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Biomedical subjects

T M Scalea

Publications and source records attributed to T M Scalea.

At least 19 recordsLinked to original sources
PubMed2002

Pattern of injury from personal watercraft.

Injury from personal watercraft has continued to increase. Prior attempts to delineate patterns of injury and relative frequencies have yielded varied results. We retrospectively reviewed Trauma Registry data and charts of all patients who suffered personal watercraft injury treated at the R. Adams Cowley Shock Trauma Center between August 1996 and January 2001. Patient demographics included mechanism of injury, injuries sustained, and outcomes. Attempts were made to correlate events around the injury and injury pattern. During the study period 24 patients were treated. Mechanisms consisted of direct collision, fails from the watercraft, handlebar straddle injuries, axial loading, and hydrostatic jet injury. Traumatic brain injury was most common occurring in 54 per cent of patients. Spinal injury was also common occurring in 29 per cent of patients. Axial loading from falls while wave jumping seemed to correlate with skeletal injury. Thoracolumbar spine injury were often skeletally unstable requiring either brace or operative fixation. Inexperience and reckless behavior were found to be the greatest contributing factors. Substance abuse did not influence injury.

Adult↗
PubMed2001

Experience with spiral computed tomography as the sole diagnostic method for traumatic aortic rupture.

BACKGROUND: Spiral computed tomographic (CT) scan is an excellent screen for aortic trauma. Traditionally, aortography is performed when injury is suspected to confirm the diagnosis. We hypothesized that it is safe and expeditious to forgo aortography when the spiral CT demonstrates aortic injury. METHODS: Retrospective review of 54 patients undergoing aortic repair from July 1994 to December 1999. Spiral CT was the initial diagnostic study in 52 patients. Pseudoaneurysm or aortic wall defect in the presence of mediastinal hematoma was considered diagnostic. Angiography, initially routine, was later performed only when requested by the surgeon, and for all "nonnegative" studies (periaortic hematoma without detectable aortic injury). RESULTS: Twenty-six patients underwent angiography before operation (group 1). Nineteen group 1 spiral CTs were unequivocally diagnostic; 7 were nonnegative and angiography was required. Twenty-eight other patients underwent repair based on spiral CT alone (group 2). There was one false-positive result in both groups. There were no unexpected operative findings. Mean time from admission to diagnosis was 5.7+/-3.4 hours for group 1 and 1.7+/-1.7 hours for group 2 (p < 0.01). CONCLUSIONS: Operating on the basis of a diagnostic spiral CT is safe and expeditious. Aortography may be reserved for those with equivocal studies.

Adolescent↗
PubMed2001

Interventional techniques in vascular trauma.

This article addresses in detail the newer role for interventional angiography, including diagnosis and newer angioembolization techniques used to control bleeding and to deal with complications of vascular injuries.

Angiography↗
PubMed2001

CT findings after embolization for blunt splenic trauma.

PURPOSE: To determine complications after transcatheter embolization for blunt splenic injury as recognized with computed tomography (CT). MATERIALS AND METHODS: From March 1997 to January 2000, 80 patients underwent transcatheter embolization after blunt splenic injury, of whom 53 underwent abdominal CT examination before and after embolization. Preembolization CT scans were reviewed to determine grade of injury, and postembolization CT scans were reviewed to identify complications secondary to embolization. Arteriography results were reviewed to determine findings and method and location of embolization. RESULTS: Splenic infarcts occurred in 63% of patients after proximal embolization and in 100% of patients after distal embolization. Infarcts after distal embolization tend to be larger and occur just distal to the embolization material, whereas infarcts after proximal embolization tend to be smaller, multiple, and located in the periphery. Most infarcts resolved without sequelae. Seven patients developed gas within an infarct or subcapsular fluid collection. Two collections were drained and found to be sterile and one patient had a splenic abscess at laparotomy. CONCLUSIONS: Infarcts are common after splenic embolization. Gas may be present within an infarct after embolization with Gelfoam; however, the presence of air/fluid level is a better predictor of abscess.

Adult↗
PubMed2001

Gender differences in adverse outcomes after blunt trauma.

BACKGROUND: High testosterone and low estradiol levels induce immunosuppression and adverse outcome after trauma in male animals. Gender-based outcome differences in human trauma have not been investigated. In order to test our hypothesis that female gender is associated with improved outcome after trauma, we conducted an inception cohort study at the R. Adams Cowley Shock Trauma Center, the adult trauma resource center for the state of Maryland. METHODS: All were blunt trauma patients (18,892) admitted from 1983 to 1995, stratified by Injury Severity Score (ISS) and age. Gender differences in mortality; nosocomial infection; and preinjury diabetes and cardiac, pulmonary, and liver diseases were determined. RESULTS: No significant differences in preinjury diseases were identified. Death and gender were independent variables in all groups except for patients who developed pneumonia. Male patients had a higher incidence of pneumonia in all groups except age 18 to 45, with an ISS < 15. The association between male gender and pneumonia was strongest in the age 46 to 65, ISS > 30 subgroup (p < 0.01). Among those with pneumonia, female patients were at 2.8 to 5.6 times higher risk for death than were male patients. CONCLUSION: These data suggest that gender has no relation to mortality in blunt trauma patients who do not develop pneumonia. In contrast, male gender was significantly associated with an increased incidence of pneumonia after injury, and female patients with pneumonia were at significantly higher risk for mortality.

Adolescent↗
PubMed2001

Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome.

BACKGROUND: The potential for ligamentous injury of the cervical spine (C-spine) may mandate prolonged neck immobilization via a hard cervical collar in the blunt trauma victim (BTV) with altered sensorium. We investigated the incidence of ligamentous C-spine injuries, and whether applying (post hoc) the practice management guidelines from the Eastern Association for the Surgery of Trauma (three radiograph views plus computed tomographic scan of C1-C2) would have detected the injuries. METHODS: The study was a 3-year retrospective review of BTVs admitted to the state's Primary Adult Resource Center for trauma from 1996 to 1998. Unreliable patients were defined as those with admission Glasgow Coma Scale score < 15. A rigorous algorithm to clear the C-spine was used. Pure ligamentous C-spine injury was defined as a C-spine having abnormal anatomic alignment, dislocation, subluxation, or listhesis, but without fracture. Demographics, diagnostic studies, presence of neurologic deficit, therapy, survival, and disposition were analyzed. RESULTS: There were 14,577 BTVs with 614 (4.2%) patients having C-spine injury. There were 2,605 (18%) unreliable patients, with 143 (5.5%) of these having C-spine injury, 129 (90%) having fracture and 14 (10% of BTVs; 0.5% of unreliable patients) having no fracture. Of the 14 unreliable patients with pure ligamentous C-spine injury, 13 had initial diagnosis by supine cross-table lateral radiograph. The one exception had a normal three-view radiographic series, but atlanto-occipital dislocation was diagnosed by computed tomographic scan. Eight patients had upper level injury (C0-C4) and six were lower (C4-C7). Four patients died within 30 minutes after admission, 4 underwent cervical fusion, and 6 were treated with collar only. Five (50%) of the survivors had no apparent neurologic deficit attributed to the C-spine at admission. Nine patients remained institutionalized after discharge and one was discharged home. CONCLUSION: Ligamentous injuries without fracture of the C-spine are rare. Application of the practice management guidelines developed by the Eastern Association for the Surgery of Trauma for identifying C-spine instability is effective and should facilitate early removal of the cervical collar in unreliable patients.

Adult↗
PubMed2001

Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study.

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) is rapidly establishing its place in the evaluation of blunt abdominal trauma. However, no prospective study specifically evaluates its role in penetrating abdominal trauma. METHODS: Data were collected prospectively in 75 consecutive stable patients with penetrating trauma to the abdomen, flank, or back, from December 1998 to June 1999. Those with an obvious need for emergent laparotomy were excluded. FAST was performed as the initial diagnostic study on all patients. Wound location, type of weapon, and findings of diagnostic peritoneal lavage, triple-contrast computed tomographic scan, or laparotomy were recorded. The presence of peritoneal blood was noted. Data were analyzed using the chi(2) test. RESULTS: Of the 75 patients, there were 32 stab and 43 gunshot wounds. There were 66 male patients and 9 female patients; the mean age was 30 years; 41 had proven abdominal injury and 34 had no injury; and 21 patients had a positive FAST. Nineteen had peritoneal blood and injuries requiring repair at the time of laparotomy. There were two false-positive studies. Fifty-four patients had a negative FAST. In 32 patients, this was a true-negative study. Thirteen patients had a false-negative FAST and had peritoneal blood and significant injury on further evaluation. Nine patients had a negative FAST and no peritoneal blood but still had abdominal injuries requiring operative repair, including liver (four), small bowel (four), diaphragm (three), colon (three), and stomach (one). The overall sensitivity of FAST was 46% and the specificity was 94%. The positive predictive value was 90%, and the negative predictive value was 60%. CONCLUSION: FAST can be a useful initial diagnostic study after penetrating abdominal trauma. A positive FAST is a strong predictor of injury, and patients should proceed directly to laparotomy. If negative, additional diagnostic studies should be performed to rule out occult injury.

Abdominal Injuries↗
PubMed2001

Impact of nosocomial infections in trauma: does age make a difference?

BACKGROUND: The effect of age and infection on outcome after trauma is unknown. We evaluated the incidence and impact that nosocomial infection (NI) and age have on morbidity and mortality. Several risk factors were identified and analyzed for correlation with infection. METHODS: Prospective data were collected on patients admitted for > or = 3 days over a 2-year period. Each patient was followed by an infectious disease specialist throughout their hospitalization. Centers for Disease Control and Prevention guidelines were used to diagnose infection. RESULTS: Of the 3,254 patients admitted, 88% were < 65 and 12% were > or = 65 years of age. Injury Severity Score was not significantly different (older vs. younger). Five hundred one (17.4%) of the younger patients developed an NI with a significantly higher hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality compared with the noninfected group. One hundred forty-seven (39%) of the older group developed an NI and also had significant increases in hospital LOS, ICU LOS, and mortality. Older infected patients had the highest hospital LOS, ICU LOS, and mortality. The greatest relative risk of mortality was demonstrated with the combination of increased age and NI. Once infected, however, younger patients with penetrating trauma had a greater relative risk of mortality in the group-specific comparison. Many risk factors were associated with infection. Only chronic obstructive pulmonary disease in elderly trauma patients was a significant independent risk factor for infection. CONCLUSION: NI significantly increases hospital LOS, ICU LOS, and mortality after injury. Age increases risk of infection matched for injury severity, with a significantly higher hospital LOS, ICU LOS, and mortality. Once infected, however, younger patients with penetrating trauma have the greatest risk of mortality. Chronic obstructive pulmonary disease in elderly trauma patients was found to be an independent predictor of infection.

Adult↗
PubMed2001

Systemic inflammatory response syndrome score at admission independently predicts infection in blunt trauma patients.

BACKGROUND: Systemic inflammatory response syndrome (SIRS) score has been demonstrated to be an accurate predictor of outcome in critical surgical illness. To our knowledge, there is a paucity of data using SIRS score as a tool to predict posttraumatic infection. Our goal was to determine whether the severity of SIRS score at admission is an accurate predictor of infection in trauma patients. METHODS: Prospective data were collected on 4,887 blunt trauma patients admitted to a primary adult resource center designated trauma center over an 18-month period. Patients were stratified by age and Injury Severity Score (ISS). SIRS score was calculated at admission. SIRS was defined as an SIRS score > or = 2. Each patient was screened for infection by an infectious disease specialist. Those at high risk for infection were then monitored daily throughout their hospitalization. Centers for Disease Control and Prevention guidelines were used to diagnose infection. RESULTS: Of the 4,887 patients, 1,850 (38%) were admitted > 24 hours and evaluated for subsequent infection (mean ISS, 16 +/- 9; mean age, 43 +/- 19, SD). Thirty-one percent (577) of the patients acquired an infection. The mean hospital length of stay (20.2 days vs. 6.5 days) and mortality (7.8% vs. 2.7%) were significantly greater in the infected group (p < 0.001). Of the four SIRS variables (temperature, heart rate, white blood cell count, and respiratory rate), hypothermia and leukocytosis were the most significant predictors of infection (p < 0.001) when adjusted for age and ISS. SIRS scores of > or = 2 were increasingly predictive of infection when analyzed by multiple logistic regression analysis. CONCLUSION: An admission SIRS score of > or = 2 is a significant independent predictor of infection and outcome in blunt trauma. Daily SIRS scores may be a meaningful method of assessing postinjury risk of infection, and may initiate earlier diagnostic intervention for determination of infection.

Adult↗
PubMed2001

Total cytokine immunoassay: a more accurate method of cytokine measurement?

BACKGROUND: Cytokines signal the normal processes of inflammation and repair in all organs, yet the aberrant expression of these peptide mediators is associated with significant organ dysfunction. The accurate measurement of cytokines is therefore critical. In this study, we sought to investigate the alterations in cytokine expression early after trauma in humans using a new competitive binding immunoassay that measures both free and bound cytokine and compare this with standard enzyme-linked immunosorbent assay (ELISA), which measures only free cytokine. METHODS: Peripheral blood was obtained from trauma patients at admission. Exclusion criteria were transfers, death within 24 hours, pregnancy, known acquired immunodeficiency syndrome, chemotherapy, transplant, or other chronic immune disorder. "Total" cytokine immunoassay was compared with ELISA for cytokines (interleukin [IL]-1, IL-6, and IL-10) measured in serum. RESULTS: Cytokine concentrations measured by total immunoassay were significantly higher (10- to 500-fold increase) than those measured by ELISA, and correlation between the two methods was poor (r2 = 0.193 for IL-10). No significant differences in mean serum cytokine concentrations were noted between trauma patients and normal controls for IL-1 (56 vs. 37 pg/mL), IL-6 (16 vs. 25 pg/mL), and IL-10 (4 vs. 26 pg/mL) using the ELISA method. In contrast, trauma patients had significantly higher serum concentrations of IL-1 (3,320 vs. 1,470 pg/mL, p < 0.05), IL-6 (2,415 vs. 1,048 pg/mL, p < 0.05), and IL-10 (2,307 vs. 1,480 pg/mL, p < 0.05) at admission compared with normal controls using total cytokine immunoassays. CONCLUSION: Cytokine measurements in peripheral blood in trauma patients and normal controls are significantly (10- to 500-fold) higher when using a total cytokine assay that measures both free and bound cytokine. Competitive immunoassays may be the method of choice when measuring endogenous cytokine levels in biologic fluids, and new normal ranges for cytokines must be established for future accurate research in critical care and trauma.

Adult↗
PubMed2001

Mesenteric and renal oxygen transport during hemorrhage and reperfusion: evaluation of optimal goals for resuscitation.

BACKGROUND: Changes in flow to the gut and the kidney during hemorrhage and resuscitation contribute to organ dysfunction and outcome. We evaluated regional and splanchnic oxygen (O2) flow distribution and calculated oxygen supply distribution during hemorrhage and reperfusion and compared them with global measures. METHODS: Seven anesthetized pigs were instrumented to evaluate global hemodynamics, visceral blood flow, and oxygen transport. Tonometric pH probes were positioned in the stomach and jejunum. Animals were bled to 45 mm Hg for 1 hour. Crystalloids and blood were infused during the following 2 hours to normalize blood pressure, heart rate, urine output, and hemo- globin. RESULTS: During hemorrhage, mesenteric flow and O2 consumption were significantly decreased, whereas systemic consumption remained normal. Renal flow was reduced, but renal O2 consumption remained normal. After resuscitation, despite normal hemodynamics, neither systemic, mesenteric, nor renal O2 delivery returned to baseline. Lactate remained significantly increased. Arterial pH, base excess, and gastric and jejunal pH were all decreased. CONCLUSION: During hemorrhage, the gut is more prone than other regions to O2 consumption supply dependency. After resuscitation, standard clinical parameters do not detect residual O2 debt. Lactate, arterial pH, base excess, and intramucosal gut pH are all markers of residual tissue hypoperfusion.

Acid-Base Equilibrium↗
PubMed2001

Epidemic increases in cocaine and opiate use by trauma center patients: documentation with a large clinical toxicology database.

BACKGROUND: Although reports have documented alcohol and other drug use by trauma patients, no studies of long-term trends have been published. We assessed substance use trends in a large cohort of patients admitted to a regional Level I adult trauma center between July 1984 and June 2000. METHODS: Positive toxicology results, collected via retrospective database review, were analyzed for patients admitted directly to the center. Data were abstracted from a clinical toxicology database for 53,338 patients. Results were analyzed for alcohol, cocaine, and opiates relative to sex, age (< 40/> or = 40 years), and injury type (nonviolence/violence). Positive toxicology test result trends were assessed for the 3 years at the beginning and end of the period (chi2). Testing biases were assessed for sex, race, and injury type. RESULTS: The patient profile was as follows: men, 72%; age < 40 years, 69%; nonviolence victims, 77%. Alcohol-positive results decreased 37%, but cocaine-positive and opiate-positive results increased 212% and 543%, respectively (all p < 0.001). Cocaine-positive/opiate-positive results increased 152%/640% for nonviolence and 226%/258% for violence victims, respectively (all p < 0.001). In fiscal year 2000, cocaine-positive and opiate-positive results were highest among violence victims (27.4% for both drugs). Cocaine-positive and opiate-positive results among nonviolence victims were 9.4% and 17.6%, respectively. Patients who were minorities or victims of violence were not tested more frequently than other patients. CONCLUSION: Epidemic increases in cocaine and opiate use were documented in all groups of trauma patients, with the greatest increases being in violence victims. Alcohol use decreased for all groups.

Adult↗
PubMed2001

Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography.

BACKGROUND: The nontherapeutic laparotomy rate in penetrating abdominal trauma remains high and the morbidity rate in these cases is approximately 40%. Selective management, rather than mandatory laparotomy, has become a popular approach in both stab wounds and gunshot wounds. The advent of spiral technology has stimulated a reassessment of the role of computed tomography (CT) in many aspects of trauma care. We prospectively investigated the current utility of triple-contrast CT as a diagnostic tool to facilitate initial therapeutic management decisions in penetrating torso trauma. METHODS: We studied hemodynamically stable patients with penetrating injury to the torso (abdomen, pelvis, flank, back, or lower chest) without definite indication for laparotomy, admitted to our trauma center during the 1-year period from 7/99 through 6/00. Patients underwent triple-contrast enhanced spiral CT as the initial study. A positive CT scan was defined as any evidence of peritoneal violation (free air or fluid, contrast leak, or visceral injury). Patients with positive CT, except those with isolated solid viscus injury, underwent laparotomy. Patients with negative CT were observed. RESULTS: There were 75 consecutive patients studied: mean age 30 years (range 15-85 years); 67 (89%) male; 41 (55%) gunshot wound, 32 (43%) stab wound, 2 (3%) shotgun wound; mean admission systolic blood pressure 141 mm Hg (range 95-194 mm Hg); 26 (35%) had positive CT and 49 (65%) had negative CT. In patients with positive CT, 18 (69%) had laparotomy: 15 therapeutic, 2 nontherapeutic, and 1 negative. Five patients had isolated hepatic injury and 2 had hepatic and diaphragm injury on CT and all were successfully managed without laparotomy. Of these seven patients, three had angioembolization and two had thoracoscopic diaphragm repair. In patients with negative CT, 47/49 (96%) had successful nonoperative management and 1 had negative laparotomy. The single CT-missed peritoneal violation had a left diaphragm injury at laparotomy. CT accurately predicted whether laparotomy was needed in 71/75 (95%) patients. CONCLUSION: In penetrating torso trauma, triple-contrast abdominopelvic CT can accurately predict need for laparotomy, exclude peritoneal violation, and facilitate nonoperative management of hepatic injury. Adjunctive angiography and investigation for diaphragm injury may be prudent.

Abdominal Injuries↗
PubMed2001

Admission angiography for blunt splenic injury: advantages and pitfalls.

BACKGROUND: To analyze the use of admission angiography as a nonoperative adjunct for management of blunt splenic injury. METHODS: Retrospective chart review of all blunt splenic injuries to a Level I trauma center from March 1997 through July 1999. RESULTS: One hundred twenty-six patients underwent angiography for splenic injury. Eighty-six patients (68%) had a negative angiogram and were treated expectantly. Of these, seven patients (8%) required laparotomy, with a splenic salvage rate of 92%. Embolization was performed on 40 patients (32%) for evidence of vascular injury. Of these, three patients (8%) required laparotomy, for a total salvage of 92%. Repeat angiography was performed for suspicion of bleeding in 12 patients (10%), with 50% requiring embolization. Outcome based on CT grade demonstrated an average grade of 2.9, with a salvage rate of greater than 70% for grade IV and V injuries. CONCLUSION: Vascular injury increases with splenic injury grade. Embolization improves nonoperative salvage rates to 92%, even with high-grade injuries. Ten percent of patients require additional therapy including "second-look" angiography. A significant portion of patients with negative screening angiograms (10%) required either embolization or laparotomy to control delayed hemorrhage.

Adult↗
PubMed2001

Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy.

OBJECTIVE: A prospective study was performed to determine the usefulness of triple-contrast helical CT in predicting peritoneal violation and the need for laparotomy in the treatment of penetrating torso trauma. SUBJECTS AND METHODS: Triple-contrast helical CT scans were obtained in 104 hemodynamically stable patients with penetrating injuries to the torso (thoracoabdominal region including tangential wounds to the anterior abdomen, flank, back, and pelvis) over a 17-month period. The study group included 54 patients with gunshot wounds and 50 with stab wounds. No patient had a radiographic or clinical indication for immediate laparotomy. A positive finding on CT was defined as evidence of peritoneal violation or injury to the retroperitoneal colon, major vessel, or urinary tract. Patients with a positive CT, except patients with isolated liver injury or free fluid, underwent laparotomy. Patients with a negative finding on CT were initially observed. RESULTS: CT studies were positive in 35 (34%) of 104 patients and negative in 69 (66%) of 104 of patients. Laparotomy was performed in 21 (60%) of 35 patients with positive CT; 19 (86%) of 22 were therapeutic, two (9%) were nontherapeutic, and one (5%) was negative (no injury was found). Nine patients with isolated hepatic injuries were successfully treated without laparotomy. Among patients with a negative CT, 67 (97%) of 69 were treated nonoperatively with success. CT had 100% (19/19) sensitivity, 96% (69/72) specificity, 100% (69/69) negative predictive value, and 97% (101/104) accuracy in predicting the need for laparotomy. CONCLUSION: Triple-contrast helical CT can accurately predict the need for laparotomy and exclude peritoneal violation in penetrating torso trauma including tangential abdominal wounds.

Abdominal Injuries↗
PubMed2000

The hemodynamic effects of cocaine during acute controlled hemorrhage in conscious rats.

BACKGROUND: Cocaine is often associated with trauma; however, little is known about how its use alters the response to blood loss. The effect of cocaine on hemodynamics following acute hemorrhage was studied in a rat model. METHODS: Following baseline measurements, rats were administered either intravenous cocaine, or saline as a control. Both groups then underwent arterial catheter hemorrhage of 30% of total blood volume. Outcome variables include blood pressure, heart rate, hematocrit, pH, PCO2, PO2, and serum bicarbonate. RESULTS: Following hemorrhage, blood pressure decreased in both groups but the hypotension was significantly greater in the saline group than the intravenous cocaine group at 0 and 5 minutes posthemorrhage. Heart rate was increased significantly for the intravenous cocaine group compared to the saline group starting at 15 minutes postcocaine and lasting for the next 25 minutes. No difference was noted for hematocrit, pH, PO2, or serum bicarbonate. CONCLUSION: Although transient, cocaine blunted the hypotensive response to acute controlled hemorrhage and resulted in tachycardia.

Animals↗