摘要:

BackgroundAs the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity.MethodsThis study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996–December 1997). Age-dependent and injury severity–dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis.ResultsElderly (age ≥ 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%;p< 0.001), moderate (ISS 15–29, 19.7% vs. 5.4%;p< 0.001), and severe traumatic injury (ISS ≥ 30, 47.8% vs. 21.7%;p< 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60–2.18;p< 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18–45 group, 0.89 fewer days in the age 46–64 group compared with the age ≥ 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%,p< 0.001) and ISS 15 to 29 (21.7% vs. 17.6%,p= 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS ≥ 30.ConclusionAge is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundReactive oxygen species can cause apoptosis and may be involved in hypoxic injury to the small bowel. Xanthine oxidase (XO) has been implicated in reactive oxygen species production. We hypothesized that administration of allopurinol would protect rat enterocytes from hypoxia-induced apoptosis.MethodsTwenty-four Sprague-Dawley rats (weight, 250–300 g) were subjected to 30 minutes of hypoxia (10% Fio2), then killed immediately or allowed to recover for an hour in room air (21% Fio2). Intraperitoneal allopurinol (50 mg/kg) or an equivalent amount of 0.9% saline was administered 1 hour before hypoxia. Control rats were exposed to 21% Fio2under similar conditions. Proximal jejunum was harvested from all animals in both groups and stained to detect apoptotic cells using terminal deoxynucleotidyl transferase–mediated biotinylated deoxynucleotide end labeling. In addition, sections of proximal jejunum were removed and the mucosal membrane was removed and flash frozen in liquid nitrogen for DNA fragmentation gel.ResultsIntraperitoneal administration of allopurinol significantly reduced the percentage of apoptotic villi in the proximal jejunum compared with those animals receiving saline (11 ± 7 vs. 25 ± 12 in the hypoxia no recovery group, 41 ± 14 vs. 67 ± 8 in the hypoxia with recovery group, mean ± SD, Mann-WhitneyUtest,p< 0.05). Intestinal XO activity was also significantly reduced in the animals receiving allopurinol compared with those receiving saline (6.8 ± 3.12 vs. 19.1 ± 4.56 mU/mL/g wet tissue in the hypoxia no recovery group, 0.86 ± 0.33 vs. 11.5 ± 7.13 mU/mL/g wet tissue in the hypoxia with recovery group, mean ± SD, Mann-WhitneyUtest,p< 0.05).ConclusionInhibition of XO appears to protect rat enterocytes from hypoxia-induced apoptosis in vivo.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundEarly enteral feeding has been shown to be beneficial in improving outcome in critically injured trauma patients. Delayed gastric emptying occurs frequently in trauma patients, increasing the time to achieve nutritional goals, and limiting the benefit of early enteral feedings. Intravenous erythromycin is an effective agent for improving gastric motility in diabetics and postgastrectomy patients. The purpose of this study is to determine the effectiveness of erythromycin for improving gastric motility in critically injured trauma patients.MethodsAll critically injured patients who received gastric feedings within 72 hours of admission were candidates for the study. Those patients who failed to tolerate feedings at 48 hours (gastric residual > 150 mL) were eligible for enrollment. Patients were prospectively assigned to two treatment groups by randomization to receive either erythromycin (ERY) or placebo (PLA). Treatment was continued in patients who tolerated gastric feedings until the feedings were no longer required. Patients with continued intolerance for 48 hours after randomization were considered failures of therapy and given metoclopramide.ResultsSixty-eight patients were enrolled and were well matched for age, sex, and Injury Severity Score. Mortality, intensive care unit length of stay, hospital length of stay, number of ventilator days, and rate of nosocomial infections were similar in each group. There was a significant difference between the ERY group and the PLA group in the amount of feedings tolerated at 48 hours (58% vs. 44%,p= 0.001). There was no difference in the amount of feedings tolerated (as a percentage of target goal volume) throughout the entire duration of the study (ERY [65% of target] vs. PLA [59%],p= 0.061). Overall success of therapy at 48 hours was 56% in the ERY group versus 39% in the PLA group, but this also did not reach statistical significance (p= 0.22).ConclusionIntravenous erythromycin improves gastric motility and enhances early nutritional intake in critically injured patients.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe purpose of this study is to investigate the usefulness of flexion and extension radiographs of the cervical spine for the acute evaluation of ligamentous injury in cases of awake blunt trauma.MethodsA review of 106 consecutive cases of blunt trauma evaluated with flexion and extension radiographs of the cervical spine obtained in the acute setting at a Level I trauma center was performed. The data compiled included the age, sex, mechanism of injury, type of radiographic evaluations, interpretation of all radiographic studies, and clinical outcome on follow-up.ResultsSixty-six of the patients (62%) were involved in motor vehicle crashes. Other injuries included 15 falls (14%), 9 blunt assaults (8.5%), and 16 other types of blunt trauma (15%). Thirteen cervical spine injuries were diagnosed in 9 of 106 patients (8.5%). Injuries included two fractures, eight acute disc herniations, two ligamentous injuries, and one cord contusion diagnosed on the basis of all radiologic evaluation and clinical follow-up. Seventy-four patients (70%) had a range of flexion and extension motion interpreted as adequate for diagnostic purposes. Five of the 74 patients (6.75%) with an adequate range of motion had cervical spine injuries. No ligamentous injuries were misdiagnosed in this group. Thirty-two of the flexion and extension examinations (30%) were interpreted as inadequate because of limited motion. Four of the 32 patients (12.5%) with inadequate flexion and extension examinations had injuries subsequently detected on cross-sectional imaging (computed tomographic scanning or magnetic resonance imaging) including severe ligamentous injury.ConclusionWhen adequate motion was present on flexion and extension radiographs, the false-negative rate was zero in this study. However, in the acute setting, 30% of the examinations were limited by inadequate motion. A higher percentage of injury (12.5%) was detected by subsequent cross-sectional imaging in these patients. Limited flexion and extension motion on physical examination should preclude the use of flexion and extension radiographs, as they are of limited diagnostic utility. Cross-sectional imaging may be warranted in this high-risk group of patients.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundRecent data suggest that sex hormones may play a role in regulating posttraumatic immunosuppression, leading to gender-based differences in outcome after injuries. This study examined gender-related outcomes in trauma patients.MethodsWe conducted a retrospective review of trauma registry data from our Level I trauma center over a 4-year period. Patients > 15 years of age, with Injury Severity Scores > 15, who survived and received mechanical ventilation for > 48 hours were included. Patients were divided into two groups on the basis of age (15–45 years and > 45 years) and the groups were further stratified by gender. Groups were matched by Injury Severity Scores, Glasgow Coma Scale score, Abbreviated Injury Score for the head, and transfusion requirement. Gender-based outcomes consisted of ventilator days, intensive care unit length of stay (LOS), hospital LOS, pneumonia, and death.ResultsData were reported as mean ± SD. There were 612 patients. In the younger age group, male patients had a higher incidence of multiple organ failure (10.5% vs. 1.5%), longer intensive care unit (13.5 ± 9.2 days vs. 9.2 ± 7.2 days) and hospital LOS (30.2 ± 37.7 days vs. 18.9 ± 13.0 days), and higher mortality (13.4% vs. 6.8%) compared with female patients (p< 0.05 for all). These differences did not exist in the older age group. The incidence of pneumonia did not differ by gender. Age > 45 years was associated with higher mortality (odds ratio, 2.0; 95% confidence interval, 1.1–3.5).ConclusionAlthough the incidence of pneumonia was not influenced by gender, female trauma patients had better outcomes than male patients in the younger age group. Outcome in the older age group was not gender-related. Our data support a gender-based difference in outcome after traumatic injuries in younger patients.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe protective effect of gender on posttraumatic mortality or acute complications (acute respiratory distress syndrome [ARDS], pneumonia, and sepsis) is unclear. To assess potential effects, we performed a retrospective case-controlled study, matching patients for injury factors including overall severity (Injury Severity Sscore), the presence of shock (systolic blood pressure [SBP] < 90 mm Hg) at admission, and the presence of closed head injury (CHI).MethodsAll female patients admitted over a 61/2-year period were reviewed and divided into four groups: group 1, SBP > 90, no CHI; group 2, SBP < 90, no CHI; group 3, SBP > 90, with CHI; and group 4, SBP < 90, with CHI. Each cohort was matched one to one with an equivalent male counterpart. Cohorts were compared for mortality or the development of ARDS, pneumonia, and systemic sepsis using standard definitions.ResultsOverall, 1,229 female patients were identified for study. The average Injury Severity Score was 16.3 and overall mortality was 2.7%. Analysis of the groups described previously demonstrated no statistically significant difference in the development of ARDS, pneumonia, systemic sepsis, or overall mortality between male and female patients including patients presenting with shock, CHI, or both.ConclusionWe conclude that female gender offers no protection from the development of ARDS, pneumonia, sepsis, or decreased mortality after blunt trauma.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundPatients with blunt aortic injury (BAI) often have concomitant liver or spleen (L/S) injuries. With increasing use of cardiopulmonary bypass with heparinization in repair of BAI, many advocate operative management of the L/S injury before aortic repair to eliminate risk of hemorrhage. We evaluated the safety of nonoperative management (NOM) of blunt L/S injuries in patients undergoing acute BAI repair with bypass.MethodsAll patients admitted over a 6-year period with BAI were identified from the registry of our Level I trauma center. Patients with isolated L/S injuries without BAI admitted over the same period served as controls. Groups were compared with regard to demographics, injury characteristics, hospital course, and mortality.ResultsEighty-four patients were diagnosed with BAI from 1994 to 2000; 28 (33%) also had blunt abdominal trauma. Three patients with severe brain injury did not undergo BAI repair, and five required laparotomy before BAI repair for other intra-abdominal injuries (two for hemodynamic instability with splenic injury, and three for concomitant bowel injury). Therefore, 20 of 28 (71.4%) BAI patients with grade I or II L/S injury (Aorta L/S group) underwent planned NOM. All BAIs were repaired using partial bypass with full heparinization. These 20 patients are compared with 894 patients with grade I or II L/S injuries with no BAI (L/S group) over the same time period. There was no difference in the nonoperative failure rate of the Aorta L/S group versus the L/S group (0% vs. 1.7%). Both groups had similar complication rates. The Aorta L/S group was also compared with 56 BAIs without solid organ injury (Aorta group). Although the Aorta L/S group was more severely injured than the Aorta group (Injury Severity Score of 35.3 vs. 26.8,p< 0.0001), transfusion rates (5.7 U of packed red blood cells vs. 8.0 U of packed red blood cells,p= NS), hospital days (17.9 vs. 19.1,p= NS) and mortality (10% vs. 9%,p= NS) were similar.ConclusionNOM of patients with grade I or II L/S injury who undergo systemic anticoagulation with heparin for repair of BAI is safe and associated with transfusion rates similar to BAI alone. Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundPelvic fractures may be associated with significant hemorrhage. Although this hemorrhage may emanate from the pelvic vasculature, it may also be secondary to abdominal visceral injury. The purpose of this study was to determine factors associated with pelvic and/or abdominal visceral bleeding in hypotensive patients with pelvic fractures to guide the appropriate therapeutic intervention sequence for these difficult-to-manage patients.MethodsMedical records of all hypotensive (systolic blood pressure ≤ 90 mm Hg) patients with pelvic fractures seen at a Level I trauma center from January 1995 to December 1999 were evaluated. Records were abstracted for age, base deficit, 24-hour blood requirement, hemoperitoneum (positive ultrasound, diagnostic peritoneal lavage, or computed tomographic scan), abdominal hemorrhage discovered at celiotomy, pelvic hemorrhage discovered at angiography, emergency department disposition, Injury Severity Score, and mortality. Pelvic fracture categories were derived by adapting the Young-Burgess pelvic fracture classification scheme. Lateral compression (LC) I and anteroposterior compression (APC) I fractures were characterized as stable fracture patterns (SFPs), and APC II, APC III, LC II, LC III, and vertical shear were characterized as unstable fracture patterns (UFPs).ResultsOf 231 hypotensive patients, 38 patients died in the emergency department, leaving 193 surviving initial resuscitation. One hundred seven patients stabilized (group I) and were transferred to the intensive care unit. Eighty-six patients (group II) required ongoing resuscitation and underwent celiotomy and/or angiography in an attempt to manage their hemorrhage. Within group II, in the SFP population, abdominal hemorrhage was responsible for hypotension in 34 of 40 (85%), and 10 patients died (25%). In patients with UFP injury, hemorrhage was predominantly from a pelvic source, as shown by 27 positive angiograms in the 46 patients (59%). Twenty-four of 46 (52%) UFP patients died. In patients with a UFP, 14 had both angiography and celiotomy. Four patients underwent angiography before celiotomy and one of four (mortality, 25%) died. In contrast, 10 patients underwent celiotomy before angiography and 6 of 10 died (mortality, 60%).ConclusionPatients with signs of ongoing shock with SFP pelvic injury and hemoperitoneum require celiotomy as the initial intervention, as the hemorrhagic focus is predominantly intraperitoneal. In patients with UFP, even in the presence of hemoperitoneum, consideration should be given to angiography before celiotomy.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of polytrauma patients treated at a Level I trauma center within the last two decades regarding the effect of changes in the management of their femoral shaft fracture.MethodsIn a retrospective cohort study performed at a Level I trauma center, the patient’s injuries and clinical outcomes were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the femur fracture (I° intramedullary nailing [I°IMN]; I° external fixation [I°EF]; I° plate osteosynthesis [I°plate]) followed during a certain time period: (1) early total care (ETC) (January 1, 1981–December 31, 1989) and early (< 24 hours) definitive stabilization; (2) intermediate (INT) (January 1, 1990–December 31, 1992) change in the protocol; or (3) damage control orthopedic surgery (DCO) (January 1, 1993–December 31, 2000), early (< 24 hours) temporary stabilization, and secondary conversion to intramedullary nailing in patients at risk of organ failure.ResultsThe patient groups were comparable regarding age, gender distribution, and the mechanism of injury. Primary external fixation was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups compared with the ETC group (16.6%) (p= 0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I°EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I°IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdominal injuries accounted for significantly higher numbers of patients submitted to I°EF in the INT (13.6%,p= 0.03) and DCO (17.3%,p= 0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of multiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I°IMN (15.1%) and I°EF (9.1%) in the DCO subgroup were compared.ConclusionA significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an increased awareness toward thoracic and abdominal injuries may have played a role. Even during the DCO era, IMN was associated with a higher rate of ARDS than I°EF. In view of a lower complication rate despite higher injury severity compared with the ETC period, the introduction of DCO appears to be an adequate alternative for patients at high risk of developing posttraumatic systemic complications such as ARDS and multiple organ failure.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID