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PubMed1994

Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes.

OBJECTIVES: To determine the hemodynamic responses to blunt trauma with a closed-head injury and to investigate the effect that volume resuscitation has on intracranial pressure. DESIGN: Prospective study with retrospective analysis of patient data and hemodynamic responses. SETTING: Surgical intensive care unit at an inner-city, Level I trauma center. PATIENTS: Consecutive patients (n = 30) who sustained multiple system injury, including a closed-head injury that was severe enough to require intracranial pressure monitoring but not a craniotomy. INTERVENTIONS: All patients underwent invasive hemodynamic monitoring with percutaneous arterial and pulmonary arterial catheters. Serum lactate concentrations and hemodynamic and oxygen transport variables were measured every 4 hrs. Intracranial pressures and vital signs were recorded each hour. Attempts were made to achieve a state of nonflow-dependent oxygen consumption and a normal serum lactate concentration. MEASUREMENTS AND MAIN RESULTS: Despite being normotensive and neither tachycardiac nor oliguric, 80% of patients had evidence of inadequate tissue perfusion. Only 50% of the remaining patients had an adequate response to volume. The other 50% received vasodilating inotropic agents. Despite volume loading and the administration of inotropic agents, intracranial pressure did not increase. This observation was found in patients who showed clinically important intracranial pathology on computed tomography scan, as well as in all other patients. Intracranial pressure did not correlate with the amount of fluid or blood infused or with hemodynamic performance, but intracranial pressures did correlate with serum lactate concentrations. CONCLUSIONS: Many patients with diffuse blunt trauma closed-head injuries, even when they are normotensive, have evidence of impaired peripheral perfusion. Volume infusion and vasodilating inotropic support improve oxygen transport without increasing intracranial pressure. The observed relationship between intracranial pressure and the serum lactate concentration requires further study.

Adolescent↗
PubMed1998

Assessment of the relationship between timing of fixation of the fracture and secondary brain injury in patients with multiple trauma.

BACKGROUND: It has been suggested that early fixation of a fracture is deleterious to eventual neurologic outcome. We undertook this study to determine whether the timing of fracture fixation is correlated to neurologic outcome. METHODS: We retrospectively reviewed patients with severe head and orthopedic injuries requiring fracture fixation. Patients were divided into two groups: early fracture fixation (< 24 hours after injury) and late fracture fixation (> 24 hours after injury). RESULTS: One hundred twenty-three patients met entry criteria. During fracture fixation, the early group had a significant 2-, 3-, and 2-fold increase in crystalloid, blood infusion, and blood loss, respectively. There was no difference in oxygen saturation and systolic blood pressure or episodes of cranial hypertension or hypoperfusion. There was no difference in outcomes as measured by in-hospital complications, stay in the intensive care unit or hospital, mortality rates, hospital discharge or follow-up Glasgow Coma Scores, or long-term orthopedic or neurologic results. CONCLUSIONS: Patients undergoing fracture fixation with severe head injury mandate monitoring of intracranial pressure and perfusion and tailored fluid resuscitation to meet specific organ end points. Integrating end organ perfusion and pressure with meticulous fluid status during the definitive repair phase may reduce the exposure to secondary brain injury in patients undergoing early fracture fixation.

Adult↗
PubMedDate not supplied

[Early mortality following multiple trauma: a retrospective study].

Early mortality after polytrauma: a retrospective study. The medical charts of all patients, who died in 1986 in the reanimation phase after an accident, were reviewed. Twenty-five patients (86%) were victim of a traffic accident, 2 of an accident at work and 2 of an accident at home. The average ISS of the 29 patients was 40.7. The patients, who received the first aid at the place of accident from an emergency doctor, had an average ISS of 44.2. The patients, who received the first aid from a team without doctor had an average ISS of 33.8. The first aid was given after an average time of 10 minutes. Ten patients were transported during the reanimation phase from the first hospital to our trauma center. Eighteen patients died due to a severe craniocerebral trauma, eight of them were transported secondarily. Six patients died due to hemorrhagic shock, only in two patients an emergency doctor was at the place of accident. Five patients died due to asphyxia after a thoracic trauma. This retrospective study clearly demonstrates that the first aid of a polytraumatized patient must be given at the place of accident by an emergency doctor, that a quick and direct transport to a regional trauma center is desirable, that a more aggressive shock therapy is necessary and that the first aid-team must be able to evacuate a tension-pneumothorax at the preclinical scene.

Adult↗