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PubMed1985

Increased dependence of leucine in posttraumatic sepsis: leucine/tyrosine clearance ratio as an indicator of hepatic impairment in septic multiple organ failure syndrome.

The body clearance of 10 plasma amino acids (AA) was determined from the rate of compared muscle-released AA and AA administered by infusion of total parenteral nutrition (TPN) compared to their estimated extracellular (ECW) pool in patients with multiple trauma with (n = 10) or without (n = 16) sepsis at 8-hour intervals. In both nonseptic and septic trauma, increasing TPN increased the mean clearance rate of all infused AA. When the individual AA clearance rates were normalized by the total AA infusion rate, regression-covariance analysis revealed that patients with sepsis had relatively impaired clearances of alanine (p less than 0.01) and methionine, proline, phenylalanine, and tyrosine p less than 0.05 for all). In contrast, the clearances of branched-chain AA (BCAA) valine and isoleucine were maintained, and the clearance of leucine was higher (p less than 0.05) in trauma patients with sepsis than in those without. At any AA infusion rate, compared with surviving patients with sepsis (p less than 0.05), patients who developed fatal multiple organ failure syndrome (MOFS) showed increased clearances of all BCAA with further impaired clearance of tyrosine. The clearance ratio of leucine/tyrosine was increased in MOFS at any AA infusion rate (p less than 0.0001), was an indicator of severity, and, if persistent, was a manifestation of a fatal outcome. Because tyrosine metabolism occurs almost entirely in the liver while leucine can be utilized by viscera and muscle, these data suggest early and progressive septic impairment of the pattern of hepatic uptake and oxidation of AA with a greater body dependence on BCAA, especially leucine, as septic MOFS develops.

Adolescent↗

PubMed1978

Blunt and penetrating injury.

Personal injury may result from deceleration of the body or of missiles by the body, resulting in blunt or penetrating multiple trauma. The extent of the deceleration injury is determined by the amount of energy absorbed. Whether the injury is blunt or penetrating depends on factors of force, surface and time. Priorities in the management of the multiple-injury patient consist of rapid evaluation and control of breathing, bleeding and shock.

Craniocerebral Trauma↗

PubMedDate not supplied

[Relation between cytokine IL-6 levels and the occurrence of systemic complications in patients with multiple injuries and blunt abdominal trauma].

Severe trauma is the third cause of death and the first one in the most vital and young population. In USA more children die of trauma then of all other causes. Blunt abdominal trauma takes 56% cases of multiple traumas of all etiologies. Among multiple injured patients, near to 50% have some system-complications, more of 60% in the group of critically injured (ISS > 35). Cytokines play the main role in the inflammatory reaction during the early phase response on trauma. Their secretion predicts system-complications as ARDS, SIRS, even MODS. Hypothetically, level of concentration of Interleukin-6 (IL 6) can improve methods of early diagnostic procedures for detecting SIRS and MODS, when scores are still low (preclinical level), at which stages therapy is more powerful and also cheaper. This prospective study includes 35 multiple injured persons with blunt abdominal trauma (75 > ISS > 18). We have used standard diagnostic procedures. Concentration of IL 6 was detected with ELISA-test. Levels of IL 6 were significantly higher in correlation with SIRS score groups. Correlation with MODS score was not significant for the lowest scores, but IL 6 showed significant higher levels in the second and the third MODS score group.

Abdominal Injuries↗

PubMed1993

Modes of death in the pediatric intensive care unit: withdrawal and limitation of supportive care.

OBJECTIVE: To determine the frequency of withdrawal or limitation of supportive care for children dying in a pediatric intensive care unit (ICU). DESIGN: Retrospective review of medical records. SETTING: Pediatric ICU in a tertiary care children's hospital. PATIENTS: All children dying in the pediatric ICU over a 54-month period (n = 300). INTERVENTIONS: Medical record review. MEASUREMENTS AND MAIN RESULTS: Data recorded for each patient included diagnosis, mode of death, and whether the child was brain dead. Each patient was assigned to one of the following mode of death categories: brain dead; active withdrawal of supportive care (meaning removal of the endotracheal tube); failed cardiopulmonary resuscitation; allowed to die without cardiopulmonary resuscitation (do-not-resuscitate status). A total of 300 patients were identified. Diagnoses included postoperative congenital heart disease (n = 56), head trauma (n = 38), near-miss sudden infant death syndrome (n = 28), pneumonia (n = 22), sepsis (n = 21), near-drowning (n = 21), various anoxic insults (n = 20), multiple trauma (n = 17), and patients with other diagnoses (n = 77). Mode of death was active discontinuation of support in 95 (32%) patients, do-not-resuscitate status in 78 (26%), brain death in 70 (23%), and failed cardiopulmonary resuscitation in 57 (19%). CONCLUSIONS: In a large, multidisciplinary pediatric ICU, the most common mode of death was active withdrawal of support. In addition, more than half (173/300, 58%) of children dying in the pediatric ICU underwent either active withdrawal or limitation (do-not-resuscitate status) of supportive care.

Brain Death↗

PubMed1992

Studies on the role of tumor necrosis factor in adult respiratory distress syndrome.

Tumor necrosis factor (TNF), rapidly becoming recognized as a mediator of inflammation, may be important in the pathogenesis of acute lung injury. Its role in the development of the adult respiratory distress syndrome (ARDS) in humans, however, has been difficult to clarify. To determine if TNF could be important early in the development of acute lung injury from multiple causes, we enrolled 103 patients within 8 h of meeting the criteria for an at-risk illness (sepsis, aspiration of gastric contents, severe pancreatitis, hypertransfusion, abdominal trauma, chest trauma, multiple fractures) and obtained multiple frequent blood samples for TNF measurements. Using five methods of TNF analysis, we were unable to find an association between TNF and the development of ARDS. However, we found significant differences in TNF measurements depending on the methods of analysis used, which could, at least in part, account for the inconsistencies in the published literature regarding the relationship between TNF and disease processes.

Adult↗

PubMed2005

Computed tomography for cervical spine trauma. The impact of MDCT on fracture detection and dose deposition.

A multidetector computed tomography (MDCT) was installed in our department. Referral rates, examination protocols and detection rates of abnormal findings in CT examinations for cervical spine trauma 6 months before and 6 months after MDCT installation were compared to look for changes in practice. Retrospective analysis of all CT cervical spine examinations in patients with multiple trauma over two contiguous 6-month periods: from July 2003 to December 2003 (helical CT) and from January 2004 to June 2004 (MDCT). Variables recorded were number of CT examinations performed, scan plane coverage and traumatic abnormalities detected. Phantom dosimetry measurements for cervical spine examination in both helical CT and MDCT were compared. One hundred and fifty four patients underwent cervical spine CT during these periods. Helical CT period: of 91 patients undergoing CT cervical spine examination for trauma, 65 (71%) were complete cervical examinations and 26 (29%) were level-specific examinations. Eight patients (9%) had cervical spine fracture, six of which were apparent on radiographs. Dose estimations for thyroid, lens and breast were 24.76, 1.86 and 0.21 mGy, respectively, for complete cervical spine examinations. MDCT period: of 63 patients who underwent CT cervical spine examination for trauma, 61 (97%) were complete examinations and 2 (3%) were level-specific examinations. Six patients (11%) had cervical spine fracture, three of which were apparent on radiographs. Dose estimations for thyroid, lens and breast were 75.8, 9.7 and 0.7 mGy, respectively, for complete cervical spine examinations, which were notably higher than those for helical CT. After installation of MDCT, clinical requests for complete examination of the cervical spine following trauma increased. This changing trend resulted in a significantly higher radiation dose to thyroid, lens and breast.

Accidental Falls↗

PubMed2004

Traumatic lumbosacral dislocation: four cases and review of literature.

Diagnosis, physiopathology, and treatments of four patients with traumatic lumbosacral dislocations are described. This is a rare but severe lesion of the lumbosacral junction that usually occurs in patients with multiple trauma. It often is not thought of and the diagnosis may be missed. Evidence of lumbosacral dislocation should be examined and confirmed by computed tomography scans in patients with multiple fractures of transverse lumbar processes, asymmetric lumbosacral joints on frontal images, or slipping of L5 over S1 on lateral images. Treatment consists of reduction of the dislocated and fractured parts, lumbosacral arthrodesis, a posterolateral graft, and posterior instrumentation. Instrumentation may be short, extending from L5 to S1, or long, from L4 to S1, depending on the extension of the lesion. In some cases, reduction can be done intraoperatively, when the L4-S1 instrumentation is inserted, provided L5 transpedicle screws are pulled posteriorly. It usually is preferable to explore the vertebral canal to ensure that there is no disc lesion compressing the dura before proceeding with reduction. Compression of the dura could be avoided with a preoperative magnetic resonance imaging scan on which a lesion of the L5-S1 disc is sought. Additional interbody vertebral arthrodesis should be considered when the L5-S1 disc is affected severely. This lesion should be looked for preoperatively with a magnetic resonance imaging scan and intraoperatively by exploring the canal. This can be done at the time of the posterior surgery or during a second anterior surgical procedure.

Accidents, Traffic↗

PubMed1982

Abdominal trauma in persons older than 60 years.

Abdominal trauma occurring in persons older than 60 years over a 30-year period (1950-79) in a well defined region of Sweden was reviewed. The 177 patients comprised 12.5% of the total with abdominal trauma during that period. Road traffic accidents were the main cause of trauma (48% of cases). The incidence of motor-car accidents rose sharply during the first two decades of the study. Injuries to the liver and bile ducts and multiple intra-abdominal injuries were more common in the elderly than in younger patients, but injury to the abdominal wall was less common. A tendency towards more severe injuries and multiple trauma with extra-abdominal involvement emerged during the study period. The mortality rate was 27.6% in the patients older than 60, but 9.1% in the overall patient series with abdominal trauma. One-third of all the deaths among the older patients were directly due to the abdominal trauma. One consequence of the increasing numbers of old people in the general population is probably that more and more cases of abdominal trauma will be seen in the higher age groups.

Abdominal Injuries↗

PubMed1998

Speed and efficiency in the resuscitation of blunt trauma patients with multiple injuries: the advantage of diagnostic peritoneal lavage over abdominal computerized tomography.

BACKGROUND: The difference in speed, efficiency, and safety between diagnostic peritoneal lavage (DPL) and abdominal computerized tomography in the evaluation of adult blunt trauma patients with multiple injuries was investigated. METHODS: A prospective protocol was analyzed. Adult blunt trauma patients admitted to a Level I trauma center in 1994 were examined. Registry and chart data were used. Patients admitted before the institution of the protocol (January 1-June 30, 1994) were compared with those admitted afterward (July 1-December 31, 1994). Time spent in the emergency department before definitive placement or surgical intervention was studied. RESULTS: Patients in the second period, when DPL was used more frequently, spent significantly less time in the emergency department and radiology. No missed injuries were identified in either group. The percentages of nontherapeutic laparotomies were similar between the two groups. Cost was significantly lower in the group that underwent DPL. CONCLUSION: Patients with severe head injury, open fractures, or any evidence of hemodynamic instability are better served by DPL as the primary diagnostic modality. Its sensitivity and specificity are equivalent to those of computerized tomography; this facilitates evaluation and allows for simultaneous procedures and quicker initiation of definitive treatment.

Abdominal Injuries↗

PubMed1989

Direct transport to the operating room for resuscitation of trauma patients.

Two hundred forty trauma patients were transported directly from the scene to a specially designed operating room (OR) for resuscitation, bypassing the Emergency Department (ED). Triage criteria included a systolic BP less than or equal to 80 mm Hg, penetrating torso trauma, multiple long-bone fractures, major limb amputation, extensive soft-tissue wounds, severe maxillofacial hemorrhage, and witnessed arrest (WA). The mechanism of injury, transport mode, age, sex, admitting Revised Trauma Score (RTS), Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), operative procedures, and outcome were recorded. Utilizing the current weights from the Major Trauma Outcome Study, the predicted survival (TRISS) of the total group and of several subgroups was compared to the observed survival. The mean ISS was 29.3. The survival rate for the total group was 70.4%. For the 58.7% who required major operative intervention, the mean time of OR arrival to anesthesia induction was 8.5 minutes. Non-arrested, hypotensive blunt trauma victims requiring therapeutic laparotomy had a higher than predicted survival observed survival = 0.75 versus average TRISS = 0.55; p less than 0.0002) and therefore appeared to benefit from this technique. Patients suffering witnessed arrest in the field did not benefit.

Adult↗

PubMed1996

The accident and emergency department as a single portal of entry for the reassessment of all trauma patients transferred to specialist units.

127 patients who were transferred to a regional referral centre for specialist treatment within 48 h of serious injury were reassessed on arrival in the receiving accident and emergency department by a trauma team. 80 transferred patients (63%) required intervention in the accident and emergency department to complete assessment or resuscitation. In view of the well recognised difficulties in managing patients with multiple trauma and the possibility that initially occult injuries may become clinically significant during transport, transferred trauma patients should be reassessed in the accident and emergency department of the receiving hospital by a trauma team consisting of senior medical staff experienced in all aspects of trauma care.

Emergency Medicine↗

PubMed2000

Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series.

STUDY DESIGN: A retrospective review of all the surgically managed spinal fractures at the University of Missouri Medical Center during the 41/2-year period from January 1989 to July 1993 was performed. Of the 51 surgically managed patients, 46 were instrumented by short-segment technique (attachment of one level above the fracture to one level below the fracture). The other 5 patients in this consecutive series had multiple trauma. These patients were included in the review because this was a consecutive series. However, they were grouped separately because they were instrumented by long-segment technique because of their multiple organ system injuries. OBJECTIVES: The choice of the anterior or posterior approach for short-segment instrumentation was based on the Load-Sharing Classification published in a 1994 issue of Spine. The purpose of this review was to demonstrate that grading comminution by use of the Load-Sharing Classification for approach selection and the choice of patients with isolated fractures who are cooperative with spinal bracing for 4 months provide the keys to successful short-segment treatment of isolated spinal fractures. SUMMARY OF BACKGROUND DATA: The current literature implies that the use of pedicle screws for short-segment instrumentation of spinal fracture is dangerous and inappropriate because of the high screw fracture rate. METHODS: Charts, operative notes, preoperative and postoperative radiographs, computed tomography scans, and follow-up records of all patients were reviewed carefully from the time of surgery until final follow-up assessment. The Load-Sharing Classification had been used prospectively for all patients before their surgery to determine the approach for short-segment instrumentation. Denis' Pain Scale and Work Scales were obtained during follow-up evaluation for all patients. RESULTS: All patients were observed over 40 months except for 1 patient who died of unrelated causes after 35 months. The mean follow-up period was 66 months (51/2 years). No patient was lost to follow-up evaluation. Prospective application of the Load-Sharing Classification to the patients' injury and restriction of the short-segment approach to cooperative patients with isolated spinal fractures (excluding multisystem trauma patients) allowed 45 of 46 patients instrumented by the short-segment technique to proceed to successful healing in virtual anatomic alignment. CONCLUSIONS: The Load-Sharing Classification is a straightforward way to describe the amount of bony comminution in a spinal fracture. When applied to patients with isolated spine fractures who are cooperative with 3 to 4 months of spinal bracing, it can help the surgeon select short-segment pedicle-screw-based fixation using the posterior approach for less comminuted injuries and the anterior approach for those more comminuted. The choice of which fracture-dislocations should be strut grafted anteriorly and which need only posterior short-segment pedicle-screw-based instrumentation also can be made using the Load-Sharing Classification.

Adolescent↗

PubMed2003

The severity of infection induces a shift in the type 1/Type 2 T-helper cell balance in patients with or without peritonitis.

BACKGROUND: A type-1 to type-2 T-helper cell (Th1/Th2) shift is hypothesized to occur among patients with severe trauma and pancreatitis. It was hypothesized that the Th2 situation caused an immune-suppressed period that led to a critical imbalance in the patients' conditions, with an increased risk of multiple organ failure and mortality. METHODS: In eight patients with localized intra-abdominal infection (diverticulitis) and six patients with peritonitis due to perforation of a hollow viscus, we examined the cytokine response of CD3(+) T cells in the greater omentum and in the peripheral blood by in vitro stimulation, intracellular cytokine staining, and flow cytometry for TNF-alpha, IFN-gamma, IL-2, and IL-4. Follow-up cytokine assays were carried out on peripheral blood on days 3 and 7. Different levels of cytokine expression in each group were examined to determine the origin of the lymphocytes, both from omentum or peripheral blood. Cytokine production in the diverticulitis group was compared with that of the peritonitis patients. RESULTS: In localized infections (diverticulitis), there was higher expression of TNF-alpha (51%/35% positive cells in omentum/blood), IFN-gamma (47%/32%), and IL-2 (33%/20%) in the omentum than in the peripheral blood mononuclear cells (PMBCs), but this was not true for IL-4 expression (0.8%/1.3%). In patients with peritonitis, there were no differences in cytokine expression between lymphocytes from the greater omentum and from PMBCs for TNF-alpha (18%/21% omentum/blood), IFN-gamma (20%/22%), IL-2 (16%/12%), or IL-4 (10.9%/7.6%). Compared to the diverticulitis group, patients with peritonitis showed reduced expression for TNF-alpha, IFN-gamma, and IL-2, but there was a significantly higher response for IL-4 for both compartments. CONCLUSIONS: There was a shift from Th1 to Th2 in patients with severe clinical symptoms of peritonitis. Immune suppression is evident because of the T cell response in the greater omentum, but immunosuppression seems to not reach its maximum level before day 7 post operation. This differs from findings in multiple trauma and pancreatitis; however, it is parallel to the clinical situation in patients with peritonitis.

CD3 Complex↗

PubMed1977

Hypertonic mannitol in the therapy of the acute respiratory distress syndrome.

Increased pulmonary artery pressure, an increase in pulmonary vascular resistance and an increase in physiologic dead space are consistent findings in patients with post-traumatic respiratory distress. Since mannitol has been shown to decrease renal vascular resistance following trauma, the effect of a bolus injection of 100 ml of 25% solution of this drug on pulmonary hemodynamics and physiologic dead space was investigated in 11 patients who had suffered multiple trauma. Five minutes after the injection, pulmonary vascular resistance fell (p less than .01), cardiac index increased (p less than .001) and physiologic dead space decreased (p less than .05). In contrast, the administration of 40 mg of furosemide produced no significant change in any of these parameters. Mannitol rapidly equilibrates in the extracellular space and exerts an osmotic effect across cell membranes. We postulate that the beneficial response to mannitol on the pulmonary vascular resistance and the improved perfusion of ventilated regions of the lung is due to a reduction in cell swelling and is not explainable by its diuretic effect. Improvement in the distribution of perfusion of pulmonary blood flow by mannitol may be a useful aid in the treatment of the post-traumatic form of the respiratory distress syndrome.

Acute Disease↗

PubMed1979

Impaired lymphocyte transformation after accidental trauma.

The effect of accidental trauma on lymphocyte transformation induced by phytohaemagglutinin (PHA), concanavalin A (Con A), pokeweed mitogen (PWM) and purified protein derivative of tuberculin (PPD) was studied in 66 patients with minor, moderate or multiple trauma. An in vitro whole blood micromethod was used. The lymphocyte transformation induced by the mitogens and the antigen was impaired in patients with trauma in proportion to the severity of the injury. A decrease of lymphocytic responses to a very low level had prognostic value for the patient as indicated by the two patients with very low lymphocytic responses and serious infectious complications.

Adult↗

PubMed1987

[Ceftazidime with and without tobramycin versus azlocillin plus tobramycin in the therapy of bronchopulmonary infections in intensive care patients].

In a still ongoing open, randomized prospective trial the preliminary data of 50 intensive care patients on artificial ventilation were analysed. The evaluation included clinical and bacteriological efficacy and tolerance of ceftazidime alone or in combination with tobramycin versus azlocillin plus tobramycin. Artificially ventilated patients who had been treated in an intensive care unit for at least five days were selected to enter the study because of a high probability of colonisation with gram-negative bacteria. 16 patients were treated for bronchopulmonary infection with ceftazidime alone, and 17 each were treated with ceftazidime plus tobramycin or with azlocillin plus tobramycin. In the ceftazidime group nine patients were cured and three were improved (75% clinical success). Of the patients treated with ceftazidime plus tobramycin, 11 were cured and one was improved (75% clinical success); one patient died from very severe multiple trauma. In the azlocillin-tobramycin group, six patients were cured and two were improved (57% clinical success). Two patients from this group died from their underlying disease and another died from multiple organ failure due to septicemia.

Adult↗

PubMed1994

"How safe is splenectomy?".

The increased risk of sepsis in patients following splenectomy has been well documented. Fear of overwhelming post-splenectomy sepsis (OPSI) has resulted in a generalized trend towards splenic salvage among surgeons. However, splenorrhaphy and attempts at splenic salvage may of themselves predispose to significant morbidity, sometimes more serious than increased susceptibility to infection associated with splenectomy. This study aims to assess the risk of splenectomy and subsequent asplenia. We reviewed 246 patients who underwent splenectomy over a 16 year period. Indications for splenectomy were considered under the following headings: haematological (N = 116), trauma (N = 69), visceral carcinoma (N = 28), incidental (N = 13) and miscellaneous (N = 20). There were 28 deaths in the series, primarily among those in the intra-abdominal carcinoma (13) and multiple trauma (13) groups. Two deaths were recorded among patients undergoing elective splenectomy for benign disease. Thrombo-embolic complications were recorded in nine patients; respiratory tract infection in 36 patients and intra-abdominal abscess in two patients. Two cases of post-splenectomy pneumococcal septicaemia were documented, neither of which was fatal. While not an entirely benign procedure, splenectomy can be performed relatively safely, especially when performed for benign disease in an adult population.

Abdominal Abscess↗

PubMed2006

Prevalence of posttraumatic stress disorder in alcohol dependent patients in Poland.

The present study investigates the prevalence of comorbid posttraumatic stress disorder (PTSD) in a sample of Polish alcohol dependent patients and examines the relationship between comorbid PTSD and alcohol use-related problems. Patients (n=458) were recruited from randomly chosen clinical settings and were administered self-report measures of trauma exposure, PTSD symptomatology, and alcohol use-related problems. From this sample, 67% of the patients reported having experienced at least one criterion A traumatic event, and 60% of them reported multiple traumas. Approximately 25% of them met the criteria for current PTSD. The only significant difference between the PTSD and non-PTSD groups was abuse/dependence of other psychoactive substances. However, patients reporting physical assaults committed by a non-stranger reported more frequent PTSD diagnosis, more extensive symptomatology, more conflicts with the law and more physical injuries due to drinking. The findings of the study confirm the importance of assessing trauma and PTSD in alcohol dependent patients.

Accidents↗