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PubMed1996

[Emergency care and treatment costs of polytrauma patients].

Treatment costs of emergency therapy, surgery and intensive care were analysed in 20 randomly chosen, representative patients with severe multiple trauma (mean ISS 32 p). For an average stay of about 22.5 days on ICU, the total costs were DM 106924.36 (about 70,000 US $). DM 39,635.88 (= 37%) were the costs for physicians and nurses; DM 67,289.08 (= 63%) were needed for materials, X-rays, laboratory investigations, drugs and blood components. The whole treatment caused daily costs of DM 4752.22 or DM 3.30/min. The first emergency diagnostic procedures and emergency therapy take a mean time of 451.9 min from admission to the beginning of the ICU treatment and by itself already generates costs of about DM 12325.99. In Germany, a new way of compensation by a diagnosis-related group was introduced in 1996. These data suggest that treatment of severe multiple trauma is very expensive and trauma care could be economically harmful for smaller hospitals. We conclude that treatment of multiply injured patients (ISS > 16 p) should be compensated for by a special daily amount of about DM 5000 (about 3500 US $) for selected trauma centres.

Adolescent↗
PubMed1996

Out-of-hospital administration of mannitol to head-injured patients does not change systolic blood pressure.

OBJECTIVE: To determine the effect of out-of-hospital mannitol administration on systolic blood pressure (BP) in the head-injured multiple-trauma patient. METHODS: This was a prospective, randomized, double-blind, placebo-controlled clinical trial involving a university-based helicopter air medical service and level-1 trauma center hospital. Endotracheally intubated head-trauma victims with Glasgow Coma Scale (GCS) scores < 12 were enrolled from November 22, 1991, to November 20, 1992, if evaluated by the participating aeromedical transport team within 6 hours of injury. Patients were excluded if they were < 18 years old, had already received mannitol or another diuretic, were potentially pregnant, or were receiving CPR. All patients were intubated prior to study drug (mannitol [1 g/kg] or normal saline) use. Pulse and BP were measured every 15 minutes for 2 hours following study drug administration. RESULTS: A total of 44 patients were enrolled. After exclusion of 3 patients who did not meet all inclusion criteria, there were 20 patients in the mannitol group and 21 patients in the placebo group. The groups were similar at baseline in age, pulse, systolic BP (baseline mannitol: 124 +/- 47 mm Hg; placebo: 128 +/- 32 mm Hg), GCS score, and Injury Severity Scale score. Systolic BP did not change significantly throughout the observation period in either group. This study had 83% power to detect a mean systolic BP drop to < 90 mm Hg. CONCLUSION: Out-of-hospital administration of mannitol did not significantly change systolic BP in this group of head-injured multiple-trauma patients.

Adult↗
PubMed1999

[Injuries due to falls from a great height. A comparative analysis of injuries and their outcome following suicide-related and accidental falls].

The aim of this study was to compare the outcome and clinical course of multiple trauma patients with accidental or intentional (suicide related) fall from heights > 4 m. 211 patients with an injury severity score (ISS) > 17 were assigned to the following groups: I: intentional fall, n = 94; A: accidental fall, n = 117) and ISS (I: 28 +/- 1; A: 30 +/- 1), ventilation time (I: 16 +/- 2; A: 15 +/- 1) were not different. Significant differences were found in sex (m/f: I: 56/44; A: 73/27%), fractures of lumbarspine (I: 34; A: 15%), pelvis (I: 51; A: 38%), lower leg (I: 47; A: 20%), pilon (I: 15; A: 5%), and os calcis (I: 17; A: 9%). Liver lacerations occurred more often after intentional fall (I: 16; A: 6%). Single or multiple organ failure (MOF) was diagnosed significantly more often in group A(I: 1; A: 8%). Main cause of death in both groups was single or multiple organ failure (MOF: I: 47; A: 69%) or related to brain-injuries (I: 35; A: 19%). Prognosis and rehabilitation of multiple trauma patients after intentional fall is related to brain-injuries, spine-fractures and the functional outcome of the injured lower leg. Prognosis of patients after accidental fall is related to the development of MOF during the ICU-course.

Accidental Falls↗
PubMed1995

The rehabilitative management of the traumatic brain injury patient with associated femoral neuropathy.

The initial diagnoses of associated injuries in patients with traumatic brain injury (TBI) are often overlooked because of the priority given to life-sustaining measures. Pelvic and abdominal injuries comprise less than 5% each of the concurrent injuries associated with TBI and multiple trauma. This report describes a 32-year-old man who sustained a moderate TBI with facial, pelvic, and extremity fractures secondary to a fall. His hospital course was complicated by sepsis, acute renal failure, and retroperitoneal hemorrhage. Admitted to the rehabilitation service 6 weeks after the fall, the patient was found to have a previously undiagnosed profound quadriceps muscle weakness. A diagnosis of femoral neuropathy was confirmed by electrodiagnostic studies and was attributed to compression by pelvic hematomas. Rehabilitation management included use of a solid ankle cushion heel (SACH) wedge, a functional knee brace, a progressive ambulation program, neuromuscular stimulation, and patient and family education with an emphasis on safety. The patient progressed rapidly with his rehabilitation program, improving from moderate assistance in all skills to independence in 3 weeks. This case illustrates the importance of the physiatrist's role in the early detection of associated injuries in patients with multiple trauma and TBI; it also illustrates some of the rehabilitation techniques that may be employed to aid a patient with a femoral neuropathy to regain junctional ability.

Adult↗
PubMed1996

Posttraumatic inflammatory response, secondary operations, and late multiple organ failure.

The objective of this study was to determine the role of surgical procedures as secondary inflammatory insults in the development of late multiple organ dysfunction syndrome in patients with multiple trauma and to evaluate both specific and nonspecific indicators of the inflammatory response in their ability to indicate the risk of severely injured patients to develop organ failure after secondary operations. In a prospective study of 106 severely injured patients (ISS 40.6) who underwent secondary operations (> 3 days after trauma), we compared the level of preoperative inflammation with the sequelae of surgical trauma. The interventions included facial reconstructions; osteosynthesis of the pelvic girdle, long bones, and spine; and others. Group 1 consisted of 40 patients (38%) who developed respiratory, renal, or hepatic failure, or combinations thereof, within 2 days after the operation or whose preexisting organ dysfunction worsened by more than 20% from baseline. The remaining 66 patients (62%) with an uneventful recovery formed group 2. The preoperative levels of neutrophil elastase (92.2 vs. 61.3 ng/dL), C-reactive protein (12.4 vs. 7.6 mg/dL), and platelet count (118,000 vs. 236,000/microL) were significantly more abnormal in the patients of group 1. PO2/FiO2 ratio was also somewhat lower in group 1 patients (305.5 vs. 351), whereas other parameters (e.g., blood pressure, heart rate, bilirubin, creatinine, urinary output, lactate, pH, and coagulation) did not allow preoperative differentiation between groups 1 and 2. An increased state of inflammation (neutrophil elastase > 85 ng/mL, C-reactive protein > 11 mg/dL, platelet count < 180,000/microL) predicted postoperative organ failure with an accuracy of 79% (sensitivity, 73%; specificity, 83%). We conclude that secondary operations may act as a second insult and may precipitate late multiple organ dysfunction syndrome if they are performed in patients with multiple trauma while they still have an increased level of posttraumatic inflammation. However, future investigations have to show whether postponing surgery until inflammation has subsided or the use of less invasive surgical techniques will decrease the rate of postoperative organ failure in the trauma patient.

Adult↗
PubMed1992

Leukotriene generation in patients with multiple injuries.

We determined the generation and metabolism of lipoxygenase products in isolated granulocyte fractions of patients with multiple trauma (n = 9) and compared the results with those of healthy volunteers (n = 8). The supernatants of stimulated cells were analyzed by high-performance liquid chromatography. During the first week after injury a significantly reduced capacity to generate LTB4 and an increased metabolism of LTB4 into omega-oxidated products (20-OH-LTB4 and 20-COOH-LTB4) were observed after stimulation of the granulocytes with Ca ionophore. The depressed leukotriene production could be partly abrogated by the addition of arachidonic acid. These findings are comparable with alterations previously described in severely burned patients with postburn sepsis. Additionally, an elevated production of LTC4 by peripheral granulocyte fractions was observed in two patients suffering from adult respiratory distress syndrome (ARDS) as well as an increased number of eosinophils during the time of lung dysfunction. Analysis of bronchoalveolar lavage in patients with multiple trauma (11 patients with ARDS and 11 patients without ARDS) by a specific radio-immunoassay confirmed an elevated production of cysteinyl-leukotrienes.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMedDate not supplied

Polyamine excretion in depleted patients with gastrointestinal malignancy: effect of perioperative nutrition and tumor removal.

Polyamines, synthesized by all mammalian cells, are involved in protein and energy metabolism. We measured urinary excretion of polyamines, putrescine, spermidine, spermine, and their metabolites N1-acetylspermidine and N8-acetylspermidine, resting energy expenditure, and nitrogen excretion in 12 depleted patients with gastrointestinal malignancy during preoperative and postoperative parenteral nutrition and in 7 patients with multiple trauma receiving similar parenteral nutrition. During preoperative nutrition support, the excretion of putrescine (p less than .05) and total polyamines (p less than .01) increased by 420% and 60%, respectively. Increases in energy balance and resting energy expenditure during nutrition could entirely explain the observed changes in polyamine excretion. Preoperatively, the excretion of N1-acetylspermidine (p less than .05), N8-acetylspermidine (p less than .001) and total polyamines (p less than .05) was higher in patients with a surgically noncurable tumor than in those with a surgically curable tumor. The energy balance and resting energy expenditure could also explain the differences in polyamine excretion between patients with surgically curable and noncurable disease, excluding the increased N8-acetylspermidine. Postoperatively, the excretion of N8-acetylspermidine in patients with multiple trauma without malignancy and in patients with palliative operation was similar, and was higher than in patients with a totally resected malignancy (p less than .01). Our results suggest that the excretion of polyamines reflects the activity of energy metabolism in general and that polyamine excretion is not specific for any particular disease.

Adult↗
PubMed1990

[Admission and organization of emergency care for multiple injured patients. The experience of the Strasbourg Center of traumatology and orthopedics].

The admission of patients with severe multiple trauma and the organization of treatment must follow a few basic principles: 1) continuous, uninterrupted management by the various links of the medical chain, 2) single location: the various persons ensuring the treatment must go to the patient's side, and not the opposite, 3) pluridisciplinary, polyvalent care, and lastly, 4) single command: for us, the orthopedist-traumatologist must direct and coordinate care to the severely injured persons, and the so-called general surgeons is in charge of the others. Three structures of admission currently coexist in France: the department of admission, the emergency department and, rarely, the center of traumatology. Carefully planned routes, adapted facilities, plenty of material and staff are essential. The initial management of patients with multiple trauma in both diagnostic and therapeutic at the same time: first aid in case of vital emergency, resuscitation, clinical, radiological and biological assessment, aimed at drawing a complete census of the lesions and establishing their hierarchy. Considering this hierarchy, the treatment must urgently, completely and definitively deal with: In the first place, and in extreme emergency, vital lesions: visceral rupture, internal and external hemorrhages as well as orthopedic priorities: neuromedullary compression, fracture with vascular lesion, open fracture. All the lesions must be treated definitively if this is possible. However, not all fractures must be operated immediately. Only the severe lesions that are a factor of shock (eg. fracture of both femurs) must be reduced and fixed in emergency. The temporary treatment of the other lesions with plaster casts or continuous extension must not be neglected.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency Medical Services↗
PubMed1992

[Effects of different intramedullary stabilizing procedures of the femur on lung function in polytrauma].

