A protocol for the initial management of unstable pelvic fractures.

The initial management of life-threatening hemorrhage associated with severe pelvic fractures has long been a source of debate. A review of the literature reveals that many advocate emergent orthopedic external fixation (EX-FIX) for severe pelvic fractures, whereas others claim greater success with angiographic embolization (ANGIO) as the first line of treatment. Although many have attempted to classify management options by fracture pattern, to date there has been no prospective trial comparing outcomes for each method of treatment. We offer a prospective study of all pelvic fracture patients admitted to our Level I trauma center between July 1994 and July 1995. Patients were classified according to fracture pattern and degree of hemodynamic instability. Those with primarily anterior pelvic ring fractures underwent emergent EX-FIX for control of hemorrhage, whereas those with primarily posterior pelvic ring fractures underwent emergent ANGIO to control hemorrhage. We found that blood product requirements and hospital stay were similar in each group. However, the complication rate was higher in patients who underwent initial emergency EX-FIX, primarily because of failure to adequately control hemorrhage. We conclude that patients with anterior-posterior compression type 2 and 3, lateral compression type 2 and 3, or vertical shear injuries, who are hemodynamically unstable as a result of their pelvic fracture, should undergo immediate ANGIO if laparotomy is not indicated. If laparotomy is indicated, EX-FIX should be placed intraoperatively, followed by postoperative ANGIO.

Speed and efficiency in the resuscitation of blunt trauma patients with multiple injuries: the advantage of diagnostic peritoneal lavage over abdominal computerized tomography.

BACKGROUND: The difference in speed, efficiency, and safety between diagnostic peritoneal lavage (DPL) and abdominal computerized tomography in the evaluation of adult blunt trauma patients with multiple injuries was investigated. METHODS: A prospective protocol was analyzed. Adult blunt trauma patients admitted to a Level I trauma center in 1994 were examined. Registry and chart data were used. Patients admitted before the institution of the protocol (January 1-June 30, 1994) were compared with those admitted afterward (July 1-December 31, 1994). Time spent in the emergency department before definitive placement or surgical intervention was studied. RESULTS: Patients in the second period, when DPL was used more frequently, spent significantly less time in the emergency department and radiology. No missed injuries were identified in either group. The percentages of nontherapeutic laparotomies were similar between the two groups. Cost was significantly lower in the group that underwent DPL. CONCLUSION: Patients with severe head injury, open fractures, or any evidence of hemodynamic instability are better served by DPL as the primary diagnostic modality. Its sensitivity and specificity are equivalent to those of computerized tomography; this facilitates evaluation and allows for simultaneous procedures and quicker initiation of definitive treatment.

Interhospital versus direct scene transfer of major trauma patients in a rural trauma system.

The purpose of organized trauma systems is to ensure the expeditious transfer of seriously injured patients to the facility best equipped to care for their injuries. Patients are referred to our trauma center, either by ambulance or helicopter, directly from the scene or through interhospital transfer. We examined the difference in outcome between those patients sent directly to the trauma center versus those seen at other hospitals and subsequently referred to the trauma center. Our hypothesis was that a delay at the referring hospital is detrimental to patient outcome. Adult trauma patients with Injury Severity Scores > 15, treated over 16 months from July 1, 1994, to October 31, 1995, were studied. Patients who survived 24 hours experienced significantly shorter intensive care unit (14 vs 10 days; P < 0.05) and hospital (21 vs 16 days; P < 0.05) lengths of stay when taken directly to the trauma center. In addition, there were significantly fewer deaths in patients with a probability of survival > 0.5 and a slightly lower overall mortality in those patients who survived at least 1 day. This study demonstrates that patients with major trauma taken directly to the trauma center had shorter hospital and intensive care unit stays and lower mortality. The study supports the paradigm that, when possible, major trauma patients should be sent to trauma centers directly from the injury scene.

Coagulopathy in severe closed head injury: is empiric therapy warranted?

Closed head injuries account for a significant portion of the morbidity and mortality following blunt trauma. Severe closed head injuries can be complicated by the development of a coagulopathy that may worsen blood loss and delay invasive neurosurgical procedures. Awaiting the results of coagulation studies prior to initiating treatment of such a coagulopathy introduces an inherent delay that may allow worsening of the coagulation disturbance and negatively influence outcome. This study was undertaken to see if a subgroup of patients with severe closed head injuries had a high probability of developing a coagulopathy and would warrant empiric treatment with fresh frozen plasma. The records of adult patients admitted to our trauma center with a Glasgow coma score (GCS) of < or = 8 and an extracranial abbreviated injury score of < or = 2 during a 9-month period were reviewed. Patients with penetrating trauma or whose altered level of consciousness was due to sedation or shock were excluded. The presence of coagulation abnormalities was determined according to prothrombin time and partial thromboplastin time obtained on admission. The time to invasive neurosurgical procedures for both coagulopathic and noncoagulopathic patients was determined as well as the mean number of hospital days, intensive care unit days, and the mortality for each group. Eighty-one per cent of the patients with a GCS < or = 6 were coagulopathic on admission, and all patients with a GCS of 3 or 4 were coagulopathic. In contrast, no patient with a score of 7 or 8 was coagulopathic. The coagulopathic patients tended to have a higher mortality than the noncoagulopathic patients (53 versus 22%) as well as longer intensive care unit and hospital stays. The mean time to neurosurgical intervention for the coagulopathic group was 226.0 +/- 190.9 minutes versus 84.8 +/- 38.4 minutes for the noncoagulopathic patients. We conclude that patients with closed head injuries who present with a GCS of 6 or less are candidates for empiric treatment for coagulopathy. Such treatment will negate the delay of awaiting coagulation studies. Whether or not such therapy shortens the interval between admission and neurosurgical procedures or alters outcome will require prospective study.

GlbN (cyanoglobin) is a peripheral membrane protein that is restricted to certain Nostoc spp.

The glbN gene of Nostoc commune UTEX 584 is juxtaposed to nifU and nifH, and it encodes a 12-kDa monomeric hemoglobin that binds oxygen with high affinity. In N. commune UTEX 584, maximum accumulation of GlbN occurred in both the heterocysts and vegetative cells of nitrogen-fixing cultures when the rate of oxygen evolution was repressed to less than 25 micromol of O2 mg of chlorophyll a(-1) h(-1). Accumulation of GlbN coincided with maximum synthesis of NifH and ferredoxin NADP+ oxidoreductase (PetH or FNR). A total of 41 strains of cyanobacteria, including 40 nitrogen fixers and representing 16 genera within all five sections of the cyanobacteria were screened for the presence of glbN or GlbN. glbN was present in five Nostoc strains in a single copy. Genomic DNAs from 11 other Nostoc and Anabaena strains, including Anabaena sp. strain PCC 7120, provided no hybridization signals with a glbN probe. A constitutively expressed, 18-kDa protein which cross-reacted strongly with GlbN antibodies was detected in four Anabaena and Nostoc strains and in Trichodesmium thiebautii. The nifU-nifH intergenic region of Nostoc sp. strain MUN 8820 was sequenced (1,229 bp) and was approximately 95% identical to the equivalent region in N. commune UTEX 584. Each strand of the DNA from the nifU-nifH intergenic regions of both strains has the potential to fold into secondary structures in which more than 50% of the bases are internally paired. Mobility shift assays confirmed that NtcA (BifA) bound a site in the nifU-glbN intergenic region of N. commune UTEX 584 approximately 100 bases upstream from the translation initiation site of glbN. This site showed extensive sequence similarity with the promoter region of glnA from Synechococcus sp. strain PCC 7942. In vivo, GlbN had a specific and prominent subcellular location around the periphery of the cytosolic face of the cell membrane, and the protein was found solely in the soluble fraction of cell extracts. Our hypothesis is that GlbN scavenges oxygen for and is a component of a membrane-associated microaerobically induced terminal cytochrome oxidase.

Myoglobin in a cyanobacterium.

Myoglobin was found in the nitrogen-fixing cyanobacterium Nostoc commune. This cyanobacterial myoglobin, referred to as cyanoglobin, was shown to be a soluble hemoprotein of 12.5 kilodaltons with an amino acid sequence that is related to that of myoglobins from two lower eukaryotes, the ciliated protozoa Paramecium caudatum and Tetrahymena pyriformis. Cyanoglobin is encoded by the glbN gene, which is positioned between nifU and nifH-two genes essential for nitrogen fixation-in the genome of Nostoc. Cyanoglobin was detected in Nostoc cells only when they were starved for nitrogen and incubated microaerobically.