ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Eight hundred fifty-four consecutive motor vehicle crash (MVC) victims admitted from August 1, 1986, through August 31, 1989, were prospectively assessed including measurement of blood alcohol concentration (BAC). One hundred six in-hospital interviews were conducted on competent consenting drivers ≥18 years old; 22.9% (n = 22) of those who were BAC tested (n = 96) were positive for alcohol on admission. The blood alcohol concentration positive [BAC(+)] and the BAC negative (-) drivers differed significantly on the following variables: driver education [BAC(-) > BAC(+): p < 0.01], license suspension ≤ 2 years before admission [BAC(+) > BAC(-):p< 0.01], frequency of self-reported intoxication in month before crash [BAC(+) > BAC(-):p< 0.05], driving within 2 hours of drinking ≤1 month before admission [BAC(+) > BAC(-):p= 0.01] and self-reported driving with BAC > 17 mmol/L ≤1 month before admission [BAC(+) > BAC(-):p< 0.01]. Follow-up interviews (n = 106) were conducted 1 year after discharge; drivers originally testing BAC(+) were more likely to drive within 2 hours of drinking (p< 0.05), and were more likely to admit to driving with a BAC > 17 mmol/L (p< 0.01). Original BAC(+) drivers were also more likely to report a subsequent MVC in the year following discharge (not statistically significant). There is a need to develop an assessment system to identify high crash-risk drivers and establish rehabilitation programs to reduce crash recidivism.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

This in vivo study confirmed impaired hemostasis during hypothermia in a swine model. Group I (normothermic, n = 8) and group II (hypothermic, n = 8) animals were anesthetized and instrumented for continuous peritoneal irrigation and monitoring of heart rate and blood pressure. The effects of hypothermia, hypotension, and inotrope on bleeding time and bleeding from two types of arterial injuries were evaluated. Our findings were that (1) bleeding time was significantly prolonged in hypothermic animals; (2) the differences in blood loss from partially torn artery (PTA) and completely cut artery (CCA) at both normothermic and hypothermic temperatures did not reach statistical significance; and (3) blood loss from PTA was greater than CCA when norepinephrine (Levophed) was infused to elevate blood pressure in hypotensive animals at normal core temperature.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Since right blunt traumatic diaphragmatic rupture (BTDR) is reported with increasing frequency, BTDR may be a disease in evolution. Data were collected on 59 left, 16 right, and five bilateral BTDRs at a level I trauma center. Patients with right BTDR had lower Glasgow Coma Scale (GCS) scores (p< 0.05), were more likely to be initially in hypovolemic shock, and were admitted directly from the field (p< 0.01). Left and right BTDRs were diagnosed from chest films in 37% and 0% of cases, respectively (p< 0.05). Diagnostic peritoneal lavage results were negative in 16% of left and 0% of right BTDRs. For right BTDRs, the liver was more likely to be injured (p< 0.001). The mortality rates were similar and ICU and hospital stays, complications, and duration of mechanical ventilation were similar for early survivors with right and left BTDRs. The clinical signs and symptoms, diagnosis, and surgical findings associated with right and left BTDR are different.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Although there has been recent comparison of the Canadian and American health care systems, the issue of trauma has received little attention. Data were collected on all adult motor vehicle crash (MVC) victims admitted to the Sunnybrook Trauma Unit (CAN), Toronto, Canada, and the R Adams Cowley Shock Trauma Center (USA), Baltimore, Maryland from July 1986 through July 1990. Similar MVC victims at CAN and USA had equivalent mortality rates with similar discharge dispositions (p= NS), but patients at USA were twice as likely to be admitted to the ICU and had longer ICU stays (p< 0.01). The hospital-based cost for an average MVC patient at CAN was significantly less than for an average patient at USA and professional charges were at least five times greater at USA. This study provides some insight into the differences in trauma care between Canada and the United States.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

From January through December 1990, a prospective study comparing the accuracy of diagnostic peritoneal lavage (DPL), abdominal computed tomographic (CT) scanning, and abdominal ultrasonographic (US) scanning was carried out. Patients with stable vital signs following their initial resuscitation coupled with equivocal physical examination findings received both CT and US scanning. A DPL was then done. If any of these three examinations produced positive findings, a laparotomy was done and the surgical findings were compared with the results of the diagnostic studies. Fifty-five patients were studied (44 men, 11 women), with a mean age of 43 years and a mean ISS of 18.5 ± 10.5. The sensitivity, specificity, and accuracy were 100%, 84.2%, and 94.5% for DPL, 97.2%, 94.7%, and 96.4% for CT scanning, and 91.7%, 94.7%, and 92.7% for US scanning. Problems do exist in identifying isolated small intestinal perforations with ultrasonography. Since more and more trauma centers are using ultrasonography in the emergency department as a screening method in the management of patients with blunt abdominal trauma, it is important to avoid overestimating its capability. Frequent re-evaluation of the patient's condition, repeat ultrasonographic scans, diagnostic peritoneal lavage, and CT scanning are complementary and important in the diagnosis of blunt abdominal trauma.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Setting priorities in the management of patients with suspected injuries to both the head and the abdomen is difficult and depends on the likelihood of different injuries. Eight hundred trauma patients were retrospectively reviewed to determine the likelihood of a surgically correctable cerebral injury. All 800 patients, at the time of initial evaluation, were thought to have potentially correctable injuries to both the head and the abdomen. Of these, 52 had a head injury requiring craniotomy; 40 required a therapeutic celiotomy. Only three patients required both craniotomy and therapeutic celiotomy. There were more cases of delay in therapeutic celiotomy because of negative results of computed tomographic (CT) scanning of the head (13 cases) than there were delays in craniotomy because of nontherapeutic celiotomy (four cases). Need for craniotomy, based on emergency department evaluation, was indicated by the presence of lateralizing neurologic signs. Low Glasgow Coma Scale score, anisocoria, fixed/dilated pupils, loss of consciousness, facial or scalp injuries, and age were of no independent value in predicting the need for craniotomy.Conclusions: Patients with surgically correctable injuries of both the head and the abdomen are rare. In stable patients with altered mental status and potential injuries to both the head and the abdomen, the abdomen is best evaluated first by diagnostic paracentesis. If paracentesis does not return gross blood, CT scanning of the head should be done. If gross blood is obtained and there are no lateralizing signs, it is best to proceed directly to celiotomy without first obtaining a CT scan of the head. If gross blood is obtained on initial paracentesis and there are lateralizing signs, CT scan of the head should be obtained before celiotomy. The likelihood of a treatable brain injury in patients with lateralizing signs is high enough that the head should take precedence over the abdomen.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Over the past 14 years, 2079 patients have been seen at our institution with renal trauma. Of these, 84 sustained gunshot wounds (81 unilateral, 3 bilateral; a total of 87 renal units). We evaluated this group to characterize the nature of their injuries and establish a methodology for renal salvage and reconstruction. Preoperative radiographic staging was performed with excretory urography (IVP) or computed tomographic (CT) scanning. The injuries were classified into five categories: 16 contusions (18.4%), 12 minor lacerations (13.8%), 44 major lacerations (50.5%), six vascular injuries (6.9%), and nine combination laceration and vascular injury (10.3%). Most patients had multiple organ injuries, with 79 requiring associated surgical procedures (94%). The mean Injury Severity Score (ISS) was 26.7 (range, 4–59). Based on radiographic and clinical staging criteria, 69 renal injuries were surgically explored (79.3%), and 12 patients underwent nephrectomy (13.8%). Forty-six renal units were reconstructed (66.6%) by various methods, including renorrhaphy, omental pedical flaps, mesh or peritoneal patch grafts, partial nephrectomy, and vascular repair. Overall, 75 renal units were salvaged (86.2%). Early renal vascular control was achieved in all patients who underwent renal exploration. Follow-up functional studies were done in 24 (28.5%): none had delayed nephrectomy or postinjury hypertension. Overall, 79 patients survived (94%); however, mortality was not related to renal injury. These findings suggest that aggressive radiographic staging coupled with early vascular control and careful selection of reconstructive techniques can ensure a high renal salvage rate in patients with renal gunshot injuries.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Continuous arteriovenous hemofiltration (CAVH) has recently become useful in the treatment of acute renal failure following trauma. It allows continuous volume removal and avoids the acute hemodynamic changes often seen with hemodialysis. To determine the risks of CAVH catheters, the records of trauma patients undergoing CAVH from August 1989 through May 1992 were reviewed. Of 4685 trauma patients, 29 developed renal failure requiring dialysis, with 26 managed with CAVH. Vascular access was obtained via 126 percutaneous 8F femoral arterial and venous catheters (64 arterial, 62 venous) and four Scribner shunts. There was a total of 309 CAVH-D days, with an average of 11.9 days per patient. Complications included one femoral arteriovenous fistula, one pseudoaneurysm, and one deep venous thrombosis, resulting in a 3.1% (2 of 64) arterial complication rate and a 1.6% (1 of 62) venous complication rate. The incidence of arterial complications compares with that of angiography, but complications were major and required surgery. Alternative techniques such as continuous venovenous hemofiltration may prove beneficial.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

The significance of candiduria in critically ill patients remains unclear. It may represent harmless colonization or a potentially life-threatening infection. We analyzed 47 patients in the surgical intensive care unit (SICU) (trauma: 20, general surgery: 15, neurosurgery: 12) who had candiduria, defined by a colony count greater than 100,000/mL. Twenty-seven of these patients were studied retrospectively. Twenty were evaluated prospectively. All patients were receiving broad-spectrum antibiotics for bacterial infections.Retrospective group:ten patients (group A) did not develop disseminated candidiasis, whereas 17 patients (group B) did. Group B had higher APACHE II scores on admission (13.4 ± 7.8) and at the time of candiduria (13.7 ± 4.4) when compared with group A [admission: 5.0 ± 4.6; candiduria: 6.7± 3.6 (p< 0.02)]. In group B, disseminated candidiasis was not diagnosed and treated until 9.9 ± 4.4 days after development of candiduria.Prospective group:twenty patients with candiduria were treated with systemic fluconazole (group C) at the time of candiduria. The APACHE II scores of group C on admission (12.8 ± 3.9) and at the time of candiduria (10.5 ± 4.0) were comparable with those of group B. No patient in Group C developed disseminated candidiasis. The septic mortality rates of groups A, B, and C were 0%, 53%, and 5%, respectively (p< 0.05–0.0001). In patients exhibiting ongoing sepsis and organ failure (high APACHE scores), candiduria may be an early indicator of systemic infection. Diagnosis of disseminated infection and its treatment may be delayed if conventional criteria for candidiasis (positive blood cultures, multiple site isolation) are awaited. Intravenous fluconazole therapy at the time of urinary isolation appears to prevent disseminated infection.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID