Patterns of injury and disability caused by forklift trucks

Over a 7-year period, 34 patients were treated at the Southern New Jersey Regional Trauma Center for forklift-related injuries, ranging from minor contusions to multiple organ-system trauma. Hospital and rehabilitation courses were prospectively evaluated, documenting long term impairment of function and disability. Patients injured by falling from forklifts generally had less severe injuries, requiring fewer surgical procedures, shorter hospital stays, and less overall disability, than patients who received crush-type (object-oriented) injuries. The more serious injuries were most frequently caused by a forklift striking or running over the patient. There were strong correlations between the Injury Severity Score assessed upon initial evaluation and subsequent length of hospitalization, degree of disability, and extent of functional impairment after recovery. These findings support the enforcement of existing safety precautions for the operation of forklift trucks.

Bradykinin receptor antagonists containing N-substituted amino acids: in vitro and in vivo B(2) and B(1) receptor antagonist activity

We report a systematic probing of the structural requirements of the bradykinin (BK) type 2 (B(2)) receptor for antagonist activity by incorporating N-alkyl-amino acid residues at positions 7 and 8 of a potent antagonist sequence. Compound 1 (D-Arg(0)-Arg(1)-Pro(2)-Hyp(3)-Gly(4)-Thi(5)-Ser(6)-D-Tic(7)-N-Chg (8)-Arg(9), CP-0597)(1,2) is a potent (pA(2) = 9.3, rat uterus; pK(i) = 9.62, binding, human receptor clone) B(2) receptor antagonist devoid of in vitro B(1) antagonist activity (rabbit aorta). Compound 1 exhibits high potency (ED(50) = 29.2 pmol/kg/min, iv, rabbit) and duration of action when tested in models for in vivo B(2) antagonist activity. Although devoid of activity in a classic B(1) isolated tissue assay, B(1) antagonist activity for 1 was demonstrated in vivo, in a LPS-treated, inducible BK(1) receptor rabbit blood pressure model (ED(50) = 1.7 nmol/kg/min). D-Arg(0) of 1 can be formally replaced by an achiral arginine surrogate, without significant loss in antagonist potency on rat uterus (compound 11, B(2) pA(2) = 9.1). Antagonist 13 (Hyp(2), Nchg(8)), pK(i) = 10.2, and agonist 4 (N-methylcyclohexyl-Gly(8)), pK(i) = 10.1, also exhibited substantial binding to guinea pig ileum membrane receptors as well as a human B(2) receptor clone. Very minor structural changes in the N-alkyl amino acid residues in positions 7 and 8 can modify the activity of this class of compounds from being extremely potent antagonists to tight binding partial or full agonists. These studies have resulted in a series of compounds containing inexpensive amino acid residues but which produce broad spectrum BK receptor blocking potency and exceptional in vivo duration of action.

Lorazepam and midazolam in the intensive care unit: a randomized, prospective, multicenter study of hemodynamics, oxygen transport, efficacy, and cost

OBJECTIVES

To evaluate and compare the clinical efficacy, impact on hemodynamic and oxygen transport variables, safety profiles, and cost efficiency of sedation and anxiolysis with lorazepam vs. continuous infusion of midazolam in critically ill, intensive care unit patients.

DESIGN

Multicenter, prospective, randomized, open-label study.

SETTING

Teaching hospitals.

PATIENTS

Ninety-five critically ill, mechanically ventilated patients with fiberoptic pulmonary artery catheters in place were randomly assigned to receive short-term (8 hrs) sedation with either intermittent intravenous injection lorazepam (group A, n = 50) or continuous intravenous infusion midazolam (group B, n = 45) titrated to clinical response.

MEASUREMENTS AND MAIN RESULTS

The severity of illness, demographic characteristics, levels of anxiety and agitation, hemodynamic parameters, oxygen transport variables, quality of sedation, nursing acceptance, and laboratory chemistries reflecting drug safety were recorded. There were no significant differences with regard to demographic data, hemodynamic and oxygen transport variables, or levels of anxiety/agitation between the two groups at baseline, 5 mins, 30 mins, and 4 and 8 hrs after administration of sedation. There were no significant differences in the quality of sedation or anxiolysis. Midazolam-treated patients used significantly larger amounts of drug for similar levels of sedation and anxiolysis (14.4 +/- 1.2 mg/8 hrs vs. 1.6 +/- 0.1 mg/8 hrs, p = .001). Both drugs were safely administered and patient and nurse satisfaction was similar.

CONCLUSIONS

Sedation and anxiolysis with lorazepam and midazolam in critically ill patients is safe and clinically effective. Hemodynamic and oxygen transport variables are similarly affected by both drugs. The dose of midazolam required for sedation is much larger than the dose of lorazepam required for sedation, and midazolam is therefore less cost-efficient.

Syncope as etiology of road crashes involving elderly drivers

A significant number of elderly drivers present without discernible external cause for their road crash. We hypothesize that syncope may contribute to their crash etiology and prospectively evaluated drivers older than 60 years with unexplained crash, presenting to our trauma center during a 1-year period. Prehospital data and prior medical history were obtained on all, followed by a standard syncope work-up. Of 79 drivers ages 60-98, 58 (73%) were at fault in the crash. In 33 (57%), the crash etiology could not be determined. Thirteen had prior syncope history. Workup was negative in two patients, and six died or were transferred before evaluation. Twenty-five of 33 (76%) had positive workups for syncope: cardiac causes in 10; neurologic in seven; psychiatric in five, endocrine in two; one indeterminant. Ten of 18 who survived had license revocation for medical reasons. Syncopal episodes are a frequent contributor to unexplained crashes among elderly drivers and should be suspected whenever external causes are not apparent.

Desensitization of Ras activation by a feedback disassociation of the SOS-Grb2 complex

Activation of Ras by the exchange of bound GDP for GTP is predominantly catalyzed by the guanylnucleotide exchange factor SOS. Receptor tyrosine kinases increase Ras-GTP loading by targeting SOS to the plasma membrane location of Ras through the small adaptor protein Grb2. However, despite the continuous stimulation of receptor tyrosine kinase activity, Ras activation is transient and, in the case of insulin, begins returning to the GDP-bound state within 5 min. We report here that the cascade of serine kinases activated directly by Ras results in a mitogen-activated protein kinase kinase (MEK)-dependent phosphorylation of SOS and subsequent disassociation of the Grb2-SOS complex, thereby interrupting the ability of SOS to catalyze nucleotide exchange on Ras. These data demonstrate a molecular feedback mechanism accounting for the desensitization of Ras-GTP loading following insulin stimulation.

Selective indications for thoracic and lumbar radiography in blunt trauma

STUDY OBJECTIVE

To determine indications for thoracolumbar radiography.

DESIGN

Case series with prospective data collection.

SETTING

Level I trauma center.

PARTICIPANTS

Blunt-trauma victims more than 12 years old who underwent routine thoracic and lumbar radiography according to institutional protocol. Patients were classified as group 1, not able to be evaluated clinically (Glasgow Coma Scale score of less than 13, intoxication, intubation, or cervical neurologic deficit); and group 2, able to be evaluated clinically.

RESULTS

Twenty-four of 319 patients sustained 25 thoracic or lumbar fractures. Seven of 136 group 1 patients and 17 of 183 group 2 patients had fractures. Eight of 17 patients with pain and 9 of 17 with tenderness had fractures (P = .001). No group 2 patients without pain, tenderness, thoracic or lumbar neuro-deficit, or major distracting injury, including cervical fracture, had fractures. The negative predictive value of pain and tenderness was 95%. Five of 46 patients with spinal fractures at any level had multiple fractures.

CONCLUSION

Blunt-trauma victims who cannot be evaluated clinically should undergo thoracolumbar radiography. Routine radiography may be unnecessary in asymptomatic patients who can be evaluated clinically and who do not have neurologic deficits or distracting injuries. Spinal fracture at any level mandates complete spinal radiography.

Morbidity of negative coeliotomy in trauma

Exploratory coeliotomy is essential in the care of abdominal trauma, but negative operation has a reported morbidity rate as high as 18 per cent. Ancillary studies such as computerized tomography, diagnostic peritoneal lavage and abdominal ultrasound have improved both sensitivity and specificity of evaluation in blunt and penetrating trauma, thus decreasing the rate of negative coeliotomy. A retrospective study of 50 consecutive negative laparotomies (10.5 per cent of all trauma laparotomies) at our Trauma Center revealed a morbidity rate of 22 per cent and mortality of 6 per cent. Although the negative coeliotomy rate was lower for blunt than penetrating trauma, morbidity was significantly higher for blunt trauma. Extra-abdominal injury alone could not account for this difference. We conclude that negative coeliotomy in penetrating trauma does not carry excessive morbidity. Negative coeliotomy in blunt trauma is accompanied by high morbidity and mortality, so adjunct diagnostic procedures should be utilized in this population in an effort to minimize negative laparotomies.

Diagnosis of unsuspected facial fractures on routine head computerized tomographic scans in the unconscious multiply injured patient

PURPOSE

This article assessed the value of routine head computerized axial tomographic (CT) scans for diagnosis of unsuspected facial fractures and its clinical implications in the multiply injured patient who is intubated, unconscious, or sedated at the time of initial assessment and requires a head CT scan to assess for brain injury.

METHODS

At a level I trauma center from June 1, 1992 to June 1, 1993 all intubated blunt trauma patients who required routine CT scan evaluation at initial assessment were studied prospectively. Routine scanning started at the foramen magnum and included the maxilla. Patients who died within the first 24 hours were excluded.

RESULTS

The study population included 116 patients (85 male, 21 female) aged 12 to 85 years (mean, 28 years) with injury severity scores ranging from 1 to 50 (mean, 23). The mechanism of injury was: motor vehicle accidents (n = 74), motorcycling (n = 5), pedestrians accidents (n = 13), falls (n = 10), bicycling (n = 5), assaults (n = 8), and boating accident (n = 1). There were 19 suspected facial fractures; 18 required surgical repair. There were 27 unsuspected facial fractures; 13 required surgical care. Three suspected fractures were ruled out.

CONCLUSION

Routine head CT scans to assess for brain injury in the multiply injured patient are also very useful in the diagnosis of unsuspected facial fractures, almost half of which will require surgical intervention.

Elderly drivers involved in road crashes: a profile

The ability of elderly citizens to drive safely has been the subject of ongoing debate. To identify the type of elderly driver who becomes involved in an injury-producing road crash, we profiled all drivers over 39 years of age admitted to our Level I Trauma Center over a 1-year period. Data were prospectively collected and drivers age 40-59 years were compared with those over 60 years. Eighty-four drivers age > or = 60 and 130 drivers age 40-59 were studied. Of the 84 elderly drivers, 67 were deemed at fault. Twenty-four of those crashes were due to driving errors, 12 due to syncopes, and in 20 no crash cause was determined. Fifty-three of the 67 at fault drivers had significant underlying medical problems, compared to 9 of 17 deemed not at fault. Only four were legally intoxicated. Of the 130 drivers in the comparison group, only 19 had significant underlying medical problems; in three syncope was suspected; 18 were legally intoxicated. We conclude from our data that underlying medical disorders occur frequently in elderly drivers and may contribute to their incidence of road crashes.

The spectrum of blunt injury to the carotid artery: a multicenter perspective

The relative infrequency of blunt carotid artery trauma prompted a multicenter review to determine the spectrum of injuries, treatment strategies, and neurologic outcome. During a six-year period, 60 carotid artery injuries from blunt mechanisms in 49 patients were treated at 11 institutions. There were 11 bilateral injuries. Injury mechanisms were diverse but involved motor vehicles in 35 (72%) patients. In 14 (29%) patients, significant neurologic deficits developed more than 12 hours after a normal admission neurologic examination. The diagnosis was confirmed by angiography in 42 (86%). Duplex ultrasound accurately demonstrated the arterial injury in 12 (86%) of 14 patients. Documented injuries included arterial thrombosis in 20 arteries, arterial dissection alone in 19, dissection with pseudoaneurysm in six, pseudoaneurysm alone in five, frank arterial disruption in seven, and carotid-cavernous fistula in three. Arterial dissection was managed nonsurgically in 15 (79%) of 19 cases, the majority with systemic anticoagulation. Arterial thrombosis was managed with supportive therapy alone for 16 (80%) of 20 arteries; most associated with fixed neurologic deficits. Pseudoaneurysm repair was performed for six (55%) injuries. Carotid-cavernous fistulas were treated in all three instances with balloon occlusion. Overall mortality was 16 of 49 patients (43%). Good neurologic outcome was achieved in 22 (45%) patients. We conclude that: (1) Neurologic symptoms may develop in a delayed fashion; prior clinical suspicion and diagnostic testing are essential; (2) arterial dissection without complete occlusion may effectively be managed by anticoagulation; (3) pseudoaneurysms in accessible anatomic locations can be repaired with good results; and (4) injuries with complete arterial thrombosis are associated with high mortality and poor neurologic outcome in proportion to the initial degree of neurologic impairment.

Penetrating posterior abdominal trauma

Wounds of the back and flank pose a risk of injury to retroperitoneal structures which may be missed on physical examination. Recently, a selective approach to these wounds has been advocated. In order to document the incidence, management, and outcome of patients with penetrating wounds of the back and flank, we undertook a retrospective review of patients admitted over the past 5 years. Twenty-nine patients with penetrating posterior abdominal wounds were reviewed. There were 17 stab wounds and 12 gunshot wounds. All six patients who exhibited haemodynamic instability or abnormalities on physical examination underwent emergency laparotomy. The remaining 23 patients were admitted for observation. All patients underwent physical examination, abdominal radiographs, and urinalysis. Nine underwent IVP. Eight patients had abdominal CTs. No peritoneal lavages were performed. There were no missed injuries, no deaths and no delayed operations. There were two complications in the operative group, and one liver abscess in the nonoperative group. We conclude that selective management is a safe approach in penetrating posterior abdominal trauma without obvious indications for laparotomy.

In vivo association of Grb2 with pp116, a substrate of the T cell antigen receptor-activated protein tyrosine kinase

Numerous recent studies have implicated the src homology 2 and 3 domain-containing protein, Grb2, in coupling protein tyrosine kinase signaling pathways with the Ras signaling pathway. Ligation of the T cell antigen receptor results in the activation of both a PTK, and Ras; therefore, we investigated whether Grb2 may serve a similar function in T cells. Here we report that a GST/Grb2 fusion protein associates with several tyrosine phosphoproteins from lysates of T cell antigen receptor-stimulated Jurkat T cells. Two of these proteins, pp36 and pp116, bind to the Grb2 fusion protein with high affinity. Through the use of mutated Grb2 fusion proteins, we demonstrate that pp116 binds the amino-terminal src homology 3 domain of Grb2, the same domain of Grb2 thought to be primarily responsible for its interaction with SOS. We demonstrate further that pp116 associates with Grb2 in vivo, and we provide evidence that in the Jurkat T cell line Grb2 may exist complexed with either pp116 or with SOS.

The pivotal role of transesophageal echocardiography in the management of traumatic thoracic aortic rupture with associated intra-abdominal hemorrhage

Rupture of the thoracic aorta after blunt trauma, particularly when associated with multiple injuries, presents a major problem of resuscitation and management. Transesophageal color Doppler echocardiography (TEE) during laparotomy played a major role in confirming the diagnosis of thoracic aortic rupture in a patient.

The association between CD45 and lck does not require CD4 or CD8 and is independent of T cell receptor stimulation

CD45, the major transmembrane tyrosine phosphatase of lymphoid cells, is required for optimal signaling via a number of receptors. A model for how CD45 regulates signaling is that it controls phosphorylation of the COOH-terminal tyrosine of src family kinases. We have shown that CD45 physically associates with lck, one src kinase. Others have shown that CD45 also interacts with the CD4 and CD8 surface antigens expressed on many T cells. In this report we examine further the relationship between CD45 and lck in a CD4+ T cell line and in peripheral T cells. We show now that CD45 associates with lck independently of both CD4 and CD8. We show also the time course of an association between CD45 and a form of lck that migrates at an apparent higher molecular mass. Finally, we demonstrate that the interaction between CD45, lck, and a previously reported 32-34 kD protein is stable after stimulation of T cells.

Novel soluble, high-affinity gastrin-releasing peptide binding proteins in Swiss 3T3 fibroblasts

Swiss 3T3 cells contained substantial amounts of soluble and specific [125I]GRP binders. Like the membrane-associated GRP receptor, they were of high affinity, saturable, bound to GRP(14-27) affinity gels, and exhibited specificity for GRP(14-27) binding. They differed in that acid or freezing destroyed specific binding, specific binding exhibited different time and temperature effects, no detergent was required for their solubilization, ammonium sulfate fractionation yielded different profiles, the M(rs) were lower, GRP(1-16) also blocked binding, and a polyclonal anti-GRP receptor antiserum did not bind on Western blots. The isolated, soluble GRP binding protein(s) rapidly degraded [125I]GRP. These soluble GRP binding proteins may play a role in the regulation of the mitogenic effects of GRP on these cells.

Colostomy in trauma surgery: friend or foe?

Twenty-five patients underwent a colostomy that came to closure. There were eight blunt, 15 penetrating and two impaling injuries. Colostomy-related complications occurred in four patients; two wound infections, one stoma prolapse, one loop obstruction. Closure was performed during a second hospital stay after a standard mechanical bowel preparation and enteral and parenteral broad-spectrum antibiotics perioperatively. The procedure performed by board certified/eligible surgeons, lasted an average of 2.5-3h. Incisional hernias occurred as the only complication in two patients. For certain injuries of the colon, rectum and perineum, diverting colostomy is still the procedure of choice. It can be performed without significant additional morbidity. Subsequent closure in experienced hands does not carry a significant complication rate.

Complications of anticoagulation for pulmonary embolism in low risk trauma patients

Trauma patients are at significant risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). Anticoagulation is standard therapy for DVT/PE, but may cause severe complications. We reviewed the course of 70 trauma ICU patients treated over a 28-month period. Thirty-six patients (51.4 percent) were treated by continuous IV heparin and/or oral warfarin. Of these, 13 patients (36 percent) developed complications requiring termination of anticoagulation. These included recurrent PE (four), subdural hematomas (three), hemothorax (two), heparin-induced thrombocytopenia (one), hemorrhagic pericardial effusion (one), retroperitoneal hematoma (one), and sudden unexplained drop in hemoglobin and shock (one). All patients with subdural hematomas had no prior evidence of head injury on brain computed tomography. All patients with recurrent PE received adequate anticoagulation therapy. Age > 55 was associated with increased risk of complications (8 of 13; p = .02:chi 2). Thirty-four other patients (48.6 percent) received inferior vena caval filters with no related complications or deaths. Anticoagulation for DVT/PE should be used selectively in trauma patients and avoided in elderly patients. Such patients should undergo early caval filter placement.

Limitations of neurological assessment in mild head injury

The authors have investigated two commonly used methods of assessing neurological status in patients with mild head injury to determine whether they can predict intracranial damage. Of 686 such patients with cranial computed tomography (CT) scans, scan results were recorded, along with total and motor components of the Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85). Despite relatively normal admission neurological examinations, 127 of the 689 patients (18.4%) had intracranial lesions, and 38 (5.5%) required surgery. There was no significant difference in distribution of the GCS in patients with and without intracranial lesions. The RLS85 was superior to the GCS in predicting intracranial pathology, and a significant association between RLS85 and lesions on CT scanning was noted. However, even this test was normal in 19 patients found to have intracranial pathology, including nine who required surgery. The authors conclude that a normal or near-normal mental status examination in a head-injured patient on arrival at the emergency room is inadequate to exclude a potentially serious intracranial lesion. It is unlikely that further refinements in the clinical evaluation will result in diagnostic accuracy comparable with that of CT scanning. Accordingly, we recommend that any patient who has suffered a loss of consciousness or amnesia following head injury have an urgent cranial CT scan.

Failure of the legal system to enforce drunk driving legislation effectively

STUDY OBJECTIVE

To evaluate the investigation and prosecution of drunk drivers and identify reasons for system failure.

DESIGN

Prospective data collection on all drivers with an elevated blood alcohol level who were treated at a Level I trauma center between January 1 and June 30, 1991.

SETTING

Level I trauma center/university medical center serving a population of 1.8 million.

INTERVENTIONS

Prospective data collection, interviewing ambulance squad members, investigating police, and results of prosecution.

MEASUREMENTS AND MAIN RESULTS

Of 321 drivers, 78 had ethanol levels of more than 100 mg/dL; nine were between 50 and 100 mg/dL. All drivers had rapid transport to a trauma center for severe injury or high-risk injury mechanism. Police reports were accessible for 84 of 87 drivers; all drivers were believed to be at fault. The crashes resulted in five deaths and 74 other victims requiring hospitalization. Six of the intoxicated drivers died. Police requests for blood alcohol levels were made for 28 drivers, one of whom died. The remaining 59 drivers had no legal blood alcohol level drawn. Although the greater the distance from our center (more rural), the less likely were requests for ethanol levels, but there were many "no requests" from nearby cities. Of the 28 drivers on whom legal alcohol levels were drawn, eight escaped central registration with the highway safety commission, which records any and every traffic violation within New Jersey. Of the remaining 20, eight were not prosecuted (excluding one death), including one repeat offender. One committed a later "driving while intoxicated" offense and was then prosecuted. The remaining 11 were all convicted; five were repeat offenders.

CONCLUSION

Reasonable cause is required for legal blood alcohol requests. Our data demonstrated that this is difficult when the driver is unavailable for questioning. However, once legal blood alcohol levels have been obtained, inadequate legal follow-up leads to nonprosecution. Once officially charged, conviction appears certain, but even this punishment and re-education fail to change behavior in many of these drivers.

Interactions of mycoplasmas with B cells: antibody production and nonspecific effects

Interactions between mycoplasmas and B cells consist primarily of the development of specific antibody and of nonspecific interactions with B lymphocytes or antibody. Antibody responses are important in the resistance to mycoplasmal disease in both humans and animals. However, the ability of mycoplasmas to survive in their host despite vigorous responses suggests that these play a limited role in the host's recovery from infection. Antibody also may prevent dissemination of mycoplasmal infections from mucosal sites and may account for the appearance of systemic mycoplasmal infections in immunocompromised patients. In some cases, antibody responses may contribute to disease pathogenesis through the development of hypersensitivity responses or the deposition of immune complexes. In addition, nonspecific interactions between mycoplasmas and B lymphocytes have been implicated in disease pathogenesis, possibly leading to autoimmune reactions, modulation of immunity, and/or promotion of lesion development. For example, several mycoplasmas, including Mycoplasma pneumoniae and Mycoplasma pulmonis, are able to activate B cells polyclonally in vitro and in vivo, but the mechanisms and consequences of these responses have yet to be defined. In addition to activating B lymphocytes, mycoplasmas are capable of producing chemotactic factors, Fc receptors, and immunoglobulin proteases that may also be involved in lesion development and/or survival of the organisms. Thus, both specific and nonspecific interactions of mycoplasmas with B cells can have important effects on disease progression, especially since many mycoplasmal infections are chronic and the cumulative effect of these interactions may be substantial.

Rescue of signaling by a chimeric protein containing the cytoplasmic domain of CD45

Surface expression of the CD45 tyrosine phosphatase is essential for the T cell antigen receptor (TCR) to couple optimally with its second messenger pathways. CD45 may be required to dephosphorylate a TCR-activated protein tyrosine kinase, which then transduces an activation signal from the TCR. A chimeric molecule that contained extracellular and transmembrane sequences from an allele of a major histocompatibility class I molecule and cytoplasmic sequences of CD45 restored TCR signaling in a CD45-deficient mutant T cell line. Thus, expression of the complex extracellular domain of CD45 is not required for the TCR to couple to its signaling machinery.

Bacterial translocation occurs in humans after traumatic injury: evidence using immunofluorescence

We evaluated the occurrence of bacterial translocation (BT) in humans after traumatic injury. Twenty trauma patients (18 with blunt trauma) requiring celiotomy and without hollow viscus injury were studied. After surgical hemostasis and repair, portal venous blood (PVB) was sampled for culture. Additionally, a mesenteric lymph node (MLN) was harvested for culture and indirect immunofluorescence analysis using, first, mouse monoclonal antibody to E. coli beta-galactosidase, then goat anti-mouse immunoglobulin G (IgG). Injury Severity Score (ISS), Trauma Score (TS), and period of hemorrhagic shock (HS; systolic BP < 90 mm Hg with blood loss > 500 mL) were recorded before specimens were obtained.

RESULTS

Fifteen patients initially had HS (mean period of 60 minutes). Mean TS and ISS were 10 and 29, respectively. Seven patients did not have HS (mean TS and ISS, 10 and 13). Three patients received antibiotics preoperatively. Portal venous blood culture produced positive results in only three patients (two with HS) and culture of the MLN specimen was positive in one. However E. coli beta-galactosidase was detected within the cytoplasm of macrophages in all MLNs. One patient developed multiple organ failure.

CONCLUSION

Bacterial translocation occurs in humans following traumatic injury and may be independent of HS. Culture techniques may not detect BT since organisms may have been phagocytized by macrophages. The clinical significance of BT in trauma patients remains unclear.

Delayed and progressive brain injury in closed-head trauma: radiological demonstration

The importance of delayed or secondary brain insults in the eventual outcome of closed-head trauma has been documented in experimental models. To understand this phenomenon in the clinical setting, we studied a series of head-injured patients in whom multiple cranial computed tomographic (CT) scans were obtained. Patients whose follow-up CT studies revealed new intracranial lesions or worsening, compared with admission findings, were considered to have delayed cerebral injury. One hundred forty-nine (44.5%) of 337 consecutively studied patients developed delayed brain injury. There were highly significant associations (P < 0.001) between the appearance of delayed cerebral insults and the severity of the initial brain injury, the need for cardiopulmonary resuscitation in the field, the presence of coagulopathy at admission, and subdural hematoma on the initial CT scan. In addition, delayed injury was associated (P < 0.001) with higher mortality, slowed recovery, and poorer outcome at 6 months. Delayed brain injury was not significantly associated with patient age, sex, injury mechanism, associated injury, the need for endotracheal intubation in the field, early talking, CT abnormality other than intracranial hematoma, or type of residual neurological deficits. We used multiple regression analysis to explore the relationship between severity of injury, delayed insults, and outcome. As expected, the severity of the initial brain trauma contributed significantly to neurological outcome. The presence of delayed cerebral injury makes the outcome dramatically worse for each category of initial injury severity. The relationship between initial and secondary brain injury is discussed.

Continuous pulse oximetry and the diagnosis of pulmonary embolism in critically ill trauma patients

The diagnosis of pulmonary embolism (PE) may be difficult to establish in trauma patients, particularly those who are unresponsive or mechanically ventilated. Based on a prior retrospective study, we hypothesized that patients monitored by continuous pulse oximetry who experienced a 10% or greater sudden sustained drop in arterial oxygen saturation (SaO2) without a change in static lung compliance (Cst) were most likely to have had a PE. We followed SaO2 in 972 patients admitted to our trauma ICU during the 18-month period ending in December 1990. Forty-eight patients (5%) with SaO2 changes, but no Cst changes, were evaluated for suspected PE using pulmonary arteriography (PA). Of these, 21 (44%) had a positive PA study. All patients with a positive PA had either clear chest roentgenograms or no change in underlying pulmonary pathologic processes. Of the remainder, 26 had evidence of a new pathologic entity on chest roentgenograms and only one patient had a SaO2 decrease, no change in Cst, and a negative PA. All mechanically ventilated trauma patients should have SaO2 monitored continuously. Patients with a > 10% drop in Sao2 with no change in Cst and no new roentgenographic chest findings should undergo PA. Based on our experience, this approach would yield a sensitivity, specificity, and predictive value of 100%, 99.9%, and 95%, respectively, for the diagnosis of clinically significant PE.

Moderate head injury: a guide to initial management

The purpose of this study is to determine the initial treatment of patients who appear to have sustained moderate head injuries when first evaluated. The authors reviewed the records of 341 patients whose initial Glasgow Coma Scale (GCS) scores ranged from 9 to 12, as well as another 106 patients with GCS scores of 13. All patients underwent cranial computerized tomography (CT) at the time of admission. In 40.3% of these patients the CT scans were abnormal (30.6% had intracranial lesions), and 8.1% required neurosurgical intervention (craniotomies for hematoma in 12, elevation of depressed fractures in five, and insertion of intracranial pressure monitors in 19). Four patients died of their intracranial injuries. A similar incidence of lesions found on CT and at surgery suggests that an initial GCS score of 13 be classified with the moderate head injury group. Skull fractures were found to be poor indicators of intracranial abnormalities. These results suggest that all patients with head injury thought to be moderate on initial examination be admitted to the hospital and undergo urgent CT scanning. Patients with intracranial lesions require immediate neurosurgical consultation, surgery as needed, and admission to a critical-care unit. Scans should be repeated in patients whose recovery is less rapid than expected and in all patients with evidence of clinical deterioration; this was necessary in almost half of the patients in this group, and 32% were found to have progression of radiological abnormalities on serial CT scans.

Review article: venous thromboembolism in trauma patients

The increased coagulability in multiple injured patients results in increased risk for deep venous thrombosis and pulmonary embolism. The authors discuss etiology, diagnosis, treatment, and prophylaxis of venous thromboembolism in trauma patients.

Blunt colonic injury--a multicenter review

During the past decade there has been a shift in the management of injuries of the colon to primary repair without a protective diverting colostomy. Unfortunately, reports concerning this practice contain relatively few patients with blunt trauma and it is unclear whether the principles established for penetrating injury should be applied in the setting of blunt colon injury. A retrospective review of 54,361 major blunt trauma patients admitted to nine regional trauma centers from January 1, 1986, through December 31, 1990, was conducted. Statistical analysis of the data collected regarding 286 (0.5%) of these patients who suffered colonic injury revealed: (1) injury to the colon is found in more than 10% of patients undergoing laparotomy following blunt trauma; (2) available diagnostic modalities are unreliable in detecting isolated colonic pathology; (3) primary repair of full-thickness injuries or resection and anastomosis may be safely performed without diversion; (4) gross fecal contamination is the strongest contraindication to primary repair. Further, delay of surgery, shock, and the timing of antibiotic administration were not associated with significantly increased morbidity.

Effects of intensity of treatment and length of stay on rehabilitation outcomes

The combined effects of intensity of treatment and length of stay during inpatient rehabilitation hospitalization on the outcomes of 95 traumatic brain injury patients were examined. Outcome was assessed using the Rancho Scale and three measures of functional status--physical performance, higher-level cognitive skills, and cognitively mediated physical skills. The effects of intensity of treatment and length of stay were assessed using 2 x 2 analyses of variance with repeated measures. The results showed clearly that both length of stay and intensity of treatment affect outcomes. Patients in the long length of stay group consistently made more progress across all outcome variables than patients in the short length of stay group. However, the greater progress of the long length of stay patients was from a point significantly more disabled than that of the short length of stay patients, with improvement at discharge to the point at which the groups were now equal. The effect of intensity of treatment was significant or closely approached significance for higher-level cognitive skills and Rancho Level. In the long length of stay group, the two intensity groups were initially equivalent, but at discharge the high-intensity group surpassed the low-intensity group. The practical implications of the results are discussed.

The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries

The evaluation and management of patients with minor head injury (MHI: history of loss of consciousness or posttraumatic amnesia and a GCS score greater than 12) remain controversial. Recommendations vary from routine admission without computed tomographic (CT) scanning to mandatory CT scanning and admission to CT scanning without admission for selected patients. Previous reports examining this issue have included patients with associated non-CNS injuries who confound the interpretation of the data and affect outcome. We hypothesized that patients with MHI and no other reason for admission with normal neurologic examinations and normal CT scans would have a negligible risk of neurologic deterioration requiring surgical intervention. To validate this hypothesis we studied 2766 patients with an isolated MHI admitted to seven trauma centers between January 1, 1988, and December 31, 1991. There were 1898 male patients and 868 female patients; injury was blunt in 99%. A neurologic examination and a CT scan were performed on 2166 patients; 933 patients had normal neurologic examinations and normal CT scans and none required craniotomy; 1170 patients had normal CT scans and none required craniotomy; 2112 patients had normal neurologic examinations and 59 required craniotomy. The sensitivity of the CT scan was 100%, with positive predictive value of 10%, negative predictive value of 100%, and specificity of 51%. The use of CT alone as a diagnostic modality would have saved 3924 hospital days, including 814 ICU days, and $1,509,012 in hospital charges. Based on these data, we believe that CT scanning is essential in the management of patients with MHI and that if the neurologic examination is normal and the scan is negative patients can be safely discharged from the emergency room.

Infection-induced airway fibrosis in two rat strains with differential susceptibility

Chronic infections play a significant role in the morbidity and mortality of patients with chronic airflow limitation. By stimulating airway inflammation, persistent infection has the potential to cause airway fibrosis. However, in patient this condition is most typically found in lungs damaged by other factors, such as smoking, abnormal secretions, or barotrauma. We report the characterization of Mycoplasma pulmonis infection-induced lung fibrosis in two immunocompetent rat strains with no preexisting lung disease. The fibrosis was predominantly in the airways, as demonstrated by the findings for infected animals of increased airway inflammation, airway fibrosis, and airway wall thickness, which correlated with the collagen content of the lungs. Also, the physiological alterations were the opposite of those found in interstitial fibrosis, with a positive correlation between lung compliance and collagen content. The airway fibrosis was noted earlier and to a greater extent in Lewis rats than in Fisher rats, and this result apparently was related to regulation of the inflammatory response. Airway wall thickness, airway inflammation, and airway fibrosis are commonly reported in tissue specimens from patients with chronic airway diseases and have been shown to correlate with airflow limitation in patients with chronic obstructive pulmonary disease. Thus, this model may be useful in furthering our understanding of the role of chronic infection and airway inflammation in airflow obstruction.

Mild head injury: a plea for routine early CT scanning

We reviewed the records of 1538 mild head injury patients admitted during a 4 1/2-year period to the Southern New Jersey Regional Trauma Center. All patients had experienced brief loss of consciousness or amnesia, but had a normal or near normal neurologic examination on admission, with Glasgow Coma Scale (GCS) scores of 13-15 and no focal neurologic deficit. Routine urgent cranial CT scans were obtained on all patients, and correlations between skull fractures and intracranial lesions investigated. Two hundred sixty-five patients (17.2%) harbored 340 lesions on CT scans, of which 131 were fractures and 209 were intracranial abnormalities. Fifty-eight patients needed surgery for their intracranial lesions; 23 of them had no skull fractures. None of the 1339 patients without CT evidence of intracranial lesions deteriorated under observation. We conclude that clinical observation with or without skull x-ray films is inadequate to rule out potentially dangerous intracranial lesions in apparently mild head injuries. If there is a history of loss of consciousness or amnesia, an immediate CT scan is indicated. If the results of the CT scan are normal and there are no other indications for admission, these patients may be safely discharged.

Effect of daytime protein restriction on nutrient intakes of free-living Parkinson's disease patients

Studies have shown that severe daytime restriction of dietary protein improves the efficacy of L-dopa and reduces response fluctuations in some Parkinson's disease (PD) patients. This study investigated the nutritional adequacy of the daytime restricted-protein diet. Eleven free-living PD patients suffering from unpredictable response fluctuations to L-dopa were counseled to limit protein intake to approximately 10 g before 1700. Three sets of 6-d food records obtained during the 8-wk study showed that while on the test diet, mean intakes of most nutrients remained above the recommended nutrient intakes, although significant decreases occurred in protein, calcium, iron, phosphorus, riboflavin, and niacin intakes. The impact of the test diet on nutritional status as evaluated by changes in body weight and serum prealbumin was small. We conclude that healthy and highly motivated patients can maintain adequate intakes of most nutrients while restricting daytime protein intake. However, nutrient intakes might be compromised in patients whose regular diets are marginally adequate.

Mycoplasma pulmonis possesses a novel chemoattractant for B lymphocytes

Mycoplasma pulmonis causes chronic murine respiratory mycoplasmosis, which is characterized by extensive peribronchial and perivascular infiltration of mononuclear cells, including B lymphocytes. B-lymphocyte recruitment into sites of inflammation is presently poorly understood but must involve directed chemotaxis of these cells in response to some external recruitment stimulus. In these studies, picogram amounts of M. pulmonis membrane protein were found to possess potent chemoattractant activity for resting rat B lymphocytes. This report is the first description of a bacterially derived chemoattractant for B lymphocytes and offers a unique opportunity to study regulation of B-lymphocyte recruitment to a site of chronic pulmonary inflammation. Furthermore, M. pulmonis membrane activation of fresh rat serum was found to produce a potent stimulus for recruitment of peritoneal and alveolar macrophages. M. pulmonis-mediated recruitment of lymphocytes and macrophages may play a significant role in the pathogenesis of murine respiratory mycoplasmosis, a role in which organisms on the bronchiolar epithelial surfaces may release proteins which can directly or indirectly promote chemotaxis of inflammatory cells from the circulation.

Delayed brain injury after head trauma: significance of coagulopathy

We reviewed the records of 253 patients with head injury who required serial computed tomographic (CT) scans; 123 (48.6%) developed delayed brain injury as evidenced by new or progressive lesions after a CT scan. An abnormality in the prothrombin time, partial thromboplastin time, or platelet count at admission was present in 55% of the patients who showed evidence of delayed injury, and only 9% of those whose subsequent CT scans were unchanged or improved from the time of admission (P less than 0.001). Among patients developing delayed injury, mean prothrombin time at admission was significantly longer (14.6 vs. 12.6 s, P less than 0.001) and partial thromboplastin time was significantly longer (36.9 vs. 29.2 s, P less than 0.001) than patients who did not have delayed injury. If coagulation studies at admission were normal, a patient with head injury had a 31% risk of developing delayed insults. This risk rose to almost 85% if at least one clotting test at admission was abnormal (P less than 0.001). We conclude that clotting studies at admission are of value in predicting the occurrence of delayed injury. If coagulopathy is discovered in the patient with head injury early follow-up CT scanning is advocated to discover progressive and new intracranial lesions that are likely to occur.

Emergency central venous catheterization during resuscitation of trauma patients

Central venous catheterization during resuscitation of trauma patients remains controversial. Such catheterizations performed at the UMDNJ-Robert Wood Johnson Medical School at Camden Cooper Hospital/University Medical Center (Camden, NJ) trauma center for the period January 1, 1988 to December 31, 1989 were retrospectively reviewed. Patients with underlying hemothorax, pneumothorax, or resuscitative thoracotomy were excluded. There were 269 catheters inserted using the Seldinger technique. Catheters were placed via the internal jugular or subclavian veins by attending traumatologists or emergency medicine and surgical house staff under direct attending supervision. Of 238 patients ages 6 to 90 years, 156 were men. Mean Trauma Score and Injury Severity Score were 9 and 30, respectively. Patients were divided into two groups: patients undergoing cardiopulmonary resuscitation or in shock (systolic bp less than 90) during resuscitation (Group 1: n - 161); and patients not in shock (Group 2: n - 77). Thirty patients (Group 1a) expired in the resuscitation area. The remainder (Group 1b) with 150 catheterizations had 12 complications (8%): pneumothorax (8), hemothorax (1), and malposition (3). Group 2, with 80 catheterizations, had 6 complications (7.5%): pneumothorax (4), hematoma (1), and malposition (1). The complication rate for patients surviving the resuscitation (230 catheterizations) was 7.8 per cent. There were no catheter-related deaths. In conclusion, emergency central venous catheterization during resuscitation of trauma patients carries a relatively low risk of serious complications when performed by experienced physicians.

Clinical predictors of unstable cervical spinal injury in multiply injured patients

All victims of major blunt trauma have been said to be at risk of cervical spinal injury. In a prospective study of 410 such patients at our institution, we identified 13 patients (6.12 per cent) with unstable cervical spines. Loss or defect of consciousness following injury (regardless of duration), neurological deficit consistent with cervical cord or nerve root injury and neck tenderness were significantly predictive of an unstable cervical spine. Immediate radiographic investigation of the cervical spine is mandatory in such patients, but may not be required in patients without these signs.

Multichamber gunshot wounds of the heart. The utility of transesophageal echocardiography

A patient had a gunshot wound to the heart involving three cardiac chambers. Conventional echocardiography failed to identify the intracardiac injuries. The utility of transesophageal echocardiography in a patient with cardiac trauma is described.

Is routine computed tomography scanning too expensive for mild head injury?

OBJECTIVE

To compare relative costs of treating mildly head-injured patients by routine admission or by using skull radiographs or cranial computed tomography (CT) scanning to screen patients for admission.

DESIGN

Retrospective record review, hypothetical costs based on actual patient course and requirements.

SETTING

Southern New Jersey Regional Trauma Center at Cooper Hospital/University Medical Center.

PARTICIPANTS

658 consecutive mildly head-injured patients admitted from 1986 to 1988. All were given cranial CT scans.

MEASUREMENTS

Records were reviewed retrospectively and hypothetical costs were calculated based on actual length of hospitalization, surgical intervention, etc. These costs were compared for different treatment protocols.

MAIN RESULTS

The average cost if every patient had been admitted for observation given skull radiographs, with CT scans done on those exhibiting skull fracture or later deterioration, was $1,207. If the CT scan had been used to identify patients with intracranial lesions and the others had been discharged, costs would have been almost 10% less. Had skull radiography been used to screen admissions, costs would have been 22% below those of routine CT scanning. However, these small savings are likely to be reduced by additional expenses related to missed intracranial lesions.

CONCLUSIONS

Every patient with loss of consciousness or post-traumatic amnesia should have routine CT scanning. If the scan is normal and there are no other reasons for admission, the patients can be discharged safely from the emergency department. This represents optimal care from a medical standpoint and is justified from a cost-effectiveness point of view.

Distal pancreatectomy for trauma: a multicenter experience

During a 5-year period, 74 patients with pancreatic injuries were managed by distal pancreatic resection at nine referral trauma centers. Patient ages ranged from 4 to 72 years. Injury mechanism was blunt trauma in 34 (46%) patients, gunshot wound in 27 (36%), stab wound in 11 (15%), and shotgun blast in two (3%). There were 19 class II, 50 class III, and 5 class IV pancreatic injuries. The resection comprised up to 33% of the pancreas in 21 (28%) patients, from 34% to 66% in 45 (61%), and greater than 67% in eight (11%). The pancreatic resection margin was closed with staples in 44 (59%), silk sutures in 20 (27%), and polypropylene sutures in eight (11%). Of 32 patients in whom the spleen was uninjured, the spleen was left intact in 17 (53%). There were nine (12%) deaths. The cause of death was irreversible shock in three patients, multiple organ failure in five, and severe head injury in one. Pancreas-related complications occurred in 32 (45%) of 71 patients who survived the initial operation. Intra-abdominal abscess developed in 24 patients; 11 were managed by percutaneous drainage alone. Pancreatic fistula developed in 10 patients; eight closed spontaneously from 6 to 54 days. Other pancreas-related morbidity included pancreatitis (6), pseudocyst (2), and hemorrhage (2). Exocrine insufficiency was not evident in any patient and diet-controlled hyperglycemia occurred in one individual following 80% pancreatic resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute posttraumatic renal failure: a multicenter perspective

Acute renal failure (ARF) following trauma is rare. Historically, ARF has been associated with a high mortality rate. To investigate this entity we conducted a retrospective review of 72,757 admissions treated at nine regional trauma centers over a 5-year period. Seventy-eight patients (0.098%) developed acute renal failure requiring hemodialysis. Detailed demographic, clinical, and outcome data were collected. Patients with pre-existing medical conditions (group I) had a 70% increase in mortality over those without pre-existing conditions (p less than 0.004). Twenty-four patients (31%) developed ARF less than 6 days after injury (group II). The remainder (group III) developed late renal failure (mean time to first dialysis, 23 days). The predominant cause of death was multiple organ failure (82%). There were no differences in mortality because of multiple organ failure among the three groups of patients. Of the 33 survivors, six (18%) were discharged with renal insufficiency, three (9%) were discharged on dialysis, 23 (70%) were discharged home or to rehabilitation, and 27 (82%) had no significant evidence of renal insufficiency.

CONCLUSION

Posttraumatic renal failure requiring hemodialysis is rare (incidence, 107 per 100,000 trauma center admissions), but the mortality rate remains high (57%). Two thirds of the cases of posttraumatic renal failure develop late and are secondary to multiple organ failure; one third of the cases of posttraumatic renal failure develop early and may result from inadequate resuscitation.

Otitis media in adult trauma patients: incidence and clinical significance

To determine the incidence and clinical significance of otitis media in traumatized adults requiring intubation, 67 adult trauma patients admitted to a level-I trauma center over a 6-month period who required three or more days of intubation were examined otoscopically for the presence of otitis media. Eleven of these intubated brain-injured patients had otitis and upon examination all were found to have purulent paranasal sinusitis as well. In conclusion, all intubated patients with severe head injuries should be evaluated otoscopically for the presence of otitis and those patients with otitis should be examined for the presence of sinusitis.

Specific and nonspecific antibody responses in different segments of the respiratory tract in rats infected with Mycoplasma pulmonis

Murine respiratory mycoplasmosis resulting from Mycoplasma pulmonis infection in rats provides a useful model for the study of immunological and inflammatory mechanisms operative in the respiratory tract. We have previously shown that LEW rats develop more severe disease than do F344 rats. To further study the production of antibody responses in chronic respiratory disease due to M. pulmonis infection, we examined the distribution and development of M. pulmonis-specific antibody-forming cells (AFC) in different segments of the respiratory tracts of infected LEW and F344 rats. In these studies, the upper respiratory nodes were the initial site of antibody production after infection and remained the major site for recovery of AFC. Since infected LEW rats had equal or higher numbers of AFC than did infected F344 rats, these results suggest that the level of local antibody production alone is not responsible for the decreased susceptibility of F344 rats to murine respiratory mycoplasmosis. The differences in total antibody responses appear to be due to the greater numbers of cells recovered from the tissues of infected LEW rats compared with those recovered from F344 rats, suggesting that LEW rats may have greater production of chemotactic factors. Also, we demonstrate that nonspecific activation and/or recruitment of B cells occurs in the respiratory tracts of both LEW and F344 rats after infection with M. pulmonis.

Routine initial computed tomography of the chest in blunt torso trauma

Computer tomography (CT) is an effective technique in the initial evaluation of the abdomen and head following blunt trauma. To evaluate the role of CT of the thorax, a prospective study comparing routine early thoracic CT scanning with initial chest roentgenogram (CXR) was carried out on 73 patients with blunt torso trauma undergoing concomitant abdominal CT examination. Initial CXR and CT scans were interpreted independently by radiologists in a blinded fashion. CXR diagnosed more bony injuries than CT, while the CT identified pulmonary contusions and effusions more accurately. Only those contusions diagnosed by CXR proved clinically significant. Patient treatment was changed in one case based on CT findings. In the absence of CXR findings, chest CT scanning frequently identifies abnormalities with limited clinical significance. Although more sensitive, CT of the thorax has a limited role in the initial emergent evaluation of victims of blunt torso trauma.

Blunt traumatic bladder rupture: the role of retrograde cystogram

STUDY OBJECTIVE

We evaluated the importance of microscopic and gross hematuria and the role of retrograde cystography and computed tomography (CT) in the diagnosis of blunt traumatic bladder rupture.

DESIGN

All cases at a Level I trauma center between January 1, 1986, and March 31, 1989, were reviewed retrospectively.

SETTING

Level I trauma center, university hospital.

TYPE OF PARTICIPANTS

All patients with acute blunt abdominal trauma admitted to this Level I trauma center.

INTERVENTIONS

The patients' charts were reviewed with emphasis on mode of diagnosis, treatment, and outcome.

MEASUREMENTS AND MAIN RESULTS

Twenty-one patients had bladder rupture. All 21 had hematuria with more than 50 RBCs/high-power field, 17 gross and four microscopic. Twenty patients underwent retrograde cystography, which accurately identified bladder rupture, and one was found at laparotomy for other injuries. Seven patients had CT of the abdomen and pelvis, which failed to demonstrate bladder rupture. There were no associated urethral injuries in any of the patients with bladder rupture.

CONCLUSION

Significant (more than 50 RBCs/high-power field) hematuria is the principal indication for evaluation for blunt bladder injury, and retrograde cystography is the diagnostic procedure of choice. CT is neither sensitive nor specific enough as primary diagnostic modality.