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PubMed2001

[Significance of findings of chest X-rays and thoracic CT routinely performed at the emergency unit: 102 patients with multiple trauma. A prospective study].

PURPOSE: To evaluate prospectively whether and to what extent both thoracic computed tomography (Tx-CT) and supine X-ray of the chest (Rx-Tx) are able to show additional findings that are therapeutically relevant. PATIENTS AND METHODS: According to a fixed study protocol, we performed Rx-Tx and Tx-CT in 102 consecutive, haemodynamically stable polytrauma patients (mean age, 41.2 yrs; age range, 12-93 yrs). Findings of therapeutical relevance drawn from both Tx-CT and Rx-Tx, and urgent interventions indicated by an attending trauma team were documented on a standardized evaluation sheet immediately. Any change in the patient's management that is different from routine life-saving procedures, and any therapeutical intervention done in the emergency room or elsewhere (operating theatre, angiographic facility) were considered therapeutically relevant. RESULTS: Of 102 patients, 43 (42.2%) had a total of 51 therapeutically relevant findings. Rx-Tx alone yielded 23 relevant findings (45.1%) in 23 patients (22.5%). Of them, Tx-CT has shown additional important findings in 7 patients (30.4%). When Tx-CT alone is considered, it revealed 22 new findings of therapeutical relevance (43.2%) in 20 patients (46.5%). Altogether, Tx-CT was able to show 30 relevant findings in 27 patients, i.e., there was a therapeutical benefit for 26.5% of all polytrauma patients included. Most frequently, there was a need for chest-tube insertion (n = 29). CONCLUSIONS: Polytrauma patients if haemodynamically stable may profit from computed tomography of the chest when therapeutically relevant thoracic injuries are looked for or early therapeutical interventions are to be checked. However, chest X-ray should stay as a "front-line" screening method because of its superbly quick feasibility and availability.

Adolescent↗
PubMed2005

Genetic predisposition for a compromised immune system after multiple trauma.

Severe trauma induces sustained changes of the immune response, which are thought to be related to secondary organ dysfunction. Despite a similar injury severity, the extent of the inflammatory response may vary between polytraumatized patients. It is unclear whether inflammatory variability is associated with genetic variations. In this prospective cohort study, patients were included when the following criteria were fulfilled: Injury Severity Score >16, age 18 to 60 years, and a survival >48 h after injury. Four different polymorphisms (TNF-Nco1, IL-1-Taq1, IL-6-174G/C, and IL-8-251A/T) were determined. Patients were separated according to the severity of the systemic inflammatory response syndrome (SIRS; ACCP/SCCM criteria: >2 criteria at 2 consecutive days or at 3 days of the observation period: group +SIRS; <or=2 criteria: group -SIRS). Ninety-seven severely injured patients were included (-SIRS, 56 patients; +SIRS, 41 patients). A significantly higher incidence of the IL-6-174G allele and the IL-6-174G homozygous genotype in +SIRS patients was observed. The IL-6-174G/C polymorphism was associated with the severity of posttraumatic SIRS. This data points toward a genetic predisposition regarding an enhanced inflammatory response after polytrauma that may be associated with adverse outcome.

Adolescent↗
PubMed1990

[Poly-, multiple trauma and intra-abdominal injuries].

The present work deals with the problem of abdominal injuries in polytraumatized patients. The results were obtained from a retrospective study of the records of 530 polytraumatized patients treated at the Central Hospital of the German Federal Armed Forces (Bundeswehr). In all, 193 of these patients had abdominal injuries. The overall mortality was 23.8% (n = 126): mortality among the patients with abdominal injuries was 26% (n = 50). Abdominal injuries alone led to death in 9.1% (n = 1), but mortality increased to 18.4% when at least one extra-abdominal injuries was also present. A combination of abdominal injuries and two or more extra-abdominal lesion led to a mortality rate of 27%. Mortality was found to be age- and sex-related: in young children and patients over 55 years (especially those around 70) mortality was 33.3%-72%. Among the cases with fatal outcome there was a female-to-male ratio of 3:2. The most common causes of death were: hemorrhage shock (62.3%), head injuries (37.7%), septicemia (8.1%), pneumonia, and ARDS (5.4% each). Within the last eight years we have used the following supplementary examination methods: computed tomography, peritoneal lavage, and ultrasonography. The retrospective study has shown that CT is not the examination of choice. The reliability with lavage and ultrasonography was approximately the same, but lavage was found to be more dangerous. Therefore, we abandoned lavage and used sonography only. However, we are of the opinion that any surgeon should use the examination method that has yielded the best results for him or her, to ensure the best possible outcome for the patient.

Abdominal Injuries↗
PubMed1993

[Quality of emergency admission (resuscitation, REA) and first aid in multiple trauma].

Undue delay between hospital admission and the beginning or urgent operative procedures is considered as a major mortality risk for polytraumatized patients in any trauma center. As part of a quality control study at our institution (Kantonsspital, University of Basel), the time spent for early resuscitation and diagnostic procedures was therefore prospectively recorded in 20 patients (mean age 38 years) with a mean ISS of 26.9 (range: 13 to 43). Time spent in the resuscitation room averaged 31.4 min (range: 10 to 50 min). Conventional radiographic diagnostic procedures took 34.7 more min (range: 20 to 60 min). An additional CT scan was performed in 15 patients requiring 19.5 min per region (head/thorax/abdomen/spine). Four patients underwent angiography necessitating 28 more min (mean). Time elapsed between admission and arrival of the patient in the OR or the ICU respectively accounted for an average of 89 min (range 22 to 200 min). For comparable injury severities this interval was shorter during the day than during the night (77 and 103 min respectively). Diagnoses established during this period were both accurate and comprehensive, as detectable from the low rate of missed diagnosis (three minor fractures). Although our results match favorably with figures reported in the literature we feel that further improvements could be achieved by performing the conventional radiographic procedures simultaneously with the early resuscitation in the resuscitation room. At present time, for reasons of X-ray protection, this is not possible in our institution.

Adolescent↗
PubMed2004

[DRG reimbursement for multiple trauma patients -- a comparison with the comprehensive hospital costs using the German trauma registry].

UNLABELLED: The introduction of diagnosis related groups (DRG) will radically change the payment system for German hospitals. In 2002 the values for most DRG's were published for the german system (G-DRG). The polytrauma working group of the German Trauma Society developed a calculating algorithm to estimate the comprehensive hospital costs for every patient in the German trauma registry. The aim of this study was to compare these costs with the reimbursement according the the G-DRG's for a standardized population of polytrauma patients. MATERIAL AND METHODS: For polytrauma patients treated at Hannover Medical School in 2000 and 2001 the reimbursement according to the G-DRG's was calculated using a base value of 2900 euro. In the same patients the total cost of inpatient treatment was calculated according to the algorithm developed by the polytrauma working group of the German Trauma Society. The difference between these values represents the economic result. This was calculated as an overall result, but also for specific subgroups of patients (injury severity, mortality, G-DRG grouping). RESULTS: Datasets of 103 polytrauma patients were included. The following G-DRG's were most frequently occuring: A06Z (n=41), A07Z (n=16), W01Z (n=13). All other G-DRG's were documented less than 3 times. The mean reimbursement according to the G-DRG was 21.380+/-12.300 euro for a polytrauma patient. However, the mean hospital cost accounted to 34.274+/-22.501 euro, which resulted in a mean deficit of 12.893+/-15.534 euro. Analysis of subgroups revealed, that an ISS of more than 35 points, patients with a prolonged hospital stay and patients of the G-DRG group A06Z show a particularly negative result. CONCLUSION: The comprehensive hospital costs for treating polytrauma patients are on average 12.893 euro higher than the reimbursement according the G-DRG's. For hospitals to be fully reimbursed G-DRG values have to be reconfigured according to the German health care system. Thus, inclusion criteria to specific G-DRG have to be changed and a specific G-DRG group for very severely injured patients needs to be established.

Adult↗
PubMedDate not supplied

Substrate efficacy in early nutrition support of critically ill multiple trauma victims.

The metabolic consequences of excessive nutrition support in patients have been increasingly recognized in recent years. Time-dependent optimal nutrition support is desired for an early and uncomplicated recovery after severe injury or illness. Metabolic effects of adding balanced amino acids to glucose infusion during total parenteral nutrition were investigated in 18 patients after major trauma (injury severity score 32 +/- 2). Two studies were conducted on each subject, one in the early "flow" phase of injury (40-60 hours postinjury) in the basal state without any dietary intake and then after 4 to 6 days of intravenous nutrition provided solely as glucose (24 +/- 2 kcal/kg per day, 80% resting energy expenditure, n = 8) or isocaloric glucose (28 +/- 3 kcal/kg per day) with amino acids (275 +/- 28 mg of nitrogen per kilogram per day, n = 10). Whole-body fuel substrate kinetics were studied for energy metabolism (indirect calorimetry), protein kinetics (primed-constant infusion of 15N glycine), and lipid mobilization (two-stage infusion of 10% glycerol). Injury-induced hypoaminoacidemia was equally modulated whether the glucose-based nutrition had amino acids or not. The negative nitrogen balance is reduced similarly in both groups. Protein breakdown rate is significantly (p = .025) decreased in both groups and it is more so (30% vs 18%) in patients receiving total parenteral nutrition. Intravenous nutrition could not stimulate protein synthesis. Whole-body lipolysis rate as well as net fat oxidation rate are suppressed more when glucose alone is given, and this also results in less reesterification. Provision of intravenous glucose alone, not to exceed the resting energy expenditure, seems to be superior to isocaloric glucose with amino acids during this early catabolic flow phase of injury because the injured body could not assimilate this exogenous amino acid.

Adult↗
PubMed1991

[Alveolo-capillary permeability following multiple trauma--monitoring by bronchoalveolar lavage].

In trauma patients (ISS greater than 40 points) bronchoalveolar lavage (BAL) as well as the first clinical measurements was performed within the first 6 hours after admission to hospital. Thereafter BAL was carried out once per day, using 100 ml NaCl 0.9% (10 x 10 ml). BAL-protein-concentrations (i.e. albumin) were converted to epithelial lining fluid (ELF) according to Rennard, using urea as an internal standard. The limitations of this method were taken into account. The alveolo-capillary permeability (ACP) was described by the quotient of the protein concentrations in ELF and plasma. Progressive lung failure (ARDS) was defined using the criteria given by Murray. Lung contusion was an exclusion criteria. The study period was 14 days. This study evaluated data from 12 patients (m: 10, f: 2; age 30.4 (17-52); ISS 63.4). Five patients developed a progressive lung failure ("+ARDS"--age 32.2; ISS 71.5), 7 patient suffered no pulmonary failure during intensive care ("-ARDS")--age 29.5; ISS 59.2). No patient died in the course of the study. An increased ACP for albumin (combined endothelial-epithelial disturbance) was detectable for both +ARDS- und -ARDS-patients after the 6th hour, reaching a maximum around the 24th hour. +ARDS-patients showed a significant higher ACP. Further, beginning from the 48th hour to the 4th day, the ACP value for -ARDS-patients again dropped to a physiologic range. The degree of the increased ACP depends on the size of the marker protein, but it is independent of pulmonary hemodynamics. It is of value for the prediction of ARDS within 24 hours and for monitoring of pulmonary damage in posttraumatic course.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMedDate not supplied

[Enteral nutrition in the multiple trauma patient].

The hypermetabolism that develops in patients with severe polytraumatism has led to the need for an aggressive metabolic-nutritional support from the start. Parenteral Nutrition is the preferred technique in many instances, due to the doubts on the effectiveness of enteral nutrition in the control of the metabolic response and to problems of gastrointestinal tolerance derived from its administration. However, the role of enteral nutrition as an important factor which limits the development of bacterial translocation and the chain of events leading to multiorganic failure appears to be more and more well-established and is an important argument for justifying the early administration of enteral nutrition in these patients. In accordance with the accumulated experience of several authors over the past few years, enteral nutrition may be administered early in polytraumatized patients. This is not only accompanied by the evidence of acceptable gastrointestinal tolerance to the diet, but also by additional advantages compared to parenteral nutrition, such as the maintenance of trophism and immunocompetence of the digestive mucosa, the reduction of septic complications and also greater nutritional effectiveness which can be evaluated by the behaviour of the seric proteins used as nutritional evolution markers. The interest of the different diet formulae which exist at present, for example diets enriched with branched-chain amino acids, diets with added fibre, peptidic diets, specific pulmonary diets or "euglycaemic diets" is evaluated in this review. All these diets may mean an increase in the effectiveness and/or tolerance of enteral nutrition in polytraumatized patients, and also contribute to the handling of specific problems such as "stress" hyperglycaemia or the withdrawal of mechanical ventilation support. The use of specific nutrients for the digestive mucosa, such as glutamine or short chain fatty acids seems to be an important factor in the reduction of bacterial translocation. The new concept of immunonutrition is opening up new expectations with regard to the possibility of reducing septic complications, which often lead to problems in the evolution of patients, by means of nutritional manipulation. Current knowledge has permitted the early administration of enteral nutrition in polytraumatized patients, although on occasions the nutritional requirements will have to be administered by the complementary use of enteral and parenteral nutrition.

Diet↗
PubMed1994

[Multiple trauma in children younger than 16 years; a retrospective study over the 1984-1991 period].

OBJECTIVE: Evaluation of incidence, treatment and outcome of multiple injuries in children and adults. METHOD: All patients aged 16 years or under with an Injury Severity Score of 18 or more admitted to the Intensive Care Unit between 1984 and 1991, were retrospectively studied. Type and severity of injuries, treatment, complications and outcome were noted. The severity of injuries was scored using both the Injury Severity Score and the Paediatric Trauma Score. RESULTS: Children are more likely to be run over by motor vehicles. Rib fractures are rare in childhood. Compared with adults, children stay relatively shortly in the Intensive Care Unit. None of the children studied developed a Respiratory Distress Syndrome (RDS) or Multi-Organ Failure (MOF). External fixation of fractures is a common treatment in children. CONCLUSIONS: I. Outcome of multiple injuries in children is relatively good. This can partly be attributed to the low incidence of RDS and MOF, but also to the more common diffuse brain injury in children compared with adults, with better outcome and lower mortality. 2. External fixation of fractures appears to be a first rate treatment in children. 3. Scoring of multiple injuries in children with the Paediatric Trauma Score instead of the Injury Severity Score offers no advantages.

Adolescent↗
PubMed1993

Value of superoxide dismutase for prevention of multiple organ failure after multiple trauma.

In a prospective, randomized trial, recombinant human superoxide dismutase (rhSOD, 3000 mg/day, Grünenthal, Aachen, Germany) or placebo was given intravenously during 5 days after multiple injuries (Injury Severity Score [ISS] > or = 27; 24 patients). Manifestation of multiple organ failure (MOF) and posttraumatic inflammatory response were evaluated over 14 days. No side effects were noted by continuous infusion of rhSOD, which allowed high SOD plasma levels (24.77 +/- 9.43 mg/L) compared with controls (0.03 +/- 0.02 mg/L). Multiple organ failure was attenuated by rhSOD treatment in respect to cardiovascular and pulmonary functions. Additionally, intensive care therapy was shortened from 30 days (Q25: 15; Q75: 37) to 21 days (Q25: 12; Q75: 41). A secondary increase of inflammatory mediators (e.g., C-reactive protein, polymorphonuclear [PMN]-elastase, phospholipase A2), as observed at the end of the first week in the placebo group, was reduced by rhSOD therapy. The results reveal an attenuation of organ failure after trauma, most likely by decreasing the release of inflammatory mediators and reduction of leukocyte-mediated organ injury. These preliminary results, while promising, need to be confirmed in a larger number of patients.

