Showing papers in "Journal of Trauma-injury Infection and Critical Care in 1998"

Analysis of upper and lower extremity peripheral nerve injuries in a population of patients with multiple injuries.

Abstract: Background: The purpose of this study was to determine the prevalence, cause, severity, and patterns of associated injuries of limb peripheral nerve injuries sustained by patients with multiple injuries seen at a regional Level 1 trauma center. Methods: Patients sustaining injuries to the radial, median, ulnar, sciatic, femoral, peroneal, or tibial nerves were identified using a prospectively collected computerized database, maintained by Sunnybrook Health Science Centre, and a detailed chart review was undertaken. Results: From a trauma population of 5,777 patients treated between January 1, 1986, and November 30, 1996, 162 patients were identified as having an injury to at least one of the peripheral nerves of interest, yielding a prevalence of 2.8%. These 162 patients sustained a total of 200 peripheral nerve injuries, 121 of which were in the upper extremity. The mean patient age was 34.6 years (SEM ± 1.1 year), and 83% of patients were male. The mean injury severity score was 23.1 (±0.90), and the mean length of hospital stay was 28 days (±1.8). Conclusions: Motor vehicles crashes predominated (46%) as the cause of injury. The most frequently injured nerve was the radial nerve (58 injuries), and in the lower limb, the peroneal nerve was most commonly injured (39 injuries). Diagnosis of a peripheral nerve injury was made within 4 days of admission to Sunnybrook Health Science Centre in 78% of the cases. Surgery was required to treat 54% of patients. Head injuries were the most common associated injury, occurring in 60% of patients. Other common associated injuries included fractures and dislocations. The present report aims to aid in identification and treatment of peripheral nerve injuries.

Geriatric falls: injury severity is high and disproportionate to mechanism.

Abstract: ObjectiveFalls are a well-known source of morbidity and mortality in the elderly. Fall-related injury severity in this group, however, is less clear, particularly as it relates to type of fall. Our purpose is to explore the relationship between mechanism of fall and both pattern and severity of inju

Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity

Abstract: Background: The coagulopathy noted in hypothermic trauma patients has been variously theorized to be caused by either enzyme inhibition, platelet alteration, or fibrinolytic processes, but no study has examined the possibility that all three processes may simultaneously contribute to coagulopathy, but are perhaps triggered at different levels of hypothermia. The purpose of this study was to determine whether, at clinically common levels of hypothermia (33.0-36.9°C), there are specific temperature levels at which coagulopathic alterations are seen in each of these processes. Methods: Of 232 consecutive adult trauma patients presenting to a Level I trauma center, 112 patients met the inclusion criteria of an Injury Severity Score of 9 or greater and time since injury of less than 2 hours. Of the included patients, 40 were normothermic and 72 were hypothermic (≥37°C, n = 40; 36.9-36°C, n = 29; 35.9-35°C, n = 20; 34.9-34°C, n = 16; 33.9-33°C, n = 7). Included patients were prospectively studied with thrombelastography adjusted to core body temperature. Additionally, PT, aPTT, platelets, CO 2 , hemoglobin, hematocrit, and Injury Severity Score were measured. Results: Analysis by multivariate analysis of variance of the relationship between coagulation and temperature demonstrated that in hypothermic trauma patients, 34°C was the critical point at which enzyme activity slowed significantly (p 0.25). Conclusions: Patients whose temperature was ≥34.0°C actually demonstrated a significant hypercoagulability. Enzyme activity slowing and decreased platelet function individually contributed to hypothermic coagulopathy in patients with core temperatures below 34.0°C. All the coagulation measures affected are part of the polymerization process of platelets and fibrin, and this process may be the mechanism by which the alteration in coagulation occurs.

Outcome after major trauma: 12-month and 18-month follow-up results from the Trauma Recovery Project.

Abstract: Background The importance of outcome after major injury has continued to gain attention in light of the ongoing development of sophisticated trauma care systems in the United States. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the 12-month and 18-month follow-ups in the TRP population and to examine the association of putative risk factors with functional outcome. Methods Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older; (2) Glasgow Coma Scale score on admission of 12 or greater; and (3) length of stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) Scale, an index sensitive to the well end of the functioning continuum (0 = death, 1.000 = optimum functioning). Follow-up at 12 months after discharge was completed for 806 patients (79%), and follow-up at 18 months was completed for 780 patients (74%). Follow-up contact at any of the study time points (6, 12, or 18 months) was achieved for 926 (88%) patients. Results The mean age was 36 +/- 14.8 years, and 70% of the patients were male; 52% were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living together. The mean Injury Severity Score was 13 +/- 8.5, with 85% blunt injuries and a mean length of stay of 7 +/- 9.2 days. QWB scores before injury reflected the norm for a healthy adult population (mean, 0.810 +/- 0.171). At the 12-month follow-up, there were very high levels of functional limitation (QWB mean score, 0.670 +/- 0.137). Only 18% of patients followed at 12 months had scores above 0.800, the norm for a healthy population. There was no improvement in functional limitation at the 18-month follow-up (QWB mean score, 0.678 +/- 0.130). The majority of patients (80%) at the 18-month follow-up continued to have QWB scores below the healthy norm of 0.800. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days were significant independent predictors of 12-month and 18-month QWB outcome. Conclusion This study demonstrates a prolonged and profound level of functional limitation after major trauma at 12-month and 18-month follow-up. This is the first report of long-term outcome based on the QWB Scale, a standardized quality-of-life measure, and provides new and provocative evidence that the magnitude of dysfunction after major injury has been underestimated. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days are significantly associated with 12-month and 18-month QWB outcome.

Outcome after Hemorrhagic Shock in Trauma Patients

Abstract: Background: It is essential to identify patients at high risk of death and complications for future studies of interventions to decrease reperfusion injury. Methods: We conducted an inception cohort study at a Level I trauma center to determine the rates and predictors of death, organ failure, and infection in trauma patients with systolic blood pressure ≤ 90 mm Hg in the field or in the emergency department. Results: Among the 208 patients with hemorrhagic shock (blood pressure ≤ 90 mm Hg), 31% died within 2 hours of emergency department arrival, 12% died between 2 and 24 hours, 11% died after 24 hours, and 46% survived. Among those who survived ≥ 24 hours, 39% developed infection and 24% developed organ failure. Increasing volume of crystalloid in the first 24 hours was strongly associated with increased mortality (p = 0.00001). Conclusion: Hemorrhage-induced hypotension in trauma patients is predictive of high mortality (54%) and morbidity. The requirement for large volumes of crystalloid was associated with increased mortality.

Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death.

Abstract: BackgroundElderly patients suffer higher mortality rates after trauma than younger patients. This increased mortality is attributable to age, preexisting disease, and complications as well as injury severity.MethodsRecords from 5,139 adult patients from a Level I trauma center were retrospectively r

Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome.

Abstract: Objective: To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS). Methods: Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H 2 O) was treated by bedside or operating room laparotomy. Results: Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11patients, eight patients (72.7%) had acidotic pHi (7.10± 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure. Conclusions: IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications.

Practice Management Guidelines for Trauma from the Eastern Association for the Surgery of Trauma

Abstract: Clinical practice guidelines are being used as a means of reducing inappropriate care, controlling geographic variations in practice patterns, and making more effective use of health care resources. Developments at the national health policy level, as well as managed care imperatives, suggest that c

Outcome after major trauma: discharge and 6-month follow-up results from the Trauma Recovery Project.

Abstract: Background: The study of both short-term and long-term outcomes after major trauma has become an increasingly important focus of injury research because of the improved survival rates attributable to the evolution of sophisticated trauma care systems. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the discharge and 6-month follow-up time points in the TRP population and to examine the association of putative risk factors with functional outcome. Methods: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older, (2) Glasgow Coma Scale score on admission of 12 or greater, and (3) length of stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) scale, a more sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Functional outcome was also measured using a standard activities of daily living (ADL) scale (range, 13 = full function to 47 = maximum dysfunction). Follow-up at 6 months after discharge was completed for 826 patients (79%). Results: The mean age was 36 ± 14.8 years; 70% of the patients were male; 52% of the patients were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living with a partner. The mean Injury Severity Score was 13 ± 8.5, with 85% blunt injuries, and a mean length of stay of 7 ± 9.2 days. QWB scores before injury reflected the norm for a healthy adult population (mean, 0.810 ± 0.171). After major trauma, QWB scores at discharge showed a significant degree of functional limitation (mean, 0.401 ± 0.045). At 6-month follow-up, QWB scores continued to show high levels of functional limitation (mean, 0.633 ± 0.122). Limitation measured using the standard ADL scale found only moderate dysfunction at discharge (mean, 30.0 ± 7.7) and at 6-month follow-up (mean, 15.0 ± 4.2). Postinjury depression, PTSD, serious extremity injury, and length of stay were significant independent predictors of 6-month QWB outcome. Conclusion: Postinjury functional limitation is a clinically significant complication in trauma patients at discharge and a 6-month follow-up. The QWB yields a more sensitive assessment of functional status than traditional ADL instruments. Postinjury depression, PTSD, serious extremity injury, and length of stay are significantly associated with 6-month QWB outcome.

Steroids and spinal cord injury : revisiting the NASCIS 2 and NASCIS 3 trials

Abstract: The National Acute Spinal Cord Injury Study (NASCIS) 2 and 3 trials are often cited as evidence that high-dose methyl-prednisolone is an efficacious intervention in the management of acute spinal cord injury. Neither of these studies convincingly demonstrate the benefit of steroids. There are concerns about the statistical analysis, randomization, and clinical end points. Even if the putative gains are statistically valid, the clinical benefits are questionable. Furthermore, the benefits of this intervention may not warrant the possible risks. This paper comments on these two clinical trials.

One hundred five penetrating cardiac injuries: a 2-year prospective evaluation.

Abstract: Objectives: To analyze the parameters measured in the field, during transport, and upon arrival of the physiologic condition of patients sustaining penetrating cardiac injuries, along with the Cardiovascular Respiratory Score (CVRS) component of the Trauma Score, the mechanism and anatomical site of injury, operative characteristics, and cardiac rhythm as predictors of outcome. We also set out to identify a set of patient characteristics that best predict mortality outcome and to correlate cardiac injury grade as determined by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) with mortality. Methods: This report was a prospective study at American College of Surgeons Level I urban trauma center. Interventions included thoracotomy, sternotomy, or both, for resuscitation and definitive repair of cardiac injury. The main outcome measures used were those parameters measuring physiologic condition of patients, CVRS, mechanism and anatomical site of injury, mortality, and grade of injury. Results: A total of 105 patients sustained penetrating cardiac injuries: 68 injuries (65%) were gunshot wounds and 37 injuries (35%) were stab wounds. The mean Injury Severity Score was 36. Of the 105 wounds, 23 wounds (22%) involved multiple-chamber injuries. The overall survival was 35 of 105 patients (33%): survival of gunshot wound victims was 11 of 68 patients (16%); survival of stab wound victims was 24 of 37 patients (65%). Emergency department thoracotomy was performed in 71 of the 105 patients (68%) with 10 survivors (14%). CVRS: 94% mortality (50 of 53) when CVRS = 0, 89% mortality (57 of 64) when CVRS = 0 to 3, and 31% mortality (12 of 39) when CVRS 4 to 11 (p < 0.001). The presence of sinus rhythm when pericardium was opened predicted survival (p < 0.001). Anatomical site of injury (injured chamber) and the presence of tamponade did not predict survival. Stepwise logistic regression analysis identified gunshot wound, exsanguination, and restoration of blood pressure as most predictive variables of mortality. AAST-OIS injury grade and mortality: grade I, 0 of 1 (0%); grade II, 1 of 2 (50%); grade III, 2 of 3 (66%); grade IV, 28 of 50 (56%); grade V, 29 of 38 (76%); grade VI, 10 of 11 (91%). Overall incidence: grades IV-VI, 99 of 105 (94%). Conclusions: Parameters measuring physiologic condition, CVRS, and mechanism of injury are significant predictors of outcome in penetrating cardiac injuries. AAST-OIS injury grades I-III are rare in penetrating cardiac trauma. AAST-OIS Injury grades IV-VI are common in penetrating cardiac trauma and accurately predict outcome.

Trauma in pregnancy: maternal and fetal outcomes.

Abstract: ObjectivePregnancy imposes significant physiologic demands that may confuse and complicate the evaluation, resuscitation, and definitive management of pregnant women who sustain trauma. Accurate prediction of fetal outcome after trauma remains elusive. The objective of this study was to characterize

Admission or Observation Is Not Necessary after a Negative Abdominal Computed Tomographic Scan in Patients with Suspected Blunt Abdominal Trauma: Results of a Prospective, Multi-institutional Trial

Abstract: Objectives: Hospitalization for observation is the current standard of practice for patients who have sustained blunt abdominal trauma and who do not require emergent operation, despite having undergone diagnostic studies that exclude the presence of an intra-abdominal injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that hospitalization will allow for the prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. The focus of this study was to determine whether hospitalization for observation is necessary after a negative diagnostic evaluation after blunt abdominal trauma, to determine the negative predictive value of abdominal computed tomographic (CT) scanning in a prospective series of patients, and to identify which patients can be safely released from the emergency department without observation or hospitalization after blunt abdominal trauma. Methods: In a prospective, multi-institutional study over 22 months at four Level I trauma centers, all patients with blunt abdominal trauma suspected by either physical examination or mechanism of injury were evaluated using the following protocol : physical examination in the emergency department, followed by abdominal CT scanning, followed by hospitalization for observation. The standardized physical examination was repeated between 4 and 8 hours. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, the need for celiotomy, and mortality. Other data collected included demographics, mechanism of injury, and findings on physical examination and abdominal CT scanning. Results: Three thousand eight hundred twenty-two consecutive patients with suspected abdominal trauma presented to the four trauma centers. Two thousand seven hundred seventy-four of these met study eligibility criteria and were prospectively enrolled. Of these, 2299 fulfilled the entire study protocol. CT scan was negative in 1,809 patients, positive for organ injury or abdominal fluid in 389 patients, and nondiagnostic in 78 patients. Abdominal tenderness or bruising was present in 1,380 patients (61%), but only 22% had a positive CT scan. Nineteen percent of patients with a positive CT scan had no tenderness. Computed tomography detected 22 of the 25 blunt intestinal injuries in this series. Free intraperitoneal fluid without solid visceral injury was present in 90 patients, and but only 7 patients had intestinal injuries. There were nine celiotomies in patients whose CT scan was initially interpreted as negative: six were therapeutic (intestine in three, bladder in one, kidney in one, and diaphragm in one), two were nontherapeutic, and one was negative. The negative predictive power of an abdominal CT scan based on the preliminary reading and as defined by the subsequent need for a celiotomy in the population fully satisfying the protocol was 99.63% (lower 95 and 99% confidence bounds of 99.31 and 99.16%, respectively). Conclusion: These data indicate that abdominal tenderness is not predictive of an abdominal injury and that patients with a negative CT scan after suspected blunt abdominal trauma do not benefit from hospital admission and prolonged observation.

Missed diaphragmatic injuries and their long-term sequelae.

Abstract: Background: Blunt or penetrating truncal traumas can result in diaphragmatic rupture or injury. Because diaphragmatic defects are difficult to diagnose, those that are missed may present with latent symptoms of obstruction of herniated viscera. Methods: A chart review of all patients admitted with late presentations of postraumatic diaphragmatic hernias from 1980 to 1996 was undertaken. Results: Ten patients with posttraumatic diaphragmatic hernias were treated in this specified period. There were six males and four females with a mean age of 65 years. Eight patients sustained blunt truncal traumas and two patients sustained penetrating truncal traumas. The hernias occurred in two patients on the right and in eight patients on the left side and contained the liver (n = 2), bowel (n = 10), stomach (n = 4), omentum (n = 5), or spleen (n = 1). The time until the hernias became clinically symptomatic ranged from 20 days to 28 years. In all but one patient, either routine chest roentgenograms or upper gastrointestinal contrast studies were diagnostic. All 10 patients underwent laparotomy (n = 9) or thoracotomy (n = 2) with direct repair of the diaphragmatic defect. One patient died 3 days after the operation, representing a mortality of 10%; the morbidity was 30%. Conclusion: Initial recognition and treatment of diaphragmatic rupture or injury is important in avoiding long-term sequelae.

In search of the optimal end points of resuscitation in trauma patients: a review.

Abstract: Complete resuscitation from shock is one of the primary concerns of the surgeon taking care of injured patients. Traditionally, the return to normalcy of blood pressure, heart rate, and urine output has been the end point of resuscitation. Using these end points may leave a substantial number of patients, up to 50 to 85% in some series, in "compensated" shock, which if it persists may ultimately lead to the death of the patient. Because of this potential other end points are being used and include supernormal values for oxygen transport variables (cardiac index, oxygen delivery, and oxygen consumption), lactate, base deficit, and gastric intramucosal pH. We believe that the current data support the use of lactate, base deficit, and/or gastric intramucosal pH as the appropriate end points of resuscitation of trauma patients. The goal should be to correct one or all of three of these markers of tissue perfusion to normal within the initial 24 hours after injury.

The End of the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS): ICISS, an International Classification of Diseases, Ninth Revision-Based Prediction Tool, Outperforms Both ISS and TRISS as Predictors of Trauma Patient Survival, Hospital Charges, and Hospital Length of Stay

Abstract: Introduction: Since their inception, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS) have been suggested as measures of the quality of trauma care. In concept, they are designed to accurately assess injury severity and predict expected outcomes. ICISS, an injury severity methodology based on International Classification of Diseases, Ninth Revision, codes, has been demonstrated to be superior to ISS and TRISS. The purpose of the present study was to compare the ability of TRISS to ICISS as predictors of survival and other outcomes of injury (hospital length of stay and hospital charges). It was our hypothesis that ICISS would outperform ISS and TRISS in each of these outcome predictions. Methods: Training data for creation of ICISS predictions were obtained from a state hospital discharge data base. Test data were obtained from a state trauma registry. ISS, TRISS, and ICISS were compared as predictors of patient survival. They were also compared as indicators of resource utilization by assessing their ability to predict patient hospital length of stay and hospital charges. Finally, a neural network was trained on the ICISS values and applied to the test data set in an effort to further improve predictive power. The techniques were compared by comparing each patient's outcome as predicted by the model to the actual outcome. Results: Seven thousand seven hundred five patients had complete data available for analysis. The ICISS was far more likely than ISS or TRISS to accurately predict every measure of outcome of injured patients tested, and the neural network further improved predictive power. Conclusion: In addition to predicting mortality, quality tools that can accurately predict resource utilization are necessary for effective trauma center quality-improvement programs. ICISS-derived predictions of survival, hospital charges, and hospital length of stay consistently outperformed those of ISS and TRISS. The neural network-augmented ICISS was even better. This and previous studies demonstrate that TRISS is a limited technique in predicting survival resource utilization. Because of the limitations of TRISS, it should be superseded by ICISS.

Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial.

Abstract: Background: Experimental and clinical work has suggested that hypertonic saline (HTS) would be better than lactated Ringer's solution (LRS) for the resuscitation of patients with head injuries. No clinical study has examined the effect of HTS infusion on intracranial pressure (ICP) and outcome in patients with head injuries. We hypothesized that HTS infusion would result in a lower ICP and fewer medical interventions to lower ICP compared with LRS. Methods/Design: Prospective, randomized clinical trial at two teaching hospitals. Results: Thirty-four patients were enrolled and were similar in age and Injury Severity Score. HTS patients had a lower admission Glasgow Coma Scale score (HTS: 4.7 ± 0.7; LRS: 6.7 ± 0.7; p = 0.057), a higher initial ICP (HTS: 16 ± 2; LRS: 11 ± 2; p = 0.06), and a higher initial mean maximum ICP (HTS: 31 ± 3; LRS: 18 ± 2; p < 0.01). Treatment effectively lowered ICP in both groups, and there was no significant difference between the groups in ICP at any time after entry. HTS patients required significantly more interventions (HTS: 31 ± 4; LRS: 11 ± 3; p < 0.01). During the study, the change in maximum ICP was positive in the LRS group but negative in the HTS group (LRS: +2 ± 3; HTS: -9 ± 4; p < 0.05). Conclusion: As a group, HTS patients had more severe head injuries. HTS and LRS used with other therapies effectively controlled the ICP. The widely held conviction that sodium administration will lead to a sustained increase in ICP is not supported by this work.

Lactated Ringer's Solution Resuscitation Causes Neutrophil Activation after Hemorrhagic Shock

Abstract: Purpose: To determine the degree of neutrophil activation caused by hemorrhagic shock and resuscitation. Methods: Awake swine underwent 15-minute 40% blood volume hemorrhage, and a 1-hour shock period, followed by resuscitation with: group I, lactated Ringer's solution (LR); group II, shed blood; and group III, 7.5% hypertonic saline (HTS). Group IV underwent sham hemorrhage and LR infusion. Neutrophil activation was measured in whole blood using flow cytometry to detect intracellular superoxide burst activity. Results: Neutrophil activation increased significantly immediately after hemorrhage, but it was greatest after resuscitation with LR (group I, 273 vs. 102%; p < 0.05). Animals that received shed blood (group II) and HTS (group III) had neutrophil activity return to baseline state after resuscitation. Group IV animals had an increase in neutrophil activation (259 vs. 129%; p < 0.05). Conclusion: Neutrophil activation occurring after LR resuscitation and LR infusion without hemorrhage, but not after resuscitation with shed blood or HTS, suggests that the neutrophil activation may be caused by LR and not by reperfusion.

Pressure-volume characteristics of the intact and disrupted pelvic retroperitoneum.

Abstract: Hemorrhage is a major cause of mortality in pelvic fractures. Bleeding can be controlled in hypotensive patients by direct ligation, angiographic embolization, pelvic packing, and acute external fixation. Acute application of an external fixator can reduce pelvic volume and reduce bleeding fractures to effect tamponade. This therapy assumes that the pelvis represents a closed space, which clearly is not true anatomically. However, the premise may hold functionally. This study explored the relationship between pressure and volume in the intact and disrupted pelvic retroperitoneum. In cadaveric specimens, the external iliac vein was dissected, ruptured, and cannulated. This method allowed controlled flow of fluid, with simultaneous measurement of pressure, into the intact retroperitoneum. Open book pelvic fractures were created by applying external rotation to the pelvis through the femoral heads. The pressure-volume measurements, without and with external fixation applied, were repeated after the fracture, as well as after a laparotomy. In the intact retroperitoneum, pressures rapidly rose to an average of 30 mm Hg after infusion of 5 liters of fluid. After fracture, up to 20 liters of fluid could be infused at pressures not exceeding 35 mm Hg. External fixation increased pressures approximately 3 mm Hg at low fluid volumes, and approximately 11 mm Hg at the highest fluid volumes. Laparotomy decreased retroperitoneal pressure from approximately 35 mm Hg to approximately 15 mm Hg. The results of the study suggest that low-pressure venous hemorrhage may be tamponaded by an external fixator, given that enough fluid volume is present in the pelvic retroperitoneum. However, external fixation may not generate sufficient pressure to stop arterial bleeding. In any case, it seems that a large volume of fluid must be lost into the pelvis before an external fixator can have much effect on retroperitoneal pressures.

Prospective Evaluation of Early Missed Injuries and the Role of Tertiary Trauma Survey

Abstract: Background: This study prospectively evaluated the prevalence, clinical significance, and contributing factors to early missed injuries and the role of tertiary survey in minimizing frequency of missed injuries in admitted trauma patients. Missed injury, clinically significant missed injury, tertiary survey, and contributing factors were defined. Tertiary survey was conducted within 24 hours. Results: Of 206 patients, 134 patients (65%) had 309 missed injuries composing 39% of all 798 injuries seen. Tertiary trauma survey detected 56% of early missed injuries and 90% of clinically significant missed injuries within 24 hours. Clinically significant missed injuries occurred in 30 patients with complications in 11 patients and death in two patients. Of 224 contributing errors, 123 errors were in clinical assessment, 83 errors were in radiology, 14 errors were patient related, and four errors were technical. The missed injury rate was significantly higher in patients with multiple injuries and in those involved in road crashes. Conclusions: Secondary trauma survey is not a definitive assessment and should be supplemented by tertiary trauma survey.

Base deficit is superior to pH in evaluating clearance of acidosis after traumatic shock.

Abstract: Objective: This study was done to evaluate the differences in base deficit (BD) clearance, pH normalization, and the occurrence of complications between survivors and nonsurvivors after trauma. Design: Concurrent data entry with retrospective review. Methods: Trauma patients meeting registry criteria from July 1990 through August 1995 with arterial blood gases performed within 1 hour of admission and admission BD ≤ -6 were included. Data was grouped by BD category (moderate, -6 to -9; severe, ≤-10). Group means ± SEM were compared with a two-tailed t test. Measurements and Main Results: Six hundred seventy-four patients met entry criteria. Survivors in both the moderate and severe BD groups had improved their BD within 4 hours and normalized their BD by 16 hours. Nonsurvivors did not improve their BD category until 8 hours (for the severe group) and 16 hours (for the moderate group) and did not normalize BD before 24 hours. The BD differences between survivors and nonsurvivors were significant at each time interval, whereas pH differences were significant at 2 hours in the moderate group and at 2, 16, and 24 hours in the severe group. Patients who failed to improve their BD > -6 had an increased frequency of adult respiratory distress syndrome, multiple organ failure, and mortality. Conclusion: Base deficit reveals differences in metabolic acidosis between survivors and nonsurvivors not shown by pH determinations and is clearly a better marker of acidosis clearance after shock.

Effects of insulin on wound healing.

Abstract: Background: Insulin plus glucose, given for 7 days to hypermetabolic burn patients, has been shown to stimulate limb protein anabolism. We hypothesized that insulin plus glucose given to burn patients would also stimulate wound healing. Methods: Six patients with burns >40% total body surface area were randomized to receive insulin or placebo in a crossover study during the healing of their first and second donor sites. Insulin treatment was titrated at 25 to 49 U/h to achieve a plasma insulin level of 400 to 900 μU/mL for 7 days. Patients receiving insulin received dextrose 50 at 20 to 50 mL/h, titrated to maintain euglycemia. Donor-site biopsies were taken at 7 days and evaluated by three observers blinded to the treatment. Results: The mean (±SD) donor-site healing time was reduced from 6.5 ± 1.0 days with placebo to 4.7 ± 1.2 days during insulin infusion (p < 0.05). Laminin showed intense staining along the basal lamina and blood vessels. Collagen type IV staining also increased after insulin therapy compared with placebo. Conclusion: Data indicate that high doses of insulin and glucose can be safely administered to massively burned patients to improve wound matrix formation.

Use of spiral computed tomography for the assessment of blunt trauma patients with potential aortic injury.

Abstract: Purpose: The purpose of this study was to prospectively examine the accuracy of contrast-enhanced spiral thoracic computed tomography (CEST-CT) for direct detection of traumatic aortic injury resulting from blunt thoracic trauma. Methods: During a 25-month period, all blunt trauma patients who had abnormal mediastinal contours on admission chest radiographs underwent CEST-CT. The presence and location of mediastinal blood and any direct signs of aortic injury, such as pseudoaneurysm, were recorded. Computed tomographic results were compared with results of aortography, when performed, surgery, or clinical status at discharge. Results: There were 7,826 patients classified as having blunt trauma admitted during the study. Of these, 1,104 (14.3%) had CEST-CT performed. Mediastinal hemorrhage was detected on 118 (10.7%) of all thoracic computed tomographic scans. Direct evidence of aortic injury was detected in 24 patients (20.3%) with mediastinal hemorrhage and 2.2% of all patients undergoing CEST-CT. In this prospective series, CEST-CT was 100% sensitive based on clinical follow-up; it was 99.7% specific, with 89% positive and 100% negative predictive values and an overall diagnostic accuracy of 99.7%. Conclusion: CEST-CT is a valuable ancillary study for the detection of traumatic aortic injury. Spiral computed tomography is accurate for the detection and localization of both hernomediastinum and direct signs of aortic injury.

Base deficit in the elderly: a marker of severe injury and death.

Abstract: Background: Base deficit has been used as a marker of significant injury and to predict resource utilization and mortality. The significance of base deficit in trauma patients 55 years and older has not been specifically evaluated. The purpose of this study was to determine the utility of base deficit in assessing older trauma patients versus a younger cohort. Methods: Data were obtained from the trauma registry on trauma patients admitted to a Level I trauma center. Arterial blood gases were obtained within 1 hour of arrival, by protocol, in 2,631 patients, and of these, 274 patients were 55 years or older. Data are presented as means ± SEM. Statistical analysis was done by paired t test, analysis of variance, and X 2 analysis. Significance was attributed to a p value < 0.05. Results: Patients older than 55 years were significantly more likely to have sustained blunt trauma (86 vs. 69%; p < 0.001). Despite similar Injury Severity Scores and base deficit values, older patients had markedly greater mortality and intensive care unit lengths of stay. A base deficit of ≤ -6 had positive predictive values for Injury Severity Scores ≥ 16 for 76% of patients younger than 55 years and 78% of patients 55 years and older. The negative predictive value of a normal base deficit for Injury Severity Scores < 16 was 60% for the younger cohort and only 40% for patients 55 years and older (p < 0.001; X 2 ). Conclusions: A base deficit of ≤ -6 is a marker of severe injury and significant mortality in all trauma patients, but it is particularly ominous in patients 55 years and older. Patients older than 55 years may have significant injuries and mortality risk without manifesting a base deficit out of the normal range.

Effect of dry fibrin sealant dressings versus gauze packing on blood loss in grade V liver injuries in resuscitated swine.

Abstract: Background: We conducted this study to determine whether the dry fibrin sealant dressing (DFSD) would stop bleeding from a grade V liver injury and to evaluate the effects of leaving the absorbable DFSD in survival animals. Methods: Twenty-four swine (40 ± 3.0 kg) received a uniform grade V liver injury and were randomized to one of four 1-hour treatment groups: (1) gauze packing, (2) DFSD, (3) immunoglobulin G placebo dressing, and (4) no treatment. All animals were resuscitated with lactated Ringer's solution. Total blood loss (TBL), mean arterial pressure, resuscitation volume, and laboratory data were monitored for 1 hour after injury. Four swine were treated with the DFSD after grade V injury and allowed to survive for 7 or 14 days. Results: The TBL was 1,104 ± 264 mL (mean ± SEM), 544 ± 104 mL, 4,223 ± 1,555 mL, and 6,026 ± 1,020 mL for groups 1, 2, 3, and 4 respectively. TBL in DFSD animals was less than that in animals treated with gauze packing (p = 0.06). Grade V injuries were uniform among the 1-hour groups, and no evidence of intrahepatic abscess, unusual adhesions, or hepatic vein, vena caval, or pulmonary thromboses were noted in the long-term survival animals. Conclusion: In this model of grade V liver injury, blood loss with the DFSD was 51% of that observed with standard gauze packing (not statistically different). Initial survival data revealed no complications attributable to the fibrin dressing. DFSD may provide simple, rapid, and definitive hemorrhage control in life-threatening liver injuries without the need for reoperation.

Rapid detection of traumatic effusion using surgeon-performed ultrasonography.

Abstract: Background: In the injured patient, rapid assessment of the thorax can yield critical information for patient management and triage. Objectives: The objectives of this prospective study were (1) to determine if experienced surgeon sonographers could successfully use a focused thoracic ultrasonographic examination to detect traumatic effusion, and (2) to compare the accuracy and efficiency of ultrasonography with supine portable chest radiography. Methods: Surgeon-sonographers performed thoracic ultrasonographic examinations on patients with blunt and penetrating torso injuries during the Advanced Trauma Life Support secondary survey. All patients also underwent portable chest radiography. Performance times for ultrasonography and chest radiography were recorded. Comparisons were made of the performance times and accuracy of both tests in detecting traumatic effusion. Results: In 360 patients, there were 40 effusions, 39 of which were detected by ultrasonography and 37 of which were detected by chest radiography. The 97.5% sensitivity and 99.7% specificity observed for thoracic ultrasonography were similar to the 92.5% sensitivity and 99.7% specificity for portable chest radiography. Performance time for ultrasonography was significantly faster than that for chest radiography (1.30 ± 0.08 vs. 14.18 ± 0.91 minutes, p < 0.0001). Conclusion: Surgeons can accurately perform and interpret a focused thoracic ultrasonographic examination to detect traumatic effusion. Surgeon-performed thoracic ultrasonography is as accurate but is significantly faster than supine portable chest radiography for the detection of traumatic effusion.

Intestinal permeability correlates with severity of injury in trauma patients.

Abstract: Background: Increased intestinal permeability (IP) and the release of toxic intraluminal materials have been implicated in the systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) observed in patients after severe trauma. Previous studies of intestinal permeability have failed to demonstrate a correlation between early measurements of IP and indicators of injury severity. This study examines the relationship between standard measures of injury severity and the early (day 1) and delayed (day 4) changes in IP. Associations between IP and the development of SIRS, MOF, and infectious complications were also studied. Methods: The metabolically inactive markers lactulose (L) and mannitol (M) were used to measure IP in 29 consecutive patients who sustained injuries that required admission to the surgical intensive care unit and in 10 healthy control subjects. Measurements were made within 24 hours of admission and on hospital day 4. Severity of injury was assessed by A Severity Characterization of Trauma (ASCOT), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Postinjury infections and parameters of SIRS and MOF were recorded. Results: The IP of healthy volunteers (L/M, 0.025 ± 0.008) was within the normal range (L/M≤ 0.03), whereas the average IP in injured patients was increased both within 24 hours (L/M, 0.139 ± 0.172) and on the fourth hospital day (L/M, 0.346 ± 0.699). No significant correlation between severity of injury and increased IP was seen within 24 hours of injury. A significant correlation was seen on hospital day 4, however, with all severity indices measured (ASCOT: r = 0.93, R 2 = 0.87, p < 0.001; TRISS: r = 0.93,R 2 = 0.87,p < 0.001; ISS: r = 0.84, R 2 = 0.70, p < 0.001; RTS: r = 0.68, R 2 = 0.47, p = 0.002; APACHE II score: r = 0.51, R 2 = 0.26, p = 0.04). Patients with markedly increased IP (L/M≥ 0.100) experienced a significant increase in the development of SIRS (83 vs. 44%;p = 0.03) and subsequent infectious complications (58 vs. 13%;p = 0.01) and showed close correlation with the multiple organ dysfunction scores (r = 0.87, R 2 = 0.76,p < 0.001). Conclusion: These observations demonstrate that the increased IP observed after trauma correlates with severity of injury only after 72 to 96 hours and not within the initial 24 hours of injury. A large increase in IP is associated with the development of SIRS, multiple organ dysfunction, and an increased incidence of infectious complications.

Cytokines and adhesion molecules in elective and accidental trauma-related ischemia/reperfusion.

Abstract: Background: The major pathophysiologic role of cytokines such as tumor necrosis factor (TNF)-α, interleukin (IL)-1, and IL-6, as well as of the (soluble) adhesion molecules ICAM-I and E-selectin, has been identified using different experimental models of ischemia/reperfusion injury. Moreover, in intensive care management, evaluation of these agents as diagnostic or prognostic tools is of great interest in ischemia/reperfusion injury caused by surgical or accidental trauma. For this reason, inflammatory mediators including those mentioned above were investigated in three different groups of surgical patients. Methods: The first group (A, n = 13) comprised patients undergoing elective limb surgery without a tourniquet The second group (B, n = 36) included patients subjected to limb surgery with a tourniquet The third group (C, n = 30) was composed of accidental trauma patients who were retrospectively divided into those with and without multiple organ dysfunction (+MOD and -MOD, respectively) as defined by the Denver Score. Serial blood samples were taken during a 5-day (elective surgery) or 14-day (accidental trauma) observation period for monitoring of cytokines and soluble adhesion molecules. The clinical course and the degree of MOD were recorded daily. Results: Only when a tourniquet was applied for a mean time of 105 minutes did elective limb surgery result in significantly increased serum levels of IL-6, IL-1ra, and IL-10 but not TNF-RII. Yet, the increase in cytokine levels was not sufficient to cause an enhanced shedding of adhesion molecules, and both soluble ICAM-I and soluble E-selectin remained unchanged in groups A and B throughout the 5-day observation period. In patients with multiple injuries (group C), all parameters increased early after trauma up to 10- to 20-fold in comparison with the elective limb surgery patients in groups A and B. When the accidental trauma patients were divided according to the Denver Score for +MOD (n = 8, mean Injury Severity Score = 33.8) and -MOD (n = 22, mean Injury Severity Score = 31.2), a clear difference became evident in serum IL-6 and IL-lra levels within the first 4 days and in serum IL-10 levels for the first 2 days after trauma, with cytokine levels being significantly higher in the +MOD patients 3 to 4 days before the onset of MOD. Although highly elevated, TNF-RII levels did not differentiate between +MOD and - MOD at any time. The increase in serum cytokine levels was associated with a remarkable expression and shedding of ICAM-I and E-selectin made obvious by significantly increased soluble serum ICAM-I levels in +MOD patients compared with the - MOD group between days 3 and 5 after trauma and increased soluble serum E-selectin levels between days 2 and 4 after trauma. Conclusion: The release of cytokines and soluble adhesion molecules into the circulation correlates well with the degree of trauma (elective surgery vs. accidental multiple trauma), depending on the extent of the associated ischemia/reperfusion injury. Both groups of mediators are also clearly related to the development of MOD in patients with multiple injuries with generalized ischemia/reperfusion injury caused by hemorrhagic shock. They may be predictive of patients at risk for MOD when measured early in the posttraumatic period

Epidemiology of childhood injury.

Abstract: A review of childhood injuries at the Wesley Guild Hospital, a component of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria, showed that 1,471 patients seen in the children's emergency room during a period of 4 years (1992-1995) were there as a result of trauma, representing 9% of all patients seen. The case notes and accident and emergency cards of 1,224 were available for review. Ages ranged from 2 months to 15 years, with a mean of 6.9 years, and 40% of the patients were between 5 and 10 years of age. More males were affected than females, with a ratio of 1.5:1. Road traffic crashes were the most common causal factor, responsible for 324 injuries (26.5%). About 90% of these were pedestrians knocked down by automobiles and motorcycles. Passengers accounted for about 10% of the cases. Falls occurred in 305 patients (25%); 229 patients fell while on level ground either playing or running, accounting for 75%. There were 122 patients (10%) with misplaced foreign bodies; about 60% of these were recovered from the ears, and 26.3% from the nostrils. Edible seeds were the most common foreign bodies, followed by beads. Injuries from bites occurred in 108 patients, with dog and snake bites taking the lead. Burns, mainly from scalding, occurred in 89 patients. Other rare injuries were knife wounds, gunshot wounds, and injuries resulting from assaults. The home was the most common site of injury (570 patients, 46.7%) followed by streets or roadways (363 patients, 29.7%); 19.5% of injuries occurred at school. The most common anatomic region affected was the head and neck, followed by the limbs. One hundred ninety-seven patients (16%) had bony fractures, femurs being the most affected bone. Head injury was seen in 104 patients, representing 8.5%, although only 17 of these injuries were severe. There were 10 cases of abdominal injury and 9 cases of chest injury, representing 0.8 and 0.7%, respectively. Wound infection occurred in 6.4% of the patients. Death occurred in 19 patients, accounting for 1.6%; 10 of these patients had severe head injuries. Road traffic injuries and burns accounted for the greatest number of complications. The findings of this study suggest that trauma is an important factor in childhood morbidity and mortality in our environment, with road traffic injuries taking the lead. Preschool pedestrian children were most commonly affected, the majority of them on errands for their parents. We believe that the majority of these injuries are preventable.