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PubMed1995

Plasma levels of insulin-like growth factor binding protein-3 in acute trauma patients.

Insulin-like growth factors (IGFs) are a family of polypeptides that regulate cell growth. Their action and bioavailability are modified by binding proteins such as IGF binding protein-3 (IGFBP-3). Plasma IGFBP-3 level was found to be growth hormone (GH)-dependent, which makes detection of IGFBP-3 useful in the evaluation of GH secretion. In the early catabolic flow phase of severe injury, when plasma levels of GH and IGF-1 are low versus uninjured levels, the role of IGFBP-3 has not been investigated. We have measured basal levels of these polypeptide hormones in 16 adult (13 men and three women aged 47 +/- 7 years) severely injured (Injury Severity Score, 32 +/- 2), hypermetabolic resting energy expenditure [REE] to basal energy expenditure [BEE] ratio, 1.30 +/- 0.05), ventilator-dependent, multiple-trauma patients within 48 to 60 hours of injury when the patients were receiving maintenance fluids without calories or nitrogen. These basal values were compared with those of 16 age-matched postabsorptive normals. In the catabolic flow phase of injury, plasma levels of GH, IGF-1, and IGFBP-3 were significantly reduced by 50%, 46%, and 45%, respectively. There was a significant linear inverse relationship between IGFBP-3 and age and also a positive correlation between IGFBP-3 and IGF-1 in both control and injured subjects. The ratio of IGFBP-3 to IGF-1 was not changed in trauma victims. Measurement of plasma IGFBP-3 levels has potential as a marker for monitoring GH therapeutic efficacy.

Adult↗
PubMed2005

Head injuries of Roman gladiators.

Gladiator remains from a recently unearthed cemetery in ancient Ephesus (Turkey) offer a unique opportunity for proving common theories involving the weaponry and techniques of gladiator fighting based on the evidence supplied by cranial bones. This mass grave is the first of its kind to undergo a thorough osteological and forensic examination. A minimum number of individuals (MNI) analyses revealed that at least 68 individuals. All individuals found turned out to have been males aged between 20 and 30 years, except for one female associated with a female slave gravestone, and one male aged 45-55 years, had been buried in this area of the cemetery. The male mean body height was 168 cm (S.D.=5 cm), which lies inside the normal range of height for Roman populations at those times. Eleven (16% of MNI) individuals exhibit a total of 16 well-healed antemortal cranial traumata. Five of the 11 individuals showed multiple trauma. Ten (15% of MNI) individuals exhibited a total of 10 perimortal cranial traumata. This is a surprisingly high frequency of deadly head injuries, taking into account that most of the gladiator types wore helmets. A possible explanation could be the frequently reported deathblow technique used by the hammer-carrying death god "Dis Pater". The gladiator weaponry is well known through historical sources. At least one injury per known type of offensive weapon could be identified, as well as evidence for the most popular, the gladiator trident, which was found to be represented by one perimortem and two antemortem injuries. Overall the reportedly very strict nature of combat rules for gladiator fights could be confirmed by the absence of multiple perimortal traumatized individuals, showing a lack of the excessive violence commonly observed on medieval battle ground victims. This graveyard gives the opportunity to confirm historical aspects and to check the reliability of forensic methods for identification of antemortem, perimortem, or postmortem bone lesions. Typical examples for these kinds of lesions and injuries are presented. The colour of the margins of the traumata proved to be the most distinguishing feature for postmortal lesions.

Adult↗
PubMed1985

Radiologic triage of the multiply-injured patient.

Integration of the principles of triage in the radiographic assessment of the trauma victim should allow efficient and timely diagnosis of most serious injuries. Use of the portable apparatus is stressed as the initial approach, but caution must be exercised in the exclusion of significant injuries by this method. Careful reading of additional information on films taken for a primary reason may allow the early diagnosis of associated problems (e.g., evaluating the upper airway on cervical spine views and the diaphragms on a chest film). Close cooperation between the emergency physician and radiologist is important in order to obtain the highest diagnostic accuracy in caring for victims of multiple trauma.

Accidents, Traffic↗
PubMed1984

Predicting the prognosis with trauma indices in surgical patients treated in the intensive care unit.

Trauma indices, acute trauma, CHOP (Creatinine, Haematocrit, Osmolality, Pressure), respiratory and renal indices, based on routinely used biochemical and physiological data, are mathematical quantities which have been developed for predicting the outcome of critically ill patients. We evaluated the use of these indices in 212 surgical intensive care patients. By fitting the index value, the age and sex of the patient to a logistic model, the probability of death (PD) was obtained. Poorest values of various indices and highest PD values were observed in postoperative abdominal surgery patients both on admission and during intensive care. Lower PD values were found in multiple trauma and brain injury patients. The outcome of a patient can be predicted already by means of the admission values. These indices are feasible since they require only easily available data. Before use, their validity must be checked at the hospital concerned.

Abdomen↗
PubMed1990

[Liver traumas].

The high mortality rate in hepatic trauma is a concern for the surgeons on duty, who must know the physiopathological problems and the therapeutic solutions in order to make the decisions needed in view of both hepatic and extra-hepatic injuries according to the available means. The early vital risk is produced by 2 facts: injuries to the liver, in which bleeding account for the death in every second case, especially in case of vascular disinsertion in the caval-suprahepatic junction, which fortunately occurs rarely; associated intra- or extra-abdominal injuries, which are unfortunately frequent, cause death in every second case of multiple trauma. On the basis of a series of 135 cases in our department and of a bibliographic study, this article is aimed at defining a strategy for treatment that will be adapted to the lesions, in order to try and improve the prognosis. With hemodynamically stable patients, a surgical watch and wait policy is possible under strict observation. Conservative surgery still has to play a dominant part. Hepatic resection is only rarely indicated, if absolutely necessary. Temporary tight packing for a few days, with early reoperation in a specialist department if required, is a logical approach in initially unfavorable circumstances.

Extracorporeal Circulation↗
PubMed1996

[The physiopathology of sepsis. Current concepts].

Clinical manifestations of sepsis, such as systemic inflammatory response and multiple organ dysfunction syndrome, are considered to be the results of a decompensated host defense response. If tissue injury is sufficiently severe to overwhelm local defense mechanisms, systemic activation of these essentially protective mechanisms may lead to autodestructive "host defense failure disease." This is not always caused by invading bacteria; sterile inflammation such as results from multiple trauma or pancreatitis can initiate a similar response. Evidence suggests that the activation of the macrophage/monocyte system that underlies the systemic inflammatory response may reflect one facet of a more generalized dysregulation of intercellular communication, as well as a dysfunction of such subcellular processes as signal transduction or stress gene expression. Alterations in signal transduction or stress gene expression can affect the host defense response to subsequent stressful events in either a negative or a positive sense. In particular, the sequential induction of acute phase and heat shock response may initiate programmed cell death, reflecting a potential molecular mechanism for the development of multiple organ dysfunction syndrome. The development of anti-inflammatory treatment strategies seems to be hampered by the discrepancy between locally protective and systemically detrimental properties of the host defense response.

Humans↗
PubMed2002

A 10-year experience of complex liver trauma.

BACKGROUND: Liver trauma is a relatively rare surgical emergency but mortality and morbidity rates remain significant. It is likely that surgeons outside specialist centres will have limited experience in its management; therefore best practice should be identified and a specialist approach developed. METHODS: Data collected from 52 consecutive patients over a 10-year interval were examined to identify best practice in the management of these injuries. RESULTS: The majority of injuries occurred as a result of road traffic accidents; 39 (75 per cent) of the 52 patients were stable at presentation to the referring hospital. In 36 patients (69 per cent) the liver injury was a component of multiple trauma. Ultrasonography, computed tomography or no radiological investigation was used in the referring hospital in 18 (35 per cent), 25 (48 per cent) and nine (17 per cent) patients respectively. Operative management was undertaken in the referring hospital in 26 patients (50 per cent). The overall mortality rate was 23 per cent (12 of 52 patients), and increased with increasing grade of severity. Eight of 26 patients managed surgically at the referring hospital died, compared with four of the 26 patients managed without operation (P not significant). The median time from arrival at the referring hospital to operation was 4 h for haemodynamically stable patients and 3 h for those who were haemodynamically unstable. CONCLUSION: Most patients with liver trauma can be managed conservatively. Operative management carried out in non-specialized units is associated with high mortality and morbidity rates. Abdominal injuries should raise a high index of suspicion of liver injury, and the data suggest that computed tomography of the abdomen should precede laparotomy (even in some haemodynamically unstable patients) to facilitate discussion with a specialist unit at the earliest opportunity.

Accidents, Traffic↗
PubMed1992

[Initial results with the ball joint fixator].

The ball-joint fixator is a one-plane external fixator system that allows correction of the reduction postoperatively. Dynamic axial loading is made possible by a telescoping device. Between January 1987 and June 1991, 312 external fixators were applied in the Department of Trauma of the Surgical University Clinic in Freiburg/Breisgau. In 25 of these cases the ball-joint fixator (Unifix) was used. The study includes 16 open and 8 closed tibial fractures and 1 open femoral fracture. The pin-tract infection rate was 14%. In 16 patients a cast was necessary for a short time after the fixator had been removed, and 3 other patients needed intramedullary nailing. The long-term complications observed were osteitis pseudarthrosis and refracture (in 1 case each). The ball-joint fixator is a device that can be applied very easily and quickly. It can be used to advantage in the treatment of multiple trauma patients with open tibial fractures. Because of the fixed distance between the pin clamps there is no advantage over the original AO fixator in fractures where the telescoping mechanism cannot be used.

Adolescent↗
PubMed1992

[Penetrating thoracic injuries].

In a period of peace in Germany and other westeuropean countries, penetrating trauma of the thorax (PTT) is much more rarer than blunt trauma. An analysis of 103 patients with PTT, treated in the Surgical Department of the University of Cologne from 1980 to 1990, showed, that these are usually isolated injuries in young patients. These occur usually following violence as stab wounds and less commonly gunshot wounds. Two thirds of the patients could be treated adequately with intensive care therapy and the use of thoracic drains. One third of the patients underwent thoracotomy, which was carried out in two thirds within one hour after hospital admission and in the remaining one third within the first 24 hours. The mortality for all PTT was 13%, being 10% for isolated thoracic injuries and 19% for patients with multiple trauma.

Adolescent↗
PubMed1976

Management of acute laryngeal injury: a critical review.

The approach to management of 30 cases of laryngeal trauma coming to open exploration is outlined. Eighteen patients had blunt trauma and 12 had penetrating wounds. Four cases resulted in airway compromise and all were in the blunt trauma group. Although significant granulation tissue response occurred in only eight of 30 cases, it was present in three of the four concluding with stenosis. It is demonstrated that the use of a stent, with a tissue graft, when mucosal approximation cannot be accomplished, facilitates prevention of endolaryngeal distortion and webbing and maintenance of skeletal framework integrity; its use did not predispose to granulation tissue development. A principal etiologic factor in those patients who had good airway but only a fair voice was arytenoid fixation, this despite anatomic reduction when subluxation occurred. Recurrent nerve injury was identified in only one patient. Foremost in management is suspicion and recognition of laryngeal injury in the multiple trauma patient. Once the urgent problems of hemorrhage, shock, and airway are attended to, attention must be directed to a systematic evaluation of the neck and larynx.

Airway Obstruction↗
PubMed1978

Prevention of liver reticuloendothelial systemic host defense failure after surgery by intravenous opsonic glycoprotein therapy.

Depression of the reticuloendothelial system (RES) was observed in rats following operative trauma consisting of laparotomy and jejunal enterotomy. This RES depression was manifested as a significant impairment in the phagocytic clearance of intravenously injected blood-borne test colloid mediated by a decline in hepatic Kupffer cell phagocytosis. Reticuloendothelial systemic host defense depression was correlated with a significant decline in bioassayable and immunoreactive opsonic alpha(2)SB glycoprotein concentration over a 1-3 hr postoperative period with rebound elevation in opsonic activity by 24 hr postsurgery. Intravenous administration of purified opsonic alpha(2)SB glycoprotein at the end of the operation prevented postoperative opsonic deficiency and restored normal hepatic RES phagocytic function. These studies coupled with previous observations in patients following surgery or after severe multiple trauma suggest that reticuloendothelial depression during and after operation mediated by opsonic deficiency may lead to a precarious imbalance between systemic host defense and the dissemination of blood-borne foreign and effete particulate matter such as injured platelets, fibrin microaggregates and immune complexes. Immunoreactive serum opsonic alpha(2)SB glycoprotein determinations may serve as a valuable index of hepatic RE clearance capacity and opsonin therapy may potentially be a selective means to augment systemic host defense.

Animals↗
PubMed1994

[Multiple organ failure syndrome in protracted tachycardia (based on 4 cases)].

The multiple organ dysfunction syndrome (MODS) is mainly caused by sepsis--community acquired or more frequently by nosocomial infections acquired on the intensive care unit. Further causes are intoxications, burns and multiple trauma. MODS worsens the prognosis of intensive care patients. We report on four cases of MODS developing outside hospital as a result of sustained tachycardia. Severity of MODS was apparently dependent on the duration of tachycardia and was rapidly reversible after termination of the tachycardia. Our observations show that sustained tachycardia may also cause MODS.

Aged↗
PubMed2005

Increased serum-GFAP in patients with severe traumatic brain injury is related to outcome.

OBJECTIVES: Several studies have established the relevance of S-100 in blood as a marker of brain damage after traumatic brain injury. However, a more specific marker is required and glial fibrillary acidic protein (GFAP) is considered to be a good candidate. METHODS: In order to assess the increase of GFAP in serum (s-GFAP) after a severe traumatic brain injury (TBI) we collected daily serum samples from 59 patients with severe TBI starting on the day of the trauma. S-GFAP was measured using a sandwich ELISA. The Glasgow outcome scale (GOS) assessed outcome after 1 year. RESULTS: All but one patient had maximal s-GFAP values above the laboratory reference value (median increased 10-fold). The highest detected levels were seen during the first days after TBI and then decreased gradually. Patients with unfavourable outcome had significantly (p<0.001) higher maximal s-GFAP values in the acute phase compared with patients with favourable outcome. All patients (n=5) with s-GFAP>15.04 microg /L died (reference level<0.15 microg/L). We found no significant difference in the maximal s-GFAP levels of patients with isolated brain injury in comparison with patients with multiple traumas. CONCLUSION: Serum-GFAP is increased during the first days after a severe traumatic brain injury and related to clinical outcome.

Adolescent↗
PubMed2002

Heterotopic ossification associated with knee dislocation.

PURPOSE: The purpose of this study was to determine the prevalence of heterotopic ossification following knee dislocation. TYPE OF STUDY: Prospective clinical evaluation and a retrospective chart review. METHODS: This study evaluated 57 knees in 55 patients who sustained high-energy blunt trauma with resultant knee dislocations. Radiographs were reviewed by 2 of the authors (J.P.S., T.C.W.), and the incidence of heterotopic ossification (HO) was documented. Additionally, patients were classified regarding the degree of HO on a scale from 0 to 4. One is punctate calcification, 2 is HO involving less than 50% of the joint space; 3 is HO involving more than 50%; and 4 is ankylosis of the joint. RESULTS: Thirteen patients with 15 knee dislocations developed HO. The incidence of HO was 26%. Seven knees demonstrated severe HO (grade 3 or 4) which represented an incidence of 12% of all knee dislocations. Injury severity score for both groups was 18, documenting that the patients in this study represent multiple trauma patients. There was no significant difference in the incidence of HO based on mechanism of injury with the current number enrolled in the study. However, 60% (3 of 5) of patients involved in a motor vehicle versus pedestrian accident developed HO. There was a significant increase in the incidence of arthrofibrosis in patients with severe HO (P <.05). Patients with significant HO had a mean flexion of 97 degrees, compared with flexion of 117 degrees in patients with no or mild HO. This difference was borderline significant (P =.058). There was no difference between the groups in mean extension. There was a significant increase in knee HO in patients with HO at another anatomic site (P =.01). CONCLUSIONS: HO is a common problem following knee dislocation. Of the 7 knees with severe HO, 5 developed HO medially, 4 developed HO posteriorly, 3 developed HO laterally, and only 1 had involvement anteriorly. A similar distribution was present in the patients with mild HO, with posterior and medial ossification being the most common. Five of the 7 severe HO cases involved at least 3 of the 4 sides (anterior, posterior, medial, or lateral) of the knee. Patients were evaluated for the presence of head injury and any relationship to the development of HO around the knee. There was no increased incidence of HO around the knee in our 10 patients with severe head injuries when compared with those with no head injury. There was also no increased incidence of HO in knee dislocations associated with periarticular fractures.

Adolescent↗
PubMed2006

Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury.

OBJECTIVE: To compare a restrictive versus a liberal transfusion strategy in patients with moderate to severe closed head injury following multiple trauma in 13 Canadian intensive care units (ICUs). METHODS: This is a subgroup analysis of a multicenter randomized controlled clinical trial involving sixty-seven critically ill patients from the Transfusion Requirements in the Critical Care trial who sustained a closed head injury. Patients had a hemoglobin concentration less than 9.0 g/dL within 72 hours of admission to the ICU. Patients were randomized to a restrictive allogeneic red blood cell transfusion strategy (hemoglobin 7.0 g/dL and maintained between 7.0 and 9.0 g/dL) or a liberal strategy (hemoglobin 10.0 g/dL and maintained between 10.0 and 12.0 g/dL). RESULTS: Baseline characteristics in the restrictive ( n = 29) and the liberal ( n = 38) transfusion groups were comparable. Average hemoglobin concentrations and red blood cell units transfused per patient were significantly lower in the restrictive compared to the liberal group. The 30-day all-cause mortality rates in the restrictive group were 17% as compared to 13% in the liberal group (risk difference 4.1 with 95% confidence interval [CI], 13.4 to 21.5, p = 0.64). Presence of multiple organ dysfunction (12.1 +/- 6.4 versus 10.6 +/- 6.3, p = 0.35) and changes in multiple organ dysfunction from baseline scores adjusted for death (4.5 +/- 6.2 versus 3.4 +/- 6.2, p = 0.49) were similar between the restrictive and liberal transfusion groups, respectively. Median length of stay in ICU (10 days, interquartile range 5 to 21 days versus 8 days, interquartile range 5 to 11 days, p = 0.26) and hospital (27 days, interquartile range 14 to 39 days versus 30.5 days, interquartile range 17 to 47 days, p = 0.72) were similar between the restrictive and liberal transfusion groups. CONCLUSIONS: We were unable to detect significant improvements in mortality with a liberal as compared to restrictive transfusion strategy in critically ill trauma victims with moderate to severe head injury.

Adult↗
PubMed1985

Rib fractures in children.

We reviewed the charts of 21 children admitted to the hospital with rib fractures to determine the cause of trauma, the relationship of the number and location of rib fractures to other injuries, the course of flail chest in children, and the frequency and characteristics of injuries caused by child abuse. Sixteen (76%) of 21 children were injured by accidental causes, most commonly by motor vehicles. However, five (24%) children were victims of child abuse. Nineteen children fractured an average of 3.5 ribs (range 1 to 8), while two other children fractured 22 and 23 ribs. Neither an increased number of fractures, nor first or second rib fractures were associated with more severe intrathoracic injuries. Two children with flail chest required intubation but recovered without further complications. The five children with nonaccidental rib fractures were young, had an unexplained history, and a paucity of multiple trauma. These characteristics should alert the physician to the possibility of child abuse in the patient with rib fractures.

Accidents, Traffic↗
PubMed2002

Acute renal failure in patients with rhabdomyolysis.

BACKGROUND: Rhabdomyolysis is a relatively rare, not always diagnosed cause of acute renal failure (ARF). This fact motivated us to present the results of ARF treatment in the course of this polyetiological clinical syndrome. MATERIAL/METHODS: The analysis was performed on 84 patients (6 F, 78 M) ranging in age from 18 to 82 years (mean 46.5), in whom rhabdomyolysis was diagnosed based on clinical manifestation and laboratory test results (CPK, GTP, GOT, LDH). RESULTS: The most frequent cause of rhabdomyolysis was alcoholic intoxication (41 patients), often accompanied by hypothermia (15 patients) or trauma (30 patients). Isolated trauma was found in 30 patients, epileptic seizure in 5, and physical exercise in 1 case. In 17 patients, besides alcohol consumption, trauma or epileptic seizure, the use of tranquilizers, anticonvulsants, or narcotic drugs was additionally noted. 78 patients developed ARF requiring dialysis therapy; 49 patients recovered, 5 required maintenance dialysis, and 30 died. CONCLUSIONS: During the initial phase of ARF in the course of rhabdomyolysis dynamic increases in serum urea and creatinine were observed, as well as a tendency to hyperkalemia. The treatment results and mortality rate in our study group were primarily influenced by the patients' general condition at admission, as well as the extent of organ damage caused by the primary etiological factor. Favorable treatment results were obtained especially in those patients who were hospitalized in a nephrological center, while the worst outcomes were noted in those patients dialyzed in intensive care units, most with multiple trauma.

Acute Kidney Injury↗
PubMed1993

Oxygen delivery-consumption relationship in adult respiratory distress syndrome patients: the effects of sepsis.

The oxygen consumption-delivery relationship (VO2/DO2) was studied in 15 sedated paralyzed patients with the adult respiratory distress syndrome (ARDS) due to multiple trauma and in whom sepsis was absent. Different levels (0 to 15 cm H2O) of positive end-expiratory pressure (PEEP) were applied. Oxygen delivery was calculated from cardiac index (thermodilution technique) and arterial oxygen content measurements. Oxygen consumption was calculated using Fick's equation. Regression lines were obtained for each patient. Oxygen supply dependency was defined as a significant (P < .05) relationship between changes in VO2 and DO2 with PEEP. Results were compared with those obtained in 18 ARDS patients in whom ARDS was due to sepsis. In nonseptic ARDS patients no significant relationship between changes in VO2 and DO2 with PEEP was found within the experimental range of DO2 on zero end-expiratory pressure (ZEEP) (347 to 845 mL/min/m2). None of these patients had multiple organ system failure (MOSF), and 73% survived. In ARDS patients in whom sepsis was present, supply dependency was present only when DO2 on ZEEP ranged between 330 and 640 mL/min/m2. All these patients developed MOSF and died. When DO2 on ZEEP ranged between 686 and 951 mL/min/m2 in septic ARDS patients, the supply dependency phenomenon was absent and only three patients developed MOSF and died (70% survivors). In almost all patients PEEP reduced DO2 and therefore worsened O2 balance by either increasing O2 extraction ratio and approaching the critical threshold for supply dependency or dismissing DO2 from the range of non-supply dependency.

Adult↗