Masanobu Kishikawa

Pulmonary contusion causes long-term respiratory dysfunction with decreased functional residual capacity.

To elucidate the mechanism of persistent dyspnea after blunt chest trauma, we prospectively studied the pulmonary function of 18 patients with blunt chest trauma for 6 months. Nine of the patients had flail chest and 12 had pulmonary contusion (PC). Pulmonary function was evaluated using spirometry, arterial blood gas analysis, chest x-ray studies and CT scans. Functional residual capacity (FRC) remained significantly reduced throughout the 6 months in patients with PC. Such patients experienced a fall in Pao2 when changed from a sitting position to a supine position and they had fibrous changes in the contused lung as demonstrated by CT scans at 6 months after injury. These findings were supported in an additional study of another 20 patients who had suffered PC 1 to 4 years previously. This study demonstrated that pulmonary function recovered within 6 months in patients without PC even with a residual deformity of the thoracic wall caused by flail chest, while patients with PC had decreased FRC and a fall in Pao2 when moved to the supine position even several years after injury. This might be related to the persistent dyspnea seen after blunt chest trauma.

Does Splenic Preservation Treatment (Embolization, Splenorrhaphy, and Partial Splenectomy) Improve Immunologic Function and Long-Term Prognosis After Splenic Injury?

BACKGROUND : To assess the immunologic alteration and long-term prognosis after splenic injury from preservation treatment (PT) (embolization, splenorrhaphy, partial splencetomy) and to compare with splenectomy (SN). METHODS : The long-term prognosis of patients with blunt splenic injury treated at seven tertiary emergency centers in Japan was retrospectively studied. Patients were followed up by telephone interview and written questionnaire. Blood samples and abdominal computer tomography scans were taken from patients who consented, and immunologic indices and the remaining volume of the spleen were measured. RESULTS : There was no episode of severe infection requiring hospitalization among the 66 SN patients (760 patient-year) and the 34 PT (213 patient-year) patients. Blood tests from 58 patients (24 SN vs. 34 PT) revealed significant differences in platelet count, Howell-Jolly body positive rate (SN 87% vs. PT 3%), white blood cells, total lymphocyte count, T-cell count, B-cell count, and serum IgG level. There was no significant difference in serum levels of IgM or specific IgG antibodies against 14 types of Streptococcus pneumoniae capsular polysaccharide, C3, C4, high-sensitivity C-reactive protein, and B -cell subset (surface marker immunoglobulins: IgA, IgG, and IgM). Most patients had anti-S. pneumoniae antibody levels less than that of the reference level for multiple serotypes (average 3 in SN and 4 in PT). A computer tomography scan was taken from 33 PT patients; the volume of spleen remaining averaged 130 mL (range, 48-287 mL). CONCLUSION : PT did not show discernible advantage over SN in immunologic indices including IgM and 14 serotypes of anti-S. pneumoniae antibodies, suggesting prophylactic measures and close follow-up are necessary after PT and SN.

Recovery from postoperative hypothermia predicts survival in extensively burned patients.

To clarify the cause of postoperative hypothermia in extensively burned patients, factors affecting postoperative hypothermia were studied in 16 extensively burned adult patients (8 survivors and 8 nonsurvivors) with a burn index greater than 35. Body temperature was monitored continuously in either the urinary bladder or rectum. Hypothermia of less than 35 degrees C occurred in 89% (66 of 74) of the total operations performed in these 16 patients. The rate of temperature rise (RTR) was significantly lower in nonsurvivors (0.4 +/- 0.2 degrees C/h) than in survivors (1.7 +/- 0.9 degrees C/h; p < 0.001). Continuous indirect calorimetry performed in seven patients (four survivors and three nonsurvivors) demonstrated that RTR was determined primarily by heat production. The measured energy expenditure reached only 1.7 +/- 0.2 times the basal energy expenditure during rewarming in nonsurvivors, whereas it was 2.7 +/- 0.9 times the basal energy expenditure in survivors (p < 0.01). Surprisingly, in nonsurvivors, the RTR was significantly decreased even during the first 2 weeks. These findings suggest that those who cannot generate heat well in postoperative hypothermia are unable to produce the additional energy required to overcome sepsis.

Predictive value of a flat inferior vena cava on initial computed tomography for hemodynamic deterioration in patients with blunt torso trauma.

BACKGROUND We aimed to investigate the value of the diameter of the inferior vena cava (IVC) on initial computed tomography (CT) to predict hemodynamic deterioration in patients with blunt torso trauma. METHODS We reviewed the initial CT scans, taken after admission to emergency room (ER), of 114 patients with blunt torso trauma who were consecutively admitted during a 24-month period. We measured the maximal anteroposterior and transverse diameters of the IVC at the level of the renal vein. Flat vena cava (FVC) was defined as a maximal transverse to anteroposterior ratio of less than 4:1. According to the hemodynamic status, the patients were categorized into three groups. Patients with hemodynamic deterioration after the CT scans were defined as group D (n = 37). The other patients who remained hemodynamically stable after the CT scans were divided into two groups: patients who were hemodynamically stable on ER arrival were defined as group S (n = 60) and those who were in shock on ER arrival and responded to the fluid resuscitation were defined as group R (n = 17). RESULTS The anteroposterior diameter of the IVC in group D was significantly smaller than those in groups R and S (7.6 mm ± 4.4 mm, 15.8 mm ± 5.5 mm, and 15.3 mm ± 4.2 mm, respectively; p < 0.05). Of the 93 patients without FVC, 16 (17%) were in group D, 14 (15%) required blood transfusion, and 8 (9%) required intervention. However, of the 21 patients with FVC, all patients were in group D, 20 (95%) required blood transfusion, and 17 (80%) required intervention. The patients with FVC had higher mortality (52%) than the other patients (2%). CONCLUSION In cases of blunt torso trauma, patients with FVC on initial CT may exhibit hemodynamic deterioration, necessitating early blood transfusion and therapeutic intervention.

Transient and repetitive rises in blood pressure synchronized with plasma catecholamine increases after head injury. Report of two cases.

The authors report two patients with repetitive episodes of acute transient rise in blood pressure synchronized with increases in plasma catecholamine after severe head injury. In both cases, the paroxysmal hypertension occurred suddenly on the 2nd day posttrauma, and its frequency declined gradually, disappearing with time. The pathophysiological basis of this peculiar clinical manifestation is discussed.

Laterality of air volume in the lungs long after blunt chest trauma.

To clarify a cause of the persistent decrease in lung capacity seen several years after blunt chest trauma, 17 patients with blunt chest trauma (10 with unilateral lung contusion, 7 with bilateral lung contusions; 11 of these with unilateral flail chest) inflicted 1 to 6 years previously and 10 normal volunteers (control) were studied. Lung air volumes (AV) were measured by spirometry (AVsp) and by computed tomographic (CT) scan (AVCT = AVCT.Rt+AVCT.Lt) under the same conditions. Hemithoracic spaces were also calculated by CT scan. The average AVsp in patients (76% +/- 8%) was lower than in the controls (98% +/- 5%). AVCT was consistent with AVsp in all the measurements. %AVCT.Rt and %AVCT.Lt, which were adjusted by the ratio of AVCT.Rt to AVCT.Lt in the controls, decreased significantly in unilateral contused lungs (71% +/- 8%). Fifty-eight percent of contused lungs showed small fibrous changes on the CT scans. The ratio of the hemithoracic space on the flail chest side to the opposite side was 0.95 +/- 0.05. These results suggest that the persistent decrease in AV long after blunt chest trauma might be caused by a constriction of contused lung resulting from fibrous changes.

Routine Head Computed Tomography for Patients in the Emergency Room with Trauma Requires Both Thick- and Thin-Slice Images.

Background. Images of head CT for the supratentorial compartment are sometimes recommended to be reconstructed with a thickness of 8–10 mm to achieve lesion conspicuity. However, additional images of a thin slice may not be routinely provided for patients with trauma in the emergency room (ER). We investigated the diagnostic sensitivity of a head CT, where axial images were 10 mm thick slices, in cases of linear skull fractures. Methods. Two trauma surgeons retrospectively reviewed head CT with 10 mm slices and skull X-rays of patients admitted to the ER that were diagnosed with a linear skull fracture. All patients had undergone both head CT and skull X-rays (n = 410). Result. The diagnostic sensitivity of head CT with a thickness of sequential 10 mm was 89% for all linear skull fractures but only 56% for horizontal fractures. This CT technique with 10 mm slices missed 6% of patients with linear skull fractures. False-negative diagnoses were significantly more frequent for older (≥55 years) than for young (<15 years) individuals (p = 0.048). Conclusions. A routine head CT of the supratentorial region for patients in the ER with head injuries requires both thick-slice images to visualize cerebral hemispheres and thin-slice images to detect skull fractures of the cranial vault.