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PubMed1983

Emergency autotransfusion.

Autotransfusion, a technique with more than 160 years of experience behind it, has become a subject of renewed interest in the emergency setting. The technique itself is not much more difficult than the tube thoracostomy or the peritoneal lavage that otherwise might be indicated in the multiple trauma victim and that would be required to start collection of autologous blood. The previously feared complications of hematologic or metabolic embarrassment and of sepsis have not proved to be of clinical significance when appropriate patient selection and careful technique are followed. In addition the use of autologous blood has a number of advantages over the transfusion of stored homologous blood in the emergency patient, including ready availability of compatible blood, homeostasis of core temperature, higher levels of red blood cell 2,3-DPG, and cost effectiveness. A review of the literature reveals that, while it is not totally free of complications, the benefits to be gained from autotransfusing the selected trauma patient outweigh the relatively limited risks of the procedure.

Blood Transfusion, Autologous↗

PubMed1984

Severity of illness and injury in pediatric air transport.

To assess severity of illness or injury in pediatric patients undergoing air transport, we prospectively evaluated 636 patients during 29 months of service. All patients were classified by age, diagnosis, and method and distance of transport. Therapeutic intervention scoring system (TISS) scores were calculated in all patients, Glasgow coma scale (GCS) scores were used in patients with altered level of consciousness, and Modified Injury Severity Scale (MISS) scores were used in patients with multiple trauma. A total of 57.5% of patients were transported by helicopter, 37.5% by fixed-wing aircraft, and 5% by ground transport. Mean distance of transport was 207 miles. Age ranged from 3 weeks to 16 years, with 45% of children under 1 year of age. Trauma (24.6%), neurologic disease (24.2%), and respiratory failure (20%) were the most common diagnoses. Eighty-one percent of patients were taken to surgery or admitted to the intensive care unit immediately on arrival at the regional children's hospital. Mean TISS score was 36.7, with 51% of patients having TISS scores greater than 30. The mean MISS score was 34.5, and 75% of patients had MISS scores greater than 25. Nineteen percent of patients had GCS scores less than or equal to 8. Overall mortality was 7%, with 9% mortality in patients with trauma versus 6.3% in nontraumatic diseases. TISS scores greater than 30, MISS scores greater than 25, and GCS scores less than or equal to 8 were associated with increased mortality (P less than .01).

Adolescent↗

PubMed1985

Diagnosis of intraperitoneal extravasation of urine by peritoneal lavage.

The diagnosis of intraperitoneal extravasation of urine in the multiple trauma patient is often delayed, resulting in increased morbidity and mortality. To determine if intraperitoneal extravasation of urine can be detected by peritoneal lavage, an animal study was designed to investigate whether urea nitrogen and creatinine levels in the urine, serum, and lavage fluid would be predictive of urinary extravasation. Seventeen adult mongrel dogs, weighing 21 to 30 kg, were divided into two groups. The six dogs in Group 1 were utilized as controls, and had peritoneal lavage (15 mL normal saline/kg) performed using the open technique (direct visualization of the peritoneum). Blood, urine and lavage urea nitrogen and creatinine and lavage red cell count were measured. Group 2 (11 dogs) had varying amounts of urine (5 mL to 330 mL) instilled into the peritoneal cavity. Diagnostic peritoneal lavage was performed 30 to 45 minutes after the instillation of urine in all Group 2 animals. Group 2A (nine dogs) had urine instilled under direct visualization through a peritoneal lavage catheter. As bladder dome rupture is the most common cause of intraperitoneal urine extravasation, Group 2B (two dogs) had bladder dome ruptures performed by cystoscopic approach using the resectoscope. Cystograms were obtained in the bladder-ruptured dogs after completion of the peritoneal lavage to confirm intraperitoneal extravasation of bladder contents. In these animals, urine was instilled back into the bladder following bladder rupture. Results demonstrate that urea nitrogen and creatinine can be measured in peritoneal lavage fluid when extravasation of urine is in amounts of 15 mL or greater, and not measurable in amounts of 5 mL or less.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1988

Decision to hospitalize: objective diagnosis-related group criteria versus clinical judgment.

Three hundred fifty patients in an observation unit attached to an emergency department received diagnostic workup of nine critical diagnostic syndromes (abdominal pain, flank pain, headache, possible cerebrovascular accident, chest pain, dizziness or syncope, head injury, seizure, multiple trauma). The decision to hospitalize for acute care after observation for 11.1 +/- 3.9 hours was examined. The objective diagnosis-related group (DRG) criteria for admission were compared retrospectively with the physician's clinical judgment of need for hospitalization. Clinical outcome was used to establish the correctness of the decision to hospitalize. Clinical judgment was compared with objective DRG criteria for reliability in predicting the presence of serious pathology necessitating acute care hospitalization; respective values were sensitivity, 100% vs 76%; specificity, 86% vs 80%; positive predictive value, 75% vs 62%; and negative predictive value, 100% vs 89%. The difference between the sensitivity of the two admission criteria was highly significant (P less than 10(-8); chi 2, 26.12). We conclude that the physician's clinical judgment outperforms DRG objective criteria in identifying which patients with critical diagnostic syndromes need acute care hospitalization for emergency medical or surgical therapy.

Decision Making↗

PubMed2000

High-velocity knee dislocation with vascular injury. Treatment principles.

A high-velocity knee dislocation is a true orthopedic emergency. A high index of suspicion is necessary to identify reduced knee dislocations in multiple trauma patients. Coexisting injuries are common in patients with high-velocity knee dislocations. After an initial assessment, the knee joint should be reduced immediately and splinted. Popliteal artery injury is common in high-velocity dislocations. Arteriograms can be helpful but should not delay operative treatment of obvious arterial injuries. Early restoration of flow to the ischemic limb will avoid amputation in most patients. The orthopedic surgeon must consider a variety of approaches when treating a patient with this type of injury. A spanning external fixator is a useful method for temporary immobilization in knee dislocation patients who have open dislocations, arterial repairs, or closed head injuries. Early surgery to improve the functional stability of the knee must be balanced against the risk of major surgery in patients with severe lower extremity and systemic injuries. The long-term risk of knee stiffness versus instability must be considered. Selective, subacute, aggressive collateral ligament repair and bicruciate reconstruction with allografts offer the best chance for optimal outcome.

Angiography↗

PubMed2000

Treatment of combined anterior cruciate ligament-posterior cruciate ligament-lateral side injuries of the knee.

ACL-PCL-posterolateral corner injuries most frequently are seen in multiple trauma patients but do occur in the athletic injury population. Acute three-ligament-injured knees may have been tibiofemoral dislocations with spontaneous reduction in the field. Careful documentation of the neurovascular status is essential in these cases to avoid the complications associated with limb ischemia. Systematic evaluation of these patients with history, physical examination, imaging studies, examination under anesthesia, and diagnostic arthroscopy will aid in the correct diagnosis and treatment plan formulation. Arthroscopically assisted, combined ACL-PCL-posterolateral complex reconstructions, using strong graft material, and performed in a timely fashion, have provided consistent and predictable results with few complications.

Anterior Cruciate Ligament↗

PubMed1998

Factors influencing the sequelae of high tension electrical injuries.

The purpose of this study was to conduct a retrospective analysis of the clinical spectrum, treatment and morbidity of the patients who have suffered high tension electrical injuries with current passage through their body (59 patients). Voltage, localization and surgical treatment seem to be the main factors influencing the lesion and the morbidity. The following points were considered: (1) Is there any relation between known factors such as voltage and the localization of the points of contact with the incidence and the type of complications and sequelae? (2) Do the observations show that wound management and the excision of dead tissues is the most adequate? From factors studied in our patients (voltage, point of entry and pathway of current, associated multiple trauma or flame burns, surgical treatment) we have found that the voltage does not have any influence on the severity of the wound nor on the percentage of sequelae (cataracts, limb amputation, neurologic complications). The current pathway, as well as its points of entry, does not show any relation with the presence of renal failure, cardiac arrhythmia and cataracts. A clear relationship between the point of entry of the current and the appearance of neurologic injury with presence of paralysis and permanent regional anaesthesia at the same level was observed. The presence of associated burns was not related to any other complications or sequelae. For those patients whose length of contact has been shorter we find a lower rate of amputations despite having associated limb fractures. Fasciotomy incisions appear to confer benefit as this series shows that this procedure decreases the rate of limb amputations.

Acute Kidney Injury↗

PubMed1999

Catecholamines in urine after death.

Noradrenaline, adrenaline and dopamine levels were measured using high-performance liquid chromatography (HPLC) and electrochemical detection and related to urine creatinine in 30 specimens from unselected autopsies. Values calculated from patients with essential hypertension were used as a reference and raised values of noradrenaline, adrenaline and dopamine were found in 76.6, 80 and 23.3%, respectively. Using the Mann-Whitney U test, there was no difference between the 11 patients with myocardial infarction and the seven who died from severe head injury or multiple trauma. The median values in mmol/mol creatinine for patients with myocardial infarction and trauma were 0.07 and 0.12 for noradrenaline and 0.012 and 0.024 for adrenaline, respectively. Physiological stress is common before death and urine noradrenaline values at autopsy overlap those found in some normal subjects and at autopsy in patients with phaeochromocytoma.

Adolescent↗

PubMed1997

Cervical prevertebral soft-tissue measurements and chest radiographic findings in acute traumatic aortic injury.

Acute traumatic aortic injury (ATAI) results in several characteristic chest radiographic findings, most notably mediastinal widening. This study was based on the hypothesis that blood or fluid in the widened mediastinum might track up into the neck and be detected on lateral cervical radiographs. In a blinded, retrospective, case-control review of radiology files, 13 consecutive adult cases of ATAI were identified and compared with 19 cases of negative aortography (NAO) and 18 multiple trauma victims (MT) without aortography. Cases with inadequate cervical films or cervical injury were excluded. Measurements included the cervical soft-tissue (ST) width at the third (C3) and sixth (C6) cervical vertebrae, mediastinal width, mediastinal-chest width ratio, and the presence of several characteristic chest radiograph findings of ATAI. The C3 ST measurements averaged 9.1 +/- 2.8 mm, 8.5 +/- 2.7 mm, and 6.9 +/- 2.2 mm for the ATAI, NAO, and MT groups, respectively. The C6 ST measurements averaged 19.2 +/- 4.5 mm, 18.6 +/- 3.9, and 16.5 +/- 3.8 mm for the ATAI, NAO, and MT groups, respectively. These cervical ST values were not significantly different between groups at either C3 (P = .188) or C6 (P = .148). The incidence of abnormal ST swelling of >7 mm at C3 was 38%, 53%, and 33% for the ATAI, NAO, and MT groups, respectively. The incidence of abnormal ST swelling of >20 mm at C6 was 54%, 42%, and 11% for the ATAI, NAO, and MT groups, respectively. Cervical ST measurements at C3 or at C6 did not correlate with mediastinal-chest width ratios. Mediastinal widening, aortopulmonic window opacification, and blurring of the aortic knob were the most sensitive chest radiography findings in ATAI, although each of these lacked useful specificity and accuracy. Cervical ST swelling is not a useful marker for ATAI.

Adult↗

PubMed1994

[Early diagnosis of traumatic extra-pericardial luxation of the heart. Value of tomodensitometry. Apropos of a case].

Heart luxation is a rare complication of chest trauma. The rupture of pericardium must be diagnosed as soon as possible, particularly before prolonged orthopaedic surgery for multitrauma, as a cardiac arrest may occur during anaesthesia. This report underlines the difficulties of diagnosis in a 40-year-old patient with head trauma, chest trauma and multiple fractures. The diagnosis was suspected on unstable blood pressure and left lung atelectasis. The computed tomography showed herniation of the left ventricle. Emergency thoracotomy showed the left rupture of pericardium with complete left heart dislocation. Orthopaedic operation was carried out three days later. Computed tomography in multitrauma patients, seems to be decisive for early diagnosis of heart luxation. Emergency thoracotomy is essential.

Adult↗

PubMed1982

[Treatment of septicemia with latamoxef. Multicentric study of 60 cases].

Sixty patients including forty two males and eighteen females, age range: 18-87 years, received antibacterial single drug treatment with latamoxef for septicemia. Forty nine patients had underlying conditions including multiple trauma, neoplasm, cardiovascular, metabolic and respiratory tract diseases. Causative pathogens were isolated in all cases. The predominant isolates were E. coli (thirty), Klebsiella pneumoniae (tent) and Enterobacter (seven). A single organism was isolated in fifty seven cases; in the other three cases two organisms were isolated from blood cultures. Mean daily dosage was 46.6 +/- 6.1 mg . kg-1 (range: 14-113 mg . kg-1). In the majority of cases (fifty two) dosage was 3 g . d-1 or less; in thirty cases it was no higher than 2 g . d-1. Duration of therapy ranged from six to thirty eight days. Serum titer was measured in many cases and latamoxef blood levels were assayed in nine patients. A satisfactory clinical response was achieved in fifty eight cases and fifty eight bacteriological cures were also obtained. There was no statistically significant difference in therapeutic response between the 2 g and 3 g daily dosage groups. Tolerance was very good; untoward effects were few and required drug discontinuation in one case only.

Adolescent↗

PubMed1983

[Evaluation of protein catabolism in multi-injured patients].

The urinary excretion of nitrogen was calculated, using the daily urinary urea nitrogen output in 19 patients with multiple trauma. The patients were followed for at least two weeks in an intensive care unit. The urinary excretion for each patient was expressed as the average of 7 day periods and the differences were evaluated with the Student's test for paired samples. Protein catabolism (defined as a urinary nitrogen excretion higher than 0.250 g per kilo and per day) was found in 18 of 19 patients during the first week, and in 16 during the second week. Catabolism was still present in 8 of 11 the third week and in 3 of 6 the fourth week after the trauma. Nitrogen excretion remained at the same level for two weeks and decreased significantly afterwards. Protein catabolism was an important contribution to weight loss. The cumulative loss of lean body mass revealed approximately 70% of weight loss over four weeks. The role of factors involved in catabolism and a therapeutic approach are discussed.

Adolescent↗

PubMed2005

[Harmonizing indications for emergency radiological examinations for adults].

INTRODUCTION: The "Collégiale des radiologistes" of the Paris public hospital system (Assistance Publique-Hôpitaux de Paris, AP-HP) has participated since 1998 in a collaborative quality improvement program for the 49 radiology departments. They work together with the AP-HP college of emergency physicians on one part of this program, which focuses on emergency radiologic work-ups. Analysis of the dysfunctions in this sector underlined the lack of agreement between clinicians and radiologists on the examinations required. OBJECTIVE: The aim of this project was to establish operational and consensual guidelines for physicians, radiologists and emergency teams for the use of diagnostic radiology in emergency situations in adults. METHOD: The working group of radiologists and emergency physicians drafted this document, largely from documentary sources. A large panel of physicians validated the draft during successive review sessions, and the two colleges then approved them. RESULTS: The guidelines are presented in 3 columns: clinical situations, quality aims (type of imaging, time within which the examination should be performed) and comments. The clinical situations were regrouped by anatomical area or system: head, neck, thorax, heart, gynecology, abdomen, urinary, non-traumatic bone and spine disorders, multiple trauma, and isolated trauma of the spine and limbs and of the head, trunk, abdomen, and pelvis. CONCLUSION: These guidelines based on consensus within the institution make it possible to harmonize the requests for and practices of radiologic examinations in emergency situations. Their implementation is an integral part of the ongoing development of operating agreements between the radiology and emergency departments.

Adult↗

PubMed2003

Clinical evidence for enteral nutritional support with glutamine: a systematic review.

OBJECTIVE: The purpose of this systematic review was to locate and assess the quality of scientific evidence to establish a graded recommendation based on the effectiveness of glutamine-enriched enteral nutrition in different medical and surgical conditions. We were concerned with the following topics: 1) benefits of enteral administration of glutamine in different pathologic conditions, and 2) dose, duration, and time of initiation of glutamine-enriched diets. METHODS: The sources consulted for the search were MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Healthstar and HSTAT. Ninety-one studies were assessed; after a methodologic review (primary review), only 16 studies met the inclusion criteria for analysis by a group of experts (secondary review). The coordinators supervised all data, and a final consensus was reached among the coordinators, experts, and methodologists. RESULTS AND CONCLUSIONS: Glutamine-enriched diets showed good overall tolerance, improvement of immunologic aspects in multiple trauma patients, cost reduction in critically ill patients, and improvement of mucositis in post-chemotherapy patients (grade B recommendations). The doses given and the duration of therapy varied widely depending on the pathologic condition. Intake of 20 to 30 g/d, early initiation of diet, and maintenance for 5 d or longer are recommended (grade C recommendations).

Critical Illness↗

PubMed2000

Heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia is a rare but complex adverse drug reaction that can produce devastating results. Treatment and clinical management of the patient requires close observation and education of the pathophysiology occurring at the cellular level. Documented cases of heparin-induced thrombocytopenia have been reported in the literature for years. This case presentation details a multiple trauma patient in whom heparin-induced thrombocytopenia developed and the effect this syndrome had on her treatment and eventual recovery.

Anticoagulants↗

PubMedDate not supplied

Use of the esophageal stethoscope in pediatric transports.

INTRODUCTION: Monitoring cardiac and respiratory function during helicopter transports can be difficult, so the authors devised a study of the esophageal stethoscope for pediatric patients. SETTING: The study was conducted at Pediflite in Tennessee, which transports between 250 to 300 pediatric patients every year. MATERIALS AND METHODS: A disposable esophageal stethoscope was used as an adjunct to other monitoring systems in intubated patients. Prior to transport, the stethoscope was placed orally by the respiratory therapist and advanced to the point where heart sounds are heard best, at which point breath sounds can also be heard clearly. The device's ear piece easily fit under the crew member's headphones, which block helicopter noise. Three sizes of stethoscope are available: a 6 French for patients 1 day to 4 years old, a 9 French for those 4 to 12 years old, and an 18 French for patients 12 years of age or older. RESULTS: The esophageal stethoscope was used in 55 patients ranging in age from newborn to 18 years. Eighteen of 55 (33%) had multiple trauma or closed head injury, and 14 of 55 (25%) suffered respiratory failure. The esophageal stethoscope proved to be easy to place, had a low risk of complications and allowed continuous access to breath sounds. In addition, the ability to hear heart tones was minimally affected by noise or vibration. CONCLUSION: Due to its ability to continuously monitor breath sounds, endotracheal tube obstruction or displacement can be rapidly detected by the esophageal stethoscope. Also, if there is failure of the cardiopulmonary monitor, heart sounds can be continuously monitored. The esophageal stethoscope is a simple but potentially valuable tool in pediatric and neonatal transports for monitoring respiratory and cardiac status.

Adolescent↗

PubMed1998

Low molecular weight heparins: current use and indications.

Thromboembolic complications are associated with significant morbidity and mortality in postoperative patients. For many years, unfractionated heparin has been used successfully in primary and secondary prophylaxis of these complications. In recent times, however, the usefulness of LMWHs has caught the attention of clinicians because of improved bioavailability, predictable anticoagulation, ease of administration, and the lack of need for monitoring anticoagulation. In clinical situations, LMWHs have been tested and proved to be safe and equipotent or supe rior when compared with unfractionated heparin or warfarin (Table 5). It is clear from clinical trials that LMWHs are superior in primary prophylaxis of DVT in orthopaedic surgical procedures, treatment of unstable angina, and in patients with multiple traumas. LMWHs were also tested and found to be an acceptable alternative to unfractionated heparin in both the primary prophylaxis of DVT in high risk general surgical procedures and in the treatment of patients with DVT and pulmonary embolism. However, the role of LMWHs in ischemic heart diseases, valvular heart diseases, postcoronary angioplasty, and vascular surgery remains to be proved. The major impact of LMWHs would be in allowing clinicians to treat PE and DVT in an outpatient setting, which would directly impact medical economics. LMWHs are associated with similar complications as unfractionated heparin is, but the complications occur less frequently. Currently, the main limitation in using LMWHs in place of unfractionated heparin or warfarin is its cost. However, taking into account the cost incurred by hospitalization and longterm monitoring of anticoagulation in patients treated with unfractionated heparin, certain trials have proved the cost of LMWHs to be the same or less than the cost of unfractionated heparin overall. We envision that LMWHs will be widely used in the future and will bring welcomed change in the treatment of thromboembolic diseases.

Ambulatory Care↗

PubMed1999

Occupational fatalities in Israel.

Occupational fatal injuries are a worldwide problem. Certain occupations pose a greater risk than others. The purpose of this study was to estimate the death rates from occupational injuries in Israel over a period of 30 months, and to examine the trends in the light of the large numbers of foreign workers who have been brought into the country in the last decade. Two-thirds of the occupational fatalities were in the construction business, mostly owing to falls from a height resulting in death from multiple trauma. About one-third of these victims were foreign workers, even though they comprise only 20% of the work force in this field. Negligible amounts of alcohol were detected in a number of cases. The construction industry is recognized worlwide as a high-risk area claiming many lives each year. The findings in this study suggest that too little attention is given to safety regulations in general, and particularly concerning foreign workers in Israel.

Journal Article↗