ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

To evaluate the efficacy of opiate administration regimens, 32 patients with multiple rib fractures were prospectively randomized to receive either continuous epidural (ED) or continuous intravenous (IV) infusions of fentanyl. Dosage was titrated to individual subjective pain relief. Ventilatory function tests (VFTs), arterial blood gases (ABGs), and visual analog scores were obtained before and after the institution of analgesia. Post-analgesia values were compared with pre-analgesia values using a two-tailed paired t-test looking for significant changes produced by the analgesic method.Both methods significantly improved analog pain scores. The ED method produced improvement in both maximum inspiratory pressure (MIP) and vital capacity (VC), whereas IV analgesia only produced improvement in VC. Intravenous fentanyl produced increases in PaCO2 and decreases in PaO2, whereas no significant changes in ABGs were observed with ED fentanyl administration. Side effects were similar between the groups, with pruritus being more pronounced with ED fentanyl administration.The data demonstrate that the continuous ED fentanyl method offers excellent relief of pain and improvement in ventilatory function and has distinct advantages over IV fentanyl administration with respect to changes in ABGs and MIP. The continuous infusion of epidural opiates should be the preferred analgesic method for patients at high risk of developing pulmonary complications following multiple rib fractures.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

The Pediatric Trauma Score (PTS) has been identified as the only accurate and adequate means of predicting outcome in pediatric trauma. In answer to the increasing number of trauma patients arriving at local hospitals, the ability of the adult Trauma Score (TS) to predict pediatric trauma outcome was tested. Of the total 2,604 pediatric trauma cases in the North Carolina State Trauma Registry, 441 had both a PTS and TS available for analysis. The primary measures of outcome were emergency department and hospital dispositions. Logistic regression demonstrated that TS (R2= 0.50) was a stronger predictor of pediatric outcome and PTS (R2= 0.35) for emergency department disposition and TS (R2= 0.63) with PTS (R2= 0.51) for hospital disposition. The correlation between TS and PTS was high (R = 0.8). Stepwise discriminant analysis demonstrated that TS was the stronger predictor of outcome and the PTS added only 9 (partial R2= 0.09) more accuracy to TS for emergency department disposition and only 6 (partial R2= 0.06) for hospital disposition. The results of this research demonstrate that TS is a useful method of predicting outcome in pediatric trauma. The use of both scores for each patient does not increase the predictive value of the scores.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Payments made for inpatient trauma care were compared using two different patient classification systems—Patient Management Categories (PMCs) and Diagnosis Related Groups (DRGs). Two databases were used in this study: 1) estimated costs for all inpatient claims from one large payor for adult injured patients (n = 5,256) treated at 79 acute care facilities (trauma centers and non-trauma centers) in one geographic region; and 2) hospital charges from statewide, all-payor Maryland data, including 25,987 adult injured patients. The accuracy of PMCs and DRGs in predicting actual costs was examined by level of injury severity and by types of hospital, trauma center vs. non-trauma center. Level of injury (minor, single significant, multiple significant, and major) were defined and operationalized using PMCs. Overall, both DRG and PMC payment systems were nearly equal to the actual costs associated with all injured patients. This relationship can be designed into the weighting scale used for payment. The distribution of DRG payments by injury severity level, however, is not reflective of the differential resources required to manage each patient type. In particular, multiple injuries and major injuries that require the specialized services of a trauma center were inaccurately categorized by DRGs and systematically underpaid by 21.0 to 39.0 by DRG payment. By contrast, the Patient Management Category System classifies patients into more clinically specific and accurate categories and offers a more equitable method of distributing payments by injury severity. These same relationships were also found at the hospital level, demonstrating the potential for use of PMCs as an equitable and viable alternative.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

The value of the TRISS method for interhospital comparisons of trauma care was studied using data for 5,616 consecutive patients from three trauma centers and five community hospitals. Z-scores were used to compare mortality rates. Three limitations of the method were documented: 1) the lack of homogeneity within the patient subcategory of penetrating injuries, specifically between patients with gunshot versus stab wounds; 2) the inability of the TRISS method to predict the survival rate of patients suffering low falls; and 3) the inability of the TRISS method to account for multiple severe injuries to a single body part. Remedies to the first two of these limitations can be addressed within the present TRISS method. A remedy for the third requires a new method.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Recent data have suggested that patients with both a normal cranial CT scan and normal neurologic examination following minimal head injury (MHI) have no risk of neurologic deterioration. This study prospectively examined the safety of discharging patients from the emergency department (ED) after MHI whether or not there was a responsible observer at home. MHI was defined as a history of loss of consciousness (LOC), a Glasgow Coma Scale (GCS) score of 14 or 15, and no focal neurologic findings. In a 4-month period 111 patients with MHI were evaluated. Fifteen (14) patients had a CT scan which revealed an intracerebral injury; 96 patients had a normal CT scan; five patients with normal CT scans were admitted because of persistent lethargy, and one patient was admitted after his CT that demonstrated an old infarct; the remaining 90 patients were discharged. There were 71 men and 19 women with a mean age of 29 years. The mechanism of injury was assault in 55, MVA in 30, and falls in five. The initial GCS in was 15 in 79 and 14 in 11. Fifty-eight per cent of patients were intoxicated. Fifty-seven (63) patients were successfully contacted by telephone; none had developed any neurologic symptoms. Thirty-one patients who could not be followed up gave fictitious phone numbers. These data suggest that CT can reliably triage patients who can be discharged from the ED following MHI, even in the absence of a responsible observer. Hospital admission can be avoided in more than 80 of patients sustaining MHI, better utilizing scarce hospital resources.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

We studied the impact of physician presence on helicopter transportation of trauma victims during two periods; when physicians were part of the flight team and when they were not. Our data failed to demonstrate that physician participation in flights had an impact on patient outcome. The groups were comparable in average distance traveled, initial Trauma Scores, number of organ systems injured, and the final Injury Severity Scores. Each group showed an improved survival over that predicted by comparison with the Multiple Trauma Outcome Study cohort. No difference was found in the number of procedures performed at the scene, en route, or on arrival at the hospital. Untreated injuries were slightly higher in the physician-present group. It appears that experienced nurses and paramedics, operating with well-established protocols, can provide aggressive care that yields equal outcome results compared with those of a flight team that includes a physician.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Twenty-two cases of traumatic below-knee amputation stumps with inadequate soft-tissue coverage salvaged with microvascular free flaps were reviewed retrospectively. All patients would have required an above-knee amputation for prosthesis fitting had microvascular free flaps not been utilized. A total of 24 flaps were used in 22 patients; parascapular 11 (46), foot filet six (25), latissimus dorsi four (17), lateral thigh, tensor fascia lata, and groin one (4). Free flaps were performed immediately after injury in five (21) cases, within the first week in two (8), between 1 and 3 months in 12 (50), and after 3 months in five (21). Fifty per cent of the patients had significant other injuries. The patients had a total of 107 operations (mean, 4.9) related to their injury: 33 (mean, 1.5) of those operations were after the free flap, 27 (25) of which were either performed because of a complication of the free flap or for revision of the free flap. Complications included partial necrosis in five (21), neuroma in three (13), hematoma in two (8), donor site complication in two (8), thrombosis requiring reoperation in one (4), and flap failure in one (4). Patient followup ranged from 12 to 116 months. All patients maintained a functional below-knee prosthetic level. The mean time to ambulation was 5.75 months, and was not significantly affected by flap complications. Most patients employed before their injury were employed after their injury.Despite a protracted course in these severely injured trauma patients, a functional below-knee amputation level was preserved in all cases utilizing microvascular free flaps.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

All cases of penetrating extremity trauma (PET) seen at an urban trauma center were prospectively studied to determine the accuracy and safety of physical examination as the sole mode of evaluation for vascular injury. All patients with PET producing obvious or “hard” signs of vascular injury underwent immediate surgery. All asymptomatic proximity wounds were observed in hospital for 24 hours before discharge to outpatient followup. Patients with non-proximity wounds were discharged immediately. Patients with shotgun wounds and thoracic outlet injuries also underwent arteriography. Of 2,674 trauma patients evaluated during the 1-year study period, 310 (11.6) had 366 penetrating extremity wounds, most (71) occurring in the lower extremities. Gunshots caused most (82) of the wounds, followed by stabs or lacerations (14.5), and shotguns (3). Clinically occult wounds in proximity to major limb vessels were the most common (78) category of clinical presentation, followed by asymptomatic non-proximity wounds (16), and wounds producing hard signs (6). There were two missed vascular injuries, both in the asymptomatic proximity group (0.7 false negatives). Every patient taken immediately to surgery for hard signs had major arterial injury requiring repair, for a 100 positive predictive value for physical examination. No mortality or morbidity were related to protocol management. These results to date support prior reports of a negligible incidence of significant vascular injury following clinically occult proximity PET, and further suggest that the overall predictive value of physical examination of PET for vascular injury approaches 100°.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

The role of arteriography in asymptomatic patients with penetrating extremity wounds in proximity to major vessels is controversial. This prospective study was designed to evaluate a precise definition of proximity, determine the incidence of positive arteriograms, and correlate angiographic interpretation with operative findings. Proximity was defined as any wound located within 1 cm of a major vessel. Excluded were patients with a pulse deficit, bruit, thrill, history of arterial hemorrhage, expanding hematoma, nerve deficit, fracture, or significant soft-tissue injury. One hundred sixty arteriograms were performed in 146 patients. One hundred forty-three (89.4) were true-negatives. Seventeen (10.6) were suggestive of injury. These included seven (4.4) true-positive arteriograms, six (3.8) false-positive studies, and four (2.5) positive arteriograms in patients who were not operated upon. The angiographic report correlated with operative findings in five (38.5) of 13 patients. These data confirm the low incidence (4.4) of vascular injury in asymptomatic patients. The use of extremity angiography when proximity is the sole indication in an asymptomatic patient with a normal vascular examination must be questioned.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID