摘要:

We have previously reported that severe burn injury was regularly accompanied by impaired lymphocyte responses to T cell mitogens, circulating suppressor lymphocytes, and serum factors suppressive of lymphocyte activation. However, in burned patients it was difficult to determine whether these manifestations of suppressed immunity were predictive of, or the result of, sepsis which was ubiquitous in this population. In an attempt to clarify this issue, we have studied 31 patients with multiple trauma (without burns) mean age, 31 years; average injury severity score, 22; range, 9–56; in whom sepsis was less common. Patients were tested for lymphocyte response to the T cell mitogens PHA and Con A, the percentage of circulating putative suppressor (OKT8) and helper (OKT4) T cells using monoclonal antibodies, circulating suppressor cell activity as revealed by functional assays, and serum suppression of lymphocyte activation. Patients were compared with ten normal volunteers (mean age, 32) studied simultaneously. Significant suppression (>50% compared with controls) in lymphocyte responses to mitogens 1 to 5 days after injury was seen in 12 patients, was accompanied by a shift in the ratio of helper (OKT4) to suppressor (OKT8) T cells (patients, 0.96:1; normals, 1.82:1;p< 0.01), and was followed by the appearance of significant (>50%) serum suppressive activity in six of the 12 patients. Circulating suppressor cell activity as revealed by functional assays was also seen early after injury in three of 12 patients. In the entire group of 31 patients mean suppression of lymphocyte PHA responses improved with time (1 to 5 day suppression, 35 ± 8%; 10 to 20 day suppression, 10 ± 6%;p< 0.005) but persisted in three patients, two of whom developed clinical sepsis and survived and one who died as a result of his injuries and sepsis. The degree of serum suppression seen early after injury in these patients correlated with the severity of trauma (r= 0.929), a finding supported by similar studies performed in 18 additional patients undergoing uncomplicated elective abdominal aortic aneurysm repair who showed minimal serum suppression of normal lymphocyte mitogen responses (14 ± 5%) postoperatively and no shift in the OKT4:OKT8 T cell ratio. We conclude that impaired lymphocyte function commonly follows serious injury and while it may predispose to sepsis it is not necessarily caused by it.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

This study was undertaken to determine the feasibility of constructing an anterior pelvic external fixator capable of resisting displacement of vertical shear fractures. Newly designed tapered thread pins for cancellous bone had better bone pin fixation and their greater 6-mm diameter provided more than twice the stiffness of Hoffmann 4-mm pins when tested in clusters. Using these pins and a more rigid anterior frame as one model, various pelvic fixators were tested to determine their resistance to vertical shear forces. These tests determined that this new fixator was 16 times stiffer than a Bonnel single anterior frame and five times stiffer than a double anterior frame (both constructed of Hoffmann components). Extrapolation from the data shows that 13 mm of posterior fracture displacement would occur with loads of one half body weight using the new fixator. Additionally it was noted that Hoffmann frames constructed with two 5-mm pins performed as well as those using three 4-mm pins.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

Military anti-shock trousers (MAST) have achieved widespread civilian usage because of reported effectiveness in treating hypovolemic shock. The literature, however, consists of either case reports or series in which no controls were evaluated. No published reports exist which compare similar groups of patients treated with and without MAST in the pre-hospital setting. We reviewed the paramedic and emergency department records of 226 patients sustaining moderate to severe trauma who were transported to San Francisco General Hospital by paramedics over a 15 month period. MAST usage during this period was approximately random as a result of logistical and training constraints. For analysis, patients were divided into two groups: those in whom MAST was applied and inflated during transport and those in whom it was not used. Paramedic interventions other than MAST were similar in both groups. Trauma Scores (TS), and blood pressure index (>90 = 4, 70–89 = 3, 50–69 = 2, 0–49 = 1, no pulse = 0), were calculated for initial field observations and initial emergency room evaluation after hospital arrival. Patients with isolated head injury were excluded. The average change in TS and BP index (E.R.—field value) was calculated for MAST and non-MAST groups of patients. Mortality and total field times were also evaluated.Average TS and BP index increased slightly in both groups. Use of MAST produced no significant improvement in trauma score, BP index, or mortality over non-MAST patients. There was no demonstrable field benefit of MAST in fully arrested patients. The field application of MAST did not delay transport as similar field times were observed in MAST and non-MAST groups.While the observed increases in TS and BP index in MAST patients are consistent with previous reports, there appears to be no advantage to using MAST in addition to conventional in-field treatment. This study suggests that the expense and extra training required for MAST utilization may not be justified in an urban setting with short transport times. Prospective randomized studies are clearly needed to establish its proper role or non-role in trauma management.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

Use of the military antishock trouser (MAST) remains controversial in part because its mechanism(s) of action are poorly understood. We studied two aspects of the hemodynamic response to MAST inflation in 14 anesthetized swine. First, in six swine the relation that existed between inferior vena cava flow and aortic pressure/cardiac output was determined before and during inflation of the MAST, and then before and after removal of 30% of the calculated blood volume. Inflation of the MAST before hemorrhage had little effect on cardiac output but increased aortic pressure by 25%. Inflation of the MAST after hemorrhage increased cardiac output by 41% and increased aortic pressure by 62%. Three different inflation pressures were studied (40, 80, and 120 mm Hg) and were found to give equivalent results. Inflation of the MAST translocated about 3 ml/kg of blood to the heart. A second group of eight swine were instrumented so that the radiomicrosphere technique could be used to measure organ blood flow. Inflation of the MAST following hemorrhage increased coronary perfusion by 50% and cerebral perfusion by about one third. Flow to kidney, liver, and small intestine was not changed. We conclude that, in addition to tamponade of venous bleeding and the splinting of lower extremity fractures, use of the MAST might cause a clinically important increase in the perfusion of the heart and brain in some trauma patients.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

Changes in intracranial pressure, mean arterial blood pressure, and cerebral perfusion pressure in response to sequential inflation of the pneumatic antishock garment were monitored in 12 patients with severe head injury and initial intracranial pressure less than 20 mm Hg. The small incremental increases in intracranial pressure that occurred with inflation of the pneumatic antishock garment were compensated for by improved hemodynamic stability and elevated mean arterial blood pressure which produced a simultaneous rise in cerebral perfusion pressure.The treatment of hypotension in traumatized patients with head injuries is paramount and sequential slow inflation of the pneumatic antishock garment can be used in such patients without apparent ill effect to the brain when the initial intracranial pressure is 20 mm Hg or below. Further study is needed to determine the safety of the device in head injured patients with elevated intracranial pressures.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

A total of 74 patients with urethral injury due to external trauma consisted of 48 posterior urethral injuries (25 complete rupture, 23 partial rupture) and 26 anterior urethral injuries (two complete rupture, 16 partial rupture, and eight contusion). The diagnosis was made by retrograde urethrography. All 48 patients with posterior urethral injury had associated injuries, including a fractured pelvis in 46, and a mortality rate of 33%. Only seven of the 26 patients with anterior urethral injury had associated injuries and a mortality rate of 14%. The management of posterior urethral injury is changing from primary realignment of the ruptured urethra to suprapubic cystostomy alone and followed later by urethral surgery for the resulting stricture. The impotence rate is significantly lower with management with suprapubic cystostomy alone. However, the type of pelvic fracture, the urethral injury itself disrupting neurovascular structures, and the surgical dissection (initial primary realignment or delayed urethroplasty) must be investigated before it can be determined whether the impotence associated with pelvic trauma is caused by the injury itself or by the surgical dissection undertaken to reconstruct the urethra.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

A case of tracheo-carotid artery erosion in a patient who required only endotracheal intubation is presented. This appears to be the first case reported in the world literature that was not associated with a tracheostomy. Etiologic factors leading to this complication include direct pressure from the tube tip, abrasions during intubation, muscosal damage from cuffs, and CPAP, even over a short time. Selection of an endotracheal tube with a high-compliance, low-pressure cuff, careful intracuff pressure monitoring, prevention of infection and hypotension, and improvement in the patient's nutritional and immunologic status will help to prevent this complication. Any patient bleeding more than 10 ml without cause should be suspected of having this complication. Rapid treatment is necessary for survival. Patients should be intubated and the cuff inflated. Bronchoscopic examination should be done in the operating room under general anesthesia with neck and chest prepped and draped. Median sternotomy or possibly right anterior thoracotomy is recommended. Resection of involved vessels has been successful.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

The successful operative treatment of aortic valve disruption caused by forceful blunt chest trauma in a 30-year-old previously healthy man is reported. The patients' left coronary cusp was completely avulsed at its annular insertion. Aortic valve replacement with a 23-mm Carpentier-Edwards porcine xenograft was performed. The literature on this rare condition is reviewed.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

We report a unique case of extensive surgery for severe lye burns. It included total esophago-gastro-duodeno-jejunectomy and partial pancreatectomy. We were unable to find a similar successfully treated case in English-language literature. Ninety-one days after the initial emergency surgery, the patient successfully underwent reconstruction of alimentary tract with isoperistaltic left colon interposition between proximal cervical esophagus and ileum.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID