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PubMed2003

[The value of subjective estimation of the severity of thoracic injuries by the emergency surgeon].

INTENTION: Thorax trauma (TT) is associated with a high rate of pulmonary failure and increased mortality. To prevent these complications, the German trauma system recommends intubation and chest tube insertion at the scene of the accident, even in cases without acute respiratory dysfunction. Due to the possible life threatening complications of the therapy, the emergency surgeon should be able to correctly identify a TT at the scene. Therefore, we retrospectively compared the evaluation of chest trauma by the emergency surgeon with objective injury severity according to the Abbreviated Injury Scale (AIS). METHOD: Data from 2,392 patients (aged 39+/-1 years, Injury Severity Score 27+/-0.3) were taken from the multiple trauma database of the German Trauma Society. The evaluation of TT (absent, light, medium, severe) by the emergency surgeon was compared with objective injury severity (AIS=0: absent, 0>AIS<3: light, AIS=3: medium, AIS>3: severe). If the difference between the subjective and objective injury severity increased or decreased two and more levels, a substantial misclassification was assumed. The influence of the estimate on outcome was tested by comparing the predicted (TRISS-method) with the observed fatalities. RESULTS: Absence of TT was estimated correctly in 62%, light in 24%, medium in 40% and severe TT in 46% of cases. Thus a correct estimate of TT was made for 49% of the patients. The chest injury severity was substantially overrated by the emergency surgeon in 20% and substantially underestimated in 17% of cases. In patients with the correct classification at the scene, a total of 81% received a chest tube. Of these patients, only 50% received their chest tube at the scene. Of the patients with an initially overlooked TT, only 37% received a chest tube and nearly all were placed in the emergency room. The number of fatalities was lower than predicted in all groups, even in patients with correctly estimated severe TT (observed: 34%, estimated: 42+/-2%), and also in patients with initially overlooked TT (observed: 16%, estimated: 24+/-2%). CONCLUSION: Due to the high rate of misclassification and possible severe complications caused by therapy, and without having any benefit in terms of outcome, intubation and chest tube insertion should not be carried out in vital, stable patients.

Adult↗
PubMedDate not supplied

Effect of nutritional therapy on polyamine metabolism in severely traumatized patients.

The polyamines (PA) spermidine (SD) and spermine and their precursor putrescine (PU) play a leading role in the regulation of protein, RNA and DNA synthesis. We examined the role of PA along with other biomarkers of injury in eight victims of multiple trauma in the early post-traumatic period when they were hypermetabolic and highly catabolic. Intravenous nutritional therapy (TPN) was started 48 to 60h after trauma and continued for 6 days. The basal response to severe trauma was a significant (twofold to threefold) rise in urinary PU (p = 0.05) and SD (p = 0.025) levels compared to normal subjects. Six days of TPN further enhanced the basal excretion of PU (157%) and SD (137%) peaking on the third day. There was a 20% reduction in the excretion of 3-methylhistidine on the first day of TPN, but it was still 40% above normal on the sixth day. The negative nitrogen balance was improved but not reversed. Injury stimulated ribonuclease and catecholamine levels were also enhanced by nutritional therapy, peaking on the first and fourth day of TPN, respectively. This study demonstrated for the first time elevated levels of PA in trauma patients that correlated well with the other known measures of protein metabolic response to injury and changes during nutritional therapy. Extracellular PA levels could be used as markers of both catabolic pathology in trauma and of its response to nutritional therapy.

Dopamine↗
PubMed1993

[Pathomorphogenesis of radio-ulnar synostosis in fractures of forearm bone shafts].

Pathomorphogenesis of radioulnar synostosis which occurred in 4 out of 174 patients treated because of recent and inveterate fractures as well as pseudoarthroses within shafts of forearm bones has been presented. Fractures of both radius and ulna, located at the same level within proximal half, inveterate or neglected, after severe or multiple trauma are at the highest risk of developing radioulnar synostosis.

Adult↗
PubMed1991

[Injury of the pelvic ring and abdominal trauma].

Fractures and disruptions of the pelvic ring are usually found in multiply injured patients and exacerbate the life-threatening character of the concomitant injuries. The main prognostic factors are haemorrhagic complications, abdominal trauma and associated injuries of the urogenital tract. All patients admitted to the Department of Surgery of the University of Münster between July 1985 to December 1989 were analysed with particular reference to pelvic ring instability and the accompanying pelvic and abdominal lesions. Of 27 patients with unstable displaced lesions of the pelvic ring, 9 were female (33.3%) and 18 male (66.7%); the average age was 35.1 years. Multiple trauma was present in 25 patients (92.6%). Associated pelvic or abdominal injuries were found in 15 cases (55.6%) [multiple entries]. In 9 patients (33.3%) there were lesions of the urogenital tract. Injuries to pelvic blood vessels were diagnosed in 3 patients (11.1%). In 2 patients (7.4%) there were lesions of the perineum. A ruptured spleen was found in 4 patients (14.8%), lesions of the liver in 3 patients (11.1%), lacerations of the mesentery in 2 patients (7.4%). Bleeding into the mesentery, lacerations of serosa of the sigmoid colon and contusion of the pancreas were each seen in 1 case (3.7%). In 12 patients (44.4%) laparotomy was performed: The mortality in this series was 22.2% (6 patients). The authors propose a procedure for immediate diagnosis of these associated pelvic and abdominal injuries. The key factor for a favourable outcome is the differentiation between intraabdominal and retroperitoneal bleeding. A treatment algorithm is described. The value of laparotomy, interventional radiology and primary anterior stabilization of the pelvic ring with an external frame is discussed.

Abdominal Injuries↗
PubMed1999

Impact of trauma stress ulcer prophylaxis guidelines on drug cost and frequency of major gastrointestinal bleeding.

Trauma patients are routinely prescribed stress ulcer prophylaxis despite evidence suggesting such therapy be limited to patients with identifiable risk factors for bleeding. With surgeons' consensus, we developed and implemented trauma stress ulcer prophylaxis guidelines, and measured the impact of clinical pharmacists on implementing the guidelines and the effect of the guidelines on drug cost and frequency of major gastrointestinal bleeding. Two groups of 150 consecutive patients admitted with multiple trauma were evaluated before and after guideline implementation and stratified by Injury Severity Score (ISS) to minor (ISS < 9) or moderate to severe (ISS > or = 9) trauma groups. The number of patients prescribed stress ulcer prophylaxis, length and cost of this therapy, and number of patients experiencing major gastrointestinal bleeding (decrease in consecutive hemoglobin > or = 2 g/dl in conjunction with coffee-ground emesis, hematemesis, melena, or hematochezia) were measured. All pharmacist interventions pertaining to stress prophylaxis were collected. Fewer patients were prescribed stress ulcer prophylaxis after guideline implementation (105/150, 70% vs 39/150, 26%, p<0.0001), leading to a decrease in total drug cost of $4558. Use decreased more in patients with minor (40/54, 74% vs 9/59, 15%, p<0.0001) than moderate to severe (65/96, 68% vs 30/91, 33%, p<0.0001) trauma. Neither length of therapy nor agent of choice (> 95% cimetidine) differed between groups. Fifteen (38%) of 38 postguideline prophylaxis orders were determined by the pharmacist not to meet guideline criteria. Recommendations to discontinue therapy were accepted in 9 (60%) of 15 instances. The frequency of major gastrointestinal bleeding remained unchanged between groups (1/150 vs 0/150, p=1.0). Implementation of trauma stress ulcer prophylaxis guidelines limiting therapy to patients with risk factors for bleeding led to a 80% decrease in drug cost and did not affect the frequency of major gastrointestinal bleeding.

Adult↗
PubMed1995

[Peripheral vascular injuries in polytrauma].

Between 1972 und 1993 a total of 68 patients were treated at the Department of Surgery of the University Clinic of Mannheim for peripheral vascular injury resulting from multiple trauma. The average age of these patients was 31.3 years, and most of them were male (88.2%; n = 60). The injured vessels were localized evenly in all the extremities: 31 patients (45.5%) presented with arterial damage of the upper extremity, and 37 (54.5%) showed lesions along the femoro-popliteal arteries. The most frequent location of injured vessels in the multiply traumatized patient was the popliteal artery (n = 18, 26.5%), the distal part of the superficial femoral artery (n = 12, 17.6%), the brachial artery (n = 14, 20.6%) and the axillary artery (n = 10, 14.6%). The dominant cause, of trauma was road traffic accidents (72%), and 20 patients (29%) acquired their vascular injuries as motorcyclists. There were also 13 occupational accidents (19%) involving vascular injuries. In addition to a vascular trauma 34 patients (50%) had complicated fractures, and a further 34 patients (50%) had multiple fractures: 12 (17.6%) had head and brain damage, 5 (7.3%) had blunt abdominal trauma and 6 (8.8%) had blunt thoracic injury. The general amputation rate was 2.9% (n = 2). One patient died on the table of a torn off subclavian artery combined with multiple other injuries. Paresis of the plexus is a particular problem after vascular lesions of the upper extremity: in 22 patients (71%) paresis of the plexus persisted after successful vascular reconstruction (follow-up period between 3 months and 16 years, median time 3.45 years).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2003

