ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Hypovolemic shock was produced in anesthetized pigs by removal of 40% of blood volume over 10 minutes. Following blood loss, the inferior vena cava (IVC) was occluded below the renal veins to simulate the hemodynamics of emergency surgical treatment. Control animals were not treated. Experimental animals received intravenous lactated Ringer's solution equal to three times the blood loss given through catheters either in the IVC or the superior vena cava (SVC) to determine if lower extremity access would be efficacious in this model. To define the path taken by the resuscitation fluids, an additional group of animals received technetium-99m-labelled crystalloid through lower extremity catheters with continuous recording of isotope counts in the IVC and right atrium. The treated animals in all experimental groups had significant improvements in mean arterial pressure, cardiac output, and pH compared with controis. There was no significant difference in hemodynamic response in animals receiving volume replacement through the IVC compared with the SVC. When fluid was infused below a clamped IVC, the arrival of isotope in the right atrium was delayed only 1.5 seconds. We conclude that in a model simulating emergency control of potentially lethal hemorrhage, the beneficial effects of fluid resuscitation are unrelated to the site of venous access. Lower extremity veins provide a valuable site for volume replacement even with IVC occlusion. These findings should have direct application to resuscitation and surgical care of seriously injured patients.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Purpose: To analyze the effect on mortality of a protocol for early mobilization with external fixation of patients with pelvic ring injuries.MethodsFrom 1981 through 1988, 605 patients with pelvic ring fractures and dislocations were treated. In 1982, a protocol for early external fixation of hemodynamically unstable patients and those with structurally unstable pelvic fracture patterns to achieve early mobilization to an upright chest position was initiated. Mortality rates were compared between 1981 (pre-protocol), 1982 (transitional), and 1983 through 1988, after initiation of a protocol of care that included external fixation of the pelvic injury. No statistical changes occurred from 1983 through 1988.ResultsMortality rates in pelvic ring injury patients fell from 26% in 1981, to 6% in 1983 through 1988 (p< 0.001), whereas during the study period the mean Injury Severity Score (ISS), 23, did not change. The mortality rate of a group of consecutive patients with comparable ISSs. but without pelvic ring injuries did not change. The mortality rate in patients with systolic blood pressure < 100 mm Hg at admission fell from 41% in 1981 to 21% 1983 through 1988 (p= 0.0001). Mortality in patients with closed head injuries associated with pelvic ring injuries fell from 43% in 1981 to 7% from 1983 through 1988 (p= 0.0001). The proportion of patients undergoing external fixation rose from 3% in 1981 to 31% in 1983 through 1988 (p= 0.0001).ConclusionsAn organized protocol including external fixation and early patient mobilization to an upright chest position reduced mortality associated with injuries of the pelvic ring. Orthopedic stabilization of major skeletal injuries should be viewed as part of patient resuscitation, not reconstruction.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Fractures caused by gunshots are increasingly common in urban hospitals and trauma centers. The rising incidence and complexity of these injuries present difficult management problems and health care burdens. In a 3-year period, from 1989 through 1991, 21 patients with femoral shaft fractures from low-velocity bullets were treated with intramedullary fixation within 15 hours of admission. Eighteen patients were available for follow-up. The fractures had healed in all patients. Average hospitalizetion for an isolated injury was 7 days. There were no complications related to immediate internal fixation. Immediate internal fixation of femoral shaft fractures caused by low-velocity gunshots can be performed in an efficient and cost effective manner.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

The efficacy and safety of very hot (65°C/149°F) intravenous fluid (IVF) were compared with those of conventional warm (38°C/100.4°F) IVF in the treatment of hypothermia. Eight anesthetized beagles (11–20 kg) were studied. Blood pressure (BP), pulse (P), and core temperature (cT°) were recorded at baseline, during hypothermia, and during rewarming. The plasma free hemoglobin (PFHg) was measured to assess hemolysis. Each subject was cooled to 32°C/89.6°F and assigned to receive either 65°C or 38°C IVF via a specially designed multiport balloon-tipped catheter in the superior vena cava (SVC). The IV fluid rate was 80% of the blood volume per hour. Conventional rewarming methods were used in all subjects. After 2 hours the subjects were killed and the SVC was examined for injury. The rate of rewarming was 2.9°C/hour in the 65°C IVF group and 1.25°C/hour in the 38°C IVF group. The cT° was significantly different in all subjects after 1 (35.2° ± 1.03°C vs. 33.2° ± 0.5°C;p< 0.006) and 2 (37.6° ± 1.17°C vs. 34.3° ± 0.9°C;p< 0.004) hours of rewarming. The BP, P, and PFHg were not different. Visual examination of the SVC revealed two lesions in the 65°C IVF group and one in the 38°C group. Mechanical or thermal injury could not be differentiated. We conclude that 65°C IVF is more effective than 38°C IVF in the treatment of hypothermia. In addition, 65°C IVF did not uniformly cause hemolysis or injure the SVC.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

We compared the rapidity of rewarming and infusing red blood cells (RBCs) mixed with 24°C, 50°C, and 60°C saline with the rapidity of administering undiluted RBCs through a heat exchanger. We measured flow rate, final temperature, and hemolysis in matched 41–45-day-old pooled AS-1 RBCs infused through high-flow tubing via a 14-gauge catheter under the influence of gravity. Undiluted RBCs were tested as controls. The final temperature of the 60°C admixture technique was lower than that with the heat exchanger (28.5 ± 0.2°C vs. 32.7 ± 0.2°C), but the flow rate was higher (258 ± 8 mL/min vs. 61 ± 4 mL/min). Admixture with 60°C saline resulted in no increase in hemolysis. This technique appears to be a simple, inexpensive method for rapid rewarming and infusion of RBCs and may be valuable for administration of RBCs simultaneously through multiple sites during resuscitation.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Vascular injury has been reported in up to one third of patients with posterior knee dislocations, which has led to the routine use of arteriograms in the management of these injuries. Recent studies have shown physical examination (PE) is reliable in detecting significant vascular injuries requiring surgery from other mechanisms. We hypothesized that PE would be similarly sufficient to assess popliteal injury in patients with posterior knee dislocations. To test this, we reviewed the records of all 37 patients with 38 such injuries at our institution over the past 5 years. The average age was 29.5 years, and 31 patients (81.5%) had other associated injuries. All dislocations were the result of blunt trauma. Two patients (5.3%) had hard signs (distal ischemia and no pulses) that clearly indicated vascular injury. Total occlusions of the popliteal artery were seen on arteriograms in both cases and these were successfully treated surgically with reversed saphenous vein bypass grafts. The remaining 36 dislocations manifested no hard signs of vascular injury (absent pulses, distal ischemia, active bleeding, bruit/thrill). Nineteen patients (50.0%) had normal vascular examination results, did not receive arteriograms, and had no adverse sequelae, with a mean follow-up of 9.3 months (range 1 day-43 months). Sixteen patients with 17 dislocations (44.7%) underwent arteriography and the findings appeared normal in ten extremities; nine of these extremities had normal pulses and one had a diminished but palpable pulse. A minimal injury (intimal defect, 3; narrowing, 4) was demonstrated in seven extremities, five with normal pulses and two with diminished pulses. All seven minimal lesions were treated conservatively (no surgical procedure or anticoagulation) and demonstrated no further complications with a mean follow-up of 11.5 months (range, 10 days-3 years). Four of these seven patients had a repeat arteriogram that showed resolution of the vascular injury at 2, 6, 7, and 12 weeks. Physical examination alone predicted the need for surgical intervention with 100% accuracy based on the presence of hard signs. Since information from arteriograms did not alter treatment over and above that of physical examination, this study suggests that the routine use of arteriography is not warranted in the management of patients with posterior knee dislocation.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Tumor necrosis factor-alpha (TNF-α) has been implicated in several late consequences of trauma such as sepsis, multiple organ failure, and ischemia-reperfusion injury. However, no data are available to indicate whether TNF-α is involved in the initial pathophysiologic response to trauma. To address this issue, serum TNF-α was determined (by ELISA) longitudinally (first blood sample on admission) in 100 randomly selected trauma patients admitted to the emergency department and trauma division at Jefferson Medical Center, Philadelphia. The TNF-α levels were detectable at one or more time points in 35 patients. Mean values tended to be elevated (50.3 ± 11.5 pg/mL) during the first 5 days, but this trend did not differ statistically from that in healthy controls (n = 12) and did not correlate with the severity of injury (Injury Severity Score and Glasgow Coma Scale score). The TNF-α response was not dependent on the mechanism and site of injury, the presence of shock (systolic blood pressure <90 mm Hg), and the need for emergent surgery. Also, serum TNF-α levels were not significantly elevated in patients who subsequently developed multiple organ failure (n = 4), septic shock (n = 5), or both (n = 3). Taken together, these data do not support a role for circulating TNF-α in the initial acute inflammatory response to trauma.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Prolonged hemorrhagic shock is characterized by the progression from hyperglycemia to hypoglycemia and failure to respond to standard methods of resuscitation. Previous studies have shown that the transition to irreversible shock is accompanied by attenuation of hepatic gluconeogenic capacity and a rising level of intracellular calcium. Additionally, it has been observed that diltiazem improves survival following prolonged hemorrhagic shock in rats. We examined the effect of resuscitation containing diltiazem upon hepatic gluconeogenesis during early and late phases of hemorrhagic shock in a rat model. Fasted male Sprague-Dawley rats (250–350 g) were rapidly bled to a mean arterial pressure of 40 mm Hg for a period of 30 minutes (group A) or 120 minutes (group B). At the end of the hemorrhagic shock period, rats were randomized to resuscitation utilizing lactated Ringer's (LR) solution, or LR + diltiazem (DZ, 1.2 mg/kg). Following resuscitation, rats underwent laparotomy and in situ liver perfusion with an oxygenated 37°C glucose-free Krebs solution via the portal vein. After equilibration, 5 mmol/L lactate and 0.5 mmol/L pyruvate were added to the perfusate as substrate and effluent samples collected. Serum glucose concentration and portal venous flow did not differ significantly between DZ and LR groups throughout the study periods. In group A, hepatic glucose production was significantly elevated in DZ animals when compared with controls (p< 0.05). A similar significant improvement in gluconeogenesis was observed following 120 minutes of hemorrhagic shock in group B (p< 0.05). Additionally, treated rats (DZ, both groups A and B) demonstrated improved gluoneogenic response to substrate when compared with controls. Hemorrhagic shock is associated with attenuation of hepatic gluconeogenesis in response to substrate. The addition of diltiazem to standard LR resuscitation restores hepatic gluconeogenic response following hemorrhagic shock.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

We investigated the effects of primary (≤24 h) intramedullary femoral nailing on lung function and pulmonary hemodynamics in patients with multiple trauma. Two groups were separated: the group with primary femoral nailing with reaming (group RFN) was submitted to femoral nailing after reaming of the medullary canal; in the group with unreamed femoral nailing (group UFN) a small-diameter solid nail was inserted without reaming. Lung function was assessed by oxygenation ratio (Pao2/Fio2), and pulmonary hemodynamics by intraoperative pulmonary artery catheter measurements. Central venous blood concentrations of elastase and the platelet count were determined during and 3 days after surgery. Lung function was stable in UFN patients (n = 14), but deteriorated in RFN patients (n = 17) from 353 ± 24 (Pao2/Fio2preoperatively) to 260 ± 28 (Pao2/Fio2postoperatively) (p< 0.05) and improved only after 48 hours. Pulmonary artery pressure (PAP) did not change during surgery in UFN patients; in RFN patients PAP increased from 27.2 ± 3.1 mm Hg (preoperatively) to 36.3 ± 4.1 mm Hg (p< 0.05) upon reaming and normalized 1 hour after insertion of the nail. Femoral nailing after reaming represents a potential risk with respect to lung function disturbances. This might trigger the development of adult respiratory distress syndrome (ARDS), especially in patients at extra risk of this complication (additional lung contusion, “borderline patient”). In these cases unreamed femoral nailing might offer an alternative by allowing primary intramedullary stabilization without the risk of adverse effects to the lung.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID