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PubMed2006

Risk and prognostic factors of ventilator-associated pneumonia in trauma patients.

OBJECTIVE: To assess the risk and prognostic factors of ventilator-associated pneumonia in trauma patients, with an emphasis on the inflammatory response. DESIGN: Case-control study. SETTING: Trauma intensive care unit. PATIENTS: Of 190 consecutive mechanically ventilated patients, those with microbiologically confirmed pneumonia (n = 62) were matched with 62 controls without pneumonia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical, microbiological, and outcome variables were recorded. Cytokines were measured in serum and blind bronchoalveolar lavage specimens at onset of pneumonia. Multivariate analyses of risk and prognostic factors for ventilator-associated pneumonia were done. Increased severity of head and neck injury (odds ratio, 11.9; p < .001) was the only independent predictor of pneumonia. Among patients with pneumonia, serum levels of interleukin-6 (p = .019) and interleukin-8 (p = .036) at onset of pneumonia were higher in nonresponders to treatment. Moreover, serum levels of tumor necrosis factor-alpha (p = .028) and interleukin-6 (p = .007) at onset of pneumonia were higher in nonsurvivors. Mortality in the intensive care unit was 23% in cases and controls. Nonresponse to antimicrobial treatment (odds ratio, 22.2; p = .001) and the use of hyperventilation (p = .021) were independent predictors of mortality in the intensive care unit for patients with pneumonia. CONCLUSIONS: Severe head and neck trauma is strongly associated with ventilator-associated pneumonia. A higher inflammatory response is associated with nonresponse to treatment and mortality among patients with pneumonia. Although pneumonia did not influence mortality, nonresponse to treatment independently predicted mortality among these patients.

Adult↗
PubMed1996

Cervical intervertebral disc protrusion in an RAAF F-111C pilot: a case report.

This case report describes a serious cervical spine injury occurring in an F-111 pilot of the RAAF. The pilot developed a significant cervical intervertebral disc protrusion with severe, progressive neurological signs and symptoms in his right arm for a period of 4 mo. Multiple investigations including MRI and myelography established the site of the lesion as C6/7. He eventually responded to bed rest and made a complete recovery. The aeromedical disposition of this aviator and the roles of different treatment modalities in the aviation environment are discussed. The need for more research into +Gz-related neck injuries and the requirement for preventive strategies to protect the cervical spines of high performance pilots are also highlighted.

Adult↗
PubMedDate not supplied

Rates, trends, and severity of depression after burn injuries.

It is commonly assumed that patients hospitalized for burn treatment will experience some level of depression. However, little is known about the trends in severity of depression over time. The purpose of this study was to determine the rates and severity of depression over a 2-year period. The Beck Depression Inventory was administered at 1 month (N = 151), 1 year (N = 130), and 2 years (N = 125) after discharge. At 1 month, 54% of patients showed symptoms of moderate to severe depression, and at 2 years, 43% of the patients responding still reported moderate to severe depression. The average correlation between scores over time was high. Women had higher depression scores than men at each time period. An interaction between gender and having a head or neck injury was also observed at 1 month and 1 year after discharge. Results suggest that routine outpatient screening for depression is warranted.

Adolescent↗
PubMedDate not supplied

Equilibrium and non-equilibrium dynamics of the cranio-mandibular complex and cervical spine.

A dynamic model of the inverted pendulum characteristics of the head and cervical spine is presented. Using simple approximations and a single rotational-degree-of-freedom approach, the model is shown to conform to the classical mathematical description of an inverted pendulum motion. It also exhibits the well-known point of unstable equilibrium which is a standard property of such systems. Specific predictions of this theoretical description are compared against other values for the tilt, angular velocity and acceleration of the head during acceleration-sled testing, and with the Kapitza relation for mechanical-dither stabilization of an inverted pendulum. Numerical evaluations of the dynamic variables, resonant frequencies and time constants important to the problem are provided, and suggestions are made about how further results might be derived from extended versions of the model. This approach can now be refined to serve as a testing ground for analysing the biomechanics of traumatic neck injuries and for interpreting the possible roles that mandibular dysfunctions and dental malocclusion may play in disorders of the cervical spine. (Some background needed for exploring the latter possibility is presented.)

Acceleration↗
PubMed1997

[Biomechanics and injury prevention in road traffic].

The main predicting factor for the injury severity is "speed". This fact is predominantly important with regard to the protection of pedestrians and two wheelers. Today's safety features such as new steering and breaking systems, car body construction, seat belts, head restraints and crash helmets etc. let us sometimes overlook the hazards on the road. However, further improvements can be expected from advanced restraint system combinations, reinforced frontal and lateral car structures and padding, perhaps side air bags and automatically adjusted head restraint systems. Collision reconstruction and assessment of causality are needed, e.g., in cases of soft tissue neck injuries, questionable overrunning, walking direction of impacted pedestrians, uncertain belt or helmet wearing etc. Considerable legal problems arise if the causality is judged only from clinical point of view while the important criterion of collision mechanics is not taken into account in acceptable quantitative detail. Therefore it is recommended that determining the causality of a mechanical event should be left to specially trained professionals.

Accidents, Traffic↗
PubMed2004

Neck pain and disability following motor vehicle accidents--a cohort study.

The primary aim of the study was to compare the prevalence of neck pain and disability in a group exposed to motor vehicle accidents (MVAs) with those in the general population. The secondary aim was to assess the prevalence of a past history of exposure to an MVA with sequelae of neck pain in the general population. The exposed group consisted of 121 patients with neck complaints following an MVA in 1983. The control group, consisting of 1,491 subjects, was randomly selected, with attention to the distribution of age and gender in the exposed group. A neck-pain questionnaire was mailed to the subjects. In the control group, it included enquiry about a history of exposure to an MVA with sequelae of neck pain. The Neck Disability Index (NDI) was used to assess neck-related disability. In the exposed group 108 subjects (89%) responded, and in the control group 931 (62%) did. Seventeen years after the MVA, 59 subjects (55%) reported neck pain in the exposed group, with no gender differences. In the control group 270 (29%) reported neck pain with a higher frequency among women (34%) than men (19%) (p<0.01). There was a significant difference between the exposed group and the control group regarding the occurrence of neck pain (p<0.001). In the control group 34% recalled a history of an MVA, among whom one-third reported neck pain in connection with the accident and 28% had persistent neck pain referable to the accident. The exposed group scored significantly higher on the NDI (p<0.001) and reported significantly higher neck pain intensity than did the control group (p<0.001). In conclusion, a past history of exposure to an MVA with sequelae of neck pain appears to have a substantial impact on future persistent neck pain and associated disability.

Accidents, Traffic↗
PubMed2006

Mechanical traction for mechanical neck disorders: a systematic review.

OBJECTIVE: To assess whether mechanical traction, either alone or in combination with other treatments, improves pain, function/disability, patient satisfaction and global perceived effect in adults with mechanical neck disorders. METHODS: We conducted a systematic review up to September 2004 of randomized controlled trials and used pre-defined levels of evidence for qualitative analysis. Two independent reviewers conducted study selection, data abstraction and methodological quality assessment. Using a random effects model, relative risk and standardized mean differences were calculated. The reasonableness of combining studies was assessed on clinical and statistical grounds. In the absence of heterogeneity, pooled effect measures were calculated. RESULTS: Of the 10 selected trials, one study was of high quality. Our review revealed low-quality trials for mechanical neck disorders, showing evidence of benefit favouring intermittent traction for pain reduction. Continuous traction showed no significant difference for defined outcomes. CONCLUSION: Inconclusive evidence for continuous and intermittent traction exists due to trial methodological quality. Two clinical conclusions may be drawn, one favouring the use of intermittent traction and the other not supporting the use of continuous traction. Attention to research design flaws and description of traction characteristics is needed.

Adult↗
PubMed1981

A pattern of facial fractures in Greece.

Four hundred and thirty-two patients with fractures of the facial skeleton, treated in our Department, were studied in relation to the cause, site and the connection of such injuries to fractures of the skull and other sites of the skeleton (limbs, etc.). The conclusions were: (a) The incidence was higher in men than in women, with ratio 3.6:1; (b) Most patients were in the 3rd decade of life, followed by those in the 4th and 2nd; (c) The leading cause encountered was traffic accidents (66%), other accidents at home and work, interpersonal violence and sporting injuries. Of the traffic accident victims, 55% were car drivers or passengers and 37.4% were involved in motorcycle and bicycle accidents, and only a rather small percentage were pedestrians; (d) Of our patients 13% had fractures in other sites of the skeleton, and 7% skull fractures. The percentage of multi-injured patients in our material was in accordance with the findings in other countries. We found that each of these patients had three to four fractures in his body. However, the low number of patients with skull fractures associated with facial fractures was attributed to a high mortality rate in cases of skull and neck injuries at the time of the accident, and following admission, which were not included in this study.

Accidents↗
PubMed1998

A randomized study on eversion versus standard carotid endarterectomy: study design and preliminary results: the Everest Trial.

PURPOSE: The EVEREST Trial was designed to determine whether the surgical technique influences the durability and complications of carotid endarterectomy (CEA). The current report focuses on the study design and preliminary results. METHODS: EVEREST is a randomized multicenter trial. A total of 1353 patients with carotid stenosis requiring surgical treatment were randomly assigned to received standard (n = 675) or eversion (n = 678) CEA. Primary end points included carotid occlusion, major stroke, death, and restenosis rate. RESULTS: The rate of perioperative major stroke and death (1.3 for each study group) and the incidence of early carotid occlusion (0.6% for eversion vs 0.4% for standard) were similar. No significant differences were found between eversion and standard CEA with respect to incidence of perioperative transient ischemic accident, minor stroke, cranial nerve injuries, neck hematoma, myocardial infarction, or surgical defects as detected with intraoperative quality controls. Clamping time was significantly shorter for eversion CEA compared with patch standard procedures (31.7 +/- 15.9 vs 34.5 +/- 14.4 minutes, p = 0.02). A shunt was inserted in 11% of patients undergoing eversion CEAs and in 16% of patients undergoing standard procedures. Overall 30-day events occurred in 13.3% of the eversion group and in 11.4% of the standard group (p = 0.3). At a mean follow-up of 14.9 months (range, 1 to 38 months), 16 (2.4%) restenoses occurred in the eversion group and 28 (4.1%) occurred in the standard group (odds ratio, 0.56; 95% confidence interval, 0.3 to 1.1; p = 0.08). CONCLUSION: The preliminary results of the EVEREST Trial suggest that eversion CEA is a safe and rapid procedure with low major complication rates. No significant differences in restenosis rates were observed between eversion and standard CEA at the available follow-up. Longer-term results are necessary to assess whether the eversion technique influences the durability of CEA.

Adult↗
PubMed1993

[Results of a 1-year follow-up study of whiplash injury].

Based on a strict definition of whiplash injury, a sample of 117 non-selected patients was examined 7.2 +/- 4.2 days and at 3, 6 and 12 months after trauma. Initially all patients underwent a neurological examination, cognitive and psychosocial factor assessment and cervical spine x-rays. 56%, 70% and 76% of patients had completely recovered at 3, 6 and 12 months respectively. The results indicated that impairment of patients' well-being and cognitive ability was closely associated with somatic symptoms. No major impairment of attentional functioning was found, but some change in cognitive equilibrium was observed which may be related to the type of medication utilized. Delayed recovery at 12 months could be predicted by the following initial variables: higher age, intensity of initial neck pain and headache, symptoms of radicular irritation, sleep disturbances, pretraumatic headache, history of head trauma, nervousness score and--significantly inversely proportional--initial concentration problems and neuroticism score. These results suggest that a more severe neck injury may in particular account for delayed recovery from whiplash.

Adult↗
PubMed1996

Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy.

OBJECTIVE: The incidence, associated injury pattern, diagnostic factors, risk for adverse outcome, and efficacy of anticoagulant therapy in the setting of blunt and carotid injury (BCI) were evaluated. SUMMARY BACKGROUND DATA: Blunt carotid injury is considered uncommon. The authors believe that it is underdiagnosed. Outcome is thought to be compromised by diagnostic delay. If delay in diagnosis is important, it is implied that therapy is effective. Although anticoagulation is the most frequently used therapy, efficacy has not been proven. METHODS: Patients with BCI were identified from the registry of a level I trauma center during an 11-year period (ending September 1995). Neurologic examinations and outcomes, brain computed tomography (CT) results, angiographic findings, risk factors, and heparin therapy were evaluated. RESULTS: Sixty-seven patients with 87 BCIs were treated. Thirty-four percent were diagnosed by incompatible neurologic and CT findings, 43% by new onset of neurologic deficits, and 23% by physical examination (neck injury, Horner's syndrome). There were 54 intimal dissections, 11 pseudoaneurysms, 17 thromboses, 4 carotid cavernous fistulas, and 1 transected internal carotid artery. Thirty-nine patients had follow-up angiograms. Mortality rate was 31%. Of 46 survivors, 63% had good neurologic outcomes, 17% moderate, and 20% bad. Logistic regression analysis demonstrated heparin therapy to be associated independently with survival (p < 0.02) and improvement in neurologic outcome (p < 0.01). CONCLUSIONS: Blunt carotid injury is more common than appreciated, seen in 0.67% of patients admitted after motor vehicle accidents. Therapy with heparin is highly efficacious, significantly reducing neurologic morbidity and mortality. Heparin therapy, when instituted before onset of symptoms, ameliorates neurologic deterioration. Liberal screening, leading to earlier diagnosis, would improve outcome.

Adolescent↗
PubMed2003

[Cirurgia Taurina--emergency medical treatment of bullfighters in Spain].

A considerable risk of life-threatening injury is inherent to bullfighting. Thus, a unique form of emergency treatment has evolved over recent decades of organized bull-fighting. Today bullfight arenas in larger cities are equipped with emergency facilities including fully furnished operating rooms. During a fiesta these facilities are run by a medical team consisting of three surgeons, one intensive care specialist, and one anesthesiologist with their supporting medical personnel. In smaller arenas or villages immediate care units consist of emergency vehicles, and a mobile container equipped with a fully functional operating room. Of all toreros the matadores including the novilleros are most often injured in 56 % of cases. This rate decreases for banderillos (30 %), and for picadores (14 %). Parts of the body that are most frequently affected are thighs, and the inguinal region (54 %). Head and neck injuries are seen in 19 %, and 12 % of cases present with open abdominal wounds including liver or gastrointestinal tract traumas. 10 % of injuries affect the thorax, and 4 % the pelvic floor. The particular form of organised medical treatment for bullfighters in Spain has only developed since the nineteen-thirties. In 1972 a scientific society for bullfight surgery was founded in Spain by specialized surgeons, and immediate care specialists holding a first convention that year. The society is continuously striving to improve technical and logistical aspects of immediate medical care for injured bullfighters.

Animals↗
PubMed1987

EEG in whiplash: a reappraisal.

Sixty-eight patients with symptomatic cervical whiplash injuries, who did not receive head trauma, had standard electroencephalograms performed with a time span of 1 day to 2 years after the occurrence of the accident. Minimal EEG abnormalities were found in a small number of patients. Plain x-rays, computerized tomography or radionuclide brain scans failed to demonstrate associated structural abnormalities. Twenty-five of the group had 24-hour EEG cassette recordings; 15 of the latter reported specific symptoms of their post-traumatic syndrome during the test but no abnormal EEG correlates were established. Sixteen patients had long-term follow-up studies and no example was encountered of early or late onset post-traumatic epilepsy. These findings contradict previous reports of the greater incidence and severity of EEG abnormalities in patients that have sustained whiplash neck injuries in isolation (no head trauma).

Adolescent↗
PubMed1979

Routine angiographic evaluation of neck and extremity injuries.

Traumatic arterial injuries are becoming more common in civilian practice. In this study arteriography was done in 91 wounds of the neck and extremities regardless of physical findings (excluding exsanguinating or trivial injuries). Physical findings suggestive of the presence or absence of arterial injury were tabulated and compared with arteriographic findings. Physical findings were often found to be unreliable, yielding a false negative result in 20% and a false positive result in 42%. It is concluded that angiography is a safe, reliable method of diagnosis and should be routinely employed in all patients with major penetrating injuries of the neck and extremities as well as in selected patients with blunt injuries.

Adult↗
PubMed1997

Head, face, and neck trauma from large animal injury in New Mexico.

BACKGROUND: Head, face, and neck injuries (HFNI) occur during animal-related trauma. We compared patients with HFNI and without HFNI after animal-related injuries to determine the significance of these injuries. METHODS: Retrospective review of admissions for animal injuries between January 1, 1990, and December 31, 1995, by age, gender, mechanism, animal, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), Abbreviated Injury Severity score for head and neck (AIS Head/Neck), AIS score for face (AIS Face), intensive care unit stay, hospitalization length, morbidity, and mortality. RESULTS: There were 153 admissions: 61 HFNI and 92 no HFNI. Significant differences occurred in gender, animal, activity, GCS, and ISS. HFNI had higher AIS Head/Neck, AIS Face, and mortality. HFNI were from horses in 87% and occurred during recreation in 89%; 39% of patients with HFNI were 18 years or younger. CONCLUSION: HFNI occur in females and young people and produce lower GCS score, higher ISS, higher AIS Head/Neck, higher AIS Face, and higher mortality. Most occur during recreational horseback riding. Protective headgear should be mandated.

Abbreviated Injury Scale↗
PubMed1992

[Prospective follow-up of neuropsychological deficits after cervicocephalic acceleration trauma].

30 patients with acute cervico-cephalic syndrome following whiplash injury (neck and head pain, vegetative symptoms and subjective complaints of impaired mental functions) without neurological deficits were investigated in a prospective follow-up of 3 months with neuropsychological examination in the acute phase (x = 5.7 days) and again 6 and 12 weeks after the accident. Attention, concentration, cognition and verbal and visual memory functions were quantified by neuropsychological tests, and changes over the observation period were analysed. In the acute phase all neuropsychological functions were below the individual's normal level. Deficits in attention and concentration recovered within the first 6 weeks. Further recovery within the following 6 weeks were observed in visual memory, imagination and analytic capacity. The capability of verbal memory and abstraction, cognitive selectivity and information processing speed was impaired for a longer time and first recovered after 12 weeks. In conclusion, intraindividual neuropsychological deficits following whiplash injury can be quantified and monitored to show the time course of recovery. Thus in clinical and forensic practice the diagnosis of a pseudoneurasthenic or even "neurotic" syndrome in acute whiplash injury should be made with caution.

Accidents, Traffic↗
PubMed1985

Hemodynamic, behavioral and biochemical disturbances induced by an experimental cranio-cervical injury (whiplash) in rats.

Two days after an experimental whiplash performed on anesthetized Long-Evans female rats, without any direct blow to the head, we observed: (1) a hypotension (in supine position) (P less than 0.01), (2) a disturbance of the postural regulation of cerebral blood flow (P less than 0.01), (3) a disturbance of learning behavior characterized by decreased acquisition and retention (conditioned avoidance response and labyrinth tests), (4) an increase of the dopamine level (whole brain, cerebellum, thalamus + hypothalamus, corpus striatum and rest), (5) a decrease of the noradrenaline level in whole brain (P less than 0.05) and in the medulla oblongata but an increase in thalamus plus hypothalamus, hippocampus and corpus striatum, (6) an increased reactivity of the peripheral alpha and beta receptors, determined by analyzing the hemodynamic consequences of i.v. injection of norepinephrine or isoproterenol, (7) there was no modification of the brain content of water or of serotonin and (8) finally, the injured rats displayed a remarkably aggressive behavior, though this was not quantified. These results are in agreement with the hypothesis that a change in brain amines metabolism could explain the different functional effects of whiplash. We therefore believe that the postconcussion syndrome is not subjective and that the neck injury is primary in the determination of the syndrome.

Animals↗