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KEY POINTS

KEY POINTS

  • Multiple organ failure (MOF) is defined as dysfunction of greater than one organ system.

  • Although multiple scoring systems of MOF exist (Marshall, Sequential Organ Failure Assessment, Denver), there is no gold standard.

  • MOF accounts for approximately 50% of delayed deaths in trauma.

  • The pulmonary, cardiac, and renal systems are affected first, usually within 3 days, followed later by derangements in hepatic function (>3 days).

  • Fifty percent of MOF mortality occurs within 3 days, with 80% of mortality occurring within 7 days.

  • Traumatic injury and resuscitation from hemorrhagic shock result in proinflammatory and anti-inflammatory responses, which affect multiple organ systems and can contribute to sequential organ dysfunction.

  • Prevention of MOF is directed at early resuscitation, avoidance of hypotension, protective lung ventilation, renal protection, and prevention of secondary infection.

HISTORICAL PERSPECTIVE ON MULTIPLE ORGAN FAILURE

With advances in emergency medical services, pharmacology, technology, surgical techniques, and other treatment modalities, the ability of the physician to keep a severely injured patient alive is ever increasing. As more patients have survived initial resuscitation, more patients potentially develop postinjury multiple organ failure (MOF), which has emerged as the leading cause of late trauma deaths.1-3

Many advances in trauma care, treatment modalities, and shock were initially stimulated by military need and experience only to be later refined in civilian trauma centers. In World War I, late battlefield casualties were attributed to the release of toxins from dead or dying tissue. Physicians during this time period, particularly Walter B. Cannon, first proposed the concept that hypovolemia is the inciting event that results in organ failure.4 This concept of hypovolemic shock was not expanded until many years later. In the 1930s, Alfred Blalock demonstrated that reduced circulating blood volume was the main cause of shock and mortality.5 This knowledge drove treatment modalities toward the restoration and normalization of blood pressure through volume expansion. Patients were resuscitated with freeze-dried plasma and later with stored whole blood. With early restoration of blood pressure, the rate of cardiac arrest observed in World War I decreased, but survivors more frequently developed renal failure. This practice of plasma and blood resuscitation continued into the Korean War, where additional advances in rapid battlefield transport helped improve overall battlefield survival. Patients who once died from hemorrhagic shock now survived initially, although many patients succumbed to late deaths from oliguric renal failure.

These late deaths led G. Tom Shires and others in the 1960s to propose that not only did hypotension lead to shock, but also extracellular or third space fluid deficits compounded the magnitude of traumatic shock. He demonstrated improved survival in animals with the addition of balanced salt solutions to shed blood during resuscitation.6 From this point until recently, crystalloids were used liberally in addition to blood and plasma resuscitation with the end points of resuscitation focused on maintaining adequate urine output. During this time period, ...

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