Knowledge of trauma is as old as mankind and survived a long way to reach new technologic developments. Being a multisystemic disease, trauma is an important social and financial problem especially in developing countries. Anesthesists possess important roles in the multisystemic management of trauma patients. In our country prehospital life support for trauma victims is primarily realized and arranged by the emergency help and rescue team 112 which belonged to the Ministry of Health. Several courses are arranged for the team especially about endotracheal intubation and resuscitation in the field. Acute major airway injuries require an early diagnosis and a prompt treatment to improve their outcomes. Typical injuries causing alterations in oxygenation or ventilation are head, spinal cord and thoracic traumas. The use of cuffed tracheal tube remains the definitive ‘gold standard’ for airway control. Tracheal tube placement requires experience and high degree of skill. The laryngeal mask airway, intubating laryngeal mask airway and oesophageal-tracheal combitube are also indicated in maintaining control of airway during emergency trauma patients in the field. A probable occurence of cervical spine fracture must be assumed while maintaining airway patency. On-site airway aspiration, and monitoring of carbon dioxide must be realized in trauma victims.

BACKGROUND: The effect of epidermal growth factor (EGF) on gastrojejunostomy (anastomosis), fascia, and skin wound healing in rats was investigated. METHODS: The animals (rats) were separated into two main groups. In the first group (control group n:23), rats were fed on standard diet and tap water without administration of EGF. In the second group (EGF group, n:19), EGF was added to the diet. Skin, fascia, and anastomosis wounds were created on three different locations via laparotomy and gastrojejunostomy in all rats. In both groups, the rats divided into three subgroups were sacrificed on the 3rd, 7th, and 21st days post operatively. Tensile strength of skin and fascia and bursting pressure strength were measured for wound healing in both groups on 3rd, 7th, and 21st days. RESULTS: Anastomosis tensile strength of EGF group on the 3rd day of postoperation was found to be significantly higher than that of the control group and when we compared anastomosis bursting pressure, fascia tensile strength, and skin tensile strength in both groups, we did not find any significant differences. CONCLUSION: The measurements indicated that on the 3rd day EGF administered group, which had a more remarkable fibroblastic activity at gastrojejunostomy site, was superior to the control group only in terms of anastomosis breaking tensile strength.

BACKGROUND: To investigate the muscular changes occurring during femoral lengthening performed in 42 rats. METHODS: The rats were randomly divided into six groups and different rates of lengthening were utilized and the rats were sacrificed at the end of the distraction. Histopathologic and histomorphometric measurements were done for all specimens. The results were analyzed statistically by Mann-Whitney U test. RESULTS: By increasing the rate of lengthening, the severity of pathologic changes such as degeneration of muscle fibers, number of vacuoles and cellular infiltration was increased. Phagocytosis of degenerated muscle fibers was observed after 14 days and cellular infiltration decreased sharply and fibrosis formed in the vacuoles and around the muscle fibers after 21 days of lengthening. Cellular infiltration was lost, the muscle had gained its normal appearance and endomysial, perimysial and epimysial fibrosis formed in the group, which were observed for 31 days. Twenty one percent of muscle fibers were atrophic but the ratio of type I to type II muscle fibers did not change. CONCLUSIONS: The findings of the current study showed that different regions with different phases of degeneration occur in the same muscle and irreversible changes in the muscle may develop even in 10 percent lengthening.

BACKGROUND: It has been showed that free oxygen radicals and cytokines contribute to tissue damage and impairment of pancreatic microcirculation in acute pancreatitis. In this study, the effects of melatonin and pentoxiphylline were investigated in rabbits with L-arginine induced acute pancreatitis. METHODS: Rabbits were divided into 5 groups (n=10). Any procedure was not applied for the control group (G1). Acute pancreatitis was induced in one group (G2). Melatonin (G3), pentoxiphylline (G4) and melatonin + pentoxiphylline (G5) were given to other groups after induction of acute pancreatitis. Plasma levels of MDA, amylase, LDH, SGOT, IL-6 and TNF-a were measured at 0., 6., 12., 24. and 48. hours and pancreatic tissue was assessed histopathologically. RESULTS: Melatonin significantly reduced amylase activities at 6., 12., 24., and 48. hours (p<0.025), and all biochemical parameters, (excl. MDA) and edema and necrosis of acinar cells after 48 hours. Although pentoxiphylline reduced abnormally increased parameters in acute pancreatitis (significant for SGOT at 6.,12.,24. and IL-6 at 12.,48. hours), it did not normalized pancreatic abnormalities. CONCLUSION: Melatonin in contrast to pentoxiphylline significantly improved biochemical and histopathological abnormalities due to its powerful antioxidant and free oxygen scavenger properties in acute pancreatitis, and it can be used for patients with pancreatitis.

BACKGROUND: Understanding the exact contribution of the supporting ligaments to the functional integrity of the wrist is crucial for the diagnosis and treatment of carpal instabilities. The present study evaluates functional significance of the wrist ligaments with respect to carpal instabilities. Materials and Methods: Sixteen fresh cadaver wrists were dissected. Extrinsic and intrinsic ligaments of the wrists (ligamentum radioscaphocapitatum, ligamentum radiolunotriquetrum and ligamentum triquetrohamatocapitatum) were sectioned sequentially. After sectioning of each ligament, the wrist was examined for clinical signs of instability such as misalignement of carpal bones, limited range of motion and dorsal translation. When instability was suspected, radiographs were taken and if instability was confirmed, then the ligament was repaired. RESULTS: Although none of the dorsal ligaments sectioning resulted in instability, sectioning of ligamentum scaphotrapeziotrapezoideum, ligamentum radioscaphocapitatum, ligamentum radiolunotriquetrum and ligamentum triquetrohamatocapitatum displayed scaphotrapeziotrapezoidal, dorsal intercalated segment, lunotriquetral and capitohamate instability respectively. In two wrists with arthrosis, sectioning of all ligaments didn’t lead to any instability. CONCLUSION: Instability of the wrist can be classified on anatomical basis after the name of these four ligaments involved i.e. l. scaphotrapeziotrapezoideum, l. radioscaphocapitatum, l. radiolunotriquetrum and l. triquetrohamatocapitatum respectively . This approach clarifies the etiology and treatment of carpal instabilities.

BACKGROUND: There is still ongoing debate on therapeutic results of traumatic colorectal perforations. The aim of this study was to evaluate and compare the incidence, management, and outcome of patients with traumatic colonic perforations. METHODS: From January 1997 to December 2002, 85 surgical patients underwent emergency operation for traumatic colonic perforations. Patients were reevaluated by analyzing the relationship between the overall morbidity and mortality and the surgical treatment options. We took into consideration the time interval between perforation and treatment as well as the nature, the site, and the cause of perforation, patients’ age, and additional organ injuries. RESULTS: Mean age was 32,1. The most injured segment was transverse segment of the colon. Hartmann's procedure was performed in 3 patients (3.5%); resection, and primary anastomosis in 11 patients (12%); primary repair in 57(67%); primary repair and proximal diverting colostomy in 11(%12) ; colostomy in 5(5.8%); and appendectomy in 1 patient. Four postoperative death and one fecal fistula occurred. Deaths were not related to the surgical therapy applied. CONCLUSION: Our early postoperative results after primary repair, and resection anastomosis were good. We conclude that either primary repair or resection and anastomosis can be performed with acceptable morbidity for perforations of the colon and rectum.

BACKGROUND: In this study the results of non-operative management of pediatric hepatic injury after blunt abdominal trauma were evaluated. METHODS: Multitrauma patients (n = 498) admitted between 1998 and 2002 were analysed as for mechanism of trauma retrospectively. Liver injuries were classified according to the American Association for the Surgery of Trauma’s Organ Injury Scaling System. Liver function tests, transfusion status, duration of hospital stay, complications, and operative intervention needed were recorded. RESULTS: Seventy-five patients had liver injuries. The mean age was 6.7 years and male/female was 2.5/1. Number of patients in terrms of injury grade: I: 15, II: 26, III: 29, IV: 4, V: 1. There was no significant difference between mean blood pressures, heart rates, and hematocrite values on admission and post-stabilisation. In three of 21 transfused patients, it exceeded 40 ml/kg and two of them were operated. The mean pediatric trauma score was +2. As a complication biloma was encountered in one patient. One patient with grade V hepatic injury died in the operating room because of heavy bleeding. The average hospital stay was 8,6 days. CONCLUSION: Our results support the efficacy of non-operative management of any grade hepatic injuries due to blunt abdominal trauma, with resultant low complication and mortality rates and shorter hospital stays.

BACKGROUND: To evaluate correlations among ultrasonographic, demographic, clinical and laboratory findings of patients with acute cholecystitis. METHODS: The patients older than 17 years of age with acute colecystitis admitted to the general surgery clinics between January 1991 and December 2000 were evaluated and compared in terms of various parameters. RESULTS: 336 (female, 212; male, 124) patients were included in the study. Mean age was 55.71±15.10 Two hundred and seventeen patients presented with more than 12 hours of pain, and 277 patients had multiple biliary stones. Gallbladder wall thickness (GWT) was found to be < 3 mm in 223, and > 5 mm in 58 patients. Pericolic fluid (PCF), distended gallbladder, sonographic Murphy positivity were found in 7.7%, 27.7%, and 9.2% of the cases. PCF was significantly higher in patients who had pain for more than 12 hours. Unlike right upper quadrant tenderness and Murphy sign, localized rebound, rigidity, and percussion tenderness showed significant correlations with abnormal USG findings. Leukocyte levels correlated significantly with PCF, multiple stones, GWT (>5mm) and distended gallbladder. Complications were significantly higher in patients with over 5 mm GWT and PCF. CONCLUSION: Due to significant correlations with abnormal ultrasonographic findings and the abovementioned parameters, prospective studies to evaluate these parameters for the diagnosis of acute cholecystitis are required.

BACKGROUND: We analysed early and late results of type A aortic dissection in patients over 70 years of age. METHODS: Sixteen patients over 70 years of age, operated for type A aortic dissections were analysed retrospectively. The mean age of the patients were 72.1±1.6 years. Five patients were operated on emergent basis for acute and 11 in elective conditions. Deep hypothermic circulatory support was used in 4 patients. Retrograd cerebroplegia was used in 7 cases. The mean duration of follow-up was 33.2±43.5 months. RESULTS: The rate of early mortality was 18.8% (n=3) due to multiorgan failure. In 4 cases, excess drainage from the chest tubes were noted, and one patient required reoperation for bleeding. Two patients had neurological complications. In 2 patients with acute dissections, low cardiac output syndrome developed. Although they didn’t have coronary artery disease, hemodynamic improvement was noted with inotropes.One patient with acute aortic dissection had renal failure postoperatively. Two patients, one of whom with a history of chronic obstructive pulmonary disease, had respiratory problems postoperatively. CONCLUSION: High variability in mortality rates indicates that advanced age, solely is not an independent predictor of death. Assuming age as a complementary factor defining patient’s clinical status will be helpful for more accurate clinical judgement.

BACKGROUND: Head trauma (HT) patients constitute a major part of referrals to emergency unit (EU). We aimed to evaluate cases with HT who applied to our emergency unit retrospectively. METHODS: A hundred and seventy seven HT cases who applied to EU between January 1, 2001 - June 30, 2003 were analyzed. Age, gender of the patients, time of intervention, type of trauma, level of consciousness, severity of trauma, concomitant systemic trauma, neuroradiological evaluation, intervention in EU, operation requirement and outcomes were recorded. RESULTS: Patients (men, 73.44% and women 26.55 %) referred because of traffic accidents (32 ± 19 yrs;59.88 %) and other etiologies (21 ± 17 yrs;40.11 %). According to Glasgow coma scale (GCS) 79.1% had minimal or mild (GCS:13-15), 3.95% had moderate (GCS:9-12), and 16.95% had severe HT (GCS:3-8). On craniography fracture was present in 25.99%,and on cranial CT lesions were present in 25.99% of the cases. Some of them (18.64%) were discharged after first examination, and 14.12% after short observation. They (24.29%) were admitted to neurosurgery, and 4.52% of them to intensive care units; 4.52% of the cases died in EU; 9.04% of the patients underwent neurosurgical operations. CONCLUSION: While traffic accidents constitute the primary cause of adulthood HT, falls take the lead during childhood. HT is usually of minimal or mild severity. Collaboration in patient transport, first aid and EU are important factors affecting prognosis of HT.

BACKGROUND: We aimed to evaluate the results of the closed manipulation or transcutaneous reduction and external fixation in the treatment of two-part fractures. METHODS: Eight patients with two-part proximal humerus fractures who had been treated in our clinic with closed manipulation or transcutaneous reduction and external fixation between 1996-2001 were evaluated for this study. We evaluated the final functional status according to the Neer’s classification system. RESULTS: Mean age of the patients was 42 (21-75) years. The major aetiologic factor was motor wehicle accident (in 5 cases). Follow-up time was 2 to 4.5 years. Mean union time was 16 weeks (10 to 24). Nonunion and avascular necrosis of the humeral head have not been observed in none of the cases. Superficial pin tract infection was developed in three cases. All of them were treated succesfully with antibiotics. Functional results according to Neer’s classification were as follows: 5 good. 2 fair and 1 failed. Mean score 77, 25 (50 to 89). CONCLUSION: External fixation of displaced two-part fractures of proximal humerus can be assessed as a reliable method with respect to satisfactory fracture reduction and stability, low rate of complications and good early functional results-obtained with this technique.

Traumatic and iatrogenic injuries of the trachea are rare. The most common causes are motor vehicle, especially motorbike accidents. The incidence of tracheal rupture during esophagectomy is reported as 4-10 %. This complication may occur during the dissection of the upper segment of the esophagus from the posterior membranous trachea, especially when there are adhesions. We reported a tracheal rupture during esophagectomy in a 29 year old man with cancer at the post cricoid region of the trachea, which had been irradiated for three months before the operation. While the esophagus was being dissected from the trachea, a vertical rupture extending to carina occurred on the posterior wall causing severe hypoventilation. To improve ventilation the cuffed armored tubes were inserted into both main bronchi which were connected to a "Y" piece. Based on this case we discussed casualties, risk factors, symptoms and anesthetic management of tracheal rupture.

A case of mesenteric fibrosis secondary to post-traumatic mesenteric hematoma, resulting in duodenal stenosis eight years after the traumatic event is presented. A 50 year-old man was hospitalized with nausea and vomiting. An intraabdominal cystic mass was seen in abdominal ultrasonography and CT. Duodenum was found to be obstructed due to extrinsic compression in upper endoscopy. At laparotomy there was an intramesenteric traumatic cyst and fibrosis around the duodenum resulting in duodenal obstruction. After the cyst was unroofed a Roux-en-Y duodenojejunostomy was performed. Both early and late (after 4 months) follow-up results were excellent.

A 14-year-old boy was admitted to the hospital with the complaints of epigastric pain and vomiting for three days following epigastric trauma. Physical examination revealed a palpable mass in the epigastrium without any signs of peritoneal irritation. Vital signs, biochemical analysis, chest and abdominal x-rays were normal. Abdominal US, CT and upper gastrointestinal endoscopy showed that there was a well-defined duodenal intramural mass suggesting hematoma. Intraabdominal solid organs were normal and we did not observe free air or extravasation of contrast media. Therefore, we followed up the patient by US. The hematoma completely resolved 48 days after the trauma.

Incisional hernias are delayed complications of abdominal surgery and occur in 0.5-13.9 % of patients according to various reported series. The causative factors of incisional hernia are related to the condition of the patient, the main disease, surgical techniques and postoperative complications. The subcutaneous herniation of the left hepatic lobe through the abdominal wall is a rare condition. In this case report, we discuss an incarcerated incisional hernia associated with medial segment of the left hepatic lobe.

In electrical injuries, new treatment modalities and guidelines are needed for improving clinical outcome and the survival of damaged tissue. Although there is no published study about hyperbaric oxygen (HBO) therapy for electrical injury in the literature, it is indicated in conditions, which may contribute to the clinical presentation of electrical injury such as thermal burns, crush injuries, necrotizing soft tissue infections, problematic wounds and compromised skin grafts and flaps. An 11-year-old child with high voltage electrical injury treated with adjunctive hyperbaric oxygen for 90 minutes twice a day at 2,4 ATA for one week, then once a day for six days for a total of 20 sessions was presented to demonstrate the beneficial effects of hyperbaric oxygen therapy initiated before irreversible damage had taken place. Although hyperbaric oxygen therapy was initiated rather late, when the most effective window for intervention had already past, HBO was effective in fighting against necrosis, infection and tissue loss. Adjunctive HBO therapy is suggested for electrical injuries for its contribution to healing. In order to see the favourable effects of HBO, it is better to start the treatment within the first 24 hours following injury.

False or pseudoaneurysm formation usually occurs after traumatic, iatrogenic or infective injury to the arterial wall. Despite the high incidence of pseudoaneurysm formation secondary to puncture injury to the common femoral artery [1] false aneurysm formation of the profunda femoris artery (PFA) is a rare complication and has not been previously reported as a complication of orthopaedic surgery. We present a patient who developed a false aneurysm of the PFA secondary to arterial damage caused by a bone fragment dislodged during orthopaedic surgery for fracture of the femur.