Leszek Brongel and Piotr Budzyński
Piotr Budzyński, Marek Kuliś, Leszek Brongel, Marek Trybus and Waldemar Hładki
Ultrasound in Diagnosing Torso Injuries
In patients with torso injuries, especially the ones with suspicion of injuries of intraabdominal organs, prompt making of diagnosis and decision about further management plays crucial role. Nowadays ultrasound is the first imaging technique used in Emergency Room in such cases.
The aim of the study. Assessment of the value of ultrasound in diagnostics of patients with torso injuries, especially in qualification for operative or conservative treatment.
Material and methods. 808 patients with an average age of 44.92 with torso injuries treated in the Department of Emergency Medicine and Multiple Injuries of 2nd Chair of General Surgery, Medical College of Jagiellonian University from 2004 to 2008, in whom ultrasound according to FAST protocol was used were included in the study. Results of sonographic examinations were verified during surgical operation (in patients treated surgically), or with the use of computed tomography (in patients treated conservatively), or on the basis of post-mortem examination (in patients who died due to sustained injuries), or on the basis of clinical course of hospitalization.
Results. Sensitivity of ultrasound in the study material amounted to 90.43%, while specificity as much as 99.44%. Positive predictive value (so percentage of patients with truly positive result amongst the patients with positive result of diagnostic test) for whole study material was 95.5 while negative predictive value was 98.75.
Conclusion. Results of the study confirm that ultrasound constitutes imaging technique of unique value in diagnostics of patients suffering from torso injuries, especially the circulatory unstable ones, allowing for precise qualification for prompt surgery.
Piotr Budzyński, Leszek Brongel, Rafał Nazimek, Marek Kuliś, Waldemar Hładki, Jacek Lorkowski and Marek Trybus
Models of Certain Types of Surgical Shock Based on the Assessment of Selected Critical Parameters
The aim of the study was to devise models that describe three types of surgical shock based on a set of simple biochemical and clinical parameters and establish a method of assigning new patients to each surgical shock scenario.
Material and methods. Prospective analysis included patients hospitalized in IInd Chair of Surgery from 2001 to 2005 who belonging to the following groups: multiple injuries (at least 7 points according to LSO), upper GI bleeding (in patients requiring blood transfusions during first day) and severe acute pancreatitis (at least 3rd degree according to Trapnell's scale). A set of nineteen parameters was evaluated on the first, fourth and seventh day in every patient. Discrimination analysis was used for statistical analysis with calculation of Mahalanobis squared distances between groups that reflect their reciprocal differences. Discrimination functions were calculated allowing the assignment of a new observation to one of the models. Eventually, reliability of categorizing patients to the studied groups was evaluated.
Results. Differences among the groups - reflected by Mahalanobis squared distances - proved statistically significant in every studied day. Overall, the ratio of proper classifications according to discrimination functions equaled about 87%. The most common mistake in categorizing was observed in groups of multiple injuries and acute pancreatitis - due to similar pathophysiological processes leading through SIRS to MOF.
Conclusions. The abovementioned results indicate that the presented models can be successfully used in diagnostic processes, especially in emergency cases. The set of clinical and biochemical parameters used is simple and easy to obtain even in non-specialized centers.
Waldemar Hładki, Jacek Lorkowski, Leszek Brongel, Marek Trybus, Rafał Nazimek, Marek Kuliś and Piotr Budzyński
Quality of Life and Disability as a Result of Multiple Injuries
The aim of the study was the comparison of quality of life as a result of multiple injury in the aspect of disability.
Material and methods. The study group comprised 1259 patients treated effectively in the years 1989-2003 whose degree of injuries amounted to at least 18 scores in the Injury Severity Scores (ISS). The prospective study included 827 (65.9%) patients. Their quality of life as a disability was determined.
Results. The results of the treatment in the successive 5-years periods were compared and statistically analyzed. In the first 5 years 71.8% persons were assessed as disable. In the second 5-years period 51.5% were found to be disabled. In the third 5-years period 47.3% of people present disability. The decrease in the number of individuals disable and increase in quality of life were observed.
Conclusions. The highest quality of live improvement and the decrease in the amount of the disabled people was noted in the second 5-years period and was statistically significant related to first 5 years. The improvement of quality of life was decreased also in the third 5-years period related to second 5-years period, but the difference was not statistically significant. The increase of injuries severity and age was one of reasons of reduction positive changes in the last 5-years period.
Leszek Brongel, Wiesław Jarzynowski, Piotr Budzyński, Waldemar Hładki, Jacek Lorkowski and Marek Kuliś
The 2+2 Rule in the Management of Long Bone Fractures in Patients with Severe Multiple Trauma
The aim of the study was to estimate the efficacy of surgically stabilizing long bone fractures within 48 hours in patients with severe multiple injuries following life-saving procedures and compensating for circulatory-respiratory parameters.
Material and methods. The study comprised 364 patients with multiple injuries scoring 7 or more LSO points, who were admitted and treated university department during 1992-2000. Upon admission patients were documented on the basis of computer case histories of diseases and the standard calculation sheets. The assumption was that all long bone fractures in patients with multiple trauma would be stabilized within 48 hours. Parameters for operating were set so that the duration time of the operative procedure could not exceed 2 hours, and the amount of blood transfused could not exceed 2 units.
Results. From among 364 patients with multiple traumas scoring 7 or more LSO points, 192 patients sustained long bone fractures that required surgical attention. One-third of the patients were female, the average age of the patients was nearly 45 years, and the average injure severity was 10.28 LSO points. 146 patients underwent 226 orthopaedic operations, out of which 127 were carried out in the first 24 hours, and 23 in the next 24 hours of the hospital stay. The mortality was 13.5%.
Conclusions. Stabilization of the long bone fractures within the first 48 hours in patients with multiple traumas, after compensating circulatory parameters, is a life-saving treatment.
Leszek Brongel, Jerzy Lasek, Jerzy Karski, Jacek Gwoździewicz, Waldemar Hładki and Jacek Lorkowski
Multicenter Study of Optimal Management Strategy in Severe Multiple Trauma
The aim of the study. The development of a triage system to implement proper treatment based on severity of injury.
Material and methods. The study is based on material from three Polish Universities' trauma departments: Cracow, Lublin, and Gdańsk. Using trauma scales, 300 of the most severely injured multiple trauma (MT) patients from 2000-2004 have been chosen for this study. Medical documentation was carefully analysed, particularly the time and extent of the surgical procedures performed as well as their potential to influence later results.
Results. There are three groups of patients:
1 - critically injured, with an ISS>50, LSO>15, RTS 3 pts, two body cavity involvement, multiple long bone and/or pelvis fractures. Only damage control was allowed and the definitive treatment necessary was within 48 hours.
2 - severely injured, with an unstable ISS 35-50, LSO 10-15, RTS 4-10 pts, one body cavity involvement, multiple long bone and/or pelvis fractures. Life-saving operations were possible with orthopaedic management (within 48 hours) provided using the "2+2 rule" (less than 2 hours of operation and no more than 2 units of blood transfused).
3 - moderately injured, with a stable ISS<35, LSO<10, RTS>10 pts, one body cavity involvement, a long bone or pelvis fracture. Classic surgical and orthopaedic management occurred within 48 hours.
Conclusions. The history and course of post-traumatic syndrome from metabolic, immune and endocrine viewpoints requires a special strategy for repairing life -threatening trauma injures at the right time, in proper sequence, and with limited surgical activity in more severe cases.
Leszek Brongel, Waldemar Hładki, Tomasz Grodzicki, Jacek Friedlein, Rafał Nazimek, Jacek Lorkowski, Marek Kuliś and Piotr Budzyński
Trauma in the Aged
After accidents, elderly patients (aged 75 years and older) have been demonstrated to have increased mortality rates after trauma, however, the prognosis of those patients surviving their hospitalization is unknown. We hypothesized that surviving elderly patients would also have decreased functional outcomes.
The aim of the study. This study examined the outcome of elderly patients exposed to varying trauma relative to all trauma patients.
Material and methods. This was a retrospective study of 5046 patients with trauma in 2001-2005 treated. 972 of these patients were aged 75 or more. Data included demographics, risks factors, cause of trauma, operative or conservative management and result of treatment.
Results. Mechanisms of injury were falls (almost 90%), motor vehicle collisions (8%) and other. Statistical differences in the mechanisms of trauma between the studied and younger groups were observed. The mortality rate was doubled in the older group. Almost 2/3 of the patients underwent surgery. The strategy of management and treatment of elderly trauma patients has not been studied in the literature. This group may require special management and monitoring, and if possible, noninvasive modes of treatment. There are big advantages by aggressive, operative treatment of oldest patients, but is the "thin red line" in profits and loss in this group.
