摘要:

The depression of interleukin-2 synthesis represents a major dysfunction within the cascade of immunologic defects induced by mechanical and thermal trauma. This study was undertaken to elucidate the negative control mechanisms that were responsible for the deficiency of IL-2 production in polytraumatized patients. Peripheral blood mononuclear cells (PBMC's) from 29 patients (average age, 35.8 years; average ISS, 35) were separated on post-trauma days 1, 3, 5, 7, 10, 14, and 21 and cultured as untreated cells (C), cells treated with indomethacin (C + INDO), and cells depleted of adherent cells (C-AC). Cell cultures were assayed for proliferative responses to PHA, IL-2 synthesis, PGE2production, γ-interferon levels, and phenotyping studies.On all days post-trauma there was found a marked reduction of IL-2 production compared to controls with a highly significant nadir from day 5 to day 10 with an almost 80% inhibition of IL-2 (p < 0.005). C + INDO cells showed increases of IL-2 synthesis over untreated cells ranging from 48% (Day 1) to 220% (Day 7). Removal of adherent cells (C-AC) did not reverse the suppression of IL-2 production. γ-interferon levels were depressed in parallel with IL-2 levels but did not increase with C + INDO. The phenotyping of the PBMC's showed highly significant suppression of OKT3+, OKT4+, and IL-2R+ lymphocytes as well as a highly significant elevation of the monocyte (p < 0.005) count. There was a highly significant increase of PGE2synthesis from monocytes, due to the monocytosis and to a higher capacity of synthesis of the individual cells following trauma. PGE2levels peaked on Day 5 and 7 post-trauma at 400% of control (p < 0.005).These data suggest that the suppression of IL-2 synthesis post trauma is caused mainly by two factors: the excessive PGE2output of inhibitory monocytes and inadequate function in immature and/or blocked lymphocytes.The partial restoration of IL-2 synthesis by indomethacin suggests that blockade of the cyclo-oxygenase pathway as an immunomodulating therapy may reverse some of the immunologic abnormalities in multiple trauma patients.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

Free flap versatility and dependability make the final result of microvascular reconstruction highly predictable. Free tissue transplantation should be considered as a primary treatment after trauma. The early use of free tissue transfer will result in fewer operations and a shortened duration of hospitalization in the initial post-trauma period.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula.Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury.We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1–2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

A multidisciplinary concurrent audit of the quality of medical care within a trauma system was carried out by a committee of physicians, nurses, and health officials representing trauma centers, nontrauma hospitals, and the public agency administrating the trauma system. Care was audited with regard to timeliness and appropriateness of diagnosis and therapy.Complications were classified as being due to an error in diagnosis, judgment, or technique. Deaths were classified as nonpreventable, potentially salvageable, or frankly preventable. During the first 22 months of operation (1 August 1984–30 May 1986), 7,936 cases were audited. Of the 224 deaths occurring at nontrauma hospitals, 17 (7.6%) were felt to be frankly preventable. Of 541 deaths occurring at trauma centers, 11 (2.0%) were felt to be frankly preventable (p < 0.001). The most common problem implicated in preventable deaths at nontrauma center hospitals was an error in diagnosis.Preventable deaths at trauma centers were most commonly due to an error in technique. Complications or protocol violations occurred in 595 of 6,564 surviving trauma patients (9.1%). During the first 12 months of system operation, 7,200 person-hours were required to perform the audit. Personnel costs alone for audit in the first year were $300,420.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

Eighty-five patients with penetrating colon injuries, treated either by exteriorized repair (39) or loop colostomy (46), were analyzed. Missile wounds accounted for 75.3% of the injuries. The Penetrating Abdominal Trauma Index (PATI) was the scoring method employed to assess quantitatively the severity of injuries in each patient. Of 21 patients with right colon injuries, eight were treated by exteriorized repair and the remainder by loop colostomy. PATI and other variables were comparable in both groups. Suture line leaks occurred in two patients (25%) with exteriorized repair. The morbidity was similar in both groups.In left colon trauma, exteriorized repair was employed in 31 patients and 33 underwent loop colostomy. The injury severity indices, clinical status, and time lapse to laparotomy were similar in both groups. Colostomy was avoided in 67.7% (21 of 31) patients with exteriorized repair. The incidence of abscesses was significantly higher in the colostomy group compared to the group treated by exteriorized repair (24.2% and 6.4%, respectively;p< 0.05).The length of hospital stay was shorter after exteriorized repair (17.2 days vs. 23.2 days;p< 0.05). All three mortalities (3.5%) were related to associated injuries. We conclude that exteriorized repair is a safe and superior alternative to loop colostomy in penetrating colon trauma.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

