Can secondary extremity compartment syndrome be diagnosed earlier?

BACKGROUND: In 2002, our institution published a 5-year retrospective review of 10 patients who developed secondary extremity compartment syndrome (SECS) with a mortality rate of 70%. Since then, we have aggressively screened for the development of SECS in high-risk patients. We postulate that awareness of SECS and vigilant monitoring for its development would result in earlier diagnosis and treatment and improved outcome. METHODS: Retrospective review of all patients at a level I trauma center developing SECS from 2002 to 2006. Data collected included demographics, mechanism of injury, injury complex, blood transfused prior to development of SECS, affected extremities, creatinine, creatine phosphokinase, management, and outcome. RESULTS: Seventeen of 11,468 trauma patients (.148%) developed SECS. Mean admission hematocrit was 31.7 +/- 8.9, mean admission base deficit was -13.3, mean worst base deficit was -17.8, and average Injury Severity Score was 36.3 +/- 16.6. Patients received 20.9 +/- 11.0 units of blood and 24.6 +/- 14 L of crystalloid prior to the development of SECS. Average time from admission to diagnosis of the SECS was 32.6 hours. Acute renal failure developed in 6 (35%) patients; 4 required dialysis, and 3 died. The number of affected extremities ranged from 1 to 4. Of the 46 affected extremities, 39 were salvaged and 7 required amputation. Mortality was 35.3%. CONCLUSIONS: SECS is an uncommon, but devastating complication in severely injured patients with hypotension undergoing massive transfusion, and developing systemic inflammatory response syndrome. Vigilance increases detection. While the overall mortality was reduced by half, patients requiring dialysis have a 75% mortality.     

Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation

BACKGROUND: The term secondary abdominal compartment syndrome (ACS) has been applied to describe trauma patients who develop ACS but do not have abdominal injuries. The purpose of this study was to describe major trauma victims who developed secondary ACS during standardized shock resuscitation. METHODS: Our prospective database for standardized shock resuscitation was reviewed to obtain before and after abdominal decompression shock related data for secondary ACS patients. Focused chart review was done to confirm time-related outcomes. RESULTS: Over the 30 months period ending May 2001, 11 (9%) of 128 standardized shock resuscitation patients developed secondary ACS. All presented in severe shock (systolic blood pressure 85 +/- 5 mm Hg, base deficit 8.6 +/- 1.6 mEq/L), with severe injuries (injury severity score 28 +/- 3) and required aggressive shock resuscitation (26 +/- 2 units of blood, 38 +/- 3 L crystalloid within 24 hours). All cases of secondary ACS were recognized and decompressed within 24 hours of hospital admission. After decompression, the bladder pressure and the systemic vascular resistance decreased, while the mean arterial pressure, cardiac index, and static lung compliance increased. The mortality rate was 54%. Those who died failed to respond to decompression with increased cardiac index and did not maintain decreased bladder pressure. CONCLUSIONS: Secondary ACS is an early but, if appropriately monitored, recognizable complication in patients with major nonabdominal trauma who require aggressive resuscitation.     

Hyperacute abdominal compartment syndrome: an unrecognized complication of massive intraoperative resuscitation for extra-abdominal injuries

Primary and secondary abdominal compartment syndrome (ACS) are well-recognized entities after trauma. The current study describes a "hyperacute" form of secondary ACS (HACS) that develops intraoperatively while repair of extra-abdominal injuries is being carried out simultaneous with massive resuscitation for shock caused by those injuries. The charts of patients requiring abdominal decompression (AD) for HACS at time of extra-abdominal surgery at our level I trauma center were reviewed. The following data was gathered: age, Injury Severity Score (ISS), mechanism, resuscitation details, time to AD, time to abdominal closure, and outcome. All continuous data are presented as mean +/- standard error of mean. Hemodynamic and ventilatory data pre- and post-AD was compared using paired t test with significance set at P < 0.05. Five (0.13%) of 3,750 trauma admissions developed HACS during the 15-month study period ending February 2004. Mean age was 32 +/- 7 years, and mean ISS was 19 +/- 2. Four of five patients arrived in hemorrhagic shock (blunt subclavian artery injury, 1; chest gunshot, 1; gunshot to brachial artery, 1; stab transection of femoral vessels, 1) and were immediately operated upon. One of five patients (70% burn) developed HACS during burn wound excision on day 2. HACS developed after massive crystalloid (15 +/- 1.7 L) and blood (11 +/- 0.4 units) resuscitation during prolonged surgery (4.8 +/- 0.8 hours). Pre- versus post-AD comparisons revealed significant (P < 0.05) improvements in mean arterial pressure (55 +/- 6 vs 88 +/- 3 mm Hg), peak airway pressure (44 +/- 5 vs 31 +/- 2 mm Hg), tidal volume (432 +/- 96 vs 758 +/- 93 mL), arterial pH (7.16 +/- 0.0 vs 7.26 +/- 0.04), and PaCO2 (52 +/- 6 vs 45 +/- 6 mm Hg). There was no mortality among the group, and all patients underwent abdominal closure by fascial reapproximation in 2-5 days. Two (40%) of the five patients required extremity fasciotomy for compartment syndrome. HACS is a rare complication of massive resuscitation for extra-abdominal injuries. It should be considered in such patients in the face of unexplained hemodynamic and/or ventilatory decompensation. Prompt AD is life saving. Early abdominal closure is usually possible. Vigilance for compartment syndromes elsewhere in the body is warranted in any patient with HACS.)     

Mechanism of acute ascites formation after trauma resuscitation

BACKGROUND: Severely injured patients have been observed to acutely develop ascites; however, the pathogenesis of this rare phenomenon is poorly understood. OBJECTIVES: To report the factors common among severely injured patients developing ascites and to formulate a hypothesis regarding its origin. METHODS: Retrospective review of case series. RESULTS: We identified 9 injured patients between January 1, 1993, and December 31, 1998, who acutely developed significant amounts of ascites. The mean +/- SD estimated ascites volume was 2.0 +/- 0.8 L. All 9 patients had severe shock and were mechanically ventilated before abdominal decompression for the abdominal compartment syndrome. The mean +/- SD peak inspiratory pressure was 39.0 +/- 5.8 cm H2O. The mean +/- SD volumes of crystalloid and blood product infusion before decompression were 16.1 +/- 10.2 L and 5.2 +/- 4.8 L, respectively, in a mean +/- SD of 17 +/- 15 hours. In comparison, the mean +/- SD volumes of crystalloid and blood product transfusion among 100 contemporary, randomly selected patients undergoing trauma laparotomy were 5.1 +/- 5.5 L and 1.1 +/- 2.5 L, respectively (P<.001). Eight patients had only extra-abdominal injuries, while 1 patient had a combination of extra- and intra-abdominal injuries. Two patients were found to be cirrhotic by liver biopsy, but the other 7 patients had no known preexisting hepatic disease. Eight patients had absorbable mesh temporary abdominal closure, and 1 patient had primary fascial closure. There was persistent ascitic drainage in 5 patients; however, in all but 1 patient with cirrhosis, the drainage did not persist beyond 3 days. Two patients died, 1 of sepsis and the other of a closed head injury. CONCLUSIONS: Common denominators of posttraumatic ascites include shock, massive fluid resuscitation, and elevated intrathoracic pressure. The rapid onset of ascites in the setting of elevated intrathoracic pressure suggests that the patient's ability to clear ascitic fluid is overwhelmed.     

Long term results of compartment syndrome of the lower limb in polytraumatised patients

Acute compartment syndrome represents a severe complication after trauma of the lower extremity. To date, there is limited knowledge about the outcome of compartment syndrome of the lower limb in patients with multiple injuries. We hypothesised that multiple injuries worsen the long term results of compartment syndrome of the lower leg. Patients who underwent fasciotomy for established compartment syndrome of the lower leg from 1999 to 2004 in our level 1 trauma centre were included. Demographic data, additional injuries (Injury Severity Score) and method of treatment were analysed. Outcome assessments included clinical examination and isokinetic strength testing of plantar flexion and dorsal extension at two different angular velocities (60 degrees /s; 120 degrees /s). The mean age was 38.0+/-4.4 years at the time of injury; males were affected twice as often as females. The mean ISS of patients with multiple injuries was 20.2+/-2.3 points. The time between admission and surgical treatment of compartment syndrome was extended in patients with multiple injuries (38.6+/-13.8h versus 13.2+/-3.8h; p=0.04). At follow-up, 15.4% of all patients complained of pain at rest and 26.9% reported pain on exertion. A significant reduction of torque and work was found in the dorsal extensors on the injured side (p<0.05). Polytraumatised patients did not show extended weakness compared to those with isolated injuries. No difference was seen between the two groups regarding pain and function. Polytraumatised patients did not suffer from worse long term effects regarding sensory or motor deficits. Associated injuries did not seem to influence the outcome of the compartment syndrome.     

Secondary abdominal compartment syndrome is a highly lethal event

BACKGROUND: Recent reports have described resuscitation-induced, "secondary" abdominal compartment syndrome (ACS) in trauma patients without intra-abdominal injuries. We have diagnosed secondary ACS in a variety of nontrauma as well as trauma patients. The purpose of this review is to characterize patients who develop secondary ACS. METHODS: Our prospective ACS database was reviewed for cases of secondary ACS. Physiologic parameters and outcomes were recorded. Data are expressed as mean +/- SEM. RESULTS: Fourteen patients (13 male, aged 45 +/- 5 years) developed ACS 11.6 +/- 2.2 hours following resuscitation from shock. Eleven (79%) had required vasopressors; the worst base deficit was 14.1 +/- 1.9. Resuscitation included 16.7 +/- 3.0 L crystalloid and 13.3 +/- 2.9 red blood cell units. Decompressive laparotomy improved intra-abdominal, systolic, and peak airway pressures, as well as urine output; however, mortality was 38% among trauma and 100% among nontrauma patients. CONCLUSIONS: Secondary ACS may be encountered by general surgeons in a variety of clinical scenarios; resuscitation from severe shock appears to be the critical factor. Early identification and abdominal decompression are essential. Unfortunately, in our experience, this is a highly lethal event.     

Combined hemorrhagic shock and head injury: effects of hypertonic saline (7.5%) resuscitation

Hypertonic saline resuscitation was compared to isotonic fluid resuscitation in a large animal model combining hemorrhagic shock with head injury. Sheep were subjected to a freeze injury of one cerebral hemisphere as well as 2 hours of hypotension at a mean arterial pressure (MAP) of 40 mm Hg. Resuscitation was then carried out (MAP = 80 mm Hg) for 1 hour with either lactated Ringer's (LR, n = 6) or 7.5% hypertonic saline (HS, n = 6). Hemodynamic parameters and intracranial pressure (ICP) were followed. At the end of resuscitation brain water content was determined in injured and uninjured hemispheres. No differences were detected in cardiovascular parameters; however, ICPs were lower in animals resuscitated with HS (4.2 +/- 1.5 mm Hg) compared to LR (15.2 +/- 2.2 mm Hg, p less than 0.05). Additionally, brain water content (ml H2O/gm dry weight) in uninjured brain hemispheres was lower after HS resuscitation (HS = 3.3 +/- 0.1; LR = 4.0 +/- 0.1; p less than 0.05). No differences were detected in the injured hemispheres. We conclude that hypertonic saline abolishes increases in ICP seen during resuscitation in a model combining hemorrhagic shock with brain injury by dehydrating areas where the blood-brain barrier is still intact. Hypertonic saline may prove useful in the early management of multiple trauma patients.     