Conclusions. In our opinion, it is necessity to operate on all elderly patients in good overall condition who were mobile and of good mental status prior to the accident, status, but we do not recommend operations in low-risk patients or those with bad prognosis for successful rehabilitation.
Leszek Brongel, Jacek Lorkowski, Waldemar Hładki, Wiesław Jarzynowski, Marek Kuliś and Piotr Budzyński
Marek Kuliś, Leszek Brongel, Piotr Budzyński, Waldemar Hładki, Jacek Lorkowski, Rafał Nazimek, Wiesław Jarzynowski and Jan Magiera
Selected Aspects in Abdominal Trauma Management
The aim of the study was analysis of diagnostic techniques relative to the type of trauma sustained (blunt versus penetrating), the patients' haemodynamic status (stable versus in shock), the character of injuries (isolated versus multiple) and the type of treatment employed (conservative versus operative) in patients with suspected abdominal injuries.
Material and methods. The study included 1406 trauma victims hospitalized in the 2nd Department of Surgery in Cracow from 1995 to 2004 who were diagnosed with or underwent surgery for suspected abdominal organ injury. In addition to the clinical examination performed in each case, the ultrasonographic examination according to FAST procedure was used in 1373 patients, diagnostic peritoneal lavage (DPL) in 46, computed tomography (CT) in 27, laparoscopy in 45 and contrast studies of the urinary tract in 45 patients. Data concerning treatment process were obtained retrospectively from the computer databases entitled "Kopernik" and "Pacjenci". The efficiency of diagnostics provided in our clinic was estimated on the basis of the percentage of exploratory laparotomies and the number of missed injuries.
Results. Of 218 patients with abdominal organ injuries, 72% underwent surgery and the remaining 28% were treated conservatively. Regardless of the type of trauma, the patients in shock received surgical treatment more often. In the group of patients suffering from blunt injuries, exploratory laparotomies were performed in 5.9% of haemodynamically stable patients and in 12.3% of patients admitted in shock. In the group of penetrating injuries the percentage of exploratory laparotomies reached 23.5 and 6.25% respectively. In six patients with blunt abdominal trauma who were treated conservatively the abdominal injuries were missed. One out of every ten patients was qualified for laparotomy solely on the basis of clinical examination. Most of these patients suffered from abdominal wounds. In the vast majority of remaining patients, FAST was used as the only diagnostic technique or (more often) in combination with additional diagnostic techniques. Except for FAST, additional diagnostic techniques were used in every tenth patient with isolated abdominal injury and in every fourth with multiple injuries. In the most abundant group of patients operated on due to bleeding, FAST was supplemented by additional techniques in half of the patients.
Conclusions. FAST played a crucial role in diagnosing patients with injuries of the torso. CT or laparoscopy was additionally recommended for patients with suspected intra-abdominal organ injury, especially in cases of multiple injuries. Peritoneal penetration of the wound without symptoms of intra-abdominal organ injury should not constitute an indication for laparotomy. Qualification for laparotomy on the basis of clinical examination only is permissible only in haemodynamically unstable patients with abdominal wounds.
Jacek Lorkowski, Leszek Brongel, Waldemar Hładki, Piotr Budzyński, Magdalena Żeglin, Marek Kuliś, Rafał Nazimek and Piotr Guzik
Evaluation of Long Term Therapy Outcomes for Achilles Tendon Ruptures
The aim of the study was to assess the results of treatment for partial and complete Achilles tendon ruptures.
Material and methods. We evaluated 94 patients suffering from the injury (61 males and 33 females) with an average age of 43.8.
Results. The most common mechanism of injury was sport-related (57 participants) or walking-related overstraining (32 participants). 81 patients underwent surgical procedures. In 77 patients, Kessler's suture was used and in 12 patients, transplantation of iliotibial tract was performed. A group of 13 patients underwent a conservative therapy. Plantar flexion immobilization was used for 3 months (constant immobilization for 6 weeks) in all groups. Every patient underwent rehabilitation following surgery. The follow up period was 2.5 years. 85 patients fully recovered lower limb function. In 9 patients, complications were noted: 4 had flexor contractions in the ankle joint requiring further treatment, 2 patients suffered from reoccurrence of tears, and 2 had thrombophlebitis. One patient developed diffuse necrosis of the posterior region of the distal leg, which required amputation.
Conclusions. An appropriate approach to the treatment of Achilles tendon injuries is surgery followed by intensive physiotherapy. During the surgical procedure, it is essential to properly realign the anatomic structures including the fibers rotating within the tendon.