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PubMed1986

Pre hospital intensive care in multiple trauma children.

From January 1979 to December 1984, 1,272 calls, concerning injured children, aged 11 days to 15 years, justified the intervention of a Mobile Medical Emergency and Intensive Care Service, in the department of "Val-de-Marne" near Paris. Three hundred and twenty-two were very serious trauma children (25%); 45 were in cardiac arrest, and 41 died on the scene of the accident despite the intensive cares delivered by the anesthetists or pediatricians. Two hundred and eighty-one children were hospitalized in an intensive multiple trauma pediatric unit (97 cases) or in a neurosurgical pediatric unit (184 cases). The mode of accident was traffic accident (252), fall (48), fire arms (4), knife wounds (7), hanging or strangulation (9), others (2). They concerned 119 females and 203 males. 126 were multiple trauma children (40%). 37% of these accidents happened between May and July, and 40% occurred between 3 to 6 p.m. The 322 children immediately received medical care but 26% died during their hospitalization (17% in the first 24 hours). Thus mortality rate is 35% (114 cases).

Accidents, Traffic↗
PubMed1994

[Missed injuries of the musculoskeletal system in multiple trauma--a retrospective study].

In order to quantify frequency, localisation and consequences of missed musculoskeletal injuries in multiple injured patients, 323 cases were retrospectively analyzed. 40 primarily missed injuries were found, 12 of them in patients, who had been transferred from another hospital. This rate of 12.4% corresponds with the literature. Four regions are mainly affected: 1. the cervical spine, especially the cervicothoracic transition, 2. the shoulder, 3. the ligaments of the knee especially with femur or tibia fractures at the same time, and 4. the forefoot. About half of the primary missed injuries are ligament lesions. Whereas spine injuries were diagnosed within the first 2 weeks (average 4 days), ligament injuries (average 28 days) and foot injuries (average 38 days) were discovered at the patient's mobilization phase. Reasons for non detecting the injuries are: Missing or inadequate x-rays, not consistently continued diagnostic steps, inaccurate or not repeated clinical examination, apparent insignificance of peripheral injuries in multiple trauma. The potential danger of neurologic deficits of vertebral fractures, delay of rehabilitation due to secondary correction surgery (e.g. secondary ligament reconstructions) and imminent permanent damage (e.g. posttraumatic foot deformities) show the importance of a quick diagnosis of all injuries, even those appearing at the first glance as unimportant.

Diagnostic Errors↗
PubMed1993

Adaptation six months after multiple trauma: a pilot study.

This pilot study investigated the functional and psychosocial adaptation of 18 survivors of multiple trauma who were in the home setting 6 months after discharge from a tertiary trauma center. Seventeen subjects reported complete functional independence and one reported the need for assistance with self-care activities as measured by the Modified Barthel Index. All subjects reported problems with psychosocial adaptation as measured by the Psychosocial Adjustment to Illness Scale (PAIS). Subjects with high PAIS scores (worst adaptation) reported problems in all domains of the PAIS, whereas those with low PAIS scores (best adaptation) reported most problems in health care orientation. Mann-Whitney U tests were significant for gender, household composition and employment status when compared with low PAIS scores (p < 0.05). An analysis of variance confirmed employment status was the best predictive factor for low PAIS scores.

Abbreviated Injury Scale↗
PubMed1989

Pulmonary problems following multiple trauma in children.

Acute respiratory failure (ARF = hypoxemia and/or hypercapnia) is a frequent finding in the polytraumatized patient. Multiple injury is often accompanied by injury of the central nervous system, and the presence or absence of ARF may play a key role for survival and late morbidity. This paper reviews the incidence of pulmonary problems after severe head injury and the possible dysfunctions of the respiratory apparatus following single or multiple trauma. Diagnostic work-up in ARF includes consideration of the mechanisms of injury, clinical examination, determinations of arterial blood gases and chest radiographs which are all essential for the choice of an effective treatment. This frequently includes supportive treatment by continuous positive pressure ventilation.

Child↗
PubMed1992

[Management of multiple traumas: possibilities and limitations in a general hospital].

The chances and the limits in the treatment of patients with multiple trauma are discussed on the example of the Marienkrankenhaus Trier-Ehrang. Definite conditions concerning to the rooms, the staff and the organisation must be realized. Most important is the cooperation between the anaesthesiologist and the surgeon. Short distances, short times and a well trained team are advantageous. If computed tomography and angiography are not available the diagnostical facilities are limited. Severe cranial trauma and spine fractures must be transferred to a special medical centre.

Accidents, Occupational↗
PubMed2006

Managing the blue man: multiple traumas involving a paint-carrying truck.

INTRODUCTION: This report describes the difficulty in evaluating a patient with multiple traumas because he was covered with paint poured from a truck in a car accident. Cleansing with paint thinner and isotonic saline solution was necessary. CASE REPORT: A 29-year-old male patient was admitted to the emergency department following the collision of his car with a paint-carrying truck. His head, face, neck and hands were covered with a cyan-blue oil paint, and bloody "paint mud" covered all frontal and occipital areas of the scalp. Abdominal guarding was identified. A rapid cleansing with normal saline solution (0.9% NaCl) was attempted in order to expose the lesions of the patient, but it had no effect on the drying paint. The patient's scalp, face and neck were cleaned with paint thinner (60% toluene). The patient was then diagnosed as having a maxillofacial fracture and underwent surgery for open reduction and rigid fixation by plastic and reconstructive surgeons. Thinner was not used for the eyes for fear of further chemical injury. Normal saline removed corneal and conjunctival paint remnants but proved ineffective for cleansing of the eyelids and eyelashes. CONCLUSION: Removal of the paint from the skin and the eyes was a prerequisite for the evaluation of the underlying structures. It is difficult to find a cleansing material that can be used effectively and safely in different parts of the body.

Accidents, Traffic↗
PubMed1990

HTLV-I viral-associated myelopathy after blood transfusion in a multiple trauma patient.

This may be the first documented case in the United States and in the orthopedic literature of transfusion-transmitted human T-cell leukemia virus Type I (HTLV-I)-associated myelopathy (HAM). Progressive myelopathy occurred in a 58-year-old white man with serologic and molecular evidence of HTLV-I infection after multiple trauma and subsequent transfusion with multiple units of banked blood products. Symptoms of myelopathy occurred 15 months after the transfusions. Myelopathy from HTLV-I infection simulates a disorder of orthopedic interest. Physicians should be aware of the symptoms of HAM and unexplained myelopathy.

HTLV-I Antibodies↗
PubMed1997

[Injuries of the urinary system and management in multiple trauma cases].

Some of the most common lesions in patients with multiple traumas are injuries to the urinary system. A blunt trauma of the abdomen mainly leads to injuries of the kidney, ureter and/or bladder, whereas the external genitals are often damaged by contusions, decollements and even amputation. The multiply traumatized patient must necessarily be cared for and treated through an interdisciplinary cooperation. Thus, "urologisation" of the condition must be avoided, as must the non-recognition of urological injuries. Iatrogenic lesions are primarily observed in the context of urological, gynecological and surgical interventions. Immediate recognition may lead to early treatment, thereby avoiding possible, complications. The procedure for treating multiply traumatized patients will be shown using a plan of specific steps. Symptoms of injuries to the genitourinary system are usually not obvious. In most cases micro- and macro-hematuria are the leading symptoms, but they are not always demonstrable. In the acute phase the drainage of urine must be protected. It is mainly during the third step that urological lesions require surgical treatment. Catheterisation of the urethra may only be performed when the possibility of injury to it is excluded.

Amputation, Traumatic↗
PubMed1993

Infection prevention in patients with severe multiple trauma with the immunomodulator beta 1-3 polyglucose (glucan).

In a effect to prevent nosocomial pneumonia and sepsis, we treated patients with severe multiple trauma with an immunomodulator--beta 1-3 polyglucose (glucan). Forty-one patients with no infection at admission were stratified using Trauma Score and included in a randomized double-blind controlled trial. They were divided into a control group (n = 20) and a glucan group (n = 21). Pneumonia occurred in 11 of 20 patients in the control group and in two of 21 recipients of glucan (p < 0.01). Sepsis occurred in seven of 20 patients in the control group and in two of 21 patients treated with glucan (p < 0.05). Considering patients with pneumonia and sepsis, a decrease was observed in nosocomial infection from 65.0 to 14.4 percent (p < 0.001). The mortality rate related to infection was 30.0 percent in patients in the control group and 4.8 percent in the group treated with glucan (p < 0.05). The general mortality rate, cerebral deaths excluded, was 42.1 percent in the control group and 23.5 percent in the glucan group.

Adjuvants, Immunologic↗
PubMed1996

Airbag protection versus compartment intrusion effect determines the pattern of injuries in multiple trauma motor vehicle crashes.

OBJECTIVE: A prospective study of the interaction between airbag (AB) and seat-belt (Bt) protection versus vehicular compartment (VC) intrusion effects on injury patterns in motor vehicle crash (MVC) trauma patients. METHODS: Two hundred MVC patients, nonejected drivers or front seat passengers with multiple trauma or severe lower extremity (LE) trauma admitted to two Level I trauma centers. RESULTS: In frontal crashes, airbags (AB) more than Bt reduced Glasgow Coma Scale severity in brain injury, face fracture, shock, and the need for MVC extrication (all p < 0.05). Frontal AB also had a protective effect on LE fractures (41% vs. 66%, p < 0.01), but had no significant protective effect on pelvic fractures. When AB protection was present, it prevented brain and face fracture injuries caused by impact contacts and reduced the incidence of these injuries resulting from VC intrusions (p < 0.05). Thoracoabdominal injuries resulting from steering wheel intrusion showed AB protection against intrusions of twice the magnitude of those seen in non-AB vehicles (p < 0.05). In frontal MVCs, AB reduced LE fracture contact injuries but did not prevent LE fractures resulting from intrusions of instrument panel, toepan, or floor pedal structures. In lateral MVCs, Bt did not protect against brain, face, thorax, or pelvic injuries. CONCLUSIONS: Safety measures beyond frontal airbags must address frontal crash LE injuries induced by steering wheel, instrument panel, and toepan passenger compartment structure intrusions. Lateral crash injuries may profit from side AB supplemental restraint protection.

Accidents, Traffic↗
PubMed1995

[A complicated case of multiple trauma in a 40-year old male patient].

The method, algorithm and result of treatment of 40 years old patient with multiple trauma has been presented. Despite ruptured diaphragm and pericardium, sub-diaphragm displacement of the heart and supra-diaphragm transposition of the stomach and bowels the final result was entirely positive.

Adult↗
PubMed1989

Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome.

Three hundred forty-three multiple trauma patients with major pelvic ring disruption were studied and subdivided into four major groups by mechanism of injury: antero-posterior compression (APC), lateral compression (LC), vertical shear (VS), and combined mechanical injury (CMI). Acetabular fractures which did not disrupt the pelvic ring were excluded. The mode of injury was: MVA, 57.4%; motorcycle, 9.3%; fall, 9.3%; pedestrian, 17.8%; crush, 3.8%. The LC and APC groups were divided into Grades 1-3 of increasing severity. The pattern of organ injury: including brain, lung, liver, spleen, bowel, bladder, pelvic vascular injury (PVASI), retroperitoneal hematoma (RPH) and complications: circulatory shock, sepsis, ARDS, abnormal physiology, and 24-hr total fluid volume administration were all evaluated as a function of mortality (M). As LC grade increased from 1 to 3 there was increased % incidence of PVASI, RPH, shock, and 24-hr volume needs. However, the large incidence of brain, lung, and upper abdominal visceral injuries as causes of death in Grade 1 and 2 fell in LC3, with limitation of the LC3 injury pattern to the pelvis. As APC grade increased from 1 to 3 there was increased % injury to spleen, liver, bowel, PVASI with RPH, shock, sepsis, and ARDS, and large increases in volume needs, with important incidence of brain and lung injuries in all grades. Organ injury patterns and % M associated with vertical shear were similar to those with severe grades of APC, but CMI had an associated organ injury pattern similar to lower grades of APC and LC fractures. The pattern of injury in APC3 was correlated with the greatest 24-hour fluid requirements and with a rise in mortality as the APC grade rose. However, there were major differences in the causes of death in LC vs. APC injuries, with brain injury compounded by shock being significant contributors in LC. In contrast, in APC there were significant influences of shock, sepsis, and ARDS related to the massive torso forces delivered in APC, with large volume losses from visceral organs and pelvis of greater influence in APC, but brain injury was not a significant cause of death. These data indicate that the mechanical force type and severity of the pelvic fracture are the keys to the expected organ injury pattern, resuscitation needs, and mortality.

Accidents, Traffic↗
PubMed1989

Biochemical and hormonal parameters in patients with multiple trauma.

We measured amount, course and duration of different parameters in order to assess metabolic-endocrine changes in patients with multiple trauma and the final outcome. Injures were initially quantified according to the Injury Severity Score. Serum levels of lactate, creatinine, bilirubin, somatomedin and thyroid hormons were measured in 51 patients (39 survivors, 12 deceased patients) for six days following the injury. In addition, neopterin levels were measured in 26 patients (19 survivors, 7 deceased patients). The patients were devided into two groups (survivors vs non-survivors). Global Index Scores and Septic Severity Scores were significantly different at the 1% and 5% level (p less than 0.05 to p less than 0.01). The same statistical differences were shown for lactate, somatomedin, neopterin and thyroid hormones.

Biomarkers↗
PubMed1993

Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma.

We investigated the effects of primary (< or = 24 h) intramedullary femoral nailing on lung function and pulmonary hemodynamics in patients with multiple trauma. Two groups were separated: the group with primary femoral nailing with reaming (group RFN) was submitted to femoral nailing after reaming of the medullary canal; in the group with unreamed femoral nailing (group UFN) a small-diameter solid nail was inserted without reaming. Lung function was assessed by oxygenation ratio (PaO2/FIO2), and pulmonary hemodynamics by intraoperative pulmonary artery catheter measurements. Central venous blood concentrations of elastase and the platelet count were determined during and 3 days after surgery. Lung function was stable in UFN patients (n = 14), but deteriorated in RFN patients (n = 17) from 353 +/- 24 (PaO2/FIO2 preoperatively) to 260 +/- 28 (PaO2/FIO2 postoperatively) (p < 0.05) and improved only after 48 hours. Pulmonary artery pressure (PAP) did not change during surgery in UFN patients; in RFN patients PAP increased from 27.2 +/- 3.1 mm Hg (preoperatively) to 36.3 +/- 4.1 mm Hg (p < 0.05) upon reaming and normalized 1 hour after insertion of the nail. Femoral nailing after reaming represents a potential risk with respect to lung function disturbances. This might trigger the development of adult respiratory distress syndrome (ARDS), especially in patients at extra risk of this complication (additional lung contusion, "borderline patient"). In these cases unreamed femoral nailing might offer an alternative by allowing primary intramedullary stabilization without the risk of adverse effects to the lung.

Adult↗
PubMed2000

[Comminuted fractures in multiple trauma patients: an analysis of 31 cases].

PURPOSE OF THE STUDY: We analyzed calcaneum burst fractures in multiple trauma patients and propose a management scheme. MATERIAL AND METHODS: In a retrospective study, we isolated 23 patients with 31 calcaneum burst fractures. All were stage V in the Duparc classification. We call them "pied de mine" fractures as they resembled those described in military reports. Half of them (16 cases; 54%) were open fractures. All patients suffered multiple injuries and 12 had a psychiatric history. These fractures were associated with spinal fracture in 17 cases (73%) and half had neurologic deficit, limb fracture in 16 (73%), and pelvic fracture in 12 (52%). The most frequent associated foot injuries were a talus fracture in 9 cases (29%) and Chopart displacement in 10 cases (32%). Clinical evaluation used the Maryland foot score, foot print and radiologic evaluation with lateral retrotibial view. RESULTS: Mean follow-up was 35 months. Mean Maryland foot score was 62.7 and 13 cases were pain free. Pain was due to conflict with the lateral malleolus, bony plantar thorns, medial malleolus and subtalar osteoarthritis. Orthopedic shoes were used 11 times. The other patients used sports shoes. Subtalar mobility was most frequently absent (23/29 cases, 2 amputations). Foot print showed 13/16 flat feet; 6 thorns were indirectly visible. Two patients had retraction toes and were initially treated by external fixation. Radiologic evaluation showed 23/29 complete subtalar arthrodeses, 23/29 migration of the great tuberosity, often(17/23 cases) associated with varus angulation. Eleven patients needed subsequent surgery: 5 for arthrodeses and 6 for resection of bony thorns. Rate of complication was high, especially for open fractures: 2 infections for 15 closed fractures, and 8 infections (50%) for 16 open fractures with 2 cases of chronic osteitis. Secondary amputation was required in 2/31 cases due to sepsis. TREATMENT PROPOSITIONS: For closed calcaneum burst fractures, it is better to wait one week before osteosynthesis. This delay is used to decrease edema with limb elevation and compressive bandaging. Skin tension due to trauma is increased by edema and osteosynthesis gives a high risk of wound disunion. We recommend reduction and Y-plate fixation even for burst fracture. Reduction must lower the tuberosity and correct the varus. After surgery, subtalar spontaneous arthrodesis is usually observed in a good position. Any bony plantar thorn must be resected. For open calcaneum burst fracture, the risk of sepsis is high. First treatment is debridement, stabilization and external fixation with antibiotic therapy. Stabilization should improve vascularization and facilitate internal fixation. The external fixation can be placed on the medial side to free the lateral approach to the calcaneum. Flap repair can be performed after one week when skin tension has subsided and areas of necrosis controlled.

Adult↗
PubMed2000

Comparison of methods of measurements of oxygen consumption in mechanically ventilated patients with multiple trauma: the Fick method versus indirect calorimetry.

OBJECTIVE: The purpose of this study was to compare the measurements of whole body oxygen consumption determined by the Fick method and by indirect calorimetry in mechanically ventilated patients with multiple trauma. DESIGN: A prospective, correlational, within-subjects design. SETTING: Surgical intensive care unit of a Level I trauma center. PATIENTS: Thirty-eight mechanically ventilated adults with multiple injuries who received a pulmonary artery catheter within 24 hrs of admission to the surgical intensive care unit. MEASUREMENTS AND MAIN RESULTS: After the initial resuscitation, simultaneous measurements of oxygen consumption (V(O2) by the reverse Fick equation and by indirect calorimetry were performed every 6 hrs for 24 hrs in normothermic patients who were at rest for at least 30 mins. At each measurement period, the mean V(O2) values determined by indirect calorimetry were significantly greater than the mean V(O2) values determined by the Fick method (time 1: 172+/-38 vs. 125+/-47 mL/min/m2, p < .0001; time 2: 170+/-31 vs. 130+/-48 mL/min/m2, p < .0001; time 3: 170+/-32 vs. 132+/-53 mL/min/m2, p < .0001; time 4: 169+/-29 vs. 130+/-60 mL/min/m2, p < .0002). By using the Bland and Altman technique, the mean bias was 41+/-3.95 mL/min/m2. Correlation coefficients of VO2 values between methods of measurements were statistically significant (r2 = .32, p = .0001; r2 = .32, p = .0001; r2 = .33, p = .0001; r2 = .18, p = .0001). CONCLUSIONS: Indirect calorimetry should be the preferred standard for measurement of oxygen consumption in severely injured patients.

Adult↗