Bone marrow failure following severe injury in humans.

BACKGROUND: Hematopoietic failure has been observed in experimental animals following shock and injury. In humans, bone marrow dysfunction has been observed in the red cell component and characterized by a persistent anemia, low reticulocyte counts, and the need for repeated transfusions despite adequate iron stores. While a quantitative defect in white blood cell count has not been noted, an alteration in white blood cell function manifesting as an increased susceptibility to infection is well established. Since the etiology of this anemia remains unknown and the bone marrow has been rarely studied following injury, we measured various parameters of hematopoiesis directly using bone marrow from trauma patients and tested the hypothesis that trauma results in profound bone marrow dysfunction, which could explain both the persistent anemia and the alteration in white blood cell function. METHODS: Bone marrow aspirates and peripheral blood were obtained between day 1 and 7 following injury from 45 multiple trauma patients. Normal volunteers served as controls. Peripheral blood was assayed for hemoglobin concentration, reticulocyte count, erythropoietin levels, white blood cell count, and differential. Peripheral blood and bone marrow were cultured for hematopoietic progenitors (CFU-GM, BFU-E, and CFU-E colonies). RESULTS: Bone marrow CFU-GM, BFU-E, and CFU-E colony formation was significantly reduced while peripheral blood CFU-GM, BFU-E, and CFU-E was increased in the trauma patients compared with normal volunteers. Bone marrow stroma failed to grow to confluence by day 14 in >90% of trauma patients. In contrast, bone marrow stroma from volunteers always reached confluence between days 10 and 14 in culture. The mean hemoglobin concentration and reticulocyte counts of the trauma patients were 8.6 +/- 1.0 g/dL and 2.75 +/- 0.7% respectively, while their plasma erythropoietin levels were 2 to 10 times greater than control values. CONCLUSIONS: Release of immature white blood cells into the circulation may also contribute to a failure to clear infection and an increased propensity to organ failure. Concomitantly, profound changes occur within the bone marrow, which include the increased release of erythroid and myeloid progenitors into the circulation, a decrease in progenitor cell growth within the bone marrow, and an impaired growth of the bone marrow stroma. Erythropoietin levels are preserved following trauma, implying that the persistent anemia of injury is related to the failure of the bone marrow to respond to erythropoietin.

Adult↗
PubMed1990

The tertiary trauma survey: a prospective study of missed injury.

The Advanced Trauma Life Support Course defines a primary and a secondary survey to rapidly identify life-threatening and associated injuries, respectively, in multiple trauma patients. However, circumstances during resuscitation, including multiple casualties, emergent operation, unconsciousness, etc., may interfere with this process. An initial review of our trauma registry data yielded a modest 2% incidence of missed injuries in a 90% blunt trauma population. In order to determine the true incidence of missed injuries, a tertiary survey was performed prospectively on all injured patients (N = 399) admitted during a recent 3-month period. After completion of the primary and secondary surveys (including appropriate roentgenographs), all injuries were listed in the trauma admission record. Patients were later reexamined immediately before ambulation or, in head-injured patients, upon regaining consciousness. All missed injuries were documented, including site and type of injury, reason missed, how identified, and attendant morbidity. Forty-one missed injuries were found in 36 patients (9%). These included: 21 extremity fractures, five spinal fractures, two facial fractures, five thoracic injuries, six abdominal injuries (including five splenic lacerations), and two vascular injuries. The most common reason for injuries to be missed was altered level of consciousness due to head injury or alcohol. Other reasons included severity of injury and instability requiring immediate operation, lack of symptoms at admission, technical problems, and low index of suspicion by the examiner. None of the missed injuries resulted in death. However, one missed injury caused serious disability and seven required operative correction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1999

[Optimal timing for secondary surgery in polytrauma patients: an evaluation of 4,314 serious-injury cases].

INTRODUCTION: It has been argued that secondary operations in multiple trauma patients impose an additional systemic burden, representing an additional risk of organ dysfunction. We investigated whether the timing of a secondary operation of > 3 h duration is related with the development of organ dysfunction. METHODS: In a retrospective analysis, 4,314 polytrauma patients treated at our institution between January 1975 and January 1999 were investigated. Patients were divided according to the presence ( + MOF) or absence (-MOF) of organ failure (Goris' criteria). RESULTS: In both groups, the injury severity, rescue time, duration and incidence of primary operations were comparable. Secondary surgery in patients who later developed organ failure was significantly more often performed between day 2 and 4, whereas patients without organ failure were usually operated between day 6 and 8 (P < 0.0001). The initial laboratory data in these two groups were comparable. If patients with organ failure were operated on days 6-8, significantly worse initial laboratory data were determined, indicating that these patients were at high risk of developing MOF. CONCLUSION: In patients with severe trauma requiring secondary operations of > 3 h duration, performance of this operation should be avoided on post trauma days 2-4.

Adult↗
PubMed2005

[Long-term results in the treatment of foot injuries in polytraumatized patients].

INTRODUCTION: The aim of this study was to evaluate the long-term outcome of multiple injured patients with foot injuries. While severity and frequency of multiple injuries could be decreased in the last years, it was not possible to decrease the severity of injuries of the foot and ankle region. These injuries are often not detected and their severity is underestimated in primarily diagnostics what might lead to complaints in the longterm course. METHODS: The multiple trauma database of the Department of Traumatology of the University of Vienna includes 386 patients from September 1992 to April 2001. 40 (10.4 %) of these patients suffered a fracture or dislocation of foot or ankle. 33 (82.5 %) multiple injured patients with injuries of foot or ankle could be reexamined between April and September 2002 and the longterm outcome of the foot and ankle region could be evaluated objectively and subjectively. RESULTS: 22 (66.7 %) patients were male, 11 (33.3 %) female. The mean age was 34.5 years. 27 (81.8 %) patients still suffered from complaints related to their injured foot and ankle region. After calculation of the AOFAS these complaints were predominantly located in the ankle-hindfoot region. 22 (66.7 %) patients had to limit their sports activity. DISCUSSION: In our study period an increasing number and severity of injuries of foot or ankle can be shown. Furthermore multiple injured patients with concomitant injuries of foot or ankle show a lower ISS what suggests that these patients might have a higher survival rate and consecutively enter rehabilitation process.

Abbreviated Injury Scale↗
PubMed2001

Diaphragmatic injury. A clinical review.

OBJECTIVE: Recent experience at King Fahad Hospital of the University, Al-Khobar University, Kingdom of Saudi Arabia was reviewed to identify the pitfalls in the diagnosis of diaphragmatic injuries, and attempt to develop a scheme by which early diagnosis is achieved in order to avoid the sequelae of delayed presentations. METHODS: A retrospective chart review of patients admitted to the surgical service, with the diagnosis of diaphragmatic injury was undertaken during the period June 1994 through to June 1999. RESULTS: The total number was 8 patients, and the age ranged between 6-71 years. Of these patients 5 were diagnosed immediately post-traumatic, 2 with delayed presentation, and one with recurrent post-traumatic repair. This case was excluded. Six patients presented following blunt and one after penetrating trauma. Rupture occurred mainly on the left dome of the diaphragm in 5 patients and on the right in 2. Complications ranged from mild chest symptoms to severe respiratory and multi-system involvement. CONCLUSION: Diaphragmatic injuries occurred in 2%-5% of multiple trauma victims. It is considered a predictor of serious associated injuries, However, as many as 10%-30% are missed during the initial evaluation. A high index of suspicion is required, and judicious use of diagnostic aids should be employed to reach early diagnosis to avoid the sequelae of missed injuries.

Adolescent↗
PubMed1998

Challenges of traction in critical care: a case study.

Traction can sometimes seem like an overwhelming challenge in the critical care setting not only to the patient and family, but also to the nurse. Critical care nurses must know the principles, purposes, methods, and patient care considerations necessary to be able to provide appropriate care and teaching for the patient in traction. This article describes these principles and then illustrates them through a case study. The case describes a patient who experiences multiple trauma and focuses on the nurse's role in the care of this patient in traction.

Accidents, Traffic↗
PubMed1990

Timing of fracture fixation: a review.

The timing of fracture stabilization has received little attention in the current orthopaedic literature. The existing data on fracture fixation will be reviewed specifically with regard to early versus delayed stabilization. Timing relative to the multiple trauma patient, open fractures, periarticular fractures, and hip fractures requires special consideration.

Aged↗
PubMed1990

[Antioxidant status after surgical stress].

Trauma and anaesthetics are responsible for local and general change in the organism. The characteristic changes in metabolism are caused by hormones. In addition, the increased glycogenolysis, gluconeogenesis, proteolysis and lipolysis are characteristic of this catabolic metabolism. Three groups (injured patients, patients with pulmonary disease, multiple trauma patients) showed an elevated lipid peroxidation as indicated by increased formation of TBA-reactive substances in the post-trauma or after surgery phase. The production of free radicals is supported by several stress factors. In this connection, the state of metabolism of the patients, several anaesthetics and the artificial respiration is very important. Enzymatic protecting systems (SOD, GSH-Px, Catalase) react to oxidative stress by positive adaptation. The non-enzymatic antioxidative systems (tocopherol, ascorbic acid, selen) are diminished, indicating an increased requirement.

Ascorbic Acid↗
PubMed1996

Carbamazepine for combativeness in acute traumatic brain injury.

Psychiatrists increasingly consult on the treatment of acute traumatic brain injury (TBI) when combativeness compromises safe critical care. The author discusses use of carbamazepine for 7 combative patients with multiple trauma including TBI. This cohort had a clinical decrease in combativeness within 4 days after carbamazepine, compared with this Level I trauma center's experience of prolonged combative periods without its use.

Accidents, Traffic↗
PubMed2001

[Hemothorax and retroperitoneal bleeding caused by warfarin use in a polytraumatized patient].

If some medical problems are not noticed to in polytraumatized patients at the right time, they may be caused by serious complications. The haematological parameters, especially bleeding and coagulation factors, are very important for them. If they use warfarin, heparin or salicylates, they should be cared intensively. In this paper, a traffic accident case, a 48-year-old woman has been reported. She broke her iliac bone and made her hemothorax. In the first health centre the patient was admitted, Hemothorax was not recognized since chest graphics was not diagnosed at an earlier stage. When dyspnoea was began, pulmonary embolism diagnosis was made and warfarin was applied which caused retroperitoneal bleeding. In fact, it is not known whether hemothorax was caused by the first trauma or by the use of warfarin. In our hospital, with the teamwork of emergency room, thorax surgery, orthopaedics, internal medicine and chest department, correct diagnosis was made and correct treatment was applied, and the patient got out of the hospital in good health. In conclusion, patients with multiple traumas should be followed with a multidisciplinary approach. There are a lot of considerations in the follow-up and treatment of this class of patients. If the traumatized patients are used warfarin, they should be observed more carefully.

Accidents, Traffic↗
PubMedDate not supplied

[Determining direction in cases of bodies run over by automobile wheels].

Investigation of injuries sustained by 110 pedestrians during fatal traffic accident and observed in 8 biomannequins during experimental overrun by car wheels resulted in detection of morphological features indicating overrun direction and posture of a victim. It was stated that in case of multiple trauma the areas of wheel rolling and primary force application in collision with a car are located at opposite sides.

Abdominal Injuries↗
PubMed1988

[Life-threatening hemorrhage in pelvic fractures of polytraumatized patients. Diagnostic issues and embolization treatment].

Between 1984-1987 6 multiple trauma patients with pelvic fractures and bleeding from pelvic vessels were treated by transcatheter embolization. Although diagnosis and therapy were early in two cases, there was an overall time delay of median 17 hours (1-38 h) until localisation of bleeding lesions. In this period multiple transfusions (median: 33.7 units of packed erythrocytes, 14.5 units of fresh frozen plasma) could not control hemorrhage. After successful transcatheter embolization circulation stabilized immediately and durably. 4 patients died, 2 of them from septic-toxic multi-organ-failure.

Adolescent↗