摘要:

BackgroundExperimental studies have shown that hemorrhagic shock is associated with the expression of inducible heat proteins, especially heat shock protein (Hsp) 72, in liver, brain, heart, and kidney. Moreover, induction of Hsp 72 by various stressors before the onset of shock has been associated with the attenuation of organ injury caused by hemorrhage. However, it is not known whether Hsp 72 is expressed after severe trauma in humans. The purpose of this study was therefore to determine whether Hsp 72 could be detected in the serum of patients early after severe trauma and whether serum levels of Hsp 72 might correlate with survival of trauma patients or the severity of the postinjury inflammatory response.MethodsClinical data were collected prospectively over a 3-year period for trauma patients mechanically ventilated for more than 2 days who met the following inclusion criteria: Injury Severity Score ≥ 16, and age > 18 years. Physiologic data for quantitative assessment of organ dysfunction were collected for each patient. Hsp 72 and nitrate and nitrite levels were measured in the serum of trauma patients collected at or 12 to 48 hours after the admission to the emergency department.ResultsSixty-seven patients with severe trauma were enrolled in the study. Hsp 72 was detected in the serum of all trauma patients. All patients with high initial serum levels of Hsp 72 (serum levels > 15 ng/mL) survived, whereas 29% of the patients with low Hsp 72 serum levels died from their traumatic injuries (p= 0.01). The overall mortality was 21%, occurring within 5 to 7 days. Patients who died were older (mean age, 54 ± 15 years) than those who survived (mean age, 36 ± 15 years) (p< 0.0.05). The cause of death was attributable to head injury in 79%, although the severity of head injury (Abbreviated Injury Scale score) was not statistically different between survivors with high serum values of Hsp 72 and patients who died. There was no correlation between the initial serum Hsp 72 values and the severity of organ dysfunction or clinical indicators of the inflammatory response.ConclusionHsp 72 can be detected in the serum of severely traumatized patients within 30 minutes after injury. Elevated initial serum levels of Hsp 72 (serum levels > 15 ng/mL) are associated with survival after severe trauma, but are not related to the incidence or severity of the postinjury inflammatory response or organ dysfunction.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundA delayed diagnosis of injury to cervicothoracic vessels from blunt trauma may cause significant adverse sequelae. The association of a cervicothoracic seat belt sign with such an injury is unknown.MethodsAlgorithms were prospectively studied for the detection of occult vascular injury in patients with cervicothoracic seat belt signs. Patients with neck seat belt signs underwent arteriography or computed tomographic angiography (CTA). Those with thoracic seat belt signs underwent aortography/arteriography if a ruptured thoracic aorta or injury to a great vessel was suspected or a neurovascular abnormality was present.ResultsDuring a 17-month period, 797 patients were admitted to the trauma service secondary to motor vehicle crashes. One hundred thirty-one (16.4%) had cervical or thoracic seat belt signs. Four (3%) of the patients had carotid artery injuries, the presence of which was strongly associated with a Glasgow Coma Scale score < 14, an Injury Severity Score > 16 (p< 0.0001), and the presence of a clavicle and/or first rib fracture (p< 0.0037). Of the remaining patients, 17 had thoracic trauma. There were no vascular injuries in the children and only one had thoracic trauma.ConclusionThe algorithms are safe and accurate for the detection of cervicothoracic vascular injury in adult and pediatric patients with seat belt signs. The cervicothoracic seat belt mark and an abnormal physical examination are an effective combination in screening for cervicothoracic vascular injury.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundIncreased intra-abdominal pressure has been shown to result in a myriad of physiologic aberrations that result in the abdominal compartment syndrome (ACS). The clinically relevant combination of hemorrhagic shock and resuscitation and subsequent ACS, however, has not been studied in detail. We hypothesized that sequential hemorrhagic shock (HS) and ACS would result in greater cytokine activation and polymorphonuclear neutrophil (PMN)-mediated lung injury than with either insult alone.MethodsTwenty Yorkshire swine (20–30 kg) were studied. Group 1 (n = 5) was hemorrhaged to a mean arterial pressure of 25 to 30 mm Hg for 60 minutes and resuscitated to baseline mean arterial pressure. Intra-abdominal pressure was then increased to 30 mm Hg above baseline and maintained for 60 minutes. Group 2 (n = 5) was subjected to HS alone and Group 3 (n = 5) to ACS alone. Group 4 (n = 5) had sham experiment without HS or ACS. Central and portal venous interleukin-1&bgr;, interleukin-8, and tumor necrosis factor-&agr; levels were serially measured. Bronchoalveolar lavage (BAL) for protein and PMNs was performed at baseline and 24 hours after resuscitation. Lung myeloperoxidase was evaluated at 24 hours after resuscitation.ResultsPortal and central vein cytokine levels were equivalent but were significantly higher in Group 1 than in other groups. BAL PMNs were higher (p< 0.05) in Group 1 (4.1 ± 2.0 × 106) than in the other groups (0.6 ± 0.5, 1.4 ± 1.3, and 0.1 ± 0.0 × 106, respectively) and lung myeloperoxidase activity was higher (p< 0.05) in Group 1 (134.6 ± 57.6 × 106/g) than in the other groups (40.3 ± 14.7, 46.1 ± 22.4, and 7.73 ± 4.4 × 106/g, respectively). BAL protein was higher (p< 0.01) in Group 1 (0.92 ± 0.32 mg/mL) compared with the other groups (0.22 ± 0.08, 0.29 ± 0.11, and 0.08 ± 0.06 mg/mL, respectively).ConclusionIn this clinically relevant model, sequential insults of ischemia-reperfusion (HS and resuscitation) and ACS were associated with significantly increased portal and central venous cytokine levels and more severe lung injury than HS or ACS alone.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe purpose of this study was to show that blunt diaphragmatic rupture does not require immediate emergency operation in the absence of other indications.MethodsWe reviewed all patients with blunt diaphragmatic rupture admitted within 24 hours of injury to one of six university trauma centers providing trauma care for the province of Quebec from April 1, 1984, to March 31, 1999. Multivariate analysis of demographic profiles, severity indices, indications for operation, and preoperative delays was performed.ResultsThere were 160 patients (91 men and 69 women) with blunt diaphragmatic rupture. Mean age was 40.1 ± 16.2 years. Mean Injury Severity Score was 26.9 ± 11.5 and mortality was 14.4%. Patients undergoing emergency surgery for indications other than diaphragmatic rupture had a significantly higher Injury Severity Score than those undergoing surgery for repair of diaphragmatic rupture alone (34.7 ± 10.7 vs. 22.0 ± 9.0,p< 0.001). In patients undergoing surgery for diaphragmatic rupture alone, delay before repair of the diaphragmatic hernia did not lead to an increased mortality compared with patients undergoing immediate surgery (3.4% vs. 5.0%,p= NS).ConclusionBlunt diaphragmatic rupture in the absence of other surgical injuries carries low mortality. Operative repair of diaphragmatic rupture can be deferred without appreciable increased mortality if no other indication mandates immediate surgery.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundFactors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system.MethodsEligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation.ResultsOf 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity.ConclusionSoft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe optimum method for skeletal stabilization of severe open fractures of the tibial shaft remains controversial.MethodsWe compared the results of the AO unreamed tibial nail (URTN) with external fixation (Ex-Fix) in the treatment of patients with a grade III injury of the tibial diaphysis. Thirty patients were retrospectively reviewed, with a mean follow-up of 25 months (range, 12–56 months). Seventeen patients were treated with external fixation (grade IIIA, 12 patients; grade IIIB, 4 patients; and grade IIIC, 1 patient) and 13 with a URTN (grade IIIA, 6 patients; grade IIIB, 6 patients; and grade IIIC, 1 patient). Both groups were comparable with respect to age, gender, fracture severity, and Injury Severity Score.ResultsMean time to full weight bearing was 37.4 weeks in the Ex-Fix group versus 22.2 weeks in the URTN group (p= 0.0069,ttest). Seven patients in the Ex-Fix group required further surgery for nonunion versus two in the URTN group. There were four significant pin track infections. Removal of URTN was required in one case of deep infection.ConclusionThis study supports the use of the URTN over external fixation in the treatment of severe open tibial fractures.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe purpose of this study was to determine the incidence, relationship with the ankle diastasis, and effect of treatment of the anterior tibiofibular ligament avulsion fracture (Wagstaffe fracture) combined with the Weber type B lateral malleolar fracture.MethodsThis study reviewed 94 cases of ankle fractures treated with operative methods.ResultsThere were 52 cases of Weber type B lateral malleolar fractures and 13 cases of Wagstaffe fractures combined with them (25%). Ankle diastases were diagnosed in 20 cases (38.5%) in all Weber type B fractures and 11 (84.6%) of the 13 Wagstaffe fractures.ConclusionThe Wagstaffe fracture can be a good diagnostic clue of ankle diastasis in Weber type B lateral malleolar fracture. The accurate reduction and fixation of the avulsed fragment is important for restoration of the stable distal tibiofibular joint and to prevent the chronic ankle joint pain caused by impingement of the avulsed fragment.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundPatients with diabetes mellitus may be at increased risk of accidents, mainly because of hypoglycemia. A variety of approaches have been adopted in an attempt to quantify this risk, but there has not been, to date, a systematic study using a national trauma register. In this study, we report findings from the Scottish Trauma Audit Group database.MethodsThe database includes all patients admitted to hospital for 3 or more days, or who died in hospital as a result of their accident. The study includes 11,244 cases aged 15 years or over entered into the database between July 1996 and June 1998. This included 151 patients with insulin-treated diabetes. Using detailed prescribing information from one representative region, we have calculated the rates of different types of accidents for patients treated with insulin and compared this with the control population. We have analyzed information on the mechanism and severity of injury, outcome, and length of hospital stay.ResultsOverall, the rate of accidents for insulin-treated patients was estimated at 291.2 per 100,000 population per year compared with 148.4 for the control population (p< 0.001; relative risk, 1.97; 95% confidence interval, 1.68–2.32). Insulin-treated patients