ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background:Fluid and sodium restriction have been advocated after brain injury as a means of controlling intracranial pressure (ICP). Recent clinical data showing no significant relationships between the amount of fluid infused or sodium administered (Na) and ICP question this practice.ObjectiveTo analyze the relationship of amount of fluid, Na, and fluid balance to cerebral edema formation and ICP.MethodsA cryogenic brain injury with and without hemorrhagic shock was studied after 24 hours in swine (n = 35) randomized to receive either lactated Ringer's solution (LR) or hypertonic sodium lactate (HSL). Cerebral edema formation as indicated by cortical water content (CWC) was determined by measurement of specific gravity.ResultsThere was a significantpositivecorrelation between the following variables: (1) amount of fluid and ICP (r= 0.598;p< 0.01); (2) fluid balance and ICP (r= 0.684;p< 0.01); and (3) free water and ICP (r= 0.614;p< 0.01). There was a significantnegativecorrelation between serum osmolarity and ICP (r= −0.654;p< 0.01). The study failed to demonstrate a significant correlation between Na and ICP, amount of fluid and CWC, or fluid balance and CWC.ConclusionsThese data suggest that both the volume of fluid infused and the fluid balance do affect the ICP, but the amount of Na infused does not. The lack of a significant correlation between any of the independent variables and CWC suggests that their effect on ICP is not related to cerebral edema formation. These findings, combined with the observed significantpositivecorrelation between free H2O infused and ICP, and the significantnegativecorrelation between serum osmolarity and ICP, suggest that HSL resuscitation increases intracranial compliance after brain injury while LR decreases it. The data also suggest that free water restriction is warranted in patients with head injuries.

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Introduction:Cervical collars play a role in the long-term treatment of cervical spine injuries. Pressure ulcers are one of the potential complications. We previously reported on three patients who developed pressure ulcers of the scalp while wearing cervical collars. The pressure exerted by different collars was measured to determine whether this was a significant factor in the clinical problem we observed.MethodsFour brands of cervical collars (Stifneck, Philadelphia, Newport, and Miami J) were tested in 20 normal volunteers. Pressure was measured at the occiput, mandible, and chin. Opinions on comfort were also collected.ResultsThe Stifneck collar exceeds capillary closing pressure (CCP) for most contact points. The Philadelphia collar exposes the wearer to high pressures when supine compared with the upright position (p< 0.001). The Newport and Miami J collars exerted pressure well below CCP. The subjective comfort (scale from 0 (poor) to 5 (best)) ratings were: Stifneck = 0.85, Philadelphia = 3.00, Newport = 3.80, and Miami J = 3.45.ConclusionsWe recommend use of “patient-friendly” collars such as the Newport or Miami J because of their favorable skin pressure patterns and superior patient comfort. These collars should potentially reduce the incidence of soft-tissue complications and improve patient compliance.

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Many ventilated trauma patients thought to have nosocomial pneumonia have pulmonary contusion of systemic inflammatory response syndrome with tracheobronchial colonization. Fiberoptic bronchoscopy with quantitative culture techniques of protected specimen brush (PSB; threshold 103cfu/mL) or bronchoalveolar lavage (BAL; threshold 105cfu/mL) can potentially eliminate the false positive cultures of the upper airway seen with routine sputum aspirates (RS). However, bronchoscopy is expensive, and routine use may not be cost effective. This prospective study evaluated the patient charges associated with bronchoscopy and quantitative cultures compared with RS for the diagnosis of nosocomial pneumonia. Specimens were obtained by RS, PSB, and BAL from the lower airway in 107 trauma patients (136 sets of triplicate cultures). All patients had clinical evidence suggestive of pneumonia (fever, leukocytosis, purulent sputum, abnormal roentgenographic findings). Typical oral flora were considered contaminants; no gram-negative specimens were excluded. Mean age was 40 years and mean ISS was 29. Seventy-eight percent had blunt injuries, 22% penetrating, and 42% had chest injuries. The incidence of nosocomial pneumonia according to each method was: RS—73%; PSB—34%; BAL—25%. Considering all charges involved (bronchoscopy, equipment, microbiologic analysis, and antibiotics), and based on a 14-day course of ceftazidime and vancomycin, the charges for PSB were 58% of RS, and charges for BAL were 43% of RS. We conclude that the charges associated with bronchoscopy are high, but can be offset by antibiotic savings. Side effects of unnecessary antibiotic therapy would be avoided. Further study is needed to determine the efficacy of PSB or BAL in trauma patients.

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:Routine admission laboratory test protocols in injured patients are costly and involve excessive phlebotomy and turnaround time. The purpose of this prospective study was to evaluate the utility of (1) a microanalyzer, NOVA-SP5 (which provides rapid results on minimal blood volume), and (2) each component of our standard laboratory test battery.MethodsLaboratory test results for 200 consecutive injured patients admitted to a level ***I trauma center were evaluated by paired sample analysis. Our standard battery [60 mL: (±348): type and screen, complete blood count, PT/PTT, electrolytes, BUN, creatinine, glucose, calcium, amylase, ethanol level, and arterial blood gas] run “stat” in the central laboratory was compared to the microanalyzer profile [<1 mL: (±182): hemoglobin, hematocrit, electrolytes, glucose, Ca2+, and arterial blood gas] run by the trauma team in the resuscitation area. Patient data and laboratory turnaround time (from time of admission to time results obtained) were recorded. Data were analyzed by linear regression.ResultsComponents of the paired samples correlated well (r20.78 to 0.99). Turnaround times were 64 (±±3) and 6 (±1) minutes for standard analysis and microanalysis, respectively. Only two of the 26 patients requiring emergent surgical procedures had standard results available preoperatively. These patients had twice as many laboratory abnormalities as the remainder. Minimal diagnosis or intervention resulted from those values exclusive to standard analysis (white blood count, amylase, ethanol level, BUN, creatinine, platelet count, PT, and PTT). Six of ten abnormal BUN or creatinine results normalized, including two values in patients who received contrast for portable intravenous pyelography, and in all patients without a history of hypertension or diabetes. Platelet count and PT/PTT were normal in 85% of non-head-injured patients, compared with 58% of those with GCS score ±8.ConclusionsMicroanalysis is accurate, expedient, conserves blood, and is sufficient for evaluation of most trauma patients. Those with hypertension, diabetes, or severe head trauma may require additional testing. Routine use of this technique could reduce cost substantially (≤16,000/100 patients). The role of microanalysis in follow-up laboratory evaluation of injured patients remains to be elucidated.

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Dissatisfied with our unnecessary laparotomy rate in patients with gunshot wounds (GSWs) to the right thoracoabdomen (RTA), a prospective study was designed to test the hypothesis that hemodynamically stable patients without peritonitis could be managed without a surgical procedure. From 1990 through 1993, 13 consecutive patients with a GSW between the right nipple, costal margin, right posterior axillary line, and anterior midline were studied. No patient had or developed more than local wound tenderness. All patients had a right hemothorax treated with a chest tube. Computed tomographic (CT) scanning of the RTA was performed within 8 hours of admission in 12 of the 13 patients, and the following injuries were noted: pulmonary contusion (12), hepatic laceration (seven), spinal cord transection (two), and a renal laceration (one). Follow-up CT scans, 3 to 14 days after injury, in six of the seven patients with hepatic wounds showed partial or complete resolution of the injury in all. In one patient, an associated renal injury was unchanged on the follow-up CT scan. Mean length of hospitalization for the 11 patients who did not have an injury to the spinal cord was 5.1 days (3–8 days). Complications included atelectasis (four), a small persistent pneumothorax (two), and pneumonia (one). No complications occurred after discharge. Conclusions from this prospective study were: (1) hemodynamically stable patients without peritonitis after sustaining a GSW to the RTA can be managed nonsurgically with a low incidence of minor intrathoracic complications; (2) thoracoabdominal CT scanning is a comprehensive means of diagnosis and follow-up when nonsurgical management is chosen; and (3) such patients will usually have injury to the right lung and the liver.

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

The triazolodiazepine WEB 2086, a specific platelet activating factor (PAF) receptor antagonist, has previously been shown to prevent pulmonary hypertension, hypoxia, and bronchoconstriction when given before bacterial lipopolysaccharide (LPS). The aim of the present study was to examine whether WEB 2086 reduced these changes even when given after the onset of LPS-induced shock. In a randomized trial LPS was given intravenously (IV) in a dose of 1 μg/kg/h for 8 hours to anesthetized, ventilated pigs. Ten animals received LPS and WEB 2086, 10 mg/kg/h IV for 6.5 hours, beginning 1.5 hours after LPS. Ten control animals received LPS and saline. During treatment with WEB 2086, pulmonary hypertension was significantly attenuated compared with the findings in the control group. Gas exchange, airway pressure, extravascular lung water levels, intrapulmonary shunt, and cathepsin B levels in plasma showed a trend toward improvement but the group differences were not statistically significant. These data indicate that the PAF antagonist WEB 2086 can partially block pulmonary dysfunction and enzyme release from inflammatory cells when given during ongoing LPS shock in pigs, and that PAF may be an important mediator of the cardiopulmonary changes seen in septic shock.

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Previously, we identified the presence of a circulating shock protein (CSP) in the plasma of hemorrhaged rats that depolarizes a variety of cells in vitro. In isolated perfused rat hearts, partially purified CSP produced dose-dependent decreases in contractility and heart rate associated with an increase in coronary perfusion pressure (CPP). Electrical pacing failed to prevent the negative inotropic effects. Preventing the coronary vasoconstriction with nitroglycerin or attenuating it with a cyclooxygenase inhibitor also failed to prevent the inotropic or chronotropic effects of CSP. Carbocyclic thromboxane A2(50 ng/min) caused a similar increase in CPP to CSP but had no effect on contractility or rate during the first minute of infusion. These data indicate that the protein that appears in rat plasma after hemorrhage produces negative inotropic and chronotropic effects on the isolated heart that are independent of changes in CPP. Vasoactive arachidonic acid metabolites elicited by CSP are partially responsible for the increase in coronary vascular resistance.

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

The levels of the endogenous opioids, β-endorphin and methionine-enkephalin, were analyzed in 21 severely traumatized patients (ISS 32, mortality 42.8%) from a first blood sample drawn at the scene of the injury before resuscitation within 32 ± 16 minutes after the injury and for 8 days after trauma. Additionally, the respiratory burst function of polymorphonuclear neutrophils (PMNs) was assessed and the results were compared with those obtained from 5 healthy control patients undergoing elective surgery with the same analgesic regimen as the multiple trauma patients. Compared with elective surgery anesthesia (controls 3.3, surgery 3.2 fmol/L), the β-endorphin levels on-scene were markedly elevated (survivors 10.1 fmol/L, non-survivors 15.0 fmol/L) (p< 0.05). Methionine-enkephalin levels after trauma were not different from those of the controls. The stimulation of PMNs with different concentrations of the opioids at the first day after trauma gave results comparable with those of the controls. On the third day after trauma the reactivity of PMNs to low opioid concentrations was markedly suppressed to 79.6% of the baseline value (p< 0.05). Endogenous opioids seem to be able to modulate the nonspecific immune-response after trauma.

ISSN:0022-5282    

出版商:OVID    

年代:1994

数据来源: OVID