The Journal of Trauma
Remote inflammatory response in liver is dependent on the segmental level of spinal cord injury
BACKGROUND: Traumatic spinal cord injury (SCI) triggers a systemic inflammatory response (SIR) that contributes to a high incidence of secondary organ complications, particularly after a cervical or high-level thoracic injury. Because liver plays a key role in initiating and propagating the SIR, the aim of this study was to assess the effects that SCI at differing segmental levels has on the intensity of the inflammatory response in the liver.
METHODS: Using male Wistar rats, clip compression SCI was performed at the 4th thoracic (T4 SCI; high-level SCI) or the 12th thoracic (T12 SCI; low-level SCI) spinal cord segment. Sham-injured rats had a partial laminectomy, but no SCI. Leukocyte recruitment to the liver, hepatic blood flow, and hepatocellular injury/death were assessed using intravital microscopy and histology. Chemokine and cytokine concentrations were assessed in the liver. Outcomes were measured at 1.5 hours, 12 hours, and 24 hours after SCI.
RESULTS: At 12 hours after injury, T4 SCI caused a threefold increase in hepatic leukocyte recruitment compared with T12 SCI (p < 0.05). T4 SCI induced 50% more hepatocyte injury than T12 SCI at 12 hours (p < 0.05). Hepatic blood flow decreased after SCI, but not after sham injury, and stayed decreased only after T4 SCI at 24 hours after injury. The T4 SCI-induced changes were accompanied by increases in the hepatic concentrations of interleukin-1β, leptin, interleukin 10, and cytokine-induced neutrophil chemoattractant-1 at 1.5 hours.
CONCLUSIONS: Our findings indicate that traumatic SCI triggers an acute SIR that contributes to hepatocellular injury. SCI-induced remote injury/dysfunction to the liver appears to be transient and is more robust after an upper thoracic SCI compared with a lower thoracic SCI.
A web-based model to support patient-to-hospital allocation in mass casualty incidents
BACKGROUND: In a mass casualty situation, evacuation of severely injured patients to the appropriate health care facility is of critical importance. The prehospital stage of a mass casualty incident (MCI) is typically chaotic, characterized by dynamic changes and severe time constraints. As a result, those involved in the prehospital evacuation process must be able to make crucial decisions in real time. This article presents a model intended to assist in the management of MCIs. The Mass Casualty Patient Allocation Model has been designed to facilitate effective evacuation by providing key information about nearby hospitals, including driving times and real-time bed capacity. These data will enable paramedics to make informed decisions in support of timely and appropriate patient allocation during MCIs. The model also enables simulation exercises for disaster preparedness and first response training.
METHODS: Road network and hospital location data were used to precalculate road travel times from all locations in Metro Vancouver to all Level I to III trauma hospitals. Hospital capacity data were obtained from hospitals and were updated by tracking patient evacuation from the MCI locations. In combination, these data were used to construct a sophisticated web-based simulation model for use by emergency response personnel.
RESULTS: The model provides information critical to the decision-making process within a matter of seconds. This includes driving times to the nearest hospitals, the trauma service level of each hospital, the location of hospitals in relation to the incident, and up-to-date hospital capacity.
CONCLUSION: The dynamic and evolving nature of MCIs requires that decisions regarding prehospital management be made under extreme time pressure. This model provides tools for these decisions to be made in an informed fashion with continuously updated hospital capacity information. In addition, it permits complex MCI simulation for response and preparedness training.
Meetings/Courses
No abstract available
Freeze drying (lyophilization) red blood cells
No abstract available
The severity of brain damage determines bone marrow stromal cell therapy efficacy in a traumatic brain injury model
BACKGROUND: Patients who survive traumatic brain injury (TBI) can undergo serious sensorial and motor function deficits. Once damage occurs, there is no effective treatment to bring patients to full recovery. Recent studies, however, show bone marrow stromal cells (BMSC) as a potential therapy for TBI.
METHODS: This study was designed to determine whether the degree of neurologic deficits influences the efficacy of cell therapy using intracerebral transplantation of BMSC in an experimental model of chronically established TBI. Adult Wistar rats were subjected to weight-drop impact causing TBI. Two months later, the animals were classified according to levels of neurologic deficits. To achieve this, we used two different functional tests: the modified Neurologic Severity Score test and internal zone Permanence Time in Video-Tracking-Box analysis. Saline only or saline containing BMSC was injected into injured brain tissue of the animals that were classified having moderate or severe neurologic damage depending on the level of established functional deficits. All experimental groups were evaluated in the course of the following 2 months to study the efficacy of BMSC administration. The animals were then killed and their brains were studied.
RESULTS: Our results showed that significant functional improvement was seen when BMSC was injected into animals with moderate brain damage, but no significant improvement was found in animals with severe functional deficits when compared with controls.
CONCLUSION: These findings suggest that the severity of neurologic damage may determine the potential effect of cell therapy when applied to chronically established TBI.
Mortality pattern of the 26/11 Mumbai terror attacks
BACKGROUND: Mumbai, one of the industrial capitals cities of the world, has witnessed a series of terror attacks over the last two decades. The 2008 Mumbai terror attacks referred as “26/11” drew widespread global condemnation and killed 166 people, in addition to wounding more than 300 people. The mortality pattern and the pathophysiology of organ injuries are presented. The objective of this study was to determine the different patterns of injury in a terrorist attack of such magnitude and clinical implications in reducing mortality.
METHODS: Data were collected from hospital records of 114 victims whose postmortems were conducted at the Sir JJ Group of Hospitals. The records were studied with respect to pattern and nature of injury.
RESULTS: A total of 175 people were killed, 9 were terrorist with 166 victims. Of the 166 mortalities, postmortems were conducted on 114 predominately male victims ages 5 to 70 years old; 108 of these were dead on arrival. Sixty-eight people died from bullet injuries, 30 from blast injuries, and 10 had both bullet and blast injuries. Six were postoperative deaths (all bullet injuries), of which two were early postoperative deaths and four late postoperative deaths due to septicemia.
CONCLUSION: There was multimodal pattern of injuries with predominance of bullet injuries sustained to vital organs. The hostage crisis resulted in varied and delayed evacuation times, which led to the death of nine victims with non-severe organ injuries. Delayed implementation of Prehospital Trauma Life Support due to the unsecured site and the hostage crisis can also be one of the causes.
LEVEL OF EVIDENCE: V, epidemiological study.
Surgical management of posttraumatic elbow arthrofibrosis
BACKGROUND: Functional loss of motion is a frequent complication after elbow trauma. The purpose of this study was to determine the effectiveness of open elbow release in restoring functional elbow motion.
METHODS: A retrospective chart review of 177 adult patients who underwent open elbow release at our institution by the senior surgeon (D.P.H.) from 2003 to 2010 was performed. Seventy-seven of the elbow contracture releases were performed for posttraumatic elbow stiffness, with loss of flexion-extension. Burns and isolated proximal radioulnar exostosis resections were excluded. The mean age of patients was 45 years (range, 20–76 years), with 68 patients demonstrating radiographic evidence of heterotopic ossification (HO). The mean preoperative flexion-extension arc was 51 degrees. All patients were treated with the same surgical protocol, which included circumferential elbow capsulectomy, HO excision, hardware removal, and ulnar nerve neurolysis with submuscular anterior transposition.
RESULTS: At a mean follow-up of 12 months (range, 3–56 months), the mean elbow flexion-extension arc was 109 degrees representing a mean gain of 58 degrees. Sixty-nine percent (53 of 77 patients) achieved a minimum 100-degree functional elbow arc of motion. Six patients (8%) developed recurrent HO, with four undergoing secondary HO excision. One additional patient required manipulation under anesthesia in the early postoperative period. Complications included five infections, one postoperative fracture, one postoperative hematoma, and one radial head implant loosening.
CONCLUSION: Open elbow contracture release and HO excision is an effective means of restoring functional elbow range of motion with a low complication rate. Furthermore, recurrent HO formation and elbow arthrofibrosis respond well to repeat surgical excision and contracture release.
LEVEL OF EVIDENCE: IV, therapeutic study.
Infusion of 4°C normal saline can improve the neurological outcome in a porcine model of cardiac arrest
BACKGROUND: This study sought to investigate induction of therapeutic hypothermia using ice-cold intravenous fluid after cardiopulmonary resuscitation (CPR). The effects on temperature, hemodynamics, cognitive performance and the accompanying neurohistopathological changes, and apoptosis were assessed.
METHODS: Fourteen piglets had 4 minutes of untreated ventricular fibrillation, followed by CPR. The animals in which spontaneous circulation was restored were randomly assigned to two groups: the hypothermia group (n = 7) was given an infusion of 4°C cold normal saline solution 30 mL/kg at an infusion rate of 1.33 mL/kg/min, followed by 10 mL/kg/h to 4 hours after restoration of spontaneous circulation; the control group (n = 7) was given the same infusion at room temperature. Variables were measured repeatedly until 4 hours after restoration of spontaneous circulation. Neurocognitive performance was evaluated 24 hours after CPR. Then animals were killed and the brains were removed for histopathology at 24 hours after restoration of spontaneous circulation. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling method was used for apoptosis evaluation.
