Significance of myocardial contusion following blunt chest trauma.

A prospective study was undertaken at a regional trauma unit (RTU) to determine the significance of cardiac complications in patients with blunt chest trauma. Radionuclide angiographic (RNA) imaging was performed as soon as possible after admission and Holter monitors were applied for 72 hours. Routine investigations included serial cardiac enzyme measurements and 12-lead electrocardiograms. Dysrhythmias were classified and ventricular dysrhythmias were stratified by ventricular ectopic score (VES) as ventricular tachycardia (4) or greater than 100 premature ventricular contractions (PVCs)/hour (3). Three hundred twelve patients were entered into the study. Analysis of dysrhythmias revealed 18 patients with a VES of 4 and nine patients with a VES of 3; there were no serious consequences. The most significant dysrhythmia as a marker of outcome was atrial fibrillation (n = 9); five of these patients died, but all of associated noncardiac injuries. A review of abnormal RNAs revealed that all associated mortalities were attributed to noncardiac injuries. A review of postmortem reports and hospital records revealed that no deaths were attributed to cardiac failure or dysrhythmia. Thus the incidence of clinically significant dysrhythmias or other cardiac complications resulting from blunt trauma to the heart may be overestimated.     

Management of lung contusion.

One hundred and thirty-two consecutive patients with lung contusion were admitted during the three-year period of 1972 through 1974. All were treated with early intubation and mechanical ventilation with positive and-expiratory pressure with the postulate that such management would minimize the progression of interstitial edema, and intra-alveolar hemorrhage. If progressive increase in the alveolar/arterial oxygen tension gradient was not observed over the ensuing 24 hours, and in the absence of other non-thoracic indications of continuance of mechanical ventilation, patients were extubated and removed from the ventilator. All other patients were further ventilated and followed by daily chest roentgenograms and blood gas studies. Mean ventilation time was 6.2 days. Progressive hypoxemia and deterioration of pulmonary function were not seen. The incidence of pneumonia and tension pneumothorax was low. Overall mortality was 10.6 per cent. The most common cause of death was brain death. No deaths were the result of hypoxemia.     

Splenic injuries and mortality in polytrauma

Severe trauma is the leading cause of death in the working population. Traffic accidents are the most frequent etiological factor, with substantially more male than female victims. In this paper we have analyzed 53 cases of dead patients, among 240 severe traumatized treated in Center of emergency surgery, Emergency Center, CCS from January, 2000-June 2002. Spleen is the most frequent injured abdominal organ. In 34% surviving period was less than 72 hours. One-third of patients required at least two surgeries, including laparotomy. The most preciously diagnosis were performed in the cases of spleen injuries. The most common cause of death was cariopulmonal insufficiency, according both clinical diagnosis and forensic findings.     

Heart contusion as an unusual cause of shock in severe polytrauma

The reported incidence of myocardial contusion after blunt chest trauma is 7-17%. Only one third of these patients present with significant morbidity. The polytrauma is generally dominated by hypovolemic and traumatic shock. Other causes of hypotension are less common, and may thus be ignored. The standard algorithm of care in multiple trauma care, however, leads to the diagnosis even in these cases, as illustrated by a case of prolonged shock induced by blunt myocardial trauma.     

Early medical care and mortality in polytrauma

This study attempts to objectively estimate the efficiency of early medical care. It is based on the comparison of two series of multiple injured patients. Ten years separated the two groups and during this period, an Emergency Medical Aid Service (SAMU 94) was created. The positive effect of early medical care was established through the variations of injury severity indices currently used in polytrauma: after the institution of Mobile Intensive Care Medical Units on the site of accidents cardiac arrests were ten times less numerous although lesions were more serious in the second series. Without taking into account the mortality rate of lower-limb trauma, where crush syndromes were very numerous, mortality rate decreased as far as spinal, chest, abdominal, and pelvic traumas were concerned. An estimation of the cost of such a system raised the problem of maximizing the efficiency of improved early medical care.     

Lung bacterial clearance following pulmonary contusion.

Bacterial infections frequently,complicate pulmonary contusion and are the leading cause of death in such patients. This study evaluated the effects of pulmonary contusion alone and contusion associated with other factors on the ability to clear aerosolized bacteria from the lung. Lung bacterial clearance of Staphylococcus aureus and Klebsiella pneumoniae was studied in animals with isolated pulmonary contusion, or contusion associated with blood loss, rapid crystalloid infusion, or steroid administration. An isolated pulmonary contusion produced no impairment of the ability of the contused lung to clear either gram-negative or gram-positive organisms. The addition of acute blood loss and crystalloid infusion resulted in decreased clearance from the contused lung; steroid administration caused a marked depression in lung bacterial clearance from the noninjured lung as well. The canine model described allowed for study of regional differences in bacterial clearance. The data presented support several conclusions; (1) the contused lung is not more susceptible to bacterial infection than the normal lung: (2) acute blood loss renders the contused lung less able to clear bacteria; (3) crystalloid infusion markedly depresses lung bacterial clearance; and (4) steroids have a deleterious antibacterial effect on both contused and noncontused lungs.     

Technetium-fibrinogen lung scanning in canine lung contusion

To detect experimentally induced acute lung contusion in anesthetized dogs, serial radionuclide images of the lung were recorded following intravenous infusion of 99mTc-labelled human fibrinogen (Tc-HF). The accumulation of Tc-HF in canine lungs was serially quantitated for up to 20 hours after lung contusion. A contusion (#1) was produced in one lung, Tc-HF was injected IV after 15 minutes, and 75 minutes later a contralateral lung contusion (#2) was produced in a series of 14 dogs. At autopsy the excised lungs were scanned, sectioned, and counted for radioactivity. Radiolabelled fibrinogen accumulated within 2-4 minutes of contusion #2 and remained stable over the next 20 hours in 14 dogs; contusion #1 was barely visible in four dogs. Lung Tc-HF activity in the central region of contusion #2 remained sixfold higher than in normal lung tissue. These data suggest that following lung contusion, fibrinogen deposition occurs rapidly and remains stable over a 20-hour interval of observation.     

Acute post-traumatic cholecystitis. Caused by or following polytrauma?

Traumatic acute cholecystitis is of secondary importance beside many other complications in the polytraumatised patient, since it is rarely diagnosed--possibly too rarely. Difficulties often arise because of a multitude of injuries, which are often life-threatening and which must be given top priority (3). Men are chiefly involved (4). In most cases, the condition is preceded by shock, but not necessarily by gallstones (10, 11). First pointers in literature were given by Mennenga (8). As early as 1939 he pointed out that blunt abdominal trauma may produce tears in the gallbladder and bile duct regions. Marre (7) described acute signs in the upper abdomen due to rupture of the bile duct. Genesis of post-traumatic acute cholecystitis is still unclarified. Apart from rupture or perforation of the gallbladder or bile ducts, it is mainly shock (4, 9, 12) which is considered to be an important causative factor.     

Postoperative cognitive dysfunction and mortality following lung transplantation

Preliminary evidence suggests that postoperative cognitive dysfunction (POCD) is common after lung transplantation. The impact of POCD on clinical outcomes has yet to be studied. The association between POCD and longer‐term survival was therefore examined in a pilot study of posttransplantation survivors. Forty‐nine participants from a prior randomized clinical trial underwent a neurocognitive assessment battery pretransplantation and 6 months posttransplantation, including assessments of the domains of Executive Function (Trail Making Test, Stroop, Digit Span), Processing Speed (Ruff 2 and 7 Test, Digit Symbol Substitution Test), and Verbal Memory (Verbal Paired Associates, Logical Memory, Animal Naming, and Controlled Oral Word Association Test). During a 13‐year follow‐up, 33 (67%) participants died. Greater neurocognition was associated with longer survival (hazard ratio [HR] = 0.49 [0.25‐0.96], P = .039), and this association was strongest on tests assessing Processing Speed (HR = 0.58 [0.36‐0.95], P = .03) and Executive Function (HR = 0.52 [0.28‐0.97], P = .040). In addition, unadjusted analyses suggested an association between greater Memory performance and lower risk of CLAD (HR = 0.54 [0.29‐1.00], P = .050). Declines in Executive Function tended to be predictive of worse survival. These preliminary findings suggest that postoperative neurocognition is predictive of subsequent mortality among lung transplant recipients. Further research is needed to confirm these findings in a larger sample and to examine mechanisms responsible for this relationship.     

Significance of the electrocardiogram in heart contusion due to blunt trauma.

In a series of 24 patients with major blunt chest trauma, 11 presented evidence of heart injury upon re-examination of serial ECGs and four were confirmed at autopsy. The clinical diagnosis had been recorded in only one patient. In every case of closed chest trauma, regardless of the degree of visible injury, cardiac injury must be suspected. A presumptive diagnosis is then made, usually on the basis of ECG changes, which cannot be ruled out by any other cause. Even in some cases with normal ECGs the clinician's suspicion is the only guide. With a presumptive diagnosis made, the patient is treated as is any patient with an irritable myocardium; bedrest, avoidance of conditions which may precipitate arrhythmias, and of fluid overload, and treatment of these complications as they arise. Anticoagulants are usually avoided. Followup for long periods is indicated, because of the occasional emergence of chronic constrictive pericarditis or ventricular aneurysm.     

Brain changes on computed tomography following metrizamide myelography. Significance and therapeutic implications

Three cases of seizures and marked behavioral changes that occurred after intrathecal metrizamide administration are reported. In each case a cranial computed tomographic scan obtained within 24 hours of the ictus showed hyperdensity of the gray matter, and created an optical illusion of diffuse white matter edema. The literature on adverse reactions and their pathogenesis and on brain parenchymal penetration of metrizamide is reviewed.     

Predictors of laparotomy and mortality in polytrauma patients with pelvic fractures

Background

The decision to perform laparotomy in blunt trauma patients is often difficult owing to pelvic fractures; however, once the decision is made, delay or failure to perform laparotomy could affect morbidity and mortality. We sought to identify predictors of laparotomy and mortality in polytrauma patients with pelvic fractures.

Methods

We divided 390 blunt polytrauma patients (Injury Severity Score [ISS] ≥ 16) with pelvic fractures into laparotomy (n = 56) and nonlaparotomy (n = 334) groups. We assessed the role of the following variables in predicting laparotomy and mortality: age, sex, hypotension, fluid and blood transfusions, positive abdominal computed tomography (CT) scans or focused assessment with sonography for trauma (FAST) examination, pelvic fracture severity and ISS. We analyzed the data using Student t and χ² tests, followed by logistic regression analysis.

Results

Mortality was higher in the laparotomy group than the nonlaparotomy group (28.6% v. 12.9%; overall mortality 15.1%). The laparotomy group had higher mean ISS (36.9 v. 24.9), higher mean abbreviated injury scores (AIS) for the abdomen (2.6 v. 0.9) and chest (3.4 v. 1.6), lower mean initial hemoglobin levels (105.2 v. 127.0 g/L), higher mean crystalloid (4249 v. 3436 mL) and blood transfusion volumes over 4 hours (12.1 v. 3.9 units), more frequent hypotension (44.6 v. 18.0%) and a higher percentage of positive CT scans (67.9% v. 28.4%) and FAST examination results (42.9% v. 3.3%) than the nonlaparotomy group. Age (mean 53.7 v. 41.5 yr); ISS (mean 39.0 v. 24.4); AIS for the head (mean 3.2 v. 1.7), abdomen (mean 1.6 v. 1.1), chest (mean 2.7 v. 1.8) and pelvis (mean 3.1 v. 2.6); crystalloid (mean 5157.3 v. 3266.4 mL) and blood transfusion volumes over 4 hours (mean 13.1 v. 3.7) and initial hypotension (61% v. 14.8%) were all greater among patients who died than those who survived. Mean initial hemoglobin levels were lower among patients who died than among those who survived (111.1 v. 126.2 g/L). Age, the AIS for the head, initial hypotension and low initial hemoglobin levels were highly predictive of mortality, whereas low initial hemoglobin levels, a positive FAST examination and high AIS for the abdomen and chest were all highly predictive of laparotomy.

Conclusion

Among the polytrauma patients with pelvic fractures, 14.3% underwent laparotomy, and mortality was higher among these patients than among those who did not have the procedure. The predictors of laparotomy and mortality are similar to those anticipated in patients without pelvic fractures.     

Post-traumatic alveolar changes in lung contusion]

Bronchoalveolar lavage (BAL) specimens taken from nine patients with lung contusion following multiple trauma were compared with specimens from different control groups. Early interstitial and intra-alveolar reactions are PMN degranulation, mediator release and high protein leakage. The alveolar reactions are similar in extent to the reaction found in post-traumatic ARDS.     

Functional and morphological characteristics of lung contusion

Interrelated disturbances of functions of the external ventilation, cardiac activity and hemodynamics in contusion of the lung in experiment are always of a phasic character and are distinctly dependent on the volume of the respiratory parenchyma injury. The most pronounced disturbances of respiration and cardiac activity are observed by the end of the first day and the beginning of the second day after trauma. The decreased activity of the pulmonary surfactant and alteration of permeability of the aerohematic barrier play a substantial part.