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PubMed2001

The determination of ketone bodies: preanalytical, analytical and physiological considerations.

The arterial ketone body ratio is calculated as the ratio of arterial levels of acetoacetate/beta-hydroxybutyrate. It correlates with survival in experimental hemorrhagic shock and outcome after liver surgery and myocardial infarction. Procedures for determination of ketone bodies are often laborious and unreliable. As yet the relationship between results from arterial and venous samples is unclear. We therefore describe the determination of the ketone bodies acetoacetate and 3-hydroxybutyrate by an easy, reliable, rapid, inexpensive enzymatic assay using 3-hydroxybutyrate dehydrogenase (E.C. 1.1.1.30) in a semi-automated setting that does not require deproteinization. Preanalytical parameters, including separation from corpuscular elements within 1 h and storage on ice for less than 1 h, must be strictly observed to avoid rapid decay of acetoacetate by spontaneous decarboxylation. The assay has high sensitivity, specificity (+/-5%), and precision (CV <2.5%) with a measurable range of 5-500 micromol/l for either ketone body, and requires only 23.5 microl of plasma. At temperatures below -17 degrees C plasma may be stored for prolonged periods. Results from prospectively scheduled simultaneous sampling of arterial blood and venous blood from the right atrium in 100 consecutive patients with severe multiple trauma (mean Injury Severity Score 38+/-13) support the view that the lung has no role in ketone body metabolism. We conclude that central venous blood can safely be substituted for arterial blood for determination of the ketone body ratio.

3-Hydroxybutyric Acid↗
PubMed1982

An improved design of the pneumatic counter-pressure trousers.

Inflation of the circumferential pneumatic counter-pressure trousers was associated with the development of hemiparesis in a multiple trauma patient. We attribute this complication to the marked movement of the spinal cord that results from inflation of the circumferential abdominal compartment of the trousers. The design of the circumferential pneumatic counter-pressure trousers was recently modified so that the inflation portion of the abdominal compartment was restricted to the anterior portion of the abdomen. Inflation of the abdominal compartment of the modified trousers resulted in considerably less movement of the spine than with the trousers having the circumferential abdominal compartment.

Adult↗
PubMed1984

Gastric response to severe head injury.

We studied the gastric response to severe head injury and multiple trauma in 53 patients admitted to the surgical intensive care unit at the University of Louisville. Twenty-two of the 32 patients with severe head injury could have endoscopy. Each patient had gastritis or duodenitis. Patients with severe head injury had a slightly higher rate of gastric acid secretion than did the other trauma patients without severe head injury, but the difference was not significant. Serum gastrin levels were normal in both groups and did not correlate with intracranial pressure. Pancreatic polypeptide levels were significantly higher in patients with severe head injury compared with the control trauma patients without head injury. Elevations in pancreatic polypeptide may be linked to increases in intracranial pressure. We conclude that erosive gastritis occurs commonly in patients with severe head injury and that severe head injury is associated with a marked increase in pancreatic polypeptide levels in the fasted, nongut-stimulated state. Gastrin levels are within normal limits. Head injury appears to specifically increase pancreatic polypeptide release, probably by influencing autonomic centers in the mid brain. Because the cephalic phase of pancreatic polypeptide release is vagalcholinergic, the data are consistent with the hypothesis that severe head injury increases vagal activity. Participation of vagal adrenergic fibers in this process cannot be excluded.

Adolescent↗
PubMed1984

Polytetrafluoroethylene grafts in the rapid reconstruction of acute contaminated peripheral vascular injuries.

Conventional wisdom dictates that autogenous tissue interposition be used in contaminated wounds when direct vascular repair is not feasible. Although there are few reports of successful use of PTFE grafts in grossly contaminated wounds, doubt still exists regarding the use of any prosthetic material in such wounds for reconstruction of vascular injury. Twenty-five vascular reconstructions were performed in 20 patients during a 3.5 year period. These patients had life-threatening multiple trauma and severe local tissue damage along with their arterial and venous injuries in open contaminated wounds after blunt (16 patients) and penetrating (4 patients) trauma. In all patients, 6 mm PTFE was used for interposition bypass for arterial injuries, and in five of these patients, 8 mm PTFE was used for concomitant venous interposition bypass. One patient died and there was one arterial and one venous graft thrombosis in the same patient 3 months after a shotgun blast injury to the groin, but there was no limb loss. All other grafts remained patent without wound infection, sepsis, or anastomatic disruption. Under the circumstances of these peripheral vascular injuries, PTFE was an acceptable choice for primary reconstruction in our patients. Its ready availability in many calibers, sparing of autogenous vein for future use, and its expedience in vascular reconstruction comprise the advantages of using PTFE in multiply traumatized patients without producing the feared evidence of infected prosthetic grafts.

Arteries↗
PubMed1985

Immediate external fixation of unstable pelvic fractures.

Immediate external fixation has been proposed as a means of stabilizing severe pelvic fractures to reduce the chance of organ failure and death. Sixty-six patients were admitted from January 1980 through December 1983 with double fractures of the pelvic ring that involved the posterior elements. Twenty-six patients (39 percent) underwent immediate external fixation for instability, and 40 patients (61 percent) with stable fractures were treated with bed rest. The two groups were similar in age, injury severity score, and degree of shock. The mortality rate of the two groups was the same (12 percent), as was the incidence of organ failure. The mean transfusion requirement in the unstable group was greater, but not significantly. Our results were better than those reported in recent studies in which immediate rigid fixation was not used. We conclude that the patient with multiple trauma without unstable pelvic fracture should undergo immediate external fixation to decrease morbidity and mortality rates and limit soft tissue damage.

Adult↗
PubMed1986

Progress in surgical emergency care: improvement in accuracy of diagnosis in a university hospital in France.

The accuracy of diagnosis in multiple trauma can be greatly improved by the use of standardized assessment routines and uniform documentation. In the three groups of patients reviewed, the diagnostic error rate decreased from 23 percent in 1979 to 1980 to 8 percent in 1981 to 1982, and decreased further to 7.6 percent in 1983 to 1984. Our latest results show that a margin of error still persists. We believe that standardization of assessment routines in the difficult area of emergency medical practice is in the patient's best interest.

Diagnostic Errors↗
PubMed1980

Cardiac contusion in the patient with multiple injuries.

We have treated 20 patients with multiple injuries and concomitant myocardial contusion. The diagnosis of myocardial contusion was based mainly on serial ECG tracings which showed arrhythmias, dynamic ischaemic patterns or conduction disturbances. The clinical and laboratory findings of cardiac contusion are sometimes indistinguishable from those found in multiple injuries. Furthermore, they are overshadowed by the overt manifestation of cerebral, thoraco-abdominal and skeletal injuries. Awareness and prompt diagnostic measures are essential in the diagnosis of cardiac injury. Strict cardiac monitoring following multiple trauma will prevent serious or even fatal outcome of cardiac injury.

Accidents, Traffic↗
PubMed1989

Quantitation of the anaphylatoxin C3a in the presence of C3 by a novel sandwich ELISA using monoclonal antibody to a C3a neoepitope.

C3a levels in plasma are usually measured by a competitive inhibition radioimmunoassay (RIA) using 125I-labelled C3a-desArg and antibodies to C3a capable of detecting C3a determinants which are also present on the native C3. Therefore, prior to the assay native, non-cleaved C3 has to be removed completely from the C3a-containing sample by precipitation. We developed a new rapid two-site sandwich ELISA system for the quantitation of C3a-desArg in plasma. This immunoassay uses a monoclonal antibody (mAb H466) reacting with C3a-desArg but not with C3. The reactivity of mAb H466 with a neoantigenic determinant of C3a-desArg permitted the direct quantitation of C3a-desArg without removal of C3 from the sample. The mAb H466 was used as a capture antibody and bound C3a-desArg was detected with a second peroxidase-labelled anti-C3a mAb. The lower limit of detection of C3a-desArg in this ELISA was 1 ng/ml. The C3a-desArg levels measured in the plasma samples of various patients were found to differ over a wide range. A good correlation was observed between the results obtained in the RIA and those obtained in the ELISA (r = 0.95). High levels of C3a-desArg were detected in plasma from patients with multiple trauma and patients undergoing haemodialysis. The C3a-desArg assay described should facilitate the routine quantitation of C3a in samples of plasma.

Antibodies, Monoclonal↗
PubMed1984

Post-traumatic insulin resistance in uninjured forearm tissue.

Insulin resistance is a hallmark of post-traumatic metabolism. The mechanism and site of this resistance, however, have not been elucidated. To further define the site of this abnormality, glucose uptake across the uninjured forearm was measured in conjunction with hyperinsulinemic glucose clamp studies in 21 normals and 5 patients with multiple trauma. Under these conditions, glucose infused approximates whole body glucose disposal (M, milligrams/kilogram/min). Forearm glucose flux (Q, milligrams/100 ml tissue/min) is the product of blood flow and arterial-deep venous glucose difference (A-DV). In the basal, unperturbed state forearm glucose uptake (Q) was significantly lower in the patients (0.01 +/- 0.04 mg/100 ml/min) than in the normals (0.06 +/- 0.02) and not significantly different from zero. Basal serum insulin in patients (17 +/- 3 microU/ml) was significantly greater than controls (11 +/- 1). During steady-state conditions of euglycemia and hyperinsulinemia, forearm glucose uptake in the patients (0.36 +/- 0.18 mg/100 ml/min was not significantly different from the basal value. At comparable serum insulin levels in controls, forearm glucose uptake was approximately three times that of the injured patients. This is the first in vivo confirmation of the hypothesis that post-traumatic insulin resistance occurs in uninjured forearm tissue, primarily skeletal muscle. Diminished forearm glucose uptake is present in the resting basal state and cannot be overcome by increasing insulin concentrations.

Adult↗
PubMed1989

Monokine depression of bile flow in the isolated perfused rat liver.

Multiple system organ failure (MSOF) is a progressive dysfunction of vital organs that may develop in clinical settings such as sepsis or multiple trauma. One component of this syndrome is cholestasis and impaired liver function. The mechanism(s) for this liver failure (and the failure of other organs) remains obscure. Macrophages and Kupffer cells have been shown to secrete cytokines such as interleukin-1 and tumor necrosis factor. These cytokines mediate many aspects of the acute phase response, and they also can produce cellular injury. The purpose of this study was to evaluate the effects of a semipurified murine monokine preparation having interleukin-1 activity on bile flow in the rat isolated perfused liver (IPL). The monokine preparation produced a significant reduction of bile flow in the IPL system. The effect could not be explained by a venoocclusive phenomenon or residual endotoxin in the monokine preparation. We conclude that a semipurified monokine preparation having interleukin-1 but not tumor necrosis activity produced a significant depression of bile flow in the IPL, and we suggest that macrophage secretory product(s) may be responsible for the cholestasis in MSOF.

Animals↗
PubMed1986

Unsuspected intraperitoneal rupture of bladder presenting with abdominal free air.

We present a case of intraperitoneal rupture of the bladder discovered during exploratory laparotomy for abdominal free air associated with an indwelling Foley catheter found in the peritoneal cavity. This report emphasizes the need for systematic and thorough evaluation of the genitourinary tract in the patient with multiple trauma.

Aged↗
PubMed1988

Post-traumatic stress disorder: a reaction to state-supported child abuse and neglect.

The policy of apartheid not only fosters conditions conducive to child abuse and neglect, but is in itself abusive. Apartheid policies have led to civil unrest and high levels of violence in South Africa's black townships. Many youth are thus exposed to multiple trauma including witnessing death, being arrested, being beaten, being in exile, and being separated from family and friends. This had led many to develop Post Traumatic Stress Syndrome (PTSD) although this term is a misnomer in the South African context as traumatic stress is not historic but is current. Treatment programs have thus to be modified to accommodate the impossibility of guaranteeing even the physical safety of patients. They have also to be modified to accommodate the fact that most black youth are totally unfamiliar with the notion of the "talking cure." This paper describes a modified treatment program for PTSD which was developed in working with a group of 60 township refugees. Systematic follow up studies of its effectiveness were impossible as many of those treated have gone into hiding to escape the continuing violence in their communities, a violence facilitated by the ultimate guardian of the child, the State. However there are indications that the program was successful in providing immediate relief.

Adaptation, Psychological↗
PubMed1980

The role of computed tomography in acute head injury.

Computed tomography (CT) of the head provides the ability to rapidly evaluate patients with acute head injuries. Moreover, CT aids in surgical planning, prognosticating outcome and recovery time, and monitoring nonsurgical injuries. The authors review the ways in which CT is employed in a multiple trauma center.

Brain Injuries↗
PubMed1989

Proposal of a new formula to calculate total urinary nitrogen from urea urinary nitrogen.

Urea urinary nitrogen (UUN) and total urinary nitrogen (TUN) were determined in 15 patients to study their relationship mainly in highly catabolic patients. The subjects were: 7 multiple trauma, 3 autologous bone-marrow transplant, 1 tetanus, 4 postcholecystectomy patients; 180 determination were made, 111 of which in highly catabolic phase (TUN > 15 g/day). TUN and UUN are well correlated (r = 0.9742; p < 0.001) in the range 3 to 52 g/ day of TUN. Urea represents the 83.2 +/- 9.4% (M +/- SD). A double-linear formula to calculate TUN from UUN is proposed (for UUN 15 g/ day: TUN = UUN x 1.17 + 0.7; for UUN > 15 g/ day: TUN = UUN + 4). The least square procedure was used to compare the differences between measured and calculated TUN, and the results obtained with the proposed double-linear formula were compared with that obtained employing pre-existing formulas (Lee's and Mackenzie's). Considering all ranges of values studied (3-52 g of TUN) the results obtained were significantly different (p < 0.005); dividing the levels of TUN in 15 g; 16-29 g and 30 g, the results were always better, but the statistical significancy was not always reached.

Journal Article↗
PubMed1991

Nitrogen and energy balance in septic and injured intensive care patients: response to parenteral nutrition.

We studied energy and nitrogen balance in 50 intensive care patients with sepsis (n = 18) or multiple trauma (n = 32). Most patients were mechanically ventilated during the study. Within 72h of admission the patients were randomised to receive one of 5 infusion regimens for 48h (group n = 9-11). The control group received hypocaloric glucose, two groups received 1.5g/kg/day of amino-acids, either with hypocaloric glucose on both days or with energy adjusted to pre-nutrition REE on the second day. The fourth group received 0.6g/kg/day of amino-acids and energy at REE, and the fifth group a high nitrogen (18g/day) regimen with a stepwise increase in energy intake from day 1 to day 2. Baseline REE was 118 +/- 18.9% of predicted. No significant differences in REE were observed between the diagnostic groups, treatments or measurements performed during mechanical or spontaneous ventilation. Nitrogen balance in the control group was -250.3 +/- 83.3 mg/kg on day 1 and 218.6 +/- 95.3 mg/kg on day 2. Nitrogen balance remained negative in all groups throughout the study (range of group means-218.6 to -48.5 mg/kg/day). Increasing energy intake equal to prenutrition REE at an amino-acid dosage of 1.5g/kg/day decreased the negative nitrogen balance by 66%. Further increase in energy balance had only a marginal effect on nitrogen balance.

Journal Article↗
PubMed1995

Psychological responses to war and atrocity: the limitations of current concepts.

Because of the prevalence of wars, political violence and other forms of man-made disaster in Third World countries many individuals and communities suffer prolonged and often multiple traumas. In Western psychiatry certain conceptions of the response to violence and trauma have been developed, including the widely used category of post-traumatic stress disorder (PTSD). We argue that because concepts such as PTSD implicitly endorse a Western ontology and value system, their use in non-Western groups should be, atmost, tentative.

Adaptation, Psychological↗
PubMed1984

Stress ulcers in intensive care (etiology, symptomatology and therapy).

The authors present a group of 48 patients with stress ulcers (36 men, 13 women) average age 56.2 years. The analysis of the cases allowed to establish, for the first time in medical literature, a correlation between the etiology, the symptomatology and the moment of onset of the haemorrhage, with important practical implications in the adoption of a treatment regime. These considerations permitted us to delineate four categories of stress ulcers: The first category included stress ulcers caused by a cerebral lesion and manifested through cerebral hypertension. The upper digestive haemorrhage occurred within 24-48 h after the aggression and required the correction of the cerebral hypertension and of the anaemia. The second category comprised stress ulcers brought about by a hypovolaemic shock through myocardial infarction, burns, frost-bite and multiple traumas. Haemorrhage in the upper digestive tract appeared within 3-6 days after the moment of aggression and required surgical control unless it was caused by myocardial infarction. The third category was represented by post-operative stress ulcers. These forms occurred usually late, between the eighth and the thirty-seventh day after the aggression, and were due to the super-imposition of the septicaemia on the post-aggressive systemic reaction. The chief aim of treatment here was the surgical control of infection. The fourth category encompassed the stress ulcers occurring after protracted coma, especially in patients with ventilatory assistance. In these conditions, the ulcers of the digestive tract and the consequent haemorrhage represented terminal elements of irreversible diseases, in which no treatment was effective.

Adult↗
PubMed1995

Phantom limb pain: are cutaneous nociceptors and spinothalamic neurons involved in the signaling and maintenance of spontaneous and touch-evoked pain? A case report.

A patient suffered multiple fractures of the right leg and a left brain-stem infarction involving the anterolateral fasciculus of the central nociceptive system following multiple trauma. Later, the right leg was amputated, resulting in spontaneous and touch-evoked phantom pain and mechanical stump allodynia. However, quantitative sensory testing revealed considerable impairment of sensations normally mediated by cutaneous nociceptors and central spinothalamic systems on the right body side, including the stump but nearly intact touch and vibration senses. Quantitative assessment of peripheral nociceptive C-fiber function (axon reflex vasodilatation and flare) showed no abnormalities on both sides. Sympathetic blocks did not change spontaneous and evoked pain. Epidural and spinal anesthesia abolished evoked pain but had no effect on spontaneous phantom pain. Extirpation of a neuroma of the sciatic nerve did not alter spontaneous and evoked pain. TENS resulted in an increase in pain. We concluded the following. (i) Painful somatosensory memories that are responsible for phantom limb pain are located in the brain, most probably in the thalamus or cortex. (ii) Touch-evoked phantom pain and stump allodynia are not mediated by cutaneous nociceptive C and A delta fibers and spinal nociceptive pathways (spinothalamic tract). Activity in the lemniscal system (low-threshold mechanoreceptive A beta afferents, dorsal columns and medial lemnicus system) may be transferred to central pain signaling neurons in the thalamus or cortex resulting in touch-evoked pain sensations. (iii) Ongoing activity in cutaneous nociceptive C fibers and spinal nociceptive systems is not necessary to maintain central processes that account for spontaneous and touch-evoked pain sensations. Activity in nociceptors of deep somatic tissues might be more important.

Amputation Stumps↗