We investigated the effects of primary (< 24 h) intramedullary femoral nailing on lung function and pulmonary hemodynamics in multiple trauma patients. The standard procedure following reaming of the medullary canal (AFN) was compared with a new procedure using a small, solid nail without prior reaming (UFN). Pulmonary hemodynamics were determined using a pulmonary artery catheter. Global lung function was assessed by means of the oxygenation ratio (PaO2/FiO2). Concentrations of elastase and the platelet count as a general parameter of the clinical course were determined from central venous blood during and 3 days after surgery. The lung function was stable in UFN patients (n = 6), but decreased significantly in AFN patients (n = 10) from 353 +/- 24 (PaO2/FiO2 preoperative) to 260 +/- 28 (PaO2/FiO2 postoperative) and did not improve until 48 h later. Pulmonary artery pressure (Pap) remained within normal limits in UFN patients, whereas in AFN patients Pap increased from 27.4 +/- 3 mm Hg (preoperative) to 37 +/- 3 mm Hg during reaming and did not normalize until 1 h after insertion of the nail. The platelet count remained unchanged in UFN patients and dropped in AFN patients from 143 +/- 25 x 1000 cells/ml blood (preoperative) to 87.5 +/- 15 x 1000 cells/ml blood 2 days after surgery. Our measurements did not show an increase in central venous triglycerides in the AFN group, probably because bone marrow does not become immediately soluble. There was no significant difference between the increase of elactase levels in the two groups. The femoral nailing procedure with reaming in multiple trauma patients involves a potential risk to the lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMedDate not supplied

Trauma, sepsis, and the immune response.

Burn patients, multiple trauma patients, and patients undergoing major surgical operations often suffer from acquired immunologic deficits that predispose them to life-threatening sepsis. This paper reviews the current research in this area, with emphasis on identifying the components of the immune response affected by injury, elucidating the mediators of immunologic change, and determining new therapeutic approaches for correcting immunologic deficits. Lessons learned from the study of immune deficiency disease are reviewed, as are basic observations of burn- and trauma-induced immune depression.

Antibody Formation↗
PubMed1990

[Polytraumatized patient. First aid care, transport and resuscitation].

The initial management of multiple trauma must achieve a triple aim: performing the actions required by a vital emergency, preventing as well as possible the complications associated with the initial lesions, and, most importantly, bringing the injured person into hospital in the best possible conditions for emergency surgery. Achieving these aims requires a perfect coordination of medical and nonmedical rescue. A rough initial categorization is important to decide whether additional medical staff is desirable, choose the type of transport planned (by ambulance, helicopter...) as well as the department or hospital due to receive the patient. Four actions must be accomplished, most often jointly, all of them contributing to the quality of treatment: 1. picking up/freeing/immobilizing the injured person, 2. controlling the hypovolemic collapse and the traumatic shock, 3. dealing with the associated distresses, 4. suppressing pain. The techniques used to pick up, free and immobilize the injured person require a close co-operation with the rescuing staff (stretcher bearers, fire department, first-aid workers). The hypovolemic shock is treated by volume replacement, mainly with colloids. Local hemostasis may sometimes be necessary. Anti-shock trousers should be widely used in cases of multiple trauma. Dealing with the associated distresses gives priority to ventilation. The indications of ventilatory support must be very wide whenever coma or signs of respiratory distress are noted, more so with an associated shock. The indications of aspiration of a gaseous or fluid pleural effusion must also be discussed. Maximal suppression of pain must be kept in mind throughout all these operations.(ABSTRACT TRUNCATED AT 250 WORDS)

Analgesia↗
PubMedDate not supplied

Biochemical pathways of acute lung injury.

Complement fragments (C3, C3d, C5a), thromboxane B2 (TxB2), 6-keto-PGF1 alpha and immunoreactive trypsin (IRT) were measured in 98 patients at risk of developing the adult respiratory distress syndrome (ARDS): 53 multiple trauma, 28 abdominal surgery and 17 acute pancreatitis. Sixty-five of these patients developed ARDS: 30 multiple trauma, 19 abdominal surgery and 16 acute pancreatitis patients. Forty of the 65 ARDS patients and 9 out of the 33 non-ARDS patients died. Mean value of the C3d to C3 ratio was abnormal in both ARDS and non-ARDS patients. C5a-like activity was detected in 70 out of the 98 patients (49 ARDS and 22 non-ARDS patients). TxB2 abnormal values (greater than 100 pg . ml-1) were found in 70% of the patients, especially when sepsis occurred. No correlation could be made between abnormal 6-keto PGF1 alpha values and ARDS or sepsis. The mean peak IRT value was 675 micrograms . 1(-1) for ARDS patients and 274 micrograms . 1(-1) for non-ARDS patients (p less than 0.05). A firm correlation was also measured between IRT and sepsis (p less than 0.01). C5a-like activity was regularly detected soon after injury, while TxB2 and IRT tend to appear later in patients developing ARDS. Neither C3d/C3, nor C5a-like activity, nor TxB2, nor IRT are specific markers of ARDS, since they also appeared in severely ill patients who did not develop ARDS.

6-Ketoprostaglandin F1 alpha↗
PubMed1975

Multiple facial trauma complicated by occlusion of the internal carotid artery.

The occurrence of thrombosis of the internal carotid artery is a rare entity. Such a case, in association with multiple facial fractures, has been presented. The management of the patient was complicated by neurological disturbances that affected definitive treatment. This case illustrates the importance of close monitoring of all patients with facial trauma before, during, and after surgery.

Adult↗
PubMed2006

[Emergency treatment of thoracic trauma].

Thoracic trauma, most often associated with other serious injuries, is the main cause of death in the first 45 years of life. The percentage of chest injuries in multiple trauma, mainly from blunt impact, has remained relatively constant at 80% during the last 30 years. Isolated thoracic injuries comprise only 25% of all trauma cases, 90% of chest injuries are due to blunt impact, while penetrating injuries make up 5-10%. Since 25% of deaths from trauma are attributable to chest injuries, they determine the survival rate in multiple trauma to a significant extent. The pattern of chest injuries is variable, frequently in different combinations comprising rib cage and diaphragm, lung parenchyma, airway and mediastinal organs. This article details the immediate simultaneous diagnostic and therapeutic procedures in the prehospital phase, management in the emergency room, the relative importance of computed tomography, ultrasound examination and endoscopy in the primary diagnostic evaluation and the principles of anaesthetic management of thoracic trauma.

Adult↗
PubMed1991

A prospective study of physical trauma and multiple sclerosis.

During an eight year period 170 multiple sclerosis (MS) patients and 134 controls without physical impairment were followed closely to record all episodes of physical trauma and to measure their effect on exacerbation rate and progression of MS. There was a total of 1407 instances of trauma, which were sorted into various categories. Overall there was no significant correlation between all-traumas and disease activity. There was, however, a statistically significant negative correlation between traumatic episodes and exacerbations in 95 patients who had exacerbations during the programme, due primarily to less activity of the disease during a three month period following surgical procedures and fractures. Electrical injury had a significant positive association with exacerbation using a three month at-risk period, but there were no other significant positive correlations in any other category of trauma, including minor head injuries; there were no cases of head injury with prolonged unconsciousness. There was no linkage between the frequency of trauma and progression of disability. MS patients had two to three times more trauma than controls.

Adult↗
PubMed1998

The cellular, immune, and metabolic response to trauma.

The major challenge in treatment of the multiple trauma victim has shifted from early and effective resuscitation to treatment of the host response to injury. Patients surviving for the first 24 h after major injury as a result of effective resuscitation remain at risk of progressive organ failure and death from what appears to be an uncontrolled inflammatory process. A septic cause is frequently not identifiable, yet the response is as if the patient were infected. While organ-supportive measures such as mechanical ventilation, extracorporeal membrane oxygenation, renal replacement therapies, and total parenteral nutrition help to maintain tissue substrate delivery and metabolite removal, these therapies eventually fail if the microvaculature ceases to function. As the soluble and cell-mediated pathways of the inflammatory response are now being unraveled, possible interventions designed to attenuate selected elements of the inflammatory pathways are being developed. These measures include antioxidants, enzyme inhibitors, pharmacological agents, antibodies both to soluble mediators and cell surface receptor antagonists. Most of these interventions are at the experimental stage and so far have only met with limited clinical success. A major problem with attenuation of the inflammatory response is the overlap of inflammatory pathways, such that modulation of one or two is unlikely to be of benefit in a patient with major injuries. In addition, the speed of these responses, once initiated, requires that therapies have to be administered very soon after injury to be effective. However, the tremendous increase in knowledge of the inflammatory response, and the increasing sophistication of laboratory science that can provide both assessment of mediators of inflammation and the patients' response to the inflammatory process allows early identification of patients at risk of post-trauma organ failure. Armed with this knowledge, treatment can be tailored to each patients' individual response to injury, and when definitive antiinflammatory regimes are available, patients who can benefit from this treatment can be identified rapidly.

Animals↗
PubMed1982

Comparison between in vitro lymphocyte activity and metabolic changes in trauma patients.

This study was designed to investigate the relationship of in vitro and in vivo components of host immunocompetence and various biochemical parameters of injury. Thirteen multiple trauma victims were evaluated within 2 to 3 days postinjury while maintained on 5% glucose. The mean nitrogen balance of the patients was -18 gm/24 hr and the resting metabolic expenditure was increased 22.3%. Seventy-five per cent of the patients skin tested were anergic or relatively anergic. Patient lymphocyte response to the T cell mitogens phytohemagglutinin and concanavalin A were suppressed 45 and 48%, respectively, when compared to 24 normal healthy individuals. Total lymphocyte count (1,558) and percentage of T lymphocytes (63%) were within normal limits. The suppression of lymphocyte response to mitogens correlated by regression analysis with the negative nitrogen balances and resting metabolic expenditures in these patients (p less than 0.05). The depression of lymphocyte activity can be correlated with the catabolic response of injury in multiple trauma patients.

Adolescent↗
PubMed2005

Impact of hypothermia on the immunologic response after trauma and elective surgery.

An Hypothermia is defined as a decrease in core temperature below 35 degrees C. The well-described deleterious effects of accidental hypothermia on outcome in multiple-trauma patients contrast the beneficial effect of controlled hypothermia on organ function during ischemia in elective surgery. Experimental studies have shown that induced hypothermia during hemorrhagic shock might have beneficial effects on outcome. The beneficial effects of induced hypothermia appear to be partly mediated by the prolongation of the "golden hour" with prevention of hypoxic organ dysfunction. However, hypothermia also has been thought to have an impact on the immunologic response after trauma and elective surgery. Induction of hypothermia seems to decrease the release of pro-inflammatory cytokines believed to influence distant organ damage positively, and is mediated by the interaction of polymorphonuclear leucocytes (PMNL) and capillary endothelial cells. Nevertheless, the incidence of posttraumatic infectious complications may be increased after induction of hypothermia due to an overexpression of anti-inflammatory cytokines. Together with this immunosuppressive profile, coagulopathy and bleeding might limit the use of induced hypothermia after multiple trauma and elective surgery. The purpose of this Chapter is to highlight current knowledge regarding the interaction of hypothermia and posttraumatic immune reactivity. A better understanding of these mechanisms would assist the introduction of preventive and therapeutic strategies into clinical practice.

Brain Injuries↗