Acute-Phase Reaction↗
PubMed1998

[How many severely injured multiple-trauma patients can benefit from the biomechanical advantage of early mobilization following femoral intramedullary nailing?].

The benefit of early operative stabilization of femoral fractures is established in patients with multiple injuries. In the last few years the unreamed femoral nail is favoured for internal fixation of femoral fractures despite pathophysiological concerns. The foremost advantage of femoral nails compared with plate fixation is the possibility of early full weight bearing. The aim of this retrospective study was to investigate, under consideration of the severity of injury, the extent of injury, and the clinical course, if multiple injured patients with concomitant femoral fractures benefit from the preferred intramedullary nailing with early weight bearing. Three hundred and two (23.8%) out of 1271 multiple injured patients (ISS > 17) had a concomitant femoral fracture. Fourty-seven out of 302 patients were children under 16 years of age, remaining 255 patients. Eighteen out of 255 patients died within the first 21 days after trauma and 66 patients required mechanical ventilation for more than three weeks (171/255). Thirty patients suffered from severe head injury (AIS-head > 3) and seven from severe pulmonary contusion with concomitant abdominal injury (134/255). Two patients had grade III open femoral fractures with vascular injury. Ipsilateral unstable pelvic fractures were seen in 11 patients, seven patients had ipsilateral intraarticular femoral fractures, and ipsilateral intraarticular fractures of the lower leg or foot were observed in 40 patients (74/255). The results demonstrate, that only 74 (29%) out of 255 multiple injured patients (> 16 years of age) had a theoretical benefit of early weight bearing. Seventy percent of the patients did not benefit from intramedullary nailing considering full weight bearing. With regard to pathophysiological concerns alternative methods of fracture fixation should be discussed for these patients. Primary fracture fixation with external fixators and secondary internal fixation proved to be a save alternative method. The complication rate of plating is comparable to intramedullary nailing but associated with less severe systemic risks. Primary plating of femoral fractures would not delay mobilization of most multiple injured patients.

Adolescent↗
PubMed2003

Plasma levels of procalcitonin and neopterin in multiple trauma patients with or without brain injury.

Clinical and experimental evidence suggests that traumatic brain injury (TBI) leads to a systemic immune response. To examine whether TBI causes a release of procalcitonin (PCT) or neopterin (NT) into the circulation, we compared plasmatic mediator levels among multiple injured patients with or without TBI. In total, 98 trauma patients (24 with TBI only, 39 with extracranial injuries excluding TBI, and 35 with combined injuries) and 35 healthy volunteers were studied. Blood was sampled at 15 predefined time points within 132 h after injury and analysed for NT and PCT. Multivariate statistical comparisons were adjusted for different severity of head, thorax, abdomen and extremity injuries, as quantified by the Abbreviated Injury Scale (AIS). PCT was normal 3 h after trauma, but 24 h after extracranial injuries a massive release (median 3 ng/mL) was observed. Significant positive associations between injury severity and posttraumatic PCT levels were found for abdominal and extremity, but not for cranial or thoracic injuries. Only modest changes of marginal statistical significance were detected for NT. The maximum increase per AIS point was 9% (95% confidence intervals [CI]: 3-16%). The effect of TBI on NT release was significant only at 108 h posttrauma with a 5% (95% CI: 1-10%) increase per AIS point. TBI induces a release of PCT and NT into the plasma, but this effect seems to be smaller for intra- than for extracranial injuries, probably due to more extensive surgery for abdominal and extremity injuries.

Adult↗
PubMed1976

Pulmonary function in patients with multiple trauma and associated severe head injury.

1) Sodium and water balance and pulmonary function studies were obtained in five patients with multiple injuries, including pulmonary contusion, plus severe intracranial trauma. All patients received dexamethasone, 4-6 every 6 hours during the 72-hour study period after injury. 2) Results were compared with those from 14 previously reported patients without head injury; none had received corticosteroids. 3) Study patients with head injury achieved negative water balance and almost-zero sodium balance within 72 hours of injury be excreting a high-volume, low-sodium urine. Despite elevated alveolar-arterial oxygen gradients and low-normal pulmonary compliance initially, there was progressive improvement and no patient developed post-traumatic pulmonary insufficiency. 4) The data suggest that the "negative" effects of major intracranial trauma on the kidney, heart, and lung are cancelled by dexamethasone, or that corticosteroids protect pulmonary function in the patient with multiple injuries and prevent post-traumatic pulmonary insufficiency, perhaps through their effect on the kidney leading to rapid restoration of sodium and water balance.

Adolescent↗
PubMed1992

The significance of multiple trauma in children.

Accident-related injuries, mainly traffic-connected, are the most serious threat to health and most-frequent cause of death in the pediatric age group. Usually these are multi-system injuries. While the total number of accidents has decreased over the last 20 years, traffic accidents have become more serious. Conventional prognostic scores are not applicable in children with multiple injuries because of their essential pathophysiologic differences with adults. The Pediatric Trauma Score closes this gap. It is simple to use and provides high reliability.

Accidents, Traffic↗
PubMed2000

Outcomes of single versus multiple trauma exposure in a screening sample.

Most studies ignore prior trauma exposure when evaluating outcomes of target events. This study explored symptom severity associated with different types of traumatic experiences occurring alone and with multiple exposure. The Stressful Life Events Screening Questionnaire categorized 1,909 sophomore women into groups including no trauma exposure, exposure to a serious non-Criterion A event only, exposure to several unique noninterpersonal and interpersonal events, and exposure to multiple interpersonal events. Women with noninterpersonal trauma did not differ from those without trauma on the Trauma Symptom Inventory. Only interpersonal trauma and non-Criterion A events were associated with elevated symptoms; multiple-exposure participants had significantly higher symptoms than all other groups. Complex trauma histories should be accounted for, even in studies of one target event.

Adolescent↗
PubMed1985

Management of multiple trauma.

The first 20 minutes of medical treatment are crucial in determining the outcome for the multiple injured child. The author chronicles management procedures and their sequence, emphasizing the systemic approach and preparation as important tools.

Child↗
PubMed1993

Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care.

From 1978 to 1991, 126 multiply-injured patients of 65 years and over were admitted to the Department of Traumatology and Emergency Surgery of the University Hospitals of Leuven. The seriousness of the injury was evaluated using the Injury Severity Score (ISS) and the Glasgow Coma Scale (GCS). Traffic accident (57 per cent) and a simple fall at home (30 per cent) were the main causes of injury. The overall mortality rate within 6 months was 17 per cent. Multiple system organ failure (MSOF) was responsible for the fatal outcome in 48 per cent of the cases and in 71 per cent of the deaths more than 7 days after trauma. Of the survivors still living at home before injury, 78 per cent were able to go back to their normal surroundings. Survivors were compared with non-survivors. There was no significant difference in age or in ISS, nor in pre-existing diseases. On the other hand, the GCS was of important prognostic value, both for survival and functional recovery (P < 0.001). Also, the need for early intubation and continued ventilation were predictive of survival (P < 0.001). Nevertheless, this need for respiratory assistance was not an indication for withdrawing support as 9 per cent of the survivors also required endotracheal intubation for 5 days or longer. In our opinion, aggressive trauma care for the elderly is justified.

Accidental Falls↗
PubMed1985

Measurement of myelin basic protein by radioimmunoassay in closed head trauma, multiple sclerosis and other neurological diseases.

A double antibody sequential radioimmunoassay for human myelin basic protein (MBP) has been developed. The assay utilizes a rabbit antibody to human MBP and purified rabbit MBP as the radiolabelled antigen. This assay was used to analyze cerebrospinal fluid (CSF) from 22 patients with severe head injury, 61 other cases of various neurological disorders, and 106 normal controls. The results showed that closed head trauma caused moderate to severe elevations in CSF MBP, and elevated CSF MBP was detectable in several diseases which involve CNS myelin.

Craniocerebral Trauma↗