were, on average, older (p< 0.005), more likely to be women (p< 0.02), and had longer stay in hospital (p< 0.001). The major excess of injuries related to low falls (< 2 m), which accounted for 62.3% of the injuries in the insulin-treated group compared with 47.1% in the remainder (p< 0.01). Low falls in the insulin-treated group (n = 94) were examined in detail: compared with the control population, there was no difference in age and sex, Injury Severity Score, Revised Trauma Score (a measure of the severity of physiologic disturbance), or calculated probability of survival (TRISS). Length of inpatient stay was higher in the insulin-treated low-fall patients (10 vs. 7 days,p< 0.01). Of the 151 catalogued injuries, the vast majority were fractures at peripheral sites. Only 23 insulin-treated individuals were admitted after a motor vehicle crash during the study period. This represents a slight but not significant increase above the rate for the background population.ConclusionThis study confirms that patients taking insulin are at increased risk of accidents. Among the different types of injury, only low-impact falls were significantly increased. This is most likely related to an increased tendency for insulin-treated patients to fall during a hypoglycemic episode. However, patients with diabetes may also be at higher risk of sustaining a fracture after a fall. The number of car crashes involving drivers with insulin-dependent diabetes is small, and the rate is not significantly greater than that of the background population. Further study of the causes and consequences of falls in diabetic patients is warranted.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundIn a statistical outcome analysis covering 10 years, 554 patients with isolated head trauma were analyzed. The aim of this study was to combine clinical and computed tomographic characteristics in a prognostic scoring system determining outcome after head injury.MethodsAfter collection of data, mortality and morbidity were determined for each clinical and radiologic parameter; a different grading from 1 to 8 points was then attached to each parameter. The total score for each patient was calculated by adding the individual points from the different parameters.ResultsSignificant differences in outcome (p< 0.01, Mann-WhitneyUtest) were registered in steps from 0 to 10 points (group I), 11 to 20 points (group II), and > 20 points (group III). Group I had a mortality of 8.3%, and patients in groups II and III died in 51.2% and 80.8%, respectively. Patients in group I had a Glasgow Outcome Scale (GOS) score of 4 and 5 in 19.4% and 56.7%, respectively, whereas group II reached a GOS score of 4 or 5 in only 9.9% and 1.7%, respectively. Patients in group III never reached a GOS score of 4 or 5.ConclusionThe presented scaling system allows a predictive value in mortality and morbidity to be determined for each patient suffering from brain trauma.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundAlcohol intoxication is associated with a high incidence of traumatic injury, particularly in the young healthy population. The impact of alcohol intoxication on the immediate pathophysiologic response to injury has not been closely examined. We hypothesized that acute alcohol intoxication would aggravate the immediate outcome from hemorrhagic shock by impairing homeostatic counterregulation to blood loss.MethodsChronically catheterized male Sprague-Dawley rats were randomized to receive an intragastric infusion of ethyl alcohol (1.75 g/kg followed by 250–300 mg/kg/h) or isocaloric dextrose (3-mL bolus + 0.375 mL/h) for 15 hours. Before initiating fixed-pressure hemorrhage followed by fluid resuscitation, an additional intragastric bolus of ethyl alcohol (1.75 g/kg) was administered. Hemodynamic, metabolic, cytokine, and acid-base parameters were assessed during the hemorrhage period and at completion of resuscitation. Lungs were obtained for cytokine determinations.ResultsBasal mean arterial pressure was significantly lower in alcohol-intoxicated (blood-alcohol concentration, 135 ± 12 mg/dL) animals than in controls during baseline (20%) and after the initial fluid resuscitation period (30%). Hemorrhage decreased arterial HCO3and Pco2, and increased Po2without significant alteration in arterial blood pH. Alcohol intoxication blunted the decrease in Pco2and increase in Po2and decreased blood pH during baseline and throughout the course of the hemorrhage period. Hemorrhage produced marked and progressive elevations in plasma glucose and lactate levels in controls, and this was inhibited by alcohol intoxication. Hemorrhage elevated plasma tumor necrosis factor-&agr; (TNF-&agr;) (686 ± 252 pg/mL) and interleukin (IL)-10 (178 ± 25 pg/mL), and did not alter IL-6 and IL-1 levels. Alcohol blunted the hemorrhage-induced rise in plasma TNF-&agr; (142 ± 48 pg/mL) and enhanced the hemorrhage-induced increase in IL-10 (678 ± 187 pg/mL). Hemorrhage produced a two- to threefold increase in lung content of TNF-&agr;, IL-1&agr;, and IL-6 without significantly altering lung IL-10. Alcohol exacerbated the hemorrhage-induced increase in lung TNF-&agr;, and did not alter the IL-1&agr;, IL-6, and IL-10 lung responses.ConclusionThese results indicate marked alterations in the hemodynamic and metabolic responses to hemorrhagic shock by alcohol intoxication. Furthermore, our findings suggest that alcohol modulates the early proinflammatory responses to hemorrhagic shock. Taken together, these alterations in metabolic and inflammatory responses to hemorrhage are likely to impair immediate outcome and predispose to tissue injury.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID