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PubMedDate not supplied

[Closed abdominal injuries: importance and results of peritoneal puncture-lavage].

In a series of 138 closed abdominal trauma, observed during the past 10 years, the authors report their experience of the peritoneal lavage with a Diacath: the method is 97.8% accurate in determining the presence or absence of abdominal injuries. The abdominal signs and symptoms, with an accuracy of 58.7% are hardly contributive, especially in cases of multiple trauma and patients with altered state of consciousness. The peritoneal lavage, as long as the technique and the contra-indications are respected, is an easy, safe and reliable test for the detection of abdominal damage. Positive diagnostic peritoneal lavage allows an earlier diagnosis and operation, and reduces the mortality for intra-abdominal injuries by eliminating deaths from undiagnosed intra-abdominal lesions. If negative, it avoids unnecessary laparotomies, especially in cases of multiple trauma.

Abdominal Injuries↗
PubMed1985

Pediatric head injury: the critical role of the emergency physician.

Neurologic injury is a significant source of morbidity and mortality in pediatric patients. In order to clarify the factors influencing outcome in pediatric patients with severe head injury, we studied 200 consecutive patients with Glasgow Coma Scale (GCS) scores of 8 or less. The following data were collected: age, GCS score, presence of mass lesions, oculovestibular reflexes (OVR), pupillary size and reactivity, intracranial pressure (ICP), apnea, presence of hypotension, hypoxia (PO2 less than 60 torr), or hypercarbia (PCO2 greater than or equal to 35 torr), presence of multiple trauma, and Modified Injury Severity Scale (MISS) score. Outcome was assessed by the Glasgow Outcome Scale at a minimum of six months following recovery. Of the 200 patients in the study, 86 (43%) had isolated head injury (IHI) and 114 (57%) had head injury plus multiple trauma (HI + MT). Overall, 26% of patients had mass lesions; 28% had altered OVR; 33% had fixed, dilated pupils; 79% had increased intracranial pressure; and 29% had hypotension, hypoxia, or hypercarbia. Overall mortality was 21.5%. Severity of injury (as judged by presence of mass lesions, GCS, OVR, fixed pupils) was more pronounced in patients with IHI, although increased ICP was more common in patients with HI + MT; however, death was almost three times more common in patients with HI + MT (30% versus 10.5%). In the IHI group, two of nine patients who died (22%) had hypotension, hypoxia, or hypercarbia; all but four patients (88%) in the HI + MT group had hypotension, hypoxia, or hypercarbia.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2001

Early predictors of mortality in penetrating compared with closed brain injury.

INTRODUCTION: Although brain injury incidence rates have been decreasing, the proportion of these injuries which are penetrating has been increasing. This study compares mortality amongst persons with penetrating and closed brain injuries and explores the relationship of early predictors of mortality. METHODS: The study included 795 moderately or severely brain injured individuals identified through the UCLA Brain Injury Research Centre. Logistic regression was used to predict mortality by GCS level and brain injury type, controlling for age, gender, and presence of multiple trauma. RESULTS: Of the 795 individuals, 110 had penetrating and 685 had closed brain injury. Case fatality rates were higher for penetrating than closed injuries for all GCS, gender, age, and cause of injury categories. When controlling for GCS level at admission, age, gender, and multiple trauma, those with penetrating injuries were 6.6 (95% CI = 3.9-11.1) times more likely to die. CONCLUSIONS: As the pool of information about survival and recovery from penetrating injuries grows, decisions regarding clinical care and prevention activities can be more appropriately focused.

Adolescent↗
PubMed1995

Effects of lactate on glucose metabolism in healthy subjects and in severely injured hyperglycemic patients.

Hepatic glucose production is autoregulated during infusion of gluconeogenic precursors. In hyperglycemic patients with multiple trauma, hepatic glucose production and gluconeogenesis are increased, suggesting that autoregulation of hepatic glucose production may be defective. To better understand the mechanisms of autoregulation and its possible alterations in metabolic stress, lactate was coinfused with glucose in healthy volunteers and in hyperglycemic patients with multiple trauma or critical illness. In healthy volunteers, infusion of glucose alone nearly abolished endogenous glucose production. Lactate increased gluconeogenesis (as indicated by a decrease in net carbohydrate oxidation with no change in total [13C]carbohydrate oxidation) but did not increase endogenous glucose production. In patients with metabolic stress, endogenous glucose production was not suppressed by exogenous glucose, but lactate did not further increase hepatic glucose production. It is concluded that 1) in healthy humans, autoregulation of hepatic glucose production during infusion of lactate is still present when glycogenolysis is suppressed by exogenous glucose and 2) autoregulation of hepatic glucose production is not abolished in hyperglycemic patients with metabolic stress.

Adolescent↗
PubMed2002

Vascular surgery of the upper limb: the first year of a new vascular service.

Upper limb vascular reconstruction represents a small part of the vascular surgical workload (5%). The aim of this study was to assess the incidence of upper limb vascular reconstruction in a Regional Hospital. During the first year of a new vascular surgical service in Waterford Regional Hospital, upper limb vascular problems were prospectively analysed. Upper limb vascular reconstruction comprised seven of the total 92 major vascular procedures performed. Three cases were emergencies and four elective. There was one case of penetrating injury, two injuries due to blunt trauma, three patients with thoracic outlet syndrome (TOS) and one chronic ischaemia. The male:female ratio was 4:3 and the mean age was 42 years. Six of the cases were arterial in nature only, and one was both venous and arterial. Two of the cases were associated with upper limb fractures and multiple trauma. Three patients had interposition reversed cephalic vein grafting. One patient had an embolectomy and endarterectomy. Procedures for TOS included excision of a cervical rib in two patients (one bilateral) and scalenectomy alone in one patient. Of these, one patient also had thrombolysis and thrombectomy of the axillary and brachial artery. All of the patients made a good functional recovery and all arteries remained patent but the patient with the brachial plexus injury is awaiting repair abroad. Upper limb vascular problems form a small but significant part (8%) of the workload. Many cases present as emergencies and maybe associated with multiple trauma. This emphasises the need for an emergency vascular surgery service in all trauma units.

Adult↗
PubMed1990

Cardiac arrhythmias in critically ill patients: epidemiologic study.

The general prevalence of cardiac arrhythmias in 2,820 consecutive patients was 78%, ranging from 44% in multiple trauma patients to 90% in primary cardiovascular patients. Patients without recorded arrhythmias (22%, n = 621) were used as control subjects. No clinical group was free from cardiac arrhythmias. Atrial tachyarrhythmias had the highest prevalence in the population as a whole (28%) and in all clinical groups except multiple trauma. Atrial fibrillation was the most common atrial arrhythmia (52%); ventricular arrhythmias followed. Patients with atrial tachyarrhythmias, nodal rhythm ventricular bradyarrhythmias, and ventricular rapid rhythms had significantly (p less than .01) increased mortality rates (40%, 44%, 77%, and 51%, respectively) when compared with patients without arrhythmias (35%). The relative risk of dying (RRD) of these clinical groups was increased by 1.16, 1.27, 2.20, and 1.47, respectively. Patients with cardiorespiratory precipitating disease and any arrhythmia except atrial bradyarrhythmia had a mortality rate between 32% and 74%, significantly (p less than .05) different from that of patients within the same clinical groups without arrhythmias. The RRD was increased by 1.67 to 3.40. Septic patients with atrial tachyarrhythmia or nodal rhythm and neurologic patients with nodal or ventricular arrhythmias also had significantly (p less than .01 and .05, respectively) increased mortality and were at higher RRD (1.53 to 2.81). Our data suggest that severe illness may be present in some clinical groups of critically ill patients with cardiac arrhythmias.

Adult↗
PubMed1997

Treatment of open tibial fractures with primary suture and Ilizarov fixation.

Thirty-two open tibial fractures were treated by irrigation, debridement, antibiotic therapy, primary closure when possible, and fixation with Ilizarov device. In the Gustilo classification, 11 were Grade I, 10 Grade II, 8 Grade IIIA, and 3 were Grade IIIB. No Grade IIIC fractures were treated in the period studied. Fifteen were in patients with multiple trauma, and in 17 patients the fracture was a single injury. All fractures healed with good anatomic alignment, except for 1 with 5 degrees angulation and another with 1-cm shortening. The healing time was 21.9 weeks in the single injury and 25.7 weeks in the patients with multiple trauma. Eleven patients had pin tract infection, and in 4 the pin had to be replaced. One patient had dermatitis near the fracture site. This treatment of open tibial fractures proved to be successful for anatomic restoration of the tibia and had a low complication rate. Primary closure should be considered a possible method of treatment in Types I to IIIA open fractures, together with the Ilizarov external fixator, if the wound edges can be approximated easily with no tension at the suture line.

Adolescent↗
PubMed1986

Granulocyte proteinases as mediators of unspecific proteolysis in inflammation: a review.

In severe inflammatory response, various blood and tissue cells, including polymorphonuclear granulocytes, release lysosomal proteinases, extracellularly and into the circulation. Such enzymes, as well as normally intracellular oxidizing agents produced during phagocytosis, enhance the inflammatory response by degrading connective tissue structures, membrane constituents and soluble proteins by proteolysis or oxidation. We first used polymorphonuclear elastase (E) as a marker of such release reactions. The liberated proteinase competes with susceptible substrates, including alpha 1-proteinase inhibitor (alpha 1PI) and alpha 2-macroglobulin, and is eliminated finally as inactive enzyme-inhibitor complexes by the reticulo-endothelial system. Using an enzyme-linked immunosorbent assay, we determined the plasma levels of E-alpha 1PI following major abdominal surgery, multiple trauma and pancreatogenic shock. Whereas the operative trauma was followed by up to 3-fold increase of the E-alpha 1-PI, postoperative septicemia was associated with a 10 to 20 fold increase. The increase of E-alpha 1-PI and a concomitant decrease of plasma factors, such as antithrombin III, clotting factor XIII and alpha 2-macroglobulin, were correlated. Multiple trauma causes a substantial increase of E-alpha 1-PI up to 14 hours after accident. The released elastase seems to correlate with severity of injury, but assessing the relationship to consumption of plasma factors is complicated by concomitant transfusions. In acute pancreatitis, peaks, of E-alpha 1-PI coincide with a massive consumption of antithrombin III and alpha 2-macroglobulin during shock.

Blood Proteins↗
PubMed1989

Determinants of urea nitrogen production in sepsis. Muscle catabolism, total parenteral nutrition, and hepatic clearance of amino acids.

The major determinants of urea production were investigated in 26 patients with multiple trauma (300 studies). The body clearances (CLRs) of ten amino acids (AAs) were estimated as a ratio of muscle-released AAs plus total parenteral nutrition-infused AAs to their extracellular pool. While clinically septic trauma (ST) patients without multiple-organ failure syndrome (MOFS) had a higher level of urea nitrogen production (25.6 +/- 13.4 g of N per day) compared with nonseptic trauma (NST) patients (14 +/- 7.5 g of N per day) and with ST patients with MOFS (4.28 +/- 1.5 g of N per day), in all groups urea N production was found to be a function of muscle protein degradation (catabolism), total parenteral nutrition-administered AAs, and the ratio between leucine CLR and tyrosine CLR (L/T) (r2 = .82, P less than .0001). Since tyrosine is cleared almost exclusively by the liver, the L/T ratio may be regarded as an index of hepatic function. The significant differences between urea N production in ST and NST patients lay in an increased positive dependence on muscle catabolism and increased negative correlation with L/T in the ST group. At any L/T ratio, urea N production was increased in ST patients over NST patients, but in ST patients with MOFS, it fell to or below levels of NST patients. These data show that the ST process is associated with enhancement of ureagenesis, due to increased hepatic CLR of both exogenous and endogenous AAs. In sepsis with MOFS, a marked inhibition of urea synthesis occurs, partially explained by a decreased hepatic CLR of non-branched-chain AAs.

Adult↗
PubMed1991

[Initial clinical experience with osteosynthesis of femoral shaft fractures with a newly developed intramedullary implant (claw interlocking nail)].

The implantation of distal interlocking screws in interlocking nailing can be difficult and time-consuming. With the AO Universal Femoral Nail as the basis, an implant was designed with which distal interlocking is accomplished from the inside of the nail by means of a simple claw mechanism. Instrumentation and interlocking are possible from the proximal standard approach, so that an additional operation adjacent to the knee (which is necessary when interlocking bolts are used) is superfluous; neither for the insertion nor for the removal of the interlocking mechanism is an image intensifier necessary. We stabilized 24 femoral shaft fractures with this new interlocking nailing device [20 fresh fractures, 3 refractures and 1 pathologic fracture caused by tumor metastasis from chronic myeloid leukemia (CML)]. The mean age of the patients concerned was 34.8 years (18-57 years). Fractures were classified according to the Müller classification with 11 type-A fractures (45.8%), 9 type-B fractures (37.5%) and 4 type-C fractures (16.7%). There were only 2 cases (8.3%) with open fractures. In 11 cases (45.8%) the fracture was located in the midshaft region, in 6 cases (25.0%) in the proximal shaft, and in 7 cases (29.2%) in the distal femoral shaft. Multiple trauma was present in 11 patients (45.8%), while in 8 patients (33.2%) the femoral shaft fracture was the only major injury. Full weight-bearing was allowed after a mean of 4.4 weeks (0.7-8.2 weeks). In 1 case we saw a deep venous thrombosis with pulmonary embolism obvious on clinical examination and scintigraphy. Two patients died of their multiple trauma, and of cachexia the patient with the CML metastasis died 6 weeks after stabilization.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2002

Bacterial contamination in postmortem bone donors.

We analyzed factors influencing the contamination rate of allografts and blood samples obtained from postmortem bone donors. 5,710 allografts were harvested, from 550 donors of which 3,164 (55%) were swab culture negative. Blood cultures were positive in 140 donors (26%). The risk of graft contamination increased with each extra team member (Odds Ratio 1.9). It was also higher with organisms of greater virulence in donors with a positive blood culture (OR 3.5). The risk of blood contamination increased per hour postmortem (OR 1.1) and the same increase was seen with organisms of high virulence. In donors with multiple trauma, the risk of blood contamination with organisms of high virulence was greater (OR 8.2), but smaller in donors with preceding organ procurement (OR 0.1). To minimize the bacterial load, donors should be obtained in operating rooms, using aseptic techniques with only a few personnel for procurement. The postmortem time should be kept to a minimum. The procurement cultures from donors with multiple trauma should be carefully interpreted. Blood cultures should be taken into account, since these can help to find contamination not detected by swab cultures.

Bacterial Infections↗
PubMed1985

Septic complications of corticosteroid administration after central nervous system trauma.

The records of 197 consecutive multiple trauma patients were reviewed to define the infectious complications of corticosteroids used to treat brain and spinal cord injury. An injury severity score (ISS) and a central nervous system (CNS) injury score were determined for each patient. Patients with an ISS less than 20 did well with or without steroids and were excluded from further study. All deaths that occurred 5 or more days after injury were caused by sepsis, and all occurred in steroid recipients. Twenty-nine of 61 steroid-treated early survivors developed infectious complications, compared to eight of 55 patients who did not receive steroids (47.5% vs. 14.5%, p less than 0.001). There was no correlation between severity of CNS trauma and infectious complication rate. Steroid-treated patients frequently developed multiple pathogen primary infections and multiple, simultaneous septic foci. Patients treated with steroids more often developed infections caused by Staphylococcus aureus, assorted gram negative rods, anerobic bacteria, or fungi. The study strongly suggests a significant increase in both the incidence and severity of infectious complications occurring in patients treated with corticosteroids for CNS trauma.

Adolescent↗
PubMed2005

Transcatheter arterial embolization in a hemodynamically unstable patient with grade IV blunt liver injury: is nonsurgical management an option?

The prevalence of liver injury in patients who have sustained blunt multiple trauma was reported to range from 1 to 8%. Because previous mortality rates were as high as 50-80% for severe hepatic injury, the choice of treatment was under intensive investigation. Whereas nonsurgical management was the standard treatment for the hemodynamically stable patient, there is no consensus on how to treat hemodynamically unstable patients. This report details the case of a patient who sustained blunt multiple trauma, resulting in a grade IV liver injury, graded according to the American Association for the Surgery of Trauma (AAST) Liver Injury Scale. With massive fluid and blood resuscitation, the patient was stable enough to be managed nonsurgically. With transcatheter arterial embolization (TAE), the left and right hepatic arteries were embolized with coils, which allowed for a good recovery. We hypothesize that TAE can be used in the hemodynamically unstable patient who responds to rapid fluid resuscitation and blood transfusion. We caution that there is insufficient evidence until now and would therefore not make any recommendations; however, we would question the need for surgery in unstable patients with this kind of injury in the future.

Accidents, Traffic↗
PubMed1987

Analysis of hyperamylasemia in patients with severe head injury.

To evaluate the influence of severe head injury (SHI) on amylase activity, we studied the amylase profile of 60 patients with SHIs and Glasgow Coma Scores less than 10. Fourteen additional multiple trauma patients without head injuries were studied as a control group. We excluded patients with pancreatic injury and abdominal trauma. Total serum amylase (TA), pancreatic isoamylase (PA), and nonpancreatic isoamylase (NPA) levels were measured on Days 0, 2, 4, 7, and 14 postinjury. Values greater than 2 SD above the normal mean were considered elevated. All SHI patients were comatose; 14 died. In the SHI group, TA increased in 23 patients, PA increased in 40, and NPA increased in 14. The source of hyperamylasemia was PA in 14, NPA in one, and mixed in 8 patients. While PA increases occurred throughout the study, NPA elevations occurred early. These increases did not correlate with shock (BP less than 80 mm Hg; 17 patients), facial trauma (24 patients), or associated injury (29 patients). On Day 7 postinjury, the mean TA (215 du%) and the mean PA (203.8 du%) were significantly elevated in the SHI patients compared to controls (122.1 du%, P less than 0.05, Wilcoxon's rank sum test). These data indicate that serum amylase is not a reliable index of pancreatic injury in patients with SHI. Severe head injury and multiple trauma activate pathways that increase amylase levels in the blood, suggesting a central nervous system regulation of serum amylase levels.

Amylases↗
PubMed1994

Childhood survival of atlantooccipital dislocation: underdiagnosis, recognition, treatment, and review of the literature.

Traumatic childhood atlantooccipital dislocation (AOD) may be overlooked, especially in patients with concomitant closed head injury and multiple trauma. We diagnosed and treated 4 children with traumatic AOD seen in less than a 2-year period. We found published descriptions of only 15 other survivors of childhood traumatic AOD in the literature. Clinical histories, radiographic findings, treatment, outcome, and complications in these 15 children as well as our 4 patients were reviewed. The age distribution of childhood AOD survivors (average age 6.8 years) closely resembles that of pediatric multiple trauma patients. Early diagnosis of traumatic AOD hinges on precise interpretation of the lateral cervical radiograph. Longitudinal AOD was seen most often. Usually these children presented with cranial nerve palsies, major motor deficits, and depressed level of consciousness. Most underwent posterior atlantooccipital fusion. Outcome varied from normal neurological function to prolonged ventilator dependency and delayed demise. AOD must be diagnosed early to avoid attributing potentially reversible neurologic changes to irreversible injuries since closed head injury and high spinal cord dysfunction may be confused clinically and the outcome of a patient with AOD is unpredictable.

Atlanto-Occipital Joint↗
PubMed2004

Damage control: extremities.

The principles of fracture management in polytrauma patients continue to be of crucial importance. Over the last five decades, various strategies of fracture treatment in the multiply injured patient have evolved. The various new methodologies remain controversial. In the beginning, early surgical fracture treatment of long bone fractures after multiple trauma was not routinely advocated. It was believed that the polytraumatised patient did not have the physiological reserve to withstand prolonged operations. The introduction of standardised, definitive surgical protocols, led to the concept of early total care (ETC) in the 1980s. This concept was subsequently applied universally, in all patient groups, regardless of injury severity and distribution. Later, it became apparent that certain patients did not appear to benefit from ETC. Indeed, extended operative procedures, during the early phase of multiple trauma recovery, were associated with adverse outcome. This applied for patients with significant thoracic, abdominal and head injuries and those with high injury severity scores (ISS). In response, the concept of damage control orthopaedics (DCO) was developed in the 1990s. DCO methodology is characterised by primary, rapid, temporary fracture stabilization. Secondary definitive management follows, once the acute phase of systemic recovery has passed. We explore the processes underlying the systemic biological impact of fracture fixation, the evolution of operative treatment strategies for major fractures in polytrauma and the current trends toward staged management of these patients.

Acute-Phase Reaction↗
PubMed1984

[Abdominal injuries. Value of emergency abdominal echotomography].

The purpose of this study was to evaluate the usefulness of abdominal ultrasonic tomography, among other methods, to detect visceral lesions in multiple traumas of the abdomen. Forty-seven case-records of abdominal traumas observed over an 8-month period were selected. We used a real-time sectorial ultrasound scanner with a 3.5 MHz probe. Positive results were obtained in 11 patients who were operated upon. None of the 33 patients with negative results and only one of the 3 patients with doubtful results underwent surgery. We found that suggestive symptoms were compatible with the absence of any severe visceral lesion and, conversely, that patients with multiple traumas but little suggestive symptoms could present with one or several intra-abdominal lesions. Abdominal ultrasonic tomography can rapidly be performed and its indications are different from, but wider than, those of peritoneal lavage. It is a safe and reliable emergency examination which does not interfere with resuscitation procedures.

Abdominal Injuries↗
PubMed1982

Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury.

During 1977-1978, 127 patients with severe head injury were admitted and underwent intracranial pressure (ICP) monitoring. All patients had Glasgow Coma Scale (GCS) scores of 7 or less. All received identical initial treatment according to a standardized protocol. The patients' average age was 29 years; 60% had multiple trauma, and 35% needed emergency intracranial operations. Treatment for elevations of ICP was begun when ICP rose to 20 to 25 mm Hg, and included mannitol therapy and drainage of cerebrospinal fluid (CSF) when possible. Forty-three patients (34%) had ICP greater than or equal to 25 mm Hg; of these, 36 (84%) died. The mortality rate of the entire group was 46%. During 1979-1980, 106 patients with severe head injury were admitted and underwent ICP monitoring. Their average ager was 29 years; 51% had multiple trauma, and 31% underwent emergency intracranial surgery. All patients received the same standardized protocol as the previous series, with the exception of the treatment of ICP. In this present series: if ICP was 15 mm Hg or less (normal ICP), patients were continued on hyperventilation, steroids, and intensive care; if ICP was 16 to 24 mm Hg, mannitol was administered and CSF was drained; if ICP was 25 mm Hg or greater, the patients were randomized into a controlled barbiturate therapy study. Twenty-six patients (25%) had ICP's of 25 mm Hg or greater, compared to 34% in the previous series (p less than 0.05), and 18 of these 26 patients (69%) died. The overall mortality for this current series was 28% compared to 46% in the previous series (p less than 0.0005). This study reconfirms the high mortality rate if ICP is 25 mm Hg or greater; however, the data also document that early aggressive treatment based on ICP monitoring significantly lessens the incidence of ICP of 25 mm Hg or greater and reduces the overall mortality rate of severe head injury.

Adolescent↗