balloon occlusion of the aorta and to determine the ease-of-use of the gamma probe localization method using human vasculature phantom and large animal. METHODS: This investigation comprised a proof-of-concept study using human vasculature phantom and feasibility study using large animal. An assistant and two general surgeons with no prior experience in handling a gamma probe participated in both studies. A gamma probe was used by each surgeon to explore the location of a catheter balloon filled with 8 mL of normal saline containing 37 MBq of Technetium. The differences between predicted and actual balloon locations and the times taken to perform the trials were recorded. Balloon locations were confirmed by planar gamma camera images. The results were analyzed and compared according to the operators and experiments. RESULTS: Overall sensitivity and specificity for the localization of the catheter balloon were 100% and 91% in phantom study, respectively, and 100% and 100% in animal study, respectively. The performance of the two operators for exploring the balloon location was similar in both the phantom and the animal studies. The mean time taken to explore the balloon locations with the aid of the gamma probe was only 2.36 minutes in phantom study and 2.65 minutes in the animal study. CONCLUSION: The gamma probe method was accurate and rapid for confirming balloon location. We suggest that the gamma probe has potential for confirming balloon placement in endovascular procedures without the need for fluoroscopy.

Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center.

PURPOSE: Pancreatic trauma is infrequent because of its central, deep anatomical position. This contributes to a lack of surgeon experience and many debates exist about its standard care. This study aimed to investigate the postoperative pancreatic fistula (POPF) and mortality of pancreatic trauma after operation. METHODS: We reviewed records in the trauma registry of our institution submitted from January 2006 to December 2016. The grade of pancreatic injury, surgical management, morbidity, mortality, and other clinical variables included in the analyses. RESULTS: Data from a total of 26,072 trauma patients admitted to the Emergency Department were analyzed. Pancreatic trauma was observed in 114 of these patients (0.44%). Laparotomy was performed in 81 patients (2 pan creatico duodenectomies, 2 pancreaticogastrostomies, peripancreatic drainage in 41 patients, distal pancreatectomies in 34 patients, and 9 patients who underwent surgery for damage control). The incidence of POPF was 38.3%. The overall mortality was 8.8% (7 of 81). In multivariate analysis, pancreas injury grade IV (≥4) (adjusted odds ratio [AOR], 4.071; P = 0.029) and preoperative peritonitis signs (AOR, 2.903; P = 0.039) were independent risk factors for POPF. All patients who died had also another major abdominal injury (≥grade 3). Multiorgan failure was a major cause of death (6 of 7, 85.7%). The mortality rate of isolated pancreas injury was 0%. CONCLUSION: The pancreas injury grade and preoperative peritonitis were significant risk factors of POPF. The mortality rate of isolated pancreatic trauma was very low.

Early postoperative small bowel obstruction after laparotomy for trauma: incidence and risk factors.

PURPOSE: This study aimed to investigate the incidence and risk factors of early postoperative small bowel obstruction (EPSBO) after laparotomy for trauma patients. METHODS: From 2009 to 2016, consecutive patients who had undergone laparotomy for trauma were retrospectively evaluated. EPSBO was defined as the presence of signs and symptoms of obstruction between postoperative days 7 and 30, or obstruction occurring anytime within 30 days and lasting more 7 days. RESULTS: Among 297 patients who met the inclusion criteria, 72 (24.2%) developed EPSBO. The length of hospital stay was significantly longer in patients with EPSBO than in those without EPSBO (median [interquartile range], 34 [21-48] days 24 [14-38] days, P < 0.001). Multivariate logistic analysis identified male sex (adjusted odds ratio [AOR], 3.026; P = 0.008), intraoperative crystalloid (AOR, 1.130; P = 0.031), and Abbreviated Injury Scale (AIS) score for mesenteric injury (AOR, 1.397; P < 0.001) as independent risk factors for EPSBO. The incidence of adhesive small bowel adhesion after 30 days postoperatively did not significantly differ between the 2 groups (with EPSBO, 5.6% without EPSBO, 5.3%; P = 0.571). Most of the patients with EPSBO were recovered by conservative treatment (95.8%). CONCLUSION: After laparotomy for trauma patients, the incidence of EPSBO was 24.2% in our study. EPSBO was associated with a longer hospital stay. Male sex, use of intraoperative crystalloid, and AIS score for mesenteric injury were significant independent risk factors for EPSBO. Patients with these risk factors should be followed-up more carefully.

Deficiencies of Circulating Mucosal-associated Invariant T Cells and Natural Killer T Cells in Patients with Multiple Trauma.

Mucosal-associated invariant T (MAIT) cells and natural killer T (NKT) cells are known to play important roles in autoimmunity, infectious diseases and cancers. However, little is known about the roles of these invariant T cells in multiple trauma. The purposes of this study were to examine MAIT and NKT cell levels in patients with multiple trauma and to investigate potential relationships between these cell levels and clinical parameters. The study cohort was composed of 14 patients with multiple trauma and 22 non-injured healthy controls (HCs). Circulating MAIT and NKT cell levels in the peripheral blood were measured by flow cytometry. The severity of injury was categorised according to the scoring systems, such as Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, and Injury Severity Score (ISS). Circulating MAIT and NKT cell numbers were significantly lower in multiple trauma patients than in HCs. Linear regression analysis showed that circulating MAIT cell numbers were significantly correlated with age, APACHE II, SAPS II, ISS category, hemoglobin, and platelet count. NKT cell numbers in the peripheral blood were found to be significantly correlated with APACHE II, SAPS II, and ISS category. This study shows numerical deficiencies of circulating MAIT cells and NKT cells in multiple trauma. In addition, these invariant T cell deficiencies were found to be associated with disease severity. These findings provide important information for predicting the prognosis of multiple trauma.