Aortic rupture as a result of low velocity crush.
A case of aortic disruption in a 35 year old lorry driver is described. This occurred as a result of a low velocity crushing force. Clinicians should be aware that this mechanism of injury may result in aortic disruption as well as the more commonly mentioned severe deceleration force. (+info)
Prophylactic inferior vena cava filters in trauma patients at high risk: follow-up examination and risk/benefit assessment.
PURPOSE: The efficacy of prophylactic inferior vena cava filters in selected trauma patients at high risk has come into question in relation to risk/benefit assessment. To evaluate the usefulness of prophylactic inferior vena cava filters, we reviewed our experience and overall complication rate. METHODS: From February 1991 to April 1998, the trauma registry identified 7333 admissions. One hundred eighty-seven prophylactic inferior vena cava filters were inserted. After the exclusion of 27 trauma-related deaths (none caused by thromboembolism), 160 patients were eligible for the study. The eligible patients were contacted and asked to complete a survey and return for a follow-up examination to include physical examination, Doppler scan study, vena cava duplex scanning, and fluoroscopic examination. The patients' hospital charts were reviewed in detail. The indications for prophylactic inferior vena cava filter insertion included prolonged immobilization with multiple injuries, closed head injury, pelvic fracture, spine fracture, multiple long bone fracture, and attending discretion. RESULTS: Of the 160 eligible patients, 127 were men, the mean age was 40.3 years, and the mean injury severity score was 26.1. The mean day of insertion was hospital day 6. Seventy-five patients (47%) returned for evaluation, with a mean follow-up period of 19.4 months after implantation (range, 7 to 60 months). On survey, patients had leg swelling (n = 27), lower extremity numbness (n = 14), shortness of breath (n = 9), chest pain (n = 7), and skin changes (n = 4). All the survey symptoms appeared to be attributable to patient injuries and not related to prophylactic inferior vena cava filter. Physical examination results revealed edema (n = 12) and skin changes (n = 2). Ten Doppler scan studies had results that were suggestive of venous insufficiency, nine of which had histories of deep vein thrombosis. With duplex scanning, 93% (70 of 75) of the vena cavas were visualized, and all were patent. Only 52% (39 of 75) of the prophylactic inferior vena cava filters were visualized with duplex scanning. All the prophylactic inferior vena cava filters were visualized with fluoroscopy, with no evidence of filter migration. Of the total 187 patients, 24 (12.8%) had deep vein thrombosis develop after prophylactic inferior vena cava filter insertion, including 10 of 75 (13.3%) in the follow-up group, and one patient had a nonfatal pulmonary embolism despite filter placement. Filter insertion complications occurred in 1.6% (three of 187) of patients and included one groin hematoma, one arteriovenous fistula, and one misplacement in the common iliac vein. CONCLUSION: This study's results show that prophylactic inferior vena cava filters can be placed safely with low morbidity and no attributable long-term disabilities. In this patient population with a high risk of pulmonary embolism, prophylactic inferior vena cava filters offered a 99.5% protection rate, with only one of 187 patients having a nonfatal pulmonary embolism. (+info)
Hypothermia and the trauma patient.
Hypothermia has profound effects on every system in the body, causing an overall slowing of enzymatic reactions and reduced metabolic requirements. Hypothermic, acutely injured patients with multisystem trauma have adverse outcomes when compared with normothermic control patients. Trauma patients are inherently predisposed to hypothermia from a variety of intrinsic and iatrogenic causes. Coagulation and cardiac sequelae are the most pertinent physiological concerns. Hypothermia and coagulopathy often mandate a simplified approach to complex surgical problems. A modification of traditional classification systems of hypothermia, applicable to trauma patients is suggested. There are few controlled investigations, but clinical opinion strongly supports the active prevention of hypothermia in the acutely traumatized patient. Preventive measures are simple and inexpensive, but the active reversal of hypothermia in much more complicated, often invasive and controversial. The ideal method of rewarming is unclear but must be individualized to the patient and institution specific. An algorithm reflecting newer approaches to traumatic injury and technical advances in equipment and techniques is suggested. Conversely, hypothermia has selected clinical benefits when appropriately used in cases of trauma. Severe hypothermia has allowed remarkable survivals in the course of accidental circulatory arrest. The selective application of mild hypothermia in severe traumatic brain injury is an area with promise. Deliberate circulatory arrest with hypothermic cerebral protection has also been used for seemingly unrepairable injuries and is the focus of ongoing research. (+info)
Total dislocations of the navicular: are they ever isolated injuries?
Isolated dislocations of the navicular are rare injuries; we present our experience of six cases in which the navicular was dislocated without fracture. All patients had complex injuries, with considerable disruption of the midfoot. Five patients had open reduction and stabilisation with Kirschner wires. One developed subluxation and deformity of the midfoot because of inadequate stabilisation of the lateral column, and there was one patient with ischaemic necrosis. We believe that the navicular cannot dislocate in isolation because of the rigid bony supports around it; there has to be significant disruption of both longitudinal columns of the foot. Most commonly, an abduction/pronation injury causes a midtarsal dislocation, and on spontaneous reduction the navicular may dislocate medially. This mechanism is similar to a perilunate dislocation. Stabilisation of both medial and lateral columns of the foot may sometimes be essential for isolated dislocations. In spite of our low incidence of ischaemic necrosis, there is always a likelihood of this complication. (+info)
Countertransference and empathic problems in therapists/helpers working with psychotraumatized persons.
Countertransference in therapists working with patients with posttraumatic stress disorder (PTSD) differs from countertransference in other psychotherapeutical settings. In this article we discuss the specificities of counter- transference in treating PTSD patients and its relation to empathy. The most difficult countertransference problems occur in treating multiply traumatized patients. Countertransference may occur towards an event (e.g., war), patients who have killed people, as well as to colleagues who avoid treating PTSD patients, or towards a supervisor who avoids, either directly or indirectly, supervision of therapists working with PTSD patients. Our recommendation for the prevention of problems in treating PTSD patients include : 1) careful selection of the therapist or helper, both in the personality structure and training; 2) prevention by debriefing and team work and peer supervision; and 3) education - theoretical, practical, and therapeutical. (+info)
Markers for domestic violence in women.
OBJECTIVE: To determine injury patterns and characteristics specific to domestic violence in women who present to the accident and emergency (A&E) department. DESIGN: A retrospective case note review of all female assaults over a one year period. The subjects were women who disclosed that their injuries were due to assaults by either a current or a previous male partner. Controls were female assault victims not injured by domestic violence. SETTING: A medium sized urban A&E department. RESULTS: There were 500 female assaults out of 48,169 new attendances. Domestic violence was disclosed in 103 cases. The following features were significantly associated with domestic violence in women: multiple injuries (p < 0.001) (especially to the head and arms), fractures (p < 0.05), loss of consciousness (p < 0.05), abdominal injuries (p < 0.05), pregnancy (p = 0.01), injury occurring on "stairs" (p = 0.01), and general practitioner referral (p < 0.01). CONCLUSIONS: Women who have been assaulted are more likely to have been injured during domestic violence if they sustain multiple injuries (including fractures), abdominal injuries, have lost consciousness, or have been referred by their general practitioner. These markers may help medical staff to identify more cases of undisclosed domestic violence. The markers need to be tested further in a prospective study. (+info)
A registry-based case-control study of risk factors for the development of multiple non-fatal injuries on the job.
Using compensation records of Taiwan, we conducted a case-control study nested within a cohort of 77,846 active workers who experienced at least one incidence of non-fatal work-related injury between 1994 and 1996 in order to explore factors associated with risk of sustaining multiple non-fatal injuries in the workplace. Cases (n = 2,616) were workers with more than three incidences of non-fatal injury during the study period and controls (n = 3,974) were randomly sampled from workers who experienced only one incidence of non-fatal injury during the same period. Compared with construction workers, workers employed in mining and quarrying (OR = 2.7), manufacturing (OR = 1.2), commerce (OR = 1.6), transport, storage and communication (OR = 1.3) and social, personal and community service (OR = 1.4) were all at significantly elevated risk of multiple non-fatal injuries. Both age and wage showed a significant dose-response effect on the risk of developing multiple non-fatal injuries. The preliminary analysis suggests that workers in certain industries are at significantly elevated risks of multiple work-related non-fatal injuries, in particular those in the mining and quarry industries. Additionally, further preventive measures should be aimed at protecting older workers from such injuries and further studies would help provide more specific interpretations on the positive association between higher wage earning and risk of multiple non-fatal injuries. (+info)
Polytrauma induces increased expression of pyruvate kinase in neutrophils.
Polytrauma (PT) leads to systemic activation of polymorphonuclear neutrophils (PMNs). Organ damage commonly found in these patients is ascribed to respiratory bursts of activated PMNs. With the use of sodium dodecyl sulfate-polyacrylamide gel electrophoresis, PMN extracts from PT patients were found to contain a clear protein band not seen in control PMNs from healthy volunteers. This band was identified by amino acid sequencing and Western blotting as pyruvate kinase (PK). Enzymatic assays revealed a 600-fold increase in PK activity in PMNs of PT patients, with the highest levels occurring between the fifth and seventh posttraumatic day. In lymphocytes, no such increase was detectable. As PK is a major regulatory enzyme in glycolysis, glucose-dependent lactate production in PMNs from PT patients was assayed. These cells showed a higher glycolytic lactate production than controls. It was additionally demonstrated that acute activation of respiratory burst activity depends mainly on breakdown of glucose to lactate via the pentose-phosphate pathway and glycolysis. In PMNs from PT patients, this glucose-dependent respiratory burst activity was more than twofold higher than in controls. The increase in expression and activity of PK in PMNs from PT patients may contribute to the high glucose-dependent respiratory burst activity seen in these cells. (+info)