J Trauma
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Severe head injury often causes an increase in intracranial pressure (ICP) and decreases in cerebral blood flow (CBF) and cerebral oxygen delivery (CO2del). To determine if this reduction in CBF and CO2del would produce cerebral ischemia and if this reduction would be abrogated by maintaining global cerebral perfusion pressure (CPP), we studied CPP, ICP, CBF, CO2del, cerebral oxygen extraction ratio (CO2ER), and cortical water content (CWC) in a porcine model of focal cryogenic brain injury. Fifteen mature swine were randomized to two groups. ⋯ Cryogenic injury significantly increased the CWC in the lesioned hemisphere. These data indicate that focal brain injury results in persistent ischemia despite the normalization of CPP, suggesting that a significant increase in cerebral vascular resistance (CVR) occurs after brain injury. We conclude that in addition to maintenance of CPP, intervention to reduce CVR may be important in the management of brain injury.
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The effect of burn wound size on the activation of fibrinolysis, coagulation, and contact factors was analyzed in 60 thermal injury patients. Blood samples from 47 male patients and 13 female patients, (average age 37 years; range 1.5-70 years) were collected within the first 36 hours and at 5-7 days following injury. The patient population was categorized by percentage of burn (second degree and/or third degree): less than 20%, n = 22; 20%-40%, n = 18; greater than 40%, n = 20. ⋯ However, specific hemostatic variables showed marked changes. Admission hemostatic markers that correlated with the severity of injury were: tissue-plasminogen activator (tPA), plasminogen activator inhibitor (PAI), D-dimer (D-di), plasminogen (Plg), proteins C and S (PrC and PrS), antithrombin III (ATIII), thrombin-antithrombin complex (TAT), kallikrein (Kal:c), kinin (Kin), C1 esterase inhibitor (C1Inh), and factor VII clotting and antigen (FVII:c, FVII:ag). These data suggest that during the early course following burn injury, thrombogenicity is increased (TAT increases) because of a decrease in ATIII, PrC, and PrS; and fibrinolysis activation (D-di increases) occurs via an increase in tPA with a p value increase in PAI.(ABSTRACT TRUNCATED AT 250 WORDS)
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Review Comparative Study
Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury.
Penetrating trauma to the intrathoracic abdomen is a difficult clinical problem, especially with reference to the detection of diaphragmatic injuries. A retrospective analysis of 657 laparotomies for penetrating abdominal trauma at our institution revealed 78 laparotomies with negative results. The majority (44.8%) were for wounds in the lower chest and upper abdomen. ⋯ Ten of the 20 patients with hemoperitoneum had therapeutic laparotomies. The incidence of diaphragmatic lesions discovered by laparoscopy in this series was comparable with that reported after a mandatory laparotomy for thoracoabdominal wounds. It is concluded that laparoscopy is an excellent modality for the evaluation of the intrathoracic abdomen and the diaphragm.
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Since 1977, six clinical trials have been performed on the subject of routine antibiotic prophylaxis in patients requiring tube thoracostomy for trauma. No definitive conclusions have been reached regarding the efficacy of antibiotic use in this setting. The results of these clinical trials were pooled to generate an unbiased estimate of the efficacy of antibiotic prophylaxis for tube thoracostomy using the technique of meta-analysis. ⋯ Meta-analysis allows synthesis of all of the available data on antibiotic prophylaxis for tube thoracostomy to resolve the controversy surrounding this issue generated by different but similar clinical studies with conflicting results. Despite different conclusions of value when taken individually, the combined analysis does not support the null hypothesis (no effect of antibiotics). The statistical method is highly significant despite different mechanisms of injury, pathologic findings, and antibiotics employed.
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Untreated flow-dependent oxygen consumption (VO2) has recently been implicated as an unrecognized risk factor for multiple organ failure (MOF). We therefore prospectively studied 39 severely injured patients with known risk factors for multiple organ failure who were subjected to an established resuscitation protocol aimed at maximizing oxygen delivery (DO2 greater than 600 mL/min.m2) to attain a VO2 goal of greater than 150 mL/min.m2. ⋯ Of note, this blunted VO2 response despite maximal efforts to enhance peripheral oxygen availability predicted MOF. These data serve to re-emphasize the importance of the initial shock insult in causing or priming the host for the development of late MOF.