摘要:

Prophylactic antibiotic regimens in trauma patients may be significantly altered by large fluid shifts and hyperdynamic physiologic responses. We prospectively studied prophylactic amikacin and clindamycin in 150 abdominal trauma patients requiring laparotomy, analyzing the effects of duration of coverage, dosing interval, and dose. No difference in infection rates was noted when 72-hour coverage was compared with 24-hour coverage (19% vs. 21%). Clindamycin dosed at 1,200 mg every 12 hours achieved acceptable serum concentrations; infection rates were not significantly higher than seen with 600 mg every 6 hours (21% vs. 12%,p> 0.05). High-dose (11 mg/kg) amikacin reduced infection rates in patients with high blood loss (p< 0.025), high Injury Severity Scores (p< 0.025), and no colon penetration (p< 0.005). These data suggest that high doses are more effective than long courses of antibiotics in reducing infections in trauma patients undergoing laparotomy.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Successful management of burned patients requires effective prevention and management of infectious complications. This study reviews the incidence of fatal sepsis in our burn center and attempts to analyze factors which may predict septic mortality. From January 1, 1978, through May 31, 1988, 1,913 patients were admitted, with a mean age of 24.8 ± 0.5 years, a mean burn size of 17.7 ± 0.4% total body surface area (%TBSA), and a mean 10.1 ± 0.5% TBSA full-thickness injury. Nine per cent of patients sustained concurrent inhalation injuries. Overall mortality was 7.4%, and 1.6% of patients died from sepsis. Regression analysis showed that overall burn size, presence of inhalation injury, and the extent of full-thickness burn injury were significant independent predictors of death from sepsis, in decreasing order of relative importance. During the period 1983–1988, the incidence of septic mortality was 0.7%, which was significantly lower than the earlier half (1978–1982) of the study period (p< 0.01). These data indicate that fatal infections are becoming increasingly uncommon after thermal injury. The reasons for this decline are probably multiple, and they include the widespread practice of early excision, and improvements in fluid resusitation and the general medical care of burned patients.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. Ninety-four patients suffered blunt chest trauma; 122 patients were victims of penetrating wounds. Patients with blunt injuries had longer ventilator requirements (12.6 ± 14 days vs. 3.7 ± 7.1 days,p= 0.003), longer intensive care stays (12.2 ± 12.5 days vs. 4.1 ± 7.5 days,p= 0.001), and longer periods of TT, (6.5 ± 4.9 days vs. 5.2 ± 4.5 days,p= 0.018). Empyema occurred in six patients (3%). Residual hemothorax was found in 39 patients (18%), seven of whom required decortication. Recurrent pneumothorax developed in 51 patients (24%) and ten required repeat TT. Complications occurred in 78 patients (36%). Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p= 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Of 210 patients with major intra-abdominal vascular injuries, 111 (53%) survived more than 48 hours. Of these, 41 (37%) developed serious infections resulting in death or a hospital stay exceeding 14 days (mean, 55 ± 49) in the 33 who survived. The most frequent serious infections were intraperitoneal and resulted in a 35% mortality rate (8/23).The 111 patients surviving 48+ hours were divided into two groups based on their initial E.D. BP and injuries. The “high-risk” patients (with no obtainable blood pressure on admission, five or more injuries or a colon injury with a systolic BP of 40 to 89 mm Hg) had a serious infection rate of 63% (25/40). This was significantly higher than the serious infection rate of 23% (16/71) in the remaining 71 “low-risk” patients (p< 0.001).The patients were then evaluated for factors which surgeons might control. In the high-risk group, resuscitation adequate to produce an initial operating room (O.R.) systolic BP greater than 70 mm Hg and early control of bleeding so that less than 10 units of blood were used resulted in a serious infection rate of only 20% (2/10) versus 77% (23/30) in the other high-risk patients (p< 0.01). In the low-risk patients, having an initial O.R. systolic BP greater than 70 mm Hg and using less than 10 units of blood resulted in a serious infection rate of 13% (6/48) versus 43% (10/23) in the others (p< 0.05).High-risk patients failing to meet these resuscitation goals must be watched particularly carefully for development of infections.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Thoracic aortic rupture is a lethal injury associated with severe blunt trauma. Survival is directly related to early diagnosis and operative treatment. Establishing the diagnosis requires a high index of suspicion, recognition of radiologic evidence of mediastinal bleeding, and identification of injuries frequently associated with aortic rupture. A retrospective review of blunt trauma patients at the Washington Hospital Center Trauma Unit and data from the Major Trauma Outcome Study identified a two- to fivefold increase in the incidence of aortic injury among patients with pelvic fracture. Twenty to forty-five per cent of patients with aortic rupture had associated pelvic fracture.Our study documents that pelvic fracture is as reliable an indicator of associated aortic rupture as many currently accepted injuries. Its presence should raise suspicion for aortic injury.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Pulmonary contusion is the usual manifestation of lung parenchymal injury following blunt chest trauma. With rapid deceleration, however, parenchymal lacerations can result in cavities best termed post-traumatic pulmonary pseudocyst (PPP). This report discusses eight adult PPP cases encountered at the Denver General Hospital over the past 30 months. Five were males and the mean age was 29 years (range, 18 to 54). Injury mechanism was motor vehicle accident in four, industrial machinery in two, autopedestrian accident in one, and large-animal rodeo rollover in another. Review of daily portable anteroposterior chest roentgenograms revealed parenchymal infiltrates consistent with pulmonary contusion that typically cavitated within the first week. Computed tomography of the chest was pursued in complicated patients and clearly influenced therapy. Three (38%) pseudocysts developed into lung abscesses; two required resection and the other responded to percutaneous drainage. Although previously described as a benign pediatric entity, in our adult experience, PPP may result in a recalcitrant lung abscess requiring aggressive intervention.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The immunologic value of the spleen is now unchallenged; recognition of this fact has changed the management of splenic trauma radically over the past decade. This review describes our clinical experience in adults during this metamorphosis. In the 10-year period ending December 1987, 314 adults had splenic injury identified at emergent laparotomy. Mean patient age was 30.1 years and 81% were men. Injury mechanism was blunt in 227 (72%), stab wound in 49, and gunshot wound in 38. In 1978 splenorrhaphy was accomplished in nine (29%) of 31 patients; during 1982–1987 the rate of operative splenic salvage has been 63% (107/170). Splenorrhaphy was achieved with hemostatic agents in 40%, debridement and suturing in 40%, formal splenic resection in 13%, and mesh bag in 7%. Grade I splenic injuries were amenable to hemostatic agents alone, and suturing or mesh enclosure was necessary in 43% of Grade II and in all Grade HI injuries. Grade IV disruption required anatomic splenic resection for hemorrhage control in 88% of the cases. During this period 63 patients underwent splenectomy; 48 (76%) had Grade V injuries that were technically unapproachable. The remaining splenectomies were performed expeditiously in multisystem injured patients harboring other critical injuries.This decade perspective documents the feasibility of operative splenic salvage in nearly two thirds of acutely injured adults. Conversely, more than one third require prompt splenectomy due to massive splenic disruption or the presence of concomitant life-threatening injuries.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

We reviewed the hospital records and autopsy data of all deaths occurring at a Level I Trauma Center during a 1-year interval to determine the epidemiology of traumatic death in a regionalized system of care: 1,581 patients were admitted and 106 died (6.6%). Nonsurvivors (NS) differed significantly from survivors (S) in age, Trauma Score, Injury Severity Score, and probability of survival, but there was no difference between NS and S in scene time or transport time. Of the NS 91.4% died within 7 days; only 8.6% died after 7 days. Central nervous system (CNS) injury was responsible for 48.1% of deaths, followed by hemorrhage (36.8%) and cardiovascular disease (5.7%). Sepsis was responsible for 5.5% of deaths. Secondary brain injury was found at autopsy in 66% of patients dying of CNS injury. The relatively small number of septic deaths may be due, in part, to improvements in treatment associated with regionalization of trauma care. The frequency of secondary brain injury, despite rapid transport and evacuation of mass lesions, suggests that it may play a major role in the pathophysiology of CNS death occurring in a trauma system.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Analysis of 185 consecutive patients admitted to a trauma center (1983–1986) with blunt traumatic injury to the liver classified by severity of hepatic injury (I-V) has demonstrated that the pattern of associated organ injuries is a major determinant of the immediate resuscitation requirements, complications, and the ultimate outcome of patients with hepatic injury. When the significance of all injuries and major complications was evaluated using simultaneous ANOVA techniques, only brain and chest trauma together were significant (p< 0.03) as injuries occurring in subsequently fatal cases for all classes of blunt hepatic injury. Sepsis (p< 0.05) and ARDS (p< 0.005) were significant complications associated with death in the patients who survived the initial operative intervention, and only brain deterioration and exsanguinating hemorrhage were significant (p< 0.0001) as direct causes of death in all groups of patients. It was of interest that neither associated bowel, spleen, stomach, or pancreatic injuries had a significant difference in incidence between survivors and deaths. Overall, the most important single injury determining ultimate outcome was blunt traumatic injury of the brain. Review of the resuscitation and operative intervention strategies, postoperative complications, and causes of death shows that the interactions between the class of liver injury and the injuries to other organs, primarily brain and lung, are the determinant of the optimization of postinjury therapy of both a surgical and critical care nature.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The effects of injury with hemorrhagic shock on the clotting and fibrinolytic systems were studied serially in 22 patients receiving 21 ± 13 transfusions and 1.26 ± 0.58 L of fresh frozen plasma (FFP) during operation (OR). The PT, aPTT, thrombin time (TT), fibrinogen (FI), factors V (FV) and VIII (FVIII), fibrin(ogen) split products (FSP) and fibrin monomers were measured in OR and after OR at 6 and 15 hours, days 2 and 4, and at convalescence (25 days). The TT, PT, and aPTT were were prolonged in OR and reflected the low FI, FV, and FVIII, respectively. After OR, clotting times and factor levels returned toward normal. By day 4 and convalescence, FI, FV, and FVIII exceeded normal levels.FSP levels were normal in OR. After OR FSP rose progressively through day 4 when all patients had levels > 10 mcg/ml and most patients had levels above 40 mcg/ml. Fibrin monomers were absent until the 15-hour study after which a small number of patients had monomers through the convalescent study. The acute fall in clotting factors is likely due to increased hemostatic demands, plasma dilution from resuscitation, and extravascular relocation from shock-induced extravascular expansion. Later factor restoration likely reflects enhanced hepatic synthesis, factor half-life, capillary selectivity retaining large molecular weight factors, and intravascular relocation from abundant extravascular stores. Throughout this biphasic response, the clotting times reflect factor levels. Fibrinolysis contributes little to these changes.

ISSN:0022-5282    

出版商:OVID    

年代:1989

数据来源: OVID