Traumatic deaths at hospital: analysis of preventability and lessons learned.

PURPOSE: The aim of the present study was to characterize traumatic deaths of major trauma patients occurring in a university trauma centre and to assess retrospectively the quality of given care by evaluating whether any of the deaths could be identified as potentially preventable. METHODS: All consecutive deaths of trauma patients between January 1, 2004 and December 31, 2008 in the Töölö Hospital Trauma Centre were retrospectively reviewed. The inclusion criterion was death of a trauma patient occurring during stay at hospital. Patients aged >65 years with an isolated proximal femoral fracture, burn patients, patients with isolated limb fracture other than femoral or tibial shaft fracture, and patients with isolated traumatic brain injuries were excluded as well as patients admitted more than 24 h after injury. RESULT: A total of 130 patients fulfilled the inclusion criteria. The autopsy reports were obtained for 103 of the cases (80.4 %). The majority of the patients were male, and the median age was 58 years (range 1-95 years). Blunt trauma was the most common type of injury. The most common injury mechanisms were fall from a higher level (31 %), fall from the level of the patient (21 %), and motor vehicle accident (17 %). Of the injuries not diagnosed before autopsy, the most common were liver lacerations, rib fractures, pulmonary contusions, sternum fractures, and blunt cardiac injuries. In our study population 12.5 % of the cases were considered potentially preventable. The reasons for preventability were inadequate treatment of coagulopathy, overuse of opioid medication, and loss of airway as well as failing to treat impending pneumonia and DVT. Trauma resuscitation was inadequate in 7.8 % of the cases. CONCLUSIONS: The most common error made was not recognising and treating traumatic coagulopathy adequately.

Anatomical reconstruction of ruptured lateral ligaments of upper ankle joint.

BACKGROUND AND AIMS: It seems that a certain patient population after conservatively treated ankle distorsions later develops chronic symptoms such as instability, pain and swelling. MATERIAL AND METHODS: The present study comprised 20 such patients, who underwent an anatomical reconstruction of ruptured ankle ligament(s) (FC, FTA and/or FTP). Patients were followed in average for 22 months postoperatively. RESULTS: Sixteen of them had excellent or good results. Clinically 5 and radiologically 4 patients had instability of the operatively treated ankle joint at the follow-up. Instability and subjective patient satisfaction did not correlate at all. CONCLUSION: Anatomical reconstruction of ruptured ankle ligaments in chronic posttraumatic instability syndrome is technically possible to perform in almost all cases. The present method of anatomical ligament reconstruction usually results in good stability, diminishes symptoms and in most cases leads into a normal functional capacity.

Single-dose antibiotic prophylaxis in osteosynthesis for hip fractures. A clinical multicentre study in Finland.

BACKGROUND AND AIMS: The use of antibiotic prophylaxis in open reduction and osteosynthesis of closed hip fractures is still controversial. The aim of this study was to demonstrate the effect of antibiotic prophylaxis in osteosynthesis of these fractures. MATERIAL AND METHODS: A total of 224 patients operated on between November 1994 and February 1998 in six hospitals by internal fixation for a fresh hip fracture were prospectively and randomly allocated to either a ceftriaxone antibiotic prophylaxis or no prophylaxis group and followed for one year. RESULTS: Within 6 weeks after the operation, 2.6% wound infections were recorded in the antibiotic group and 4.7% in the control group. Two (1.9%) of the five infections in the control group were deep infections (both sensitive to ceftriaxone). There were no statistically significant differences between the infection rates in both groups. However, when analyzing all complications recorded within 6 weeks, significantly more complications were found in the control group (p < 0.01). In the multivariate analysis the most important factor predicting postoperative complications was the lack of antibiotic prophylaxis. CONCLUSION: In this study the antibiotic prophylaxis group had significantly less postoperative complications than the control group within 6 weeks after the operation.

Treatment of infection and non-union after bilateral complicated proximal tibial fracture.

BACKGROUND AND AIMS: Complicated tibial fractures form a great challenge for orthopaedic surgeons. Non-unions and infections are more common in complicated than in closed fractures. In the present study, we describe a patient case treated for non-union combined to chronic osteomyelitis after bilateral open proximal tibial fractures. MATERIAL AND METHODS: A female patient born in 1946 was multi-traumatised, when a car hit her as a pedestrian. She went through multiple operations of both tibias due to bilateral complicated proximal fractures. Fractures were stabilised at first with internal fixation, which had to be changed to external fixation due to infection of both sides. During the last operative step a commercial bone graft based on hydroxyapatite and bovine type I fibrillar collagen/tricalcium phosphate ceramic (Collagraft) mixed with autogenous bone marrow was applied. RESULTS: Fractures united after 28 (right tibia) and 22 (left tibia) months of follow-up. At the final follow-up visit 55 months after the initial accident patient walked without any aid and showed no signs of an infection. CONCLUSIONS: The use of commercial mixed xeno-/autogenous-bone graft may provide a feasible alternative in complicated chronic non-unions of the tibia even when an infection is present, especially when autogenous bone is not easily available after previous attempts of bone grafting.

A safe surgical technique for the partial resection of the ruptured spleen. A clinical report.

A consecutive series of 11 patients with an acute blunt splenic injury were treated with a 'safe resection' technique. 57% of the injured spleens (range 35-100%) were saved. None of the patients had any signs of secondary bleeding in control CT scan and the mortality was zero. No second-look laparotomies were performed. Follow-up time was at least two months (range 2 month-6 yr). Operation time was in average 120 min. Total mean peroperative bleeding was 1400 ml. Partial resection may offer patient a change for normal function of the injured spleen. However, it is not yet known what is the critical mass of spleen tissue needed for humans. The follow-up time of the present study is still too short to estimate this fact, but further studies may show the benefit of the present method in avoiding serious long term immunological complications of splenectomy. This present study introduces a novel technique for partial resection of injured spleen. Operation can be performed safely and quickly with a complication risk comparable to splenectomy. Resection is applicable even for multi-trauma patients.

Clindamycin versus cloxacillin in the treatment of 240 open fractures. A randomized prospective study.

BACKGROUND AND AIMS: Systemic administration of antibiotics is recommended and has proved to lower infection rates in open fractures. However, no antibiotic has proved to be superior to any other. MATERIAL AND METHODS: In a prospective study 227 patients with 240 open fractures were randomized to receive either clindamycin or cloxacillin for infection prevention. RESULTS: The overall infection rate was 15%. Infection occurred in 9.3% of the clindamycin treated and in 20% of the cloxacillin treated fractures (p < 0.05). In the Gustillo Type I and II open fractures all the pathogens causing infection were gram-positive, while in the Type III open fractures 21 pathogens (57%) were gram-positive and 16 (43%) gram-negative. In the clindamycin treated fractures the infection rates in Type I and II open fractures were 3.3 and 1.8%, respectively, while in the cloxacillin group they were 20 and 3.8%, respectively. Both clindamycin and cloxacillin showed low effectiveness in the treatment of Type III open fractures, the highest infection rates being 75 and 67%, respectively (Type III B). CONCLUSIONS: Clindamycin provides good antimicrobic coverage against the most common pathogens causing Type I and II open fracture infections. In the treatment of Type III open fractures additional administration of an antibiotic with good gram-negative coverage is recommended.

Diagnostic performance of low field MRI in acute knee injuries.

The diagnostic performance of low field (0.1 T) magnetic resonance imaging (MRI) was studied prospectively and double-blindly among 33 patients with acute knee injuries. The subsequent arthroscopy was the golden standard. For lesions of the medial meniscus low field MR had a sensitivity of 88% and a specificity of 80%; for lesions of the lateral meniscus the sensitivity was 25% and the specificity 97%. For anterior cruciate ligament tears, low field MRI had a sensitivity of 83% and a specificity of 85%. The specificity for posterior cruciate ligament tears was 97%. The performance of low field MRI equalled that reported earlier for high field MRI, the only exception being the sensitivity for lateral meniscus lesions.

Maintenance of visceral protein levels in serum during postoperative parenteral nutrition.

Nitrogen metabolism and plasma insulin level were studied postoperatively in 14 patients (six males and eight females) with a disease of the upper gastrointestinal tract and therefore operated on electively. The patients received one of the two isocaloric parenteral nutrition regimens postoperatively: one, on the average, with 1.2 g of amino acids/kg/day and the other with 3.1 g of amino acids/kg/day. During postoperative intravenous alimentation rich in amino acids the cumulative nitrogen balance over 3 days was +13.1 (interval from -1.3 to +21.4) gN but -10.1 (interval from -12.1 to -2.4) gN during parenteral nutrition with a smaller amount of amino acids. The difference was significant (p less than 0.001). During parenteral nutrition rich in amino acids the changes of the serum albumin level, ie, -0.4 (SEM 1.1) g/liter, and of the serum transferrin level, ie; -0.16 (SEM 0.22) g/liter, were statistically insignificant (p greater than 0.05). During intravenous alimentation poor in amino acids serum albumin decreased by 3.8 (SEM 1.2) g/liter (p less than 0.01) and serum transferrin by 0.44 (SEM 0.05) g/liter (p less than 0.001). The differences of the changes between the groups were significant (p less than 0.01 and p less than 0.01, respectively). These various effects of the two parenteral nutrition regimens were not dependent on the different fluid balances during intravenous alimentation or on the different plasma insulin levels. It is concluded that a rich supply of amino acids--more than 1.2 g/kg/day--in postoperative parenteral nutrition better maintains the visceral protein levels in the serum, which possibly depends on the greater protein production in the liver.

Haematological changes during parenteral nutrition of malnourished patients with an enteral disease.

The present study assesses the blood haemoglobin concentration, the mean corpuscular haemoglobin concentration and the mean corpuscular volumes, as well as the serum iron levels and the total iron binding capacities in 28 malnourished patients with an enteral disease before and after 10-12 days of pre-operative parenteral nutrition of three different kinds: one with glucose, a second with glucose and fat as energy source, and a third rich in amino acids. About half of the patients in each group also received intramuscular iron supplementation of 1.79 mmol every 2 days. Before the nutritional therapy, 54% of the patients had a subnormal serum iron level; on average, serum iron was 10.5 (SD 7.4) mumol/l. In spite of this, 50% of the patients had a TIBC level less than normal and 43% of the patients within the normal range. Ninety-three percent of the patients had an anaemia which, in most cases, was normochromic and normocytic. On average, blood haemoglobin was 110 (SD 12) g/l. After 10-12 days of parenteral nutrition, the blood haemoglobin concentration decreased independently of the quality of the intravenous alimentation, the serum iron level and the intramuscular iron supplementation. The fall in the blood haemoglobin level was on average 11.2%.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of total parenteral nutrition on the zinc, copper, and manganese status of patients with catabolic disease.

The zinc, copper, and manganese concentrations in liver and muscle and the serum zinc were measured in 24 malnourished patients before and after 10-12 days' parenteral nutrition with 3 different alimentation programs. The nutrition programs contained similar trace element substitutions. Malnutrition caused by different catabolic diseases resulted in an increase of zinc and copper contents in the liver and a rise of serum zinc in many patients and in a decrease of muscle zinc concentration in certain patients. Parenteral nutrition of any kind resulted in a decrease of liver zinc and copper content and of serum zinc, yielding subnormal zinc values in 25-58% of the patients in spite of a daily substitution of 1.9 mg zinc. There was no significant change in the manganese status because of malnutrition or parenteral alimentation. It is concluded that the serum zinc concentration does not show the real zinc status of the body in the patients with catabolism, that in certain catabolic diseases zinc and copper are redistributed to the liver, that certain catabolic diseases cause a zinc depletion of the muscle, that parenteral nutrition results in a fall of zinc and copper in the liver and in a decrease of serum zinc, which may be harmful from the healing point of view, and that the daily substitution of zinc used in this study, 1.9 mg/day, is not sufficient during parenteral nutrition of catabolic patients.

Stress fracture of the navicular bone. Nine cases in athletes.

Nine cases of stress fractures of the tarsal navicular bone were treated in athletes. The diagnosis was made with radiographs and bone scan within 6 months. Only two patients were treated surgically. The only poor result was seen in a patient in whom the fracture was only explored.

Changes of high density lipoprotein subfraction concentration and composition by intralipid in vivo and by lipolysis of intralipid in vitro.

Serum lipoproteins were measured during a single infusion of intralipid and during parenteral nutrition with intralipid and glucose. Postheparin plasma lipolytic enzymes and plasma LCAT activity were assayed before and after the parenteral nutrition. Both single and repeated infusions of intralipid were followed by a significant rise of HDL2 concentration (p less than 0.01), whereas the HDL3 decreased. The composition of HDL subclasses altered. The HDL2 triglyceride and phospholipids increased, while the HDL3 esterified cholesterol and protein decreased. In vitro incubation of serum with intralipid alone caused no changes in the zonal profile of HDL subclasses, but hydrolysis of intralipid by lipoprotein lipase was followed by conversion of HDL3 into lighter particles floating in the density range of HDL2. The present results provide additional evidence for a precursor-product relationship between the HDL2 and HDL3. During 4 days of parenteral nutrition with intralipid, the basal (morning) values of serum total and VLDL triglyceride did not change. The LDL phospholipids increased progressively (from 67 to 98 mg/dl, p less than 0.05). The total HDL cholesterol decreased and this change was due to the fall of HDL3 cholesterol esters (from 19 to 12 mg/dl, p less than 0.05). Also the basal values of apo A-I and A-II in HDL3 decreased. The basal level of the HDL2 remained constant. Postheparin plasma LPL activity increased by 52% (p less than 0.01) but hepatic lipase activity fell by 49% (p less than 0.05). These changes may account for the maintenance of plasma HDL2, whereas the progressive fall of the basal HDL3 is probably due to the lack of intestinal apoprotein synthesis during absent intestinal absorption.

Morphological fatty changes and function of the liver, serum free fatty acids, and triglycerides during parenteral nutrition.

Morphological fatty changes and function of the liver and serum free fatty acids and triglycerides were investigated in 37 catabolic patients (22 men, 15 women) given different parenteral nutrition regimens. In the glucose group energy was supplied as carbohydrate alone, in the lipid group as carbohydrates and fats, and in addition both groups received amino acids. In the amino acid group amino acids were given in excess and less energy was supplied as carbohydrates. Each patient served as his own control. During parenteral nutrition liver steatosis rose from 5% to 35% (p less than 0.001) in the glucose group and from 7% to 23% (p less than 0.01) in the amino acid group, but no increase occurred in the lipid group. Liver fat accumulation was associated with the rises in serum aminotransferase activities and with the lack of or a poor rise in serum prothrombin and proconvertin. The conjugation function of the liver was not disturbed. No cholestatis was found. During lipid infusion serum free fatty acids increased to 4.41 mmol/l (p less than 0.01) and serum triglycerides to 3.06 mmol/l (p less than 0.01), but they decreased to normal range 12 h after lipid infusion was stopped. In the glucose and amino acid groups serum free fatty acid levels fell, as expected, below the normal range. Serum triglycerides rose 1.4-fold (p less than 0.05) in the amino acid group. On the basis of liver tests and histological examination steatosis in the liver caused only a minor disturbance in hepatocellular integrity. The very high levels of serum free fatty acids and triglycerides during lipid infusion may be harmful in certain pathological states.

Hormonal changes in catabolic patients during parenteral nutrition.

This study assesses the hormonal changes in 23 catabolic surgical patients during the three different regimens of parenteral nutrition: one with glucose, another with glucose and fat as energy sources, and a third one rich in amino acids. Before treatment, plasma insulin and cortisol concentrations, as well as daily urinary excretion of 17-oxogenic steroids and catecholamines, were normal. Plasma growth hormone concentration was close to normal. Plasma testosterone and daily urinary excretion of 17-oxosteroids were decreased. The response of plasma cortisol concentration to glucagon was impaired but the responses of insulin and growth hormone were close to normal. During the glucose regimen plasma insulin increased by 270% and plasma testosterone by 60%. There was a 55% decrease in plasma growth hormone concentration and a 31% rise in plasma cortisol concentration. The lipid regimen enhanced plasma insulin by 120%. During the amino acid regimen plasma insulin concentration was 150% higher, but plasma growth hormone concentration 45% lower than initially. The glucose and amino acid regimens augmented the response of insulin to glucagon by 180 and 50%, respectively, but decreased that of growth hormone by 59 and 80%, respectively. The lipid programme caused no significant change in the hormonal response to glucagon.

Effect of parenteral nutrition on the blood levels of insulin, glucagon, growth hormone, thyroid hormones and cortisol in catabolic patients.

The changes in plasma insulin (IRI) glucagon (IRG), IRI:IRG ration, growth hormone (HGH), cortisol and thyroid hormones during two different but isocaloric parenteral nutrition regimens were investigated in 11 malnourished patients and 21 postoperative patients. The nutrition program which used glucose as a non-nitrogen energy source favoured anabolism by a higher rise in plasma IRI and by a higher rise in the initially low plasma IRI:IRG ratio in both malnourished and postoperative patients more than the alimentation regimen with glucose and lipid. The glucose program augmented the IRI:IRG ratio to an average of 5.5 +/- 1.2 (SEM) in malnourished patients and to 8.4+/-2.7 in postoperative patients. The corresponding values for the glucose-lipid program were 3.9+/- 1.0 and 1.9 +/- 0.4. In malnourished patients the difference between the anabolic effect of these nutrition regimens was further increased by a fall in the plasma HGH level to 0.7 +/- 0.3 microgram/l during fat infusion. Over a period of four days both alimentation programs similarly increased in the initially low serum T3 and free T3 index to the normal reference interval and decreased serum rT3 to a subnormal level (0.18+/-0.7 nmol/l) in malnourished patients. In postoperative patients the only change in thyroid hormones which was dependent on the four-day parenteral nutrition was the decrease in the initially elevated serum rT3 to the normal reference interval by both alimentation programs (by 54% in the glucose and by 30% in the glucose-lipid program).

Effect of parenteral hyperalimentation on serum lipoproteins and on lipoprotein lipase activity of adipose tissue and skeletal muscle.

This study reports on the effects of parenteral nutrition with glucose along or in combination with Intralipid on heparin-releasable lipoprotein lipase (LPL) activity of adipose tissue and skeletal muscle and on serum lipoproteins. Thirteen patients with postoperative hypercatabolism and nine patients with caloric malnutrition were studied. The average adipose tissue LPL activity increased 5-fold during 4-day glucose infusion (P less than 0.001) and 7.4-fold during Intralipid plus glucose infusion (P less than 0.001). In contrast, no change occurred in the LPL activity of skeletal muscle. Glucose infusion caused a significant increase in VLDL and LDL triglyceride concentrations and the Intralipid plus glucose infusion was followed by a rise in LDL and HDL triglyceride concentrations. HDL cholesterol decreased by 26% (P less than 0.01) during glucose and by 19% (P less than 0.05) during Intralipid plus glucose. Apoprotein A I was very low already at the start of parenteral alimentation and it did not change during either nutrition. The HDL cholesterol and apoprotein A I and A II levels were each positively correlated with adipose tissue LPL activity before parenteral nutrition but not after it.

Changes in nitrogen metabolism in catabolic patients given three different parenteral nutrition regimens.

Nitrogen metabolism was investigated in 24 catabolic patients (15 men and 9 women) given three different parenteral nutrition regimens for 10-12 days. Energy was supplied as either carbohydrates alone (glucose group) or as carbohydrates and fats (lipid group) and nitrogen as amino acids. In the third group (amino acid group) amino acids were given in excess and less energy was supplied as carbohydrate. Each patient served as his own control. On the basis of daily urinary urea excretion all infused amino acid was retained in the body in the glucose and lipid groups during parenteral nutrition, but in the amino acid group 54% of infused amino acids were metabolized in gluconeogenesis apparently for energy production. In the glucose and lipid groups nitrogen balance rose to a "plateau" within 2-4 days but in the amino acid group within 5-7 days. The increment of nitrogen balance, 0.169 +/- 0.030 g N/kg/day, in the glucose group was greater than that, 0.140 +/- 0.037 g N/kg/day, in the lipid group (p less than 0.05) and that, 0.122 +/- 0.044 g N/kg/day, in the amino acid group (p less than 0.01). The initially low values of serum and liver protein did not change in the glucose and lipid groups, but in the amino acid group serum protein rose from 53.7 +/- 6.5 g/l to 61.1 +/- 5.9 g/l (less than 0.01) and liver protein from 47.4 +/- 7.2 mg/mgDNA to 65.0 +/- 22.6 mg/mgDNA (p less than 0.05). It seems tht a parenteral nutrition program rich in amino acids stimulates the vital protein synthesis of the liver more than regimens with abundance of non-nitrogen energy sources and poorer in amino acids. Nitrogen balance does not reveal information about the important protein metabolism of the liver. The results of this study support the opinion that during parenteral nutrition carbohydrates improve nitrogen balance more than isocaloric amount of fat.

Muscle metabolism during and after strenuous intermittent running.

Muscle and blood metabolites, plasma insulin and cyclic adenosine 3',5'-monophosphate (cAMP) levels were investigated in five male runners before and after strenuous intermittent running exercise of short duration. Immediately after the exercise, the mean muscle creatine phosphate level (CrP) had fallen by 74% (P less than 0.02) and 30 min later the initial level was regained in only one subject. Other immediate results were increases in mean muscle lactate (460%, P less than 0.005), glucose (130%), glucose-6-phosphate (G6P, 320%) and fructose-1,6-diphosphate (FDP, 32%). Muscle ATP and glycogen concentration had decreased by 31 and 23% (P less than 0.05), respectively. However, ATP, glucose, G6P and FDP changes were not significant owing to the great individual variation. This may have been due to the different training programmes of the runners. Immediately after the exercise mean plasma insulin was 210% (P less than 0.01), blood glucose 71% (P less than 0.005) and plasma cAMP concentration 260% (P less than 0.01) higher than the pre-exercise values. After running urinary excretion of cAMP was 29% higher than before the exercise. It is concluded that exhaustive, short-term exercise activates the liver adenylate cyclase system so giving rise to an increased level of blood glucose, which is an important source of energy during this type of exercise.