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Objective: This retrospective study evaluated all trauma patients who were admitted to intensive care unit in Turku University Central Hospital, Finland in 2000-2004., Methods: We reviewed details of demographic factors, injury mechanism, treatment details, and the overall recovery of patients after the hospital episode., Results: A total of 427 trauma patients were identified, 66% of these were severely injured (ISS > 15). 79% of patients were men. The median age of 44 years. The most frequent injury type was road traffic accidents, leisure-time accidents and injury mechanism a high-energy blunt trauma. Head injuries were the most frequently diagnosed severe injury and 59% of the patients were multiple traumatized., Conclusions: Current results suggest that the overall survival of these patients is satisfactory, although, the head and cervical spine injuries are still often related to compromised prognosis. Despite the improvements in morbidity and mortality of these patients during last decades, still almost every tenth of trauma patient treated in the ICU dies to the complications of the injury., (Copyright © 2017 by Taiwan Society of Emergency Medicine & Ainosco Press. All Rights Reserved.)

Background: The aim of this prospective cohort study was to assess the incidence and characteristics of acute myocardial infarction in patients undergoing surgery for acute hip fracture., Methods: A consecutive cohort of patients (n = 200, 68 men) referred to acute surgical correction of hip fracture was studied. Troponin T (TnT) measurements and electrocardiographic (ECG) recordings were performed at admission, before operation, and on the first and 2nd postoperative days, which were used for diagnosis., Results: The age of the patients ranged from 32 to 98 years (mean, 80.8 years), and 65 patients had a history of coronary artery disease. A significant rise in TnT as a sign of myocardial infarction was observed in 71 patients (35.5%), and 25 of them had a TnT elevation exceeding five times the upper normal limit. TnT elevation was observed in 36 patients (51%) already before surgery. Seven patients (10%) had ST elevation myocardial infarction, 23 patients (32%) had new ST depressions, and 21 patients (30%) had no new ST segment changes in the serial electrocardiographic recordings. In 40 patients (56%), the perioperative myocardial infarction was the first manifestation of coronary artery disease. Multivariate logistic regression revealed that old age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.10; p = 0.002), earlier revascularization (OR, 3.29; 95% CI 1.12-9.73; p = 0.03), and heart failure (OR, 2.42; 95% CI 1.04-5.61; p = 0.04) were independent predictors of TnT elevation. Majority of myocardial infarctions were asymptomatic or unrecognized. Evidence-based medications of myocardial infarction were seldom started and cardiologist was consulted in 12 patients (16.9%)., Conclusion: Patients with hip fracture often develop asymptomatic and clinically unrecognized perioperative myocardial infarctions. Earlier diagnosis and appropriate treatment of cardiac infarction may improve survival of hip fracture patients., Level of Evidence: Epidemiologic study, level III.

A prospective long-term follow-up study of bioactive glass (BAG)-S53P4 and autogenous bone (AB) used as bone graft substitutes for posterolateral spondylodesis in treatment of degenerative spondylolisthesis during 1996 to 1998 was conducted. The surgical procedure was a standardized instrumented posterolateral fusion that used USS/VAS. BAG was implanted on the left side of the fusion bed and AB on the right side. The operative outcome was evaluated on x-rays and computed tomography scans, and a clinical examination was also performed. Seventeen patients (12 women, 5 men) participated in the 11-year follow-up. The mean Oswestry Disability Index score at the follow-up was 21 (range 0 to 52), compared with 49 (range 32 to 64) at the preoperative time. A solid bony fusion was seen on computed tomography scans on the AB side in all patients and on the BAG side in 12 patients. The fusion rate of all fusion sites (n=41) for BAG as a bone substitute was 88% at the L4/5 level and 88% at the L5/S1 level. The use of BAG as a bone graft extender can be considered as a good alternative in spinal surgery in the future.

Background: Patients undergoing intramedullary nailing of long bone fractures have pathologically altered pulmonary vascular tone, right heart strain, and transient impairment of pulmonary gas exchange. The purpose of this study was to examine the acute differences in cardiopulmonary variables between reamed and unreamed nailing techniques in 18 (9 + 9) healthy patients with unilateral femoral shaft fractures., Methods: Intramedullary nailing was performed under general anesthesia within 12 hours after the trauma. For blood sampling, recording, and measurements, the patients were cannulated with radial artery and pulmonary artery catheters. Changes in central hemodynamics and oxygenation were studied pre-, peri-, and postoperatively for 16 to 20 hours., Results: Abnormally high pulmonary shunting (23 +/- 12% in the reamed and 27 +/- 11% in the unreamed group) was observed before the operation. The trends of all variables were very similar in both groups except for the last phase in which the mixed venous oxygen saturation tended to be lower (65 +/- 8 vs. 70 +/- 5%) and the oxygen consumption index was higher (186 +/- 21 vs. 151 +/- 20 mL/min/m) in the unreamed group than in the reamed group (p < 0.05). The timepoints most strenuous to the heart were at the end of operation and in the recovery room., Conclusions: The unreamed intramedullary nailing technique does not offer any advantage in cardiopulmonary variables over the reamed technique. In both groups, there was considerable deviation in over 10 cardiopulmonary variables from normal reference values during the study. We suggest the use of invasive monitoring on patients with a long bone fracture and poor preoperative oxygenation or a history of cardiopulmonary or cardiac disease.

Background: It is known that posterior malleolar fracture is often associated with tibial diaphyseal fractures. However, in literature there are very few studies on tibial shaft fractures with respect to posterior malleolus fragment. We hypothesized that the incidence of posterior malleolar fracture is higher than in previous studies., Methods: A total of 74 closed tibial shaft fractures were treated with intramedullary nailing in Turku University Central Hospital between January 1994 and December 1998. There were 55 men and 19 women, with a mean age of 39 years (range, 16 to 58 years). Two cases were excluded and 72 tibial shaft fractures were analyzed retrospectively., Results: Posterior malleolar fracture was observed in 18 cases (25.0%). Only 10 were observed preoperatively in plain films, seven were detected postoperatively and one was not detected at all during the treatment. Retrospectively, all 18 posterior malleolar fractures were detectable in preoperative plain films., Conclusion: A fracture of the posterior malleolus was involved in every fourth tibial diaphyseal fracture. The fractures of the posterior malleolus were always detected in preoperative plain films and should be suspected, especially in cases of low-energy spiral distal tibial diaphyseal fractures. We recommend additional plain films to be taken at the ankle region to better visualize these fractures.

We evaluated the effect of hyperbaric oxygen (HBO2) therapy on tibialis posterior (TPA), dorsalis pedis (DPA), and sum (TPA + DPA) arterial peak signals, as well as transcutaneous oxygen (PtcO2) tension and leg skin temperature (T) after intramedullary nailing of tibial shaft fractures. Twenty consecutive patients with closed and simple tibial shaft fractures treated with reamed intramedullary nailing were assigned randomly to HBO2 or control groups. HBO2 therapy was given postoperatively at 2.5 atm abs pressure for 90 min daily for a total of five treatments. The first HBO2 therapy was given 1 h after the operation. In both groups, measurements were performed preoperatively, 30 min and 6 h postoperatively, and on the following 5 days. There was a statistically significant improvement in TPA values in the nailed legs in the HBO2 treatment group after the first postoperative day, and these values remained at a significantly higher level until the end of the study when compared to the nailed legs in the control group. Further, there was a statistically significant improvement in PtcO2 values in the nailed legs in the HBO2 group after the third HBO2 treatment. However, there were no statistically significant differences in DPA and TPA + DPA values within or between the nailed legs in HBO2 and control groups. HBO2 therapy seemed to decrease the skin temperature of the nailed legs, but this alteration was not statistically significant. In addition to the clearly documented advantages in the management of crush injuries and compartment syndromes, HBO2 therapy has a positive effect on the perfusion parameter (TPA) and PtcO2 in patients with low energy, intramedullary nailed simple tibial shaft fractures. The improvement in TPA and PtcO2 values may result from the vasoconstrictive and edema reductive effect on HBO2 with concomitant inhibition of inflammatory reactions with slight cooling.

Backgrounds and Aims: To measure noninvasively the effect of circulative changes caused by fracture and intramedullary nailing on tibialis posterior (TPA), dorsalis pedis (DPA) and sum (TPA + DPA) arterial peak signals, transcutaneous oxygen tension (PtcO2) as well as local skin temperature (T) in patients with tibial shaft fractures., Patients, Material and Methods: A total of thirty tibias consisting of ten closed, reamed, intramedullary nailed simple tibial shaft fractures (Type AO A), ten contralateral tibias and as controls, ten intact tibias of healthy volunteers. The measurements took place one day before and immediately after nailing, six hours later and during five days postoperatively. The values were compared to those of contralateral legs and to control legs., Results: In the nailed legs the mean TPA and PtcO2 remained at a significantly lower level compared to the contralateral legs throughout the study (p < 0.003 in both cases). However, the alterations in DPA and TPA + DPA were not statistically significant. Additionally, skin temperature on the fracture site was averagely 3 degrees C warmer than that of the contralaterals (p < 0.001). All the measured parameters were statistically significantly higher in control legs compared to contralateral legs. There were no statistically significant differences between pre- and postoperative values in any measured parameters., Conclusion: The changes in the local tissue perfusion variables measured in the present study reflect rather the injury mechanism itself than the effect of reaming and intramedullary nailing in simple tibial fractures. Additionally, arterial circulation was reduced in the contralateral legs.

Objective: To evaluate the in vivo production of prostacyclin and thromboxane A2 during the initial phase of experimental fat embolism as assessed, respectively, by determinations of urine 2,3-dinor-6-ketoprostaglandin F1alpha and 11-dehydrothromboxane B2 excretion., Design: Randomized, controlled trial., Setting: Animal laboratory., Subjects: Twenty seven domestic pigs, weighing 24 to 31 kg., Interventions: All pigs were anesthetized and mechanically ventilated during the experiment. Eighteen pigs were subjected to an intracaval infusion of 10% allogeneic bone marrow suspension at a dose of 100 mg/kg over 5 mins. Nine pigs received only bone marrow suspension (fat embolism group). Nine pigs were given an intravenous bolus of aspirin (300 mg) 1 hr before the bone marrow suspension infusion. After the induction of fat embolism, intravenous aspirin was administered at a dose of 150 mg/hr for 2 hrs (aspirin-treated group). Nine pigs were infused with saline (control group)., Measurements and Main Results: In the fat embolism group, cardiac index decreased within 30 mins, while mean arterial pressure remained unchanged. Central venous pressure and pulmonary artery occlusion pressure remained relatively stable over time in the animals with fat embolism. Mean pulmonary arterial pressure and pulmonary vascular resistance increased immediately after the bone marrow suspension infusion from 23 +/- 0.8 (SEM) to 34 +/- 1.3 mm Hg and from 305 +/- 28 to 585 +/- 45 dyne x sec/cm5, respectively; these variables remained increased throughout the study period. Simultaneously, pulmonary shunt in the fat embolism group increased persistently from the baseline of 12.3 +/- 2.8%, and reached its maximum of 26.1 +/- 4.8% at the end of the experiment. Instant and gradual decreases in PaO2 (from 95 +/- 4 to 67 +/- 5 torr [12.6 +/- 0.5 to 8.9 +/- 0.7 kPa]), hemoglobin oxygen saturation (from 97.2 +/- 0.4 to 91.8 +/- 1.8%), and oxygen delivery (from 16.3 +/- 1.0 to 12.6 +/- 0.4 mL/min/kg) were observed in the fat embolism group. In the bone marrow suspension-infused animals, urine 2,3-dinor-6-ketoprostaglandin F1alpha excretion increased transiently from 451 +/- 63 up to 1466 +/- 499 pg/micromol creatinine, while urine 11-dehydrothromboxane B2 excretion increased transiently from 385 +/- 36 up to 2307 +/- 685 pg/micromol creatinine. In the aspirin-treated animals, urinary excretion of these prostanoid metabolites was reduced by 81% and 88%, respectively. The changes in mean pulmonary arterial pressure and PaO2 were ameliorated, and the alterations in pulmonary shunt and SaO2 were abolished in the animals with aspirin treatment., Conclusions: Pulmonary hypertension, increased pulmonary vascular tone, and increased pulmonary shunt are hallmarks of the present fat embolism model. These hemodynamic responses may, at least partly, be related to the changed balance between prostacyclin and thromboxane A2 production.

