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We report the case of a patient with multiple trauma who developed pronounced anaphylactic shock, and was successfully treated with 1000 mg tranexamic acid intravenously (Exacyl). This antifibrinolytic agent is also a potent inhibitor of the complement system and its use for the prevention and treatment of anaphylactic or anaphylactoid shock is discussed.
Ultrasonography is accepted as a valuable screening method for the detection of renal trauma, although it does not make any functional contribution. Computerized tomography has replaced excretory urography for the evaluation of blunt renal trauma, because it makes more precise diagnosis possible. Arteriography is mandatory when injuries of the renal branch are suspected. The management of renal trauma should restore normal circulation and renal function and should preserve as much functioning renal tissue as possible. For renal contusion and minor cortical lacerations, even when there is a small extravasation of urine, conservative management is sufficient, while major cortical lacerations and injuries of the renal vessels require prompt operative methods. The classification of urethral ruptures is based on rectal palpation of the prostate, distribution and size of hematomas and urethrography. A primary catheter for diagnostic purposes is strictly contraindicated. Urinary diversion proximal to the urethral lesion is the primary therapeutic procedure, while the definite management of the ruptured urethra can be postponed. Injuries to the organs of the urogenital system are rarely life threatening, and in the case of multiple trauma their management can be adapted to fit in with the treatment of injuries to other vital organs. Nevertheless, diagnosis and adequate treatment of injured urogenital organs must not be neglected as long-lasting or permanent damage could result.
Soda pop vending machine tipping continues to be a dangerous behavior that can result in lethal or crippling injuries. This study analyzes 64 cases of injuries secondary to crushing by a soda machine. All were male victims except one. The average age was 19.8 years with a range of 5-39 years. Thirteen victims sustained multiple trauma. Fifteen victims were killed. Increased public awareness coupled with support by the government and private industry has contributed to a sharp reduction in incidence of accidents and improved public safety.
Until recently the costs of patients in German hospitals have mainly been calculated according to the length of hospital stay. However, in December 1999, a dramatic change was announced in the social laws in the "Gesundheitsreform 2000." Beginning in 2003 a prospective payment system based on the classification of the "Australian Refined DRGs (AR-DRG)" will be introduced. DRGs are already used in quite a lot of industrialized countries and basically are "per case" payment systems that group patients with homogeneous average costs based on the diagnoses and procedures performed in the hospital. When preparing for this new system, the clinician has a lot of additional tasks. Besides correctly documenting all clinical findings with the ICD-10 Diagnoses and the German OPS301 procedure codes, a knowledge of the economical impact of the clinical decision is absolutely crucial. The most important task is the optimizing of all clinical treatment processes (e.g. by the introduction of clinical pathways), because only hospitals that can do highly efficient treatment will be able to survive in the upcoming competitive situation. In the Krankenhaus München--Schwabing DRGs have been used as a benchmarking tool since 1997. Based on valuable experience, many direct measures to optimize efficiency have been taken. Especially in patients with multiple trauma, it became evident that the use of efficient and standardized treatment can bring economic gain without loss of quality.
In the UK, when the standard brain death criteria are met, further investigations are not necessary. Confirmatory tests can be useful, however, when it is not possible to carry out all of the brainstem tests. We report the case of a patient with multiple trauma and a high spinal cord injury who was apnoeic. Confirmatory tests (EEG, brainstem, auditory evoked potential) were essential in supporting the diagnosis of brainstem death to allow withdrawal of artificial ventilation, as organ donation was being considered.
Gas chromatographic-(tandem) mass spectrometric (GC-MS(-MS)) methods for the analysis of cysteinyl leukotrienes (LTs) and leukotriene B4 (LTB4) in biological fluids were developed. The enzymatic synthesis of the stable-isotope labelled analogues [1,1-18O2] LTE4 and [14,15,17,17,18,18-2H6] LTB4 in high isotopic purity is described. Utilizing [1,1-18O2] LTE4 as an internal standard and GC-MS-MS enhanced cysteinyl LTs synthesis was found in patients with multiple trauma and psoriasis compared to healthy volunteers, respectively. The metabolism of LTB4 by human monocytes was investigated and two novel LTB4 metabolites were structurally identified by GC-MS as 10,11-dihydro-LTB4 and 10,11-dihydro-12-oxo-LTB4.
The early diagnosis and adequate treatment of respiratory complications in trauma cases has a decisive influence upon the patients' posttraumatic development. Pulse oximetry enables us to evaluate and monitor the prehospital respiratory situation objectively for the first time. Within a prospective study conducted from October 1988 to October 1989 in 336 unselected, primarily traumatized, emergency patients rescued by our "SAR Ulm 75" helicopter team, to determine the possibilities and limitations of this method, we maintained continuous pulse oximetric monitoring in all cases. The practical applicability and functional stability of the pulse oximeters used were adequate. On-the-spot intubation was necessary in 45% of the patients (or they were intubated prior to our taking over). Oxygen inhalation by nasal cannula was needed in 55%. While not being decisive for immediate intubation, monitoring with a pulse oximeter does play an essential role in controlling respiratory therapy. In 32% of our cases, pulse oximetric monitoring permitted early adjustment of the respiratory therapy to meet the patients requirements. This method is of special value in disclosing life-threatening respiratory complications (9.3%) i.e., valve pneumothorax. Within a group with a high percentage of multiple traumas (27%) and thorax traumas (39%), this was of enormous assistance in the differential diagnosis. Level and rate of increase of oxygen saturation can be an indication of the severity of a thorax trauma. The limitations of pulse oximetric monitoring, especially those resulting from low peripheral perfusion in trauma cases (7 patients), are fairly rare.
We present the case of a patient with multiple trauma, including a radial shaft fracture, a distal radioulnar joint dislocation, and a fracture-dislocation of the radial head. The combined open reduction of the radial shaft and head and the closed reduction of the distal radioulnar joint allowed early range of motion exercises and return to a functional level.
BACKGROUND: Management of patients with multiple trauma requires prophylaxis for venous thromboembolism (VTE). This involves recognition of the physiologic factors that are associated with VTE risk. Currently, there is no effective strategy for risk assessment. The purpose of this study is to investigate the relationship of serum P-selectin and interleuken-10 (IL-10) with VTE as a possible physiologic marker. METHODS: Patients admitted to two trauma centers with an Injury Severity Score >/=9 had blood samples drawn and underwent duplex ultrasound scanning of the lower extremities before initiating prophylaxis at admission, on days 3 and 7, and weekly until discharge. Patients were prophylaxed according to institutional protocols. RESULTS: One hundred eighty-six patients were enrolled with a VTE incidence of 17.8%. The population was predominantly male (60%), with a mean age of 48 years. sP-selectin levels were not statistically different between the groups (64.4 versus 74.8 pg/mL). However, IL-10 was significantly lower in the VTE group at both the initial and subsequent blood draws (21 versus 165 ng/mL, p = 0.012). Further, the ratio of sP-selectin to IL-10 (3.92 versus 0.92, p = 0.014) was statistically higher in the VTE group at admission. CONCLUSION: An elevated sP-selectin to IL-10 ratio appears to be associated with the development of VTE in patients at high risk and may prove to be a useful clinical marker for this dreaded complication among trauma patients. Early recognition of this high-risk group improves the accuracy of the risk/benefit determination for prophylaxis and identifies a group in whom routine ultrasound screening would be cost-effective.
BACKGROUND: An analysis from the prospective multicenter randomized controlled trial (Transfusion Requirements in Critical Care Trial) compared the use of restrictive and liberal transfusion strategies with resuscitated critically ill trauma patients. METHODS: Critically ill trauma patients with a hemoglobin concentration less than 90 g/L within 72 hours of admission to the intensive care unit were randomized to a restrictive (hemoglobin concentration, 70 g/L) or liberal (hemoglobin concentration, 100 g/L) red blood cell transfusion strategy. RESULTS: The baseline characteristics in the restrictive (n = 100) and liberal (n = 103) transfusion groups were comparable. The average hemoglobin concentrations (82.7 +/- 6.2 g/L vs. 104.3 +/- 12.2 g/L; p < 0.0001) and the red blood cell units transfused per patient (2.3 +/- 4.4 vs. 5.4 +/- 4.3; p < 0.0001) were significantly lower in the restrictive group than in the liberal group. The 30-day all-cause mortality rates in the restrictive group were 10%, as compared with 9% in the liberal group (p = 0.81). The presence of multiple organ dysfunction (9.2 +/- 6.3 vs. 9.0 +/- 6.0; p = 0.81), the changes in multiple organ dysfunction from baseline scores adjusted for death (1.2 +/- 6.1 vs. 1.9 +/- 5.7; p = 0.44), and the length of stay in the intensive care unit (9.8 +/- 8.1 vs. 10.2 +/- 8.7 days; p = 0.73) and hospital (31.4 +/- 17.1 vs. 33.7 +/- 17.7 days; p = 0.34) also were similar between the restrictive and liberal transfusion groups. CONCLUSIONS: A restrictive red blood cell transfusion strategy appears to be safe for critically ill multiple-trauma patients. A randomized controlled trial would provide the appropriate level of evidence with regard to the daily use of blood in this population of patients.
The aim of Neurosurgical care is to minimise the secondary brain damage that occurs after a severe head injury. This includes the evacuation of an intracranial space occupying haematoma, the reduction of intracranial volume, external ventricular drainage with hydrocephalus, and conservative therapy to reduce intracranial pressure (ICP) and to maintain tissue oxygen p(ti)O2. When conservative treatment fails, a decompressive craniectomy might be successful in lowering ICP. From September 1997 until April 1999 we operated on 128 patients with severe head injuries. 19 patients (15%) were treated by means of a decompressive craniectomy. The prognosis after decompression depends on clinical signs and symptoms on admission, patients' age and the existence of major extracranial injuries. Our guidelines for decompressive craniectomy after failure of conservative intervention and evacuation of space occupying hematomas included: a patient's age below 50 years without multiple trauma or a patient's age below 30 years in the presence of major extracranial injuries; severe brain swelling on CT scan (primary brainstem injuries were excluded). In 8 patients conservative 1TU treatment had failed.
