摘要:

BackgroundWe have advocated the use of a D-dimer assay to exclude the diagnosis of pulmonary embolism (PE) and deep venous thrombosis (DVT) in surgical and trauma patients suspected of having these diagnoses. Injury is known to increase D-dimer levels independent of thromboembolism. The purpose of this study was to assess the period after injury over which the D-dimer assay remains positive because of injury exclusive of thromboembolism.MethodsWe prospectively sampled the plasma of severely injured patients for D-dimer using an enzyme-linked immunosorbent assay method at admission; at hours 8, 16, 24, and 48; and at days 3, 4, 5, and 6. Patients were then screened for DVT with a routine duplex Doppler at day 7. Patients were followed for PE, adult respiratory distress syndrome, and disseminated intravascular coagulation.ResultsOne hundred fifty-four patients (mean Injury Severity Score of 23) underwent a total of 1,230 D-dimer assays. Twenty-six (17%) had thromboembolism. Nine (6%) patients developed DVT, 2 (1%) developed PE, 13 (8%) developed disseminated intravascular coagulation, and 11 (7%) developed severe adult respiratory distress syndrome. None of the trauma patients with thromboembolism had a (false) negative D-dimer at or after the time of their thromboembolic complication. True-negative D-dimer results as a function of time from injury are: 0 hours, 18%; 8 hours, 16%; 16 hours, 17%; 24 hours, 22%; 48 hours, 37%; day 3, 34%; day 4, 32%; day 5, 30%; and day 6, 30%. The negative predictive value of the assay was 100%. D-dimer levels were significantly higher in those who developed a thromboembolic complication than in those who did not (independent of Injury severity Score).ConclusionThese data serve to validate D-dimer as a means of excluding thromboembolism, specifically in patients with severe injury (100% negative predictive value). Before 48 hours after injury, however, the vast majority of these patients without thromboembolism had positive D-dimer assays. Because of the high false-positive rate early after severe injury, the D-dimer assay may be of little value before postinjury hour 48.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundRecombinant activated factor VII (rFVIIa) was approved for treatment of hemorrhages in patients with hemophilia who develop inhibitors to factors VIII or IX. Conditions with increased thromboembolic risk, including trauma with or without disseminated intravascular coagulation, were considered a contraindication for the drug. The mechanism of action of rFVIIa suggests enhancement of hemostasis limited to the site of injury without systemic activation of the coagulation cascade. Therefore, use of the drug in trauma patients suffering uncontrolled hemorrhage appears to be rational.MethodsSeven massively bleeding, multitransfused (median, 40 units [range, 25–49 units] of packed cells), coagulopathic trauma patients were treated with rFVIIa (median, 120 &mgr;g/kg [range, 120–212 &mgr;g/kg]) after failure of conventional measures to achieve hemostasis.ResultsAdministration of rFVIIa resulted in cessation of the diffuse bleed, with significant decrease of blood requirements to 2 units (range, 1–2 units) of packed cells (p< 0.05); shortening of prothrombin time and activated partial thromboplastin time from 24 seconds (range, 20–31.8 seconds) to 10.1 seconds (range, 8–12 seconds) (p< 0.005) and 79 seconds (range, 46–110 seconds) to 41 seconds (range, 28–46 seconds) (p< 0.05), respectively; and an increase of FVII level from 0.7 IU/mL (range, 0.7–0.92 IU/mL) to 23.7 IU/mL (range, 18–44 IU/mL) (p< 0.05). Three of the seven patients died of reasons other than bleeding or thromboembolism.ConclusionThe results of this report suggest that in trauma patients rFVIIa may play a role as an adjunctive hemostatic measure, in addition to surgical hemostatic techniques, and provides the motivation for controlled animal and clinical trials.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundThe changes in microvascular permeability characteristic of postinjury inflammation and sepsis may involve dysfunctional regulatory mechanisms at the capillary level. Pericytes, positioned abluminal to microvascular endothelium may, by their contractility, contribute to this regulation. Reactive oxygen metabolites (ROMs), well-known participants in lung inflammation, may exert an effect on pericytes, leading to changes in permeability and adult respiratory distress syndrome. This study investigates the effect of ROMs and antioxidants in an established in vitro assay of pericyte contractility.MethodsRat lung pericytes were cultured on collagen gel matrices. After exposure to the ROMs, the surface area of the collagen disks was digitally quantified (an integrated measure of cellular contraction) at 10 and 30 minutes. The cells were exposed to hydrogen peroxide and pyrogallol at 10, 100, and 1,000 &mgr;mol/L. Antioxidant effects of catalase (100 &mgr;mol/L), superoxide dismutase (100 &mgr;mol/L), and pretreatment with vitamin E (1 mmol/L) were quantified.ResultsHydrogen peroxide and pyrogallol induced concentration-dependent relaxation at 10 minutes. Conversely, concentration-dependentcontractionwas seen at 30 minutes. Catalase completely attenuated both responses, whereas superoxide dismutase had no effect. Vitamin E had no effect at 10 minutes but partially attenuated the contraction seen at 30 minutes.ConclusionROMs are capable of producing early relaxation and late contraction in cultured lung pericytes. Whereas catalase attenuates both responses, membrane-bound vitamin E only partially attenuates late contraction. This suggests two separate mechanisms: early physiologic relaxation through signaling pathways affecting actin/myosin tone, and late membrane damage causing contraction. Either pathway may cause dysfunction in pulmonary capillary fluid regulation.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundPrimed neutrophils are thought to play a key role in inflammatory pathology. We have shown though in vitro studies that interleukin (IL)-8 and growth-related oncogene-&agr; (GRO&agr;) (CXCR2-specific chemokines) regulate the respiratory burst via the CXCR2 receptor. We have also shown in vivo, CXCR2 receptors are down-regulated in severely injured patients. Our hypothesis is that regulation of the respiratory burst by CXCR2 is lost after severe injury.MethodsPatient neutrophils were studied within 24 hours of admission to the hospital; excluded were severe head injury and patients with Injury Severity Score < 16. Patient and normal neutrophils were isolated by Ficoll-Hypaque centrifugation after dextran sedimentation. Neutrophils were plated with buffer, 50 nmol/L IL-8 or GRO&agr; on fibronectin-coated plates for 15 minutes, then stimulated with 10 ng/mL of TNF&agr;. CXCR2 expression was measured by flow cytometry. Receptor function was assessed by calcium mobilization.ResultsOne female and 10 male patients with an average age of 37 ± 3 and Injury Severity Score of 24 ± 5 suffered blunt injury. CXCR2 showed a 32% ± 7% loss, whereas CXCR1 showed 15% ± 6% reduction. GRO&agr; stimulation of patient neutrophils showed 60% ± 16% decrease in calcium mobilization, whereas IL-8 showed no decline. At 40 minutes, IL-8 and GRO&agr; significantly inhibited TNF&agr; adherence-dependent peroxide production in normal neutrophils (35% ± 4% and 45% ± 3%, respectively;p< 0.05). Both IL-8 and GRO&agr; lost the ability to suppress the respiratory burst in severely injured patients, but GRO&agr; had a significantly greater loss of this suppression (p= 0.004).ConclusionIL-8 and GRO&agr; lose the ability to regulate the TNF&agr;-induced respiratory burst. This may contribute to neutrophil dysregulation after injury and result in organ injury.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectivesThe modulation of polymorphonuclear neutrophil (PMN) function by injury is unpredictable, and can predispose either to hyperimmune states (adult respiratory distress syndrome [ARDS], multiple organ failure) or to immune dysfunction, infection, and sepsis. Such outcomes have been related to excess production of the CXC chemokine interleukin (IL)-8, but PMN responses to IL-8 are mediated by both the relatively stable and IL-8 specific CXC receptor 1 (CXCR1) and the labile, promiscuous CXCR2. We hypothesized that progression to septic and multiple organ failure outcomes could be related to early differences in PMN CXC receptor status.MethodsPMNs were isolated 12 ± 3 hours after injury from 15 major trauma patients (Injury Severity Score of 34 ± 2, 11 men and 4 women, age 36 ± 4 years) who survived at least 7 days. Volunteer normal PMNs (n = 6 donors) were studied for comparison. Cells were stimulated either with the CXCR2 specific agent growth-related oncogene-&agr;, or with IL-8, which stimulates CXCR1 and CXRR2. Receptor response was assessed as the mobilization of cell calcium. The development of ARDS, sepsis, and pneumonia was assessed according to standardized criteria. Day 1 receptor activity in the clinical groups was then compared by analysis of variance with Tukey’s orttests as appropriate.ResultsIn patients that were otherwise comparable, CXCR2 responses were markedly diminished in the PMNs of patients who went on to sepsis and pneumonia, but were elevated in PMNs from the patients who went on to ARDS. CXCR1 responses were modestly lower in trauma patients than volunteers, but showed no significant variations among the various clinical outcome groups.ConclusionThe activity of PMN CXCR2 receptors soon after injury may be reflected in the later clinical sequelae of PMN activity. High CXCR2 activity may correlate with PMN hyperfunction and outcomes such as ARDS, whereas the loss of CXCR2 function in inflammatory environments may impair PMN functions in a manner that predisposes to pneumonia or sepsis. Early responses of PMN CXC receptors to injury may influence the clinical course of trauma patients.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundWe have previously documented that the admission systemic inflammatory response syndrome (SIRS) score, calculated with four variables—temperature, heart rate, neutrophil count, and respiratory rate—is a significant predictor of outcome in trauma (n = 4,887). The objective of this current study was to validate our previous findings in a larger trauma patient population, to analyze the predictive accuracy of the four individual components of the SIRS score (temperature, heart rate, neutrophil count, and respiratory rate), and to assess whether the admission SIRS score is an accurate predictor of intensive care unit (ICU) resource use in trauma.MethodsProspective data were collected on 9,539 patients admitted to a Level I trauma center over a 30-month period (January 1997–July 1999). Patients were stratified by age, sex, race, and Injury Severity Score (ISS). SIRS score was calculated at admission, and SIRS was defined as a SIRS score ≥ 2.ResultsSIRS score was validated as a significant independent predictor of outcome in trauma by logistic regression analysis after controlling for age and ISS. Of the four SIRS variables, hypothermia (temperature < 36°C) was the most significant predictor of mortality after controlling for age and ISS. Leukocytosis (neutrophil count > 12,000/mm3) was the most significant predictor of total hospital length of stay. SIRS scores of ≥ 2 were increasingly predictive of mortality and ICU admission by logistic regression analysis (p< 0.001).ConclusionThese data provide further validation that an admission SIRS score of ≥ 2 is a significant independent predictor of outcome and ICU resource use in trauma. Temperature (hypothermia) is the individual component of the SIRS score with the greatest predictive accuracy. SIRS score should be calculated on all trauma admissions.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveAccurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, and trauma registries, have been used to perform these functions. This study compares data for trauma patients from administrative and trauma registry databases at a Level I trauma center.MethodsData from patients injured in 1998 were obtained from both the trauma registry and administrative database. TheseInternational Classification of Diseases, Ninth Revision, Clinical Modificationcodes signify an admitting diagnosis of trauma. Patients from each database were “matched” by admission date, medical record number, age, and name. The two matched data sets were compared for accuracy in recording data. &khgr;2analysis was used to compare groups.ResultsThere were 2,702 patients found in both databases. One hundred eighteen patients with significant trauma were recorded in the trauma registry, but not in the administrative database. Comparison of recorded data for “matched” patients is as follows. The underreporting of mechanism of injury, diagnoses, diagnostic interventions, surgical procedures, and complications was rampant throughout the administrative database. Statistical significance was seen in the comparison between the trauma registry and the administrative database with motor vehicle collisions (458 vs. 391), abdominal injuries (346 vs. 293), orthopedic injuries (1,243 vs. 1,101), and thoracic injuries (486 vs. 397). Diagnostic interventions such as diagnostic peritoneal lavage, head computed tomographic scans, and abdominal computed tomographic scans were all grossly underrecorded, with only 40%, 12%, and 9% captured by the administrative database, respectively. Analysis of surgical procedures revealed these same trends, with statistical significance seen in abdominal and orthopedic procedures. Complications such as acute respiratory distress syndrome and deep venous thrombosis showed statistically significant differences. Mortality was underreported in the administrative database, with 14 deaths omitted.ConclusionThis study shows that administrative data have copious omissions of specific injuries, diagnostic and therapeutic interventions, as well as complications. The trauma registry recorded more of the diagnoses, diagnostics, procedures, and outcomes in the care of trauma patients. Trauma registries may be more useful than administrative databases in assessing quality of care and diagnostic and therapeutic interventions.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundSide impact collisions pose a great risk to children in crashes, but information about the injury mechanisms is limited.MethodsThis study involves a case series of children in side impact collisions who were identified through Partners for Child Passenger Safety, a large, child-focused crash surveillance system. The aim of the current study was to use in-depth crash investigations to identify injury mechanisms to children in side impact collisions.ResultsNinety-three children in 55 side impact crashes were studied. Twenty-three percent (n = 22) of the children received an Abbreviated Injury Scale (AIS) score ≥ 2 (clinically significant) injury. In these 22 children, head (40%), extremity (23%), and abdominal injuries (21%) were the most common significant injuries. Cases that illustrate body region-specific injury mechanisms are discussed.ConclusionThe cases revealed that serious injuries, particularly head injuries, occur even in minor crashes, and efforts should be made to make the interiors of vehicles more child occupant friendly. Lower extremity and abdominal injuries occurred because of contact with the intruding door. Design of vehicles to minimize crush should mitigate the occurrence and severity of these injuries.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundInstitutional protocol designates the adult trauma service as the primary manager of all adolescent traumas (age 14–18 years) unless admission to the pediatric intensive care unit (PICU) occurs. In the PICU, primary care becomes the responsibility of the pediatric intensivist, with trauma service as a consultant. The purpose of this study was to identify differences in the management of adolescent trauma between the pediatric intensivist in the PICU, and the adult trauma team in the surgical intensive care unit (SICU).MethodsFrom January 1993 to January 1998, the medical records of all adolescent trauma patients requiring intensive care unit (ICU) management were reviewed. Depending on bed availability, patients younger than 16 were admitted to the PICU, and those 16 or older to the SICU. Demographic data obtained were age, sex, race, mechanism of injury, length of stay (LOS), ICU length of stay, days on mechanical ventilation, intubation, tracheotomy, intracranial pressure monitor, and Swan-Ganz catheter placement. Home discharge, rehabilitation placement, and death were recorded. Morbidity was measured using Injury Severity Score methodology, Pediatric Trauma Score, and Pediatric Risk of Mortality.ResultsOne hundred nine completed records were reviewed (SICU, n = 58; PICU, n = 51). There was no statistical difference in sex, race, mechanism of injury, ICU LOS, tracheotomy, and intracranial pressure monitor placements. There was no difference in morbidity, as measured by Injury Severity Score, Pediatric Trauma Score, and Pediatric Risk of Mortality score or in outcome measurements (death, rehabilitation placement). SICU patients were older (SICU, 16.9 ± 1.0 years; PICU, 15.4 ± 1.0 years;p≤ 0.1 Mann-WhitneyUtest), more likely to be intubated (SICU, n = 42; PICU, n = 24;p≤ 0.05 Fisher’s exact test), more likely to have pulmonary artery catheter placement (SICU, n = 7; PICU, n = 0), and had longer LOS (SICU, 12.2 ± 10.6; PICU, 9.8 ± 14.1;p≤ 0.03 Mann-WhitneyUtest).ConclusionAdolescent trauma patients admitted to the PICU were less likely to be intubated or have a Swan-Ganz catheter placed. They had decreased LOS and days of mechanical ventilation. There was no difference in outcome measurements.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundThe aim of this prospective study was to estimate annual incidences of hospitalization for severe traumatic brain injury (TBI) (maximum Abbreviated Injury Score in the head region [HAIS] 4 or 5) in a defined population of 2.8 million.MethodsSevere TBI patients were included in the emergency departments in the 19 hospitals of the region. A prospective data form was completed with initial neurologic state, computed tomographic scan lesions, associated injuries, length of unconsciousness, and length of stay in acute care centers. Outcome at the time the patient left acute hospitalization was retrospectively assessed from medical notes.ResultsDuring the 1-year period (1996), 497 residents fulfilled the inclusion criteria, leading to an annual incidence rate of 17.3 per 100,000 population; 58.1% were HAIS5. Mortality rate was 5.2 per 100,000. Men accounted for 71.4% of cases. Median age was 44 years, with a quarter of patients more than 70 years old. Traffic accidents were the most frequent causes (48.3%), but falls accounted for 41.8% of all patients. Age and severity were different according to the major categories of external causes. In HAIS5 patients, 86.5% were considered as comatose (coma lasting more than 24 hours or leading to immediate death) but only 60.9% had an initial Glasgow Coma Scale score < 9. In the HAIS4 group, 7.2% had an initial Glasgow Coma Scale score < 9. Fatality rates were 30.0% in the whole study group, 7.7% in HAIS4, 12.8% in HAIS5 without coma, and 51.2% in HAIS5 with coma.ConclusionThis study shows a decrease in severe TBI incidence when results are compared with another study conducted 10 years earlier in the same region. This is because of a decrease in traffic accidents. However, this results in an increase in the proportion of falls in elderly patients and an increase in the median age in our patients. This increased age influences the mortality rate.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID