摘要:

ObjectiveTo determine the neurologic risks associated with early fracture fixation (FF) in multitrauma patients with head injuries.Methods24 hours after injury. The two groups were well matched in regards to age, 40.3 years (range, 8-88 years) versus 36.4 years (range, 8-75 years), admission Glasgow Coma Scale score (12 +/- 4 vs. 11 +/- 5), and Injury Severity Score (25 +/- 10 vs. 27 +/- 12). Additionally, the groups had similar neurologic and orthopedic injury scores (AIS-CNS score = 3.3 +/- 0.9 vs. 3.1 +/- 0.9, AIS-Ortho score = 3.0 +/- 0.9 vs. 2.9 +/- 0.7). Data were collected concerning the volume of fluid resuscitation, neurologic complications, and clinical outcomes.ResultsThe early FF group received significantly more fluids in the first 48 hours (14.0 +/- 10.2 vs. 8.7 +/- 3.5 liters, p < 0.05). The early group trended towards a higher rate of intraoperative hypotension (systolic blood pressure < 90 mm Hg, 16% vs. 7%) and intraoperative hypoxia (02-Saturation < or = to 90, 11% vs. 7%). The neurologic complication rate was similar in the two groups (early FF = 16% vs. late FF = 21%), but the average discharge Glasgow Coma Scale score was lower in the early group (13.5 +/- 3.7) when compared with the late FF patient group (15.0 +/- 0.0).ConclusionsEarly FF leads to greater fluid administration in patients with head injuries. Hypoxemia and hypotension, risk factors for secondary brain injury, may contribute to a poor neurologic outcome after early fixation. Prospective studies evaluating the impact of the timing of FF on head injury are indicated.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundReliable prediction of outcome after head injury is a daunting task. Although previous reports have highlighted the difficulties of determining outcome in the cohort of severe head injury Glasgow Coma Scale (GCS) score < or = to 8), we wondered within the very severely injured population (GCS score 3-5) if a simple combination of clinical parameters may be predictive of poor outcome.MethodsAll patients admitted to a Level 1 trauma center with a GCS score of 3 to 5 from 1986 to 1991 inclusive (380 patients) were retrospectively reviewed and outcome a minimum of 6 months after injury was determined by chart review or telephone.ResultFollow-up was accomplished in all but five patients (1.3%). Functional survival (nonvegetative) was correlated to admission GCS score, pupillary abnormalities, and age. As anticipated, overall functional survival was poor (12.5%), and even worse among those evidencing pupillary abnormalities (6.6%). Interestingly, there was an absence of survivors in the advanced age decades, with the oldest functional survivor of any GCS increasing in a stepwise fashion with increasing coma score. This translated into the oldest survivor of a GCS score of 3 being in their chronologic 30s, a score of 4 in their 40s, and a score of 5 in their 50s. Among patients older than these age decades, that is beyond this simple age/GCS cut-off (32.8% of cohort), there were no functional survivors (95% confidence interval 0, 2.4).ConclusionsWithin the population of very severely head injured patients (GCS score 3-5), the simple combination of age and admission GCS score appears to predict accurately nonfunctional outcome in almost one third of patients. If confirmed at other centers, this may have wide-ranging implications regarding counseling of families, utilization of resources, and the design of head injury studies.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundTibial fractures with an associated vascular injury are a challenging management problem for the orthopedic and vascular surgeon. The effect of a concomitant vascular injury on fracture healing has not been specifically delineated previously.MethodsWe performed a retrospective review of 29 fractures of the tibial shaft with an associated vascular injury in 28 patients.ResultsOverall there were 44 vessels injured (38 arterial and six venous). A total of six patients had an amputation performed; patients requiring amputation were significantly older than those without amputation. Fractures with an associated injury to the posterior tibial artery had a significantly higher nonunion rate and a greater number of weeks to union than fractures without this vascular injury.ConclusionOutcomes of tibial fractures with an associated vascular injury are poorest in older patients (who are at increased risk of amputation) and those with an injury to the posterior tibial artery (who are at increased risk of delayed union and nonunion).

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundThe management of ipsilateral femoral shaft fractures after hemiarthroplasty is controversial.MethodsFifteen patients (average age 82.4 +/- 8 years) with ipsilateral femoral shaft fractures after uncemented hemiarthroplasty were treated by closed reduction and Ender nailing. Under radiographic control, closed reduction was attempted. If not possible, cerclage of the shaft fracture was accomplished through a limited lateral approach. Ender nails were then inserted well past the tip of the stem of the prosthesis.ResultsThere were a superficial wound infection and a deep vein thrombosis. At 6 months, five patients had died, and backing out of the nails necessitated removal in one patient. At 1 year, nine patients were still alive. Of these, seven were able to walk with aids. At 2 years, seven patients were still alive and were walking with aids. Two patients presented shortening of more than 1.5 cm of the operated femur. After an average of 5 years, 11 patients were dead, two were still walking, and two were bedridden.ConclusionsThe technique described is an option in the treatment of fractures of the ipsilateral femoral shaft after uncemented hemiarthroplasty.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundAdrenocortical dysfunction is unusual in the unselected critically ill patient. Case reports document a state of corticosteroid responsive vasopressor dependence, resembling the systemic inflammatory response syndrome. The exact incidence of this disorder is unknown.MethodsWe prospectively studied the incidence of adrenal insufficiency during a 9-month period in a surgical intensive care unit (ICU) population. Trauma, general surgery, urology, and gynecologic-oncology patients were included. Patients who met criteria were given a cosyntropin stimulation test.ResultsOverall, the incidence of adrenal insufficiency was 0.66%. In the subgroup of patients with greater than 14 days stay in the ICU, 6% were found to have adrenal insufficiency. In patients aged more than 55 years and with ICU stays of 14 days or greater, 11% were adrenally insufficient.ConclusionsScreening of critically ill patients for adrenal insufficiency, particularly those with prolonged ICU stay and age greater than 55 years, is warranted.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundResuscitation with acellular oxygen carrier solutions offers the potential advantage of improved oxygen delivery compared with crystalloid solutions, but the detailed consequences of improved resuscitation have not been fully evaluated. This study evaluated local and systemic cellular effects of trauma, hemorrhage, and resuscitation in a model of hemorrhage and surgical trauma.MethodsRats with a 10 cm full-thickness incisional wound and a 15 mL/kg hemorrhage were either not resuscitated or resuscitated with blood or diaspirin cross-linked hemoglobin (DCLHb). Cellular proliferative responses were evaluated at 1.5, 6, 24, and 48 hours after wounding by labeling in vivo with 5-bromo-2'-deoxyuridine. Plasma levels of interleukin-6, tumor necrosis factor-alpha, and interferon-gamma were measured by bioassay or enzyme-linked immunosorbent assay (ELISA). Bacterial translocation was measured by culturing liver homogenates.ResultsTrauma inhibited keratinocyte and hepatocyte proliferation at 1.5 and 6 hours, and stimulated subsequent proliferation of keratinocytes and liver nonparenchymal cells. DCLHb stimulated wound keratinocyte proliferation, attenuated the inhibition of hepatocyte proliferation, eliminated bacterial translocation to the liver, protected the intestine from ischemic damage, and induced a rapid increase of interleukin-6 during the early phase of injury.ConclusionsSurgical trauma alone, or in combination with hemorrhage, modulated cell proliferation both in the wound and in the remote organs of intestine and liver. DCLHb enhanced wound healing and cell proliferation as well as, or better than, freshly drawn blood, which may be beneficial for trauma care.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundAlthough Cocaine use is common in trauma victims, little is known about how cocaine affects the cardiovascular response to trauma and associated blood loss. This study determined the effect of chronic cocaine use on the cardiovascular response to hemorrhage in awake and anesthetized sheep.MethodsThe hemodynamic and acid-base responses to graded hemorrhage were determined in awake and anesthetized sheep at baseline and after 15 and 18 days of chronic cocaine exposure.ResultsChronic cocaine exposure resulted in a moderate paradoxical bradycardic response to hemorrhage in awake sheep, but did not otherwise alter the hemodynamic response to hemorrhage. In anesthetized animals, cocaine exposure impaired the ability to maintain mean arterial pressure and cardiac output during hemorrhage, and resulted in a marked paradoxical bradycardic response to hemorrhage.ConclusionsChronic cocaine exposure did not have an important effect on the cardiovascular response to hemorrhage in awake sheep. However, in anesthetized sheep, chronic cocaine exposure diminished the compensatory cardiovascular response to graded hemorrhage.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundPancreatic trauma occurs in up to 10% of all cases of blunt pediatric trauma. Here we attempted to identify markers of pancreatic injury in children and to assess our current diagnostic approach to pancreatic injury.MethodWe performed a retrospective chart review of all patients with a pancreatic injury admitted to a Level I pediatric trauma center between January of 1980 and September of 1994.ResultsIn all, 26 children were included. All pancreatic injuries were due to blunt trauma. Handlebar injuries were the most common mechanism of injury and resulted in a unique pattern of isolated pancreatic trauma, often complicated by the development of a pseudocyst. Computed tomographic scans, performed with intravenous and oral contrast and done in the acute setting, were 85% sensitive for diagnosing a pancreatic injury.ConclusionsDouble contrast computed tomographic scan is a more sensitive test than ultrasound in diagnosing pancreatic injury. The constellation of abdominal pain, an elevated serum amylase and a handlebar mechanism of injury warrants hospitalization and a double contrast abdominal computed tomographic scan.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

The prevalence of impairments and disabilities in activities of daily living (ADL), nonwork activities, and work were registered in a consecutive series (n=69) of subjects with severe injuries. At follow-up 3 years after trauma, residual impairments prevailed in 80%. Only a few (6%) were ADL-dependent. Seventy-six percent had lost at least one nonwork activity, while vocational disability caused by the trauma occurred in 19%. Cognitive impairment was significantly associated with vocational disability, while physical impairment and pain were significantly associated with nonwork disability. Other parameters that influenced vocational disability negatively were age and blue-collar employment status. Although overall changes in social network quantity and quality were small, significantly more subjects with cognitive impairment or vocational disability experienced a decline in the quality and quantity of their social network after trauma. Furthermore, 25% of the subjects reported an increase in feelings of loneliness after trauma. We recommend the design of individualized, multidisciplinary rehabilitation plans before discharge from departments of surgery.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID