J Trauma
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To investigate alterations in host defense produced by trauma, skin testing with five standard recall antigens was done on admission and weekly on 53 patients with blunt trauma and seven with penetrating missile injuries, who then were classified as normal (N), 2 or more positive responses; relatively anergic (RA), one positive response; or anergic (A), no response. Neutrophil chemotaxis was tested 145 times in 32 patients. Degree of injury was assessed by assigning one point to pelvic fracture, long-bone fracture, head, chest, or abdominal injury, to a maximum of five. ⋯ Neutrophil chemotaxis in A and RA patients was significantly (p less than 0.001) worse at 96.7 +/- 2.4 mu and 99.8 +/- 1.7 mu compared to N, 113.2 +/- 1.7 mu, and controls 121 +/- 4 mu. With recovery, chemotaxis returned to normal. It is concluded that failure of delayed hypersensitivity responses follows trauma, is related to the severity of injury and age of patient, and is associated with an abnormality of neutrophil chemotaxis and increased rate of sepsis.
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Randomized Controlled Trial Clinical Trial
Prospective trials of dexamethasone and aerosolized gentamicin in the treatment of inhalation injury in the burned patient.
The addition of an inhalation injury to a cutaneous burn results in a significant increase in patient mortality rates, both from early pulmonary edema and, later, Gram-negative pneumonitis. Steroids have been shown to decrease mortality in an inhalation injury model. Aerosolization of gentamicin has been used successfully to treat severe bronchial infections. ⋯ Both drug-treated groups were comparable to their controls in age and mean burn size. Results of the steroid trial showed no major differences in mortality, pulmonary complications, or changes in pulmonary functions. Results of the gentamicin trial showed no major differences in mortality, time of death, or pulmonary and septic complications between treated and control groups.
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Twenty-two of 604 patients (4%) with pelvic fracture (PF) had open fractures. Eight per cent of all pedestrian and motorcycle accidents resulted in open PF, compared to 0.8% of all vehicular accidents. With one exception, all patients sustained multiple injuries. ⋯ Therapy directed to restoring blood volume, identifying and repairing major vessel injury, and attempting to decrease the diffuse retroperitoneal hemorrhage is essential. If drainage is necessary, it should be accomplished with a closed system. Immediate colostomy and use of antibiotics should decrease the infectious complications.
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Our experience with 829 patients with penetrating abdominal trauma treated in an Adult Trauma Service over 8 1/2 years managed by "selective conservatism" is reviewed, and 207 additional patients with blunt abdominal trauma handled in the same fashion were also studied. This pattern of management prompted exploratory celiotomy in only 29% of stab wounds and 54% of gunshot wounds. ⋯ There were no deaths or errors in management in those patients definitively selected for nonoperative management. The philosophy of using specific objective indications for abdominal exploration in both penetrating and blunt abdominal trauma, especially when bolstered by routine abdominal paracentesis and lavage, is safe and reliable, and is adaptable to all clinical facilities.
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A rare case of arteriovenous fistula of the left internal mammary artery after blunt chest trauma is described. The patient was seen 3 weeks later because of a pulsating mass which varied in size, over the left midsternal area. ⋯ The fistula was ligated and excised followed by complete recovery. The literature is reviewed and differential diagnosis from congenital heart conditions, A-V shunts of other thoracic wall vessels, and vascular tumors is discussed.