Acute placement of a suprapubic bladder tube followed months later by open urethroplasty has been the traditional manner for managing traumatic disruption of the proximal urethra. The latter procedure has generally been performed via the transpubic or perineal approach. These procedures have been complicated by excessive blood loss, impotence, incontinence, strictures, and extended hospitalizations. Since 1979, 12 patients with obliterated urethras (ten membranous, two bulbous) have been treated by direct vision urethrotomy using a second cystoscope or sound passed through the previously placed suprapubic tract as a guide. Mean blood loss, hospital stay, and followup were 70 ml, 6 days, and 22 months, respectively. Six patients required at least one additional internal urethrotomy. With the exception of one patient who still requires intermittent self-catheterization, all have stable strictures. Ten are continent (one was incontinent secondary to previous radical prostatectomy before urethrotomy and one became incontinent after a TURP performed 3 years after urethrotomy). Five are potent and none lost potency as a result of urethrotomy. Flow rates range from 15–25 ml/second in the continent patients. This is a reasonable first procedure for restoring continuity of traumatically obliterated membranous and bulbous urethras.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

Gastric rupture from blunt abdominal trauma is a rare occurrence. Six patients are presented and reviewed with the literature since 1930. Several features of the diagnosis and management of this injury are emphasized, including a strong association with thoracic trauma and a high incidence of intra-abdominal abscess formation which results from massive intraperitoneal contamination. Mortality is not usually from gastric rupture per se, but rather from concomitant vascular or neurologic injury. The key to survival for these patients is early operative intervention and an aggressive approach to reoperation and drainage of abscesses.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

An independent observer was placed with city paramedic teams to: a) record exactly how long emergency field procedures take; and b) determine the paramedic's perception of elapsed field time.One hundred eighteen runs were monitored; 33% required advanced life support skills, and 36% were for trauma. The response time (mean ± S.E.M.) averaged 5.4 ± 0.26 min, scene time 11.2 ± 0.54 min, and transport time 9.5 ± 0.86 min. The average time required to perform scene procedures ranged from 1.5 ± 0.5 min for defibrillation to 5.0 ± 0.47 min to start an IV. Paramedic perception of elapsed time for the entire run varied from the actual time by an average absolute value of 20%, with the greatest errors occurring in scene time estimates. Paramedics tended tooverestimateelapsed time duringshortruns, andunderestimatetime onlongruns.This report provides realistic field procedure times for urban paramedics.Distortion of time perception in the field environment emphasizes the need for strict medical control.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

Whether drains should be used in the management of hepatic wounds has been a subject of controversy since 1970. A limited retrospective review of 13 patient charts disclosed an intra-abdominal abscess rate of 23% with Penrose drains. Prospective analysis of 56 patients who qualified for inclusion in a closed-drain versus no-drain study showed a 4.2% and 3.1% intra-abdominal abscess rate, respectively. Results of this study indicate that the use of closed-drainage versus no-drainage should remain the surgeon's choice, depending on evaluation of related factors. In hepatic injury, however, open drainage should not be used.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

Our experience with 56 patients who sustained massive transfusion exceeding two times their estimated blood volume is reviewed. Survival was 39% for the entire group, which included six cases of blunt multiple trauma and seven nontraumatic surgical emergencies, and 51% for the subgroup who sustained penetrating trauma. Six patients arrived without detectable vital signs, but half of them left the hospital alive. Three subgroups sustained 100% mortality: cirrhotics, nontraumatic surgical emergencies, and victims of blunt trauma. Thirty-eight per cent of the noncirrhotics developed a post-transfusion bleeding disorder, but the specific patients who would develop coagulopathy could not be predicted on the basis of any clinical parameter scrutinized, including lowest measured platelet count. Pulmonary morbidity was rare among penetrating trauma patients in spite of an average of 35 units of blood transfusion. Acute respiratory failure developed in a subgroup with penetrating trauma who received an average of 59 units of blood; blunt trauma patients developed acute respiratory failure at an average transfusion volume of 35 units. The 77% mortality among patients who developed coagulopathy, and our inability to predict in advance which patients will develop serious clinical bleeding, argue strongly in favor of an aggressive approach toward prophylaxis in these patients in spite of the theoretical risk of disease transmission from the additional units of platelets and frozen plasma required.

ISSN:0022-5282    

出版商:OVID    

年代:1987

数据来源: OVID