Prevention of venothromboembolic complications remains a challenge in trauma care. Guidelines for prophylaxis published by the Eastern Association for the Surgery of Trauma stratify patients by risk and recommend therapies based on scientific evidence. New innovations such as retrievable inferior vena cava filters are being used by trauma surgeons for patients at risk for pulmonary embolism but in whom anticoagulation is contraindicated. Some available devices offer a limited timeframe for retrieval beyond which the device becomes permanent. The increased utilization of this technology presents case management challenges to trauma teams. Patients who are unreliable or may be difficult to track posthospitalization (homeless, migrant workers, prison system, etc.) run the risk of not having their filters removed as initially intended. Nurses can play a critical role in helping to manage and direct the discharge plan and case management of trauma patients with retrievable inferior vena cava filters.

The initial care of the patient with blunt polytrauma involves a systematic search for causes of hemodynamic instability. Bleeding most often occurs in the pleural space, peritoneal cavity, and retroperitoneum. Orthopaedic injuries also can contribute to instability after blunt trauma. Blood loss from open fractures may be substantial, and exposure with direct vessel control should be performed early. Pelvic fractures can be associated with severe retroperitoneal bleeding. The treatment of patients with complex pelvic fractures includes closing the pelvic space with a binding device, and early pelvic angiography with embolization. Care of patients with multiple organ and bone injuries requires coordination by one trauma team leader. This physician oversees the resuscitation and sets treatment priorities, including the type and amount of time allowed for fracture stabilization. In many cases, nonorthopaedic injuries will need to be addressed before definitive fracture care. However, optimal care typically involves a coordinated multispeciality approach that sometimes includes concurrent operative procedures. Patients with severe physiologic derangements may require damage control techniques to decrease blood loss and operative time. Understanding the overall care of patients who are injured critically will facilitate the integration of the orthopaedic surgeon into the trauma team.

Auerbach, Susan MHA, RHIA; FitzPatrick, Mary Kate MSN, RN; Garuffe, Alicia RHIA; Williams, Bridget MS, RN; McMaster, Janet MS, RN; Stum, Marilyn LPN; Reilly, Patrick MDEditor(s): Auerbach, Susan MHA, RHIA Author Information

Health information management systems have had a tremendous impact on the delivery of healthcare. The implementation of an integrated, concurrent trauma registry and performance improvement system has had a remarkable impact on the University of Pennsylvania's trauma program. Having both the registry and performance improvement programs concurrent and integrated has allowed better utilization of staff and has produced more accurate, relevant and timely data.

The management of extremity injuries above the knee has been well described, but the evaluation and treatment guidelines for penetrating injuries below the popliteal crease has received less attention. A 6-year retrospective review of 100 patients who sustained isolated below-knee gunshot wounds. Patients with proximal extremity, torso, or head wounds were excluded from review so that we could focus on principles of managing below-knee wounds. All patients were evaluated with complete physical examination, ankle-brachial index, and plain X-rays. One patient presented with hemodynamic instability. Twenty-four patients underwent arteriography based on physical examination, an ankle-brachial index less than 0.9, or both. Twenty-two vascular injuries were identified in 19 patients, and an additional injury was found in a patient who went directly to surgery for pulsatile bleeding. Six of these 22 vascular injuries required treatment for bleeding or arteriovenous fistula. Treatment was by embolization in 5 and surgical ligation in 1. Thirteen patients had compartment syndromes. Thirty-five patients had fractures, and ten (29%) of these had an associated vascular injury. Four patients had peroneal nerve injuries, and three of these had long term disability. No limb loss or death occurred. We conclude that patients with low-velocity below-knee gunshot wounds sustain fractures, vascular injuries, compartment syndromes, and nerve injuries, in decreasing order of frequency. Arteriography and embolization may be useful to control bleeding; vascular reconstruction was unnecessary in our experience, and limb loss did not occur.

Scientific foundations of trauma , Scientific foundations of trauma , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

OBJECTIVE:To provide an overview of the splanchnic hemodynamic response to circulatory shock. DATA SOURCES:Previous studies performed in our own laboratory, as well as a computer-assisted search of the English language literature (MEDLINE, 1966 to 1991), followed by a selective review of pertinent articles. STUDY SELECTION:Studies were selected that demonstrated relevance to the splanchnic hemodynamic response to circulatory shock, either by investigating the pathophysiology or documenting the sequelae. Article selection included clinical studies as well as studies in appropriate animal models. DATA EXTRACTION:Pertinent data were abstracted from the cited articles. RESULTS OF DATA SYNTHESIS:The splanchnic hemodynamic response to circulatory shock is characterized by a selective vasoconstriction of the mesenteric vasculature mediated largely by the renin-angiotensin axis. This vasospasm, while providing a natural selective advantage to the organism in mild-to-moderate shock (preserving relative perfusion of the heart, kidneys, and brain), may, in more severe shock, cause consequent loss of the gut epithelial barrier, or even hemorrhagic gastritis, ischemic colitis, or ischemic hepatitis. From a physiologic standpoint, nonpulsatile cardiopulmonary bypass, a controlled form of circulatory shock, has been found experimentally to significantly increase circulating levels of angiotensin II, the hormone responsible for this selective splanchnic vasoconstriction. CONCLUSIONS:While angiotensin II has been viewed primarily as the mediator responsible for the increased total vascular resistance seen during (and after) cardiopulmonary bypass, it may also cause the disproportionate decrease in mesenteric perfusion, as measured in human subjects by intraluminal gastric tonometry and galactose clearance by the liver, as well as the consequent development of the multiple organ failure syndrome seen in 1% to 5% of patients after cardiac surgery.

BACKGROUND:To determine whether the gene expression of both acute-phase reactants (APR) and the major heat-shock protein (hsp-72) can occur simultaneously, transcriptional rates were measured during shock and resuscitation.METHODS:A nuclear runoff technique was applied to hepatic biopsy specimens obtained from pigs before shock, during 40% blood volume hemorrhagic shock (1 and 2 hours), and after resuscitation (4 and 6 hours).RESULTS:Shock-induced transcription of hsp-72 was elevated elevenfold over sham operation at 2 hours (p less than 0.02, Mann-Whitney rank test). Individually shocked animals did not transcribe both classes of stress genes but segregated into two groups: (1) strong APR transcriptional responders and (2) hsp-72 transcriptional responders. In group 2, APR transcription was significantly suppressed. Antichymotrypsin transcription was an average of eighteenfold lower in group 2 versus group 1 (p less than 0.05 at 1,2, and 6 hours).CONCLUSIONS:Different classes of stress protein genes are not transcribed simultaneously. We infer that their increased accumulation at the mRNA level is the result of sequential transcription. Hsp-72 transcription excludes that of the APR genes that may be critical to survival after stress.

Background. To determine whether the gene expression of both acute-phase reactants (APR) and the major heat-shock protein (hsp-72) can occur simultaneously, transcriptional rates were measured during shock and resuscitation. Methods. A nuclear runoff technique was applied to hepatic biopsy specimens obtained from pigs before shock, during 40% blood volume hemorrhagic shock (1 and 2 hours), and after resuscitation (4 and 6 hours). Results. Shock-induced transcription of hsp-72 was elevated elevenfold over sham operation at 2 hours (p < 0.02, Mann-Whitney rank test). Individually shocked animals did not transcribe both classes of stress genes but segregated into two groups: (1) strong APR transcriptional responders and (2) hsp-72 transcriptional responders. In group 2, APR transcription was significantly suppressed Antichymotrypsin transcription was an average of eighteenfold lower in group 2 versus group 1 (p < 0.05 at 1,2, and 6 hours). Conclusions. Different classes of stress protein genes are not transcribed simultaneously. We infer that their increased accumulation at the mRNA level is the result of sequential transcription. Hsp-72 transcription excludes that of the APR genes that may be critical to survival after stress.

Oxygen-derived free radicals and other reactive oxygen metabolites have emerged as a common pathway of tissue injury in a wide variety of otherwise disparate disease processes. This has given rise to the hope that efforts directed towards the phamacologic control of free radical-mediated tissue injury (Reilly, P. M., Schiller, H. J. and Bulkely, G. B. (1991) Pharmacologic approach to tissue injyr mediated by free radicals and other reactive oxygen metabolitis. Am. J. Surg.161: 488–503) may have particular application to patients suffering from Crohn's disease and/or ulcerative colitis. However, because tissue injury by any mechanism, even direct mechanical trauma, can elicit an inflammatory response which entails the possibility of an etiologic role for these toxic compounds from their presence as a reflection important that the evidence for this association be examined critically, so as to discriminate the possibility of an etiologic role for these toxic compounds from their presence as a reflection of injury caused primarily by other agents. Similarly, in considering the therapeutic potential of free radical ablation for the treatment of patients with IBD it is important to distinguish between interventions that might specifically block the fundamental injury mechanism from those which woukd act in a more nonspecific, anti-inflammatory role.

In recent years courts have shown more recognition of the rights of parolees and probationers. Spurred by a Supreme Court decision that certain due process protections were applicable to parole revocation procedures, revocation hearings are now providing parolees and probationers some of the procedural protections available to criminal defendants at trial. Policy considerations have dictated, however, that the protections available at revocation hearings must fall far short of conferring upon the accused “the full panoply of rights due a defendant” at trial. As a result of the Supreme Court’s emphasis on the difference between revocation hearings and criminal proceedings, lower courts have held that some constitutional protections available to defendants at trial do not apply at revocation hearings. Thus, the exclusionary rule has been held inapplicable to revocation hearings. This is in contrast to a recent district court decision, Standlee v. Rhay, where it was held that because of the punitive nature of a revocation hearing, it should be treated in some respects as equivalent to a criminal proceeding. These contrasting results are not as inconsistent as they may seem at first glance, but may be harmonized, to some extent, through an analysis of the principles underlying the respective doctrines. Although revocation hearings often present both exclusionary rule and collateral estoppel problems, these are essentially distinct legal concepts.