M. Stalp

Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications.

OBJECTIVE Recent literature suggests that patients who undergo emergent tube thoracostomy in the field are at increased risks for complications. This study evaluates indications, complications, and effectiveness of field placement of chest tubes by an aeromedical service. METHODS In a prospective study, 624 consecutive patients with chest injuries (Abbreviated Injury Scale score 1-6) were included. All patients were treated at the scene by a physician-staffed aeromedical service and transported by air to a Level I trauma center. Indications, clinical findings before and after chest tube insertion, and subsequent radiologic diagnosis by chest roentgenography were documented prospectively. RESULTS Seventy-six chest tubes (50 unilateral, 13 bilateral) were inserted laterally in 63 patients (10%) by blunt dissection. Clinical findings included pneumothorax in 30 patients and hemothorax in 18 patients. In 15 patients receiving field chest tubes, neither pneumothorax nor hemothorax was confirmed. Six patients (<1%) arrived at the trauma center with unsuspected pneumothoraces and required chest tube insertion. No tension pneumothoraces escaped field detection and treatment. Four chest tubes placed in the field required repositioning in the hospital because of malfunction or malpositioning. Radiologic findings excluded intraparenchymal tube placements in all patients. No pleural infections were observed in these 63 patients during their hospital stay. No antibiotics were administered as a result of prehospital chest tube placement. CONCLUSION Prehospital chest tube thoracostomy is safe, effective, and associated with low morbidity. Nontherapeutic chest tube placements occurred in 15 of 624 patients (2.4%); missed pneumothoraces occurred in 6 of 624 patients (<1%). Aggressive prehospital physician management of blunt chest trauma leads to an earlier treatment of potentially life-threatening injuries. Significant morbidity can be avoided by prompt pleural decompression using proper techniques.

Standardized outcome evaluation after blunt multiple injuries by scoring systems: A clinical follow-up investigation 2 years after injury

OBJECTIVE The objective of this study was to evaluate the state of rehabilitation in patients with blunt multiple injuries 2 years after their initial injuries, using several standardized scales and a recently described comprehensive scoring system, by means of a prospective clinical multicenter study. METHODS Two years after the initial injury, patients with blunt multiple injuries (Injury Severity Score > or = 16) underwent a clinical follow-up in 5 German Level I trauma centers. The reassessment included a complete head-to-toe examination of the musculoskeletal system and a neurologic examination. The following patient-assessed health status scores were used to determine the quality of life: Short-Form 12, Functional Independence Measurement, and Musculoskeletal Function Assessment. Moreover, a comprehensive scoring system developed in our department (Hannover Score for Polytrauma Outcome [HASPOC]) was used that includes provider-report (physicians examination) and self-report (score systems) criteria. RESULTS Two hundred fifty-four of 312 patients who had been injured between January 1995 and July 1996 were reexamined between January 1, 1997, and July 1, 1998. Among the remaining 58 patients, 9 had died by the time of follow-up, and 49 patients had not accepted the invitation. The mean age of those patients who underwent reexamination was 36 +/- 13 years, the mean Injury Severity Score was 24 +/- 6, and the mean initial Glasgow Coma Scale score was 11 +/- 4 (Abbreviated Injury Scale (AIS) head score of 3.3 +/- 1.1; AIS face, 1.4 +/- 0.1; AIS chest, 3.0 +/- 0.8; AIS abdomen, 1.7 +/- 0.6; and AIS extremities, 3.4 +/- 0.8). The general outcome (Short-Form 12) was as follows: grade I, 9%; grade II, 25%; grade III, 29%; grade IV, 25%; grade V, 6%; and grade VI, 6%. The outcome of the injured extremity demonstrated moderate or severe restrictions according to the Musculoskeletal Function Assessment in 41% of injuries of the lower extremity and in 16% of injuries of the upper extremity. Among patients with injuries to the lower extremity, 52% experienced pain or impaired ability to walk related to an injury of the foot or ankle, 31% indicated pain after a knee or thigh injury, and 27% indicated pain after a femoral or hip injury. The most severe deficits in the range of motion occurred in the foot and the ankle region (13.4% deficit of range of motion < 20% of normal range, p < 0.05 to other injuries). The results of the outcome obtained by self-report correlated with the clinical examination when a scoring system was used that was described recently, the HASPOC. CONCLUSION In a standardized multicenter reexamination of patients with blunt multiple injuries, the general outcome was usually fair or good. Both the complaints and the objective results of specific extremity areas demonstrated that most limitations were because of injuries below the knee. These results were adequately reflected by a comprehensive scoring system, combining self-report and provider report (HASPOC).

Correlation between crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study

BACKGROUND The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis. METHODS A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed. RESULTS Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred. CONCLUSION The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.

Modulation of innate immune functions by intracerebroventricularly applied neuropeptide Y: dose and time dependent effects.

Centrally applied neuropeptide Y (NPY) interacts with the autonomic nervous system and the hypothalamo-pituitary-adrenal (HPA) axis activity. Since these physiological systems have been shown to modulate innate immune functions, the effects of intracerebroventricular (i.c.v.) NPY administration on leukocyte subsets in the blood, spleen and intravascular pool of the lung, blood granulocyte chemiluminescence response, and splenic natural killer (NK) cell-mediated lysis were studied in Lewis rats. Concentration-dependent NPY effects were tested at 15 min and 24 h post i.c.v. injection at dosages of 10(-6) M, 10(-9) M, and 10(-12) M. Time dependent effects were investigated at 15 min, 1 h and 24 h after i.c.v. administration of 10(-9) M NPY. Compared to saline controls, an increased number of granulocytes and NK cells in the blood, associated with a decreased granulocyte function and NK cytotoxicity was observed 15 min following NPY infusion. This initial immunosuppression was followed by long lasting stimulatory effects of NPY on the functional capacity of both cell populations when tested at 1 h and 24 h. The dosage of i.c.v. 10(-6) M NPY produced no changes, whilst 10(-9) M produced maximal, and 10(-12) M still significant effects. Results provide evidence that centrally applied NPY influences innate immunity in a dose and time dependent fashion. Cell mobilization from the vascular marginal pool is likely to be an underlying mechanism for the initial immunosuppression.

Brain NPY Y1 receptors rapidly mediate the behavioral response to novelty and a compartment-specific modulation of granulocyte function in blood and spleen

Neuropeptide Y (NPY) alters behavioral activity and innate immune functions of rats within minutes of intracerebroventricular (i.c.v.) application. Using combinations of the Y1-5a,b(6) agonist NPY, the Y1,3,5 agonist [Leu31-Pro34]NPY (LP-NPY), and the selective Y1 antagonist BIBP3226 (BIBP), we investigated whether the NPY-Y1 receptor (Y1R) subtype regulates NPY-induced behavioral and immunological effects at 15 min after i.c.v. application. Administration of both NPY and LP-NPY decreased rearing activity in the open field and suppressed granulocyte function in the blood. These effects were blocked by BIBP pre-treatment. In contrast to the blood, NPY and BIBP+NPY treatments stimulated granulocyte function within the splenic compartment. In addition, a blood leukophilia composed of granulocytes and NK cells was induced by NPY only. We conclude that the tested early effects of NPY are mediated by either the Y1R (rearing, blood granulocyte function), or a non-Y1R (splenic granulocyte function), or by a combined receptor activation (leukocyte mobilization). Furthermore, the immunological effects of NPY demonstrate compartment specificity.

Behaviorally conditioned effects of Cyclosporine A on the immune system of rats: specific alterations of blood leukocyte numbers and decrease of granulocyte function

Immunosuppression induced by Cyclosporine A (CsA) can be behaviorally conditioned. It is unknown, however, whether a taste aversion paradigm using CsA as an unconditioned stimulus (UCS) induces alterations of blood leukocyte numbers and function. Results obtained by three-colour flow cytometry and granulocyte chemiluminescence response demonstrate that in conditioned rats, absolute numbers of lymphocyte subsets, including B, CD8+ T cells and CD4+ naive and memory T cells, and granulocyte numbers and function were significantly decreased. In contrast to the conditioned response, CsA treatment alone increased lymphocyte numbers and did not affect granulocyte function. Thus, our data demonstrate that behaviorally conditioned CsA effects can be monitored in the blood. In addition, results indicate that the CNS mediates the behaviorally conditioned immunosuppression by reducing the availability and function of granulocytes and lymphocytes.

Glycine reduces the inflammatory response and organ damage in a two-hit sepsis model in rats.

The goal of this study was to investigate whether prefeeding of glycine reduces the immunoinflammatory response, the degree of distant organ injury (liver), and/or the mortality rate in a two-hit model using intestinal ischemia/reperfusion and endotoxin (ET) challenge 6 h later in rats. The liver damage was greatest at 24 h after ET challenge and completely inhibited by glycine. The early systemic increase of the proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin (IL) -6 as well as the secretion of the antiinflammatory cytokine IL-10 was reduced by glycine. Tissue cytokine mRNA expression (TNF-alpha, IL-1beta, IL-10) was decreased in the lung and the liver but not in the mesenteric lymph node or ileum, in the glycine-fed group. However, glycine did not decrease the mortality rate. These results suggest that prefeeding of glycine reduces liver damage as well as the systemic and local (lung and liver) inflammatory response after intestinal ischemia/reperfusion and endotoxin challenge in rats.

Centrally applied NPY mimics immunoactivation induced by non-analgesic doses of met-enkephalin.

NEUROPEPTIDE Y (NPY) and endogenous opioids (EOPs) such as methionine-enkephalin (Met-enk) regulate similar physiological responses, but it is not known whether nociceptive and immune responses also show analogy after intracerebroventricular (i.c.v.) application. Dose–response studies show that Met-enk stimulates the blood granulocyte and splenic natural killer (NK) cell function of Lewis rats at a low dose (102 ng/kg, i.c.v.), whereas a high dose (105 ng/kg) causes suppression of innate immune functions associated with analgesia in the hot-plate test. At 15 min, 1 h and 24 h after i.c.v. application, both Met-enk (102 ng/kg) and NPY (1 ng/kg) produced similar effects: An initial suppression of innate immune function was followed by a long lasting stimulatory action on cell functions and serum inter-leukin-6 (sIL-6) levels. Thus, central NPY application resembles Met-enk-induced immunostimulation at doses not affecting nociception, suggesting an involvement of both peptides in shaping stress-induced immunomodulation of the non-analgetic form, possibly via activation of a common immunomodulatory effector mechanism.

Documentation of Blunt Trauma in Europe Survey of the Current Status of Documentation and Appraisal of the Value of Standardization

During the last decade, several European communities have begun to perform multicenter approaches to document trauma care and trauma care outcome. So far every country has begun to do this without communicating with each other and no coordination has been performed. The current manuscript compares these modes of documentation, their advantages and evaluates options for future standardization. Even though to date a wide variety of structures is available, the value and the opportunities of a European-wide standardized documentation process is highlighted.

Organ-Specific Cytokine Gene Expression in Sepsis – an Experimental Study in a Two-Hit Septic Model

AbstractBackground: Interstinal ischemia and the subsequent cytokine response are believed to play a pivotal role in the pathogenesis of multiple organ failure after trauma, shock, and sepsis. However, the relative importance of the interstinal inflammatory response in comparison with other organs has not been investigated. Material and Methods: Rats were subjected to 45 min of superior mesenteric artery occlusion (first hit) and intraperitoneal endotoxin (15 mg/kg body weight)/sodium chloride challenge 6 h later (second hit). Plasma tumor necrosis factor-alpha (TNF-α), interleukin-(IL-)6 and IL-10 levels were measured by enzyme-linked immunosorbent assay (ELISA). The mRNA expression of TNF-α, IL-1β, IL-6 and IL-10 in lung, liver, mesenteric lymph node and ileum were determined by competitive reverse transcriptase polymerase chain reaction (RT-PCR). Results: Superior mesenteric artery occlusion and endotoxin challenge led to an early increase of plasma TNF-α and IL-10 levels, while the plasma IL-6 response peaked 3 h after intraperitoneal injection of endotoxin. The mRNA expression of all cytokines was significantly increased in the two-hit compared to the one-hit group. Although cytokine mRNA was expressed in the ileum, all cytokines showed significantly higher mRNA levels in the lungs compared to the other organs in the two-hit group. Even in the one-hit group, the TNF-α nRNA expression in the lung was significantly higher compared to the liver. Conclusions: The lung was the primary source of pro- and anti-inflammatory cytokines compared to all other organs in this two-hit sepsis model. However, the gut could be identified as a site of cytokine gene expression. These results furhter confirm the concept, that intestinal mediators reach the systemic circulation via the intestinal lymphatic duct and not the portal vein and therefore lead to an inflammatory response of the lung rather than the liver.