RESULTS: Compared with the control group, the core temperature of the hypothermia group was significantly decreased (p < 0.01). The cerebral performance categories at 24 hours after restoration of spontaneous circulation in the hypothermia group were better than that in the control group (p < 0.05). The percentage of terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling-positive cells in the cortex and dentate gyrus of the hippocampus were significantly reduced in the hypothermia group compared with the control group at 24 hours after restoration of spontaneous circulation. By observation of transmission electron microscopy, the neuron damages were significantly reduced in hypothermia group.
CONCLUSION: 4°C normal saline solution is a safe and effective method to reduce brain damages and prevent apoptotic cell death after cardiac arrest.
Serum levels of ubiquitin C-terminal hydrolase distinguish mild traumatic brain injury from trauma controls and are elevated in mild and moderate traumatic brain injury patients with intracranial lesions and neurosurgical intervention
BACKGROUND: This study compared early serum levels of ubiquitin C-terminal hydrolase (UCH-L1) from patients with mild and moderate traumatic brain injury (TBI) with uninjured and injured controls and examined their association with traumatic intracranial lesions on computed tomography (CT) scan (CT positive) and the need for neurosurgical intervention (NSI).
METHODS: This prospective cohort study enrolled adult patients presenting to three tertiary care Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score 9 to 15. Control groups included normal uninjured controls and nonhead injured trauma controls presenting to the emergency department with orthopedic injuries or motor vehicle crash without TBI. Blood samples were obtained in all trauma patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for UCH-L1 (ng/mL ± standard error of the mean).
RESULTS: There were 295 patients enrolled, 96 TBI patients (86 with GCS score 13–15 and 10 with GCS score 9–12), and 199 controls (176 uninjured, 16 motor vehicle crash controls, and 7 orthopedic controls). The AUC for distinguishing TBI from uninjured controls was 0.87 (95% confidence interval [CI], 0.82–0.92) and for distinguishing those TBIs with GCS score 15 from controls was AUC 0.87 (95% CI, 0.81–0.93). Mean UCH-L1 levels in patients with CT negative versus CT positive were 0.620 (±0.254) and 1.618 (±0.474), respectively (p < 0.001), and the AUC was 0.73 (95% CI, 0.62–0.84). For patients without and with NSI, levels were 0.627 (0.218) versus 2.568 (0.854; p < 0.001), and the AUC was 0.85 (95% CI, 0.76–0.94).
CONCLUSION: UCH-L1 is detectable in serum within an hour of injury and is associated with measures of injury severity including the GCS score, CT lesions, and NSI. Further study is required to validate these findings before clinical application.
LEVEL OF EVIDENCE: II, prognostic study.
Folded free vascularized fibular grafts for the treatment of subtrochanteric fractures complicated with segmental bone defects
BACKGROUND: Subtrochanteric fractures of the femur complicated with segmental bone defects are uncommon injuries and challenging to manage. We evaluated the effect of reconstructing extensive bone defect in the subtrochanteric area (mean, 6.9 cm) with folded free vascularized fibular graft (FVFG).
METHODS: Between 2001 and 2007, 14 cases of subtrochanteric fractures complicated with huge bone defects treated by folded FVFG transfer in our hospital were retrospectively reviewed. The defect was reconstructed by folded FVFG transfer and locking plate stabilization in 10 patients with no sign of infection at admission (group 1). In the other four patients presented with infections (group 2), the defect was reconstructed by folded FVFG transfer and external fixator fixation. The average follow-up period was 67.4 months.
RESULTS: Bone union was achieved in all of the cases at an average of 5.4 months (range, 4–6 months). Primarily, bone union was achieved in all of the cases in group 1, but one stress fracture occurred in group 2. The full weight bearing time was 5.4 months (range, 5–6 months) in group 1 and 8.5 months (range, 8–9 months) in group 2. Seven patients in group 1 had the locking plate removed in an average of 27 months (range, 18–38 months). In group 2, the external fixator removal time was 13 months (range, 10–18 months). There was no varus deformity at the final follow-up in group 1. The neck-shaft angle measured during the postoperative period and at final follow-up was 129.6 degrees and 129.4 degrees, respectively. In group 2, the neck-shaft angle at the final follow-up was significantly less than the angle measured at the postoperative period (115.5 vs. 129.5 degree, p = 0.021). The range of motion of the hip and knee joint (extend and flex) was 100 degrees or more in all patients at the final follow-up.
CONCLUSIONS: The results of this study showed that huge subtrochanteric bone defects reconstructed by folded FVFG and locking plate were highly successful in achieving bone union, reducing risks of postoperative stress fracture and preventing malunion. When huge bone defects in the subtrochanteric area complicated with acute or chronic infections, the technique of external fixator offers an alternative to reconstruct the stability of the proximal femur after folded FVFG. However, because of the inadequate stabilization, the risks of varus malunion and postoperative stress fracture could be increased after external fixator fixation.
LEVEL OF EVIDENCE: V, therapeutic study.