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C Waydhas

Publications and source records attributed to C Waydhas.

At least 55 records · Page 3Linked to original sources
PubMed1997

Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries.

BACKGROUND: Most prognostic indices for severely injured patients are based on anatomical findings and the vital signs. The posttraumatic organ failure, however, is thought to be triggered by the initial inflammatory response. The objective of this study was to evaluate the correlation between the early activation of inflammation and the rate of organ failure and death. METHODS: Sixty-six patients with multiple injuries (Injury Severity Score > 18, age 18-70 years, admission within 6 hours after accident, survival > 48 hours) were included in this prospective study. During a 14-day observation period, serial blood samples were collected starting within 30 minutes after admission. Plasma levels of neutrophil elastase, lactate, antithrombin III, and interleukin-6 and -8 were determined. The clinical course and the degree of organ failure were recorded daily until death or transfer to a general ward. RESULTS: The 66 severely injured patients had a mean Injury Severity Score of 40 points. Eleven patients died from multiple organ failure (group 1), 38 subjects survived a single or multiple organ failure (group 2), and 17 patients had an uneventful recovery (group 3). The initial plasma concentrations for neutrophil elastase (650 vs. 355 ng/mL), lactate (5.0 vs. 3.1 mmol/L), antithrombin III (48 vs. 62% from normal), interleukin-6 (703 vs. 177 pg/mL), and interleukin-8 (1,101 vs. 301 pg/mL) were significantly different between groups 2 and 3 already in the initial posttraumatic period. Patients from group 1 presented with significantly higher levels of these parameters as early as 24 hours after trauma compared with group 2. Different patterns were identified with respect to early versus late posttraumatic organ failure. CONCLUSIONS: These data show that the degree of the initial inflammatory response corresponds with the development of posttraumatic organ failure. Besides anatomically and physiologically based trauma scores, these parameters might be used as indicators for the injury severity.

Adolescent↗
PubMed1997

Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study.

OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest trauma (94 multiple injured patients with chest trauma, nine patients with isolated chest trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center. RESULTS: In 67 patients (65%) TCT detected major chest trauma complications that have been missed on CXR (lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005), and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement, chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of respiratory failure, adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with multiple trauma and with blunt chest trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group. CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualzing lung contusions, pneumothorax, and hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with multiple injuries and with suspected chest trauma because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.

Adolescent↗
PubMed1997

[Can diagnosis and subsequent trauma management of the multiple trauma patient with blunt thoracic trauma be improved by early computerized tomography of the thorax?].

OBJECTIVE: The aim of this prospective study was to evaluate, whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work up of blunt thoracic trauma and whether these additional informations influence subsequent therapeutical decisions in the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiple injured patients with chest trauma, 9 patients with isolated chest trauma) with an average ISS of 30 and an average AIS thorax of 3 initial CXR and TCT were compared after first assessment in our emergency department of a level I trauma center. RESULTS: In 67 patients (65%) TCT detected major complications of chest trauma, that have been missed on CXR [lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)], in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT and in 14 patients CXR and TCT showed the same pathological results. 11 patients had both CXR and TCT without pathological findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005) and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement or chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1). CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions, pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work up of multiple injured patients with suspected chest trauma, because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.

Adolescent↗
PubMed1997

[Evaluation and quality management in multiple trauma care].

In total quality management of polytraumatised patients, it is necessary to use analysis of structure, process and outcome quality to search for problem areas and improvement possibilities. The structure includes the attributes of material and human resources. The process denotes the real treatment course with the demand for treatment guidelines (algorithm) and an exact documentation of treatment. To prove the outcome quality, an internal and external judgement is possible. Our own results show that quality assessment, concerning the process as well as the internal and external quality outcome, brings a significant improvement to the care of polytrauma patients.

Algorithms↗
PubMed1997

[A time and priority-oriented algorithm].

Algorithms represent a graphical display of decision-making by giving clearly defined and formalized guidelines. The systematic order of decisions and consequent actions is guided by medical priority and regulates the time frame and sequence of each single step in a logical manner. With the help of clinical algorithms highly complex processes such as the management of the severely injured patient can be translated into a clearly structured, logical pathway. They delineate a consistent and valid guideline but require aberrations in proven exceptions. The use of algorithms allows a systematic search for errors in the process of quality management. In emergency situations they suggest a structured way of problem-solving to the less experienced user. Algorithms are useful instruments in teaching medical decision-making.

Algorithms↗
PubMed1997

[Shock room management in severe craniocerebral trauma].

Early clinical management of severe head injury should take place in an emergency resuscitation room and be conducted according to the guidelines of the treatment of severely injured patients with attention given to time. The first phase (with a maximum duration of 30 min) comprises physical examination, stabilisation of vital functions and basic technical diagnostics. With pulmonary and circulatory functions stabilized, the second phase begins with a craniol computed tomography examination followed by adequate therapeutic measures, including, if necessary, the CT-controlled implantation of an intracranial pressure catheter.

Brain Edema↗
PubMed1997

[The trauma register of the 'Polytrauma' Committee of the German Society of Trauma Surgery as the basis for quality management in the management of severely injured patients].

The data of 1037 severely injured patients (mean ISS = 20) from 15 clinics were centrally and prospectively collected in the Trauma Registry of the German Society of Trauma Surgery and analyzed anonymously. Significant differences in respect to the treatment criteria (i.e., duration of basic diagnostics in severe trauma) and quality of outcome (TRISS method and Z statistic) were revealed for some clinics. The feedback of their data offers the associated clinics the possibility of identification of treatment phases that are worth being optimized.

Germany↗
PubMed1996

[The injury pattern in polytrauma. Value of information regarding accident process in clinical acute management].

To investigate the correlation between the mechanism of an accident and the resulting injury pattern we reviewed the data of 195 prospectively documented multiply traumatized patients. Information on the accident was based on descriptions given by eye witnesses, police and the emergency medical staff. Only moderate to severe lesions (AIS > or = 3; Abbreviated Injury Scale Version 1990) of each body region were analyzed. The mean injury severity (ISS) for all these patients was 39.5 (18-75); the lethality was 34%. Different types of accidents led to various injury patterns. We found a high incidence of lesions of the head in frontal (F) motor vehicle crashes (MVC) nonbelted (76%), of the chest in lateral (L) MVCs (80%), of the abdomen in F MVCs belted and in LMVCs (60%), of the pelvis after suicidal fall (SF; 69%) and of the lower extremities in motorcycle accidents (90%), SFs (69%) and collisions with a train (67%). Severe lesions of the spine were frequently seen after accidental falls (41%), SFs (30%) and F MVCs belted (25%). There was a very substantial difference in the injury pattern after suicidal jump (26% head, 69% pelvis, 65% lower extremity lesions). and accidental fall (54% head, 19% pelvis, 23% lower extremity lesions). As a result of the correlation with specific injury patterns, the preceding mechanism of accident should be exactly documented and considered by the physician during the early phase of resuscitation.

Abbreviated Injury Scale↗
PubMed1996

Posttraumatic inflammatory response, secondary operations, and late multiple organ failure.

The objective of this study was to determine the role of surgical procedures as secondary inflammatory insults in the development of late multiple organ dysfunction syndrome in patients with multiple trauma and to evaluate both specific and nonspecific indicators of the inflammatory response in their ability to indicate the risk of severely injured patients to develop organ failure after secondary operations. In a prospective study of 106 severely injured patients (ISS 40.6) who underwent secondary operations (> 3 days after trauma), we compared the level of preoperative inflammation with the sequelae of surgical trauma. The interventions included facial reconstructions; osteosynthesis of the pelvic girdle, long bones, and spine; and others. Group 1 consisted of 40 patients (38%) who developed respiratory, renal, or hepatic failure, or combinations thereof, within 2 days after the operation or whose preexisting organ dysfunction worsened by more than 20% from baseline. The remaining 66 patients (62%) with an uneventful recovery formed group 2. The preoperative levels of neutrophil elastase (92.2 vs. 61.3 ng/dL), C-reactive protein (12.4 vs. 7.6 mg/dL), and platelet count (118,000 vs. 236,000/microL) were significantly more abnormal in the patients of group 1. PO2/FiO2 ratio was also somewhat lower in group 1 patients (305.5 vs. 351), whereas other parameters (e.g., blood pressure, heart rate, bilirubin, creatinine, urinary output, lactate, pH, and coagulation) did not allow preoperative differentiation between groups 1 and 2. An increased state of inflammation (neutrophil elastase > 85 ng/mL, C-reactive protein > 11 mg/dL, platelet count < 180,000/microL) predicted postoperative organ failure with an accuracy of 79% (sensitivity, 73%; specificity, 83%). We conclude that secondary operations may act as a second insult and may precipitate late multiple organ dysfunction syndrome if they are performed in patients with multiple trauma while they still have an increased level of posttraumatic inflammation. However, future investigations have to show whether postponing surgery until inflammation has subsided or the use of less invasive surgical techniques will decrease the rate of postoperative organ failure in the trauma patient.

Adult↗
PubMed1996

[Intramedullary nailing in multiple trauma].

The indication and best time for intramedullary nailing of long bones in the multiple trauma patient is still controversial. While in the Anglo-American literature primary intramedullary nailing is regarded as the method of choice, differentiated management is preferred in German-speaking countries on account of reports about the pathogenesis of trauma shock. On the one hand, it has been shown that severe thoracic injury greatly influences the course after multiple trauma and, in particular, its combination with femoral fracture represents an increased risk. On the other hand, every surgical intervention represents an additional trauma for the patient. Intramedullary reamed nailing of femur fractures represents considerable trauma, whereas unreamed intramedullary nailing of the femur or intramedullary stabilization of the tibia or humerus causes (in descending order) fewer changes. For early respiratory care (e.g., changing between the prone and supine position), however, primary stabilization of long bones is required. External fixation of the femur appears to be the method of choice for the severely injured patient. Definite fracture healing can be achieved by a change to intramedullary nailing in a secondary operation.

Bone Plates↗
PubMed1996

[Preclinical diagnosis and management in severe craniocerebral trauma].

Both prehospital and hospital management of patients with severe head injury has clearly improved in the last decades. There is a greater knowledge of how secondary brain injury is caused and how it can be prevented. Intracranial mechanisms (e.g. haematoma and elevated intracranial pressure and systemic mechanism (e.g. shock and hypoxaemia) are two of the major causes of secondary brain injury. Adequate prehospital evaluation and treatment determine the later outcome for the patient. The Glasgow Coma Scale has become the standard score for assessing the level of consciousness. Early prehospital treatment must prevent secondary brain damage through adequate oxygenation (intubation, ventilation) and a sufficient cerebral perfusion pressure (treatment of shock). The neck of the patient should be positioned straight and the upper part of the body should be elevated to about 30 degrees. The prophylactic use of steroids, mannitol or high dose barbiturates is not indicated. Aggressive hyperventilation (pCO2 < 30 mmHg), especially during the first few days after severe brain injury, should be avoided.

Brain Damage, Chronic↗
PubMed1995

Deterioration of respiratory function after intra-hospital transport of critically ill surgical patients.

OBJECTIVE: To evaluate the impact of intra-hospital transport of artificially ventilated patients on respiratory function, and to define predictors that may allow estimation of the risk of post-transport pulmonary deterioration. DESIGN: Prospective observation study. SETTING: Surgical ICU, University Hospital. PATIENTS: 49 intra-hospital transports (median Apache-score before transport 21, of 28 consecutive patients (all intubated and mechanically ventilated) were studied. INTERVENTIONS: 32 transports were destined to the radiology department and 17 to the operating theatre. Patients were ventilated during transportation with a transport ventilator. MEASUREMENTS AND RESULTS: The base-line condition of the patients and any changes of hemodynamic function were noted. Arterial blood gases were determined before transport as well as 0.25, 1, 6, 12, and 24 h after return of the patient to the ICU. Of the transports 41 (83.7%) resulted in a decrease of PO2/FIO2-ratio with a deterioration of more than 20% from baseline in 21 cases (42.8%). The impairment of respiratory function lasted longer than 24 h in 10 subjects (20.4%). Ventilation with positive end-expiratory pressure correlated significantly (r = -0.4) with post-transport change of PO2/FIO2-ratio, whereas initial FIO2, initial PO2/FIO2-ratio, Apache II-score, patients' age or transport time did not distinguish between patients with and without a consecutive decrease of pulmonary function. CONCLUSION: Intra-hospital transport of ventilated critically ill patients may result in a considerable and long-standing deterioration of respiratory function. Patients ventilated with positive end-expiratory pressure are at an increased risk and the indication for procedures away from the ICU has to be weighted carefully in these subjects.

APACHE↗
PubMed1995

[Postoperative homeostatic imbalance after trauma surgical interventions of various degrees in polytrauma].

The objective of this study was to evaluate and compare the derangement of body homeostatis and the inflammatory response after different types of traumatological operations in patients with multiple injuries. These were determined in a total of 60 operations. The procedures comprised osteosynthesis of the femur (n = 28), the pelvic girdle (n = 11) the spine (n = 8), and facial and basal skull reconstructions (n = 13). Specific and unspecific parameters of the inflammatory response were determined on the morning of the operation, immediately after the procedure, every 6 h on the 1st day and 48 h after the end of surgery. After all types of operations (pelvis, femur, spine, face/basal skull) significant alterations were observed for neutrophil elastase, C-reactive protein, interleukin 6, interleukin 8, antithrombin III, partial thromboplastin time and other parameters. The degree of postoperative changes differed significantly (Kruskal-Wallis test, P < 0.05) among the four types of operations for lactate, heart rate, PO2/FiO2 ratio and nitrogen excretion and showed a strong discriminating tendency for neutrophil elastase and C-reactive protein. The changes were most pronounced after operations on the pelvic girdle, followed by procedures in the femoral, spinal, and facial/basal skull regions. We conclude that a considerable inflammatory response and pronounced disturbance of body homeostasis follow traumatological operative procedures, varying in severity with the type of surgery. Several parameters allow quantitation of the surgical trauma and differentiation between different operations/regions. Further research should focus on the interrelationship between pre-existing preoperative inflammation and the additional trauma inflicted by surgery in patients with severe injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute-Phase Reaction↗
PubMed1995

[Cost analysis of clinical treatment of polytrauma patients].

In order to assess the costs arising from the treatment of polytraumatized patients we analysed the data of 100 prospectively studied multiple trauma patients (ISS 38) calculating all medical expenses during their clinical stay. The average cost per patient in the studied group (n = 100) amounted to 63989.- DM. About 65% of this sum derived from the costs of intensive care, while the expenses for operations covered 19%. The group of primarily deceased patients (n = 25) generated the lowest costs of 8468.- DM (per pat.). The highest costs of 95626.- DM were caused by the treatment of patients (n = 32) that developed one or more complications (organ failure) during their stay in the intensive care unit or died (n = 10) during this therapy (101940.- DM). Since the data concerning medical equipment (i.e. surgical devices, radiological equipment) were not centrally registered in the administration department of our clinic, it was not possible to include these costs into this calculation. Thus the total costs must be presumed higher. A relationship between costs of treatment and injury severity (ISS) appeared in polytrauma only by a cost reduction in early deceased very severely injured patients (ISS > 70). The primary diagnosis (injury pattern and severity) cannot predict the incidence of complications increasing the costs of treatment. In the presented study we did not find a correlation between age and treatment costs.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

[Effect of early intubation on the reduction of post-traumatic organ failure].

In a prospective multiple trauma study lasting from 1986 to 1991 the influence of early intubation (EI) within 2 h after the accident on posttraumatic (multiple) organ failure (M)OF was compared with that of delayed intubation (DI) in 131 patients with multiple injuries (ISS 37). The indications for intubation were unconsciousness following severe head injury in 45 cases (45 EI, 0 DI), major chest trauma (AIS > or = 3) in 40 (31 EI, 9 DI) and other severe injuries (no head or chest trauma, but ISS > 24) in 40 patients (30 EI, 10 DI). One hundred and six trauma victims (81%) were intubated early and 19 patients (14.5%) required intubation and artificial ventilation in the later course, whereas in 6 subjects (4.5%) spontaneous respiration was adequate. The pattern of injured body regions did not differ substantially between the two groups, but the severity of injury was significantly greater (p < 0.001) in the EI group (ISS 39) than in the DI patients (ISS 29). Among the EI patients, 67% developed at least one OF, 45% respiratory failure (RF), and 28% multiple organ failure (MOF); 15% died. The DI group showed almost the same incidence of RF (42%) and other OF (63%), and even a higher (n.s.) incidence of MOF (37%) and mortality rate (26%). In view of the significantly less severe injuries in the DI group, the observed OF and mortality rates are inappropriately high compared with the incidence of OF and death in the EI group.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed1995

A multicenter study of phospholipase A2 in patients in intensive care units.

BACKGROUND: Multiple organ failure (MOF) is becoming the most common cause of death in patients in surgical intensive care units. In this respect, a multicenter study in four different groups of patients in surgical intensive care units was done to evaluate the role of phospholipase A2 (PLA2) in comparison with C-reactive protein (CRP) and polymorphonuclear (PMN) elastase. STUDY DESIGN: A total of 223 patients entered the study: 73 patients with multiple injuries, 46 patients with diffuse peritonitis, 52 patients with sepsis, and 52 patients in a control group who were at a higher risk for postoperative sepsis after defined surgical interventions. The patients underwent a daily monitoring of PLA2, CRP, and PMN elastase for seven days. RESULTS: Phospholipase A2 activity remained within the normal range in patients with multiple injuries and patients in the control group, indicating that this parameter is not influenced by the postaggression metabolism. In contrast, in patients with peritonitis, high PLA2 values were found from the beginning. The efficiency for predicting a lethal MOF was 85 percent for PLA2 (cut-off 80 U/L) in patients if determined at the day of operation. A comparably favorable efficiency (84 percent) was demonstrated for PMN elastase in patients with multiple injuries (cut-off 205 micrograms/L) measured at day one. CONCLUSIONS: These efficiency rates of PLA2 in peritonitis and PMN elastase in multiple injuries were comparable or even better than multifactorial scoring systems used in the study. C-reactive protein did not contribute to an early estimation of the prognosis in all groups analyzed. Therefore, the measurement of PLA2 in patients with diffuse peritonitis and PMN elastase in patients with multiple injuries, as single parameters, is recommended to estimate the individual risk for the occurrence of lethal MOF.

Adolescent↗