Aortic dissection after trauma: case report and review of the literature.
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Accidents, Traffic↗
Biomedical subjects
S R Shackford
Publications and source records attributed to S R Shackford.
High-risk behavior and the public burden for funding the costs of acute injury.
OBJECTIVE: To determine if high-risk behavior is associated with increased injury severity and cost and if public agencies bear a disproportionate burden of that cost. DESIGN: Case comparison study utilizing patient data collected over a 10-year period. SETTING: Five level 1 and 2 trauma centers in an urban-suburban community with a population of 2.4 million. PARTICIPANTS: Trauma registry data from 37,304 consecutive hospitalized adult patients with trauma. Financial data were reported and analyzed on 28,842 of these. MAIN OUTCOME MEASURES: Incidence of alcohol intoxication, other drug use, use of vehicular protective devices, and firearm violence injuries in patients with private vs public health care sponsorship. Length of hospital stay, injury severity, and hospital unit charges were assessed for high-risk behavior. RESULTS: High-risk behavior was more prevalent among trauma patients relying on public funding to cover the costs of their injuries (P < .001). Total hospital unit charges were 28% and 35% higher for motorists not wearing seat belts and motorcyclists not wearing helmets, respectively. Injury severity and length of stay were also higher (P < .001). CONCLUSIONS: High-risk behavior is associated with increased injury severity and cost. Trauma victims exhibiting high-risk behavior more often depend on public agencies to cover the cost of acute injury. Failure to establish and enforce laws and policies designed to reduce or prevent injury may generate enormous trauma care costs, borne to a large extent by public agencies. Further restriction of certain types of high-risk behavior and the institution of "users' fees," taxes, or penalties may be necessary to reduce the disproportionate public agency cost generated by this activity.
Acute Disease↗
The evolution of modern trauma care.
The implementation of trauma systems has decreased the incidence of preventable death following injury and improved the quality of trauma care. Further improvements in outcome are unlikely to result from conventional therapies. Future strategies must include renewed interest in prevention and abrogation of secondary injury by modification of clinical protocols and manipulation of the inflammatory response by using molecular technologies.
California↗
Colloid infusion after brain injury: effect on intracranial pressure, cerebral blood flow, and oxygen delivery.
OBJECTIVES: We sought to determine the effects of colloid osmotic pressure on cerebral edema formation after brain injury. We hypothesized that an increase in plasma oncotic pressure accompanying a colloid infusion would be associated with a decrease in intracranial pressure and increases in cerebral blood flow and oxygen delivery when compared with isotonic crystalloid. DESIGN: Prospective, laboratory study. SETTING: University surgical research laboratory. SUBJECTS: Adult swine, both genders. INTERVENTIONS: Cryogenic brain injury with intravenous fluid infusion of either lactated Ringer's solution or 6% dextran-70 in normal saline. The effect of this intervention was monitored for 24 hrs. MEASUREMENTS: Mean arterial pressure, central venous pressure, intracranial pressure, hemoglobin concentration, plasma oncotic pressure, serum osmolality, cerebral blood flow, and specific gravity of cortical biopsies. RESULTS: Cryogenic injury significantly increased the cortical water content and the intracranial pressure and significantly decreased the cerebral blood flow and oxygen delivery (p < .05). Dextran infusion significantly increased the colloid oncotic pressure. There were no differences between the lactated Ringer's solution and dextran groups in intracranial pressure, cerebral oxygen delivery, or cortical water content after 24 hrs. CONCLUSIONS: Colloid infusion after a focal cryogenic injury does not increase cerebral oxygen delivery or reduce either cerebral edema formation or intracranial pressure when compared with lactated Ringer's solution. Colloid is not superior to isotonic crystalloid in the management of isolated brain injury.
Animals↗
Organ injury scaling: spleen and liver (1994 revision).
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Humans↗
Delayed presentation of splenic artery pseudoaneurysms following blunt abdominal trauma: case reports.
Splenic artery pseudoaneurysms are known to be caused by either pancreatitis or operative trauma. We present two patients who had delayed presentation of splenic artery pseudoaneurysms secondary to blunt abdominal trauma. This is the first report of splenic artery pseudoaneurysms following trauma and demonstrates the importance of follow-up computed tomography scans in patients with splenic injuries who are treated nonoperatively.
Abdominal Injuries↗
Epidemiology of rural traumatic death in children: a population-based study.
To determine the epidemiology of traumatic death in pediatric patients in a rural state, we reviewed all deaths caused by injury in victims < 19 years old between 1985 and 1990. We hypothesized that mortality would be higher than equivalent populations in urban areas. During the study period, 5,322 children were hospitalized for trauma (14% of total admissions for children in the state) and 36 died (0.67%). For this subgroup, head injury was the most common cause of death (72%). When compared with data from the National Pediatric Trauma Registry from urban centers, the mortality rate for hospitalized children in this rural state was lower (0.67% vs. 2.7%, p < 0.001). On review of the population-based statistics for the entire state, we found that these numbers were deceivingly low. In all, 731 children died during the study period, of which 283 were determined by autopsy or coroner's report to have died of trauma (38.7%). Eighty-seven percent of children who died never reached the hospital. Mortality (age-adjusted) was highest in the 15- to 18-year-olds (68.5 of 100,000), then < 1-year-old (26.8 of 100,000), 1- to 5-year-olds (15.6 of 100,000), and 5- to 14-year-olds (11.8 of 100,000), which significantly exceeds the predicted national averages for these age groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls.
OBJECTIVE: To determine the effect of the timing of fracture fixation and the physiologic status on admission of elderly patients with hip fractures from low impact falls on resource utilization and outcome. METHODS: A 5-year retrospective review of 82 elderly (age > 65 years) patients with isolated low-impact hip fractures stratified into early (< 24 hours), intermediate (24 to 72 hours), and late (> 72 hours) operative fixation. Admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores, number of comorbidities, fracture type, complication rate, length of stay, discharge acuity, and mortality were calculated for each group. RESULTS: Values are mean +/- SD. The mean admission APACHE II score of the entire group was 8.1 +/- 0.2, indicating that these patients were physiologically stable on arrival. The mean numbers of comorbidities or APACHE II were not significant between groups. No differences existed in the mean APACHE II scores for survivors and nonsurvivors (7.95 +/- 2.34 vs. 9.17 +/- 3.06, p = 0.2409). There were no differences in the mean APACHE II scores and predicted survival for each group. However, a significant decrease in actual survival was observed with late fixation (p < 0.001; Fisher's Exact Test). Patients who were fixed late also had a significantly higher infectious morbidity (p = 0.00469), length of stays (p = 0.0226), and total hospital cost (p = 0.0001), compared with those fixed early or immediate, despite having no difference in average acuity upon discharge (p = 0.3883). CONCLUSIONS: Delay in fracture fixation, in elderly patients who are physiologically stable on admission, significantly increases morbidity and mortality and adversely affects resource utilization.
APACHE↗
U83836E reduces secondary brain injury in a rabbit model of cryogenic trauma.
Oxygen-derived free radicals have been implicated in secondary brain injury after head trauma. Although oxygen-free radicals may be derived from multiple sources, the activation and accumulation of neutrophils in areas of brain injury is a potential source of deleterious inflammatory mediators, including free radicals, which may exacerbate the primary insult. Neutrophils may also impede the cerebral microcirculation by congestion and occlusion of postcapillary venules. The lazaroid U83836E is a potent-free radical scavenger that inhibits lipid peroxidation. U83836E was studied in a cryogenic model of cerebral injury in pretreatment paradigm. Fifteen rabbits received a unilateral cryogenic brain lesion. Six animals received U83836E, and nine animals received vehicle only. Arterial blood gases, hematocrit, temperature, and mean arterial pressure were controlled in physiologic range throughout the experiment. Intracranial pressure was continuously monitored. Lesion size was determined by triphenyltertrazolium chloride staining and planimetric image analysis. Neutrophil aggregation and oxygen-free radical generation was assessed in whole blood by impedance aggregometry and simultaneous luminol-mediated chemiluminescence, respectively. Myeloperoxidase assay was used to determine neutrophil accumulation within the brain. Elevations in intracranial pressure from baseline values were significantly greater in the untreated (control) animals at all time points (p < 0.0001). Mean lesion size (% hemisphere +/- SEM) was significantly reduced in animals receiving U83836E (4.41 +/- 0.64, n = 6) when compared with controls (15.09 +/- 2.28, n = 9, p < 0.001). A reduction in both the release of oxygen-free radicals and in neutrophil aggregation following the cryogenic injury in the U83836E animals correlated with a smaller lesion volume.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Neurogenic pulmonary edema in fatal and nonfatal head injuries.
Impaired pulmonary function is a frequent but poorly understood complication of acute head injury (HI). A potential early contributor to the pulmonary dysfunction seen in HI patients is neurogenic pulmonary edema (NPE). We hypothesized that NPE would occur early after HI and that it would have a continuum of clinical severity depending on the severity of the HI and associated intracranial hypertension. A large autopsy data base and inpatient HI data base were used to search for cases of NPE. Patients in the autopsy data base were stratified according to injury type and whether they died at the scene or within 96 hours of injury. There were significant (p < 0.0001, analysis of variance) elevations in lung weights in patients dying at the scene and within 96 hours from HI, compared with those dying from other noncentral nervous system injuries. No other organs studied showed significant weight increases. The incidence of NPE in isolated HI patients dying at the scene was 32%. In patients with isolated HI dying within 96 hours, the incidence of NPE was 50%. We found an inverse correlation (r = 0.62; p < 0.0014) between the initial cerebral perfusion pressure and the PaO2/FIO2 ratio despite a normal-appearing chest x-ray film. We conclude that NPE occurs frequently in HI patients. The process of edema formation begins early in the clinical course and is isolated to the lung.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Organ injury scaling. VI: Extrahepatic biliary, esophagus, stomach, vulva, vagina, uterus (nonpregnant), uterus (pregnant), fallopian tube, and ovary.
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Biliary Tract↗
Routine prophylactic vena cava filter insertion in severely injured trauma patients decreases the incidence of pulmonary embolism.
BACKGROUND: Trauma patients are at increased risk for venous thromboembolism despite routine prophylaxis. A five-year retrospective review of pulmonary embolism at the Medical Center Hospital of Vermont showed that four types of injuries (head injuries, spinal cord injuries, complex pelvic fractures, and hip fractures) accounted for 92 percent of pulmonary emboli in patients on the trauma service. STUDY DESIGN: Beginning July 1991, all patients who met criteria for a high-risk injury (excluding hip fractures) had prophylactic vena cava filters inserted percutaneously in the radiology suite. Weekly impedance plethysmography was performed for the detection of deep vein thrombosis. Following discharge, abdominal duplex ultrasound was performed at one month, six months, and yearly to check filter position and patency. RESULTS: To date, a total of 63 patients, or 2 percent of the total trauma population, had prophylactic vena cava filters inserted. There were 19 (30 percent) deep vein thromboses in this population of patients and one patient had a pulmonary embolism (1.5 percent). Overall there was significant (chi-square, p < 0.00072) reduction of pulmonary embolism on the trauma service compared to the historical controls. Follow-up examination with abdominal duplex ultrasound showed a 30-day patency rate of 100 percent and a one- and two-year patency rate of 96.1 +/- 3.8 percent by life-table analysis. CONCLUSIONS: We concluded that prophylactic vena cava filters are efficacious in decreasing the risk of pulmonary embolism in high-risk trauma patients.
Adult↗
Prompt fixation of isolated femur fractures in a rural trauma center: a study examining the timing of fixation and resource allocation.
Early fixation is defined by most authors as fracture fixation within 24 hours of admission. This definition of early is arbitrary and may not be achievable in a rural environment where interhospital transfer is often required and operating room resources are constrained. A review of isolated femur fractures was performed to determine if prompt fixation (24-72 hours, Early) was more effective than late fixation (> 72 hours, Late) and similar to immediate fixation (< 24 hours, Immediate) with regard to complications, mortality, and resource utilization. Between October 1, 1987 and December 31, 1990, 67 patients were admitted and stratified into one of the three groups based on the timing of fixation. The number of emergency operations was significantly greater in the Immediate group and the surgery took significantly longer to perform than in either the Early or Late groups (p < 0.004; ANOVA). There were significantly fewer pulmonary and infectious complications in the Immediate and Early groups compared with the Late group (p < 0.05, chi 2). Fixation of isolated femur fractures after 24 hours but before 72 hours had morbidity similar to fixation within the first 24 hours, but utilized operating room resources more efficiently.
Adult↗
Blunt traumatic thoracic aortic lacerations in the elderly: an analysis of outcome.
We found no previous work examining outcome after blunt traumatic aortic laceration (TAL) that has focused on elderly patients (age > 55 years) with this lesion. A 20-year retrospective review from two trauma centers of survival outcome for patients with TAL was performed to assess the effects of surgical therapy in the elderly cohort. Seventy-five cases were identified. Patients were assigned to one of two groups (Young < 55 or Old > or = 55) and data were analyzed for differences between them. There was a significantly higher mortality rate in the elderly patients (82.4% Old vs. 12.1% Young; p < 0.001). Moreover, surgical treatment in the Old group had up to a 163-fold increased likelihood of mortality compared with surgical treatment in the Young group (p < 0.001). We conclude that Old patients have higher mortality associated with surgical repair of TAL. Because of the increased risk of surgical intervention for TAL, elderly patients may be candidates for nonsurgical management as has been advocated for patients with asymptomatic peripheral traumatic pseudoaneurysms.
Adolescent↗
Brain edema formation after brain injury, shock, and resuscitation: effects of venous and arterial pressure.
BACKGROUND: Recent work suggests that increased intracranial pressure (ICP) following brain injury and shock is related to increased central venous pressure (CVP) following resuscitation. OBJECTIVE: To analyze the relationship of intravascular pressures to edema formation and ICP in an experimental model. METHODS: In a porcine model of cryogenic brain injury and hemorrhagic shock, we studied CVP, mean arterial pressure (MAP), ICP, and cortical water content (CWC, as cortical specific gravity) at baseline (BL), 45 minutes after shock (H45), and 1, 3, 6, 12, and 24 hours (H) after resuscitation. Group 1 was the control group, group 2 brain injury only, group 3 shock only, and group 4 brain injury and shock. RESULTS: Brain injury significantly increased ICP and CWC. Mean arterial pressure significantly correlated with ICP (r = 0.54, p = 0.02) and with CWC (r = -0.48, p = 0.03) in group 4 at 24H but not in the other groups at any time period. There was no significant correlation between CVP and ICP or CWC in any group at any time interval. CONCLUSIONS: These data suggest that brain edema formation in the injured hemisphere is related to MAP and not CVP, but variability in MAP accounts for only 29% of the variability in CWC and ICP, suggesting the importance of factors other than hydrostatic pressure in determining the amount of edema and the ICP after brain injury. Previous work demonstrating the significant correlation of polymorphonuclear leukocyte infiltration with ICP (r = 0.71, p < 0.001) and with CWC (r = -0.63, p < 0.001) suggests that inflammation may be one of these factors.
Animals↗
The spectrum of blunt injury to the carotid artery: a multicenter perspective.
The relative infrequency of blunt carotid artery trauma prompted a multicenter review to determine the spectrum of injuries, treatment strategies, and neurologic outcome. During a six-year period, 60 carotid artery injuries from blunt mechanisms in 49 patients were treated at 11 institutions. There were 11 bilateral injuries. Injury mechanisms were diverse but involved motor vehicles in 35 (72%) patients. In 14 (29%) patients, significant neurologic deficits developed more than 12 hours after a normal admission neurologic examination. The diagnosis was confirmed by angiography in 42 (86%). Duplex ultrasound accurately demonstrated the arterial injury in 12 (86%) of 14 patients. Documented injuries included arterial thrombosis in 20 arteries, arterial dissection alone in 19, dissection with pseudoaneurysm in six, pseudoaneurysm alone in five, frank arterial disruption in seven, and carotid-cavernous fistula in three. Arterial dissection was managed nonsurgically in 15 (79%) of 19 cases, the majority with systemic anticoagulation. Arterial thrombosis was managed with supportive therapy alone for 16 (80%) of 20 arteries; most associated with fixed neurologic deficits. Pseudoaneurysm repair was performed for six (55%) injuries. Carotid-cavernous fistulas were treated in all three instances with balloon occlusion. Overall mortality was 16 of 49 patients (43%). Good neurologic outcome was achieved in 22 (45%) patients. We conclude that: (1) Neurologic symptoms may develop in a delayed fashion; prior clinical suspicion and diagnostic testing are essential; (2) arterial dissection without complete occlusion may effectively be managed by anticoagulation; (3) pseudoaneurysms in accessible anatomic locations can be repaired with good results; and (4) injuries with complete arterial thrombosis are associated with high mortality and poor neurologic outcome in proportion to the initial degree of neurologic impairment.
Adolescent↗
The relationship of fluid balance and sodium administration to cerebral edema formation and intracranial pressure in a porcine model of brain injury.
BACKGROUND: Fluid and sodium restriction have been advocated after brain injury as a means of controlling intracranial pressure (ICP). Recent clinical data showing no significant relationships between the amount of fluid infused or sodium administered (Na) and ICP question this practice. OBJECTIVE: To analyze the relationship of amount of fluid, Na, and fluid balance to cerebral edema formation and ICP. METHODS: A cryogenic brain injury with and without hemorrhagic shock was studied after 24 hours in swine (n = 35) randomized to receive either lactated Ringer's solution (LR) or hypertonic sodium lactate (HSL). Cerebral edema formation as indicated by cortical water content (CWC) was determined by measurement of specific gravity. RESULTS: There was a significant positive correlation between the following variables: (1) amount of fluid and ICP (r = 0.598; p < 0.01); (2) fluid balance and ICP (r = 0.684; p < 0.01); and (3) free water and ICP (r = 0.614; p < 0.01). There was a significant negative correlation between serum osmolarity and ICP (r = -0.654; p < 0.01). The study failed to demonstrate a significant correlation between Na and ICP, amount of fluid and CWC, or fluid balance and CWC. CONCLUSIONS: These data suggest that both the volume of fluid infused and the fluid balance do affect the ICP, but the amount of Na infused does not. The lack of a significant correlation between any of the independent variables and CWC suggests that their effect on ICP is not related to cerebral edema formation. These findings, combined with the observed significant positive correlation between free H2O infused and ICP, and the significant negative correlation between serum osmolarity and ICP, suggest that HSL resuscitation increases intracranial compliance after brain injury while LR decreases it. The data also suggest that free water restriction is warranted in patients with head injuries.
Animals↗