J Trauma
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Tension pneumoperitoneum is a known although rare complication of barotrauma, which can accompany blast injury. We report two patients who suffered from severe pulmonary blast injury, accompanied by tension pneumoperitoneum, and who were severely hypoxemic, hypercarbic, and in shock. ⋯ Several mechanisms to explain this improvement are suggested. In such cases the release of the tension pneumoperitoneum is mandatory, and laparotomy with delayed closure can be contemplated.
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Lactate production after hemorrhagic shock may be produced by aerobic glycolysis, which has been linked to activity of the Na+/K+ pump in smooth muscle and other tissues. We tested whether increased muscle Na+/K+ pump activity after shock was linked to increased lactate production. ⋯ Hypoxia is unlikely to account for increased muscle lactate production after resuscitated hemorrhagic shock, because high lactate production persists under well-oxygenated incubation conditions. Inhibition of shock-induced lactate production by ouabain indicates energetic coupling of glycolysis to the Na+, K+-ATPase.
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Complete resuscitation from shock is one of the primary concerns of the surgeon taking care of injured patients. Traditionally, the return to normalcy of blood pressure, heart rate, and urine output has been the end point of resuscitation. ⋯ We believe that the current data support the use of lactate, base deficit, and/or gastric intramucosal pH as the appropriate end points of resuscitation of trauma patients. The goal should be to correct one or all of three of these markers of tissue perfusion to normal within the initial 24 hours after injury.
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Comparative Study
Cytokines and adhesion molecules in elective and accidental trauma-related ischemia/reperfusion.
The major pathophysiologic role of cytokines such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-1, and IL-6, as well as of the (soluble) adhesion molecules ICAM-1 and E-selectin, has been identified using different experimental models of ischemia/reperfusion injury. Moreover, in intensive care management, evaluation of these agents as diagnostic or prognostic tools is of great interest in ischemia/reperfusion injury caused by surgical or accidental trauma. For this reason, inflammatory mediators including those mentioned above were investigated in three different groups of surgical patients. ⋯ The release of cytokines and soluble adhesion molecules into the circulation correlates well with the degree of trauma (elective surgery vs. accidental multiple trauma), depending on the extent of the associated ischemia/reperfusion injury. Both groups of mediators are also clearly related to the development of MOD in patients with multiple injuries with generalized ischemia/reperfusion injury caused by hemorrhagic shock. They may be predictive of patients at risk for MOD when measured early in the posttraumatic period.
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Although computed tomography is used widely in evaluating injuries from blunt abdominal trauma, grading of injuries does not reliably predict the need for intervention. Objective reporting is essential to evaluate accuracy and facilitate patient triage. We established and tested a five-point grading system for overall severity of injury. ⋯ Standardizing reporting of injuries enhances accuracy, and grading eliminates equivocation. Diagnostic certainty in computed tomography of blunt abdominal trauma is reduced by motion and metallic artifacts.