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PubMed2002

[Reasons for lethal outcomes in severe multiple trauma].

The article is based on an analysis of causes and terms of lethal outcomes of 490 patients after a severe combined trauma. Lethal outcome in 16.9% of the patients took place within an hour after admission to clinic. Within the first 24 hours died 50.2% of the patients, during the second day--8%, on the third day--8.4%. At the period from 3 to 7 days 14.3% of the patients died, during the second week--11.8% of the patients, 7.3% survived for more than 14 days. One direct cause of death was shown in 73.5% of cases, in 21.6%--there were two and in 4.9%--three causes. Acute massive blood loss was the direct cause of death of 43.9% of the patients, critical injury of the brain--in 25.1%, pneumonia--in 27.6%, sepsis--in 6.9%. Altogether 26 causes of lethal outcomes were formulated.

Humans↗
PubMed1994

[Blood coagulation parameters as prognostic factors in multiple trauma: can clinical values be an early diagnostic aid?].

INTRODUCTION: Polytraumatized patients develop complex changes in blood coagulation and fibrinolysis even before their arrival at the emergency room (ER). Hemostaseological parameters (i.e. antithrombine 3, alpha-2-antiplasmine, D-dimers) obtained upon admission however, permit advance differentiation of later mortality vs. survival and of possible future secondary organ failure with varying specification. OBJECTIVES: Which clinical findings enable to identify such patients early in the ER even when no specialized hemostaseological laboratory is available? MATERIAL AND METHODS: a) Prospective study of 40 polytraumatized adults upon arrival at the hospital; b) Blood sampling at the earliest possible time during takeover in the ER; c) Injury Severity Score (ISS) for descriptive purposes; d) Evaluation of the prehospital emergency physician's records in regard to respiratory therapy, fluid resuscitation, and arterial blood pressure; e) Statistics; Wilcoxon test, Spearman correlation coefficient. RESULTS: All 40 patients (m:f = 28:12; mean age: 36 (SD: 16.6) years; mean ISS: 34.7 (SD: 11.4)) displayed advanced disseminated intravascular coagulation with secondary hyperfibrinolysis upon arrival in the ER. The amount of deviation from the hemostaseological norm could not be derived from either the correlation of the typical activated parameters of coagulation of fibrinolysis with the ISS or the analysis of the separate injuries. On the other hand the subgroup of patients displaying a systolic blood pressure of less than 100 mmHg at the site of the accident or upon arrival at the ER all had significantly lower antithrombine 3, protein C, and alpha-2-antiplasmine activities as well as increased concentrations of specific reaction products resulting from activated coagulation (thrombine-antithrombine 3-complex) and of fibrinolysis (D-dimers). CONCLUSION: In our study patients with multiple injuries displaying a systolic blood pressure of less than 100 mmHg either at the scene of the accident or upon arrival in the ER showed coagulation values which by other investigators were regarded as a sign of potential secondary organ failure or death.

Adult↗
PubMed1995

[Effect of multiple trauma on rehabilitation of patients with craniocerebral injuries].

The aim of this investigation was to proof, wether there is a direct influence of polytrauma on rehabilitation and outcome in patients with severe head injury (SHI). 558 patients were investigated 3 years after the accident. 82% (447) had combined SHI and polytrauma. Patients with polytrauma and similar degrees of SHI showed significantly poorer outcome than those with isolated SHI. The healing process in the rehabilitation hospital was complicated especially by tracheo-pulmonary factors and wrong bedding factors (atrophi, calcification, decubital ulcers). It can be concluded, that diagnostics and operative treatment must be done under continuous intensive and neuromonitoring. Only life-saving operations should be done in the acute stage. All patients with moderate and severe head injury need early rehabilitation parallel to the intensive care treatment.

Adolescent↗
PubMed1991

Glucose infusion improves endogenous protein synthesis efficiency in multiple trauma victims.

Metabolic costs of excessive nutritional support in stressed patients have been increasingly recognized. The decreased endogenous protein synthesis efficiency (PSE) following major injury has been attributed to the predominant need of amino acid precursors for gluconeogenesis. The present study tested the hypothesis that provision of glucose alone, not to exceed the resting energy expenditure (REE), for the first 4 to 5 days after trauma would be enough to restore PSE and stimulate the injured body to accept full nutrition. Eight severely injured, adult, hypermetabolic, and highly catabolic patients admitted to the Trauma Intensive Care Unit (TICU) served as our subjects. Integrated measurements of whole body fuel-substrate kinetics were obtained for energy metabolism (indirect calorimetry), protein kinetics (primed constant infusion of 15N-glycine), and glucose kinetics (labeled glucose infusions). Two studies were conducted on each same subject, one in the early flow phase of injury (48 to 60 hours after trauma) and a second after 4 to 5 days of hypertonic glucose (4.1 +/- 0.5 mg/kg/min; 80% REE calories) infusion with electrolytes, trace elements, and minerals. Significant (P less than .05) increases in PSE (14%, 65% +/- 2% to 74% +/- 2%), plasma growth hormone and insulin levels, and respiratory quotient (RQ) (31%, 0.74 +/- 0.03 to 0.97 +/- 0.04), and decreases in endogenous glucose appearance rate (55%, 3.1 +/- 0.5 to 1.4 +/- 0.1 mg/kg/min), and negative N balance (48%, 219 +/- 26 to 114 +/- 15 mgN/kg/d) were observed. The results suggest that hypertonic glucose infusion alone may be sufficient for physiological adaptation in the immediate posttrauma days. This therapy restores normal PSE, which should protect the labile protein pool.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

[Pulmonary pasteurellosis in a young patient with multiple trauma].

A case is reported of an 18-year-old male patient who had a road traffic accident, with head and chest injuries. The patient was admitted to the surgical intensive care unit 24 h later because of an alteration of his level of consciousness. He required artificial ventilation. Five days later, he developed right-sided lower lobe pneumonia, treated with positive end-expiratory pressure. A Gram negative organism was found on bronchial brushing, but not in haemocultures. It was identified as Pasteurella multocida, sensitive to beta-lactamines, but not to amikacin. Cefotaxime, which had been started immediately after the arrival of the Gram stain result, was continued. Artificial ventilation was discontinued on day 12, and the patient left the unit on day 15. The patient was probably a P. multocida carrier, being in close contact with animals before his accident. This bacteria is often found in infected animal bite wounds. Pneumonia due to this bacteria usually occurs in immunodepressed patients, which was not the case here.

Adolescent↗
PubMed1992

[Multiple trauma management: reliable documentation of the 1st phase supplying a standardized, machine-readable encounter sheet for the emergency rescue team].

Adjust preclinical treatment is an inevitable compound of polytrauma-management. Instantaneously applied expert therapy of the traumatic shock and acutely performed diagnosis of the pattern and dignity of injuries often are crucial for the patients' outcome. Precise documentation of the first phase of treatment thus gains importance for clinical investigations to come and for questions put scientifically. Applying data processing with data input through an optical mark reader a standardized encounter sheet, that proved to be usable as a checklist, has been developed in our hospital for the emergency-rescue-team. Being simple to use and handy to fill out it serves as a clinical record as well as a means for direct data input to a personal computer. The encounter sheet is presented in this paper together with first results of the application in daily routine.

Adolescent↗
PubMedDate not supplied

[Significance of tissue perfusion disorders and disseminated intravascular blood coagulation in the pathogenesis of post-resuscitation disease in patients with massive hemorrhage and severe multiple trauma].

A total of 198 patients with massive blood loss and grave combined injury treated at the intensive care ward were monitored for 5 days. This paper presents data on the blood content of peripheral tissues assessed by rheovasography and the time course of coagulating characteristics of the blood and fibrinolysis. Despite the stabilization of arterial pressure in the first hours of treatment, disorders of tissue perfusion persisted for 5 days. Signs of disseminated intravascular coagulation were detected as soon as after 6 h in the presence of expressed progressing thrombinemia, decelerated fibrinolysis in the blood plasma, thrombocytopenia, and consumption of some blood clotting factors. According to our data, disseminated intravascular blood coagulation in the microvessels is possible after 12 h and reaches its maximum on day 2 of treatment; it persisted over the entire follow-up (5 days) period and was associated with clinically manifest involvement of the functions of parenchymatous organs and systems starting from the end of the first or beginning of the second day of treatment.

Acute Disease↗
PubMed2000

[Ventilation in prone position in a 5-year-old child after multiple trauma. Effective treatment of persistent atelectasis].

We report on the ventilation in prone position in a 5-year-old traumatized child with severe thoracic and abdominal injuries (lung contusion, rib fractures, rupture of liver and spleen). Under continuous analgesic sedation, the young patient was ventilated in prone position for 6 h, since acute lung injury and atelectasis persisted despite various therapeutic measures (artificial ventilation in the pressure controlled mode, fiberoptic bronchoscopy, reexpansion maneuver). After initiation of the prone position, we observed a rapid increase in arterial oxygenation, which persisted in the following period. The hemodynamic situation remained stable. The complete disappearance of atelectasis was demonstrated radiologically after supine repositioning. After cessation of analgesic sedation, the extubation was performed 2 days later. Furthermore, we found no side effects of the prone position on the injured abdomen, and the liver function improved rapidly. Although there is a lack of experience with ventilation in prone position in pediatric intensive care, our report might be a recommendation for the indication of this technique in children.

Abdominal Injuries↗
PubMed1998

Is early kinetic positioning beneficial for pulmonary function in multiple trauma patients?

Body positioning (kinetic therapy) is known to improve oxygenation in patients with impaired pulmonary function and ARDS. We have used body positioning prophylactically in trauma patients whose injury and pattern predispose to ARDS. This retrospective study reports the effects of early prophylactic (group P) versus late (group L) axial rotation on pulmonary function and the incidence of ARDS. Both groups were comparable in age, injury severity and the degree of thoracic injury. Systemic oxygenation was significantly better and the incidence of ARDS significantly lower in group P (group P: 34.3 per cent, group T: 74.1 per cent, P < 0.05). There was a tendency towards a lower incidence of pneumonia and a better survival in group P, which did not reach statistical significance. The duration of kinetic therapy and of ventilation was comparable in both groups. In this retrospective evaluation early prophylactic kinetic therapy was associated with a significantly lower incidence of ARDS compared with that instigated later.

Adult↗
PubMed1997

[Mediators and antagonists in therapy of multiple trauma. Reliable outcome or wishful thinking?].

The response of the immune system to any trauma starts at the moment of injury. Macrophages are activated and produce proinflammatory mediators. All the stimuli of the cytokine system lead to a final common pathway where a therapeutic approach might start. However, any strategy of cytokine therapy cuts both ways. There are a lot of data derived from in vitro and animal studies. Both the classification and the clinical application of these results are rather difficult. Some therapeutic concepts seem promising, but the advantages and disadvantages have to be carefully considered. The aim of all strategies must be to improve or adjust the patient's immune defence system. First of all, the patient, the disease or the specific injury has to be treated, not only the mediators and cytokines. The philosopher's stone has not been found yet. There are several approaches, but it is still a long and difficult process to find new insights and effective treatments.

Combined Modality Therapy↗
PubMed1997

Early operative reconstruction of severe ligamentous knee injuries in patients with multiple trauma.

Although operative reconstruction of severe knee ligament injuries has been the preferred method of treatment, the timing of that reconstruction relative to the injury has not been previously addressed. In a retrospective review of multitrauma cases, we identified 32 patients with 34 severe knee ligament injuries. Of these 34 knees, 19 (56%) were treated with early reconstruction (within 2 weeks of injury). Of the remaining 15 knees, 8 were managed by delayed reconstruction at an average of 4.8 months after injury, and 7 knees were not surgically treated. All 19 knees treated by early operation were clinically stable, and 89% were pain free at an average of 25 months' follow-up. In contrast, only 13% of the knees treated by delayed or no reconstruction were clinically stable, 33% were persistently painful, and 40% required bracing intermittently to allow activities of daily living. In this study, patients treated by delayed reconstruction or non-operatively had poor functional results. We believe early operative reconstruction of severe knee injuries in multitrauma patients is crucial to maximize functional outcome and minimize long-term sequelae.

Adolescent↗
PubMed2004

[The "Würzburg T". A concept for optimization of early multiple trauma care in the emergency department].

INTRODUCTION: Anaesthesia management, radiological diagnostic and the concept of damage control surgery should be combined in the resuscitation room. Defined clinical targets and their realisation are a CT-scan and complete damage control surgery in the shock room. Furthermore minimised patient transfer and positioning with continuous access to the head, upper parts of the body and anaesthesia machine should be realised during diagnostic procedures. METHODS: Based on a carbon-slide fixed on a turntable and innovative alignment of diagnostic devices, a three phase treatment algorithm has been established. RESULTS: Phase A includes primary survey, anaesthetic management and ultrasound examination. Following a turn of the table conventional x-ray diagnostic is assessed in phase B. Tracks for the slide enable immediate transfer to a spiral CT-scan without additional patient positioning (phase C). Following complete CT-scan rearrangement of the table to phase A facilitates immediate damage control surgery. To accelerate device operation and treatment the integrated anaesthesia workstation is ceiling-mounted and manoeuvres close to the patient. CONCLUSIONS: This concept realizes complete diagnostic procedures and damage control surgery without time consuming patient transfer or rearrangement.

Algorithms↗
PubMed2000

Missed injuries in patients with multiple trauma.

BACKGROUND: Understanding the etiology of missed injuries is essential in minimizing its occurrence. A retrospective review was conducted to identify the incidence, contributing factors, and clinical outcomes of missed injuries. METHODS: All trauma patients assessed by St Michael's Hospital trauma service from April 1, 1995, to July 31, 1997, were included in the study. Demographic and medical data were compared and statistically analyzed in two patient groups to identify factors associated with missed injuries. RESULTS: Forty six of 567 patients (8.1%) had missed injuries. Patients with missed injuries had higher mean Injury Severity Scores and longer stays in the hospital and intensive care unit compared with patients without missed injuries (p < 0.05). Patients with missed injuries were more likely to have lower Glasgow Coma Scale scores and to have required pharmacologic paralysis (p < 0.05). Of the factors contributing to missed injuries, 56.3% were potentially avoidable and 43.8% were unavoidable. Seven patients with missed injuries had clinically significant outcomes, including one patient death. Of the seven clinically significant missed injuries, five were attributable to potentially avoidable factors. CONCLUSION: Patients with missed injuries tend to be more severely injured with initial neurologic compromise. The majority of missed injuries are potentially avoidable with repeat clinical assessments and a high index of suspicion.

Adult↗
PubMed1994

[Diagnosis and tactics in multiple trauma].

It is difficult to establish the diagnosis in combined injuries because of the peculiar pathogenesis leading to unusual symptomatology and diagnostic errors. This is associated with some peculiarities of a combined injury: it is marked by the syndrome of mutual aggravation; signs of less severe injuries often come to the forefront; the usual complex of symptoms may be indistinct or even absent. For instance, in internal hemorrhage combined with contusion of the brain arterial pressure may be normal or even increased, while the signs of "acute abdomen" may not be manifested as the result of diminished abdominal reflexes. At the same time pain in the region of the anterior abdominal wall simulating the picture of generalized peritonitis may be caused by traumatic compression of the thoracolumbar nerve roots. Under such conditions, the standard scheme of examination of the patients makes it possible to answer two main questions in the shortest time: whether the patient needs an emergency operative intervention, and if he does, on which organ or system should the operation be performed first. With this scheme, instrumental methods of examination acquire primary significance and special diagnostic value because physical examination and the medical history often lose their importance. Such methods are thoraco- and laparocentesis, contrast roentgenography, determination of C.V.P. etc. Moreover, such tactics facilitates recovery of the patients from shock because these methods are diagnostic and, at the same time, therapeutic.

Diagnosis, Differential↗
PubMed1994

The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures.

The management of hemodynamically unstable patients with displaced pelvic ring fractures and associated abdominal, thoracic, or head injuries is controversial. We studied 312 consecutive trauma patients with pelvic fractures admitted from July 1, 1989 through June 30, 1993: thirty-six of these patients were in shock (SBP < or = 90 mm Hg) and were treated by a protocol including volume resuscitation, and treatment of the associated injuries, without use of acute external fixation. Evaluation of the pelvic fractures revealed 39% to be rotationally unstable; 61% were both rotationally and vertically unstable. The mean injury Severity Score was 27 +/- 12, the average Glasgow Coma Scale score was 12 +/- 5, and the Abbreviated Injury Scale (AIS) scores stratified for the abdomen and the thorax were 1.9 +/- 1.7 and 1.6 +/- 1.8, respectively. Eighteen patients required thoracotomy, laparotomy, or both. The total blood requirement in the initial 24 hours postinjury was 4.0 +/- 4 Units. Deaths of four patients (11%) were a function of associated injuries and comorbid factors, not the result of uncontrolled pelvic hemorrhage. The data suggest that aggressive resuscitation of these patients and treatment of extrapelvic injuries in conjunction with early or delayed ORIF, without application of acute external fixation, resulted in a low overall mortality rate.

Adult↗
PubMedDate not supplied

Efficacy of a mixture of medium-chain triglyceride (75%) and long-chain triglyceride (25%) fat emulsions in the nutritional management of multiple-trauma patients.

Ten severely injured patients who were admitted to the intensive care unit and who needed total parenteral nutrition (TPN) were randomly enrolled in a prospective double-blind study comparing two 20%-fat intravenous emulsions: one (MCT-LCT) containing a physical mixture of 75% medium-chain triglyceride (MCT) and 25% long-chain triglyceride (LCT) and another containing 100% LCT. TPN (30 kcal.kg-1.day-1) was given continuously as amino acids (20% of energy) and glucose (50% of energy) over 7 days with the respective lipid emulsion (30% of energy) provided from 0800 to 1600 each day. Plasma substrate concentrations, nitrogen balance, resting energy expenditure, substrate net oxidation rates, whole-body lipolysis rates, and fatty acid reesterification rates were measured or calculated. Plasma concentrations of lipid metabolites (glycerol, triglycerides, and fatty acids) indicated rapid hydrolysis and efficient use of the MCT-LCT emulsion. Whole-body lipolysis rate decreased by 53% in the MCT-LCT group and by 34% in the LCT group. Net fat oxidation was greater and FFA reesterification less with MCT-LCT than with LCT, indicating more efficient and rapid fuel utilization in the post-traumatic period with the MCT-LCT emulsion. In critically ill patients dependent on intravenous nutrition, an MCT-LCT mixture may be useful as an obligate fuel and to limit net hepatic lipogenesis.

Adolescent↗
PubMed2005

[Missed injuries in patients with multiple trauma: analysis of a trauma registry].

INTRODUCTION: The frequency of missed injuries (MI) in patients with trauma oscillates between 0.5 and 38%, depending on the distinct studies and their inclusion criteria. In the present study, we evaluated the incidence, contributory factors and clinical relevance of these lesions, based on the Severe Trauma Registry of our center. PATIENTS AND METHODS: We retrospectively analyzed a registry of 912 cases of severe trauma, which were prospectively gathered. Of these, 19 patients had a MI (2%). Demographic (age and sex) and clinical variables (severity scales and mechanism of injury) were compared and avoidable contributory factors and clinically relevant MI were evaluated. RESULTS: Of the 19 patients with a MI, 58% had closed injuries. No statistically significant differences were found in any of the variables studied, although penetrating injuries were clearly more frequent in patients with MI than in those without. Forty-seven percent of MI were musculoskeletal, 26% were visceral and 21% were vascular. Sixty-three percent of contributory factors were potentially avoidable and the most frequent reason for MI was incorrect clinical evaluation. Mortality due to lesions with a delayed diagnosis was 21%. CONCLUSIONS: Incorrect clinical evaluation was the avoidable factor that would have the greatest impact on reducing the number of MI. Another factor that clearly contributes to reduction of MI is appropriate interpretation of radiological images in the context of a tertiary survey. All teams treating these patients should periodically evaluate their results and intervene in the factors contributing to missed diagnoses.

Adult↗
PubMed1997

[Whole body spiral CT in primary diagnosis of patients with multiple trauma in emergency situations].

PURPOSE: The aim of this study was to evaluate the role of a fast whole body helical CT scanner for primary diagnosis in trauma patients. METHODS: 27 severely injured patients (9 women, 18 men; mean age 43 years) were first examined with a helical CT scanner allowing for digital radiograms up to a length of 1024 mm and continuous helical scans of up to 70 seconds (slice thickness 3 to 10 mm, pitch factor up to 2). The primary CT diagnosis was verified either by x-ray after the CT examination or during the subsequent days, by abdominal ultrasound, by additional CT scans in the following days, and by clinical follow-up. RESULTS: CT showed all clinically relevant injuries of the head, spine, chest, abdomen and pelvis. The diagnosis and classification of vertebral fractures was performed immediately. 4% of the fractures of the extremities and the ribs were not seen primarily. 6% of the injuries were outside the CT scan field. CONCLUSION: Helical CT is a reliable and fast method to obtain vital information and to improve management planning in severely injured patients. It reduces the number of conventional x-ray examinations. In certain cases, additional x-rays of extremity fractures may be required.

Abdominal Injuries↗