[Trauma surgery in the USA (II): Restricted use of antibiotics in septic reaction after multiple trauma].
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Anti-Bacterial Agents↗
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Results for “Multiple Trauma”
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Acute IGF-1 deficiency in multiple trauma victims.
The circulating levels of IGF-1 in the catabolic flow phase of injury were measured in multiple trauma victims once before nutritional support and again after 4 days of intravenous feeding. The hypermetabolic and highly catabolic state of injury is characterized by a diminished level of IGF-1 along with increased levels of stress hormones. Inverse relationships of adiposity and aging on IGF-1 levels are seen both in injured and uninjured subjects. Feeding could restore the IGF-1 levels in non-obese, young patients but it is delayed in obese or elderly subjects. This diminished responsiveness to feeding of IGF-1 hormone deficiency in obese and elderly subjects should be taken into consideration in their post-trauma treatment and may warrant adjuvant administration in these types of patients.
Journal Article↗
[A case of hepatic pseudoaneurysm treated with percutaneous embolization in a child with multiple trauma].
Hepatic artery pseudoaneurysms are rare complications of blunt abdominal trauma in children. Diagnosis is frequently delayed and made by splanchnic angiography. Most of the indications for surgical treatment have disappeared after the development of selective catheterization and embolization. We report a case in an 8-year-old pedestrian who was struck by a car and suffered a multiple trauma with a severe blunt abdominal trauma. A severe collapse upon admission commanded immediate laparotomy that depicted a liver fracture with associated jejunal and pancreatic lesions. Recovery was progressive until the 15th postoperative day where an abrupt haemobilia occurred. A CT-scan exploration was performed and revealed a vascular mass lesion in the left lobe of the liver. The performance of a selective angiography confirmed the diagnosis of left artery pseudoaneurysm, but because of technical difficulties, no embolization could be performed by this way. A direct percutaneous puncture and embolization of the aneurysm allowed a complete exclusion of the lesion. Eventually, recovery was complete. This percutaneous technique could be a valuable alternative to classical embolization and could avoid surgical treatment that still carries a high morbidity.
Aneurysm, False↗
[Emergency nursing and the multiple trauma patient].
The most important characteristics of nursing care of the acutely ill patients in the accident and emergency ward are safety and continuity. To work under pressure in periods and to handle many tasks at the same time also are important features. This kind of nursing care is very intensive. A patient's vital functions are of the first priority. There is no room for own feelings. Those can be analyzed afterwards. When the condition of a patient is stabilized there is time for holistic nursing and to look for his/her capability to self-care. The nurses of Töölö Hospital (University Central Hospital of Helsinki) describe the nursing care of the multiple trauma patient. The work is rewarding, one can see the results immediately.
Acute Disease↗
Olive oil based nutrition in multiple trauma patients: a pilot study.
OBJECTIVE: A negative effect of hyperglycemia on clinical outcome has been proposed for patients treated under intensive care conditions. So far, however, the safety and effect of fat based nutrition regimen, especially of olive oil based emulsions, have not been systematically studied. DESIGN AND SETTING: Prospective, open-labeled, randomized, pilot study in a 14-bed surgical intensive care unit. PATIENTS AND INTERVENTIONS: Thirty-three consecutive, severe multiple trauma patients (injury severity score 31.6+/-11.5) were included; 18 (L group) received a parenteral lipid-based nutrition; 15 (G group) were given a standard parenteral glucose-based nutrition. MEASUREMENTS AND RESULTS: The energy expenditure (EE) showed no difference between groups and no significant difference between the energy intake/EE ratio. The daily mean energy intake was lower in the L group (17.9+/-6.3 kcal/kg) than in the G group (22.3+/-4.2 kcal/kg). Triglycerides and nitrogen balance showed no significant differences between groups. The L group had significantly lower blood glucose (L 7.4+/-1.6, G 8.7+/-1.6 mmol/l), carbon dioxide production, and minute volume and shorter duration of mechanical ventilation (L 13.0+/-8.9, G 20.4+/-7.0 days), and stay in the ICU (L 17.9+/-11.2, G 25.1+/-7.0 days). CONCLUSIONS: Our findings suggest a good tolerance, a decrease in blood glucose, clinically relevant shortening of ICU stay, and shorter time on mechanical ventilation for patients treated with olive oil based than with conventional glucose-heavy nutrition.
Adult↗
Multiple trauma in pediatric patients.
We analyzed the causes and diagnoses, the treatment, short and long-term outcome of a consecutive series of 70 pediatric polytrauma patients. From 1989 to 1996, 70 children (aged 10 months to 16 years, mean 7.4 years) presented with multiple trauma. A follow-up investigation was performed 4.2 years (mean) after the accident. Traffic accidents (68%) were the leading cause of injuries. Among all injuries (mean ISS 24.6 range 17-57), injuries of the head/neck area were most frequent (87%) followed by extremity fractures (76%) and 135 operations were performed on 55 children, mostly for fracture stabilisation. All multiple injured children survived. At discharge 25 children were still impaired (36% of 70). At follow-up 58 patients were revisited, 11 (19% of 58) presented with impairments, 8 of those (73% of 11) following severe head trauma. This study showed a 10% rate of late impairment due to the severity of the primary head trauma.
Adolescent↗
Use of the kinetic treatment table to prevent the pulmonary complications of multiple trauma.
The kinetic treatment table (KTT) has been developed to prevent and treat complications of immobility. Because atelectasis and pneumonia may be related to immobility, we studied the effect of the KTT on the prevention and treatment of pulmonary complications in a prospective randomized study of 30 patients with severe traumatic injuries. All were receiving mechanical ventilation and were randomly assigned to treatment with a KTT or a conventional bed. Both groups received conventional medical-surgical therapy while pulmonary function, chest roentgenograms, and the presence or absence of lung infection were monitored for one week. In the patients who began the study with a clear chest roentgenogram, atelectasis and pneumonia were significantly less frequent in those treated with a KTT (P less than .05). Thus, the KTT can reduce pulmonary complications in selected patients with multiple trauma. The effect of this benefit on overall outcome is uncertain.
Adolescent↗
[Case report of severe multiple trauma. Anesthesiologic techniques].
The modern anaesthetic devices have now put an end to the sixties-fashioned aphorism: "Closed circuit=open coffin". The currently renewed interest in the recirculation systems is justified by the following reasons: economic benefit; environmental advantages; clinical features, such as: 1) better humidification of gases; 2) better preservation of warmth; 3) monitoring of O2 consume; 4) gas analysis on each respiratory act. This allows the use of fresh gases at low flow without the risk of hypoxia or overdosage in patients and it guarantees for safe anaesthesia. The following clinical case clearly shows the application of the above mentioned principles. An extremely serious case of head, chest and abdominal multiple trauma, personally observed, is described. The so called technics "partial rebreathing" was adopted thanks to the availability of a device which permits a punctual monitoring of SAO2, ETCO2, FI and FET, FLO2, VM, VT, VEmin, % of N2O, invasive SAP and body temperature. These are very important parameters for a safe anaesthesia and in conditions like those of the above described clinical case.
Adult↗
[Quality assessment of multiple trauma management bu ISS, TRISS or ASCOT?].
OBJECTIVES: Scores have been developed to assess the quality of trauma treatment. Our objective was to investigate prospectively whether there is a significant difference between the predicted survival and mortality rates with ISS, TRISS and ASCOT and observed rates in our patients. If the answer is affirmative, we also wished to evaluate whether the difference is significant enough to justify the greater data collection effort required for ASCOT as opposed to TRISS, and for TRISS as opposed to ISS. PATIENTS AND METHODS: Charts from 470 of 484 blunt multiple trauma patients with an ISS of 8 or more documented as part of a National Fund Study between June 1990 and June 1996 were reviewed. We compared the survival and mortality rates calculated by ISS, TRISS and ASCOT with the observed survival and death rates. RESULTS: Only the predicted survival and death rates calculated by ISS differed significantly from the observed rates. There were also significant differences between ISS and TRISS, and ISS and ASCOT, with regard to the predicted rates. CONCLUSIONS: In our unit ISS, which is simple to use, is not suitable for quality assessment. TRISS and ASCOT are of equal value. We prefer TRISS until a better, internationally recognised score is available, since it involves less effort and is less error-prone. General recommendations for Switzerland cannot be made until further results from other national accident and emergency units are available.
Adolescent↗
Severity measurement in multiple trauma by use of ICDA conditions.
We report here the results of a study of grading injury severity for patients with multiple traumatic injuries from ICDA codes listed on the face sheets of hospital medical records. We developed a method of scoring the severity of individual ICDA traumatic injuries with use of data from the NCHS Hospital Discharge Survey. When tested on a set of patients having multiple trauma conditions (also from the NCHS Hospital Discharge Survey), these scores had a strong relationship with fatality. The development of an injury severity index based on ICDA codes has considerable impact on the feasibility of conducting studies involving large numbers of patients hospitalized with traumatic injuries.
Diagnosis-Related Groups↗
Admission surgery for the multiple trauma patient. Statistics from a Level I trauma center.
This is the report on a study of patients admitted to a Level I trauma center. For a description of a trauma unit and a detailed analysis of the perioperative nurse's role in caring for the trauma patient in the OR, please see the accompanying article, "Perioperative nursing care of the multiple trauma patient: When seconds count."
Clinical Protocols↗
Evaluation of an artificial neural network to predict urea nitrogen appearance for critically ill multiple-trauma patients.
BACKGROUND: Computer-based simulated biologic neural network models have made significant strides in clinical medicine. METHODS: To determine the predictive performance of a conventional regression model and an artificial neural network for estimating urea nitrogen appearance (UNA) during critical illness, 125 adult patients admitted to the trauma intensive care unit who required specialized nutrition support were studied. The first 100 consecutive patients were used to develop the 2 models. The first model used stepwise multivariate regression analysis. The second model entailed the use of a feeding-forward, back-propagation, supervised neural network. Bias and precision of both methods were evaluated in 25 separate patients. RESULTS: Multivariate regression analysis revealed a significant highly correlative relationship (r(2) = .918, p < or = .01): Predicted UNA (g/d) = (0.29 x WT) + (1.20 x WBC) + (0.44 x SUN) with WT as current body weight in kg, WBC as white blood cell count in cells/mm(3), and SUN as serum urea nitrogen concentration (mg/dL). The regression method was biased toward overestimating measured UNA, whereas the neural network was unbiased. Precision (95% confidence interval) of the neural network was significantly better than the regression (3.3-7.2 g vs 7.3-11.6 g, respectively, p < .01). Regression analysis successfully predicted UNA within 3 g of measured UNA in 16% (4 of 25) of patients, whereas the neural network successfully predicted UNA in 44% (11 out of 25) of patients (p < .06). CONCLUSIONS: These preliminary data indicate that use of an artificial neural network may be superior to conventional regression modeling techniques for estimating UNA in critically ill adult multiple-trauma patients receiving specialized nutrition support.
Adult↗
Early physiologic predictors of injury severity and death in blunt multiple trauma.
The importance of admission physiological and biochemical variables was modeled on data from 185 patients with blunt liver trauma with regard to their significance in prediction of mortality. The variables used were admission Glasgow Coma Score, base excess (or deficit), arterial lactate, Injury Severity Score, and initial 24-hour volume of blood required for replacement. Each variable was modeled as a predictor of survival alone and in combination, using a linear logistic model. In any two-variable combination, Glasgow Coma Score had a high likelihood ratio for prediction representing the influence of brain injury. But as a single variable reflecting the probability of death, both base excess (LD50 = -11.8 mmol/L) and initial 24-hour volume of blood (LD50 = 5.4 L) were highly significant. A combined logistic model of admission Glasgow Coma Score and base excess had the greatest likelihood of accurate prediction of outcome: P death = e lambda/l + e lambda; where lambda = -0.21(Glasgow Coma Score) -0.147(base excess) + 0.285. Testing of this predictive model on data from 323 additional patients with multiple trauma who had pelvic fracture as their index injury also showed it to be a highly significant early predictor of outcome.
Fluid Therapy↗
[Effect of severe multiple trauma complicated by acute lung injury on endothelial cell activity].
The pulmonary endothelium synthesizes many bioactive compounds and their activation or injury may cause release these substances into the blood. We determined the influence of trauma severity for endothelium activation/injury by measurement of specific endothelial cell markers--soluble E-selectin (sES) and von Willebrand factor antigen (vWF:Ag). Thirty six severely traumatized patients were stratified according to an Injury Severity Score (ISS). Group I--patients with ISS > or = 35, Group II--patients with ISS < 35. Eleven healthy volunteers served as controls. Serum sES and plasma vWF:Ag concentrations were measured and PaO2/FiO2 ratio, Lung Injury Score (LIS) and APACHE II ratio were calculated at the admission to IC, after 24 h and on 2, 3, 5, 7, 10th day. In all investigated time periods, we observed significant increase in serum sES concentration among patients from group I, in comparison to initial value and control. On day 3, serum sES concentration was significantly increased in group I, in comparison to group II. In the first seven days, plasma vWF:Ag concentration in patients with severe multiple trauma (ISS > or = 35) was significantly elevated, in comparison to group II and control. At the admission, significant correlation between plasma vWF:Ag and ISS was found (Rs = 0.568, p < 0.001). Significant correlation between plasma vWF:Ag and serum sES concentration was also observed (Rs = 0.501, p < 0.001). In conclusion, severe trauma patients manifest endothelial cell activation/injury. Plasma vWF:Ag concentration seems to be an important, early marker of trauma severity, while serum sE-selectin level may serve as prognostic factor in immediate postinjury period course.
APACHE↗
The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial.
OBJECTIVE: Evaluation of selective decontamination of the digestive tract (SDD) on late mortality in ventilated trauma patients in an intensive care unit (ICU). METHODS: A multicenter, randomized controlled trial was undertaken in 401 trauma patients with Hospital Trauma Index-Injury Severity Score of 16 or higher. Patients were randomized to control (n=200) or SDD (n=201), using polymyxin E, tobramycin, and amphotericin B in throat and gut throughout ICU treatment combined with cefotaxime for 4 days. Primary endpoint was late mortality excluding early death from hemorrhage or craniocerebral injury. Secondary endpoints were infection and organ dysfunction. RESULTS: Mortality was 20.9% with SDD and 22.0% in controls. Overall late mortality was 15.3% (57/372) as 29 patients died from cerebral injury, 16 SDD and 13 control. The odds ratio (95% confidence intervals) of late mortality for SDD relative to control was 0.75 (0.40-1.37), corresponding to estimates of 13.4% SDD and 17.2% control. The overall infection rate was reduced in the test group (48.8% vs. 61.0%). SDD reduced lower airway infections (30.9% vs. 50.0%) and bloodstream infections due to aerobic Gram-negative bacilli (2.5% vs. 7.5%). No difference in organ dysfunction was found. CONCLUSION: This study demonstrates that SDD significantly reduces infection in multiple trauma, although this RCT in 401 patients was underpowered to detect a mortality benefit.
Adult↗
Multiple organ dysfunction syndrome (MODS) following multiple trauma: rationale and concept of therapeutic approach.
The multiple organ dysfunction syndrome (MODS) represents the number one cause of death in surgical intensive care units. It is divided into a primary and a secondary MODS based on time of manifestation and pathophysiologic events which attribute to it. The therapy of the primary MODS includes sufficient and quick resuscitation, adequate oxygen delivery and early enteral nutrition to reduce or avoid the incidence of bacterial translocation. In addition, a reduction of the "antigenic load" by control of hemorrhage, radical wound debridement, decompression, and fixation of long bone fractures appears to be effective in reducing the occurrence of MODS. The treatment of the secondary MODS remains supportive and its prevention is essential. Further studies are necessary to evaluate the clinical significance of new therapeutic agents such as monoclonal antibodies or cytokine receptor antagonists.
Humans↗
The variable effect of PEEP in acute respiratory failure associated with multiple trauma.
Both short and longterm effects of positive end-expiratory pressure (PEEP) on oxygenating capacity (OC) were investigated in three groups of patients with acute respiratory failure following multiple trauma (MT). Group A consisted of six patients with "uncomplicated" MT; Group B, eight patients with MT and generalized sepsis; Group C, nine patients with MT and lung contusion. OC was evaluated in terms of PaO2/FIO2 and P(A-a)DO2 on FIO 2 = 1.0. OC was markedly and equally reduced in the three patient groups before use of PEEP. The use of a mean PEEP of 6-7 cm H2O resulted in an initial improvement in mean PaO2/FIO2 of 152.5, 36.1, and 59.2 mm Hg, and an overall improvement of 196.8, 57.5, and 107.0 mm Hg in Groups A, B, and C, respectively. There was a similar improvement in both the initial and the overall effect of PEEP on P(A-a)DO2 in the three groups. The difference in the improvement in OC due to PEEP was statistically significant between Groups A and B. It is concluded that acute respiratory failure following MT includes a wide spectrum of clinical syndromes, and that the improvement in OCT due to PEEP depends on the clinical sydrome that is responsible for the respiratory failure associated with MT.
Acute Disease↗
[The meaning of the term multiple trauma].
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Humans↗