ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;Deaths from uncontrollable hemorrhage might be prevented by arresting the circulation under protective hypothermia to allow resuscitative surgery to repair these injuries in a bloodless field. We have shown previously that in hemorrhagic shock, circulatory arrest of 60 minutes under deep hypothermia (tympanic membrane temperature, Ttm = 15°C) was the maximum duration of arrest that allowed normal brain recovery. We hypothesize that profound cerebral hypothermia (Ttm < 10°C) could extend the duration of safe circulatory arrest. In pilot experiments, we found that the cardiopulmonary system did not tolerate arrest at a core (esophageal) temperature (Tes) of <10°C. Twenty‐two dogs underwent 30‐minute hemorrhagic shock (mean arterial pressure 40 mm Hg), rapid cooling by cardiopulmonary bypass (CPB), blood washout to a hematocrit of <10%, and circulatory arrest of 2 hours. In deep hypothermia group 1 (n = 10), Ttm was maintained at 15°C during arrest. In profound hypothermia group 2 (n = 12), during cooling with CPB, the head was immersed in ice water, which decreased Ttm to 4°‐7°C. The Tes was 10°C in all dogs during arrest. Reperfusion and rewarming were by CPB for 2 hours. Controlled ventilation was to 24 hours, intensive care to 72 hours. In the 20 dogs that followed protocol, best neurologic deficit scores (0% = normal, 100% = brain death) at 24‐72 hours were 23% ± 19% in group 1 and 12% ± 8% in group 2 (p= 0.15). Overall performance categories and histologic damage scores were significantly better in group 2 (p= 0.04 andp< 0.001, respectively). We conclude that profound cerebral hypothermia with CPB plus ice water immersion of the head can extend the brain's tolerance of therapeutic circulatory arrest beyond that achieved with deep hypothermia.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;Tumor necrosis factor (TNF) is a potent cytokine mediator of the shock states associated with sepsis and burn injury. This experimental study was done to determine whether circulating TNF plays a major role in the vasomotor collapse seen following experimental hemorrhage and blunt injury. Twenty anesthetized pigs were divided into two groups. Ten animals were bled 60% of their calculated blood volume in 15 minutes. Animals in Group IA (n = 5) had no treatment, and Group IB animals (n = 5) were given twice the shed volume as crystalloid 30 minutes after hemorrhage. The other animals, groups IIa and IIb (n = 5 each), were first subjected to a blunt injury to the thigh sufficient to cause a midshaft femur fracture, then bled and similarly treated. In both groups, mean arterial pressure (MAP), cardiac output (CO), and serum TNF activity by L929 bioassay were measured at 15‐minute intervals for 120 minutes after hemorrhage or hemorrhage and blunt injury. An additional three animals were infused with 4 × 108/kg heat‐killedE. colito validate the TNF assay. All bled animals sustained a fall in MAP and CO to a mean of 33% of baseline values, with or without fracture. Group IB and IIB animals responded to fluid resuscitation by restoration of MAP and CO to 85%‐97% of the baseline values. Tumor necrosis factor was not detectable before injury and remained undetectable in all these animals during the 120 minutes of the experiment despite hemorrhage alone or combined hemorrhage and blunt trauma, with or without fluid resuscitation. The test animals receiving theE. coliresponded with markedly elevated TNF levels, which peaked at 90 minutes after injection. We conclude that hemorrhage alone causes no detectable elevation in serum TNF levels, and the combination of blunt injury and hemorrhage is also without effect on circulating TNF levels during the experimental period. Tumor necrosis factor presumably plays no role in the pathogenesis of shock in this model. This negative finding should help direct future studies and potential pharmacologic manipulation of traumatic shock.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;The alterations in lung glutamine (GLN) metabolism that occurs in the endotoxin‐injured lung were studied in rats and subsequently correlated with flux changes that occur in patients with the adult respiratory distress syndrome (ARDS). Measurements in animals were made at various timepoints following the administration of endotoxin, while studies in surgical patients were done in a group of healthy controls, in patients with “early” sepsis who had normal chest x‐ray films, and in patients with radiographic and physiologic evidence of ARDS. In healthy control rats, net amounts of GLN are released by the lungs into the systemic circulation. This release rate doubled 30 minutes after intravenous endotoxin (1,580 ± 320 nmol GLN/100 g BW/min vs. 736 ± 179 in controls,p< 0.01) but glutamine synthetase activity was unchanged, suggesting an outpouring of cellular glutamine stores. Two hours after endotoxin treatment, this accelerated fractional release of glutamine by the lungs was no longer detected. By the 12‐hour timepoint, the lungs reversed to an organ of net glutamine balance (234 ± 248 nmol/100 g BW/min,p< 0.05 vs. controls and ENDO30 min) despite a more than two‐fold increase in glutamine synthetase activity (p< 0.01). Simultaneously, lung weights were increased by 21% (p< 0.01) and histologic examination showed an interstitial infiltrate and pulmonary edema. Similar observations were made in humans; patients with “early” sepsis exhibited a marked increase in lung glutamine release, while patients with ARDS demonstrated glutamine balance across the lungs (4,030 ± 910 nmol GLN/kg BW/min vs. 637 ± 496 in ARDS,p< 0.05). These observations in rodents and patients suggest that the lungs release increased amounts of glutamine within minutes to hours after a septic insult; this could occur secondary to mobilization of a pre‐existing pool or possibly from a “glutamine leak” out of damaged endothelium. This net release is short lived and the apparent reversal to glutamine balance at a time when endogenous de novo glutamine biosynthesis is occurring may be caused by increased local consumption of glutamine by injured cells that require increased amounts of glutamine for repair.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;The results of 163 patients (49 SWs, 85 GSWs, 29 blunt trauma) who had resuscitative thoracotomy in the emergency room (ERT) were reviewed to reassess the indications for the procedure. The Revised Trauma Score (RTS) of the patients ranged from 0 to 3 in 138, 4 to 8 in 21, and > 8 in four. No patient with blunt trauma survived. Sixteen patients [12 (24.5%) with stab wounds and 4 (4.7%) with gunshot wounds] were eventually discharged, an overall survival of 9.8%. Eight of the survivors were without vital signs on arrival at the emergency center and one of them had only signs of life at the scene. Survival was best when the site of penetration was thoracic (n = 84) and the ERT was “directed” at potential cardiac injury. Fifty‐six of these patients (66.6%) did have cardiac wounds with tamponade and 12 of them survived (21.4%). Two of the remaining 28 patients, both with pulmonary injury, were salvaged. This was significantly (p< 0.001) higher than in patients with head and neck (n = 4), abdominal (n = 19), or multiple site (n = 40) injury when the ERT was nondirected. Two of the five patients (40%) with extremity vascular injuries survived after ERT was successful in restoring a cardiac rhythm. These data suggest that in patients without vital signs, ERT “directed” at potential cardiac injury based on thoracic penetration is an important prognostic prerequisite for survival. Emergency room thoracotomy is not beneficial in blunt trauma and its role in penetrating abdominal injuries remains unproven.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;Sepsis and multiple system organ failure (MSOF) are major causes of morbidity and mortality in trauma patients. Bacterial translocation induced by hypotension, endotoxemia, or burns is a reproducible phenomenon in the laboratory. The incidence of bacterial translocation to mesenteric lymph nodes (MLNs) in 29 critically ill patients was evaluated to determine its relationship to subsequent sepsis and MSOF. Bacterial translocation was documented in 3 of 4 patients who underwent laparotomy for gastrointestinal (GI) disease. No trauma patient (25 patients), even at second exploration 3‐5 days after injury, had a positive MLN culture. Five patients died; 4 trauma patients, one with GI disease. Forty percent of the trauma patients had major complications, predominantly pulmonary infections with gram‐negative bacteria. However, infectious complications and outcome were not related to MLN culture results. The classical progression of bacteria from the gut to the bloodstream via the MLNs may require time and gut mucosal injury. The data suggest that bacterial translocation to the MLNs is not a common occurrence in acutely injured trauma patients.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;Over a 7‐year period, 151 patients with gunshot wounds to the colon surviving beyond 24 hours were managed. The bullet was retained in the body in 66% and exited in 34%. Thirty‐four (23%) developed major septic complications (diffuse peritonitis, 21%; intraperitoneal abscesses, 24%; and extraperitoneal abdominal abscesses, 56%). The septic complication rate was 26% in the bullet‐present group compared with 16% in the remainder (p< 0.15). The increased septic rate in those with bullets present was the result of abscesses developing around the retained missile. That group with missile abscesses had a lesser degree of injury as measured by the abdominal trauma index compared with the other patients with spetic complications (p< 0.001). Fifteen (79%) of the 19 patients with missile and missile track abscesses had them develop in the psoas muscle. These abscesses occur by fecal contamination of the muscle following inoculation by the bullet, which passes through the large bowel. Computed tomography‐guided and operative drainage tend to fail if the foreign body is not removed. Computed tomography‐guided or operative drainage should be successful in draining missile track abscesses when the bullet has exited the patient.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;Our previous work demonstrated that geriatric trauma patients (age ≥ 65 years) consume disproportionate amounts of health care resources. In the past, we hypothesized that late mortality is high, long‐term outcome is poor, and return to independence is low in a severely injured geriatric population. Of 6,480 trauma admissions over 5 years, geriatric patients (n = 495) with blunt trauma injury (n = 421) and an ISS ≥ 16 (n = 105) who survived until discharge (n = 61) underwent long‐term follow‐up (mean = 2.82 years). We surveyed 20 measures of functional ability; 10 measures of independence; availability and use of rehabilitation resources; employment history; alcohol use; support systems; and nursing home requirements. Of the 105 patients, 7 were subsequently lost to follow‐up. Among the remaining 98, 44 (44.9%) died in hospital and 54 (55.1%) were discharged and interviewed. The mean age of the contacted patients was 72.6; their mean ISS was 23.3. Forty eight of 54 (88.9%) were alive at the time of interview, while 6/54 (11.1%) had died. Although only 8/48 patients regained their preinjury level of function, 32/48 (67%) returned to independent living. The 32 independent patients, those with “acceptable” outcome, were compared with an “unacceptable” outcome group composed of the 44 in‐hospital deaths, the 6 late deaths, and the 16 dependent patients. Factors associated with poor outcome include a GCS score ≤ 7 (p= 0.001), age ≥ 75 (p= 0.004), shock upon admission (p= 0.014), presence of head injury (p= 0.03), and sepsis (p= 0.03). Conclusions: (1) The majority of severely injured geriatric patients who survive their injury return to a level of independence; (2) factors associated with poor long‐term outcome include shock upon admission, age ≥ 75, the presence of head injury and/or a GCS score ≤ 7, and sepsis.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;This study examined a mesh wrap technique that provides effective hepatic tamponade and clinical experience with the technique in 6 patients is reported. Technical feasibility and effectiveness were investigated in 8 miniature swine. The animals were divided into two groups: group A (n = 4), control animals; stellate liver lacerations without mesh wrap or other measures for hemostasis, and group B (n = 4); stellate liver laceration with synthetic absorbable mesh wrap applied for hepatic hemostasis. Except for mesh application, all variables were held constant for both groups. All animals in the control group died within 20 to 120 minutes (mean: 65 minutes). All animals in group B survived (p= 0.029). The livers were harvested for gross and microscopic examinations. No abscess, bile leak, or hematoma was noted. Clinically, total mesh wrapping was attempted in 6 patients with blunt exsanguinating liver injuries. The technique failed intraoperatively in two patients with juxtacaval lacerations and hepatic vein avulsion injuries. One patient with a bilobar gunshot wound died later of sepsis. In three patients with bursting injuries, the technique successfully controlled bleeding and resulted in long‐term survival. In conclusion, the total hepatic mesh wrap (1) is geometrically, technically, and mechanically feasible, (2) was not associated with complications in this series, and (3) can effectively secure hemostasis following parenchymal liver injury.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

&NA;Linked multiple data sources were analyzed to provide a population‐based collision and injury severity profile among pedestrians under 20 years of age struck by a motor vehicle during 1986‐1987 in Hartford, Connecticut. Data sources included police accident reports, medical examiner records, and hospital charts. There were 234 motor vehicle‐pedestrian collisions reported to the police in the study period. Of these, 213 were Hartford residents resulting in an annual age‐specific pedestrian collision rate of 22.8 per 10,000 persons. A spot map of collision location reveals several well‐defined geographic areas, which includes nearly half (45%) of the motor vehiclepedestrian collisions. We reviewed 143 of 192 medical charts (75%) and 6 medical examiner records. The case fatality rate was 4.2% and the mean Injury Severity Score was 4.4. These findings will be useful for designing, implementing, and evaluating a targeted child pedestrian safety program.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID