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Under investigation were specific features of the clinical picture in 34 patients with associated wounds of the heart and pericardium. Four dissimilar clinical groups were established. A comparative analysis of associated and isolated injuries (38 patients) has been made from the viewpoint of frequency of diagnostic errors, volume of the intraoperative blood loss and character of postoperative complications.
The management of the trauma victim admitted to the emergency department must be rapid and efficient. Within the first hour, vital functions must be stabilised while a systematic survey of all injuries is carried out. This survey must be as complete as possible, and depends on the patient's status and response to initial resuscitative measures. The need for urgent surgical intervention, therapeutic radiology, or other treatment modalities must be quickly established. This systematic approach, which follows a seven step sequence, can only be carried out by a well-trained team. Because at this time emergency and SMUR are often staffed with general practitioners, and because the trauma centers do not yet exist in Belgium, the application of the treatment protocol presented in this paper is a pre-requisite to quality of care for these patients. It is the only means to end, once and for all, the improvised or intuitive, and often erroneous, approach to these patients.
In a retrospect study we evaluated the clinical impact of traumatic rib fractures. Our series included 96 patients treated between 1986 and 1988. Haemato- and/or pneumothorax corresponded closely to the number of fractured ribs. There was a highly significant association (p less than 0.001) between the number of fractured ribs and polytrauma. The leading cause of injuries was a traffic accident.
Social and professional rehabilitation was studied in 77 patients who had sustained 1 to 5 years before a polytraumatism without brain or spinal cord injury. 36 patients (46%) remain professionally disabled, most of them manual workers, despite of long-term specific treatments. Only 41 patients (53%) judge their present quality of life good or satisfactory.
On the basis of 80 cases of traumatic lesion of the pelvis with associated vascular and visceral lesions, observed between 1985 and 1994 at the Department of Surgery in Modena and at the Rizzoli Orthopaedic Institute in Bologna, the options for diagnosis as related to the specificity of lesions are examined, and the choices of indications and surgical technique are illustrated.
The follow-up of 70 patients with trauma-related locomotor disorders proved that breathing exercises, vibratory massage, chest heparin electrophoresis, drug inhalations early after the injury can be effective in prevention and treatment of pulmonary complications. Transcutaneous neuroelectrostimulation noticeably enhanced the recovery of the locomotor function.
A patient with a severe liver injury and an acute cardiac failure due to a traumatic tricuspid valve failure is presented. During liver surgery, massive venous bleeding was caused by regurgitation of blood through the insufficient tricuspid valve. Right ventricular failure, leading to persistent hemodynamic instability, and caused by massive posttraumatic tricuspid regurgitation, has been treated with biological valve replacement. Diagnosis and management of posttraumatic tricuspid insufficiency are discussed.
OBJECTIVE: To investigate the activity of intravenous immunoglobulin (IVIG) as a prophylactic agent against infection in trauma victims. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: A 20-bed university intensive care unit. PATIENTS: Thirty-nine trauma patients with injury severity scores (ISSs) of 16-50. INTERVENTIONS: Penicillin was given at the time of admission and continued at least until day 4. Twenty-one patients received IVIG and 18 patients received human albumin at 1 g/kg in four divided doses (days 1, 2, 3, and 6). The two groups had similarities in age, gender, Acute Physiology and Chronic Health Evaluation II score, risk of death, and Glasgow Coma Scale score, but differing ISSs (p = .02), at the time of admission. Blood was collected on days 1, 4, and 7. MEASUREMENTS AND MAIN RESULTS: Clinical variables related to infection were recorded. The complement components C3c, C4 and CH50, IgG, and the fractions of IgG were measured. The serum bactericidal activity (SBA) was assessed at 37 degrees C (98.6 degrees F) and 40 degrees C (104.0 degrees F) at the time of admission and during the course of IVIG administration. Controlling for ISS, IVIG-treated patients had fewer pneumonias (p = .003) and total non-catheter-related infections (p = .04). Catheter-related infections (p = .76), length of stay in the intensive care unit, antibiotic days, and infection-related mortality did not differ between the two groups. A significantly increased trend in IgG and its subclasses was shown on days 4 and 7 in the IVIG group but not in the control group (p<.000001). No important differences were noted in complement fractions. The SBA of the groups was similar on day 1, but significantly higher on days 4 and 7 (p<.000001) in the IVIG group, remaining so controlling for complement and ISS. SBA was higher at 40 degrees C (104.0 degrees F) compared with 37 degrees C (98.6 degrees F) (p<.0001) under all three conditions. In both groups, low SBA (on days 1, 4, and 7) was associated with increased risk of pneumonia (p<.01) and non-catheter-related infections (p = .06 for day 1; p<.01 for days 4 and 7). CONCLUSIONS: Trauma patients receiving high doses of IVIG exhibit a reduction of septic complications and an improvement of SBA. Early SBA measurement may represent an index of susceptibility to infection.
BACKGROUND: Many nonthyroidal illnesses, such as major trauma, severe burn injury, sepsis or immune deficiency are associated with a reduced T3 concentration without increased serum TSH secretion. The pathopysiologic meaning of this phenomenon was controversely discussed since its investigation 20 years ago. The identification of the Type I 5-iodthyronine-deiodinase as a selenoenzyme brought many new aspects into this discussion. PATIENTS AND METHODS: To investigate the correlation of T3 blood levels and the selenium concentrations in consideration of the severity of the nonthyroidal illness 20 patients with major trauma where included in this study. In all these patients frequently T3, T4, fT3, fT4, TSH, Se (whole blood), Se (plasma) and Glasgow-Coma-Scale (GCS), APACHE II and MOF-Score where measured until the 28th day of illness. RESULTS: Five patients (20%) died during the study until the 8th day of measurement. Survivors and nonsurvivors initial showed a low T3 and fT3 level in serum. While the T3 serum concentrations of nonsurvivors remained on a low level the thyronine concentrations of survivors distinctly increased. The measured thyroid hormone concentrations were significantly correlated with MOF-score, APACHE II and inversely with GCS. There was no significant correlation between low T3/fT3 blood levels and low selenium concentrations in all observed patients. CONCLUSION: The selenium deficiency in all patients with major trauma seems to be not the single cause of the low T3 syndrome. The distinctly suppression of TSH could be caused by the action of various cytokines such as IL-6 and TNF-alpha. Further investigations should improve the effectivity of substitution of selenium and/or thyroid hormones in the therapy of patients with severe nonthyroidal illness.
The management of hepatic and splenic injuries in childhood has evolved over the past 30 years from prompt operation upon recognition of injury to nonoperative management in the large majority of children. Many aspects of nonoperative management have become increasingly standardized and efforts continue to further refine this strategy. The appropriate intensive care unit and acute care unit length of stay, the number of laboratory draws, the length of activity restriction and the need for radiographic evidence of healing prior to release from activity restriction remain areas of study. Previously demonstrated variation in the management and outcome of injured children between adult and pediatric surgeons has led to debate over which type of facility should best care for injured children. The Pennsylvania Trauma Systems Foundation dataset was used to derive a series of children with severe liver injuries. Finally, the risk of post-splenectomy sepsis, a stimulus for the initial development of nonoperative management, has been further clarified by a literature review. While falls from a low height may infrequently lead to a significant injury, falls from greater heights are more likely to induce a solid organ injury.
External fixation of fractures in polytraumatized patients normally should be regarded as temporary. After the patient's general condition is stabilized, in most cases it is necessary to change the procedure in order to provide sufficient mobility of joints, timely bony healing and early mobilisation. The earlier the transition toward internal osteosynthesis, the lower the complication rate. The follow up of 37 polytraumatized patients who were subjected to 50 changes of method after primary external fixation is described.
The typical presentation of hypoglycemia involves a diaphoretic patient with a history of diabetes mellitus who is found with an altered mental status. The hypoglycemic patient's presentation may lead the physician to believe that the altered mentation may have been caused by some other condition. Hypoglycemia occurs rarely in the traumatic setting, yet is easily and rapidly diagnosed with bedside testing. A retrospective review was conducted in a university hospital emergency department (ED) (level 1 trauma center) of adult trauma patients with a Glasgow Coma Scale (GCS) score of <15 who had presented from July 1995 through August 1996. Hypoglycemia was defined as a serum glucose level of <60 mg/dL. A total of 926 patients (49% of all trauma cases encountered in the period) met entry criteria. Four (0.4%) cases of hypoglycemia were encountered in 1 nondiabetic and 3 diabetic patients; no patient had medical alert warnings. Rapid bedside screening identified 2 cases within a mean of 7 minutes after arrival; 1 patient had an improvement in mental status after dextrose therapy. Two cases were identified by formal laboratory analysis a mean of 35 minutes after ED arrival; dextrose therapy improved the mental status in 1 patient. These results show that hypoglycemia, rare in trauma patients with abnormal GCS scores, may mimic significant traumatic injury with mental status alterations. Physicians should consider such a diagnosis in patients with an abnormal GCS score and known risk situations for hypoglycemia, including diabetes mellitus and chronic alcohol use; in such cases, appropriate bedside screening should be performed after initial stabilization.
STUDY OBJECTIVE: The aims of the study were to evaluate the technique of selective digestion decontamination (SDD) in preventing the development of nosocomial infections in a selected population and to assess the effects on colonization of the oropharynx, nares, and bronchi. A financial assessment was also performed. DESIGN: Prospective, double-blind, randomized placebo-controlled trial using amphotericin B, colistin sulfate (polymixin E), and gentamicin applied to the nares, the oropharynx, and enterally; no parenteral antibiotics were given during the study period. The SDD was applied every 6 h during the study period. SETTING: Multidisciplinary ICU in a university hospital. PATIENTS: A total of 148 trauma patients admitted emergently and intubated within less than 24 h were enrolled. Seventy-two patients who received placebo and 76 treated patients were analyzed on an "intention-to-treat" basis. INTERVENTIONS: Microbiologic surveillance samples of oropharyngeal and bronchial secretions, urine, and any other potentially infected sites were taken at the time of ICU admission and twice weekly thereafter until discharge from the unit. MEASUREMENTS AND RESULTS: With the use of SDD, colonization was significantly reduced in the oropharynx and nares (<0.05) but not in bronchi. However, episodes of bronchopneumonia were significantly reduced (19 in the active group vs 37 in the placebo group; p,0.01). Staphylococcus aureus remained the main potential pathogen causing bronchial colonization and subsequent bronchopneumonia. There was no reduction in the incidence of other infections. Days in the ICU, duration of mechanical ventilation, and mortality rate were unchanged. After the use of SDD, Gram-positive colonization tended to increase and this was mainly due to methicillin-resistant coagulase-negative staphylococci. The total cost of antibiotic therapy ($62,117 [US] in the placebo group and $36,008 in the SDD group) was decreased by 42% with the use of SDD. Clinically important complications of SDD were not encountered. CONCLUSIONS: The use of SDD in this population of trauma patients reduced the incidence of bronchopneumonia and the total charge for antibiotics. Stay in the ICU, mechanical ventilation, and mortality rate were unchanged. Methicillin-resistant coagulase-negative staphylococci were selected by SDD in some patients and the clinical relevance of this colonization needs further evaluation.
Hemorrhage after traumatic injury results in coagulopathy which only worsens the situation. This coagulopathy is caused by depletion and dilution of clotting factors and platelets, increased fibrinolytic activity, hypothermia, metabolic changes and anemia. The effect of synthetic colloids used for compensating the blood loss, further aggravates the situation through their specific action on the hemostatic system. Bedside coagulation monitoring permits relevant impairment of the coagulation system to be detected very early and the efficacy of the hemostatic therapy to be controlled directly. Administration of fresh frozen plasma (FFP), platelet concentrates and antifibrinolytic agents is essential for restoring the impaired coagulation system in trauma patients. Clotting factor concentrates should be administered if coagulopathy is based on diagnosed depletion of clotting factors, if FFP is not available and if transfusion of FFP is insufficient to treat the coagulopathy. Recombined FVIIa is frequently employed during severe bleeding which could not be treated by conventional methods but the results of on-going clinical trials are not yet available.
220 of 268 polytraumatized patients (82.1%) presented an additional head injury, which increased the mortality significantly. By the Hannover Polytrauma Score we could demonstrate that the severity of the polytrauma and the prognosis depended on the extent of the brain injury. Important risk factors were skull fractures and shock on arrival. 66.7% of the patients with a severe brain trauma and a skull fracture died; without this fracture, only 36.8% died. 76.1% of the children with a systolic blood pressure (SBP) > 80 mm Hg survived, but only 31.2% with a SBF < or = 80 mm Hg did not die. For all polytraumatized children we recommend a computer tomography of the head. In spite of a negative initial CT a follow up CCT should be performed.
The article touches upon the practical significance of methods of extracorporeal detoxication, pathogenesis of endotoxicosis, phases of its development. An analysis of data was made concerning treatment of 98 wounded and patients having injuries of three and more anatomical areas and who were in severe and critically severe states. Practical conclusions were made determining the expediency of using the methods of extracoprporeal detoxication in traumatic disease, special attention being given to optimization of functioning the detoxicating systems of organism.
A multidisciplinary approach to severe polytraumatized patient is very important for a rapid, uncomplicated recovery. Specialized centres with special beds, monitoring equipment, and a multidisciplinary team are required. The authors report a case of a 26-year-old man admitted to their department in an emergency setting for a crush injury (occupational trauma) of the lumbar, gluteal and perineal areas, complicated with septic shock and gas gangrene of the injured areas. A multidisciplinary approach to the patient, consisting in surgical and plastic surgical therapy, hyperbaric oxygen therapy and the use of a special antidecubitus fluidized bed allowed complete recovery within 7 months without any motor or sphincter disorders.
Tracheobronchial ruptures resulting from blunt chest trauma are rare events. Depending on their anatomical location and extension they may be nearly asymptomatic and escape early diagnosis, on the other hand they may induce an acute life-threatening situation with dramatic symptoms. The awareness of the different clinical and radiological findings may point to this lesion, the definite diagnosis, however, is made by bronchoscopy. A rapid surgical reconstruction intends to avoid severe late complications and to protect all uninjured lung areas for an adequate gas exchange in case of associated lung contusion. In patients with thoracoabdominal injuries, whether to perform thoracotomy or celiotomy first must be decided for each individual case depending on the urgency. The clinical course of a patient, who after a traffic accident suffered from main bronchus rupture, bilateral lung contusion, liver rupture and multiple fractures of the upper extremities illustrates these problems.