Factors associated with mortality in patients with penetrating abdominal vascular trauma

OBJECTIVE: Prehospital transport, resuscitation, and operative intervention are all critical to the care of the penetrating trauma victim. We determined which factors most affected mortality in patients with penetrating abdominal vascular injuries. METHODS: Consecutive patients with penetrating abdominal vascular injuries from an urban Level I trauma center from January 1993 to December 1998 were identified from the trauma registry and their charts reviewed. All patients who died prior to operative intervention were excluded. Data collected included mortality, age, scene time (ST), EMS transport time (TT), time in the emergency department (ED), initial systolic blood pressure in the ED (BP), operating time, intraoperative estimated blood loss (EBL), and worst base deficit in the first 24 h (BD). These variables were compared between nonsurvivors and survivors by univariate ANOVA. Multivariate ANOVA (MANOVA) determined independent effects on mortality. RESULTS: Forty-six penetrating abdominal vascular injuries were identified in 31 patients, 11 of whom died (38.7%). Examining prehospital parameters, mean ST averaged 16.5 +/- 3.6 min, while TT was 31.8 +/- 7.1 min. For ED parameters, initial BP was 94.8 +/- 6.4 mm Hg and initial heart rate was 109 +/- 7 beats per minute. Mean operative EBL for all patients was 3518 +/- 433 ml. The mean BD for all patients was -12.9 +/- 1.8. Significant differences were noted in the univariate analysis between survivors and nonsurvivors for BD (P < 0.0001), BP (P = 0.0062) and EBL (P = 0.0002). MANOVA revealed that only base deficit (P < 0.0001) had an independent effect on mortality. CONCLUSIONS: In patients with penetrating abdominal vascular injuries who survive their ED stay, adverse physiologic parameters reflecting the adequacy of resuscitation are more predictive of mortality than identifiable prehospital parameters.     

Predictors of the need for nephrectomy after renal trauma

BACKGROUND: Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma. METHODS: This is a retrospective review of renal injuries admitted over a 12-year period to a Level I trauma center. RESULTS: Ninety-seven patients (73% male) sustained a kidney injury (mean age, 27 +/- 16; mean Injury Severity Score, 13 +/- 10). Of the 72 blunt trauma patients, 5 patients (7%) underwent urgent nephrectomy, 3 (4%) had repair and/or stenting, and 89% were observed despite a 29% laparotomy rate for associated intraabdominal injuries in this group. Twenty-five patients with penetrating trauma underwent eight nephrectomies (31%), one partial nephrectomy, and two renal repairs. Regardless of the mechanism of injury, patients requiring nephrectomy were in shock, had a higher 24-hour transfusion requirement, and were more likely to have a high-grade renal laceration (all p < 0.05). Bluntly injured patients requiring nephrectomy had more concurrent intraabdominal injuries (p < 0.0001). Overall, patients after penetrating trauma were more severely injured, had higher 24-hour transfusion requirements, and a higher nephrectomy rate (all p < 0.05). Despite a higher injury severity in the penetrating group, however, mortality was higher in the bluntly injured group (p < 0.0001). Univariate predictors for nephrectomy included: revised trauma score, injury severity score, Glasgow Coma Scale score, shock on presentation, renal injury grade, and 24-hour transfusion requirement. No patient with a mild or moderate renal injury required nephrectomy, whereas 6 of 12 (50%) grade 4 injuries and 7 of 8 (88%) grade 5 injuries required nephrectomy. Multiple logistic regression analysis confirmed penetrating injury, renal injury grade, and Glasgow Coma Scale score as predictive of nephrectomy. CONCLUSION: Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.     

Bilateraler Funktionsverlust der Quadrizepsmuskulatur nach einseitiger Kreuzbandruptur mit Begleitverletzung durch zentrales Aktivierungsdefizit

The aim of the study was to investigate the ability to activate the quadriceps femoris muscle voluntarily in patients after severe knee injuries and it's influence on muscle function. 33 male patients after ACL-rupture with concomitant injuries were investigated with a twitch-interpolation-method to determine the maximal voluntary contraction force (MVC) and the ability to activate the quadriceps muscle voluntarily. The results were compared to a previously investigated group of patients after isolated ACL-rupture and to an aged-matched control group. The patients with extensive knee injuries presented a significant higher deficit of voluntary quadriceps muscle activation on the injured (78.8 +/- 2.09%, mean +/- SEM) and equally on the uninjured side (78.9 +/- 1.91%) compared to the patients after isolated ACL-rupture and to controls. A minor MVC-deficit of the patients quadriceps muscle of the uninjured side could be explained by the voluntary activation deficit alone, the major MVC deficit of the injured side by muscle atrophy and a voluntary activation deficit. The activation deficit is probably the underlying reason for persisting muscle wasting and [not readable: see text]     

The impact of obesity on the outcomes of 1,153 critically injured blunt trauma patients

BACKGROUND: Several small series have had mixed conclusions regarding the impact of obesity on outcomes of trauma patients. The purpose of the present study was to evaluate a large cohort of critically injured patients to better understand the influence of obesity on the outcomes of patients after severe blunt trauma. METHODS: Retrospective review using the trauma registry and intensive care unit (ICU) database of all blunt trauma patients admitted to the ICU at our urban, Level I trauma center over a 5-year period (1998-2003). Obese patients (body mass index [BMI] > or = 30 kg/m) were compared with non-obese patients (BMI < 30 kg/m). RESULTS: There were 1,153 blunt trauma patients admitted to the ICU during the study period, including 283 (25%) obese (mean BMI = 35 +/- 6 kg/m) and 870 (75%) non-obese (mean BMI = 25 +/- 3 kg/m) patients. There was no difference between groups regarding age, sex, Injury Severity Score, or admission vitals. Obese patients had fewer head injuries (42 versus 55%; p = 0.0001) but more chest (45 versus 38%; p = 0.05) and lower extremity (53 versus 38%; p < 0.0001) injuries. There was no difference in the need for laparotomy, thoracotomy, or craniotomy. Obese patients suffered more complications (42 versus 32%; p = 0.002). Although there was only a trend toward higher mortality in obese patients (22 versus 17%; p = 0.10), stepwise logistic regression revealed obesity as an independent risk factor for mortality (odds ratio, 1.6; 95% confidence interval, 1.0-2.3; p = 0.03). Among survivors, obese patients required longer stays in the hospital (24 +/- 21 versus 19 +/- 17 days; p = 0.01), the ICU (13 +/- 14 versus 10 +/- 10 days; p = 0.005), and 2 more days of mechanical ventilation (8 +/- 13 versus 6 +/- 9 days; p = 0.07). CONCLUSION: Obese patients incur different injuries after severe blunt trauma than their non-obese counterparts. Despite sustaining fewer head injuries, obese patients suffer more complications, require longer stays in the hospital, more days of mechanical ventilation, and obesity is independently associated with mortality.     

Compartment syndrome in multiple uninjured extremities: a case report

Compartment syndrome is a common problem in trauma patients. It can occur within any space bound by a dense fascial layer, such as the extremities or abdomen. It exists when increased tissue pressure within the limited anatomic space compromises perfusion. Failure to decompress the compartment leads to a self-perpetuating ischemia-edema process and resultant irreversible tissue damage. In the extremities, it typically arises from a vascular injury in that same extremity. Herein is reported a case of the unexpected development of compartment syndrome in multiple uninjured extremities in a trauma patient with hypotension requiring systemic vasopressors.     

Blunt vascular trauma in the extremity: diagnosis, management, and outcome

BACKGROUND: Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity. METHODS: A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted. RESULTS: From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors. CONCLUSION: Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.     

Hypertonic saline resuscitation of head injury: effects on cerebral water content

Ideal resuscitation would simultaneously replete intravascular volume and minimize cerebral edema. We assessed the effects of hypertonic saline (HS) shock resuscitation on cerebral edema after head injury. Rats were subjected to hemorrhagic shock (40 mm Hg for 1 hour) in the presence or absence of mechanical brain injury, followed by 1 hour of resuscitation with either hypertonic saline (6.5%) or lactated Ringer's (LR). After resuscitation, animals were sacrificed and brain water contents determined. Results: Less HS than LR was needed for resuscitation both in animals without brain injury (7 +/- 2 ml/kg vs. 97 +/- 16 ml/kg; p less than 0.0003) and with brain injury (10 +/- 1 ml/kg vs. 68 +/- 6 ml/kg; p less than 0.0001). Brain water content (ml H2O/gm dry wt) after HS resuscitation was decreased compared to LR resuscitation in animals without brain injury (3.36 +/- 0.12 vs. 3.74 +/- 0.08; p less than 0.025) and in the uninjured hemisphere of head-injured animals (3.29 +/- 0.11 vs. 3.78 +/- 0.09; p less than 0.025). Brain water content was increased in injured brain in both resuscitation groups, but the increase was the same (HS 4.10 +/- 0.13; LR 4.25 +/- 0.17; p greater than 0.05). Conclusions: HS resuscitation of hemorrhagic shock decreases brain water content in uninjured but not injured brain. HS may be useful in resuscitation of combined hemorrhagic shock and head injury.     

Penetrating trauma in patients older than 55 years: a case-control study

BACKGROUND: Multiple studies have compared young and elderly blunt trauma patients, and concluded that, because elderly patients have outcomes similar to young patients, aggressive resuscitation should be offered regardless of age. Similar data on penetrating trauma patients are limited. STUDY DESIGN: In a retrospective review, 79 patients with penetrating injuries and age > or =55 were blindly matched for Injury Severity Score (ISS) and Abbreviated Injury Scores (AIS) with 79 penetrating trauma patients aged 15-35 years, who were admitted to the hospital over the same 4 year period (June 1994-June 1998). Mortality rates and length of stay in the intensive care unit (ICU) and the hospital were compared between the two groups. RESULTS: The average ISS for all patients was 12 (range 1-75) and identical for both groups. Both groups had similar injuries and were evaluated by an equal number and type of diagnostic studies. The mean ISS was not different between severely injured older and younger patients who required ICU admission or died. Among 32 nonsurvivors (18 older and 14 younger), older patients were more likely than younger patients to present with normal vital signs, although the comparison did not reach statistical significance (50% vs. 13%, P=0.25). There was a clinically significant trend for longer ICU (15+/-30 vs. 3+/-2 days, P=0.096) and hospital stay (10+/-18 vs. 6+/-8 days, P=0.08) among older patients, but mortality rates were similar (23% in older vs. 18% in younger, P=NS). Furthermore, these outcome parameters showed no difference when both groups were classified according to severity of injury or physiologic response. CONCLUSIONS: Following penetrating trauma, older patients arriving alive and admitted to the hospital are as likely to survive as younger patients who have injuries of similar severity, but at the expense of longer ICU and hospital stays.     

Prevalence and patterns of foot injuries following motorcycle trauma

OBJECTIVES: To determine the prevalence and patterns of foot injuries following motorcycle trauma. DESIGN: Prospective. SETTING: Yorkshire Region Trauma Units (Level 1 trauma centers with trauma research). PATIENTS: Individuals injured in motorcycle road traffic accidents between January 1993 and December 1999. OUTCOME MEASUREMENTS: Patient demographics, protective devices (helmet) use, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), clinical details, therapeutic interventions, resuscitation requirements, duration of hospital stay, mortality, and type of foot injuries sustained. RESULTS: The parent population of 1239 contained 53 (4.3%) foot-injured motorcyclists (49 men) with a mean age of 31.7 years (range 18-79 years). Fifty-two were drivers and one was a rear-seat passenger. Mean ISS was 6.9 (range 4-33), significantly lower than the parent population mean of 34.98 (range 9-75) (P = 0.001). Mean GCS was 14.7 (range 13-15). The motorcyclists' injuries included 26 metatarsal fractures (49.1%), 14 talar fractures (26.4%), 7 os calcis fractures (13.2%), and 6 toe fractures (11.3%). Associated foot injuries included three partial foot amputations, four Lisfranc dislocations, three cases of foot compartment syndrome (two crush injuries with no fracture, one open fourth metatarsal fracture with associated Lisfranc dislocation). Forty-six motorcyclists had more than one foot injury. Associated injuries included 22 ankle fractures (41.5%), 15 tibial fractures (28.3%), 6 femoral fractures (11.3%), 5 pelvic ring fractures (9.4%), 23 upper limb injuries (43.4%), and 3 cases of chest trauma (5.7%). No one sustained abdominal trauma or head injury compared with the parent population. All patients required operative stabilization of foot fractures, including their associated injuries. Mean hospital stay was 10.9 days (range 1-35 days). In the parent population, there were 71 deaths (6.0%), whereas there was only 1 death (1.9%) in the foot-injured group (with fractures including open book pelvic, T6-8, unilateral open femur, tibial, ankle, and metatarsal) with an ISS 33, who died of multiorgan dysfunction syndrome. At final follow-up, all patients underwent radiologic and clinical assessment of foot injuries. Forty-three patients returned to their previous occupation and level of mobility. Ten of the more significantly injured patients had to modify their occupation from manual to sedentary-type jobs due to their foot injuries. We noted a pattern of complex ipsilateral foot and limb injury in nine patients, which we postulate was due to the actual mechanism of contact with the road surface. CONCLUSION: Motorcycle accidents continue to be a source of severe injury, especially to the foot. The most common foot injury is a metatarsal fracture; however, there must be a high index of suspicion for associated injuries. Although these injuries are associated with a low mortality rate, they require prompt assessment and treatment to limit long-term morbidity and disability. The difference in foot injury pattern and mortality between the parent population and our series, among other factors, potentially may be influenced by the actual mechanism of contact with the road surface and the modifying action of the foot during the accident.     

Survival analysis of the factors affecting in mortality in injured patients requiring dialysis due to acute renal failure during the Marmara earthquake: survivors vs non-survivors

BACKGROUND: We reviewed medical records of dialyzed patients admitted to our hospital after the Marmara earthquake and evaluated the factors affecting mortality in survivors and non-survivors according to the survival times. PATIENTS AND METHODS: Crush syndrome (CS) was diagnosed in 110 patients. Dialysis treatment was initiated in 60 patients; 21 of all died. The patients were divided into 2 groups which consisted of 39 survivors (Group A, 25 male, 14 female, mean age: 31 +/- 2.2 years) and 21 non-survivors (Group B, 9 male, 12 female, mean age: 27 +/- 3.0 years). Victims treated by any form of renal replacement therapy, including daily or intermittant hemodialysis and/or continuous venovenous hemodiafiltration. Clinical and laboratory findings were recorded regularly. Statistical analysis was performed with Kaplan-Meier method, log rank test and Cox regression analysis for the survival functions. RESULTS: APACHE II scores were 13.5 +/- 0.5 for Group A and 13 +/- 0.9 for Group B. Dialysis support was started to patients in Group A in a mean period of 2.8 +/- 0.2 days and in Group B in a mean period of 3.7 +/- 0.6 days after the earthquake (p > 0.05). The most frequent site of trauma was lower extremity (61.5%) and upper + lower extremities (23%) in Group A, and lower extremity (38.1%) and trunk + lower extremity (23.8%) in Group B. The frequencies of abdominal trauma, pelvic fracture and thoracic trauma in Group B were 23.8%, 19% and 14.2%, respectively. Multiple trauma was more frequent in Group B than in Group A (42.8% vs 2.5%). The rates of fasciotomy, amputation and surgery were similar in both groups. The frequency of sepsis was higher in non-survivors. In our center, the overall mortality rate was 8%, mortality rate in CS was 21% and in dialyzed patients it was 35%. Mortality was mainly associated with sepsis. Survival periods (52.3 +/- 4.0 days) in Group A were longer than in Group B (17.3 +/- 2.5 days). With Cox regression analysis, the parameters such as systolic hypotension on admission, female gender, high serum peak creatine kinase (> 20,000 U/l) and multiple trauma including thoracic and abdominal regions, were factors increasing risk of mortality. CONCLUSION: As a result, sepsis, multiple trauma and severe crush injury were the main factors increasing mortality risk in dialyzed injuries after the earthquake.     

Assessment of the pregnant trauma patient

Although less than 10% of pregnant patients are likely to experience some type of physical trauma, injury is the leading non-obstetric cause of maternal mortality. The assessment and resuscitation of the injured pregnant patient must take into account the specific needs of both the mother and the foetus. This paper will review the physiology of pregnancy, discuss recent changes in assessment and resuscitation, and identify special injuries and issues specific to the pregnant trauma patient.     

Secondary abdominal compartment syndrome: an underappreciated manifestation of severe hemorrhagic shock

OBJECTIVE: Abdominal compartment syndrome (ACS) has multiple well-described etiologies, but almost no attention has focused on ACS in the absence of abdominal injury. This study describes a secondary ACS that occurs after severe hemorrhagic shock with no evidence of abdominal injury. METHODS: The trauma registry at a Level I trauma center was reviewed for a 13-month period beginning July 1, 1997. RESULTS: During the study period, there were 46 of 1,216 intensive care unit admissions (4%) who required laparotomy and mesh closure of the abdominal wall because of visceral edema. In that subgroup, six patients (13% of mesh closures, 0.5% intensive care unit admissions) had hemorrhagic shock (5/1, blunt/penetrating trauma) but no evidence of intra-abdominal injury. Associated extremity compartment syndrome developed in two of six (33%). Overall mortality was four of six (67%), secondary to sepsis (n = 3), and head injury (n = 1). Time from admission to decompression averaged 3 hours in survivors and 25 hours in nonsurvivors (overall average = 18+/-9 hours). Resuscitation volume before abdominal decompression averaged 19+/-5 liters of crystalloid and 29+/-10 units of packed red blood cells. Bladder pressure averaged 33+/- 3 mm Hg. Decompression significantly improved peak inspiratory pressure (p < 0.003) and base deficit (p < 0.003). CONCLUSION: ACS can occur with no abdominal injury; The incidence of secondary ACS was 0.5% in this cohort trauma intensive care unit patients, so it probably occurs more frequently than is currently appreciated. Because survivors were decompressed 20 hours before nonsurvivors, early recognition might improve outcomes. On the basis of these observations, we recommend that bladder pressures should be routinely checked and acted on appropriately when resuscitation volumes approach 10 liters of crystalloid or 10 units of packed red cells.     

Wirbelsäulenfrakturen bei Mehrfachverletzten

OBJECTIVE: Spinal trauma is frequently found in multiply injured patients. To gain more insight into the epidemiology and the clinical course of this entity, we analyzed the relevant data held in the German Trauma Registry (German Trauma Society, DGU). The Registry provides prospective, standardized and anonymous documentation on severely injured patients at different predetermined time points from the site of the accident until they are discharged from hospital. METHODS: Out of 8,057 patients whose details are recorded in the German Trauma Registry, 772 (approximately 10%) with severe spine trauma (AIS>/=3) patients were identified. Far more men (72%) than women (28%) had such spinal injuries. The mean age of the patients with severe spine injury was 37+/-17 years; their mean Injury Severity Score (ISS) was 29+/-15 (range 9-75) points. RESULTS: The age group 15-54 years was the largest (80%). Motor vehicle accidents (MVA) were the most frequent cause of severe spine trauma (49%), followed by falls from a great height (20%). About half of all severe spine injuries were not suspected in the prehospital setting. Symptoms of incomplete paraplegia were found in 20% of the patients and symptoms of complete paraplegia, in 27%. Patients with injuries to the thoracic spine more often had a lengthy average stay in the intensive care unit, because they were accompanied by thoracic trauma significantly more often than were injuries to the other spinal segments (96% vs 37%). Patients who underwent spinal surgery at an early stage (70% operated on <72 h after their injuries were sustained) showed a tendency to shorter periods ventilatory support and did not remain in the intensive care unit or indeed in the hospital as long as the other patients. Seventy-eight percent of the patients had survived for 90 days after sustaining their injuries. CONCLUSION: Almost 10% of all documented cases of patients with severe injuries in the German Trauma Registry had severe spinal injuries. These injuries were frequently not recognized or their extent underestimated in the preclinical setting. About 70% underwent spine stabilization within 72 h after being injured. These results support previous findings suggesting that early stabilization of vertebral fractures might be beneficial in multiply injured patients.