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PubMed1997

Enterobacter cancerogenus ("Enterobacter taylorae") infections associated with severe trauma or crush injuries.

Five cases of Enterobacter cancerogenus infections (wound, n = 4; bacteremia, n = 1) in adults are described. All infections seemed to be community acquired and occurred after precipitating events such as multiple trauma to the head or severe crush injuries. All five strains of E cancerogenus were recovered in pure culture, and three of these were isolated on multiple occasions. The results indicate that E cancerogenus can cause wound infections and septicemia in persons environmentally exposed to these organisms during traumatic events.

Adolescent↗
PubMed1986

Trauma serum suppresses superoxide production by normal neutrophils.

The effect of trauma serum on superoxide production by normal neutrophils was studied in 47 serum samples from 18 patients with multiple trauma. Ten patients became septic and eight patients remained nonseptic. Incubation in trauma serum significantly suppressed superoxide production by normal neutrophils compared with incubation in normal serum: 3.6 +/- 1.44 vs 4.04 +/- 1.64 nmole of superoxide produced by 10(6) neutrophils (mean +/- SD). There was no difference in the suppressive effect between septic and nonseptic trauma serum samples. The chemiluminescence response of normal neutrophils was likewise suppressed following incubation in trauma serum compared with incubation in normal serum. The chemiluminescence response correlated with superoxide reduction of cytochrome C. In addition, the chemiluminescence response was significantly less in septic-trauma serum than in nonseptic-trauma serum. Suppressive serum was found to inhibit the neutrophil-membrane depolarization response to latex particles, as measured by flow cytometry. We conclude that trauma serum suppresses superoxide production by normal neutrophils, and that such suppression can be detected reliably using the clinically applicable technique of chemiluminescence. A normal chemiluminescence response excludes serum-mediated suppression of neutrophil superoxide production. In addition, chemiluminescence may be of value in detecting altered resistance to sepsis following injury, while superoxide determinations do not seem to be helpful in this regard. The mechanism of action of the suppressor may involve reversible inhibition of membrane depolarization necessary for the production of bactericidal oxygen species.

Adolescent↗
PubMed2004

Excessive volume of trauma workload out of hours: is it really true?

To determine whether an excessive out of hours workload might contribute to the current lack of interest in trauma orthopaedics as a sub-specialty in the United Kingdom we reviewed data collected prospectively on 467 multiple trauma patients (ISS > 15) presenting to a teaching hospital over a 5 year period (January 1996-January 2001). Almost half of the patients (48.6%) presented between the hours of 18:00 and 08:00 with the trauma team called more frequently out of normal working hours. Two hundred and eleven (45.2%) patients underwent an operative procedure during their admission with an orthopaedic surgeon involved in the procedure in the majority of cases. Nearly half (41.5%) of these cases started between 18:00 and 08:00 with a larger portion (49.6%) finishing between these hours. A Consultant was the primary surgeon in 123 (82.0%) cases and involved in the majority of out of hours operating. Intensive care was required for 151 (32.3%) patients. The median hospital stay was 9 days (1-93). The out of hours workload for Orthopaedic consultants working in a busy teaching hospital is considerable. Planning issues need to be addressed to ensure that a career in trauma surgery is made attractive to current and future orthopaedic trainees.

Adolescent↗
PubMedDate not supplied

Children of traumatized and exiled refugee families: resilience and vulnerability. A case study report.

This paper focuses on the main problems and outcomes of two children of a traumatized refugee family who have been in Britain since 1993. Their parents witnessed near death experiences and physical assaults, and suffered losses and a wide range of physical problems; the father manifests post traumatic stress disorder (PTSD) symptoms. The children have been exposed regularly to episodic rage and violent behaviour by their father, and have developed separation problems and psychosomatic complaints. Their mother has coped better and is very resilient in her care and approach to problems. This report acknowledges the negative experience of trauma, but also the sources of resilience of parents, children's adjustment and cultural differences in coping styles. Refugee experiences devastate individual well-being and coping mechanisms if there is no hope, support and faith in one's own potential. Protective and risk factors that may affect the manifestation of trauma symptoms are highlighted. A variety of treatment approaches are required for both adult and child victims of multiple trauma. A wide range of techniques, such as group therapy, behaviour and cognitive therapy, and desensitization and relaxation training, can help sufferers to enhance their coping skills and deal effectively with devastating life events.

Adaptation, Psychological↗
PubMed2000

Death related to propofol use in an adult patient.

OBJECTIVE: To report an adult trauma patient fatality related to propofol administration. DESIGN: Retrospective case review. SETTING: Trauma intensive care unit (ICU) in a level one trauma center. PATIENT: An 18-yr-old man involved in a motor vehicle crash. INTERVENTIONS: Treatment for multiple trauma injuries and propofol sedation. MEASUREMENTS AND MAIN RESULTS: Posttrauma ICU monitoring was performed. The patient developed cardiac arrhythmia, metabolic acidosis, and cardiac failure, which resulted in death. CONCLUSION: Death related to propofol infusion can occur in adults as well as in pediatric patients.

Acidosis↗
PubMed1995

Financial strategies and outcomes management in trauma care: current status and predictions for the future.

In the competitive health care market of the 1990s, trauma centers face a multitude of fiscal challenges that threaten their survival. Trauma centers are confronted with the tremendous task of balancing the cost of caring for the patient with multiple trauma who requires resource-intensive care with the most fiscally responsible outcomes. Academic medical centers and residency training programs are faced with an even greater burden associated with controlling cost while providing learning experiences for physicians and nurses. Outcomes management represents the future strategy that trauma centers nationwide must embrace. Outcomes management gives trauma centers the opportunity to demonstrate their contribution to the community and society through improved patient and systems outcomes.

Financial Management, Hospital↗
PubMed1994

Correlation of trauma scoring and outcome in a Canadian trauma centre.

OBJECTIVE: To study the effectiveness of treatment and the outcome in trauma patients, and to correlate these with trauma scoring systems. DESIGN: A prospective study over 1 year of the probability of survival after trauma, based on TRISS methodology. A computerized database provided outcome statistics. SETTING: A regional trauma centre in a Canadian university teaching hospital serving regional and referral patients. PATIENTS: Three hundred consecutive patients treated at a single trauma unit. Two patients were excluded because of lack of physiologic data. Blunt injuries (94%) were most frequently from motor vehicle accidents (46%). INTERVENTIONS: Those appropriate to multidisciplinary trauma management in a level 1 trauma centre. MAIN OUTCOME MEASURES: Survival (Z values) and injury severity (M values) for the total group and subsets were calculated for comparison of outcomes with the Multiple Trauma Outcome Study baseline and other Canadian centres for multisystem and single-system injuries. RESULTS: The mean Injury Severity Score was 21.16 and the mean Revised Trauma Score was 6.75. There were 51 (17%) deaths--a Z value for the study group of 2.26. The M value was 0.78. Forty of the 51 single-system injuries were head injuries and accounted for 15 deaths. The Z value for multisystem injuries only was 0.54, and the M value was 0.77. CONCLUSIONS: The TRISS method for analysing blunt trauma is comparable to other trauma scoring systems. The correlation of outcome analysis with other scoring systems is affected by exclusion rates, pre-referral resuscitation and single- versus multiple-injury mix of cases.

Abdominal Injuries↗
PubMed1995

[A standardized large animal model of multiple organ failure after severe trauma].

In the past various attempts have been made to develop a standardized animal model of multiple organ failure (MOF). Until now there has been no large animal model, that imitates the clinical situation of multiple trauma patients up to MOF. In a manner similar to the pathophysiological sequence in multiple trauma patients, the combination of damaging mechanisms in the early phase (hemorrhagic shock, operating trauma, application of endotoxin (ET; 0.75 microgram/kg body weight) and zymosan-activated plasma (ZAP; 20 ml) every 12 h on days 1-5) leads to sequential irreversible damage to several organs in the late phase (> day 6) in sheep (n = 10). In this animal model representative organ parameters showed a similar course to that in MOF after multiple trauma in humans. The cardiac index increased significantly in the late phase (day 1: 6.47 +/- 0.41 ml/min x m2; day 10: 10.36 +/- 0.79 ml/min x m2), arterial oxygen pressure declined significantly (day 1: 103.1 +/- 1.6 mmHg; day 10: 89.8 +/- 4.2 mmHg). Liver function was impaired, bilirubin levels showed a significant increase (day 1: 2.94 +/- 0.34 mumol/l; day 10: 7.19 +/- 0.91 mumol/l). Creatinine clearance was low on day 1 (54.3 +/- 7.4 ml/min), increased up to day 5 and deteriorated again significantly in the late phase over the entire period (day 2: 104.3 +/- 26.8 ml/min; day 10: 53.1 +/- 17.6 ml/min).

Animals↗
PubMed1992

Semi-quantitative measurement of myoglobinuria in trauma patients with a latex-agglutination test (Rapi-Tex).

UNLABELLED: A semi-quantitative test (Rapi-Tex) for myoglobinuria was tested in trauma patients. All test results were evaluated blindly. Test specimens were obtained from 20 patients consecutively admitted with severe multiple trauma (Injury Severity Score: 29; range 26-41). The myoglobin concentration was measured semi-quantitatively by Rapi-Tex of three independent observers and quantitatively by enzyme-immuno-assay (EIA). Undiluted as well as 1:2, 1:6, 1:11, and 1:22 diluted samples were used. Test readings were done after 3 min and 5 min, respectively. The Rapi-Tex test classified the myoglobin concentrations correctly in 92.8% of the readings after 3 min and in 87.5% (mean, range: 85.5-91.6%) of the readings after 5 min. CONCLUSION: Rapi-Tex enables immediate bedside diagnosis of myoglobinuria in trauma patients. The test should be performed on both undiluted and 1:6 diluted urine samples with test reading after 5 min.

Adult↗
PubMed1999

Pregnancy complicated by traumatic diaphragmatic rupture. A case report.

BACKGROUND: Diaphragmatic rupture may be easily overlooked at the time of multiple trauma. Occult diaphragmatic rupture may first manifest during pregnancy as severe dyspnea. CASE: A parous woman who had sustained multiple traumatic injuries prior to pregnancy presented in midtrimester with abdominal pain and dyspnea. Chest roentgenography and computed tomography revealed bowel in the left hemithorax, compatible with a left-sided diaphragmatic rupture. Surgical correction was indicated secondary to the symptomatic nature of the presentation. CONCLUSION: Diaphragmatic rupture may be occult and may first present during a subsequent pregnancy. Surgical therapy is the cornerstone of management when a diaphragmatic defect is symptomatic. The route of delivery may be individualized for patients with diaphragmatic repairs in whom there has been sufficient time for healing.

Adolescent↗
PubMed2000

External laryngeal trauma.

External laryngeal trauma, blunt or penetrating, is a rare but potentially life-threatening injury. This is frequently seen in multiple-trauma patients and can go unrecognized in the absence of astute clinical awareness. Injuries may range from small endolaryngeal hematomas or lacerations to complete laryngotracheal separation. Proper airway management is of utmost importance and is one of the most controversial aspects of treatment of laryngeal trauma. Flexible fiberoptic laryngoscopy and high resolution computed tomography scanning of the larynx has greatly enhanced the evaluation of these injuries. Treatment options range from conservative, nonsurgical observation to evaluation in the operating room. Surgical intervention may involve endoscopy, open surgical exploration, and possibly laryngeal stenting. Long-term goals are aimed at maintaining voice, airway, and swallowing ability. A systematic approach to this condition often results in predictable and acceptable outcomes.

Female↗
PubMed2002

Effects of vaginal trauma and oophorectomy on the continence mechanism in rats.

