What injuries should we expect in the emergency room?

INTRODUCTION: Beside serious and potentially fatal injuries, the majority of pediatric trauma patients present with minor injuries to emergency departments. The aim of this study was to evaluate age-related injury pattern, trauma mechanism as well as the need for surgery in pediatric patients. PATIENTS AND METHODS: Retrospective Study from 01/2008 to 12/2012 at a level I trauma center. All patients <18years of age following trauma were included. Injury mechanism, injury pattern as well as need for surgery were analyzed according to different age groups (0-3 years, 4-7 years, 8-12 years and 13-17 years). Major injuries were defined as fractures, dislocations and visceral organ injuries. Minor injuries included contusions and superficial wounds. RESULTS: Overall, 15300 patients were included (59% male, median age 8 years). A total of 303 patients (2%) were admitted to the resuscitation room and of these, 69 (0.5% of all patients) were multiply injured (median Injury Severity Score (ISS) 20 pts). Major injuries were found in 3953 patients (26%). Minor injuries were documented in 11347 patients (74%). Of those patients with a major injury, 76% (2991 patients) suffered a fracture, 3% (132 patients) a dislocation and 3% (131 patients) an injury of nerves, tendons or ligaments. The majority of fractures were located in the upper extremity (73%) (elbow fractures 16%; radius fractures 16%; finger fractures 14%). Patients with minor injuries presented with head injuries (34%), finger injuries (10%) and injuries of the upper ankle (9%). The most common trauma mechanisms included impact (41%), followed by falls from standing height (24%), sport injuries (15%) and traffic accidents (9%). Overall, 1558 patients (10%) were operated. Of these, 61% had a major and 39% a minor injury. CONCLUSION: Almost 75% of all children, who presented to the emergency department following trauma revealed minor injuries. However, 25% suffered a relevant, major injury and 0.5% suffered a multiple trauma with a median ISS of 20. Overall, 10% had to be operated. The most frequently found major injuries were extremity fractures, with elbow fractures as the most common fracture.

I-FABP is a Novel Marker for the Detection of Intestinal Injury in Severely Injured Trauma Patients.

BACKGROUND: Intestinal injury is a rare injury in multiply traumatized patients, and its diagnosis remains difficult. Delayed diagnosis of an intestinal injury increases the risk of sepsis, multiple organ failure and mortality. The intestinal fatty acid-binding protein (I-FABP) is solely expressed in the intestine and is released extracellulary after tissue damage. This study evaluates the validity of I-FABP as an early biomarker to detect an abdominal injury and particularly an injury to the intestine. PATIENTS AND METHODS: Patients with an Abbreviated Injury Scale (AIS) score for abdominal body region (AIS abdomen) ≥3 were included in this study from 07/2006 to 12/2014. Of those, ten patients retrospectively had an intestinal injury (int. injury). According to the Injury Severity Score and the AIS abdomen, corresponding patients with an abdominal injury but without an intestinal injury (no int. injury) were included for matched-pair analysis. Twenty healthy volunteers served as controls. Plasma I-FABP levels were measured at admission to the emergency room and up to 10 days daily (d1-d10). RESULTS: Median I-FABP levels were significantly higher in the "int. injury" group compared to the "no int. injury" group [2101.0 pg/ml (IQR = 1248.1-4117.8) vs. 351.4 pg/ml (IQR = 287.6-963.3), p < 0.05]. Furthermore, I-FABP levels of both groups were significantly higher compared to the control group [Ctrl: 127.2 pg/ml (IQR = 57.4-310.6), p < 0.05]. The time course of I-FABP levels showed a peak on the day of admission and a decline to the control levels in the further post-traumatic course. The development of complications such as single- or multi-organ failure, sepsis, acute respiratory distress syndrome, pneumonia and mortality was higher in the "int. injury" group; however, this difference was not statistically significant. CONCLUSION: This study confirmed our previous observation that I-FABP might be used as a suitable early biomarker for the detection of abdominal injuries in general. In addition and more specific, I-FABP may be a useful and promising parameter in the diagnosis of intestinal injuries.

Characterization of blunt chest trauma in a long-term porcine model of severe multiple trauma.

Chest trauma has a significant relevance on outcome after severe trauma. Clinically, impaired lung function typically occurs within 72 hours after trauma. However, the underlying pathophysiological mechanisms are still not fully elucidated. Therefore, we aimed to establish an experimental long-term model to investigate physiological, morphologic and inflammatory changes, after severe trauma. Male pigs (sus scrofa) sustained severe trauma (including unilateral chest trauma, femur fracture, liver laceration and hemorrhagic shock). Additionally, non-injured animals served as sham controls. Chest trauma resulted in severe lung damage on both CT and histological analyses. Furthermore, severe inflammation with a systemic increase of IL-6 (p = 0.0305) and a local increase of IL-8 in BAL (p = 0.0009) was observed. The pO2/FiO2 ratio in trauma animals decreased over the observation period (p < 0.0001) but not in the sham group (p = 0.2967). Electrical Impedance Tomography (EIT) revealed differences between the traumatized and healthy lung (p < 0.0001). In conclusion, a clinically relevant, long-term model of blunt chest trauma with concomitant injuries has been developed. This reproducible model allows to examine local and systemic consequences of trauma and is valid for investigation of potential diagnostic or therapeutic options. In this context, EIT might represent a radiation-free method for bedside diagnostics.

Effects of positive blood alcohol concentration on outcome and systemic interleukin-6 in major trauma patients.

BACKGROUND: The influence of alcohol on the outcome after major trauma remains controversial. In several recent studies, alcohol has been associated with neuroprotective effects in head injuries, while others reported negative or no effects on survival and/or the in-hospital stay in major trauma patients (TP). The purpose of this study was to examine the relationship of alcohol with injury characteristics and outcome as well as to analyze possible anti-inflammatory properties in major TP. PATIENTS/METHODS: 184 severely injured TP with an Injury Severity Score (ISS) ≥16 were successively enrolled. All patients had measured blood alcohol concentration (BAC). Patients were grouped according to their positive BAC (>0.5‰, BAC) vs. <0.5‰ alcohol (no BAC) upon arrival at the emergency department (ED). Injury characteristics, physiologic parameters and outcome with respect to organ or multiple organ failure (MOF), SIRS, sepsis, pneumonia, ARDS or mortality were assessed. Systemic levels of interleukin (IL)-6 at ED were determined. RESULTS: Forty-nine TP had positive BAC without chronic alcohol abuse history and 135 patients had BAC levels below 0.5‰. Overall injury severity and age were comparable in both groups. No BAC TP received significantly higher numbers of packed red blood cells and fresh frozen plasma (transfused within the initial 24h or in total) compared to BAC TP. Organ failure, MOF, SIRS, sepsis, pneumonia, ARDS and the in-hospital mortality were not different between both groups. Trauma patients with positive BAC had significantly decreased leukocyte numbers and systemic IL-6 levels compared to no BAC group. There was a significant positive correlation between leukocyte counts and IL-6 as well as BAC and leukocytes. BAC levels did not correlate with IL-6. CONCLUSIONS: Positive BAC is associated with reduced leukocyte numbers and lowered systemic IL-6 levels at admittance indicating immune-suppressive effects of alcohol in major trauma patients.

[Pediatric multiple trauma]. / Polytrauma des Kindes.

Multiple trauma in children is rare so that even large trauma centers will only treat a small number of cases. Nevertheless, accidents are the most common cause of death in childhood whereby the causes are mostly traffic accidents and falls. Head trauma is the most common form of injury and the degree of severity is mostly decisive for the prognosis. Knowledge on possible causes of injury and injury patterns as well as consideration of anatomical and physiological characteristics are of great importance for treatment. The differences compared to adults are greater the younger the child is. Decompression and stopping bleeding are the main priorities before surgical fracture stabilization. The treatment of a severely injured child should be carried out by an interdisciplinary team in an approved trauma center with expertise in pediatrics. An inadequate primary assessment involves a high risk of early mortality. On the other hand children have a better prognosis than adults with comparable injuries.

Skin permeation and stability studies of 5-aminolevulinic acid in a new gel and patch preparation.

A new cubic gel as well as a patch system containing additional carrageenan as matrix were used as vehicles for 5-aminolevulinic acid (5-ALA). Standard diffusion experiments of 5-ALA using Franz-type diffusion cells and porcine skin were performed. Drug stability was monitored by analysing the 5-ALA content in the formulations. The analysis of 5-ALA as non-fluorescent probe was performed after chemical reaction leading to a fluorescent derivative. The 5-ALA permeation through porcine skin after 48 h was the highest from the patch formulation with 80.3% and the second highest from the cubic gel with 66.4%, however only about 40% of 5-ALA were chemical stable after 14 days storage in the patch formulation, whereas no degradation of 5-ALA was measured in the cubic gel over 90 days of observation.

Phloretin and 6-ketocholestanol: membrane interactions studied by a phospholipid/polydiacetylene colorimetric assay and differential scanning calorimetry.

The aim of this study was to investigate membrane interactions of phloretin and 6-ketocholestanol using different methods. A previously reported colorimetric assay with phospholipid/polydiacetylene (PDA) vesicles was used to examine a possible interaction of phloretin and 6-ketocholestanol with this target. During this interaction the used aggregates of lipids and conjugated PDA undergo a visible and quantifiable blue to red color transition. A positive result is indicative for a reaction response with membrane lipids of a simplified bilayer structure instead of the complex bilayer system of the stratum corneum. Results of this test confirm previous proposed membrane interactions by skin diffusion studies. Additional differential scanning calorimetry studies with 1,2-dimyristoyl-sn-glycero-3-phosphocholine (DMPC) and 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) liposomes confirm a membrane interaction and indicates that phloretin and 6-ketocholestanol interact with the lipid layer and change structural parameters. They strongly decrease the lipid phase transition temperature of DMPC and DPPC liposomes by at least about 6.6 degrees C and maximally about 13.9 degrees C which refers to a higher fluidity of the membrane.

Influence of lipophilic counter-ions in combination with phloretin and 6-ketocholestanol on the skin permeation of 5-aminolevulinic acid.

In this study, the effect of lipophilic counter-ions on the permeation of 5-aminolevulinic acid (ALA) in combination with skin impregnation by phloretin and 6-ketocholestanol was evaluated. Standard in vitro permeation experiments with porcine skin were performed analysing the ALA content by HPLC and fluorescent detection after ALA derivatisation. The shake flask method in combination with a trinitrobenzensulfonic acid test for ALA analysis was performed to calculate the apparent partition coefficient (logP(Oct)). The permeation of ALA was enhanced by cetylpyridinium chloride and benzalkonium chloride at pH 7.0 and by sodium-1-octanesulfonic acid, sodium-1-heptanesulfonic acid and sodium-1-pentanesulfonic acid monohydrate at pH 4.0. Corresponding effects of these additives were observed on the partitioning of ALA. Pre-impregnation of porcine skin with phloretin and 6-ketocholestanol increased the ALA diffusion about 1.7-fold at pH 7.0. Moreover, this transport enhancement by 6-ketocholestanol was 3.5-fold higher when a combination of ALA and cetylpyridinium chloride was used as donor.