Trauma causes sustained elevation of soluble tumor necrosis factor receptors.

BACKGROUND: Soluble tumor necrosis factor receptors (sTNF-R) are thought to modulate the systemic effects of tumor necrosis factor (TNF) by binding to serum TNF and preventing its interaction with target organs. Recently, it has been shown that traumatic injury causes the early release of the soluble forms of the 55 and 75 kDa membrane receptors for TNF. This study was done to determine the magnitude of TNF receptor elevation after trauma, to delineate the duration of this elevation, and to determine if sTNF-R levels correlate with severity of injury and outcome. STUDY DESIGN: One hundred injured patients treated at a Level I Trauma Center were included in the study (74 males, 26 females, mean age of 29.4 years [range of ten to 72 years], mean injury severity score of 16.8 [range of zero to 75]). Serum samples were drawn from these patients beginning within one hour of injury and continuing for as many as 15 days. Samples were analyzed using polyclonal ELISA assays for TNF and sTNF 55 and 75 kDa receptor levels; control levels of receptor were determined from healthy volunteers. RESULTS: Tumor necrosis factor was not measurable, but trauma caused immediate elevation of both receptor levels (within one hour of injury). Receptor levels remained elevated for as many as 15 days after injury. Late variations in levels were related to complications, that is, hypoxia, infection, and sepsis. Levels were significantly more elevated in critically ill patients and nonsurvivors. CONCLUSIONS: We conclude that sTNF-R levels are significantly elevated after trauma, in the absence of measurable TNF. Levels are elevated for variable periods of time, which seem to depend on the severity of injury and complications.

A method to determine the adequacy of resuscitation using tissue oxygen monitoring.

The change in tissue PO2 in response to an increased inspired O2 challenge may be related to the state of cellular oxygenation, and hence the adequacy of resuscitation. To test this hypothesis, we measured tissue PO2 during inspired O2 challenges in 29 injured patients during acute resuscitation or intensive care unit monitoring. The O2 challenge test had 100% sensitivity and specificity in detecting flow-dependent O2 consumption in invasively monitored patients in the intensive care unit. During acute resuscitation, 60% of patients had negative initial O2 challenge test results, indicating that flow-dependent O2 consumption might have been present. Of nine such patients, five had subsequent positive O2 challenge test results after fluid resuscitation, indicating successful resuscitation. Four patients (27% of acute resuscitations), however, had repeatedly negative findings, possibly indicating persistent inadequate cellular oxygenation despite fluid resuscitation. Other commonly measured variables did not differentiate these patients. Monitoring of tissue PO2 during an inspired O2 challenge may be a useful test for determining the adequacy of resuscitation from hypovolemic shock.

Emergency thoracotomy with lung resection following trauma.

Over a 7-year period, 9443 trauma patients were evaluated with 2934 (31%) sustaining chest trauma. Of these, 347 (12%) patients required thoracotomy, with 12 patients undergoing emergency lung resection. Mean age was 23.1 years with mean Injury Severity Score of 32. Mechanism of injury was blunt in three (25%), gunshot wound in seven (58%), and stab wound in two (17%). Associated injuries included head injury in two (17%), intra-abdominal injury requiring laparotomy in four (33%), cardiac injury in three (25%), and great vessel injury in one (8%). Indications for operation included persistent hemorrhage in 11 and suspected tracheobronchial disruption in one. Non-anatomic lung resection was performed in five patients, lobectomy in three patients, and pneumonectomy in four patients. Overall mortality was 33 per cent: 20 per cent for non-anatomical lung resection, 33 per cent for lobectomy, and 50 per cent for pneumonectomy. All survivors fully recovered except for one patient with an associated head injury. Our experience supports the selective use of lung resection, including pneumonectomy, to immediately control hemorrhage and to impact survival in severe chest trauma.

Orotracheal intubation in trauma patients with cervical fractures.

OBJECTIVE: To evaluate orotracheal intubation with in-line stabilization of the cervical spine for emergency airway treatment of trauma patients with cervical spine injuries. DESIGN: Of 7518 trauma patients examined, 81 patients with cervical spine injuries received emergency orotracheal intubation. All intubations were performed by experienced anesthesiologists, with a separate individual maintaining in-line stabilization. Neurologic examination was documented before and after intubation. RESULTS: Peripheral neurologic deficit was present from the outset in 20 patients. There were unstable cervical fractures in 38 patients with no neurologic deficit. Twenty-three patients were neurologically intact with fractures that were later judged stable. In no instance was there a deterioration of neurologic status following intubation. Peripheral neurologic deficits improved after intubation in four patients. CONCLUSION: Orotracheal intubation, performed with manual in-line stabilization by trained and experienced personnel, is a safe emergency procedure in patients with cervical fractures.