Search

Background: The management of hypotensive patients with severe combined head and abdominal trauma is challenging, regarding the need, timing, and sequence of craniotomy or laparotomy. The purpose of the present study was to determine whether rare situations requiring craniotomy prior to laparotomy can be identified on admission with simple clinical parameters. We hypothesized that hypotension is rarely associated with the need of a combined procedure, especially in patients with mildly depressed consciousness., Methods: National Trauma Data Bank study, including adult blunt trauma patients with combined severe head (Abbreviated Injury Scale score, ≥ 3) and abdominal injury (Abbreviated Injury Scale score, ≥ 3). Data collection included demographic and clinical characteristics, laparotomy, and craniotomy within 24 hours of admission, types of intracranial pathologies, survival, and hospital stay. Multivariate regression analysis was used to determine factors predictive for the need of both operative procedures., Results: Of 25,585 patients with severe combined head and abdominal trauma, 8,744 (34.2%) needed only laparotomy, 534 (2.1%) only craniotomy, and 394 (1.5%) required both procedures within 24 hours of admission. In the subgroup of 4,667 hypotensive patients, 2,421 (51.9%) underwent only laparotomy, 54 (1.2%) only craniotomy, and 79 (1.7%) both procedures within 24 hours of admission. Only 5 (0.7%) of 711 hypotensive patients with Glasgow Coma Scale (GCS) score above 8 who required a laparotomy also needed a craniotomy. Among clinical parameters available on patient's arrival, GCS score of 7 to 8 was independently associated with the highest need for craniotomy in hypotensive patients requiring laparotomy (odds ratio, 7.94; p = 0.004)., Conclusion: The need for craniotomy in patients with severe combined head and abdominal injury requiring exploratory laparotomy is very low. In hypotensive patients requiring laparotomy, GCS score of 7 to 8 was an independent predictor of the need for craniotomy. In hemodynamically unstable patients with a GCS score greater than 8, it may be safer to proceed with a laparotomy first and address the head with a computed tomography scan at a later stage., Level of Evidence: Therapeutic, Level IV., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The aim of this study was to present our surgical experience of isolated blunt major pancreatic injury (IBMPI), and to compare its characteristic outcomes with that of multi-organ injury., Materials and Methods: From 1994-2015, 31 patients with IBMPI and 54 patients with multi-organ injury, who underwent surgery, were retrospectively studied., Results: Of the 31 patients with IBMPI, 22 were male and 9 were female. The median age was 30 years (interquartile range, 20-38). Twenty-one patients were classified as the American Association for the Surgery of Trauma-Organ Injury Scale Grade III, and 10 patients as Grade IV. Patients with IBMPI had significantly lower shock-at-triage rates, lower injury severity scores, longer injury-to-surgery time, and shorter length of hospital stay than those with multi-organ injury. There were no statistically significant differences in sex, age, trauma mechanism, laboratory data, surgical procedures, and complications between the two groups. Eight patients with IBMPI underwent endoscopic retrograde pancreatography, and 5 patients with complete major pancreatic duct (MPD) disruption underwent pancreatectomy eventually. The remaining 3 patients had partial MPD injury and two of them received a pancreatic duct stent for the treatment of existing postoperative pancreatic fistula. Spleen-sacrificing distal pancreatectomy (SSDP) was performed in 13 patient with IBMPI, followed by spleen-preserving distal pancreatectomy (n = 12), peripancreatic drainage (n = 4), and central pancreatectomy with Roux-en-Y reconstruction (n = 2). The overall complication rates, related to the SSDP, SPDP, peripancreatic drainage, and central pancreatectomy, were 10/13 (77%), 4/12 (33%), 3/4 (75%), and 2/2 (100%), respectively. Three patients died resulting in a 10% mortality rate, and the other 16 patients developed intra-abdominal complications resulting in a 52% morbidity rate. In the subgroup analysis of the 25 patients who underwent distal pancreatectomy, SPDP was associated with a shorter injury-to-surgery time than SSDP., Conclusions: Patients with IBMPI have longer injury-to-surgery times, compared to those with multi-organ injury. Of the distal pancreatectomy patients, the time interval from injury to surgery was a significant associated factor in preserving or sacrificing the spleen., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Pulmonary contusions are thought to worsen outcomes. We aimed to evaluate the effects of pulmonary contusion on mechanically ventilated trauma subjects with severe thoracic injuries and hypothesized that contusion would not increase morbidity., Methods: We conducted a single-center, retrospective review of 163 severely injured trauma subjects (injury severity score ≥ 15) with severe thoracic injury (chest abbreviated injury score ≥ 3), who required mechanical ventilation for >24 h at a verified Level 1 trauma center. Subject data were analyzed for those with radiographic documentation of pulmonary contusion and those without. Statistical analysis was performed to determine the effects of coexisting pulmonary contusion in severe thoracic trauma., Results: Pulmonary contusion was present in 91 subjects (55.8%), whereas 72 (44.2%) did not have pulmonary contusions. Mean chest abbreviated injury score (3.54 vs 3.47, P = .53) and mean injury severity score (32.6 vs 30.2, P = .12) were similar. There was no difference in mortality (11 [12.1%] vs 9 [12.5%], P > .99) or length of stay (16.29 d vs 17.29 d, P = .60). Frequency of ventilator-associated pneumonia was comparable (43 [47.3%] vs 32 [44.4%], P = .75). Subjects with contusions were more likely to grow methicillin-sensitive Staphylococcus aureus in culture (33 vs 10, P = .004) as opposed to Pseudomonas aeruginosa in culture (6 vs 13, P = .003)., Conclusions: Overall, no significant differences were noted in mortality, length of stay, or pneumonia rates between severely injured trauma subjects with and without pulmonary contusions., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2018 by Daedalus Enterprises.)

Introduction: Practice management guidelines for screening and treatment of patients with blunt cerebrovascular injury (BCVI) have been associated with a decreased risk of ischemic stroke., Treatment: of patients with BCVI and multisystem injuries that delays immediate antithrombotic therapy remains controversial. The purpose of this study was to determine the timing of BCVI treatment initiation, the incidence of stroke, and bleeding complications as a result of antithrombotic therapy in patients with isolated BCVI in comparison to those with BCVI complicated by multisystem injuries., Materials and Methods: This study was a retrospective review of all adult blunt trauma patients admitted to a level 1 trauma center from 2009 to 2014 with a diagnosis of BCVI., Results: A total of 28,305 blunt trauma patients were admitted during the study period. Of these, 323 (1.1%) had 481 BCEVIs and were separated into two groups. Isolated BCVI was reported in 111 (34.4%) patients and 212 (65.6%) patients had accompanying multisystem injuries (traumatic brain injury (TBI), solid organ injury, or spinal cord injury) that contraindicated immediate antithrombotic therapy., Treatment: started in patients with isolated BCVI at a median time of 30.3 (15, 52) hours after injury in contrast to 62.4 (38, 97) hours for those with multisystem injuries (p<0.001). The incidence of stroke was identical (9.9%) between groups and no bleeding complications related to antithrombotic therapy were identified., Conclusion: The lack of bleeding complications and equivalent stroke rates between groups suggests that the presence of TBI, solid organ injury, and spinal cord injury are not contraindications to anti-thrombotic therapy for stroke prevention in patients with BCVI., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Precise diagnostics and an adequate therapeutic approach are mandatory in the treatment of air leak in polytrauma patients with blunt chest trauma. The aim of this study was to evaluate the incidence, characteristics, and management of air leak following this injury pattern., Patients and Methods: Data from 110 polytrauma patients was collected retrospectively. Fifty-four patients received initial treatment by chest tube placement for pneumothorax. These patients were classified into two groups, one with severe air leak and one with minor air leak. An evaluation of injury pattern, chest wall injuries in particular, duration of air leak, reason for drainage maintenance in place, hospital length of stay, ICU stay, ventilator duration, type of treatment, and the delay to surgical intervention was performed., Results: Whereas 4 patients showed severe air leak and were subsequently scheduled for timely surgical intervention, the remaining 50 patients only showed minor air leak. Only 7 patients with minor air leak suffered from prolonged air leak (>5days), which spontaneously resolved in all of them after a mean duration of 7.7days (range 6-12days). Absence of a prolonged air leak resulted in a shorter length of stay and a shorter duration of mechanical ventilation, although no statistical significance was observed., Conclusions: Early spontaneous cessation of most minor air leaks as well as early surgical intervention for severe air leak lead to very satisfactory patient outcomes with a relatively short hospital stay in our patients. We therefore advocate early surgery for lacerations of the pulmonary parenchyma resulting in severe air leak, whereas minor air leaks can usually be treated conservatively., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose: Continuous lateral rotational therapy (CLRT) has been described as a promising approach for prophylaxis and treatment of respiratory complications in critically ill patients over two decades ago. However, meta-analyses failed to demonstrate any significant benefit on outcome by CLRT, possibly due to the heterogeneity and low overall quality of available studies., Methods: Observational trial over a 3-year period on outcome in trauma patients (Injury Severity Score, ISS ≥16) with severe thoracic injury (Abbreviated Injury Scale, AIS Thorax ≥3) initially treated with CLRT as standard of care. Epidemiological data, injury severity, and pattern and physiological parameters were recorded. Outcome indicators were time on mechanical ventilation, length of stay, rates of pneumonia, sepsis and acute respiratory distress syndrome, hospital mortality, and rates of re-intubation. Additionally, data are compared with the results from the TraumaRegister ® of the German Trauma Society., Results: Over the 3-year period 76 patients with ISS ≥16/AIS Thorax ≥3 received CLRT, equaling 24 % of all patients with ISS ≥16 between 18 and 80 years. Mean ISS was 35.3 (standard deviations, SD 12.2) [71.1 % male, 97.4 % blunt trauma, mean age 43.9 years (SD 18.7)]. Mean time on CLRT was 3.3 days (SD 2.2), time on mechanical ventilation 7.8 days (SD 7.1), and 9.2 % had to be re-intubated due to respiratory complications. CLRT-related complications occurred in 8.9 %. Overall 25 % of the patients developed pneumonia (VAP = 13.2 %). Despite a significantly higher ISS we observed shorter times on mechanical ventilation and intensive care unit in our collective in comparison to data published from the nationwide TraumaRegister ® ., Conclusions: CLRT remains a therapeutic option to reduce pulmonary complications after severe chest trauma in our center. However, a RCT is needed to study the effects of other treatment options such as early extubation and non-invasive ventilation or prone/supine positioning.

Chest trauma has a significant relevance on outcome after severe trauma. Clinically, impaired lung function typically occurs within 72 hours after trauma. However, the underlying pathophysiological mechanisms are still not fully elucidated. Therefore, we aimed to establish an experimental long-term model to investigate physiological, morphologic and inflammatory changes, after severe trauma. Male pigs (sus scrofa) sustained severe trauma (including unilateral chest trauma, femur fracture, liver laceration and hemorrhagic shock). Additionally, non-injured animals served as sham controls. Chest trauma resulted in severe lung damage on both CT and histological analyses. Furthermore, severe inflammation with a systemic increase of IL-6 (p = 0.0305) and a local increase of IL-8 in BAL (p = 0.0009) was observed. The pO 2 /FiO 2 ratio in trauma animals decreased over the observation period (p < 0.0001) but not in the sham group (p = 0.2967). Electrical Impedance Tomography (EIT) revealed differences between the traumatized and healthy lung (p < 0.0001). In conclusion, a clinically relevant, long-term model of blunt chest trauma with concomitant injuries has been developed. This reproducible model allows to examine local and systemic consequences of trauma and is valid for investigation of potential diagnostic or therapeutic options. In this context, EIT might represent a radiation-free method for bedside diagnostics., Competing Interests: R.T. has an advisory relationship to Dräger A.G., Lübeck, Germany, S.U. has a consulting relationship to Boehringer Ingelheim, Ingelheim, Germany and G.M. has a consulting relationship to BBraun, Melsungen, Germany as well as Adrenomed, Hennigsdorf, Germany.

Background: The treatment of popliteal artery injury (PAI) caused by blunt or penetrating mechanism is demanding. Concomitant injuries and prolonged ischemia are the major causes of lower extremity morbidity and poor rates of limb salvage. This study assessed the amputation rate and, subsequently, the therapeutic management and clinical outcomes regarding the affect of concomitant injuries among patients with PAI in a setting of central European trauma care., Methods: Sixty-four patients (20 female and 44 male), with an average age of 44 years (range, 17-79 years) at the time of injury, were evaluated for clinical characteristics, concomitant injuries, complications, amputation rates, and functional outcome after traumatic PAI. The mechanism of injury was blunt trauma in 35 patients (54.7%) and penetrating trauma in 29 (45.3%). The Mangled Extremity Severity Score and the Injury Severity Score were assessed initially and the modified Functional Independence Measure (FIM) Score at 12 months after the primary surgery., Results: Thirty patients (47%) returned to their normal activity level within 1 year after trauma, and 16 (25%) were limited in their daily activity or suffered from chronic pain symptoms. Within the blunt trauma group 26 of 35 patients (74%) sustained severe concomitant injuries, whereas two of 29 patients (7%) in the penetrating group showed severe concomitant injuries (P < .046). Eleven patients (17%) had to undergo revision surgery due to their associated injuries. The median modified FIM score was 10.3, whereas patients with blunt trauma had significantly lower FIM score (P < .0082). The median Mangled Extremity Severity Score was 6 points (range, 6-16 points). Primary or secondary amputation was required in 18 patients (28%) due to failure of revascularization. Patients who sustained blunt trauma had significantly higher amputation rates than those with penetrating injuries (P < .035)., Conclusions: Clinical outcome and limb salvage of patients with PAI were influenced by the mechanism of trauma, concomitant injuries, prolonged ischemia time, and the type of surgical procedure. Patients after blunt trauma had a higher incidence of concomitant injuries, and (comminuted) fractures or knee dislocations and severe soft tissue damage had the highest effect on the amputation rate., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Biological sex is considered a risk factor for adverse outcome after major trauma. We hypothesized that female sex is protective against organ failure, sepsis and mortality in patients with traumatic haemorrhage., Patients and Methods: We selected patients from TraumaRegister DGU(®) (TR-DGU) with primary admission for blunt trauma with an injury severity score ≥ 16 and an ICU stay ≥ 3 days that presented with relevant bleeding in the years 2007-2012. Relevant bleeding was defined as Abbreviated Injury Scale (AIS) ≥ 3 with an estimated blood loss exceeding 20%, any femoral shaft fracture, any pelvic clamp as surrogate for unstable pelvic fracture or the presence of at least one criteria of haemorrhagic shock: shock index of 0.8-1.4; base excess of -2.0 to -10.0 mmol/L; body temperature ≤ 34°C; transfusion of ≥ 4 units of packed red blood cells; application of recombinant activated factor VII; any embolization during trauma room phase and pre-hospital resuscitation volume ≥ 3000 ml or any catecholamine use during pre-hospital care in the absence of cardiopulmonary resuscitation. A total of 7560 males and 2774 females were selected and analyzed for sex differences., Results: Higher rates of multiple organ failure (24.4 vs. 21.3%, Odds ratio [OR] 1.19 (95% confidence interval [95%CI] 1.07-1.33), p=0.001*) and sepsis (16.5 vs. 11.3%, OR 1.55 (95%CI 1.35-1.77), p<0.001*) were observed in males. Organ function of lung, cardio-circulatory system, liver and kidney were better in females, however, there was no difference in mortality. Stratification by age group revealed that in particular age-group 16-44 years was related to improved organ function which may indicate effects of sex hormones in females at reproductive age. Increased rates of sepsis in males were observed throughout virtually all age groups starting at 16 years of age, except in age group 54-64 years. This may suggest suppressive effect of testosterone on immune function., Conclusions: Our study supports the hypothesis that female sex is associated with improved organ function following traumatic injury and haemorrhagic shock, in particular in age groups that are at reproductive age. However, further studies are warranted before sex steroids can be deployed as therapeutic intervention in critically ill trauma patients., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

The article presents results of diagnostics and surgical treatment of diaphragmatic rupture in 32 victims with an estimation of diagnostic value of different instrumental methods of investigation and the efficacy of surgical approach. The correct interpretation of typical clinical and instrumental signs in consideration with trauma mechanogenesis allowed diagnostics of diaphragmatic rupture before the operation in 17 (53.1%) cases. It was observed that an undiagnosed rupture of the left hemidiaphragm caused a formation of posttraumatic diaphragmatic hernia in 2 (6.2%) patients. The laparotomy was applied in 28 patients as a surgical approach and thoracotomy--in 2patients. The laparotomy and after that thoracotomy were performed on one patient. The thoracotomy and laparotomy were carried out on the second patient in turn. The authors consider the laparotomy as optimal variant of surgical approach in acute period of trauma. The postoperative lethality was 15.6%.

In 91 injured persons, suffering severe closed combined abdominal trauma, the staged surgical treatment was conducted, in 41 of them the operation was performed during one narcosis, but with surgical pause after temporary stopping of hemorrhage, in 50 the "damage control surgery" was applied. Unstable critical state of the injured persons, "unfavorable" prognosis of course of an acute period of the traumatic disease served as indications for the staged surgical treatment conduction. While the urgent laparotomy performance the surgical manipulations were conducted in minimal volume, surgical pause was applied with the patient's state reestimation. Operative intervention was restarted when a stable hemodynamics and the homeostasis indices improvement were achieved. Middle value of surgical pause have constituted (94.5 +/- 7.2) min. In 50 injured persons, regardless of the hemorrhage stopping and stabilization of systolic arterial pressure, the hemostasis indices were disordered, they were admitted to department of reanimation and intensive therapy with consequent conduction of programmed relaparotomy (the technology of "damage control surgery"). Application of differentiated staged surgical treatment in the injured persons, suffering severe closed combined abdominal trauma, have permitted to reduce the occurrence rate of decompensated shock--by 6.4%, the syndrome of disseminated intravascular coagulation--up to 1%, polyorgan insufficiency--up to 7.1%, general lethality--by 9.5%.

The article describes the clinical case and analyzes the literature concerning endoprosthesis replacement in the case of traumatic thoracic aortic injury in polytrauma. Current strategy of diagnostics and treatment of patient in critical condition with rupture of isthmic aortic part is based on the principle of multistage surgical treatment (damage control orthopedic). The external fixation of multiple pelvis and extremities fractures and on-time implantation of stent-graft in thoracic aortic part were performed at first hours after the admission. A condition of the patient was stabilized. The delayed reconstructive operations on pelvis and extremities bones allowed obtaining the satisfactory functional result. The principles of staged surgical treatment and the use of on-time high-technology methods allowed saving life for the patient even in critical situation in I level traumatologic centre.

The morbidity, mortality, and economic costs resulting from trauma in general, and blunt abdominal trauma in particular, are substantial. The "panscan" (computed tomographic [CT] examination of the head, neck, chest, abdomen, and pelvis) has become an essential element in the early evaluation and decision-making algorithm for hemodynamically stable patients who sustained abdominal trauma. CT has virtually replaced diagnostic peritoneal lavage for the detection of important injuries. Over the past decade, substantial hardware and software developments in CT technology, especially the introduction and refinement of multidetector scanners, have expanded the versatility of CT for examination of the polytrauma patient in multiple facets: higher spatial resolution, faster image acquisition and reconstruction, and improved patient safety (optimization of radiation delivery methods). In this article, the authors review the elements of multidetector CT technique that are currently relevant for evaluating blunt abdominal trauma and describe the most important CT signs of trauma in the various organs. Because conservative nonsurgical therapy is preferred for all but the most severe injuries affecting the solid viscera, the authors emphasize the CT findings that are indications for direct therapeutic intervention., (©RSNA, 2012.)

Polytrauma patients needing aggressive resuscitation can develop intra-abdominal hypertension (IAH) with subsequent secondary abdominal compartment syndrome (SACS). After patients fail medical therapy, decompressive laparotomy is the surgical last resort. In patients with severe pancreatitis SACS, the use of linea alba fasciotomy (LAF) is an effective intervention to lower IAH without the morbidity of laparotomy. A pilot study of LAF was designed to evaluate its benefit in patients with SACS polytrauma. We conducted an observational study of blunt injury polytrauma patients undergoing LAF. Variables measured before and after LAF included intra-abdominal pressure (IAP, mmHg), abdominal perfusion pressure (APP, mmHg), right ventricular end diastolic volume index (RVEDVI, mL/m2), and ejection fraction. Of the five trauma patients with SACS, the mean age was 36 +/- 17, four (80%) male with an Injury Severity Score of 27 +/- 9. Pre- and post-LAF, IAP was 20.6 +/- 4.7 and 10.6 +/- 2.7 (P < 0.0001), APP 55.2 +/- 5.5 and 77.6 +/- 7.1 (P < 0.0001), RVEDVI 86.4 +/- 9.3 and 123.6 +/- 11.9 (P < 0.0001), and EF 27.6 +/- 4.2 and 40.8 +/- 5 (P < 0.0001), respectively. One patient needed full decompression for bile ascites from unrecognized liver injury. Linea alba fasciotomy, as a first-line intervention before committing to full abdominal decompression in patients with SACS trauma, improved physiological variables without mortality. Consideration for LAF as a bridge before full abdominal decompression needs further evaluation in patients with polytrauma SACS.

This study uses computer simulations to study the impact of a motorcycle with the conventional w-beam guardrail. A three-dimensional computer simulation of a scaled hybrid III 50th-percentile male dummy mounted on a motorcycle and colliding with a w-beam guardrail is carried out. A multi-body model of the motorcycle and finite element model of the guardrail are developed using commercially available software. The simulation model is validated with a physical crash test conducted with same initial impact configurations. Impacts at speeds of 32, 48, and 60 km/h at an impact angle at 45 degrees are considered. The predicted forces and accelerations are compared with the biomechanical limits for each body part and the risk of injury to the rider are evaluated. Speed was found to have a significant influence on the level of injury to the head, neck, chest, and femur. A significant reduction of the severity of injuries was found when the impact speed was reduced from 60 to 32km/h. The accelerations experienced by the head and chest are found to be higher than safe levels for impact speeds of 48 and 60 km/h. The biomechanical limit for the right femur is exceeded at all three considered impact speeds. Neck injuries are also a concern, with the predicted tension values and neck bending extent being higher than the biomechanical limit for the 60 km/h impact speed. In light of these results, it is suggested that the design of guardrails should be reviewed with a focus on the safety of motorcyclists.

Objective: To characterize the gender dimorphism after injury with specific reference to the reproductive age of the women (young, <48 yrs of age, vs. old, >52 yrs of age) in a cohort of severely injured trauma patients for which significant variation in postinjury care is minimized., Design: Secondary data analysis of an ongoing prospective multicenter cohort study., Setting: Academic, level I trauma and intensive care unit centers., Patients: Blunt-injured adults with hemorrhagic shock., Interventions: None., Measurements and Main Results: Separate Cox proportional hazard regression models were formulated based on all patients to evaluate the effects of gender on mortality, multiple organ failure, and nosocomial infection, after controlling for all important confounders. These models were then used to characterize the effect of gender in young and old age groups. Overall mortality, multiple organ failure, and nosocomial infection rates for the entire cohort (n = 1,036) were 20%, 40%, and 45%, respectively. Mean Injury Severity Score was 32 +/- 14 (mean +/- SD). Men (n = 680) and women (n = 356) were clinically similar except that men required higher crystalloid volumes, more often had a history of alcoholism and liver disease, and had greater ventilatory and intensive care unit requirements. Female gender was independently associated with a 43% and 23% lower risk of multiple organ failure and nosocomial infection, respectively. Gender remained an independent risk factor in young and old subgroup analysis, with the protection afforded by female gender remaining unchanged., Conclusions: The independent protective effect of female gender on multiple organ failure and nosocomial infection rates remains significant in both premenopausal and postmenopausal women when compared with similarly aged men. This is contrary to previous experimental studies and the known physiologic sex hormone changes that occur after menopause in women. These results suggest that factors other than sex hormones may be responsible for gender-based differences after injury.

Grading of the clinical status in patients with multiple trauma is important regarding the treatment plan. In recent years, 4 different clinical conditions have been described: stable, borderline, unstable, in extremis. Clinical parameters have been widely used in patients with penetrating injuries, and 3 categories were found to be important: shock, hypothermia, coagulopathy. However, in blunt trauma patients, the role of conventional parameters for decision making regarding the timing of fracture treatment is poorly described. After blunt trauma, additional factors seem to play a role, because the injuries affect multiple body regions. These additional factors are summarized under the term, "soft-tissue injuries," which may include the soft tissues of the extremities, lung, abdomen, and pelvis. The study describes four pathophysiologic cascades that are relevant to the clinical conditions listed above. Threshold values for separation of the patient conditions are documented, leading to a staged surgical strategy.

Background: Recombinant factor VIIa (rFVIIa) is a novel haemostatic agent originally developed to treat bleeding in haemophiliacs. Several case reports suggest effectiveness of rFVIIa in the treatment of patients without pre-existing bleeding disorders. The aim of this study is to evaluate treatment with recombinant (rFVIIa) in blunt trauma patients with uncontrolled bleeding., Patients and Methods: This study was designed as a retrospective case review. Consecutive patients with life-threatening uncontrolled bleeding due to blunt trauma who were treated with rFVIIa were selected. Data were obtained from medical records., Results: A total of eight blunt trauma patients were treated with rFVIIa for uncontrolled bleeding. After treatment the need for transfusion of red blood cells (RBC) decreased significantly from 31.3 +/- 15.8 to 6.1 +/- 6.8 units (P = 0.003), fresh frozen plasma (FFP) from 13.3 +/- 6.6 to 5 +/- 6.3 units (P = 0.02), and platelets from 3.6 +/- 1.8 to 1.5 +/- 2.3 units (P = 0.01). Three patients died of non-bleeding complications. The other five fully recovered., Conclusion: Treatment with rFVIIa reduced or stopped bleeding in all patients. No adverse events were registered. Prospective studies are mandatory to elucidate the role of rFVIIa in blunt trauma.

This study examined if use of clinical screening criteria for selective radiography of blunt trauma patients can identify all patients with thoracolumbar (TL) spine injuries. The study was a prospective cohort of patients undergoing TL spine radiographs following blunt trauma. Patients were considered at risk for TL spine injury if they had any of the following clinical criteria: 1) complaints of TL spine pain, 2) TL spine tenderness, 3) a decreased level of consciousness, 4) intoxication with ethanol or drugs, 5) a neurologic deficit, or 6) a painful distracting injury. Patients without any of these findings were considered at low risk for TL spine injury. Severity of mechanism of injury was also recorded. Data sheets were completed prior to TL radiography. Injury status was determined by the final faculty radiologist interpretation of all radiographic studies. A total of 2404 patients were enrolled. TL spine injuries were identified in 152 patients. Of these 152 patients with spine injuries, all 152 (100%, 95% confidence interval 98-100%) were considered high risk by having at least one of the high-risk criteria. These criteria have a specificity of 3.9%, a positive predictive value of 6.6%, and a negative predictive value of 100%. All of the high-risk criteria but intoxication with ethanol or drugs were important as sole predictors of TL spine injury. The use of high-risk clinical screening criteria identified virtually all blunt trauma patients with acute TL spine injuries. These criteria, however, have poor specificity and positive predictive value., (Copyright 2003 Elsevier Science Inc.)

The microscopic and histostereometric examinations of specific features of blood circulation in the lungs (in lethal cases) performed during the early period after combined trauma showed pronounced disturbances of blood circulation in body organs which had a certain sequence in the development of vascular reactions and vascular temporal dynamics. The influence of a preceding alcoholic intoxication and intensive hemorrhage on the circulatory dynamics was demonstrated.

Objective: To review the diagnostic strategy of management of multiple trauma patient during the first hours., Data Sources: Extraction from Pubmed database of French and English articles on the management of multiple trauma patient published for ten years., Data Selection: The collected articles were reviewed and selected according to their quality and originality. The more recent data were selected., Data Synthesis: The first hours of management of multiple trauma patients are a particular challenge. The first dilemma is to drive the patient toward an adequate structure. In case of poor haemodynamic tolerance, the patient will be drive in the nearest hospital. When haemodynamic parameters are restored, multiple trauma patient has to be receive in a high level hospital by a trained medical team with an anesthesiologist, intensivist, neurosurgeon, general surgeon and radiologist. The initial assessment may have two priorities: quality and speed. The total body CT scan is actually the answer to these priorities.

A previously fit 22 year old man was struck in the chest by a concrete block dropped through the windscreen of his car while he was driving on the motorway. He suffered extensive chest wall trauma and lung contusion, which subsequently precipitated acute respiratory distress. On admission ECG showed right bundle branch block and left axis deviation. Three days later QRS duration was normal but there was anterior ST segment elevation and subsequent T wave change. There was a large rise in creatine kinase, and echocardiography revealed septal and apical hyokinesis as well as a mobile mass attached to the left side of the interventricular septum, which had the echogenic texture of myocardium. The patient had fixed perfusion defects in the areas of hypokinesis on thallium scanning but the coronary arteries were unobstructed at angiography. He was treated with warfarin in the short term and an angiotensin converting enzyme inhibitor in the longer term and has made an asymptomatic recovery. Outpatient echocardiography two months after the injury demonstrated some recovery in overall left ventricular systolic function and no evidence of the intracardiac mass. This case illustrates some of the typical features of non-fatal cardiac contusion associated with non-penetrating cardiac trauma, and was complicated by partial thickness avulsion of a strip of the myocardium in the interventricular septum.

Pulmonary gas exchange in correlation with condensed lung volume was prospectively studied in 10 patients with multiple injuries and blunt chest trauma. The purpose was to find nomograms that allow the estimation of the extent of pulmonary density from gas exchange parameters. The condensed lung volume was determined planimetrically from serial transverse sections of chest computed tomographic scans. There was no correlation between condensed lung volume and mean pulmonary artery pressure, pulmonary vascular resistance, systemic vascular resistance, or cardiac index and a week negative correlation to the oxygenation index (PaO2/FIO2) (r2 = 0.46) and to the total static lung compliance (r2 = 0.29). A strong correlation between pulmonary density and intrapulmonary shunt fraction (Qs/Qt) (r2 = 0.95) as well as alveoloarterial PO2 difference (P[A-a]O2) (r2 = 0.86) was evident. By using linear regression equations (linear regression line with 95% confidence interval), nomograms were calculated. The extent of pulmonary density can easily be obtained from these nomograms by measuring Qs/Qt or P(A-a)O2. The presented nomograms may be helpful in monitoring the effect of treatment in patients with blunt chest trauma.

Ventilation impairment, due to ineffective elimination of the mucous-hemorrhagic content from the tracheobronchial tree (TBT), obstructs the upper airways with the ensuing ventilation reduction giving rise to atelectases and progressive alveolar block. There is evidence of transudation and exudation into the pulmonary pathways and pleural cavity. A series of 276 patients presenting closed chest trauma are subjected to fibrobronchoscopy (FBS) and follow-up study. In 92 of them bronchoscopy is performed 2 to 15 times per patient, accordingly: in 75-twice, in 10-five times and in 15-twice. One-hundred twenty-nine of the total of 276 cases under study are on mechanical ventilation. In 56 instances FBS is carried out through a tracheostomy cannula, in 73-by intubation, in 18-through the mouth, and in two--through the nose. Based on the obtained results, algorithms for assessment of the rheological properties of tracheobronchial secretion and degree of impairment of TBT drainage function during emergency FBS in closed chest injuries are worked out, having an essential practical bearing on the diagnostic and therapeutic approach to closed thoracic trauma.

Combined flail chest and pulmonary contusion is a frequent problem in patients with blunt multisystem trauma admitted to the intensive care unit. These patients are at high risk for pneumonia and adult respiratory distress syndrome, which adds substantially to their morbidity and mortality rates. This article discusses the epidemiology and pathophysiology of this condition and the role of the respiratory care practitioner in the optimal management of these critically injured patients.

To gain some quantitative understanding of the nature and properties of stress wave propagation and the pathological characteristics of lung injuries, pressure values at eight sites in the lungs during an impact period were recorded. The lung injury severity scores in the corresponding regions were determined in 11 dogs, which were subjected to blunt, left lateral impact at a velocity of 16.33 m/sec with a 24.5% compressive response. The results showed that the pressure value at the contact point was the greatest and that pressure decreased significantly from left side to right side. However, at the left hilum a second pressure peak developed. The pressure value at the contact point was 0.68 and 0.50 times greater than those at left lung and left hilum, respectively. The speed at which the pressure at the contact point rose was much faster than the speed at other points. The lung injury scores at different sites corresponded well with the pressure values (p < 0.001). The data indicated that the reflection and refraction of the stress waves result in the accumulation of forces at some points, transferring more energy to the tissues at those points. Therefore, the severity of injury at these points in these tissues was more severe.

Hemodynamic changes were monitored in eight dogs subjected to blunt impact (velocity = 19m/s) in the cardiac region. There was a transitory cardiac arrest for 1 to 2 seconds in some animals after trauma. The heart rate decreased markedly at 30 minutes after trauma, and recovered at 4 hours. At 15 minutes after trauma, the cardiac index, stroke volume index, left ventricular stroke work index, and mean artery pressure were much lower than that before trauma (p < 0.05 or p < o.o1). However, the mean pulmonary artery pressure, pulmonary capillary wedge pressure, and central venous pressure at 30 minutes after trauma were higher than that before trauma (p < 0.05). The above changes recovered generally at 8 to 16 hours after trauma. The pathological results showed that superficial spotty or flat hemorrhages and ecchymoses were most common in the injured heart. Severe contusion on the anterior wall of the left or right ventricle was also seen.

The remains of 53 men that had been beaten to death were examined. Six (11.3%) died of either blood aspiration or intracranial hemorrhage; 15 of the cases (28.3%) succumbed to hypovolemic shock, and 32 of the cases (60.4%) died of fat embolism syndrome (FES). Fractures of long bones were found only in four victims. Fatal FES produced by the mechanical disintegration of adipose tissue that migrates into the bloodstream seems to be a common phenomenon in the fatalities examined in this study. No correlation, however, was found between the presence of long bone fractures and the severity of FES, and no bone marrow emboli were detected on histologic examination of target organs. Scattered subcutaneous hematomata were present in all of the victims, although the volume of extravasated blood could not be calculated from the total surface area of the bruises. Contusions limited to the limbs have the potential of masking fatal volumes of extravasated blood that suffuse the musculature mass. Hypovolemic and neurogenic shock, as well as systemic effects of crush injury, should be considered contributing factors to death from FES. These findings contradict the previously published postulate that victims of blunt force trauma succumb primarily to massive hemorrhages.

Out of 566 children with closed abdominal trauma, treated in the EMI "Pirogov" over a five-year period, 79 present serious impairment of the basic vital functions (respiration, hemodynamics and the like) connected with the trauma and not infrequently with massive blood loss, necessitating the undertaking of resuscitation measures and intensive care. Of the latter 67 are restored to health, and in twelve the outcome is fatal. In terms of hemodynamic parameters a significant tachycardia along with maintaining normal or even increased arterial pressure are the most characteristic, whereas hypotension is present in 6.4 per cent of successfully cured children only on the first day. Regardless of the fact that merely 13.4 per cent of them have direct chest traumas, the gas exchange is considerably disturbed by hypoxemia--in 89 per cent on the first, and in 100 per cent of the children on the third postinjury day; in one-fourth of the cases the hypoxemia is markedly expressed--below 8.0 kPa (60 mm Hg). Along with the decrease in hemoglobin level the latter accounts for pronounced oxygen transport impairment. During the first postinjury day, the acid-base metabolism is characterized by metabolic acidosis development (in 44 per cent of children), with metabolic alkalosis becoming manifest during the next few days. Twelve children presenting severe combined injuries die within several hours of the accident with signs of a serious traumatic-hemorrhagic shock, or within 2-3 days thereafter with evidence of multiple organ failure.

Study Objective: To identify patients presenting with hypotension due to blunt trauma who should undergo computed tomography (CT) of the head before urgent chest or abdominal operation., Design: Retrospective registry-based record review., Setting: Urban Level I trauma center., Participants: Consecutive trauma patients with suspected head injury, blunt mechanism of injury, and hypotension who were discharged between January 1, 1989, and December 31, 1991. Patients who were dead on arrival or died within 15 minutes of arrival were judged unsalvageable and excluded. Review of 3,224 trauma patients identified 212 as the study population., Interventions: Frequency of neurosurgical intervention or general surgical intervention within 6 hours of admission and the time required for completion of CT of the head were noted., Results: Overall, 40 general surgical operations (19%) and 16 craniotomies (8%) were performed, with a mortality rate of 18%. Patients with Glasgow Coma Scale scores of less than 8 had a 19% rate of craniotomy, and those with scores between 8 and 13 had a 9% rate. Sixteen patients had CT before surgery, with an average delay of 68 minutes. No patient who responded to initial resuscitation experienced hemodynamic instability in the CT suite, including 15 patients with positive diagnostic peritoneal lavage., Conclusion: CT scan of the head before general surgical operation appears to be safe in patients who respond to initial resuscitation. The likelihood of craniotomy in patients with Glasgow Coma Scale scores of 13 or less is comparable to the likelihood of general surgical operation. Physicians should be encouraged to make CT of the head a high priority in this group.

A prospective study assessing the interest in and the results of systematic transesophageal echocardiography (TEE) examination in nonselected intubated multiple injury patients was carried out from January 1992 through June 1993. Seventy patients were included and divided into two groups according to the results of admission screening, including clinical examination, EKG, CK-MB and chest radiograph. Group 1 (60 patients) had abnormalities on initial screening, while group 2 (10 patients) had no symptom of thoracic or mediastinal injury. TEE was performed within 48 hours following admission and its results were compared with those of the initial screening. TEE usefulness was evaluated on a score grade from 0 (no interest) to 4 (outstanding interest). Myocardial contusion was suspected in 25 patients. TEE invalidated 18 suspected and found 5 unsuspected myocardial contusions. Pericardial effusion was suspected in only one case, while TEE documented 13 additional cases. A mediastinal enlargement was seen in 13 patients, but TEE invalidated aortic lesions in all these cases and made an unsuspected diagnosis of aortic tears. Eight cases of severe hypovolemia and seven cases of left ventricle dysfunction were detected by TEE. The score of interest showed that TEE allowed new interesting diagnoses in 70% of group I patients and in 33% of group II patients. TEE is of utmost importance in multiple injury patients, with or without any evidence of thoracic or mediastinal injury, providing a safe and rapid examination of the mediastinal structures and an evaluation of the hemodynamic status.

The authors present a program of rational improvement of intensive therapy of acute respiratory insufficiency responsible for the development of normal compensatory processes of external ventilation. The main components of intensive therapy are: rational analgesia (continuous subpleural blockades), elimination of obstruction of respiratory pathways by sessions of independent respiration with oxygen mixture with positive pressure at the end of breathing out with phytoncides, moderate hemodilution, early recovery of enteral coming of fluid, prevention and treatment of respiratory infection. The use of the proposed intensive therapy in 41 patients improved the function of external ventilation and made the amount of pulmonary complications 4 times less.

Traumatic traction injuries occurring mostly during road traffic accidents frequently cause severe lesions of the brachial plexus. 108 patients with such lesions were surgically explored in the last 5 years by one surgeon. By contrast, 101 patients with other lesions to the brachial plexus or various injuries to neighbouring nerves were operated on during the same period. Among the former, root avulsions were found in 73 patients, 33 presenting with 4 or all roots avulsed. In 14 of these patients the subclavian artery was ruptured. Out of 17 patients with infraclavicular distal plexus lesions 7 presented with a rupture of the axillary artery. The severity of the lesions to nerves and vessels in the shoulder girdle region seems to have increased over the past 10 years. The different injury patterns seen at operation are presented.

The clinical entity of "scapulothoracic dissociation" has been reported as an uncommon but devastating shoulder girdle disruption. All previously identified closed injuries have been associated with arterial and brachial plexus compromise; therefore, neurovascular disruption has been presented as an essential diagnostic clinical finding of scapulothoracic dissociation. We have identified and managed four patients who satisfy all the radiographic criteria for scapulothoracic dissociation but who have presented with a spectrum of neurovascular conditions ranging from entirely normal to complete disruption. These patients illustrate a previously unrecognized, or at least unreported, continuum of potential neurovascular compromise associated with disruption of the scapulothoracic articulation. An expanded and more descriptive classification scheme for "traumatic lateral scapular displacement" is proposed to emphasize the spectrum of possible presentations of this injury.

During a 5-year period, we treated 14 cases of traumatic asphyxia. There were 12 male and 2 female patients ranging in age from 2 to 32 years. Most suffered crushing injuries at work or were run over by motor vehicles. Mild to severe cervicofacial cyanosis and petechiae developed in all patients. A fear response was reported by 12 of the patients. Subconjunctival hemorrhage was also found in 12 patients. Nine patients had tachypnea and 7 complained of dyspnea. Most of the patients suffered some associated injuries including 8 head injuries, 7 pulmonary contusions, and 6 cases of blunt abdominal trauma. Less-associated injuries were rib fractures, brachial and radial nerve injuries, hemothorax, and pneumothorax. The hospital stay ranged from 4 to 28 days (mean, 14 days) and follow-up from 10 to 60 months (mean, 32 months). Treatment for traumatic asphyxia included measurement of arterial blood gases, oxygen supplementation, and intubation with mechanical ventilation. The patients' recovery conditions were relative to the severity of injury and the associated injuries.

The importance of admission physiological and biochemical variables was modeled on data from 185 patients with blunt liver trauma with regard to their significance in prediction of mortality. The variables used were admission Glasgow Coma Score, base excess (or deficit), arterial lactate, Injury Severity Score, and initial 24-hour volume of blood required for replacement. Each variable was modeled as a predictor of survival alone and in combination, using a linear logistic model. In any two-variable combination, Glasgow Coma Score had a high likelihood ratio for prediction representing the influence of brain injury. But as a single variable reflecting the probability of death, both base excess (LD50 = -11.8 mmol/L) and initial 24-hour volume of blood (LD50 = 5.4 L) were highly significant. A combined logistic model of admission Glasgow Coma Score and base excess had the greatest likelihood of accurate prediction of outcome: P death = e lambda/l + e lambda; where lambda = -0.21(Glasgow Coma Score) -0.147(base excess) + 0.285. Testing of this predictive model on data from 323 additional patients with multiple trauma who had pelvic fracture as their index injury also showed it to be a highly significant early predictor of outcome.

Geriatric trauma survival rates are reported to approach 85%, but no series to our knowledge has included a predominance of multiply injured patients. In 1985, we treated 60 patients more than 65 years of age who sustained blunt multiple trauma, excluding burns and minor falls. A pedestrian-motor vehicle mechanism, initial BP less than 150 mm Hg, acidosis, multiple fractures, and head injuries all predicted mortality. To investigate this, in 1986, we began invasive monitoring in all patients with any of these risk factors and modified this in 1987 to emergent monitoring, postponing all but the most critical diagnostic studies. All patients included were hemodynamically stable after initial evaluation. Attempts were made to optimize all patients with volume, inotropes, and afterload reduction as needed. There was no difference between 1986 and 1987 in patient age, injury severity, or per cent of patients requiring operation. In 1986, mean time from ED admission to monitoring was 5.5 hours. Eight of 15 patients had an initial cardiac output (CO) less than 3.5 L/M and/or mixed venous saturation (MVO2) less than 50%. All developed progressive pump failure despite therapy and died within 24 hours. The other seven had an initial CO between 3.4-5.5 L/M, but five had an MVO2 less than 50%. All augmented their CO with therapy over 6-12 hours to a mean CO of 6.8 L/M and resolved their MVO2, but six died from MOF. Survival was 7%. In 1987-88, we reduced time to monitoring to 2.2 hours by limiting diagnostic tests. Thirteen of 30 patients treated had an initial CO less than 3.5 L/M.(ABSTRACT TRUNCATED AT 250 WORDS)