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PubMed1992

The impact of leucine infusion on skeletal muscle amino acid and energy metabolism in severely traumatized patients.

The response to trauma is associated with increased energy requirements and net protein breakdown. The branched chain aminoacids, especially leucine, are considered to act by serving as a fuel for muscle tissue and by stimulating synthesis of proteins and controlling protein breakdown. Such results have been obtained mainly from in vitro studies. The present study was designed to evaluate the pharmacological effect of leucine infusion on muscle energy/amino acid metabolism in man after severe multiple trauma. 16 patients were studied and randomly allocated into 2 groups. Group 1 was given fat and 20% glucose while group 2 received 6 g N in form of leucine dissolved in 10% glucose solution and fat. The patients received 40 kcal/kg/24 h over an 8 day period after trauma. Biochemical analyses, muscle biopsies (energy substrates, electrolytes, amino acids), nitrogen balance and 3-methyl histidine excretion in urine were evaluated. Biochemical data revealed a significant increase (p < 0.05) of serum urea in group 2 day 4 and 8 after trauma. Muscle intracellular electrolytes (K(+), Mg(2+)) and energy substrates (ATP, phosphocreatine) showed a similar decrease in both groups. The intracellular muscle amino acids displayed a pattern known to be related to trauma without differences between the groups. The cumulative nitrogen balance 8 days after the injury was -93.5 g N +/- 10.1 (SEM) in group 1 and -73 g N +/- 7.5 in group 2. The 3-methylhistidine excretion was markedly increased similar in both groups. The present study demonstrated no significant pharmacological effect of leucine administration on muscle metabolism, nitrogen balance or 3-methylhistidine excretion in severely traumatized patients. Conventional balanced amino acid solutions are probably optimal to meet the patients actual requirements.

Journal Article↗
PubMed2000

The independent effect of gender on outcomes following traumatic brain injury: a preliminary investigation.

Although epidemiological studies of gender differences in outcome after brain injury are limited, studies in animals indicate higher fatality rates for females. Studies in which healthy human brain metabolism was investigated also suggest gender differences. In this paper the authors examine gender as an independent predictor of survival following brain injury. A prospective cohort of severely and moderately brain injured individuals was identified from two trauma centers over a period of 3.5 years. Patients enrolled in the cohort were followed for as long as 18 months postdischarge. The Glasgow Outcome Scale was used to measure long-term outcome. Overall, mortality was 1.28 times higher in females than males, with the greatest difference of 2.14 found in deaths postdischarge. Controlling for age, admission Glasgow Coma Score, penetrating as compared with blunt injury, and the presence of multiple trauma, females were 1.75 times more likely than males to die of their brain injury (95% confidence interval 1.09-2.82). Furthermore, females were 1.57 times more likely to experience poor outcomes (that is, severe disability or persistent vegetative state) than males. These findings suggest the need to examine similar effects in different cohorts and to identify the pathophysiological basis for the differences observed in this epidemiological study.

Adolescent↗
PubMed2000

Trauma, stress and multiple sclerosis.

It has been suggested that physical trauma, involving the cervical spinal cord or the brain, and psychological stress may precede MS onset or may influence the disease course, although this hypothesis has mainly come from anecdotal case reports or small uncontrolled or controlled studies. So far there are no studies providing a clear causative relationship between physical trauma (especially head trauma) and MS onset, exacerbation or progression of the disease. On the other hand, recent MRI and experimental studies, supporting the important role of nervous and immune system interactions, particularly by the hypothalamic-pituitary-adrenal axis and by the sympathetic nervous pathways, seem to demonstrate a significant correlation between stress and MS exacerbations. Further frequent MRI and immunological evaluations should be warranted to objectively document the temporal association between stress and clinical and/or sub-clinical disease activity.

Animals↗
PubMed2000

[Prioritizing suspected diagnosis of both brain and abdominal injuries--is it a problem?].

Current guidelines for management of suspected head and abdominal injuries are based on retrospective studies like that of Wisner & al, Following a recent review in this journal by Y. Kluger & al, which was based on non-Israeli data, we decided to define the current status at our trauma center. We compare our data of 18 months of hospital admissions for acute trauma in which head CTs were done with those of 5 articles advocating specific protocols for decisions in pre-laparotomy diagnosis. In the 861 cumulated cases, compared with the 800 of Wisner & al, craniotomy was required in 15% vs 7% (p < 0.05); laparotomy was much less frequent, 2.7% vs 12.9% (p < 0.05). The chance of finding a case requiring both craniotomy and laparotomy was 1 in 300. As the clinical condition of multiple trauma involving the head and abdomen is becoming less frequent and includes diverse situations, a comprehensive algorithm might be inaccurate. Good clinical judgment of the clinician and teamwork are therefore preferable.

Abdominal Injuries↗
PubMedDate not supplied

Organ-specific support in multiple organ failure: pulmonary support.

The catastrophic pulmonary failure that complicates management of patients with multiple trauma or sepsis syndrome with shock is recognizable to nearly all experienced surgeons. However, the spectrum of injury is broad, the distribution of lung injury may be heterogeneous within a single patient, and many patients will not develop acute respiratory distress syndrome (ARDS) even after a major predisposing insult. The lung responds stereotypically to many disparate insults, so a better conceptual construct of ARDS may be to consider it as one component of the multiple organ dysfunction syndrome. Support of oxygen transport with positive pressure ventilation and high levels of positive end-expiratory pressure, long the mainstay of pulmonary support, has been criticized for its predilection to cause barotrauma. Newer modes of ventilation, such as pressure-controlled, inverse-ratio ventilation and permissive hypercapnia, are under investigation but have not yet been reported with scientific rigor. However, pulmonary support extends beyond the support of gas exchange. Fluid management requires close attention so that the circulation is supported but lung water accumulation is minimized. Nosocomial pneumonia greatly increases the mortality rate in ARDS, but is difficult to diagnose and must be sought aggressively. Until recently, pharmacologic therapy has held little promise, but inhalation of very low concentrations of nitric oxide appear to decrease pulmonary vascular pressures and intrapulmonary shunt. It remains unknown whether nitric oxide is effective therapy for the underlying injury, or is simply treatment for certain manifestations.

Acute Disease↗
PubMed2000

Psychological and physical health effects of sexual assaults and nonsexual traumas among male and female United States Army soldiers.

Lifetime trauma history was assessed in a health study of active duty United States Army soldiers. Five hundred fifty-five male and 573 female soldiers in the sample were asked whether they had ever experienced 14 different potentially traumatic experiences, including sexual assaults, violent stressors to self, and terrifying events that occurred to others and were secondarily traumatic through exposure by gaining information or as a witness to the event. Most soldiers had experienced multiple traumas, and premilitary exposure to events was much more common than exposure to events after entering the military. Global measures of current psychological distress and physical health symptoms were predicted by the lifetime number of sexual assaults and traumas to self. Social support from military unit leaders moderated the relationship between accumulated exposure to traumas and both health measures, whereas unit cohesion was directly associated with fewer mental health problems.

Adolescent↗
PubMed1993

Blunt chest trauma.

Chest trauma remains the major initiating cause of respiratory failure in the trauma patient. The degree of injury can be substantially modified with appropriate early preventive and treatment measures. The lung injury itself can be divided into early and late phases. The early phase is primarily the result of mechanical forces transmitted to the chest. Initial management should focus not just on the lung; there should also be a search for commonly present, associated, nonpulmonary injuries. Optimizing early restoration of perfusion is also crucial in the multiple trauma patient, instead of too "wet" or too "dry." The most complex phase is the late phase resulting from the host inflammatory response to injury, both local and systemic. Stress modification and control of inflammation are the keys to controlling this aspect of the disease process.

Biomechanical Phenomena↗
PubMed1988

Microwave hyperthermia radiosensitized iridium-192 for recurrent brain malignancy.

Twenty-one patients whose solitary detectable biopsy proven recurrent brain malignancies produced Central Nervous System (CNS) symptoms warranting further intervention received 60-minute 43 degrees C (180 degree-minute) interstitial 2450 MHz microwave hyperthermia fractions. All received brain teletherapy prior to recurrence. The first 15 received no brachytherapy and served as a toxicity pilot. All 15 enjoyed neurologic improvement, 12 symptomatic improvement, and 12 objective response as mass reduction and/or tumor necrosis. The next 6 patients were selected with more favorable Karnofsky performance status, no known active malignancy elsewhere, and received afterloading Ir-192 interstitial implantation juxtaposed to radiosensitizing hyperthermia. Volume dose varied from 1000 to 2245 rad, and dose rate from 40 to 100 rad/hr. Dose selected varied as a function of pre-recurrence teletherapy dose, general condition, histologic type, and volume. Neurosurgical debulking, if technically indicated through no additional aperture or trauma, was permitted if consistent with preservation of neurological function. Six enjoyed neurologic improvement, symptom reduction, and objective tumor response; three remain alive, and one experienced transient improvement. Complications, histologic subtypes, autopsy findings, stereotactic approach, thermal monitoring methods and CT follow-up of objective response are presented along with computer dosimetry and isotherm chart. Our microtraumatic universal catheter technique for CT guided stereotactic biopsy, aspiration, decompression, thermal sensory loop, thermalization antennae, and brachytherapy without multiple trauma nor changing catheters is stressed. The rationale for combined modes peculiar to the CNS will be outlined.2+ Proposal for incorporating controlled-release ARA-C chemotherapy polymer micro-rods into the interstitial format will be offered. The preceeding is an FDA-approved controlled clinical trial.(ABSTRACT TRUNCATED AT 250 WORDS)

Brachytherapy↗
PubMed2003

Reformatted visceral protocol helical computed tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated in the evaluation of blunt trauma patients.

BACKGROUND: Patients suffering high-energy injuries are at risk for occult thoracic and lumbar spine fractures, and the standard of care includes radiographic spine screening. Most such patients require computed tomographic (CT) scanning to screen for chest and/or abdominal visceral injury. Helical CT (HCT) scanning represents a major technologic change that allows data to be reformatted after the patient has left the radiology suite. We explored the possibility of using reformatted visceral protocol HCT scanning to replace radiographs of the thoracic and lumbar spine in the evaluation of seriously injured patients. METHODS: A prospective evaluation of consecutive patients with thoracic and lumbar spine fractures admitted over a 12-month period to an urban Level I trauma center was completed. The ability of conventional radiography and reformatted HCT scanning to detect spine fractures was compared. RESULTS: Of 1,915 trauma patients admitted, 78 (4.1%), with an average Injury Severity Score of 21.3 +/- 1.2, sustained one or more thoracic (n = 35 patients) or lumbar (n = 43 patients) spine fractures. The sensitivity of reformatted HCT scanning as a screening test for spine fractures was 97% for thoracic and 95% for lumbar spine fractures, compared with a sensitivity of 62% for thoracic and 86% for lumbar conventional radiographs. CONCLUSION: Data obtained from HCT scanning performed to evaluate seriously injured multiple trauma patients for thoracic and abdominal visceral injury can be reformatted to screen for thoracic and lumbar spine fractures, providing accurate screening while eliminating the time, expense, and radiation exposure associated with conventional film radiography.

Adolescent↗
PubMed1995

Comparative analysis of transcription and protein release of the inflammatory cytokines interleukin-1 beta (IL-1 beta) and interleukin-8 (IL-8) following major burn and mechanical trauma.

The precondition for the systematic modulation of host impairing behavior of hyperactivated monocytes following trauma is to fully understand the mechanistic basis of cellular dysfunction. It was the objective of this study to scrutinize the synthesis patterns and the level of regulation of the functionally related inflammatory cytokines interleukin (IL)-1 beta and IL-8 under stressful conditions. We compared the quantity of cytokine protein release in lipopolysaccharide-stimulated in vitro cultures of peripheral blood mononuclear leukocytes with the signal intensity of the corresponding detectable mRNAs. Fourteen patients with major burn or multiple trauma on consecutive days post-trauma and healthy volunteers were studied. We saw an almost identical pattern of synthesis for both monokines during the time of observation, with a considerable impairment until day 5 post-trauma and recovery thereafter. In contrast to IL-1 beta, a clear concurrence between mRNA signal intensity and the quantity of protein release was found in the majority of patients for IL-8. From these data we conclude that the launching mechanisms for the de novo synthesis for both monokines under stress differ greatly, with IL-8 being clearly regulated on the transcriptional level, whereas the downregulation of IL-1 beta occurs, most likely, on the post-transcriptional level.

Adolescent↗
PubMed2006

Traumatic pseudoaneurysm of the pharyngeal artery: An unusual cause of hematemesis and hematochezia after craniofacial trauma.

BACKGROUND: Traumatic aneurysms of the internal maxillary artery are extremely rare. We report a case of traumatic pseudoaneurysm of the pharyngeal artery, a branch of the internal maxillary artery, presenting with hematemesis and hematochezia. CASE DESCRIPTION: An 18-year-old man presented with deep drowsy consciousness after a motor vehicle accident, in which he had a severe craniofacial injury. Three days later, he had hematemesis and hematochezia with a marked decrease in circulating hemoglobin level. External carotid arteriography performed to rule out vascular injury revealed active leakage from a false aneurysm of the pharyngeal artery. The lesion was successfully obliterated by superselective endovascular embolization. CONCLUSIONS: In patients with craniofacial injury associated with multiple traumas, traumatic pseudoaneurysm of the pharyngeal artery should be suspected as one of the possible causes of hematemesis and hematochezia. Selective endovascular embolization with cerebral angiography is an effective modality for the treatment and diagnosis of this lesion.

Accidents, Traffic↗
PubMed1986

Indications for intravenous pyelography in trauma.

The cornerstone for radiographic evaluation of genitourinary trauma is intravenous pyelography (IVP). Despite its widespread use, however, the indications for emergency IVP in trauma remain controversial. Some authors recommend the use of an IVP for all patients with hematuria, while others are selective, basing their decision on the degree of hematuria or such other factors as the mechanism of injury, physical examination, or the presence of associated injuries. Based on the data reviewed for blunt and penetrating trauma, we recommend that an IVP be performed in: all patients with gross hematuria; all patients who present with pain or tenderness that could be referrable to the genitourinary tract, even in the absence of hematuria; all patients with flank hematoma or ecchymosis; and all patients with penetrating trauma that could reasonably be expected to injure the genitourinary tract. Recently computed tomography (CT) has been proposed for the evaluation of renal trauma. The CT proponents cite superior definition of the extent of renal injury and superior detection of injuries not clinically suspected. Some have proposed the following algorithm, incorporating computed tomography. If an isolated renal injury is suspected clinically, an emergency IVP is performed. If the IVP is normal, expectant conservative treatment follows. If the IVP is abnormal or if the patient has persistent symptoms, an emergency CT scan is performed. Furthermore computed tomography is performed initially in the stable patient with multiple trauma and in the patient with suspected severe renal injury. While this algorithm has not been universally accepted, future studies confirming the theoretical advantages of this approach are anticipated.

Child↗
PubMed1997

[Synchronized independent pulmonary ventilation in the treatment of adult respiratory distress syndrome].

INTRODUCTION: Synchronized independent lung ventilation (SILV) is an effective mode of mechanical ventilation for treating both unilateral and bilateral pulmonary lesions. Oxygenation improves with an increase in the ventilation/perfusion ratio and also diminishes the risk of barotrauma. We describe our broad experience with this technique. Our main objective was to confirm whether SILV is able to improve the alveolar-arterial oxygen difference [P(A-a)O2] of patients with severe adult respiratory distress syndrome (ARDS) in whom conventional mechanical ventilation has not brought about improvement after being used for over 48 hours. PATIENTS AND METHODS: We carried out a descriptive, open, controlled prospective study of 45 patients with severe ARDS, enrolled from among 68 who underwent treatment with SILV. The most frequent cause of ARDS in our study was multiple trauma. The patients diagnosed of ARDS who did not improve with conventional mechanical ventilation were treated with SILV. Clinical characteristics and mortality are described. APACHE II scores, PAOA-aO2, dynamic distensibility were analyzed before and after SILV. The results of SILV were considered good if PA-aO2 improved at least 30% within 48 hours, with no increase in distensibility. RESULTS: No complications due to the technique were observed. Twenty-two patients (48.8%) died, 18 as a result of multiple organ failure and only one (4.5%) because of hypoxia. The improvements in APACHE II and (PA-aO2 were statistically significant, while distensibility did not change. The result was defined as good in most cases (n = 34, 83.8%). CONCLUSIONS: SILV is useful for providing ventilatory support when ARDS fails to improve with conventional mechanical ventilation. Clear improvement in respiratory function was observed, with significant decrease in PA-aO2 and no change in distensibility. SILV is a safe technique with few complications and can be managed by the intensive care unit nursing staff.

Adult↗
PubMed1995

Pulsatile nature of growth hormone levels in critically ill trauma victims.

BACKGROUND: Circulating growth hormone (GH) levels in normal persons fluctuate widely because of pulsatile GH secretion. It is not known whether this pulsatile nature and rhythmicity exist in severe injury. These data become necessary to decide the timing of supplementary GH administration for its optimal utilization. The purpose of this study was to investigate the GH circadian variation with respect to that of insulin-like growth factor-1 (IGF-1), insulin, C-peptide, and cortisol in the early flow phase of injury. METHODS: Plasma GH, IGF-1, insulin, C-peptide, and cortisol levels were measured at 1-hour intervals during 24 hours (8 AM to 8 AM) in 10 severely injured adults with multiple trauma during the early catabolic flow phase 24 to 48 hours after injury, when patients received maintenance fluids without calories or nitrogen. RESULTS: The 24-hour integrated GH concentration is not different from either 12-hour mean diurnal or 12-hour mean nocturnal or mean 8 AM GH concentration. Pulsatile GH bursts persist in injured patients during both day and night. Pulsatile bursts do not exist for IGF-1, insulin, and C-peptide. The plasma levels of cortisol show time-dependent daily maximum and minimum levels. CONCLUSIONS: Pulsatile GH bursts persist in injured patients but less frequently than seen in normal persons. The time of bolus administration of GH to augment the anabolic GH action in patients with trauma does not matter; however, for convenience morning administration may be preferable for patients in the intensive care unit.

Activity Cycles↗
PubMed1994

Bronchoscopy findings and early treatment of patients with blunt tracheo-bronchial trauma.

Five of 238 patients who suffered blunt chest trauna required surgery to repair a tracheobronchial injury. All patients were injured in a motor vehicle accident. The site of the injury was within 2.5 cm of the carina in four patients and 5.5 cm proximal to the carina in one. Pre-, intra-, and post-operative respiratory management was facilitated by the insertion of a Univent tube, an endotracheal tube with movable blocker capable of excluding one lung. The Univent tube prevented aspiration of blood by the healthy lung and the development of acute respiratory failure. Improved control over ventilation has the secondary benefit of allowing the surgeon to assess other injuries under less duress in patients with multiple trauma.

Accidents, Traffic↗
PubMed2002

Vascular trauma in Latin America: a regional survey.

As has been demonstrated, significant differences exist in demographics and the likelihood of accidents among Latin American countries; however, when figures were standardized, they showed a clear similarity in all the reviewed features of vascular trauma. A total of 66.4% of cases were managed solely on a clinical basis, with 78.9% of surgical procedures being performed within 6 hours of injury. Vascular repair was attempted in 84% of arterial injuries and 43% of venous injuries. Results are extremely good, with an 89% rate of success, especially considering that 63% of injuries were gunshot wounds and that the largest series, from Brazil, had a 21.3% rate of abdominopelvic injuries. The mortality rate amounted to 12.7%, but associated injuries, and particularly multiple trauma, account for 50.0% of the deaths.

Arteries↗
PubMed1982

Fractures of the mandible: a review of 580 cases.

The anatomic distribution of fractures in this study showed more fractures of the condylar and parasymphysis/symphysis regions, with correspondingly fewer body and angle fractures, than in other reported studies. The site of fracture is related to the type of trauma involved. Altercations, in which most force is directed in a single blow to the lateral aspect of the jaw, tend to result more frequently in angle and body fractures and less often in condylar, symphysis, and alveolar fractures. Automobile accidents, which more frequently involve trauma to the anterior mandible, result in more fractures of the symphysis region, alveolus and condyle. Motorcycle accidents produce many more alveolar fractures, suggesting that the traumatic force in this kind of accident is often directed to the alveolus. As might be expected, those individuals involved in motor vehicle accidents had the highest incidence of other injuries in addition to the mandibular fractures. Injuries to the head and neck were most common, but a wide variety of other injuries occurred. Complications are more common in the patient who has sustained multiple trauma. Most fractures were treated by closed reduction. When open reduction was necessary, the most common sites were the angle, body, and symphysis regions.

Adolescent↗
PubMed1976

[Value of puncture-lavage in abdominal closed trauma. Comparison with the laparoscopy and symptomatology (author's transl)].

In a series of 120 closed abdominal trauma the authors compare the reliability of the abdominal symptomatology (60%), of puncture-lavage with an Intracath (92.5%) or with a Diacath (98%) and of laparoscopy (100%). Laparoscopy and puncture-lavage with a Diacath have the same advantages: rapid execution, safeness, reliability. However the preference of the authors goes to the catheter and peritoneal dialysis because of its simplicity and feasability by the surgeon himself. This technique discloses visceral lesions: if positive it allows an earlier diagnosis and operation; if negative it avoids unnecessary laparotomies especially in cases of multiple trauma.

Abdominal Injuries↗