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PubMedDate not supplied

Long-term multi-dimensional outcome following isolated traumatic brain injuries and traumatic brain injuries associated with multiple trauma.

We retrospectively investigated long-term, multi-dimensional quality-of-life outcomes in 68 male patients who suffered pure head injuries and 63 male head-injured patients with associated multiple trauma. Results indicated that patients sustaining associated multiple trauma were significantly younger and more deeply comatose on admission. Trends were found to suggest that patients sustaining associated multiple trauma also remain in coma longer, and experience more difficulties in social interaction and overall psychosocial functioning, but less difficulties in mobility compared with pure-head-injured patients. These findings should be taken into account in the evaluation of results of treatment as well as in the planning and allocation of resources for head-injured patients.

Activities of Daily Living↗
PubMed2004

[Events related with injury severity in pediatric multiple trauma].

AIMS: Epidemiological analysis of main factors affecting multiple trauma in children in our environment. METHODS: We reviewed the data collected from the patients (n = 2.166) admitted to our hospital because of trauma and included in our Registry from January 1995 to December 2000. Among this group 79 patients were considered severely injured trauma patients according Injury Severity Score (ISS) (ISS > 15) and selected for the study. Statistical analysis was done using chi2 and Student t test, p values under 0.01 were considered significant. RESULTS: Group gender distribution was 49 males and 30 females, age average was 9.7 years (range 0-15 years) Traffic related injuries were the leading cause of trauma in this group (77,2%). Initial triage by using the Pediatric Trauma Score allowed identifying the injury severity in 73,4% of patients (58 children obtained a PTS < or = 8). In 32,9% of the cases the patient was in coma at admission in the Emergency (Glasgow Coma Scale < or = 8, n = 26). ISS average was 23.4 (range 16-75). Most patients suffered from multiple injuries (87,3%), average of injuries number was 4,7 (range 1-9). The most frequent trauma localization was cranial trauma. Admission in the intensive care unit was necessary in 65,8% of patients, and any kind of surgical procedure was done in 35,4%. Average length of stay was 17,1 days (range 0-214 days). Injury severity was higher in automotive patients without restraining systems (I.S.S. average 27,2, mortality 16,6%). Overall mortality was 11,4% (n = 9), and 94.3% of patients presented any functional or anatomic disability. CONCLUSIONS: Traffic related injuries are the main cause of multiple trauma in children. The severity and high mortality of these injuries make imperative polytonal education systems and the use of restraining devices.

Adolescent↗
PubMed2003

Life satisfaction several years after severe multiple trauma--a retrospective investigation.

OBJECTIVES: To describe the prevalence of self-reported changes in life satisfaction after multiple trauma, to analyse associations between satisfaction with life as a whole and with domains in life, and to identify important contributors for satisfaction with life. DESIGN: Retrospective follow-up study. SETTING: Rehabilitation hospital three years after multiple trauma. SUBJECTS: Sixty-nine subjects with severe multiple trauma (ISS > or = 16). MAIN OUTCOME MEASURES: Clinical examinations to reveal prevalences of impairments and disabilities. Questionnaires about satisfaction with life as a whole and eight domains of life, both for the time before trauma, and for the actual situation; sense of coherence (SOC-13); social network. RESULTS: A total of 87% experienced a decrease in at least one of the nine life satisfaction items from before to after trauma (six-graded scale). After trauma significantly fewer subjects reported to be satisfied with life as a whole, as well as the domains sexual life, ADL, contact with friends, leisure, vocational and financial situation. Satisfaction with family life and partner relationship did not decrease significantly. The most important domains after trauma were satisfaction with leisure, family life and vocation. Vocational and leisure disability after trauma were important determinants for satisfaction with life as a whole. A strong sense of coherence and sufficient social network quality had significant impact on satisfaction with life as a whole and some of the domain-specific satisfactions. CONCLUSIONS: Both personal resources (a strong sense of coherence) and the presence of a qualitatively sufficient social network can buffer the negative influence of disabilities on life satisfaction after trauma.

Activities of Daily Living↗
PubMed1978

Plasma lipids, coagulation factors, and fibrin formation after severe multiple trauma, and in adult respiratory distress syndrome.

