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PubMed2002

[Caesarean section after severe trauma and cardiac arrest - a case report].

A 40 year-old woman with a prominent abdomen was hit by a car on the motorway. The emergency call was "cardiac arrest after multiple trauma in a woman in the late stages of pregnancy". The patient was asystole as indicated by the electrocardiogram 6 minutes after the primary emergency call. Cardiopulmonary resuscitation and endotracheal intubation was performed and a total dose of 3 mg epinephrine was given intravenously. The patient remained asystole. In this preclinical situation the suspected pregnancy could neither be excluded nor confirmed. At least 30 minutes would have been necessary to transfer the patient to the next hospital to perform a caesarean section under controlled conditions. A second physician - trained in obstetrics - was called to perform caesarean section preclinically. In addition, a special ambulance was called to provide sufficient postdelivery care of the neonate. However, the second physician who arrived 18 minutes later was not an obstetrician but also an anaesthesiologist who was trained in neonatal intensive care. At this time - 33 minutes after the first emergency call - the emergency physicians decided to perform a caesarean section immediately. However, the patient was not pregnant. Obviously, the primary emergency call was misleading. The skills of the emergency physicians and the conditions at the site of the emergency have to be weighed carefully against the expected time that is needed to reach the next hospital where a caesarean section can be performed under controlled conditions. In this case, both emergency physicians were anaesthesiologists and they had no doubt that the patient was in the late stages of pregnancy. Due to the prolonged cardiac arrest that did not respond to cardiopulmonary resuscitation both physicians were convinced that immediate preclinical caesarean section represented the only therapeutical option for the unborn patient.

Accidents, Traffic↗
PubMed2005

Stent-assisted arterial reconstruction of traumatic extracranial carotid dissections.

OBJECTIVES: Dissection of the internal carotid artery is a well-recognized complication of craniocervical trauma with potentially grave neurological outcome in patients with significant ischemic symptoms. Traditional anticoagulation therapy may not be applicable, since anticoagulation is contraindicated in multiple trauma or penetrating injuries. In these circumstances, rapid stenting followed by antiplatelet therapy may be performed. METHODS: Patients with angiographically proven traumatic carotid artery dissection were prospectively selected for endovascular stenting according to clinical and radiological criteria. Essentially, patients with hemodynamic significant hemispheric hypoperfusion (as indicated by angiography or perfusion MRI), or in whom anticoagulant therapy failed clinically, or anticoagulation was contraindicated, were considered at high risk for stroke and were selected for stenting. Twelve patients were selected for stenting. RESULTS: In seven patients, multiple stents were implanted. Endovascular treatment reduced mean dissection stenosis from mean 65+/-33% (range, 10-100%) to mean 7+/-9% (range, 20-0%). In a mean clinical follow-up of 11.5+/-6.3 months (range 3-24 months), eight patients improved and four remained stable, and none of the patients had a TIA or stroke. Doppler U/S studies did not detect any signs of de novo in-stent stenosis in any of the patients at a mean follow-up time of 9.2+/-6.4 months. CONCLUSIONS: In selected cases of traumatic dissections of the carotid artery, endovascular stent-assisted angioplasty may immediately restore the integrity of the vessel lumen, even of acutely occluded arteries. This approach efficiently prevented the occurrence of new ischemic events, without additional anticoagulation.

Adolescent↗
PubMed1994

Prevalence of traumatic events and post-traumatic psychological symptoms in a nonclinical sample of college students.

The lifetime prevalence of traumatic events and their psychological impact were assessed in 440 undergraduate students. Eighty-four percent of the subjects reported experiencing at least one event of sufficient intensity potentially to elicit Post-Traumatic Stress Disorder (PTSD). One-third of the sample had experienced four or more traumatic events. Subjects who had experienced trauma reported higher levels of depression, anxiety, and PTSD symptomatology than nontraumatized subjects, and these symptoms were more intense in subjects who experienced multiple traumas. Events that were particularly negative in their impact included unwanted sexual experiences and events that subjects reported were too traumatic to discuss openly. Males and females differed in their probability of experiencing some types of events and in the psychological response to certain events.

Adolescent↗
PubMed2002

The relationship between mothering in infancy, childhood experience and adult mental health: results of the Brody prospective longitudinal study from birth to age 30.

This longitudinal study has followed seventy-six individuals from birth to age 30 using films of the mother-child interaction, psychoanalytically informed interviews of parents and children, and psychodiagnostic testing to assess how the quality of mothering a child receives in the first year of life contributes to his/her subsequent emotional well-being. The thirty-year follow-up of the now adult participants found that those who had received more effective care in infancy in terms of maternal empathy, consistency, control, thoughtfulness, affection and management of aggression had higher-level psychological defence mechanisms as adults than children receiving less effective nurturing--suggesting a process in which the children internalised their mothers' own defence mechanisms. Other measures at 30 years (Global Functioning, Erikson psychosocial attainment, mental representation of security of attachment to parents and presence or absence of a psychiatric diagnosis) did not achieve statistical significance. On the other hand, trauma after infancy and before age 18 provided the strongest correlation with adult outcome: consistent with the theory of the effect of cumulative trauma on psychic functioning, children experiencing two or more adverse circumstances had significantly lower levels of global functioning as adults than those spared multiple traumas. With case examples, the findings illustrate how the effect of pre-verbal experience attenuates over time, and how later influences overlie early life in the course of psychological structuralisation.

Adolescent↗
PubMed1994

[Traumatic internuclear ophthalmoplegia].

The authors report a case of traumatic internuclear ophthalmoplegia and discuss its pathophysiologic mechanism. Internuclear ophthalmoplegia due to head trauma is uncommon, though it may be more common than reported since signs and symptoms typically resolve over weeks to months, and in multiple trauma patients other serious injuries overshadow disturbances of eye movements. A lesion involving medial longitudinal fasciculus was found by magnetic resonance imaging in the early post-traumatic period; this lesion was not seen when routine X-ray computed tomography was performed at the time of injury, confirming that magnetic resonance scanning is definitely superior to computed tomography for evaluating internuclear ophthalmoplegia.

Aged↗
PubMed1985

Hemorrhagic acalculous cholecystitis causing acute pancreatitis after trauma.

Hemobilia is an uncommonly recognized entity and postoperative acute acalculous cholecystitis is an uncommon clinical entity. Hemorrhagic acalculous cholecystitis causing pancreatitis has apparently not been reported before. We report the case of a multiple trauma victim who, several weeks after his initial injuries, developed acute pancreatitis secondary to hemobilia caused by postoperative hemorrhagic acalculous cholecystitis.

Abdominal Injuries↗
PubMed2002

Prospective evaluation of handheld ultrasound in the diagnosis of blunt abdominal trauma.

OBJECTIVES: To evaluate the Sonosite 180 handheld ultrasound in the diagnosis of haemoperitoneum in blunt abdominal trauma. METHODS: Trauma ultrasound using the Focused Assessment with Sonar for Trauma (FAST) technique was performed using the Sonosite 180 handheld ultrasound during the primary survey of adult patients triaged to the resuscitation room with multiple trauma or suspected abdominal injury. The ultrasound findings were compared against the investigation of choice of the attending surgeon/accident & emergency physician--CT, DPL, laparotomy or clinical observation. RESULTS: 50 patients who had sustained blunt abdominal trauma were evaluated using FAST. Satisfactory images were obtained in 96%. There were 5 true positive scans confirmed by CT, DPL or laparotomy. There were no false negative or false investigations. The sensitivity and specificity of handheld FAST was 100%. CONCLUSIONS: Handheld ultrasound using the Sonosite 180 system can be successfully used by appropriately trained doctors as the primary investigation in the acute evaluation of blunt abdominal trauma.

Abdominal Injuries↗
PubMed1982

Diagnostic peritoneal lavage.

From the preceding review, it can be seen that diagnostic peritoneal lavage is a safe, reliable means of evaluating the various acute conditions of the abdomen. Patients who have sustained, blunt trauma of the abdomen, particularly with associated injuries, are prime candidates for the procedure. Children who have sustained injuries, either suspected abdominal injuries or multiple trauma, should be included. Other groups include paraplegic patients with possible abdominal disease and patients with findings which are suggestive of an acute condition of the abdomen but an uncertain diagnosis. Relative contraindications for peritoneal lavage include a distended abdomen, a history of previous surgical procedures of the abdomen and gravid uterus. Peritoneal lavage may be performed upon these patients but with modifications of technique. Patients for whom the diagnosis is certain and those patients upon whom exploration is planned are not candidates for lavage. Peritoneal lavage has been shown to be an effective adjunct in the evaluation of the abdomen in a wide variety of conditions. Its use has decreased the rate of unnecessary laparotomy both in patients with blunt trauma to the abdomen and in those with nontraumatic, acute disease of the abdomen. It can be used to arrive at an early decision for operative and nonoperative therapy and thereby reduce morbidity and mortality in patients with abdominal disease.

Abdomen, Acute↗
PubMed1987

Outcome of massive transfusion exceeding two blood volumes in trauma and emergency surgery.

Our experience with 56 patients who sustained massive transfusion exceeding two times their estimated blood volume is reviewed. Survival was 39% for the entire group, which included six cases of blunt multiple trauma and seven nontraumatic surgical emergencies, and 51% for the subgroup who sustained penetrating trauma. Six patients arrived without detectable vital signs, but half of them left the hospital alive. Three subgroups sustained 100% mortality: cirrhotics, nontraumatic surgical emergencies, and victims of blunt trauma. Thirty-eight per cent of the noncirrhotics developed a post-transfusion bleeding disorder, but the specific patients who would develop coagulopathy could not be predicted on the basis of any clinical parameter scrutinized, including lowest measured platelet count. Pulmonary morbidity was rare among penetrating trauma patients in spite of an average of 35 units of blood transfusion. Acute respiratory failure developed in a subgroup with penetrating trauma who received an average of 59 units of blood; blunt trauma patients developed acute respiratory failure at an average transfusion volume of 35 units. The 77% mortality among patients who developed coagulopathy, and our inability to predict in advance which patients will develop serious clinical bleeding, argue strongly in favor of an aggressive approach toward prophylaxis in these patients in spite of the theoretical risk of disease transmission from the additional units of platelets and frozen plasma required.

Blood Coagulation Disorders↗
PubMed1987

[Lack of prognostic value of the determination of 3 serum proteins during the acute phase of brain injury].

In has been suggested that monitoring of blood levels of serum proteins could be of value in order to assess the prognosis of trauma patients. A study was set up to assess the value of albuminaemia, prealbuminaemia, transferrin and ceruleoplasmin levels in intensive care unit patients admitted after multiple trauma including head injury. This study involved 43 patients (31 men and 12 women), with a mean age of 26 years (range: 15 and 71 years). Two patients had extradural haematoma. The other patients had brain contusion associated with extradural haematoma (5 cases), subdural haematoma (1 case) and open brain wound (1 case). All these patients were sedated with penthiobarbital, paralysed with pancuronium bromide and mechanically ventilated. Serum protein levels were measured on the first and eighth days of the stay in the intensive care unit. In these patients that survived, there was a significant decrease in albuminaemia and transferrin levels, no change in prealbuminaemia and a significant increase in ceruleoplasmin levels. Ten patients died during the study. They presented a greater decrease in albuminaemia and prealbuminaemia as compared with the survivors. There was no difference in the evolution of ceruleoplasmin and transferrin levels between the two groups. Thus, whilst the difference between survivors and non-survivors was significant for the group, for the individual patient the difference was too small to be of any prognostic value.

Acute-Phase Proteins↗
PubMed1997

Posttraumatic stress disorder in a community group of former prisoners of war: a normative response to severe trauma.

OBJECTIVE: The goal of this study was to assess and describe the long-term impact of traumatic prisoner of war (POW) experiences within the context of posttraumatic psychopathology. Specifically, the authors attempted to investigate the relative degree of normative response represented by posttraumatic stress disorder (PTSD) in comparison to other DSM axis I disorders often found to be present, either alone or concomitant with other disorders, in survivors of trauma. METHOD: A community group of 262 U.S. World War II and Korean War former POWs was recruited. These men had been exposed to the multiple traumas of combat, capture, and imprisonment, yet few had ever sought mental health treatment. They were assessed for psychopathology with diagnostic interviews and psychodiagnostic testing. Regression analyses were used to assess the contributions of age at capture, war trauma, and postwar social support to PTSD and the other diagnosed disorders. RESULTS: More than half of the men (53%) met criteria for lifetime PTSD, and 29% met criteria for current PTSD. The most severely traumatized group (POWs held by the Japanese) had PTSD lifetime rates of 84% and current rates of 59%. Fifty-five percent of those with current PTSD were free from the other current axis I disorders (uncomplicated PTSD). In addition, 34% of those with lifetime PTSD had PTSD as their only lifetime axis I diagnosis. Regression analyses indicated that age at capture, severity of exposure to trauma, and postmilitary social support were moderately predictive of PTSD and only weakly predictive of other disorders. CONCLUSIONS: These findings indicate that PTSD is a persistent, normative, and primary consequence of exposure to severe trauma.

Age Factors↗
PubMed1979

Experience with a simplified trauma registry: profile of trauma at a university hospital.

A simplified computer-based trauma registry system with well-defined limits of data capture is presented. This registry was utilized to describe the profile of trauma at a university hospital. In 1 year there were 882 trauma victims hospitalized, with an overall mortality of 3.3%. The majority of the patients had relatively minor injuries, primarily involving soft tissue and bone. Severe multiple trauma was associated with a significant mortality. Intracranial or intra-abdominal injuries occurred in less than 10% of the patients. Transport accidents, falls, and assaults were the cause of injury in 70%. Key access to specific information about the trauma patient population demonstrated the potential of the registry system. The advantages and limitations of the registry are discussed.

Adolescent↗
PubMed1991

Helicopter transport of trauma victims: does a physician make a difference?

We studied the impact of physician presence on helicopter transportation of trauma victims during two periods; when physicians were part of the flight team and when they were not. Our data failed to demonstrate that physician participation in flights had an impact on patient outcome. The groups were comparable in average distance traveled, initial Trauma Scores, number of organ systems injured, and the final Injury Severity Scores. Each group showed an improved survival over that predicted by comparison with the Multiple Trauma Outcome Study cohort. No difference was found in the number of procedures performed at the scene, en route, or on arrival at the hospital. Untreated injuries were slightly higher in the physician-present group. It appears that experienced nurses and paramedics, operating with well-established protocols, can provide aggressive care that yields equal outcome results compared with those of a flight team that includes a physician.

Aircraft↗
PubMed2005

[Indications for computed tomography in patients with mild head injuries].

BACKGROUND: To identify clinical parameters that may be associated with intracranial lesions in patients with mild head injuries, Glasgow Coma Scale (GCS) scores of 15 but without any focal neurological deficit. METHODS: All head trauma patients admitted to the emergency room within 3 months with GCS scores of 15 (n = 371) were evaluated. Patients with focal neurological deficits, penetrating or multiple traumas, gun shot wounds were not evaluated. RESULTS: Mean age of 222 male and 149 female patients was 22.4 years. Frequency of intracranial lesions detected in CT was higher in patients older than 60 years of age. A significant difference was not found between both genders. Detection rate of abnormalities was higher after motorway accidents. Loss of consciousness and post-traumatic fits were associated with higher rates of pathological sequelae. A significant difference was not found between patients with or without headache, nausea, and vomiting. Sensitivity and specificity of cranial x-ray were estimated to be 38.2% and 93.2% when compared with cranial CT respectively. CONCLUSION: The incidence of intracranial lesions in patients with mild head injuries, GCS scores of 15, younger than 60 years of age, and without any focal neurological deficits, loss of consciousness, post-traumatic fits, gun shot wound, and penetrating injury is 0.6%.

Adolescent↗
PubMedDate not supplied

Surgical management of duodenal injury.

Seven patients with duodenal injuries following penetrating or blunt upper abdominal trauma are presented. In five, debridement, primary closure and drainage were performed; the postoperative course was uneventful. One other patient developed complications as a results of multiple trauma not directly related to duodenal injury. The seventh patient suffered from duodenal and small bowel fistulas, which closed after prolonged nonoperative treatment. All patients survived. Early diagnosis through accurate exploration and appropriate surgical interventions is essential to reduce morbidity and mortality in cases of serious insult to the duodenum. Debridement, primary closure (transversely in two layers) is the surgical treatment advocated. Gastroenterostomy is not recommended.

Adult↗
PubMed2005

Pediatric fractures of the humerus.

Humeral shaft fractures constitute only 3% of fractures in children younger than age 16 years. They are most common in children younger than 3 and older than 12 years old. They can be classified according to the fracture pattern, location, and tissues damaged. Fractures resulting from minor trauma may be caused by an occult unicameral bone cyst. Each age group requires different diagnosis, treatment, and prognosis. Fractures at birth are seen mostly with macrosomic and breech presentation. In children younger than 3 years, humeral fractures often are linked to child abuse. In those older than 10 years, fractures are related to direct or indirect trauma. Sports activities have been reported also to cause injuries in skeletally immature patients. Most humeral fractures are controlled nonoperatively; however, potential operative indications include open fractures, multiple trauma, bilateral injuries, compartment syndromes, pathological fracture, significant nerve injuries, and inadequate closed reduction.

Child↗
PubMed2003

Challenges in treating post-traumatic stress disorder and attachment trauma.

Treating women suffering from trauma poses significant challenges. The diagnostic prototype of post-traumatic stress disorder (PTSD) is based on single-event trauma, such as sexual assault in adulthood. Several effective cognitive- behavioral treatments for such traumas have been developed, although many treated patients continue to experience residual symptoms. Even more problematic is the complex developmental psychopathology stemming from a lifetime history of multiple traumas, often beginning with maltreatment in early attachment relationships. A history of attachment trauma undermines the development of capacities to regulate emotional distress and thereby complicates the treatment of acute trauma in adulthood. Such complex trauma requires a multifaceted treatment approach that must balance processing of traumatic memories with strategies to contain the intense emotions this processing evokes. Moreover, conducting such treatment places therapists at risk for secondary trauma such that trauma therapists also must process this stressful experience and implement strategies to regulate their own distress.

Adult↗
PubMed1985

Postsplenectomy complications.

Postsplenectomy complications were reviewed among 420 patients with simple splenic injury, splenic plus multisystem trauma, elective splenectomy, incidental or accidental splenectomy, and those having splenectomy prior to renal transplantation. Complications not specifically related to splenectomy occurred postoperatively in 52 per cent and 41 per cent, respectively, in the complex trauma and incidental-accidental splenectomy groups. Nonfatal complications specifically related to splenectomy occurred in 15 per cent of patients with multi-organ injury and in 18 per cent of patients with incidental-accidental splenic removal. Morbidity was infrequent when simple splenic trauma prompted splenectomy or in elective splenectomy. Mortality related to splenectomy occurred most often following renal transplantation, but also appeared high when the spleen was removed for multiple trauma or incidental to other surgery. The latter category is at risk for morbidity and mortality when splenectomy is incidental to a planned procedure (e.g., radical gastrectomy) or accidental as when injured by the surgeon. These splenectomies and those planned prior to transplantation may be unnecessary in many instances. The postsplenectomy sepsis syndrome was encountered late only once in this entire series; nonetheless, sound indications for splenectomy must prevail before splenic removal since significant early morbidity and mortality follows splenectomy.

Adult↗