PURPOSE: To establish an animal model for studying the effects of vaginal trauma and oophorectomy on the continence mechanism in rats. METHODS: Ninety-six female rats were used in the experiments. The rats were divided into 8 groups that received either no treatment (control), or single vaginal trauma at 0 day and 4 weeks, multiple vaginal traumas, oophorectomy at 4 and 12 weeks, and combined oophorectomy and single vaginal trauma or multiple vaginal traumas at 4 weeks. In vivo experiments were performed to determine abdominal leak point pressure (ALPP) by recording the intravesical pressure obtained during compression of the lower abdomen. In vitro urethral contractility experiments were then performed using isolated urethra and electrical field stimulation, acetylcholine, and norepinephrine. Finally, histological study of the urethral muscles and paraurethral structures was performed. RESULTS: Single or multiple vaginal traumas resulted in a significant reduction of ALPP. The reduced ALPP recovered at 4 weeks after single vaginal trauma. Oophorectomy did not significantly affect ALPP compared to controls; however, when oophorectomy was combined with multiple vaginal traumas, a significant reduction in ALPP occurred. Urethral contractility was reduced after multiple vaginal traumas but was not significantly different from the control after oophorectomy. Histological studies revealed disruption of the ventral part of striated muscles after single or multiple vaginal traumas. Degenerative and hyalinization changes were noted in submucosal and muscle layers after oophorectomy combined with multiple vaginal traumas. CONCLUSIONS: Vaginal trauma can injure the urethral muscles and nerves. Single or multiple vaginal traumas can induce denervation of periurethral muscles and reduce ALPP. With a period of recovery, the urethral resistance increases and ALPP returns. Oophorectomy mainly affected the intrinsic urethral closure mechanism and resulted in a nonsignificantly reduced ALPP; however, a significant reduction of ALPP developed when oophorectomy was combined with multiple vaginal traumas.

Animals↗
PubMed1998

Lactoferrin effects on the in vitro immune response in critically ill patients.

The aim of the study was to investigate whether lactoferrin can improve the immune competence of cells from patients with systemic inflammatory response syndrome (SIRS). We studied the effect of lactoferrin (LF) on the proliferative response of peripheral blood mononuclear cells (PBMC) to lipopolisaccharide (LPS) in vitro and its influence on production of 2 proinflammatory cytokines: interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha). Three groups of patients: septic survivors, septic nonsurvivors and multiple trauma patients, were investigated. Blood samples were taken upon admission to intensive care unit and after 2, 3 and 5 days. The proliferative response of PBMC in vitro was tested using 3-day culture with LPS. Cell proliferation/death was measured using MTT colorimetric method. The spontaneous and LPS-induced activity of TNF-alpha and IL-6 were measured with bioassays using indicator cell lines WEHI-164.13 and 7TD1, respectively. We demonstrated that LF inhibited the proliferative response, both spontaneous and LPS-induced, in all groups of patients. Lactoferrin alone was a good inducer of IL-6 and TNF-alpha production by monoclear cells in vitro. Addition of LF to the cultures of LPS-activated mononuclear cells stimulated IL-6 production, most markedly in the group of septic survivor patients (mean 1479, 1452, 1728, 1980 pg/ml on day 1, 2, 3 and 6 respectively). Lactoferrin also upregulated TNF-alpha production. That effect was very significant in the septic survivor patients (mean 7407, 6739, 7498 and 8509 pg/ml on day 1, 2, 3 and 5 respectively) and less pronounced in the group of trauma patients. We conclude that lactoferrin exhibited regulatory actions on the altered reactivity of PBMC from patients with sepsis and multiple injury. Lactoferrin is a good inducer of IL-6 and TNF-alpha production. However, in most cases of septic nonsurvivors LF could not abolish low reactivity of cells with regard to cytokine production.

Adolescent↗
PubMed1997

Delayed extradural hematoma after mild head injury: report of three cases.

BACKGROUND: Extradural hematoma has been classically considered to be an acute complication of head injury whose maximum development takes place in the minutes following trauma. Delayed extradural hematoma (DEH) is defined on the basis of an exclusively radiologic criterion: epidural hematoma that is not present in the first neuroradiologic examination made after trauma but that appears in sequential neuroradiologic examinations during patient evolution. This is an infrequent complication that usually appears in hypotensive multiple trauma patients or is related to severe head injury with other intracranial lesions. CASE DESCRIPTION: We present three cases of DEH after mild head injury (GCS > 12) without associated intracranial or traumatic systemic lesions. Therefore, those usually considered to be "protective mechanisms" responsible for delayed development of an extradural hematoma were absent in our three patients. Diagnosis was attained by means of repetition of cranial computed tomography (CT) scan after neurologic impairment was noted. Surgical evacuation of DEH was immediately performed after diagnosis. Postoperative outcome was favorable in two patients who suffered DEH in the supratentorial compartment. One patient who presented a posterior fossa DEH died 3 days after surgery. CONCLUSIONS: Early diagnosis and immediate treatment have proved to be essential for improving the prognosis of patients affected by DEH. Hospital admission under neurologic observation is recommended for patients who have sustained mild head injury associated with those factors that are related to the development of DEH, including GCS score under 15 or the detection of a skull fracture. Normality of a CT scan does not rule out subsequent appearance of delayed traumatic lesions.

Adolescent↗
PubMed2002

A prospective analysis of trauma exposure: the mediating role of PTSD symptomatology.

Trauma exposure has been associated with increased risk of exposure to additional traumatic events. Reactions to trauma exposure, specifically PTSD symptomatology, may mediate the link between trauma exposure and later traumatic events. Data from a longitudinal sample of Gulf War veterans (N = 2,949) were analyzed using a series of regression models. Higher levels of combat exposure were related to increased reports of PTSD symptomatology immediately upon return as well as increased reports of traumatic events in the 2 years following the Gulf War. PTSD symptomatology partially mediated the link between combat exposure and later trauma. Symptom clusters were also analyzed separately as potential mediators. Implications for the treatment of PTSD and prevention of exposure to multiple traumas are discussed.

Adult↗
PubMed2002

Immunoparalysis in patients with severe trauma and the effect of inhaled interferon-gamma.

OBJECTIVE: To evaluate the local immune status in patients with severe trauma and the influence of interferon-gamma on patients with immunoparalysis. PATIENTS: Fifty-two mechanically ventilated patients with severe multiple trauma. SETTING: A 14-bed polyvalent intensive care unit. INTERVENTIONS: The local immune status was evaluated by examining bronchoalveolar lavage fluid. Subsequently, the patients were divided into two groups: immunoparalyzed (group 1) and nonimmunoparalyzed (group 2). Immunoparalysis was defined as a decreased level of human leukocyte antigen-DR expression of alveolar macrophages in <30%. Patients with immunoparalysis were treated with 100 microg of inhaled recombinant human interferon-gamma, three times daily (group 1a, 11 patients) or placebo (group 1b, ten patients). A second bronchoalveolar lavage fluid was obtained 3 days after the initiation of therapy. MEASUREMENTS: The alterations in human leukocyte antigen-DR expression, as well as in pro- and anti-inflammatory markers, such as platelet-aggregating factor, phospholipase A2, interleukin-1beta, platelet-aggregating factor acetylhydrolase, and interleukin-10, were evaluated in the bronchoalveolar lavage fluids. RESULTS: In 21 of 52 (40%) patients, immunoparalysis was established. After interferon-gamma administration, the level of human leukocyte antigen-DR expression increased in group 1a from 17 +/- 5% to 46 +/- 9%. In parallel, platelet-aggregating factor and interleukin-1beta as well as the specific activities of phospholipase A2 and platelet-aggregating factor acetylhydrolase significantly increased. In contrast, interleukin-10 decreased after interferon-gamma therapy. In group 1b, no statistically significant changes appeared in the levels of human leukocyte antigen-DR expression or in the concentrations of inflammatory mediators. The incidence of ventilator-associated pneumonia was significantly lower in group 1a than in group 1b. The administration of interferon-gamma did not affect the outcome of the patients. CONCLUSIONS: A significant proportion of multiply injured patients developed immunoparalysis. The administration of interferon-gamma resulted in the recovery of levels of human leukocyte antigen-DR expression in alveolar macrophages, influenced the inflammatory reaction, and decreased the incidence ventilator-associated pneumonia, without affecting the patients' outcome.

Administration, Inhalation↗
PubMed2006

Prophylaxis against venous thromboembolism in orthopedic surgery.

Venous thromboembolism (VTE), which is manifested as deep vein thrombosis (DVT) and pulmonary embolism (PE), represents a significant cause of death, disability, and discomfort. They are frequent complications of various surgical procedures. The aging population and the survival of more severely injured patients may suggest an increasing risk of thromboembolism in the trauma patients. Expanded understanding of the population at risk challenges physicians to carefully examine risk factors for VTE to identify high-risk patients who can benefit from prophylaxis. An accurate knowledge of evidence-based risk factors is important in predicting and preventing postoperative DVT, and can be incorporated into a decision support system for appropriate thromboprophylaxis use. Standard use of DVT prophylaxis in a high-risk trauma population leads to a low incidence of DVT. The incidence of VTE is common in Asia. The evaluation includes laboratory tests, Doppler test and phlebography. Screening Doppler sonography should be performed for surveillance on all critically injured patients to identify DVT. D-Dimer is a useful marker to monitor prophylaxis in trauma surgery patients. The optimal time to start prophylaxis is between 2 hours before and 10 hours after surgery, but the risk of PE continues for several weeks. Thromboprophylaxis includes graduated compression stockings and anticoagulants for prophylaxis. Anticoagulants include Warfarin, which belongs to Vitamin K antagonists, unfractionated heparin, low molecular weight heparins, factor Xa indirect inhibitor Fondaparinux, and the oral IIa inhibitor Melagatran and ximelagatran. Recombinant human soluble thrombomodulin is a new and highly effective antithrombotic agent. Prophylactic placement of vena caval filters in selected trauma patients may decrease the incidence of PE. The indications for prophylactic inferior vena cava filter insertion include prolonged immobilization with multiple injuries, closed head injury, pelvic fracture, spine fracture, multiple long bone fracture, and attending discretion. Multiple-trauma patients are at increased risk for DVT but are also at increased risk of bleeding, and the use of heparin may be contraindicated. Serial compression devices (SCDs) are an alternative for DVT prophylaxis. Compression devices provide adequate DVT prophylaxis with a low failure rate and no device-related complications. Immobilization is one of important reasons of VTE. The ambulant patient is far less likely to develop complications of inactivity, not only venous thrombosis, but also contractures, decubitus ulcers, or osteoporosis (with its associated fatigue fractures), as well as bowel or bladder complications.

Anticoagulants↗
PubMed1996

Conservative management of penetrating and blunt Type III renal injuries.

OBJECTIVE: To determine the optimal management, conservative or surgical, of patients with penetrating or blunt Type III renal injuries. PATIENTS AND METHODS: This retrospective study comprised 122 patients with blunt abdominal or penetrating trauma with suspected significant renal injuries. Forty-five patients (32 penetrating and 13 blunt trauma) with Type III injury were identified. Of these patients, 28 (17 penetrating and 11 blunt trauma) had their renal injuries treated conservatively while 14 patients, all with penetrating injuries, underwent immediate surgical repair. Three patients died from multiple trauma shortly after arrival in the emergency room. RESULTS: In the 42 surviving patients with Type III renal injuries, four required delayed intervention. These included two of those managed conservatively and two of the 14 who underwent initial surgical intervention. Three renal units were lost, all of which were in those treated surgically. Thus, of the 42 surviving patients with Type III renal trauma, 28 (67%) were successfully managed conservatively without renal loss. CONCLUSION: This study suggests that Type III penetrating trauma may be successfully managed conservatively with a similar outcome to those patients with Type III blunt injuries. Initial surgical intervention may only be necessary in those with associated intra-abdominal injuries or haemodynamic instability.

Clinical Protocols↗