Following severe multiple trauma, decreases were observed in a) Free cholesterol, b) Cholesteryl esters, c) Total phospholipids, and d) Lysolecithin. Comparatively slight changes in coagulation parameters did not differ regardless of whether pulmonary complications developed. In contrast, increased fibrin lipid complexing was more closely correlated with clinical data, because: a) Plasmatic lipids, particularly triglycerides complexed with fibrins, were elevated severalfold in patients with adult respiratory distress and fat embolism syndromes when compared with multiple trauma patients without pulmonary complications. This was independent of plasma lipid levels. b) Plasmatic triglycerides complexed with fibrins were significantly higher in patients who died than in those who survived. The considerable changes in the plasma lipid pattern following severe trauma suggest the presence of an abnormal lipoprotein with increased affinity to fibrin, thereby inhibiting fibrinolysis. This might well be one pathogenic mechanism in the development of post-traumatic respiratory distress syndrome.

Adult↗
PubMed1992

Left ventricular performance in patients with thermal injury or multiple trauma: a clinical study with echocardiography.

Left ventricular (LV) contractile and diastolic performance was evaluated in patients with thermal injury or multiple trauma using precordial and transesophageal echocardiography. Thirty-nine patients were divided into four groups: group B1 (within 24 hours after thermal injury); group B2 (from 24 to 72 hours after thermal injury); group M (multiple trauma); and a control group (outpatients). Left ventricular contractile indices, including ejection fraction, mean velocity of circumferential fiber shortening, and the ratio of systolic blood pressure to LV end-systolic dimension, were not impaired in any of the experimental groups. The ratio of LV filling volume during rapid filling to stroke volume, obtained from M-mode echocardiography as an index of LV distensibility, was significantly decreased in groups B1 (44.5% +/- 8.8%) and B2 (46.8% +/- 8.5%) compared with controls (61.9% +/- 7.4%) (p less than 0.05). The ratio of the peak velocity in the atrial contraction phase to that in the rapid filling phase, obtained using pulsed Doppler echocardiography, also showed significant impairment of LV distensibility in groups B1 (1.08 +/- 0.12) and B2 (1.09 +/- 0.07) compared with controls (0.71 +/- 0.12) (p less than 0.01). Group M showed no significant impairment of these diastolic indices. A profound depression of LV diastolic function thus occurs following thermal injury but not following multiple trauma.

Adolescent↗
PubMed1994

Dynamics of interleukin 1, 2, and 6 and tumor necrosis factor alpha in multiple trauma patients.

The involvement of cytokines in trauma still has not been satisfactorily elucidated. The development of multiorgan failure, the very serious complication of multiple trauma with high mortality, should also be controlled by cytokines, endotoxin, and other mediators. We therefore prospectively studied 42 consecutive patients with multiple trauma admitted from June to December 1992 to the Research Institute for Traumatology and Surgery in Brno. Study patients were characterized by Injury Severity Score (ISS), Revised Trauma Score, and TRISS methodology. In all patients, tumor necrosis factor alpha (TNF-alpha) and interleukin (IL) 1, 2, and 6 levels were investigated. Of the cytokines, only IL-6 levels were elevated at admission and significant correlation with ISS was observed (r = 0.735; p < 0.001). Multiple organ failure (MOF) developed in 14 patients (seven died) and it was not possible to predict this MOF development nor survival by initial cytokine levels. A significant difference was observed when IL-6 concentrations one day before death (423 +/- 105 pg/mL) were compared with the highest concentrations in MOF survivors (112 +/- 71 pg/mL; p < 0.001). This difference was found also for TNF (528 +/- 314 pg/mL vs. 216 +/- 165 pg/mL; p < 0.05). None of six MOF patients with IL-6 > 400 pg/mL survived. In conclusion, the IL-6 and TNF-alpha levels seem to play a significant role in multiple trauma and their late elevation in patients with MOF conveyed a poor prognosis. A significant correlation between initial IL-6 levels and ISS was observed. Other cytokines did not show dynamic changes during the study.

Adult↗
PubMed2000

[Evaluation of organ function monitoring and supporting during the treatment of multiple trauma].

OBJECTIVE: To analyse the evaluation of organ function monitoring and supporting during the treatment of multiple trauma. METHODS: Eighty-eight patients with severe multiple trauma were admitted into Department of Intensive Care Unit(ICU) and the cardiovascular, respiratory, renal, and coagulation functions, milieu interieur, and infectious sources were monitored. RESULTS: Seventy-six cases survived and twelve cases died. The major delayed diagnoses included pneumothorax hematopneumothorax, intraperitoneal organ injury, and fracture. The major complications were severe infection, hypotension, acute renal failure, adult respiratory distress syndrome (ARDS), and multiple organ disfunction syndrome(MODS). CONCLUSION: Active monitor and support of organ function can lower the rate of missed or delayed diagnoses and also decrease complications.

Accidents, Traffic↗
PubMed1991

[Aggressive volume therapy for prevention of acute renal failure in multiple trauma patients].

Immediate fluid resuscitation is of the utmost importance for patients with multiple trauma. Evaluation of this form of treatment for the prevention of acute renal failure was the purpose of this study. Of 262 patients with multiple trauma, 112 were in shock on admission. The patients were treated with large volumes of Ringer's lactate and sodium bicarbonate until urine production was 60-100 ml/h. Hemoglobin and electrolytes were substituted according to the laboratory findings. There were 32 patients who developed renal complications, such as bacteriuria (13), hematuria (7), reduction of renal function (3), and acute renal failure (9). The renal failure did not develop during the first 24-48 h but during treatment in the intensive care unit, mostly in the course of multiple organ failure. Death supervened in 35 of the 262 patients (13.5%). Thus, immediate rapid fluid replacement with large volumes of crystalloid solutions can prevent acute renal failure.

Blood Volume↗
PubMed1988

Right ventricular dysfunction in multiple trauma victims.

We studied 17 victims of multiple trauma and found that right ventricular function can be reliably monitored at the bedside using the thermodilution method. In addition, we noted that right ventricular dysfunction occurred early in victims of major trauma without affecting the left ventricular function. If right ventricular function does not improve, the patient is likely to die. Further studies are needed to determine if early intervention aimed at improving right ventricular function can improve survival.

Adolescent↗
PubMed2002

Selective decontamination of subglottic area in mechanically ventilated patients with multiple trauma.

OBJECTIVE: To determine whether selective decontamination locally in the subglottic area (SDSA) reduces tracheal colonization and prevents ventilator-associated pneumonia (VAP) in patients with multiple trauma. DESIGN AND SETTING: A prospective randomized, controlled, clinical study in a 14-bed general intensive care unit of a university hospital. PATIENTS: 79 consecutive multiple trauma patients admitted to the ICU who were expected to be mechanically ventilated for more than 5 days; 61 patients completed the protocol. INTERVENTION: Patients were randomly assigned to receive SDSA using a continuous infusion of a suspension containing three nonabsorbable antibiotics (polymyxin, tombramycin, and amphotericin B; n=30) or placebo ( n=31). MEASUREMENTS: The incidence of bronchial and gastric colonization and the number of cases of VAP were recorded. Gastric fluid and tracheal secretion cultures were obtained soon after intubation and thereafter every 4 days. Etiological diagnosis of VAP was based on samples taken by a specific protected double catheter set. RESULTS: VAP developed in 5 of 30 (16.6%) patients receiving SDSA and 16 of 31 (51.6%) patients receiving placebo. Negative bronchial secretion cultures were found in 14 of 30 (46.6%) patients in the SDSA group and in only 3 of 31 (9.6%) patients in the control group. No patient with negative bronchial secretion culture developed VAP. No significant differences in outcome were found. CONCLUSIONS: The SDSA is an effective and safe type of chemoprophylaxis against tracheal colonization and can significantly reduce the incidence of VAP in mechanically ventilated patients with multiple trauma.

Adult↗
PubMed1994

[Indications of blood components and outcome of transfusion practices in hemorrhage of multiple trauma].

Bleeding occurring in a patient with multiple trauma has an unpredictable evolution; blood losses are often very important and their origins mostly unclear. These problems should not prevent the use of a strategy for optimal use of blood components. Indications for packed red cells, fresh frozen plasma, platelets and coagulation factors are discussed. Indications for packed red cells are discussed in relation with the patient's conditions (myocardial, cerebral and pulmonary functions) and the clinical status. If the patient is shocked, transfusion must be ordered to maintain a haemoglobin level greater than 10 g.100 ml-1. Considering its cost, the use of albumin must and can be reduced when fluid replacement is realized with long lasting colloids, like starch. Warming of transfused blood is necessary, especially if acceleration disposals are used to prevent or minimize hypothermia. Use of portable monitors for haemoglobin and coagulation parameters is recommended.

Blood Transfusion↗
PubMed1995

Urgent laparotomy versus emergency craniotomy for multiple trauma with head injury patients.

In blunt multiple trauma (MT) with head injury (HI) patients, it is difficult to decide whether to proceed with immediate laparotomy or craniotomy. In August 1989, abdominal ultrasonography (US) using a simple US scoring system was introduced for MT and HI patients as an initial rapid screening procedure. In MT and HI patients with a US score > or = 3 (n = 14), urgent laparotomy was the procedure of first choice. However, immediate head CT scan, then emergency craniotomy, may be justified in hemodynamically stable MT and HI patients with a US score < 3 (n = 98). Appropriate decision making can be applied to decide which procedure is most exigent.

Abdomen↗
PubMed1995

Stabilization of rural multiple-trauma patients at level III emergency departments before transfer to a level I regional trauma center.

STUDY OBJECTIVE: To determine whether triage and stabilization of severely injured rural trauma victims in outlying Level III emergency departments before transfer to Level I trauma centers results in outcomes similar to national normative data. DESIGN: Retrospective review of trauma transfers and deaths during a 4-year period. SETTING: Two Level III EDs in rural, upstate New York and an urban Level I regional trauma center. PARTICIPANTS: Fifty multiple-trauma victims with a Trauma Triage Score (T-RTS) of < or = 11 or less. Forty-three patients were stabilized before transfer, and 7 died in the rural Level III ED. RESULTS: There were 45 blunt injuries and 5 penetrating injuries. Mean patient age was 34 years (range, 9 months to 97 years). The Revised Trauma Score (RTS) on admission to the Level III ED was calculated for each patient (median score, 5.97; interquartile range (IQR), 4.09 to 6.90), as was the ultimate Injury Severity Score (ISS) (median score, 23; IQR, 13 to 29). With TRISS methodology, probabilities of survival (Ps) and death (Pd) were calculated. Results were compared with the Major Trauma Outcome Study (MTOS) by use of current coefficients derived from Walker-Duncan regression analysis of MTOS data. The predicted number of deaths was 13.5, whereas the actual number was 12, Z statistic, -.710. There were two unexpected survivors and three unexpected deaths. The 43 patients who were stabilized and transferred had a median RTS of 5.97 (IQR, 4.30 to 6.90) and an ISS of 18 (IQR, 12 to 25). The median interval in the Level III ED before transfer was 1 hour 43 minutes (IQR, 1 hour 11 minutes to 2 hours 40 minutes). There were two unexpected survivors (Ps = .32, Ps = .49) and 1 unexpected death (Ps = .52). The predicted number of deaths was 8.1, whereas the actual number was 5. The 7 patients who died in the rural Level III ED had a median RTS of 4.41 (IQR, 2.98 to 4.71) and a median ISS of 50 (IQR, 44 to 65). The median interval in the Level III ED before death was 42 minutes (IQR, 41 minutes to 1 hour 20 minutes). There were 2 unexpected deaths (Ps = .66, Ps = .55). The predicted number of deaths was 5.4 whereas the actual number was 7. CONCLUSION: Triage and stabilization of severely injured rural trauma victims at Level III EDs before Level I transfer provide outcomes similar to national results. Unexpected death of severely injured trauma victims remains a problem in rural Level III EDs.

Adolescent↗
PubMed2005

Predicting total urinary nitrogen excretion from urinary urea nitrogen excretion in multiple-trauma patients receiving specialized nutritional support.

OBJECTIVE: We investigated the accuracy of methods to estimate total urinary nitrogen (TUN) excretion from urinary urea nitrogen (UUN) excretion for patients who have multiple trauma and receive specialized nutritional support. METHODS: Fifty-five critically ill, adult patients who had multiple trauma and were receiving specialized nutritional support were evaluated. A 24-h urine collection for urea nitrogen and total nitrogen was performed 4.4 +/- 2.6 d after admission to the trauma intensive care unit. Patients with significant renal impairment, liver dysfunction, or obesity (>150% of ideal body weight) were excluded from study entry. Eight publications that examined the relation between TUN and UUN were evaluated for bias and precision in estimating TUN from UUN. RESULTS: TUN was 20.8 +/- 10.8 g/d with an average difference of 3.8 +/- 2.8 g/d between TUN and UUN. Linear regression analysis comparing TUN with UUN indicated a significant correlative relation (TUN = 1.1 x UUN + 2; r = 0.958, P < 0.001). The difference between TUN and UUN varied based on UUN: for UUN lower than 10 g/d, TUN minus UUN was 1.5 +/- 1.0 g/d; for UUN 10 to 20 g/d, TUN minus UUN was 4.1 +/- 3.2 g/d; and for UUN higher than 20 g/d, TUN minus UUN was 5.3 +/- 1.9 g/d (P < 0.001). Six methods were biased toward underpredicting TUN, one method was unbiased, and one was biased toward overpredicting TUN. A practical method for estimating TUN from UUN was developed: TUN = UUN + 2 for those with UUN lower than 10 g/d and TUN = 1.1 x UUN + 2 for those with UUN of at least 10 g/d. CONCLUSIONS: Our method, the modified Velasco method, UUN/0.84, and UUN/0.85 provided reasonable estimates of TUN from UUN in critically ill, adult patients who had multiple trauma and were receiving specialized nutritional support; however, our method requires further validation.

Adult↗
PubMed1996

[Intramedullary nailing in multiple trauma].

The indication and best time for intramedullary nailing of long bones in the multiple trauma patient is still controversial. While in the Anglo-American literature primary intramedullary nailing is regarded as the method of choice, differentiated management is preferred in German-speaking countries on account of reports about the pathogenesis of trauma shock. On the one hand, it has been shown that severe thoracic injury greatly influences the course after multiple trauma and, in particular, its combination with femoral fracture represents an increased risk. On the other hand, every surgical intervention represents an additional trauma for the patient. Intramedullary reamed nailing of femur fractures represents considerable trauma, whereas unreamed intramedullary nailing of the femur or intramedullary stabilization of the tibia or humerus causes (in descending order) fewer changes. For early respiratory care (e.g., changing between the prone and supine position), however, primary stabilization of long bones is required. External fixation of the femur appears to be the method of choice for the severely injured patient. Definite fracture healing can be achieved by a change to intramedullary nailing in a secondary operation.

Bone Plates↗
PubMed2005

Evaluation of criteria for temporary external fixation in risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients: "evidence-based medicine" versus "reality" in the trauma registry of the German Trauma Society.

BACKGROUND: Femur-shaft fracture treatment (FSFT) follows controversial management concepts after multiple trauma: primary-definitive osteosynthesis, secondary-definitive osteosynthesis after temporary external fixation (EF) in all patients, or individualized primary- or secondary-definitive osteosynthesis ("risk-adapted damage control orthopedics"). This study compares the concepts by analyzing literature evidence and a prospective multicenter database. METHODS: A systematic literature analysis was performed. The German Trauma Society trauma registry was used to assess variables predictive of treatment concept. RESULTS: Contradictory results in 63 controlled trials failed to support a "generalized management strategy." In all, 1,465 FSFTs in 8,057 trauma registry patients (age 39 +/- 19.5 years; Injury Severity Score [ISS] 23.5 +/- 14.9; 17.3% mortality) were treated initially (<24 hour) by EF, nail, or plate in 47.0%, 41.1%, and 11.9%, respectively. Despite large interhospital variability, EF was more likely with increasing severity of ISS, Glasgow Coma Score, thorax trauma, base excess, coagulation abnormalities, and initial probability of death. CONCLUSIONS: Clinical "reality" reflects the controversies of "scientific evidence" for FSFT after multiple trauma in Germany. Although decision making is currently based on unvalidated criteria, anatomic and physiologic injury severity appears to influence the choice of management concept.

Adolescent↗
PubMed1999

Local effect of lung contusion on lung surfactant composition in multiple trauma patients.

OBJECTIVE: The aim of this study was to investigate the direct influence of lung contusion on pulmonary surfactant in multiple trauma patients. DESIGN: Prospective, nonrandomized study. SETTING: University hospital, trauma intensive care unit. PATIENTS: Eighteen multiple trauma patients with unilateral lung contusions and Injury Severity Scores >19 were studied prospectively. INTERVENTIONS: Bronchoalveolar lavage was performed daily until either day 7 or extubation. Samples from the side of lung contusion (n = 62) and the contralateral, uninjured side (n = 62) were obtained at the same time in 14 patients. Total phospholipids, total phospholipid classes, and surfactant apoprotein A were quantified. Additionally, surfactant function was measured with a pulsating bubble surfactometer in four patients. All data are presented as mean +/- SEM. Statistical analyses were performed using programs of SPSS for Windows 6.1.3 (SPSS Inc., Chicago, IL) (Student's t-test; p < .05). MEASUREMENTS AND MAIN RESULTS: Total phospholipids were significantly increased on the side of lung contusion (contusion side, 40+/-7 microg/mL; contralateral side, 21+/-3 microg/mL; p = .004). The percentage contents of phosphatidylcholine (contusion side, 87.1%+/-1.0%; contralateral side, 84.3%+/-1.0%; p = .04) and sphingomyelin (contusion side, 2.9%+/-0.3%; contralateral side, 1.9%+/-0.2%; p = .004) were significantly higher. In contrast, the percentage content of phosphatidylglycerol was significantly decreased (contusion side, 4.1%+/-0.1%; contralateral side, 6.9%+/-0.6%; p = .001). No alterations were found for the relative contents of phosphatidylethanolamine (contusion side, 2.4%+/-0.2%; contralateral side, 2.2%+/-0.2%; p = .47), phosphatidylinositol (contusion side, 3.5%+/-0.4%; contralateral side, 4.6%+/-0.5%; p = .06), and surfactant apoprotein A (contusion side, 7177+/-1404 ng/mL; contralateral side, 4513+/-787 ng/mL, p = .10). There was no statistical difference for minimal surface tension measured with the pulsating bubble surfactometer after 5 mins of oscillation (contusion side, 29.5+/-2.3 mN/m; contralateral side, 23.7+/-2.1 mN/m; p = .08). CONCLUSIONS: Direct damage of lung parenchyma by lung contusion alters the composition of surfactant. No additional changes in surfactant function were observed that would argue in favor of functional compensation.

Adult↗
PubMed2005

Multiple-trauma management: standardized evaluation of the subjective experience of involved team members.

BACKGROUND AND OBJECTIVE: Staff attitude plays a pivotal role in quality management. The objective of the present study was to further define how interdisciplinary emergency hospital staff experience their daily work and the extent to which the professional speciality and training of an individual influences his/her assessment of multiple-trauma team performance. METHODS: The clinical staff involved in multiple-trauma emergency management of a university hospital was asked to answer a confidential questionnaire. Factorial analysis was used to identify 8 major dimensions from a total of 53 items. RESULTS: The questionnaire was returned by 128 team members. All professional groups were most dissatisfied with the dimensions 'education and training', 'work sequence between specialities' and 'communication between specialities'. Assessment of the quality of in-hospital emergency-trauma management differed significantly between professional specialities (ANOVA, F=5.2; P=0.028); surgeons gave the highest ratings for all but one dimension. Having taken an Advanced Trauma Life Support (ATLS) course influenced significantly the total rating of multiple-trauma treatments of anaesthetists and surgeons (F=5.5; P=0.024). CONCLUSIONS: The perceptions of interdisciplinary trauma team members without the completion of an ATLS training course were that they did not communicate enough with each other and that there were differences between their expectations and reality. The differences and the communication deficits were overcome in team members who had passed an ATLS course.

Anesthesia↗