New guidelines for treating severely injured patients

If someone is injured in an automobile collision or is severely burned, emergency room physicians across the country would probably take similar steps to stabilize each condition. But subsequent treatment in the intensive care unit or operating room is less well established and may vary significantly.

That is likely to change based on the work of an interdisciplinary team of dozens of scientists and physicians funded by the National Institute of General Medical Sciences (NIGMS). Drawing from the best available evidence, the team is developing a series of standard procedures for the care of severely injured patients. The guidelines will describe how to implement the most successful treatment protocols in the clinic and will include summaries of each procedure ready to print on 3-by-5 index cards for quick bedside reference.

The team's first article--on mechanical ventilation--appeared in the September 2005 issue of the Journal of Trauma: Injury, Infection, and Critical Care. Planned future topics will cover resuscitation, prevention and treatment of venous blood clots, diagnosis of ventilator-associated pneumonia, blood sugar control, nutritional support, transfusion thresholds, and sedation. The team chose to cover aspects of care for which practices vary the most and those that have the greatest potential to influence patient outcomes.

The scientific team is part of a collaborative, NIGMS-supported initiative called the Inflammation and Host Response to Injury "glue grant" program. Glue grants bring together scientists with diverse expertise to address major biomedical questions that are beyond the scope of any one research group--in this case, to uncover why patients who experience comparable traumatic injuries can have dramatically different outcomes. This project was launched in 2001 with a 5-year award totaling $37 million.

"This program shows how partnerships between clinical and basic researchers can speed the pace of improving medical practices," said NIH Director Elias A. Zerhouni, M.D. "Combining cutting-edge basic science tools with clinical know-how is a powerful formula for solving complex medical problems."

The outcomes for trauma and burn patients often depend on the strength of their inflammatory response to their injury. Inflammation helps the healing process in many cases, but an excessive response can lead to multiple organ failure, a common cause of death following a traumatic injury.

"Thanks to the increased skills of paramedics and first responders, more and more severely injured patients are making it to the emergency room," said Ronald Maier, M.D., director of the team's clinical group and surgeon-in-chief at Harborview Medical Center in Seattle. But with this change come new challenges. "What we're now faced with is treating the patient's own aberrant response to the injury, which can cause far more damage than the injury itself."

While the magnitude of the injury and the quality of care affect the inflammatory response, the patient's genetic make-up is also thought to contribute. To pinpoint the relevant genetic factors, the researchers are looking for gene activity patterns that correlate with specific outcomes. All nine of the clinical institutions participating in the project are adopting the standard practices, which will make these genetic patterns easier to discern.

"Establishing standard treatment procedures is an important first step in improving patient care," said NIGMS Director Jeremy M. Berg, Ph.D. "But we expect the real breakthrough to come when genetic data from the project helps physicians tailor treatments for each critically injured patient."

While the inflammation glue grant focuses on the care of patients once at the hospital, a complementary NIH program, the Resuscitation Outcomes Consortium, aims to improve patient survival before an injured person reaches the emergency room.