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PubMed1996

Adjuvant recombinant human growth hormone does not augment endogenous glucose production in total parenteral nutrition-fed multiple trauma patients.

Hyperglycemia and insulin resistance are well-known, consistent responses to severe injury. The purpose of this study was to investigate the mechanism for the further exaggerated hyperglycemia due to adjuvant recombinant human growth hormone (rhGH) treatment in multiple trauma patients. We have measured in 20 adult severely injured, highly catabolic, hypermetabolic multiple trauma patients, the glucose kinetics (appearance, clearance, oxidation, and recycling) once in the basal state (study I), 48 to 60 hours after injury but before starting nutritional therapy, and again (study II) after 7 days of intravenous nutrition (1.1 times resting energy expenditure, 250 mg nitrogen [N]/kg/d) with or without adjuvant rhGH. Group H (n = 10) randomly received daily (8 AM) rhGH (0.15 mg/kg/d) and group C (n = 10) received the vehicle of infusion. Adjuvant rhGH treatment in intravenously fed trauma patients (1) increases plasma insulin-like growth factor-1 (IGF-1) and insulin concentrations, (2) improves N balance, and (3) exaggerates the hyperglycemic response without affecting endogenous glucose output, glucose oxidation, or recycling. The mechanism for the hyperglycemic hyperinsulinemia in trauma may be due to a defective nonoxidative glucose disposal, as well as inhibition of glucose transport activity into tissue cells.

Adjuvants, Pharmaceutic↗
PubMed1995

Ancrod as prophylaxis or treatment for thromboembolism in patients with multiple trauma.

OBJECTIVE: To report the initial clinical experience with fibrinogen depletion using ancrod as prophylaxis and treatment for deep vein thrombosis and pulmonary embolism (DVT/PE) in patients with multiple trauma. DESIGN: A series of cases, selected because of their extreme risk of DVT/PE or because of the appearance of thromboembolic complications despite prophylaxis using conventional methods. SETTING: University teaching hospital. PATIENTS: A referred sample comprising 30 patients with multiple blunt trauma. The mean injury severity score was 30. Most cases involved a combination of lower extremity, pelvic and chest injuries. INTERVENTIONS: Fibrinogen was slowly depleted over 24 to 36 hours and the concentration maintained at 0.2 to 0.5 g/L thereafter. Ancrod was continued prophylactically (22 patients) or for established DVT/PE (8 patients) until the patients were mobilized or until there was no longer a contraindication to heparin, or until treatment with warfarin became practical. MAIN OUTCOME MEASURE: Monitoring for DVT by duplex ultrasonography or iodine-125-labelled-fibrinogen scanning, whichever could be applied. RESULTS: Twenty patients were treated with ancrod for prophylaxis from the outset because it offered theoretic and practical benefits over other methods. No patient treated with ancrod for prophylaxis suffered a clinically significant DVT/PE. Patients in whom heparin prophylaxis failed and who experienced thromboembolic complications were effectively managed with ancrod. There were no deaths and no bleeding complications specifically due to the therapy. CONCLUSIONS: Slow depletion of fibrinogen with ancrod may provide a safe and effective means to prevent DVT/PE in multiple trauma patients or to treat DVT/PE when the risk of bleeding from heparin is great. This initial experience should be evaluated by a randomized controlled trial.

Adolescent↗
PubMed2002

Using the SF-36 for characterizing outcome after multiple trauma involving head injury.

BACKGROUND: The purpose of this study was to evaluate the validity of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) for examining outcomes after multiple trauma and to investigate whether the addition of items selected to measure cognitive function could improve the sensitivity of the SF-36 for identifying differences in outcomes for patients with and without head injury. METHODS: One thousand two hundred thirty patients discharged from 12 trauma centers were interviewed 1 year after injury. The interview included the SF-36 supplemented with four items chosen to assess cognitive function. RESULTS: The resulting cognitive function scale is internally consistent and measures a component of health that is independent of the dimensions incorporated in the SF-36. It correlates well with established measures of brain injury severity and discriminates among patients with and without brain injury. CONCLUSION: This study underscores the need to supplement the SF-36 with a measure of cognitive function when evaluating outcome from multiple trauma involving head injury. Further studies are needed to validate the specific items chosen for measuring cognitive function.

Adult↗
PubMed2006

Correlation of procalcitonin and C-reactive protein to inflammation, complications, and outcome during the intensive care unit course of multiple-trauma patients.

BACKGROUND: A comparison of the amount of and the kinetics of induction of procalcitonin (PCT) with that of C-reactive protein (CRP) during various types of and severities of multiple trauma, and their relation to trauma-related complications, was performed. METHODS: Ninety adult trauma patients admitted to the intensive care unit of our tertiary care hospital were evaluated in a prospective case study. During the initial 24 hours after trauma the Injury Severity Score, the Sepsis-related Organ Failure Assessment score, and the Acute Physiology and Chronic Health Evaluation II score were evaluated. PCT, CRP, the sepsis criteria (American College of Chest Physicians/Society of Critical Care Medicine definitions), and the Sepsis-related Organ Failure Assessment score were measured at days 1-7, as well as at days 14 and 21, concluding the observation period with the 28-day survival. RESULTS: The induction of PCT and CRP varied in patients suffering from trauma. PCT increased only moderately in most patients and peaked at day 1-2 after trauma, the concentrations rapidly declining thereafter. CRP ubiquitously increased and its kinetics were much slower. Complications such as sepsis, infection, blood transfusion, prolonged intensive care unit treatment, and poor outcome were more frequent in patients with initially high PCT (>1 ng/ml), whereas increases of CRP showed no positive correlation. CONCLUSION: In patients with multiple trauma due to an accident, the PCT level provides more information than the CRP level since only moderate amounts of PCT are induced, and higher concentrations correlate with more severe trauma and a higher frequency of various complications, including sepsis and infection. Most importantly, the moderate trauma-related increase of PCT and the rapidly declining concentrations provide a baseline value near to the normal range at an earlier time frame than for CRP, thus allowing a faster and more valid prediction of sepsis during the early period after trauma.

APACHE↗
PubMed1996

Effect of lung contusion on surfactant composition in multiple-trauma patients.

OBJECTIVE: The aim of this study was to investigate alterations of the surfactant system in multiple-trauma patients (MTP) with lung contusion and the influence of single- or multiple-organ dysfunction syndrome (OF/MOF) on the surfactant system. SETTING: University hospital, trauma-intensive care unit. DESIGN: Prospective, nonrandomized study. METHODS: MTP with an Injury Severity Score > 19 points have been recorded prospectively since 1992. Bronchoalveolar lavages were obtained daily either until day 14 or extubation. Three groups of MTP were compared: noL: MTP, no lung contusion (n = 14); LuCo-: MTP, lung contusion, no OF/MOF (n = 17); LuCo+: MTP, lung contusion, with OF/MOF (n = 10). Also, surfactant samples of 11 healthy volunteers (Con) were investigated and compared with MTP. All data were presented as mean +/- SEM. Statistical analysis were performed using programs of SPSS 6.0.1. (univariate ANOVA, Fisher's Exact Test, p < = 0.05). RESULTS: There were no differences in sex and age. Injury Severity Score was significantly impaired in group LuCo+ (44 +/- 4), compared with groups noL (31 +/- 3) and LuCo- (34 +/- 3). Group noL showed no statistical differences for lung function, total protein, and total phospholipid content of the bronchoalveolar lavage compared with group LuCo-. Furthermore, the relative content of phosphatidylcholine and phosphatidylglycerol in total phospholipids and surfactant-associated protein A were not significantly altered compared with group LuCo-. Lung function in group LuCo+ was significantly impaired and led to hypoxemia on the day of trauma. Total protein content and total phospholipids were significantly elevated in group LuCo+ compared with groups noL and LuCo- on the first day. Also, the relative content of phosphatidylcholine was significantly increased in group LuCo+ up to day 4, compared with groups noL and LuCo-. In comparison with groups noL and LuCo-, a significant decrease of the relative content of phosphatidylglycerol was obtained in group LuCo+ up to day 7. The surfactant-associated protein A was increased in group LuCo+ during the whole observation time, compared with the other groups. CONCLUSIONS: Multiple trauma leads to alterations in the surfactant system. The composition of surfactant was not further influenced by lung contusion alone. Only MTP with OF/MOF during the intensive care unit treatment showed significant alterations in surfactant composition and a decrease in lung function.

Adolescent↗
PubMed1995

Beta-endorphin in multiple trauma victims.

BACKGROUND: In animals and in humans, stress is known to be accompanied by increased beta-endorphin secretion. METHODS: Blood samples from 47 patients in a state of stress induced by multiple trauma were assessed for beta-endorphin concentration by radioimmunoassays. RESULTS: We show that there is a clearcut correlation (Spearman's R = 0.72, P = 2.1 x 10(-6) between the level of consciousness evaluated with the Glasgow score and levels of circulating beta-endorphin. In addition, beta-endorphin levels are higher than normal in patients with Glasgow coma with scores higher than seven, and lower than normal in those with Glasgow coma scores of seven or less. Finally, in the complete absence of stress (shown by the lack of brain activity in six irreversible coma patients), there is a severe drop in the level of circulating beta-endorphin. CONCLUSION: beta-endorphin serum levels correlate with the state of consciousness of multiple trauma patients.

Adult↗
PubMed1999

[The indications and controversies for the use of corticosteroids in respiratory deficits in the multiple-trauma patient].

The rational use of corticosteroids in terms of doses, timing and methods of administration, has proved useful in management of the effects of morbidity and mortality in respiratory insufficiency in multiple trauma patients. MPSS (methyl prednisone sodium succinate) is the drug of choice because, compared to other steroids, it penetrates lung tissue more easily (as demonstrated using autoradiographic techniques). The effect of reducing permeability, shown by MPSS, is more marked in the first 6 hours, followed by a progressive diminution. For this reason, it is advisable to administer the drug every 6-8 hours, irrespective of T 1/2 (12-36 h). However, in syndromes of post-traumatic respiratory distress, corticosteroid therapy is only symptomatic, namely it reduces short term mortality, but does not influence the prognosis in the event of persistent microembolism. On the other hand, it is important not to overlook the disadvantages and possible damaging effects linked to the use of corticosteroids in multiple trauma patients. With regard to the use of "alternative" type or support treatments to corticosteroids, the lack of markers documented using atraumatic and reliable techniques hinders the development and clinical application of specific and effective antioxidising treatments. However, alongside the perfection of methods of detecting markers, among the antioxidant drugs, a decisive contribution is expected from the lazaroids or 21-aminosteroids (synthesis steroids). With powerful scavenger activity and antioxidant properties (twice those of MPSS), the lazaroids can provide more suitable solutions to the complex therapeutic problems of these patients, also because they lack glucocorticoid and mineralocorticoid activity.

Adrenal Cortex Hormones↗
PubMed1989

Families in crisis due to multiple trauma.

The key to effective management of patients and families with multiple trauma is an early assessment of family system structure, relationship process, and function. Immediate management through the application of a firm knowledge base incorporating family systems principles can enhance existing family strengths and target potential dysfunction early in the crisis. Trauma nurses are in key, pivotal positions to identify functional and/or dysfunctional family adaptation and to intervene accordingly. Incorporation of patient and family issues into family care plans should lead to increased participatory care and greater ease in transition for patient and family through subsequent stages of recovery.

Adaptation, Psychological↗
PubMed1989

Complications of multiple trauma.

Patients who acquire sepsis, ARDS, ARF, or MSOF subsequent to multiple trauma have a high mortality rate. The pathophysiology of these complications is complex and is thought to involve ischemia, the generation of mediators, alterations in regional perfusion, and cellular oxygen use. Because of the critical nature of the patient with these complications, nursing care requires indepth knowledge as well as competent nursing management, necessitating use of both the art and science of nursing.

Acute Kidney Injury↗
PubMed1991

[Hemopleuritis in closed thoracic injuries and multiple trauma].

In examination of 817 patients with closed chest injury and multiple trauma 57% of them were found to have obvious or latent hemopleuritis. According to the character of the primary damage and the developing pathophysiological changes, 3 forms of hemopleuritis were revealed: cardiac, pulmonary, and abdominal. A single complex of symptoms forms finally: pulmonary hypertension, venous stasis in the lungs, right-ventricular cardiac insufficiency. As a result, venous blood escapes through the lymph nodes, mainly those of the right lung, and together with the lymph flows in the dilated lymph vessels of the lungs into the pleural cavity. The differential-diagnostic signs of each form of hemopleuritis are pointed out, the prognostic criteria of their development are revealed, and the pathogenetically substantiated therapy is determined.

Abdominal Injuries↗
PubMed1990

Oxygen delivery and consumption in head-injured and multiple trauma patients.

Critically ill patients often demonstrate that whole body oxygen consumption (VO2) is dependent on oxygen delivery (DO2). In this retrospective study, the relationship of VO2 to DO2 in patients with isolated head injury (HI, n = 18) was compared to that in patients with multiple trauma (MT, n = 60) without serious head injury. Mean pulmonary capillary wedge pressure, central venous pressure, arterial PCO2, cardiac index, and oxygen delivery were significantly lower in HI, but oxygen consumption was not different in the groups. In both groups, changes in DO2 (delta DO2) within each patient were significantly correlated with changes in VO2 (delta VO2) in that same patient. This relationship was not different between the HI patients, (delta VO2 = (0.20 +/- 0.02) delta DO2), and the MT patients (delta VO2 = (0.17 +/- 0.01) delta DO2). When these groups were further divided into those with high hematocrit (greater than 32%) and low hematocrit (less than 32%), HI patients with a low hematocrit demonstrated a steeper regression slope, with 26 +/- 3% of the DO2 change being reflected in the VO2 change. This was significantly greater than the slope in HI patients with high hematocrit (13 +/- 3%) and the MT patients at high (19 +/- 2%) or low (16 +/- 2%) hematocrits. These data show a correlation between changes in oxygen delivery and consumption that is similar in both head-injury patients and multiple trauma patients without serious head injury. This relationship was greatest in head-injured patients at low hematocrit. This relationship of VO2 and DO2 in both groups suggests an influence of neurohumoral factors rather than local tissue phenomena.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Gastric tonometry in multiple trauma patients.

Splanchnic ischemia, leading to intestinal mucosal damage, is thought to be common in patients after severe trauma. The adequacy of mucosal oxygenation can indirectly be determined by gastric intramucosal pH (pHi) measurement. We prospectively examined the posttraumatic gastric pHi values in 15 multiple trauma patients. In all patients gastric pHi was measured using a tonometer via the nasogastric route. A pHi value < or = 7.32 was used to differentiate between normal and low gastric pHi. Six hours after the injury four patients showed abnormally low pHi levels. Four other patients with normal initial pHi values exhibited low pHi values during one or more of the next measuring periods. Three of these eight patients developed major complications (two, ARDS) and two of them subsequently died. The seven remaining patients never had abnormal pHi levels and all patients had an uncomplicated recovery. Although intestinal ischemia was expected to be a common condition in multiple trauma patients, no consistent pattern of abnormal pHi measurements in the direct posttraumatic course could be discovered. No correlation was found between initial pHi values (at 6 hours) and ISS, shock, and lactic acidosis or APACHE II scores on admission. It is concluded that monitoring gastric pHi is useful in severely injured patients admitted to the ICU.

Adolescent↗
PubMed2000

Epidemiologic aspects of pediatric multiple trauma in a Spanish urban population.

BACKGROUND/PURPOSE: Trauma is still the most frequent cause of mortality and disability in childhood and adolescence. An epidemiologic prospective study on children under 16 years of age with multiple trauma (MT) was conducted in a large Spanish urban university hospital over a 6-year period. METHODS: Of 1,937 children admitted at the pediatric trauma unit for musculoskeletal injuries from March 1988 until March 1994, 56 patients including 37 boys and 19 girls had MT. MT was considered when at least 2 long bones were fractured or there was a fracture of 1 long bone combined with an injury of 4 other major anatomic regions (face and neck, thorax, abdomen, or neural system). The severity of injuries was evaluated according to the modified injury severity score (MISS). RESULTS: Injury to pedestrians was the most frequent cause of MT (54%). The overall mortality rate of the series, including those children dying during transport to the hospital was 11.5%. The average MISS for the whole group was 15 (range, 5 to 59). Head trauma was the most frequent associated injury (52%), two thirds of which were considered minor injuries (Glasgow Coma Scale >15). Seventy-seven fractures were registered, 10% of which were open fractures. External fixation was the most common surgical technique among operated fractures. The average hospitalization period was 16 (median, 13; range, 1 to 150) days. Children with a MISS above 18 points showed a significant longer hospitalization period (mean, 31 +/- 45 days) as compared with those with MISS below 18 points (mean, 10 +/- 7 days; P < .05). There was a strong correlation between the MISS and both the period of hospitalization at the pediatric intensive care unit and the total length of hospital stay. CONCLUSIONS: Pedestrian accidents caused by motor vehicles in children playing at the street contributed most significantly to MT in the urban pediatric population. Special care for prevention must be taken in the age group of 6 to 10 years. Head injury was the main cause of death in children with multiple trauma. MISS was found to be a good predictor of survival and duration of hospital stay in pediatric MT.

Adolescent↗
PubMedDate not supplied

Accuracy of methods to estimate ionized and "corrected" serum calcium concentrations in critically ill multiple trauma patients receiving specialized nutrition support.

BACKGROUND: The purpose of this study was to determine the accuracy of 22 published methods to estimate serum ionized calcium (iCa) and "corrected" total serum calcium (totCa) concentrations in critically ill, multiple trauma patients. Seven of these formulas estimated iCa and 15 were directed toward predicting a "corrected" totCa. METHODS: Adult patients admitted to the trauma intensive care unit who received specialized nutrition support were consecutively recruited for study. Patients who received blood products, i.v. calcium, or therapeutic doses of heparin within 24 hours before the laboratory measurements or had a history of cancer, bone disease, parathyroid disease, hyperphosphatemia (> or = 6 mg/dL), hyperbilirubinemia (> 3.5 mg/dL), or renal failure requiring dialysis were excluded. The 22 published methods were analyzed for sensitivity, specificity, percentage false negatives, and percentage false positives for predicting hypocalcemia or hypercalcemia. RESULTS: One hundred patients were studied 4.9 +/- 3.3 days postinjury and were receiving enteral nutrition (n = 81), parenteral nutrition (n = 18), or both (n = 1) at the time of study. Twenty-one patients were hypocalcemic (iCa < or = 1.12 mmol/L) and 6 were hypercalcemic (iCa > or = 1.32 mmol/L). The mean sensitivity of the 22 methods for assessing hypocalcemia was 25% +/- 32% and the specificity was 90% +/- 18%. Although the average percentage of false positives for assessing hypocalcemia was 10% +/- 18%, the mean percentage of false negatives was inordinately high at 75% +/- 32%. The most common method for determination of "corrected" totCa concentration ["corrected" calcium = totCa + (0.8 x (4-serum albumin concentration))] had a sensitivity of only 5%. The McLean-Hastings nomogram method, the most common method for estimating serum iCa concentration, had a sensitivity of 67% but unfortunately also had a significant false-positive rate of 27%. Serum totCa correlated modestly with iCa (r2 = .334, p < .001). Those patients with a serum albumin < or = 2 g/dL (n = 43) had a significantly higher prevalence of hypocalcemia than those with a higher serum albumin concentration (37% incidence of hypocalcemia vs 10%, respectively, p < .002). CONCLUSIONS: Aberrations in calcium homeostasis are frequent (27%) in postresuscitative critically ill multiple trauma patients. Methods for predicting hypocalcemia lack sensitivity and are often associated with an unacceptable rate of false negatives. Predictive methods for estimating ionized or corrected serum concentrations should not be used. Direct measurement of serum iCa concentration is indicated for assessing calcium status for this population.

Adult↗
PubMed2003

[Clinical examination of the pelvis in patients with multiple traumas is unreliable].

BACKGROUND: The primary examination of a seriously injured patient is often done according to the Advanced Trauma Life Support concept. This concept calls for routine x-rays of the chest, pelvis and cervical spine. We have seen a tendency in Norway towards selective use of the pelvic film according to trauma mechanism and physical findings, even in patients with multiple traumas. MATERIAL AND METHODS: Four cases illustrate the risk of missing serious injuries in patients with multiple injuries if routine pelvic x-ray is omitted. A review of the literature confirms that routine pelvic x-ray may be omitted only if the patient is alert, has a negative physical pelvic examination, and no other distracting painful injuries. INTERPRETATION: Early x-ray of the pelvis should still be a routine in patients with multiple injuries, but may be omitted in patients with normal consciousness, no distracting painful injuries and no pain on examination of the pelvis.

Accidental Falls↗
PubMed2006

A novel multiple-trauma CT-scanning protocol using patient repositioning.

Emergency CT examination is considered to be a trade-off between a short scan time and the acceptance of artifacts. This study evaluates the influence of patient repositioning on artifacts and scan time. Eighty-three consecutive multiple-trauma patients were included in this prospective study. Patients were examined without repositioning (group 1, n=39) or with patient rotation to feet-first with arms raised for scanning the chest and abdomen/pelvis (group 2, n=44). The mean scan time was 21 min in group 1 and 25 min in group 2 (P=0.01). The mean repositioning time in group 2 was 8 min. Significantly, more artifacts were observed in group 1 (with a repeated scan in 7%) than in group 2 (P=0.0001). This novel multiple- trauma CT-scanning protocol with patient repositioning achieves a higher image quality with significantly fewer artifacts than without repositioning but increases scan time slightly.

Adolescent↗
PubMed1994

Selective decontamination of the digestive tract in multiple trauma patients--is there a role? Results of a prospective, double-blind, randomized trial.

OBJECTIVE: To evaluate the efficacy of the technique of selective decontamination of the digestive tract in preventing the development of secondary infection and its influence on morbidity and mortality rates in multiple trauma patients with chest injuries requiring intermittent positive-pressure ventilation. DESIGN: Prospective, double-blind, randomized study. SETTING: A multidisciplinary respiratory intensive care unit (ICU) in a 1,500-bed teaching hospital. PATIENTS: Seventy-two patients (mean Injury Severity Score of 29.5) who were intubated for > 48 hrs and remained in the ICU for > 5 days. INTERVENTIONS: Patients were randomized on admission to receive selective decontamination therapy or placebo. All patients received intravenous cefotaxime for 72 hrs and the treatment group received oral and enteral selective decontamination with amphotericin B, polymyxin E, and tobramycin (n = 39), while the placebo group received a placebo containing oral paste and enteral solution (n = 33). MEASUREMENTS: Secondary infection was determined clinically and microbiologically and surveillance cultures were monitored for gastrointestinal colonization. RESULTS: The patient groups were fully comparable for age, severity of illness, and compromising factors. There was no difference in the number of patients infected (11 treatment group vs. 11 placebo), infections (17 vs. 16) and deaths (5 vs. 3); the duration of ICU (15.5 vs. 14.2 days) and hospital stays (26.3 vs. 25.5) were also similar. Microbiological surveillance cultures confirmed effective elimination of aerobic Gram-negative bacilli, and infections in the treatment group were largely due to Staphylococcus aureus and Staphylococcus epidermidis. CONCLUSION: We have been unable to show any benefit from the use of selective decontamination of the digestive tract in the prevention of secondary infections in multiple trauma patients.

Adult↗
PubMed1999

[The clinical features of multiple-trauma patients APACHE II score system].

The clinical features of 76 multiple-trauma patients in the intensive care unit were observed with acute physiology and chronic health evaluation (APACHE II) system. The results showed that the mean value of APACHE II scores in 76 patients was 18.4; the mean duration of staying at the ICU was 91.5 hours. Six patients died in the ICU (7.9%), 13 patients were complicated with MODS (17.1%), and 10 patients developed ARDS (13.2%). As APAHCE II scores increased, the duration of the patient staying at the ICU lengthened and the mortality went up.

APACHE↗