Hypoglycemia in multiple trauma victims

The typical presentation of hypoglycemia involves a diaphoretic patient with a history of diabetes mellitus who is found with an altered mental status. The hypoglycemic patient's presentation may lead the physician to believe that the altered mentation may have been caused by some other condition. Hypoglycemia occurs rarely in the traumatic setting, yet is easily and rapidly diagnosed with bedside testing. A retrospective review was conducted in a university hospital emergency department (ED) (level 1 trauma center) of adult trauma patients with a Glasgow Coma Scale (GCS) score of <15 who had presented from July 1995 through August 1996. Hypoglycemia was defined as a serum glucose level of <60 mg/dL. A total of 926 patients (49% of all trauma cases encountered in the period) met entry criteria. Four (0.4%) cases of hypoglycemia were encountered in 1 nondiabetic and 3 diabetic patients; no patient had medical alert warnings. Rapid bedside screening identified 2 cases within a mean of 7 minutes after arrival; 1 patient had an improvement in mental status after dextrose therapy. Two cases were identified by formal laboratory analysis a mean of 35 minutes after ED arrival; dextrose therapy improved the mental status in 1 patient. These results show that hypoglycemia, rare in trauma patients with abnormal GCS scores, may mimic significant traumatic injury with mental status alterations. Physicians should consider such a diagnosis in patients with an abnormal GCS score and known risk situations for hypoglycemia, including diabetes mellitus and chronic alcohol use; in such cases, appropriate bedside screening should be performed after initial stabilization.     

Priorities in management of trauma victims.

Good results of the emergency management of trauma victims depend on recognition of serious injuries and rapid, effective treatment as well as anticipation and prevention of complications. The most spectacular injury is not always the most urgent and life-threatening. Based on priorities of management, care is recommended to improve mortality and morbidity statistics. Suggestions for effective treatment of rapidly lethal lesions and preparations for transporting seriously injured patients are also outlined.     

Outcomes of admitted geriatric trauma victims

Conflicting data exist as to the outcome of elderly victims of trauma. With recent improved outcomes for functional recovery, aggressive management of these patients has been advocated. The purpose of this study is to determine outcomes of admitted elderly trauma victims based on initial mechanism of injury and the degree to which other factors affected their overall outcome. A prospective study involving admitted patients > or =65 years was performed at an urban university center from September 15, 1996 until August 31, 1997. Patients sustaining any potentially serious form of trauma were included. Data about mechanism of injury (MOI), comorbid conditions, preinjury medications, types of injuries sustained, length of stay, functional outcome, and ultimate disposition were recorded. Two hundred thirty-nine consecutive patients were enrolled. Mean age was 78.1 +/- 8.1 years. There were 130 women (54%) and 109 men (46%). MOI was as follows: 132 low-mechanism falls (LMFs), 64 high-mechanism motor vehicle crashes (HMMVCs), 22 high-mechanism falls (HMFs), 8 pedestrian versus car (PVCs), and 13 other types. Mean length of stay surviving beyond the ED was 12.9 days. 8 patients were either DOA or died in the ED. There were 19 in-hospital deaths. Deaths were seen in 14% of HMMVCs, 13.6% HMFs, 9.1% LMFs, 25% PVCs, and 7.7% for other mechanisms. Overall outcomes by mechanism were categorized as functional (or baseline), fair, alive but poor, and dead. Functional outcomes were seen in 76.6% of HMMVCs, 81.8% of HMFs, 84.1% of LMFs, 50% of PVCs, and 84.6% for all other injuries. Forty-five percent were discharged home, 26% went to rehabilitation units, 16% went to nursing homes, and 11% died; the remaining 2% were either transferred to a psychiatric facility or to another hospital. Preexisting comorbid conditions did not appear to play a significant role in the ultimate outcomes of these patients. Severity of injury was the leading determinant of death, but severely injured patients often had functional outcomes. Elderly trauma victims most often achieve functional outcomes despite multiple or severe injuries.     

生理创伤评分预测创伤结局

目的 探讨生理创伤评分，包括SIRS评分与其他常用的生理指标联合预测创伤结局的数学模型。方法 回顾分析1131例创伤数据，以生存概率为变量，Logistic回归分析伤员刚进急诊科时的GCS、收缩压、SIRS评分和年龄，并建立新的数学模型。结果 预测结局的准确性、敏感性与特异性接近ASCOT法，误判率降低。结 论该统计学模型具有简单实用、准确性高等特点，建议临床应用。     

The metabolic needs of head trauma victims

Malnutrition increases the morbidity and mortality associated with severe illness, injury, and sepsis. The neuroendocrine changes associated with trauma intensify the body's metabolic demands. The neuroendocrine response to trauma is discussed. Methods to determine calorie needs of head trauma patients are presented, along with a case study.     

Treatment of hypothermia in trauma victims: thermodynamic considerations

The relatively high specific heat of the human body makes hypothermia very difficult to treat. Although there are many treatment methods available, most evaluations of rewarming techniques are based on clinically observed rewarming rates, and they do not take into account initial core temperature, ambient temperature, the patient's own heat production, the effects of anesthesia, paralytic agents, and other variables. A heat transfer model is proposed that simulates the flow of heat through the body of a hypothermic patient. The model uses first principles involved in heat transfer and thermodynamics to describe the effects of currently available rewarming techniques. A commercially available routine is used to solve the equations, which also include any heat exchange between the patient's body and the environment, as well as metabolic heat generation as a function of time and core temperature. This thermodynamic analysis of rewarming, based on computer modeling of heat transfer, provides a scientific basis on which to establish guidelines for appropriate selection of treatment strategies for hypothermia, and it indicates that direct blood warming or infusion of warm intravenous fluids are the most effective rewarming techniques.     

Immediate and follow-up management of hepatic trauma

There has been a considerable evolution in the management of patients with hepatic injuries in the past 5-10 years. CT is now the mainstay of diagnosis for stable patients with blunt hepatic injuries. This allows for nonoperative therapy in many patients with lacerations, intrahepatic hematomas, or subcapsular hematomas. Simple operative techniques are used in 60% of patients with blunt injuries, and any deaths in this group are usually due to associated injuries. In patients requiring advanced techniques of repair, postoperative management emphasizes basic techniques including correction of hypothermia and coagulopathies and early use of enteral feeding. Postoperative complications are not rare when Class III, IV, or V hepatic injuries have been treated, but can be managed with the assistance of the interventional radiologist, blood bank, or by use of early reoperation. Mortality depends on mechanism of injury and magnitude of hepatic injury, and ranges from 14-31% for patients with blunt trauma.     

Ruptured spleen due to blunt trauma in children: analysis of blood transfusion requirements.

Selective non-operative management of splenic injury in children is generally considered to be safe, and the majority of those with isolated injuries do not require blood transfusion. Eighty-four children were treated for blunt splenic trauma from 1988 to 1997 in the Department of Paediatric Surgery, The Medical Faculty of Uludag University, Bursa, Turkey. Management involved non-operative care in 56 cases (66.7%), splenectomy in 20 (23.8%) and splenorraphy in eight (9.5%) cases. There were no later complications related to splenic injury. The overall mortality was 9.5% (8/84) and the factors effecting mortality were additional intra-abdominal and/or other system injuries. Twenty-two children were not transfused during non-operative treatment. In our study, only 57.1% of the children in the non-operative group received blood transfusions. Some of the patients in this group received only small amounts of blood and probably would have recovered without it. It is concluded that, based on a very strict protocol in conservative management, the total amount of transfused blood could be reduced in children with splenic injuries due to blunt abdominal trauma.     

Driver behaviour of ethanol-impaired non-vehicular trauma victims.

During a recent 12-month period, a group of patients injured from causes other than road accidents were studied. Twenty-four patients with no evidence of alcohol impairment served as controls for another group of 24 patients with a blood alcohol concentration of greater than 100 mg%. Examination of public records revealed that the alcohol-impaired group had committed more serious traffic violations, including reckless driving, crashes causing bodily injury, and property damage. Eleven of the 24 alcohol-impaired subjects had a total of 18 previous citations for driving under the influence of alcohol while there were none in the control group (P less than 0.001). Alcohol-related non-vehicular trauma is highly predictive of alcohol-impaired driving behaviour.     

Caring for trauma victims: the emotional impact

The potential for significant emotional trauma exists for nurses working with trauma victims and their families. There is very little in the nursing literature that addresses the wide range of normal feelings that nurses may experience during or following the care of trauma victims. There is also a scarcity of articles identifying strategies that nurses may employ to assist them through these significant incidents. This article describes the range of feelings that nurses may experience in the course of delivering care and relates these feelings to the traumatic event. Potential aggravating factors are discussed, and strategies are provided that nurses can use to survive the psychologic impact of these incidents and to achieve a higher level of emotional functioning.     

Upper airway mucus deposition in lung tissue of burn trauma victims

Previous study in an ovine model of smoke inhalation and burn (S + B) injury has shown distal migration of upper airway mucus. This study examines the localization of an upper airway gland specific mucus, mucin 5B (MUC5B) in lung autopsy tissues of burn-only injury and in victims of S + B injury. We hypothesize that victims with S + B injury would exhibit increased distal migration of MUC5B than that seen in victims of burn-only injury. Autopsy lung tissue from victims of burn injury alone (n = 38) and combined S + B injury (n = 22) were immunostained for MUC5B. No normal lung tissues were included in the study. Semiquantitative analysis of the extent of MUC5B in bronchioles and parenchyma was performed on masked slides. Irrespective of injury conditions, all victims showed MUC5B in bronchioles. Mucin 5B was seen in the parenchyma except in two burn victims. No statistically significant difference was seen in the mean bronchiolar and parenchyma MUC5B scores between S + B and burn-only victims (P > 0.05). No strong statistical correlation of MUC5B scores with days postinjury or to the number of ventilatory days was evident. The percentage of pneumonia, identified histologically, was also similar between study groups. This study did not confirm our results in an ovine model of S + B injury. In contrast, virtually all pediatric burn victims, regardless of concomitant inhalation injury, showed MUC5B in their bronchioles and parenchyma. Increased mucus synthesis and/or impaired mucociliary function may contribute to the pulmonary pathophysiology associated with burn injury.     

Accuracy of the Prehospital Index in identifying major hemorrhage in trauma victims

PURPOSE: To determine the sensitivity of the Prehospital Index (PHI) in identifying patients with severe blood loss, a one-year review was conducted at a regional trauma facility. METHODS: The study population consisted of 217 consecutive trauma admissions (ages 3 to 88 years). Patients were managed using standard resuscitation techniques; blood transfusions were ordered at the discretion of attending physicians and did not follow any preplanned protocol. Medical records were examined to determine total blood requirements for each patient during the first 12 hours of hospitalization, the emergency department (ED) disposition, and final outcome of treatment. The following clinical variables were analyzed (unpaired t-test) to determine their value as predictors of blood loss: age, gender, mechanism of injury, initial vital signs, revised trauma score, PHI, and injury severity score. RESULTS: Forty-two percent (92 patients) received transfusions during the first 12 hours of hospitalization. The best predictor of blood loss was the Prehospital Index. Of the total group, 45% had a PHI greater than 3; 77% (75/98) of these patients required transfusion and received an average of 7.1 units of packed cells. Fifty-five percent (119/217) had a PHI less than or equal to 3; 86% (102/119) of these patients did not require transfusion. CONCLUSION: The data suggest that patients with PHI scores greater than 3 require close hemodynamic monitoring to rule out significant blood loss and may warrant immediate cross-matching on arrival to the ED.     

Cognitive processing of trauma cues in rape victims with post-traumatic stress disorder

Rape victims with post-traumatic stress disorder (PTSD) (n =12), rape victims without PTSD (n =12), and nontraumatized control subjects (n =12) performed a computerized Stroop color-naming task in which they named the colors of high-threat words (e.g., RAPE), moderate-threat words (e.g., CRIME), positive words (e.g., LOYAL), and neutral words (e.g., TYPICAL). In contrast to rape victims without PTSD and to nontraumatized control subjects, those with PTSD were slower to color-name high-threat words than moderate-threat, positive, and neutral words. Rape victims without PTSD nevertheless exhibited greater Stroop interference for high-threat words than did nontraumatized subjects. Interference for high-threat words was correlated with scores on the Impact of Events Scale —Intrusion subscale, but not with scores on the Avoidance subscale. These findings suggest that interference for trauma cues may provide a nonintrospective index of intrusive cognitive activity. Preparation of this article was supported, in part, by grants from the Henry and Ramsey Pevsner Fund in Neuropsychology and Behavioral Medicine and the American Association of University Women — Aurora, Illinois, Chapter awarded to Karen Lynn Cassiday, and National Institute of Mental Health grant MH43809 awarded to Richard J. McNally.This study was part of the first author's doctoral dissertation, conducted under the supervision of the second author. It was conducted when the authors were at the Department of Psychology, University of Health Sciences/The Chicago Medical School. A shorter version of this paper was presented at the annual meeting of the Association for Advancement of Behavior Therapy, San Francisco, November, 1990.