Seat belt sign (SBS) is frequently seen as a clinical finding in motor vehicle accidents. The purpose of this study is to determine the diagnostic value of SBS. All adult patients presenting with an history of motor vehicle accident to a tertiary care university hospital emergency department was included in this prospective, observational study covered the time period between July 01, 1999 and February 01, 2000. 213 patients were included in this study; 135 (63.4%) were male, and 76 patients (35.7%) were seat-belted. SBS was seen on 27 (35.5%) belted patients. Fourteen of seat-belted had rib fractures nine of those patients with rib fractures were found to have SBS. There was a statistically significant difference between the patient groups with or without SBS in rib fractures (p = 0.0128) While no significant differences were detected between groups regarding the frequency of intra-cranial, intra-thoracic, intra-abdominal and extremity injuries three of four patients who had sternum and clavicular fractures took place in SBS(+) group (p = 0.090). The presence of SBS in trauma patients may create a high index of suspicion for thoracic injuries, especially for rib fractures. It is widely accepted that any delay in the diagnosis may increase morbidity and mortality following thoracic injuries. Further studies are needed to investigate the possible role of SBS in the prediction of the severity of injuries following thoracic trauma.

This study was designed to determine the values of C-Reactive Protein measurements (an acute phase reactant, CRP) and leucocyte counts in prevention of negative appendectomies. Despite improvements in diagnostic methods, negative appendectomy rates still remain between 10-30% in acute appendicitis. Cost-effective and easily applicable diagnostic methods with prompt results are required to reduce negative appendectomy rates. In this prospective study, one hundred twenty-six patients were operated on for initial diagnosis of acute appendicitis between July 1999 and July 2000. CRP and leucocyte count were measured in all cases. The data of the outcomes of clinic and pathological findings were analyzed statistically. Among the 126 study patients, 71 (56.3%) were male and 55 (43.7%) were female. 79 (62.6%) cases had noncomplicated appendicitis, 27 (21.4%) cases had complicated appendicitis and 20 (15.8%) cases had negative appendectomy. The mean CRP level was significantly higher (p < 0.001) in patients with complicated acute appendicitis than in those with noncomplicated acute appendicitis and in those with negative appendectomy. The mean leucocyte count was significantly lower (p < 0.001) in patient with negative appendectomy than in those with noncomplicated appendicitis and in those with complicated appendicitis. Although CRP increases with inflammation, it increases markedly after the occurrence of complication. The increase in leucocyte count is early sign of appendix inflammation. CRP measurements or leucocyte counts are not effective alone to prevent negative appendectomies

This study was performed on 200 patients with a prospective method, between July and October 1998. The aim of the study was to analyze the patients who were admitted directly or referred from another hospital, if they were suitable with the transfer criteria to a level I trauma center. One hundred and seven patients (53.5%) were admitted without ambulance and 93 patients (46.5%) by ambulance to our center. 34% of those patients applied directly and 66% of them were sent from other hospitals. Private ambulances consisted 70%, and 30% the belonged to the national health service. Only 26% of the ambulances had doctor as staff. The most common trauma etiologies were: traffic accidents (42.5%), falling from a height (37.5%) and assaults (11.5%). The mean Glasgow coma score (GCS) of the patients was calculated as 13.9 and mean revised trauma score was 11.7. The Glasgow coma score, revised trauma score and appropriateness to the transfer criteria of the American College of Surgeons were statistically analyzed according to the Fischer Exact test. The results revealed that 96% of the patients with RTS, 86% of the patients with GCS and 60% of the patients with ACS were not appropriate to the transfer criteria to a level I trauma center. In conclusion; we believe that GCS will predict better results in the triage of trauma patients with head trauma in our country

Uncontrolled intracranial hypertension is an important cause of mortality and morbidity in severely head injured patients. Monitoring intracranial pressure (ICP) and controlling intracranial hypertension are essential in preventing herniation and avoiding ischemic secondary brain injury. Head injured patients may require specific ICP treatment to maintain it below 20 to 25 mmHg and improve cerebral perfusion pressure (CPP) above 70 mmHg. The optimal values of ICP and CPP are vary among patients and over time. A basic goal of neurotrauma intensive care is to develop methods for treatment the various traumatic cerebral conditions for individual patients. Various methods to controlling ICP have evolved over the past two decades. Most of these therapeutic maneuvers are critical to optimizing outcomes beyond simply lowering ICP. Continuous ICP monitoring reflects the brain decompensation, allowing early detection of herniation. The present article aims to define the roles of ICP and CPP monitoring as a methods of the ICP reduction therapy after severe brain injury.

The use of thrombolytic agents to treat peripheral arterial occlusions is a new method. There have been clinical trials with Streptokinase, Urokinase and rt-PA (recombinant tissue plasminogen activator). Despite its advantages, information about complications caused by the use of rt-PA and about its place in treatment is still not complete. And there are not enough studies that are made to form a safe protocol for the use of rt-PA in the treatment of acute peripheral arterial occlusions. The aim of this study was to establish a dose range for rt-PA and to follow the patients with a protocol during and after thrombolysis. Between May 1999 to January 2000, 14 patients with symptoms of pain, poikilothermia, cyanosis and loss of function came to Istanbul Medical Faculty Emergency Surgery Unit. Bolus injection of 5 mgr of rt-PA was followed by 15 minutes of interval. The extent of thrombolysis was checked by angiography and then bolus injection of 5 mgr of rt-PA was repeated. After angiographic control, patients having insufficient thrombolysis, received 0.05 mgr/kg/hour of infusion for 12 hours. At the end of 12 hours, thrombolytic treatment ended with a control angiography. A thromboembolectomy operation was made to patients still having an occlusion after thrombolysis. On the other hand, to avoid re-occlusions, all of the patients received 1.5 mgr/kg/day low molecular weight heparin (enoxyparine). for 1 week. At the end of thrombolysis, 9 patients had complete lysis. A patient, having an occlusion in superior mesenteric artery had 60% recanalisation. After thrombolysis, 2 patients (14%) had a stroke. There were no amputations. In conclusion pulse spray thrombolysis with rt-PA is safe and efficient. Moreover there is a reduction in complications and need for surgical procedure. The recent problem is to find the optimum dosages for the best thrombolysis and for least complications.

Insertion of chest drain is always a life saving procedure in emergent conditions. Especially in crowded traffic accidents more than one patient has brought to the emergency service. In this study we review our experience in chest drainage by using classic laparoscopic trocars. During the period between August 1997, and March 2000 chest tubes were inserted using laparoscopic trocars in 27 patients in emergency service, Yozgat State Hospital. We have no complications related to use of this technique. We concluded that use of laparoscopic trocars in chest tube insertion in emergency conditions is an safe and rapid procedure.

In our study, we aimed to present our cases with heart wounds and to determine the factors influencing mortality. We retrospectively evaluated 23 cases with cardiac injuries who were treated among years 1986-99 in our clinic. There were 4 female and 19 male cases, and the average age was 32 years (range 12-52). Heart wounds were caused by blunt trauma in 6 cases, and penetrating trauma in 17 cases. Penetrating heart wounds was caused by gunshot wounds in four patients and stab wounds in 13 patients. Our cases were underwent to rapid resuscitation and emergency surgery. Mortality rate was 17% with 3 cases. Blunt cardiac wounds was caused by motor vehicle accidents in all cases. Diagnosis with immediate echocardiography and efficient treatment was performed. Mortality rate was 33% with 2 cases. We think that emergent resuscitation and immediately surgical exploration in patients with penetrating heart wounds and immediate diagnosis by echocardiography and prompt treatment in patients with blunt heart injuries may improve overall survival.

Twenty-nine cases, penetrating wounds to the heart, who were operated in the thoracic and cardiovascular surgery department of our University during January 1995-August 2000 were reevaluated. Twenty nine patients were men and the mean age was 22.6 (min 12, max 45). The cause of injury was stab wounds in 28 cases and gunshot wounds in 1 case. Besides the clinical findings; teleradiography, echocardiography were valuable for the diagnosis. Surgery was applied in emergent conditions for all cases. Interventions were performed 28 anterolateral thoracotomy, 1 bilaterally anterolateral thoracotomy and additionally 4 laparatomy were performed. The most frequent side of injury was right ventricule. Our mortality ratio was 17.2%, morbidity ratio 17.2%. We think that fast transportation, urgent diagnostic study and immediate surgical intervention important parameters which decrease of the mortality.

Erciyes Üniversitesi Týp Fakültesi Genel Cerrahi Anabilim Dalýnda 85 travmatik diafragma rüptürlü hasta tedavi edilmiþtir. Bu olgular travma mekanizmasý, yaralanma bölgesi, herniye olan organlar, yandaþ yaralanmalar, tedavi þekli, morbidite ve mortaliteye göre retrospektif olarak deðerlendirilmiþtir. Rüptürler 61 hastada (%72) solda ve 24 hastada (%28) saðda idi. 51 hastada (%60) organ fýtýklaþmasý söz konusu idi. Mide %57 ile en sýk fýtýklaþan organ idi. 78 hastada (%92) yandaþ organ yaralanmasý mevcuttu, 1 hasta peroperatif dönemde kanamaya baðlý olarak ve 5 hasta ise postoperatif dönemde multipl organ yetmezliði ile kaybedildi. Genel mortalite oraný %7 idi. (6 olgu). Ameliyat sonrasý komplikasyonlarý yara infeksiyonu (4 hasta) ampiyem (2 hasta), atelektazi (2 hasta), pnömoni (1 hasta) ve intraabdominal apse (1 hasta) idi. Bir hasta yapýþýklýklara baðlý barsak týkanýklýðý nedeniyle tekrar ameliyat edildi. Sonuç olarak, mortalite ve morbiditede en önemli etken yandaþ organ yaralanmasý olarak belirlenmiþtir.

The management of lower extremity trauma with vasculary involvement should be directed toward to the salvage of the extremity or to the primary amputation according to the additional pathologies, parameters of the patient and the extremity. We investigated the efficiancy of Mangled Extremity Severity Score (MESS) system which is proposed as an grading system to evaluate the change to extremity salvage or the risk for onset of systemic complications. 81 patients with lower extremity trauma were analyzed according to MESS criteria. 79 of the patients were men and mean age was 23±4. Fourteen patients had higher MESS score. (MESS > 7). Seven of them were older than 50 years. Primary amputation was performed in four of these 7 patients. Vascular repair was performed in three of patients. Multiorgan failure was developed in two of them and both patients died. Secondary amputation was performed to another patients underwent vasculary repair who had MESS>7 score. Primary amputation was not performed directly in young patients who had MESS > 7. Secondary amputation was required in two of these patients. MESS scoring system can easily predict amputation in older patients but may cause unnecessary amputation in young patients.

PURPOSE: To evaluate the results of the surgical treatment of hepatic injuries in our institution for liver injuries. PATIENTS AND METHODS: One hundred seventy four patients who underwent operations between January 1986-December 1999 in Ataturk University Medical School, Emergency Service were reviewed retrospectively. RESULTS: 135 patients were male (77.5%). The mean age was 25.4 (range 3-84). Sixty three patients (36.3%) had only hepatic injuries and the others had co-existing abdominal organ injury [62 patients (35.7%) had one organ, 29 (16.7%) had two, 17 (9.7%) had three, 2 (1.1%) had four, and 1 (0.5%) had 5 organ injuries]. Five patients (2.8%) had inferior vena cava and 1 (0.5%) had vena porta injuries. One hundred seven patients (61.4%) had blunt, 44 (25.3%) had stab wound and 23 (13.3%) had gunshot injuries. Management was simple suture in 104 patient (60%), primary suture + surgical cell patching in 52 (29.8%), hepatectomy (5 right hepatectomy, 5 non anatomic hepatectomy) in 10 (5.7%), perihepatic packing in 4 (2.3%), primary suture + omental patch in 2 (1.1%), primary suture + arterial ligation in 2 (1.1%). Eleven patients (16.4%) in penetrating trauma group "Penetrating Abdominal Trauma Index" (PATI) score were higher than 25. Fever was the most common complaint postoperatively (5%). Three patients (1.7%) underwent reoperation. Twenty-six patients (14.9%) which one of them ware died. Died in the postoperative periods, 23 (13.2%) had blunt and 3 (1.7%) had penetrating traumas. CONCLUSION: Liver trauma still has high mortality rate injuries are very momentous. Especially blunt trauma related hepatic.

Head trauma is a major health problem which affects young people, especially young males and also causes serious economic losses. Although major head injuries are cause greater morbidity and mortality, minor head injuries are more common presentations to emergency departments. In this study our goal is to determine the prevalence of CT usage in minor, adult head injury patients and determine clinical variables for the use of head CT scans. In our study we retrospectively examined 230 adult head injury patients who were presented to the Dokuz Eylul University Medical School Hospital Emergency Department. We recorded age, gender, symptoms of nausea, vomiting, headache, alcohol use, physical examination findings, history of loss of consciousness prior to presentation, concurrent injuries, and Glasgow Coma Scale (GCS) scores. Head CT ordering and abnormal findings were correlated with the above clinical variables. We ascertained that all variables affected the ordering of CT scans except age, gender and alcohol use. The prevalence of abnormal head CT in all patients were 21.7%. We found that GCS is only one clinical variability of which statistically significant relationship to acquaint abnormal CT findings.

Human being has been encountering huge natural mass disasters since the dawn of existence. In the earthquake both Marmara region on August 17 1999 and Duzce region on November 12 1999, according to official records, 18.287 people were dead and 46.857 were injured. The purpose of this study is to get information by bilateral interviews with those who witnessed this big earthquake in different districts and to contribute in forming a prepared "disaster administration" consciousness for the prospective disasters, under the basis of these information. This study was made by interviewing with 262 people, 82 of whom witnessed the earthquake in the city of Yalova, 90 in Izmit, Bolu and Golcuk and 90 in Istanbul, used a questionnaire form consisted of multi choice and commentary questions. It is of very importance to diffuse educational programmes to increase social consciousness and sensibility about earthquake. Some projects to meet the basic requirements like communication, rescue, accommodation, nutrition and urgent medical support must be developed and embodied. Measures enabling to determine the identities of those who lose their lives in the earthquake must be determined and organized with the collaboration of forensic medical units.

Blunt injury of the aortic arch and its great vessels is rare. Although most of the cases die at the event side, those who can reach the hospital present with a clinic of pseudoaneurysm or arterial occlusion. The mainstay of diagnosis is to have a high suspicion index. As the physical examination findings are subtle, radiodiagnostic tools are helpful. Aortography is the most important investigation technique in suitable cases in order to plan surgery. Extracorporeal circulation and deep hypothermia may successfully be used with known side effects. In this study, we report our recent experience with two cases of blunt injury of the arcus aorta.

A 30 year old man is admitted to the emergency section with the complaint of bleeding from the neck after an industrial explosion. A laceration, 5 cm's in length, is seen on 'zone II', near the medial border of the anterior jugular triangle. The patient was hemodynamically stable, but there was active bleeding from the laceration. A round mass is detected with palpation adjacent to the bifurcation of carotis. The wound is explored under anesthesia with endotracheal intubation. Major vessels and other vital structures found to be undamaged. Many authors suggest mandatory exploration for the neck wounds that penetrated the platysma, while others prefer exploration for selected cases on the basis of diagnostic studies. Immediate exploration is indicated in the presence of active bleeding, and diagnostic studies should be reserved for haemodynamically stable patients. Injury of major vessels might be tamponaded by foreign bodies, therefore blind removal of the objects may cause life-threatening hemorrhage. Endotracheal intubation is appropriate in the management of airway, as for convenient surgical approach.

Acute appendicitis is the most common acute surgical condition of the abdomen. The concept of lumen obstruction as the cause has been widely accepted in the pathogenesis of acute appendicitis. In the literature, we have found a few case reports and a retrospective clinical study related to abdominal trauma as a possible factor in etiology of acute appendicitis. Whether blunt abdominal trauma can be the inciting event leading to acute appendicitis or only is a coincidence is not clear. We represent a case of perforated acute appendicitis after blunt abdominal trauma. Although a causative relationship between trauma and appendicitis cannot be proved in our case, we suggest that appendicitis should be considered in the patients with blunt abdominal trauma for not only medical but also its potential legal implications.

Unwanted haemorrhage can be seen due to long-term oral anticoagulant use. Sometimes these may lead obstructions forming intramural haemotomas. We noticed a case of duodenal obstruction due to an intramural hematoma in a patient who is on chronic oral anticoagulant therapy. In Taksim Hospital 1st General Surgery Department in April 2000, we treated a patient who presented anaemia, jaundice, pyloric obstruction conservatively. As a result we implicated to treat such cases nonoperatively.