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PubMed1983

The postmortem determination of CK isozymes in the pericardial fluid in various causes of death.

The authors have studied the CK isozyme pattern in the pericardial fluid of 100 cadavers autopsied in the Anatomic Forensic Institute of Granada. The samples were classified into several groups according to the cause of death: --Multiple trauma with thoracic contusion --Pneumonia and pulmonary embolism --Mechanical asphyxia --Cranio-cerebral trauma --Acute haemorrhage --Myocardial infarction --Others. The results showed that the CK isozyme pattern of pericardial fluid provides useful postmortem information of cardiac "status", adding to the diagnostic potential of CK isozymes.

Asphyxia↗
PubMed1987

Candida vertebral osteomyelitis: report of three cases and a review of the literature.

We have recently treated three patients with Candida vertebral osteomyelitis. In each patient there was at least one characteristic prodromal condition, including trauma, multiple antibiotics following bowel surgery, and acute nonlymphocytic leukemia. All patients were treated successfully with amphotericin B. Based on our findings and a review of the literature, we would recommend a 1.0-1.2 gm total dosage of amphotericin B. Alternative therapeutic choices such as 5FC and/or ketoconazole, under specific clinical conditions, have been successfully employed. However, cure can best be confirmed by post-treatment biopsy.

Adult↗
PubMed1988

Nalbuphine analgesia in the prehospital setting.

Forty-six patients with moderate to severe pain caused by orthopedic injuries, burns, multiple trauma, or intraabdominal conditions were treated with intravenous (IV) nalbuphine hydrochloride (Nubain; DuPont Pharmaceuticals, Wilmington, DE) by paramedics before arrival at the hospital. Patients who weighed less than 60 kg received 15 mg nalbuphine, and patients weighing greater than 60 kg received 20 mg nalbuphine. Forty-one of 46 patients (89%) experienced pain relief from nalbuphine, with maximum relief occurring within 15 minutes after the administration of the drug. Two addicted patients received no pain relief. There were no untoward side effects following nalbuphine administration, and the patients' heart rates, mean arterial pressures, and respiratory rates remained constant and stable throughout the study period. Repeated assessment of the patient by paramedics in the field was not impaired by nalbuphine treatment. In summary, nalbuphine hydrochloride is a useful and safe analgesic drug for IV use by paramedics in the prehospital setting.

Adolescent↗
PubMedDate not supplied

Management of nasal bone fractures.

This review discusses treatment options for nasal fracture, a common condition due mainly to road accidents, sport injuries, and physical confrontations. Being frequently associated with multiple trauma, many broken noses are not promptly diagnosed and treated, leading to secondary nasal deformities and chronic obstructions. A description of nasal anatomy is followed by considerations on the pathogenesis of nasal fracture and its clinical assessment. Each patient's history must be recorded (cause of trauma, previous facial injuries, prior nasal deformity, or obstruction) and careful physical examination guides the choice of treatment (open vs closed reduction), its timing, and the type of anesthesia required. Adequate follow-up is essential. Manipulation under local anesthesia is an effective first-line treatment for simple nasal fractures and should become a standard practice, but any associated septal injury can be responsible for postoperative nasal deformity and obstruction so other options may need to be considered.

Fractures, Bone↗
PubMed2006

Endovascular repair of thoracic aortic tears.

BACKGROUND: Standard treatment of traumatic thoracic aortic transection (TTAT) is open repair by left thoracotomy with or without the use of partial cardiopulmonary bypass. However, open repair is associated with high rates of morbidity and mortality, particularly in multiply injured trauma patients. We reviewed our experiences of endovascular repair of acute TTAT. METHODS: Between February 2001 and February 2006, 30 patients (male 24, female 6, mean age 43 years) who had sustained severe blunt trauma with multiple injuries (mean injury severity score = 42) underwent endovascular repair for TTAT. Devices used included commercially available proximal abdominal aortic extension cuffs and thoracic stent-grafts. Either low dose or no systemic heparin was used. Arterial access was obtained by femoral-iliac cutdown (n = 19) or completely percutaneous through the femoral artery (n = 11). Mean follow-up was 11.6 months (range, 1 to 48 months). RESULTS: Technically success was achieved in 100% of patients, as determined by angiographic and computed tomographic (CT) scan exclusion of TTAT. Mean operating time was 132 minutes. Mean blood loss was 300 cm3. Three patients had complications: 1 iliac artery rupture, 1 cerebellar stroke, and 1 partial stent collapse. There were 2 perioperative deaths. There were no instances of procedure-related paralysis. Clinical and CT follow-up did not reveal evidence of endoleak, stent migration, or late pseudoaneurysm formation. CONCLUSIONS: The adaptation of commercially available stent-graft devices to treat TTAT is technically feasible, and can be performed with low rates of morbidity and mortality. The long-term durability of endovascular repair of TTAT remains unknown, but early and midterm results appear promising.

Accidents, Traffic↗
PubMed2004

Diagnostic efficacy of biochemical markers in diagnosis post-mortem of ischaemic heart disease.

In forensic medicine, there is a need for more sensitive biochemical markers for the post-mortem diagnosis of acute myocardial infarction. A study of the distribution of biochemical markers in different fluids is of great significance in post-mortem diagnosis, because their distribution depends on the location of tissue damage and release kinetics. The aim of this study is to compare the sensitivities and specificities of creatine kinase-MB (CK-MB), myoglobin and cTnI in serum and pericardial fluid for the post-mortem diagnosis of acute myocardial infarction (AMI). We studied 188 cadavers selected during 1 year from medicolegal autopsies. The groups were as follows: (1) myocardial infarction (n = 52); (2) asphyxia (n = 59); (3) multiple trauma (n = 41); (4) natural deaths excluding myocardial infarction (n = 36). We obtained statistically significant differences in pericardial fluid for all the biochemical markers, the highest levels being obtained in the group of cadavers who had died from myocardial infarction. A common factor is the high negative predictive value found in biochemical markers, which is contrary to the findings obtained in clinical practice, when the percentages of sensitivity are very high.

Adolescent↗
PubMed2005

Secondary effects of femoral instrumentation on pulmonary physiology in a standardised sheep model: what is the effect of lung contusion and reaming?

Intramedullary nailing is the treatment of choice for patients with femoral shaft fractures. However, there is an ongoing debate in multiple trauma patients with associated lung contusion when primary or secondary definitive stabilisation of the long bone fracture should be performed, as nailing is thought to play an important role in the pathogenesis of adult respiratory distress syndrome (ARDS). In a standardised sheep model, this study aimed to quantify the development of acute pulmonary endothelial changes, to assess the activation of polymorphonuclear leucocytes (PMNL) and to observe the effects on the coagulation system associated with the reamed nailing procedure. Furthermore, the effect of coexisting lung contusion in an experimental model was evaluated. The animals were randomly assigned to one of four different groups (6 animals/group). In control groups, only a sham operation (thoracotomy) was performed, whereas in study groups, lung contusion was induced prior to femoral stabilisation either by external fixation or reamed femoral nailing. Using bronchoalveolar lavage (BAL) pulmonary permeability changes were quantified and PMNL activation was assessed by chemiluminescence. Additionally PMNL diapedesis and interstitial lung oedema were determined by histological analysis. All animals were sacrificed 4 h after the start of the femoral instrumentation. Without an associated lung injury, instrumentation of the femoral canal with the reamed nailing technique induced a transient increase in pulmonary permeability. In the face of an induced lung contusion, reamed femoral nailing resulted in significant increases in PMNL activation, pulmonary permeability and interstitial lung oedema, compared with external fixation. Without pulmonary contusion, reaming of the femoral canal was associated with a transient increase in pulmonary permeability. This was exacerbated in the presence of lung contusion along with increased PMNL activation. External fixation did not provoke similar changes. The findings of this study support the view that reaming of the femoral canal should be avoided in polytrauma patients with severe chest trauma as it could act as an additional stimulus for adverse outcome. Temporary external fixation appears to be a safe method for fracture stabilisation until inflammatory and coagulatory disturbances after trauma have been normalized.

Animals↗
PubMed2005

Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures.

BACKGROUND: Risk factors for deep infection in secondary intramedullary nailing (IMN) after external fixation (EF) for open tibial fractures were investigated by multivariate analysis following univariate analyses. METHODS: Forty-two open tibial fractures were treated with secondary IMN after EF. The open tibial fractures were classified according to the criteria proposed by Gustilo et al.: type II, 11; type IIIA, 8; type IIIB, 22 and type IIIC, 1. Locked IMNs with limited reaming were performed in 27 patients, and locked IMNs without reaming in 15 patients. The following factors contributing to deep infection were selected for analysis: age, gender, Gustilo type (II or III), fracture grade by AO type (A or B+C), fracture site, existence of multiple trauma (Injury Severity Score, ISS<18 or ISS> or = 18), existence of floating knee injury, debridement time (< or = 6 h or > 6 h), reamed (R) versus unreamed (UR) nailing, duration of external fixation (< or = 3 weeks or >3 weeks), interval between removal of EF and IMN (< or = 2 weeks or >2 weeks), skin closure time (< or = 1 week or >1 week), existence of superficial infection (+ or -) and existence of pin tract infection (+ or -). The relationship between deep infection and the above factors was evaluated by univariate analyses. RESULTS: Seven (16.7%) of the 42 open tibia fractures developed deep infections. All deep infections occurred in Gustilo type III (22.6%, 7/31). Only the skin closure time was a significant factor affecting the occurrence of deep infection on the present analysis (p = 0.006). CONCLUSION: The present evaluation showed that early skin closure within 1 week is the most important factor in preventing deep infections when treating open tibial fractures with secondary IMN after EF.

Adolescent↗
PubMed2005

An enzyme-linked immunosorbent assay for human cathepsin X, a potential new inflammatory marker.

The human lysosomal cysteine-type carboxypeptidase cathepsin X is mainly present in monocytes and macrophages and may be released into the circulation due to constitutive and/or regulated secretion by (activated) immune cells. To define its potential diagnostic value as an inflammatory marker, we have developed a highly sensitive and specific sandwich-type immunoassay (ELISA) for cathepsin X permitting both intra- and extracellular detection and quantification. The dynamic range of the cathepsin X ELISA was determined to be 100 (detection limit) to 8000 pg/ml. Reproducibility of both within and between runs yielded coefficients of variation (CVs) of 2.7-3.5% and 6.3-7.3%, respectively. Cross-reactivity with other members (cathepsin B, L) of the thiol-dependent cathepsin family was not observed. The ELISA was used to quantify cathepsin X in leukocytes as well as in plasma of healthy volunteers and patients with multiple trauma. During the first 72 h after trauma, plasma levels of cathepsin X increased significantly, particularly in patients who died during the posttraumatic period. In comparison to the well-known inflammation marker neutrophil elastase, cathepsin X levels predicted survival with a higher significance in the later posttraumatic phase. In conclusion, this report provides the first evidence of cathepsin X immunoreactivity not only in cell lysates but also in plasma samples. We suggest that the newly developed highly reproducible ELISA will be of great value for further evaluation of this protease as a diagnostic and/or prognostic marker in inflammatory diseases.

Animals↗
PubMed1996

A comparison of the pathophysiologic effects of carbon dioxide, nitrous oxide, and helium pneumoperitoneum on intracranial pressure.

BACKGROUND: Previous studies have suggested that diagnostic laparoscopy may be contraindicated in multiple trauma patients with closed head injuries because of the detrimental effects of carbon dioxide (CO2) pneumoperitoneum on intracranial pressure (ICP). In this study we compared the effects of two alternative inflation gases, helium (He) and nitrous oxide (N2O), against the standard agent used in most hospitals, CO2. ICP was monitored in experimental animals both with and without a space occupying intracranial lesion designed to simulate a closed head injury. METHODS: Twenty-four domestic pigs (mean, 30 kg) were divided into four groups (6 CO2, 6 He, 6 N2O, and 6 control animals without insufflation). All animals were monitored for ICP, intraabdominal pressure, mean arterial pressure, end-tidal CO2 (ETCO2), and arterial blood gases. These parameters were measured for 30 minutes prior to introducing a pneumoperitoneum and then for 80 minutes thereafter. The measurements were repeated after artificially elevating the ICP with a balloon placed in the epidural space. RESULTS: The mean ICP increased significantly in all groups during peritoneal insufflation compared with the control group (P < 0.005). The CO2-insufflated animals also showed a significant increase in PaCO2 (P < 0.05) and ETCO2 (P < 0.05), as well as a decrease in pH (P < 0.05). After inflating the epidural balloon the ICP remained significantly higher in animals inflated with CO2 as compared with the He and N2O groups (P < 0.05). CONCLUSIONS: Peritoneal insufflation with He and N2O resulted in a significantly less increase in ICP as compared with CO2. That difference was most likely due to a metabolically mediated increase in cerebral perfusion (PaCO2) in the CO2 group. Further studies need to be conducted to determine the safety and efficacy of using He and N2O as inflation agents prior to attempting diagnostic or therapeutic laparoscopy in patients with potential closed head injuries.

Animals↗
PubMed1996

Cisapride as a treatment for gastroparesis in traumatic brain injury.

Gastroparesis is a well-documented finding among patients with severe traumatic brain injuries. The treatment of choice has been metoclopramide, but it is less than ideal given its central dopaminergic blocking activity. Cisapride is a newer prokinetic agent without side effects on the central nervous system and might be a superior treatment. The case of a healthy 22-year-old man who suffered a severe traumatic brain injury and multiple trauma in a motor vehicle accident is reported. The patient required gastrostomy tube placement but developed recurrent aspiration pneumonia once feedings were initiated. Despite receiving metoclopramide, barium studies revealed gastroparesis, a significant decrease in gastric peristalsis, and reflux. A jejunostomy tube was placed to prevent further aspiration. The administration of cisapride was begun, and 2 days later the patient was changed back to G-tube feedings with no evidence of residual aspirates. Repeat barium study showed definite improvement in peristalsis. This case demonstrates the potential usefulness of cisapride in patients with traumatic brain injury. Although further research is necessary, efficacy without central dopamine blockage may make cisapride the treatment of choice for gastroparesis and reflux in traumatic brain injury.

Adult↗
PubMed1993

Adult respiratory distress syndrome in children: associated disease, clinical course, and predictors of death.

The adult respiratory distress syndrome is a common cause of respiratory failure; however, its incidence, risk factors, course, and mortality rate for children remain incompletely understood. A 24-month surveillance of pediatric intensive care admissions identified 60 children with adult respiratory distress syndrome constituting 2.7% of such admissions, 8% of total days spent in a pediatric intensive care unit, and 33% of deaths. The mortality rate was 62% (confidence interval, 48.2% to 73.9%). Adult respiratory distress syndrome occurred in approximately 12% of children admitted for sepsis, viral pneumonia, smoke inhalation, or drowning. A low incidence (< 3%) was observed in children admitted with pulmonary contusion or multiple trauma. Ongoing changes in measures of pulmonary gas exchange varied with the magnitude of alveolar injury; no differences were associated with the underlying acute disease or lung injury mechanism. Efficiency of oxygenation differed among outcome groups by the second day after onset of adult respiratory distress syndrome. An alveolar-arterial oxygen tension difference > 420 was the best early predictor of death (sensitivity 80%, specificity 87%, positive predictive value 87%, negative predictive value 80%, and odds ratio 26.7). We conclude that adult respiratory distress syndrome behaves clinically as a single disease regardless of the underlying cause; its course and outcome are dependent on the magnitude of alveolar injury. We speculate that strategies for minimizing secondary lung injury may benefit all patients with adult respiratory distress syndrome.

Acute Disease↗
PubMed1994

Pain management and sedation in the pediatric intensive care unit.

Several situations arise in the PICU patient that require the administration of drugs for sedation and analgesia. A "cookbook" approach is impossible because of the diversity of patient and clinical scenarios. When amnesia is required, these authors prefer a continuous infusion of a benzodiazepine such as midazolam or lorazepam. Although the majority of clinical experience has been with midazolam, lorazepam either by bolus dose or continuous infusion offers a cost-effective alternative. When analgesia is required, the addition of a continuous infusion of narcotic or the use of a PCA device in the older patient should prove effective. Although fentanyl is frequently chosen, morphine is an effective and cost-effective alternative for patients with stable cardiovascular function. The synthetic narcotics are recommended for neonates, especially following cardiac surgical procedures and those at risk for pulmonary vasospasm. Narcotics may also be used for the treatment of agitation in those situations that do not necessarily require analgesia. Our clinical experience suggests that narcotics may be more effective for sedation than benzodiazepines in children less than 1 year of age. When the above agents fail to be effective or are associated with cardiovascular depression, alternatives may include ketamine or pentobarbital. Ketamine may be useful for the unstable patient or those with a bronchospastic component to their disease process. We have found pentobarbital to be effective when the combination of benzodiazepines and narcotics fails to provide the desired level of sedation. Aside from these techniques, regional anesthesia may offer a more effective means of controlling pain in the PICU patient. These techniques may be effective when parenteral narcotics are inadequate or lead to undesired effects. Although most commonly used for postoperative analgesia, their use in patients with pain from other causes (e.g., multiple trauma) may be indicated, especially when parenteral narcotics may interfere with respiratory function or the ongoing assessment of the patient's mental status.

Analgesics↗
PubMed2004

[Radiocarpal dislocation: twelve cases and a review of the literature].

PURPOSE OF THE STUDY: Radiocarpal dislocation is an uncommon entity in traumatology. Proper management depends on the type of dislocation and the presence of concomitant injury. The purpose of this study was to detail the pathogenesis of radiocarpal dislocation and describe its complications and treatment. MATERIAL AND METHODS: Twelve radiocarpal dislocations were reviewed retrospectively. Nine were associated with multiple trauma. For this review, physical examination was performed to determine the functional status, presence of pain, joint motion, and grip force. The Green and O'Brien score as modified by Cooney was used to assess function. Grip force was measured with a Jamar dynamometer and weighted by the non-dominant/dominant ratio. Dumontier and Moneim classifications were used to define different types of radiocarpal dislocation. Radiological evaluation was based on anteroposterior (ulnar and radial inclination) and lateral views of the wrist. RESULTS: Dorsal displacement was observed for nine dislocations. All were associated with fractures (eleven fractures of the lateral cuneal process and eight fractures of the styloid process). Other associated injuries were distal radioulnar dislocation and intracarpal sprains (two scapholunate and two lunotriquetral). There were three median nerve compressions which all regressed without sequelae. Ten patients were treated by styloradial osteosynthesis alone and two patients by capsule-ligament suture via an anterior approach. Pinning was used to stabilize the two lunotriquetral injuries and the one neglected radioulnar dislocation. RESULTS: At last follow-up (mean 46.2 months), the overall functional outcome was satisfactory. The Green and O'Brien (modified by Cooney) score was excellent for one patient, fair for eight, and mediocre for three (75% satisfactory results). Distal radioulnar degeneration developed in the patient who had a neglected radioulnar dislocation. Three cases of radiocarpal degeneration were observed in patients with neglected scapholunate sprains whose wrist was symptomatic at last follow-up. DISCUSSION: Radiocarpal dislocation is associated with intracarpal fracture and/or injury. Intracarpal injury must be treated in order to limit the risk of future degeneration. Pure radiocarpal dislocation (or in association with a minimal fracture of the styloid) should be treated surgically, irrespective of the approach, in order to achieve capsule-ligament suture. Other radiocarpal dislocations can be simply reduced with osteosynthesis of associated fractures. Intracarpal and/or distal radioulnar lesions must be stabilized. Osteosynthesis or capsule-ligament suture must be achieved to obtain a satisfactory clinical result.

Adult↗
PubMed1997

Physical and biological significance of peptide sequences mediating the interaction between high molecular weight kininogen and plasma prekallikrein.

HK31 (S565-K595) has previously been shown to encompass the binding domain for plasma prekallikrein (PK) within domain 6 of high molecular weight kininogen (HK). The complementary binding domain for HK within PK is mapped to PK56 (F56-G86), in the Apple 1 domain and to PK266 (K266-C295) in the Apple 4 domain. Isothermal titration calorimetry demonstrated that either PK peptide binds to HK31 in 1:1 stoichiometry. Binding of the alternate PK peptide into a ternary complex is facilitated nearly 2-fold. Fluorescence emission spectroscopy revealed that only the binding of PK56 caused a limited decrease in intrinsic tryptophane fluorescence emission intensity of HK31. We conclude that the two PK peptides bind to the HK peptide at different sites. To map the minimal sequence within HK31, truncated new peptides were tested for their ability to compete with HK for binding PK in a cell-free system. D567-T591, a 25-residue peptide which contains sufficient structural information for binding kallikrein in solution, blocked the binding of kallikrein to HK bound to endothelial cells and inhibited PK activation to kallikrein and the generation of kallikrein-activated urokinase on endothelial cell surfaces. HK-derived peptides could modulate excessive fibrinolysis and hypotension in sepsis and multiple trauma.

Amino Acid Sequence↗
PubMed1990

Southeast Alaska to Seattle emergency medical air transports: demographics, stabilization, and outcomes.

Most rural EMS aeromedical transport studies have been based on distances of less than 100 miles. No current published studies exist evaluating long-distance transports. A retrospective chart review was conducted of all patients transported from southeast Alaska to Seattle, Washington, by an intensive care air ambulance over a five-year period (1982-1986). During the study period, 442 patients were transported an average one-way distance of 703 +/- 58.9 miles. Of these, 134 had a diagnosis of major or multiple trauma and were the focus of the study. Patient demographics and medical stabilization by Alaskan physicians, the flight team, and the receiving hospital were analyzed. Injury severity and outcomes also were evaluated. Of the study group, 31% required air transport within Alaska before being seen by a physician. The flight team provided major stabilization for 11% of the trauma victims, minor stabilization for 42%, and no further stabilization for 47%. Patient flights were categorized using previously published criteria as "essential" to survival in 27% of the cases, "helpful" in 55%, and "noncontributory" in 18%. This study presents a profile of patients injured in remote areas who require stabilization by rural, often nonsurgical physicians and face long-distance transfers before reaching definitive care. Health-care systems in sparsely populated areas may use this study as a reference for comparing trauma outcomes and quality of care in long-distance air transport.

Adolescent↗
PubMed1992

Neuromuscular blockade in aeromedical airway management.

STUDY OBJECTIVE: Induction of paralysis before intubation is controversial in the aeromedical setting. We reviewed our experience using neuromuscular blockade with nurse/paramedic aeromedical teams to determine effectiveness and outcome. MATERIALS AND METHODS: In 670 flights during a 16-month period, 119 patients required endotracheal intubation aided by muscle relaxant administration. Age ranged from two months to 83 years, with a mean of 33 years. All patients were hyperventilated with 100% oxygen before intubation. Sedation was given if presenting systolic blood pressure was greater than 100 mm Hg. A short-acting depolarizing agent was then given in a 1-mg/kg dose. Once the airway was secure, a longer-acting, nondepolarizing agent and/or sedation was given. RESULTS: Of the 119 patients, 115 (96.6%) were orally intubated. Four (3.4%) required surgical airway intervention because of injuries and conditions prohibiting oral intubation. Of 115 oral intubations, 99 (86%) were achieved on the first attempt. Eight patients (7%) were intubated on a second attempt, and another eight were intubated on a third attempt. There was no change in operator. Sixty-eight percent of patients requiring airway management were multiple trauma victims with associated head injuries. There were no laryngeal injuries, detected cardiac rhythm changes, bleeding episodes, or neurologic complications despite incomplete cervical-spine evaluation. CONCLUSION: Neuromuscular blockade can be used safely and effectively in the field by experienced nurse/paramedic teams. Although problematic intubation was not eliminated, the difficulties encountered were manageable and the overall risk/benefit ratio was acceptable.

Adolescent↗
PubMed1980

Sledding injuries.

Sixty-one sledding accidents presenting to two Philadelphia-area hospitals during a three-week period were reviewed. The majority of injuries were contusions and abrasions. Eight patients required hospitalization: four had abdominal injury. One patient with multiple trauma was pronounced dead on arrival. The physics of sledding and possible mechanisms of injury are discussed.

Abdominal Injuries↗