Traumatic injuries have been described as the largest epidemic of the 20th century. In view of the number of victims and the associated costs, they have been also called the most severe and longest war of the contemporary world. According to Lipiński, every year every tenth Pole is involved in an accident and every one hundred-thirteenth Polish citizen requires specialist medical care. Thus, the general incidence is approximately 750 accidents per 100,000 Poles per year. 300,000 of them need hospital treatment, 30,000 die from accidents. Despite considerable progress in medical sciences and profound changes in the organization of emergency services within the past quarter of this century, multiple traumas continue to be a major problem in traumatology and the associated mortality rates in the best centers worldwide exceed 10%. Although, according to the recent reports, the most common cause of hospital deaths (30-50% or more of all fatal outcomes) is found in late complications of a severe trauma and posttraumatic shock, for example septic complications and multiorgan failure (MOF). Apart from severe primary injuries of the central nervous system, exsanguination continues to be the main cause of death (50-70%) immediately after the injury, at the site of the accident and in the ambulance (i.e. in the pre-hospital period) and in the first hours of hospitalization. The third life threatening cause is acute respiratory insufficiency after thoracic trauma. The "golden hour" procedures are particularly described as a prehospital time period (ABC ... system), emergency room period (ATLS system), damage control period and other life saving operations period. The general conception of these standards is minimalization of the effects of shock, respiratory insufficiency and intracranial hypertension in multitrauma patients.
BACKGROUND: Post-traumatic thrombotic events are exceptional in the caval system. We report a case of inferior vena cava thrombosis in a traffic accident victim. CASE REPORT: A 53-year-old male victim of a traffic accident suffered multiple trauma including blunt trauma of the abdomen. Three months after the accident, the patient was hospitalized with signs of pulmonary embolism proven by angiopneumography. Phlebocavography evidenced a thrombus floating in the inferior vena cava. DISCUSSION: We found 9 other cases of caval thrombus secondary to abdominal trauma in the literature. Tht thrombus usually developed due to endothelial damage secondary to shear forces. Computed tomography of the abdomen with contrast injection contributes greatly to diagnosis. Treatment is a matter of debate due to the prognosis dominated by the risk of massive embolism.
The emergency room functions as a junction between preclinical and early clinical treatment of patients with multiple trauma and should have defined technical and room possibilities. The personal staff should continue resuscitation measures and perform clinical and technical diagnostic procedures according to trained algorithms. The recognition of life-threatening injuries, the set up of correct priorities and application of respective surgical procedures characterize a good emergency room management.
BACKGROUND: The aim of this study was to evaluate forearm and hand injuries in multitrauma patients and to compare this group of patients to the overall multitrauma population. PATIENTS AND METHODS: Out of a prospectively gathered polytrauma data base a retrospective analysis, including demographics, injury severity, injury pattern and treatment of forearm and hand injuries was performed. RESULTS: Out of 386 patients (G) that had been entered in our polytrauma data base, 26 had forearm and hand injuries (H). The mean age of group (H) was 36.4 years (G: 40.3 years, p = 0.220), the mean ISS of this population was 28,3 (G: 34.5, p = 0.003). Mostly fractures of the radius (50.0%), the metacarpus (53.8%) and the carpus (50.0%) were diagnosed. Surgical interventions of hand- and forearm injuries were done in 15 cases within 24 hours, 4 patients were treated after 24 hours. CONCLUSION: Multiple trauma patients with hand- and forearm injuries showed a statistically significant decreased injury severity and were younger compared to the overall multitrauma population.
Bronchoalveolar lavage (BAL) specimens taken from nine patients with lung contusion following multiple trauma were compared with specimens from different control groups. Early interstitial and intra-alveolar reactions are PMN degranulation, mediator release and high protein leakage. The alveolar reactions are similar in extent to the reaction found in post-traumatic ARDS.
Double-level noncontiguous spinal injury is a more common occurrence than generally appreciated. A large number of these patients have neurological injury. Because these injuries occur in patients who meet the criteria for categorization as multiple trauma patients, we feel that a complete radiographic survey of the spine must be accomplished in the emergency room in any situation where clinical assessment is impaired. Treatment must be individualized with the same guidelines for treatment as for the isolated injury in the majority of circumstances.
Two independent groups of patients were studied by bone scintigraphy to demonstrate age-dependent changes in the appearance time of fractures: 83 patients with 123 fractures of the spine showed neither by multiple regression analysis nor by separation into two subgroups (younger and older than 55 years) a clinically significant difference by scintimetric evaluation. A second group of 162patients with multiple trauma demonstrated no age dependence of the rate of additional bone lesions shown by scintigraphy. Instead a clear dependence on the site of the lesion and the time after trauma was found: fractures of the shafts of long bones and fractures of the pelvis and spine showed up significantly later than fractures in the neighbourhood of the distal joints. 12-14 days after a trauma all fractures may be detected with a high accuracy independently from the fracture site (except for fractures of the skull which did not show up at all in most cases). Thus, the differences in the appearing time of fractures are not age- but site-dependent.