Objective: To investigate the catalytic activity of phospholipase A2 in serum during the early phase of experimental fat embolism., Design: Randomised controlled experimental study., Setting: Animal laboratory, Finland., Subjects: 18 domestic pigs weighing 25-31 kg., Interventions: Allogeneic bone marrow suspension at a dose of 100 mg/kg was infused intracavally in 9 anaesthetised, mechanically ventilated, and haemodynamically monitored pigs; 9 control pigs received saline., Main Outcome Measures: Central haemodynamics, blood gases, catalytic activity of phospholipase A2., Results: In the fat embolism group, there were significant increases in mean pulmonary arterial pressure (p < 0.001), pulmonary vascular resistance (p < 0.001) and pulmonary shunting (p < 0.05) and simultaneously, systemic oxygenation was significantly impaired. The animals with fat embolism developed gradual fever and leucocytosis, whereas the catalytic activity of phospholipase A2 remained relatively unchanged., Conclusion: In this experimental model the measurement of serum phospholipase A2 activity does not provide a useful tool for the early detection of experimental fat embolism.

Objective: To investigate the acute effects of experimental fat embolism on splanchnic and peripheral perfusion and oxygenation in pigs., Design: Randomized, controlled trial., Setting: Animal laboratory., Subjects: Eighteen domestic pigs, weighing 25 to 31 kg., Interventions: The 18 pigs were randomized to either the fat embolism or control groups. Nine anesthetized and mechanically ventilated pigs were intracavally infused with a 10% allogeneic bone marrow suspension at a dose of 100 mg/kg over 5 mins (the fat embolism group); nine control pigs received normal saline in the same volume and speed (control group)., Measurements and Main Results: Mean pulmonary arterial pressure, pulmonary vascular resistance, and pulmonary shunt increased, and PaO2 decreased immediately after the bone marrow suspension infusion. In the fat embolism animals, oxygen delivery decreased, oxygen content difference widened, and total oxygen consumption remained high, indicating enhanced oxygen extraction. Further, superior mesenteric artery blood flow and mesenteric oxygen delivery decreased, while intramucosal pH in the small bowel was stable. Subcutaneous PO2 decreased in both groups, whereas transcutaneous PO2 decreased only in the animals receiving bone marrow suspension. Skin red cell flux showed no significant changes., Conclusions: The present model of fat embolism results in significant impairment in systemic oxygenation. Despite this fact, the intestinal oxygenation remains unaffected probably due to sufficient compensatory mechanisms. Transcutaneous PO2 measurements may provide a useful index for early detection of fat embolism.

Background and Methods: Renal cortical and serum carnitine concentrations were studied in seven anesthetized beagle dogs in which acute circulatory collapse was induced by an iv injection of Escherichia coli endotoxin, 0.5 mg/kg given over 15 mins. Four controls received normal saline., Results: The endotoxin injection resulted in cardiac depression, renal hypoperfusion, acidosis with a decrease in urinary output, and hematuria. Arterial and renal venous free carnitine concentrations increased significantly in endotoxemia during the 5-hr experiment, but remained low and unchanged in the controls. Circulating acyl-carnitine concentrations underwent no essential changes in either group. Total, free, and acyl-carnitine concentrations decreased in endotoxic renal tissue., Conclusions: These data suggest that endotoxemia decreases carnitine concentrations in the renal cortex, but increases free carnitine concentrations in the circulation.

Central and renal hemodynamics, renal oxygenation, renal uptake of glucose, lactate, fats, renal carnitine metabolism, arterial atrial natriuretic factor (ANF) and catecholamine release were studied in sixteen adult beagle dogs during pentobarbital anesthesia. Renal cortical oxygen tension was recorded by means of a Silastic tonometer. Twelve animals underwent acute circulatory shock induced by intravenous Escherichia coli endotoxin 0.5 mg/kg. Four control dogs received normal saline. The endotoxin infusion resulted in decreased cardiac function, renal blood flow and renal cortical PO2. The renal venous PO2 increased during the experiment. Arterial and renal venous glucose concentrations increased transiently during endotoxemia. Circulating lactate concentrations increased significantly whereas the arteriovenous lactate difference remained almost unchanged. Renal uptake of lactate and glucose were not influenced during the moderate renal hypoperfusion caused by endotoxin. Arterial free fatty acid (FFA) concentrations increased significantly 2 hours after onset of the endotoxin infusion whereas renal venous FFA levels remained rather stationary. The renal uptake of FFA increased with increasing arterial FFA concentrations. Circulating free carnitine concentrations increased significantly in endotoxin shock. Blood acyl-carnitine concentrations remained essentially unchanged. Carnitine concentrations declined significantly in endotoxic renal tissue. The arterial concentrations of ANF, epinephrine, norepinephrine and the norepinephrine metabolite 3,4-dihydroxyphenylglycol (DHPG) increased in plasma during early endotoxemia. The levels of these hormones remained very low and constant in the controls. To summarize, endotoxin injection resulted in impaired renal perfusion and oxygenation, increased uptake of free fatty acids and unchanged uptake of glucose, lactate, glycerol and triglycerides. Decreased renal carnitine concentrations were observed. Arterial plasma concentrations of ANF and catecholamines increased in endotoxin shock.

Circulatory changes and renal uptake of free fatty acids (FFA), glycerol and triglycerides were studied in ten adult beagle dogs during pentobarbital anesthesia. Six dogs were injected intravenously with E. coli endotoxin 0.5 mg/kg over 15 min and four control dogs received saline. Cardiac depression, hypotension, renal hypoperfusion and acidosis resulted in endotoxin shock. Arterial FFA concentrations increased significantly 2 hours after onset of shock whereas renal venous FFA levels remained rather stationary during the 5-hour study. Arterial and renal venous glycerol levels increased during the first two hours and decreased thereafter. Unchanged triglyceride levels were observed in endotoxin shock. The renal uptake of FFA increased with increasing arterial FFA concentrations. Net renal uptake of glycerol and triglycerides were observed as well. Blood concentrations and renal uptake of fats and glycerol remained relatively stationary in the control animals through the observation period. These data suggest renal ability to consume FFA, glycerol and triglycerides during endotoxin shock.

Renal hemodynamics and oxygen metabolism were studied in eight adult beagle dogs during shock induced with an iv infusion of Escherichia coli endotoxin. Renal blood flow (RBF) and renal cortical PO2 decreased profoundly during the 15-min endotoxin infusion. RBF increased sharply immediately after cessation of infusion, but soon declined and remained depressed throughout the rest of the 4-h experiment. The renal cortical PO2 remained depressed for approximately 2 h and then gradually increased toward the baseline level. Endotoxin infusion was followed by an increased renal PvO2 and a decreased renal arteriovenous oxygen difference. Renal oxygen consumption declined abruptly during endotoxin infusion, but increased toward the end of the experiment. These results suggest impaired tissue oxygenation and possibly increased oxygen shunting in the kidney during endotoxin shock.

Changes in arterial plasma levels of atrial natriuretic factor and catecholamine release were studied in 11 beagle dogs during pentobarbital anesthesia. Seven dogs were injected intravenously with Escherichia coli endotoxin, 0.5 mg/kg over 15 min. Four control dogs received only saline solution. The endotoxin injection resulted in cardiac depression,, hemoconcentration, acidosis and renal hypoperfusion. The central venous pressure remained relatively unchanged in both groups during the 2-hour study. The concentrations of epinephrine, norepinephrine and the norepinephrine metabolite 3,4-dihydroxyphenylglycol increased in arterial plasma during the acute hypodynamic endotoxin shock. In the control dogs the levels of these hormones remained very low and constant. Increased circulating levels of atrial natriuretic factor were observed in endotoxin shock with renal hypoperfusion, unchanged central venous pressure and no concomitant tachycardia.

Renal metabolism of glucose and lactate was studied in ten adult beagle dogs during pentobarbital anesthesia. Six dogs were submitted to hypodynamic shock by means of an intravenous bolus injection of Escherichia coli endotoxin, 0.5 mg/kg over 15 min. Four dogs received only saline solution and served as controls. Sudden cardiac depression, hypotension and moderate renal hypoperfusion were observed in the endotoxin-injected animals. Acidosis and oliguria also occurred during the 5-hour study. Arterial and renal venous glucose concentration increased transiently during the early phase of endotoxin shock. In the control group glucose levels increased slightly by the end of the experiment. Despite marked hyperlactatemia in the endotoxin group, the arteriovenous lactate difference remained almost unchanged. Renal uptake of lactate and output of glucose were not influenced during the moderate renal hypoperfusion caused by endotoxin.