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PubMed1996

[Intensive care medicine aspects of polytrauma].

Multiple trauma often leads to systemic inflammatory reaction and multiple organ dysfunction. Modulation of this response may be promising. Several pharmacologic approaches, such as antioxidants (e.g. superoxidedismutase), calcium channel blockers (e.g. diltiazem), cytokines (e.g. interferone gamma), and modulators of intracellular signal transduction pathways (e.g. pentoxiphylline) have been shown to improve outcome in experimental models and/or in clinical pilot studies. However, up to now no definitive evidence has been provided in prospective, randomized, and blinded "intention to treat" trials that these agents are able to reduce mortality and morbidity of the traumatized patient. Hence, supportive care of failing organs, treatment of hypoxemia and maintenance of an appropriate systemic blood pressure remain the mainstay of critical care therapy. Widely accepted therapeutic measures are (i) immediate treatment of hypoxia by administration of oxygen and ventilatory support, if needed, to maintain an oxygen tension of 60 mmHg or higher (ii) maintenance of adequate oxygen content by transfusion of red packed cells in order to restore a hematocrit of 23-30% (iii) treatment of hypovolemia by infusion of crystalloids, colloids and blood products (iv) normoventilation and restoration of a normal or elevated blood pressure in patients with severe head injury (v) immobilisation and early administration of methylprednisolone in patients with spinal cord injury (vi) analgesia by administration of opioids, non-steroidal antiinflammatory drugs, or ketamine (vii) sedation with benzodiazepines, gamma-hydroxbutyrate or propofol (viii) early enteral nutrition (ix); antibiotic therapy of infections (x) pressure controlled ventilation in patients with acute lung injury (xi) continuous veno-venous hemofiltration in patients developing acute renal failure and (xii) early surgical interventions to control bleeding and/or to evacuate intracerebral hematomas.

Combined Modality Therapy↗
PubMedDate not supplied

[The Institute of Surgery in Novi Sad as a trauma center--10 years' experience].

UNLABELLED: Trauma is a surgical disease and a leading cause of death in the population in the age of forties. The Institute for Surgery in Novi Sad (trauma center of the first rank) takes care of all injured people brought to the Institute either directly from the place of accident or from other centers. AIM OF THE STUDY: Retrospective analysis of the injured people treated at the Institute for Surgery in the period 1987-1996. MATERIAL AND METHODS: Multivariate analysis of the traumas from the register of the Institute for Surgery according to the trauma system elements: number of injured individuals, sex and age structure, categorization of injuries, etiology of injuries, distribution of serious injuries by regions, results obtained from the treatment of serious injuries. RESULTS: They show a global representation of all elements involved with injured people: due to moderately serious, serious and critically serious injuries 21.6% of patients were hospitalized; in the age of 29-30 years men with traumas caused on work or in traffic were predominant, while women with injuries caused by falling were predominant in the age of 60-69 years; drastically increased injuries caused by fire-arms in the period 1991-1993 were directly caused by the state of war and these injuries are still numerous; in case of hospitalized patients isolated trauma (80%) was predominant, multiple trauma was under 20% and polytrauma was registered in 5% of patients; after surgical treatment of injuries approximately 17% of patients were indicated for postoperative prolonged treatment and in intensive care unit at the Institute for Surgery; the average mortality of hospitalized patients was 5-7% but with extremely high mortality rate (< 70%) in the group of patients with polytraumas.

Adult↗
PubMed1987

Acute gastric dilatation after trauma.

During a 2-year period, 248 consecutive patients were admitted with multiple trauma. Acute gastric dilatation was documented in 67 (27%) patients by review of all admission roentgenograms. There were 51 (76%) males and 16 females. Ages ranged from 2 to 80 years (mean, 29.2 years). The incidence of acute gastric dilatation in children was 44% vs. 25% for adults (p less than 0.05). The mechanism of injury was motor vehicle accident in 45 (67%), agricultural accident in 8 (12%), fall in four (6%), bicycle accident in four (6%), and miscellaneous in six (9%). There were 38 orthopedic, 35 craniocerebral, 34 abdominal, 31 thoracic, 27 maxillofacial, and 14 spinal injuries. Injury Severity Scores ranged from 4 to 66 (mean, 23.5). Thirteen (19%) patients presented in shock and there were four (6%) hospital deaths. No death was attributable to gastric dilatation. Nasogastric tubes were placed in 41 (61%) patients and 26 were managed without tube placement. Complications associated with acute gastric dilatation included pulmonary aspiration in three (4%) patients, gastric hemorrhage in three (4%), gastrointestinal perforation in one (1%), and prolonged ileus in 12 (18%). In addition, gastric dilatation rendered abdominal examination difficult and delayed peritoneal lavage. Acute gastric dilatation after trauma is frequent in our rural trauma center. Early placement of a nasogastric tube in the absence of a clear contraindication is strongly supported in the management of multiply injured patients.

Acute Disease↗
PubMed2004

[Abdominal trauma. Injury oriented management].

Successful management of abdominal trauma is characterized by efficient emergency-room work-up aimed at immediate determination of the prognosis by rational use of diagnostic techniques. The purposes of any conservative and/or surgical procedures are the preservation of organ function and low mortality and morbidity in multiply injured patients. State-of-the-art computed tomography with fast trauma scanning has become well accepted among patients with multiple trauma. Organ resections are becoming less common, except in the case of bowel injuries. The surgical treatment of hepatobiliary, splenic and large-vessel trauma is still challenging, as it involves the risk of life-threatening bleeding, while in the case of pancreatic and bowel injuries the challenge lies in the avoidance of septic complications. Interdisciplinary management of complex injuries with application of the "damage control" concept contributes to high-quality results in abdominal trauma.

Abdominal Injuries↗
PubMed2000

[Multidisciplinary management of trauma patients. Role of the maxillofacial surgeon].

The approach of patients with multiple trauma is considered to be complicated. Many (non)medical disciplines are involved. This article describes the treatment in the early post-traumatic period and the organisation of the care in both the pre-hospital and hospital phase. Special attention is given to the treatment of patients with maxillofacial injuries. The task of the oral and maxillofacial surgeon in particular when dealing with facial injuries is described.

Algorithms↗
PubMed1999

Seventy cases of injuries of the small intestine caused by blunt abdominal trauma: a retrospective study from 1970 to 1994.

BACKGROUND: Injuries of the hollow viscera are far less common in blunt abdominal trauma than in penetrating abdominal trauma. This article is a 25-year retrospective study of 70 patients with injuries of the small intestine caused by blunt trauma. All patients were treated surgically at the trauma hospital (Unfallkrankenhaus) in Graz. In our series, blunt abdominal trauma causing hollow viscus injuries occurred in conjunction with multiple trauma in 68.8% of cases. The overall mortality rate was 25.7%. METHODS: The following methods were used for evaluating the intestinal injury: detailed history of the accident and examination of the patients (e.g., transverse abdominal bruise) diagnostic peritoneal lavage before 1984, abdominal sonography since 1984, computed tomography, and laboratory tests. RESULTS: Prognosis and results depended partly on the general condition of the patient, as well as the timeliness of diagnosis and surgical management of the small bowel injury. Delays in diagnosis were common because of the overall condition of the patient, as well as the difficulty in establishing a definitive diagnosis by using current radiologic and serologic modalities. CONCLUSION: It should be stated that the high mortality of small bowel injuries after blunt abdominal trauma justifies an aggressive approach to diagnosis and surgical treatment of these injuries. This article focuses on injury mechanisms and current concepts in diagnosis and the therapy of small intestine lacerations in blunt abdominal trauma.

Accidents↗
PubMed2000

Low platelet count and elevated serum thrombopoietin after severe trauma.

Platelet count is regularly low in patients after multiple trauma, mainly due to blood loss and dilution. Thrombopoietin (TPO) is the main regulator of the circulating platelet mass. Under several clinical conditions an inverse correlation between TPO and the circulating platelet mass was reported. Since platelets bind and internalize TPO, a platelet-dependent regulation of TPO was suggested. Thus, acute blood loss should be accompanied by elevated TPO. We measured serum TPO, platelets, interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) in 17 multiple traumatized victims. Blood was collected within 12 h after trauma as well as in the morning of days 2, 4, 6 and 9 after admission at the intensive care unit. Platelet count was low at admission and remained low until day 4. Thereafter platelets increased until day 9. TPO nearly doubled within the first 2 d, reaching its maximum on day 6. IL-6 was initially very high and steadily decreased until day 9. VEGF increased 3-fold during the 9 d. Statistically significant correlations of TPO were found with platelets and IL-6, but not with VEGF. In multiple traumatized patients low platelet count is followed by a rapid increase in serum TPO. This fits into the concept of a feedback regulation between circulating TPO and platelet mass.

Adult↗
PubMed2006

[Treatment of the combined pelvic and thoracic trauma in the emergency room].

Priorities in the diagnosis and treatment of a multiple trauma with injuries to the thorax and pelvis are usually determined by the pattern and the severity of the injury sustained. In this case a haemodynamically unstable patient with severest pelvic trauma and a moderate thoracic trauma developed progressive haemodynamic instability during an intervention to the pelvis, resulting in a lethal outcome for the patient. The cause only became obvious when computed tomography of the thorax (CTT) was performed which was able to demonstrate venous pulmonary bleeding compressing the left atrium. In haemodynamically unstable patients with a major pelvic trauma combined with a moderate thoracic trauma, early CTT should therefore be a main priority in the initial management of such patients in the resuscitation room. The time spent on such a diagnostic procedure seems to be worth the information gained, which can significantly influence the initial choices and priorities in treatment.

Accidents, Traffic↗
PubMed1994

Circulatory response of young adult trauma victims with alcohol intoxication.

Young adults are a subgroup particularly susceptible to traumatic injury; alcohol intoxication is a major risk factor for trauma in young adults. During the first hours following multiple trauma, however, little is known about the specific effects of alcohol intoxication on the circulatory response of critically injured young adults. The purpose of this prospective study was to compare the circulatory response of 5 severely injured young adults (15-40 years old) with acute alcohol intoxication to the circulatory response of 5 severely injured, nonintoxicated young adults. Data were collected every hour for the first 8 hours after admission to a surgical intensive care unit. Subjects with alcohol intoxication had significantly higher heart rates (t = 2.8176, p < .05) than their nonintoxicated counterparts. Heart rate and blood pressure, however, showed no statistically significant (p < .05) Group x Time interaction between the two groups. Subjects with alcohol intoxication also had injuries that caused more blood loss, more invasive monitoring, more operative procedures, more fluid replacement, and higher oxygen requirements.

Adolescent↗
PubMed1999

[Horizontal deceleration trauma with diffuse decollement bleeding--a casuistry].

Treatment of severe haemorrhage caused by multiple trauma is a serious challenge to preclinical as well as clinical management. This is a case report of a motorcycle accident in which a patient sustained total amputation of both legs. Following adequate preclinical care, vital indication led to the patient's immediate surgical treatment. After initially successful haemodynamic stabilisation, the patient developed a horizontal deceleration trauma which resulted in an extended decollement of the muscles of the back and buttock. During the further clinical course, soft tissue bleeding occurred that affected the whole torso. Due to its extent, the bleeding could not be treated surgically, nor did it allow of haemodynamic stabilisation despite continuous massive transfusion. Retrospectively, the impressing amputation injury was treated successfully. In spite of all available surgical and intensive care efforts, however, the slowly demasking monstrous decollement with diffuse tissue bleeding proved to be an injury pattern leading to the patient's death.

Accidents, Traffic↗
PubMed1998

Mediators in polytrauma--pathophysiological significance and clinical relevance.

Multiple trauma induces an inflammatory response syndrome of the whole body that is triggered by (a) hemorrhage inducing an ischemia/reperfusion (I/R) syndrome and (b) fractures or organ contusions inducing tissue-repair processes. I/R injury generates oxyradical/proteolytic metabolites and adhesion molecules, while tissue and endothelial injury directly stimulate complement, coagulation and kinin pathways. Membrane-derived phospholipase A2 and lipid mediators potentiate cellular interactions and increase microvascular permeability. The tissue-repair process mediates macrophage/monocyte and T-cell activation which releases pro- and anti-inflammatory cytokines. Mediator action follows a "three-level model", proposing that depending on the degree of traumatic injury cellular and humoral responses may spread from a cellular to an organ and then a systemic level. The systemic response can result in a severe immunological dys-homeostasis that potentially hazards the survival of the trauma patient by uncontrollable cellular dysfunction, appearing clinically as multiple organ-dysfunction syndrome. Blood-mediator concentrations often parallel the inflammatory process; initially, high levels of cytokines are followed by severe organ dysfunction. However, interpretation of these data remains difficult due to distinct beneficial or detrimental effects of mediators on the different levels of inflammation and missing prognostic threshold values, indicating a risk of adverse effects. Future studies must determine pro- and anti-inflammatory mediators directly, during the intensive care therapy, and evaluate their clinical relevance prospectively for the different levels of inflammation at local and systemic sites.

Humans↗
PubMed2002

[The levels of serum interleukins in the children with trauma].

BACKGROUND: We investigated the levels of IL-I, IL-2, IL-4, IL-6, IL-I0 and IL-12 in serum of the children with trauma and its relation with the severity of trauma. METHODS: We included 45 children with moderate or severe multiple trauma and 21 healthy children for control group to our study. The serum IL-I, IL-2, IL-4, IL-6, IL-IO and IL-12 were measured by micro ELISA. RESULTS: We found a statistically significant difference between the serum values of IL-l, IL-4, 1 L-6, IL-I0 in the children with trauma and healthy control group. A similar difference was also observed between the control group and the trauma group with injury severity score (ISS) 30 and also ISS 32. Serum values of IL-2 and IL-12 did not show significant difference between the groups.W e detected a positive correlation between ISS and IL-l, IL-6, IL-I0 and IL-I2 (respectively r = 0,602, p = 0,000; r = 0,391, p = 0,008; r = 0,399, p = 0,007; r = 0,475, p = 0,001 ). CONCLUSION: These results point out that serum IL-6, IL-I0, IL-12 and especially IL-l has a close relationship with the severity of the tissue damage after trauma. Key words: Child, cytokine, ISS, trauma, the severity of trauma

Case-Control Studies↗