摘要:

The effect of burn wound size on the activation of fibrinolysis, coagulation, and contact factors was analyzed in 60 thermal injury patients. Blood samples from 47 male patients and 13 female patients, (average age 37 years; range 1.5–70 years) were collected within the first 36 hours and at 5–7 days following injury. The patient population was categorized by percentage of burn (second degree and/or third degree): <20%, n = 22; 20%-40%, n = 18; <40%, n = 20. The average percentage of burn was 32% (range, 4%-95%). The mechanism of injury was by flame (25), explosion and flame (19), scald (12), electric (3), or chemicals (1). An associated inhalation injury was present in 12 patients. The overall mortality rate was 13% (8). Sepsis or serious infection occurred in 23% (14) of the patients. On admission, 83% of the patients had normal prothrombin times (PT) and activated partial thromboplastin times (APTT). However, specific hemostatic variables showed marked changes. Admission hemostatic markers that correlated with the severity of injury were: tissue-plasminogen activator (tPA), plasminogen activator inhibitor (PAI), D-dimer (D-di), plasminogen (Pig), proteins C and S (PrC and PrS), antithrombin III (ATIII), thrombin-antithrombin complex (TAT), kallikrein (Kal:c), kinin (Kin), C1 esterase inhibitor (C1lnh), and factor VII clotting and antigen (FVIkc, FVIhag). These data suggest that during the early course following burn injury, thrombogenicity is increased (TAT↑) because of a decrease in ATIII, PrC, and PrS; and fibrinolysis activation (D-di↓) occurs via an increase in tPA with a p value increase in PAI. C1lnh levels were depressed in all groups and may have contributed in part to post-burn fluid sequestration. This study determined that following thermal injury, there is an activation of thrombotic and fibrinolytic mechanisms and that the severity of these abnormalities increases with the severity of injury. The ATIII abnormalities provided the most significant correlation with the clinical status of the patient (p≤ 0.0001). All hemostatic markers, which had a greater sensitivity than the global markers of coagulation, revealed abnormalities, which resolved in the majority of patients by day 7 when given routine resuscitative treatment unless complications developed.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Untreated flow-dependent oxygen consumption (Vo2) has recently been implicated as an unrecognized risk factor for multiple organ failure (MOF). We therefore prospectively studied 39 severely injured patients with known risk factors for multiple organ failure who were subjected to an established resuscitation protocol aimed at maximizing oxygen delivery (Do2> 600 mL/min·m2) to attain a Vo2goal of >150 mL/min·m2. Fifteen (38%) of these high risk patients did not meet this Vo2goal by 12 hours. These nonresponding patients had significantly elevated lactate levels, suggesting defective aerobic metabolism. Of note, this blunted Vo2response despite maximal efforts to enhance peripheral oxygen availability predicted MOF. These data serve to reemphasize the importance of the initial shock insult in causing or priming the host for the development of late MOF.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

In an attempt to identify a group of blunt trauma victims with asymptomatic myocardial contusion (MC) who do not benefit from intensive cardiac monitoring, we prospectively divided 336 patients admitted to the SICU with possible MC following blunt trauma in the 6 years prior to January 1990 into three groups: Group 1 (n = 155, age 30.5 ± 9 years) consisted of those patients admitted for mechanism of injury, J-point elevation, with or without minor chest injury. None developed arrhythmias. Their SICU length of stay (LOS) was 2.41 ± 0.77 days. Group 2 (n = 43, age 31.5 ± 10 years) patients had the same admission criteria as the patients in group 1 plus an abnormal emergency department ECG, i.e., arrhythmia, heart block, ischemia. None had cardiac complications. Their SICU LOS was 2.47 ± 0.94 days. Group 3 (n = 138, age 40 ± 20 years) patients had four or more rib fxs, a pulmonary contusion, a flail chest, or extra-thoracic injuries or were greater than 60 years of age. All required SICU admission for their non-cardiac injuries. Nineteen patients had cardiac complications requiring treatment. None had a cardiac death. Their SICU LOS was 10 ± 22 days. We conclude that young patients with minor blunt thoracic trauma and a normal or minimally abnormal ECG do not benefit from cardiac monitoring.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

One hundred five (70%) of 151 patients hospitalized in the intensive care unit and undergoing mechanical ventilation had bronchial secretions that tested positive for interleukin-8 within 36 hours of admission. Arterial blood, mixed venous blood, and urine collected simultaneously all tested negative, except for 11 patients admitted with intra-abdominal septic foci. The presence of interleukin-8 in the pulmonary air space early in the course of hospitalization was significantly associated with patients with multiple injuries, the need for greater ventilatory support, the occurrence of pulmonary dysfunction, and a 66% incidence of nosocomial bacterial pneumonia. We conclude that the early local production of interleukin-8 in the lungs is an early marker of pulmonary injury and may be involved in the pathogenesis of nosocomial bacterial pneumonia.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Severe head injury often causes an increase in intracranial pressure (ICP) and decreases in cerebral blood flow (CBF) and cerebral oxygen delivery (co2del). To determine if this reduction in CBF and co2del would produce cerebral ischemia and if this reduction would be abrogated by maintaining global cerebral perfusion pressure (CPP), we studied CPP, ICP, CBF, co2del, cerebral oxygen extraction ratio (co2ER), and cortical water content (CWC) in a porcine model of focal cryogenic brain injury. Fifteen mature swine were randomized to two groups. The experimental group (n = 7) had a brain lesion and was studied for 24 hours. The control group (n = 8) was instrumented only. Cryogenic injury significantly increased ICP and decreased CBF and co2del compared with controls. There were no significant differences in CPP between the groups for the entire experiment, and the CPP was well above the ischemic threshold. The co2ER significantly increased in the first three hours after brain injury. However, co2ER in experimental animals tended to decrease 12 hours after brain injury and was not significantly different from that in controls. Cryogenic injury significantly increased the CWC in the lesioned hemisphere. These data indicate that focal brain injury results in persistent ischemia despite the normalization of CPP, suggesting that a significant increase in cerebral vascular resistance (CVR) occurs after brain injury. We conclude that in addition to maintenance of CPP, intervention to reduce CVR may be important in the management of brain injury.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

The treatment of hypothermia associated with hemorrhage, exposure, or intraoperative intervention continues to represent a challenge for trauma care teams. An innovative technique for combining microwave heating with continuous temperature monitoring into a feedback-controlled system for blood warming has been developed. The effect of microwave warming on the structure and function of blood was compared with that in nonheated controls. Erythrocyte structural integrity (hemolysis) was evaluated by comparing levels of lactate dehydrogenase (LDH), potassium (K+), and plasma hemoglobin (PHGB), and hematocrit (HCT) in heated and nonheated (control) samples of banked red blood cells. Hemoglobin function was evaluated in fresh blood by comparing the P50and hemoglobin electrophoresis of experimental and control samples. Prewarming temperatures were 3° or 23°C; temperatures after warming were 35°, 37°, or 39°C. The results reflect the percentage of changes for 84 heated and 24 unheated blood samples. There were no statistical differences in any of the biochemical variables measured. The P50for three heated and three unheated samples was 30.7 ±1.2 and 30.5 ± 0.9 mm Hg (p> 0.05). There were no changes in the hemoglobin electrophoretic patterns in experimental or control samples. This system is designed to deliver microwave energy in a uniform and controlled manner, overcoming the limitations of conventional microwave ovens that in the past caused local overheating and subsequent hemolysis when used for blood warming. The structural and functional integrity of erythrocytes after microwave warming indicate the safety and effectiveness of this technique.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

This study was performed to determine if prolonged mechanical ventilation (MV) could be predicted by objective clinical variables present at 48 hours after MV was instituted. During a 3-month period, 49 (54%) of 91 mechanically ventilated surgical intensive care unit patients required MV for 2 or more days. Twelve (24%) of these patients died. Patients requiring 2–13 days of MV had significantly lower alveolar-arterial oxygen gradients (PAO2— Pao2), PEEP, and Fio2on MV day 2 compared with patients with MV ≥14 days. PAO2- Pao2>175 mm Hg on day 2 in patients without chronic obstructive pulmonary disease (COPD) was 60% sensitive and 91% specific for MV ≥14 days. In survivors, a day-2 PAO2- Pao2≥175 mm Hg (without COPD) or a GCS score ≤9 had a 91% positive predictive value and a 96% negative predictive value for MV ≥14 days. We conclude that mechanical ventilation for 14 or more days can be accurately predicted at 48 hours after the institution of ventilatory support by these objective criteria.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Penetrating trauma to the intrathoracic abdomen is a difficult clinical problem, especially with reference to the detection of diaphragmatic injuries. A retrospective analysis of 657 laparotomies for penetrating abdominal trauma at our institution revealed 78 laparotomies with negative results. The majority (44.8%) were for wounds in the lower chest and upper abdomen. The role of laparoscopy in evaluating these difficult areas was studied in 40 (34 stab wounds and 6 gunshot injuries) patients. Fifteen stab wounds and five gunshot wounds were nonpenetrating. Laparoscopy revealed eight clinically unsuspected diaphragmatic lacerations in seven patients. Twenty patients had hemoperitoneum. Five patients with omental bleeding and abdominal wall bleeding and four with nonbleeding liver lacerations underwent nontherapeutic laparotomies. One patient with a nonbleeding liver laceration was observed successfully without laparotomy. Ten of the 20 patients with hemoperitoneum had therapeutic laparotomies. The incidence of diaphragmatic lesions discovered by laparoscopy in this series was comparable with that reported after a mandatory laparotomy for thoracoabdominal wounds. It is concluded that laparoscopy is an excellent modality for the evaluation of the intrathoracic abdomen and the diaphragm.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Since 1977, six clinical trials have been performed on the subject of routine antibiotic prophylaxis in patients requiring tube thoracostomy for trauma. No definitive conclusions have been reached regarding the efficacy of antibiotic use in this setting. The results of these clinical trials were pooled to generate an unbiased estimate of the efficacy of antibiotic prophylaxis for tube thoracostomy using the technique of meta-analysis. Meta-analysis is a statistical method for synthesizing results from separate but similar experiments, grouping them, and comparing each to the null hypothesis. Meta-analysis allows synthesis of all of the available data on antibiotic prophylaxis for tube thoracostomy to resolve the controversy surrounding this issue generated by different but similar clinical studies with conflicting results. Despite different conclusions of value when taken individually, the combined analysis does not support the null hypothesis (no effect of antibiotics). The statistical method is highly significant despite different mechanisms of injury, pathologic findings, and antibiotics employed.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID