ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundControversy exists regarding the impact of pediatric trauma centers (PTC) on survival for injured children. However, functional outcome for children treated at PTC compared with adult trauma centers (ATC) has not been evaluated.MethodsAn analysis of children entered in the Pennsylvania Trauma Outcome Study between 1993 and 1997 was conducted. Patients were stratified according to type of trauma center: PTC; Level I ATC; Level II ATC; or ATC with added qualifications (AQ). Functional outcome at discharge was analyzed.ResultsFor severely injured children, there was an overall trend toward improved functional outcome at PTC compared with ATC AQ and ATC I, but no difference compared with ATC II. PTC showed improved functional outcome at discharge for head injury compared with ATC AQ and ATC I.ConclusionThere is an overall trend toward improved functional outcome at discharge for children treated at PTC compared with those treated at ATC AQ and ATC I. Improved outcome for head injury may be a key factor contributing to improved outcome at PTC.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundMultiple organ failure (OF/MOF) was found to be the major complication after blunt multiple trauma during the last 25 years and was correlated with a high mortality rate. Recently, several publications reported a decreased ARDS-related mortality, but there is little information about mortality rates from posttraumatic MOF. The purpose of this study was to describe the development of MOF-related death after blunt multiple trauma during the last 25 years.MethodsBlunt multiple trauma patients with an Injury Severity Score (ISS) > 15 points were included in this evaluation. According to the year of trauma, the population was divided into five groups: years 1975–1980 (n = 317), years 1981–1985 (n = 308), years 1986–1990 (n = 246), years 1991–1997 (n = 368), and years 1998–1999 (n = 122). Main outcome measurements were death, cause of death, and length of ICU stay. Patients dying within the first 24 hours after trauma were excluded. All data indicated in the Results section are presented as mean ± SEM. Continuous variables were compared by ANOVA.Ordinal variables were analyzed by &khgr;2contingency table analysis and, if significant, subsequently by Fisher’s exact test (two-tailed test,p< 0.05).ResultsMean ISS remained unchanged between 1975–1980 (ISS 29 ± 1) and 1998–1999 (ISS 31 ± 1) (p= 0.56). During the observation period, the mean age increased from 33 ± 1 years (1975–1980) to 40 ± 2 years (1998–1999) (p= 0.03). The overall incidence of OF/MOF slightly increased from 25.6% (1975–1980) to 33.6% (1998–1999) (p= 0.1). Length of ICU stay was not different between 1975–1980 (LOS: 14 ± 1 d) and 1998–1999 (LOS: 19 ± 2 d) (p= 1.0). The overall mortality decreased significantly, from 28.7% (1975–1980) to 13.9% (1998–1999) (p< 0.001). While the mortality due to severe head injuries remained unchanged (1975–1980, 8.2%; 1998–1999, 9.0%) (p= 0.85), mortality due to OF/MOF decreased significantly (p< 0.001), from 18.0% (1975–1980) to 4.1% (1998–1999). The age of patients dying from OF/MOF increased significantly (p= 0.04) during the observation period, from 44 ± 3 years (1975–1980) to 63 ± 6 years (1998–1999).ConclusionAlthough MOF incidence remains unchanged, there is a significant fall in MOF-related mortality in patients with severe trauma, and death from single organ failure is virtually absent. Severe brain injury is now the leading cause of death in patients with severe multiple injuries admitted to the ICU.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundThe exact mechanism by which tracheostomy results in clinical improvement in respiratory function and liberation from mechanical ventilation remains unknown. Physiologic dead space, which includes both normal and abnormal components of non-gas exchange tidal volume, is a clinical measure of the efficiency of ventilation. Theoretically, tracheostomy should reduce dead space ventilation and improve pulmonary mechanics, thereby facilitating weaning from mechanical ventilation.MethodsThis study compares arterial blood gases (ABG), pulmonary mechanics, including minute ventilation (VE) and dead space ventilation (Vd/Vt) within 24 hours before and after tracheostomy in 45 patients admitted to a surgical intensive care unit.ResultsThere was no difference noted in patients’ ABG or VE. Pre- and posttracheostomy change in Vd/Vtwas negligible (50.7 and 10 vs. 51.9 and 11;p= NS). On subgroup analysis, those patients that were weaned from mechanical ventilation with 72 hours of tracheostomy (T3) were compared with those patients weaned from mechanical ventilation 5 days or more after tracheostomy (T+5). Again, no difference was found in pulmonary mechanics or Vd/Vtpre- and posttracheostomy.ConclusionThere is minimal improvement in pulmonary mechanics after tracheostomy. The change in physiologic dead space posttracheostomy does not predict the outcome of weaning from mechanical ventilation. Tracheostomy does allow better pulmonary toilet, and easier initiation and removal of mechanical ventilation and control of the upper airway.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundIn multiple trauma patients, early continuous cardiac output (CCO) monitoring is frequently desired but is difficult to routinely employ in most emergency departments because it requires invasive procedures. Recently, a noninvasive cardiac output (NICO) technique based on the Fick principle and partial CO2rebreathing has shown promise under a variety of conditions. Since this method has not been tested after lung damage, we evaluated its utility in a clinically relevant model.MethodsAnesthetized, ventilated swine (n = 11, 35–45 kg) received a unilateral blunt trauma via a captive bolt gun followed by a 25% hemorrhage. After 60 min of shock, crystalloid resuscitation was given as needed to maintain heart rate < 100 beats/min and mean arterial pressure > 70 mm Hg. Standard CCO by thermodilution (Baxter Vigilance, Irvine, CA) was compared with NICO (Novametrix Medical Systems Inc., Wallingford, CT) for 8 hr.ResultsThe severity of the injury is reflected by seven deaths (average survival time = 4.25 hr). Trauma increased dead space ventilation (19%), airway resistance (30%), and lactate (3.2 mmol/L), and decreased dynamic compliance (48%) and Pao2/Fio2(54%). In these extreme conditions, the time course and magnitude of change of CCO and NICO were superimposed. Bland-Altman analysis reveal a bias and precision of 0.01 ± 0.69 liters/min. The linear relationship between individual CCO and NICO values was significant (p< 0.0001) and was described by the equation NICO = (0.74 ± 0.1)CCO + (0.65 ± 0.16 liters/min) but the correlation coefficient (r2= 0.541) was relatively low. The cause for the low correlation could not be attributed to increased pulmonary shunt, venous desaturation, anemia, hypercapnia, increased dead space ventilation, or hyperlactacidemia.ConclusionNICO correlated with thermodilution CCO, but underestimated this standard by 26% in extreme laboratory conditions of trauma-induced cardiopulmonary dysfunction; 95% of the NICO values fall within 1.38 liters/min of CCO; and with further improvements, NICO may be useful in multiple trauma patients requiring emergency intubation during initial assessment and workup.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectivesThe objective of this study was to compare the injuries and outcomes of ejected victims who reached a Level I trauma center with nonejected MVC occupants.MethodsData from 6,909 MVC victims admitted to a Level I trauma center, over a 91/2-year period, were retrospectively reviewed. Three mutually exclusive groups were studied: ejected, nonejected nonrestrained, and nonejected restrained.ResultsThe patient distribution was as follows: ejected 6.4% (n = 443), nonrestrained 50.1% (n = 3,461), and restrained 43.5% (n = 3,005). Ejected patients were younger, required ICU care more frequently, and a higher percentage were males compared with nonrestrained or restrained patients. Injury Severity Score (ISS) and length of stay (LOS) were significantly higher in ejected patients. Ejected patients suffered more injuries per anatomic region, and had a higher number of severe injuries in the head and neck region. The overall in-hospital mortality was 3.9% (272/6,909), and 10.8% (48/443) for the ejected group. The incidence of restrained patients increased during the study period but was not associated with a change in the incidence of ejected patients.ConclusionPatients who were ejected after motor vehicle collisions were more severely injured and had a worse outcome than those not ejected. Efforts should be concentrated on enforcement and enactment of better seat belt laws, as well as the development of new strategies that will prevent ejection regardless of occupant behavior.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundThe nontherapeutic laparotomy rate in penetrating abdominal trauma remains high and the morbidity rate in these cases is approximately 40%. Selective management, rather than mandatory laparotomy, has become a popular approach in both stab wounds and gunshot wounds. The advent of spiral technology has stimulated a reassessment of the role of computed tomography (CT) in many aspects of trauma care. We prospectively investigated the current utility of triple-contrast CT as a diagnostic tool to facilitate initial therapeutic management decisions in penetrating torso trauma.MethodsWe studied hemodynamically stable patients with penetrating injury to the torso (abdomen, pelvis, flank, back, or lower chest) without definite indication for laparotomy, admitted to our trauma center during the 1-year period from 7/99 through 6/00. Patients underwent triple-contrast enhanced spiral CT as the initial study. A positive CT scan was defined as any evidence of peritoneal violation (free air or fluid, contrast leak, or visceral injury). Patients with positive CT, except those with isolated solid viscus injury, underwent laparotomy. Patients with negative CT were observed.ResultsThere were 75 consecutive patients studied: mean age 30 years (range 15–85 years); 67 (89%) male; 41 (55%) gunshot wound, 32 (43%) stab wound, 2 (3%) shotgun wound; mean admission systolic blood pressure 141 mm Hg (range 95–194 mm Hg); 26 (35%) had positive CT and 49 (65%) had negative CT. In patients with positive CT, 18 (69%) had laparotomy: 15 therapeutic, 2 nontherapeutic, and 1 negative. Five patients had isolated hepatic injury and 2 had hepatic and diaphragm injury on CT and all were successfully managed without laparotomy. Of these seven patients, three had angioembolization and two had thoracoscopic diaphragm repair. In patients with negative CT, 47/49 (96%) had successful nonoperative management and 1 had negative laparotomy. The single CT-missed peritoneal violation had a left diaphragm injury at laparotomy. CT accurately predicted whether laparotomy was needed in 71/75 (95%) patients.ConclusionIn penetrating torso trauma, triple-contrast abdominopelvic CT can accurately predict need for laparotomy, exclude peritoneal violation, and facilitate nonoperative management of hepatic injury. Adjunctive angiography and investigation for diaphragm injury may be prudent.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundTo determine the utility of routine serial head computed tomography (H-CT) for predicting need for invasive neurosurgical intervention in patients with blunt intracranial injuries (BICI).MethodsPatients treated at a Level I trauma center with BICI over a 4-year period were reviewed.ResultsOf the 4,273 blunt trauma patients evaluated, 9.7% (415/4,273) were diagnosed as having BICI. Invasive intervention (craniotomy, ICP monitoring, ventriculostomy, or angiogram) was performed in 41.2% (171/415) of patients with BICI. Of these, 94.7% (162/171) had the procedure performed as a result of the initial H-CT. The remaining 5.3% (9/171) had the intervention performed as a result of a subsequent H-CT. Serial H-CT documented worsening of BICI in 32.3% (64/198) of the patients, but only those who had significant corresponding clinical deterioration had an invasive procedure as a result.ConclusionIn patients with an unchanged or normal neurologic exam, a routine serial H-CT did not influence subsequent invasive neurosurgical intervention.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundDespite the current emphasis on injury prevention, little has been done to incorporate alcohol intervention programs into the care of the injured patient. The purpose of this study was to determine whether patients admitted to a trauma center with positive toxicology findings (TOX+) have a higher subsequent injury mortality than those without such findings (TOX−).MethodsWe followed a cohort of 27,399 trauma patients discharged alive between 1983 and 1995 to determine subsequent mortality. Death certificates were obtained to identify the cause of death.ResultsTOX+ patients had an injury mortality rate approximately twice that of the TOX− group (1.9% vs. 1.0%,p< 0.001). Overall, 22.7% of the deaths were due to injury; the TOX+ rate was 34.7% versus 15.4% for the TOX−.ConclusionThese data add strength to the premise that untreated substance abuse-related injury remains an untapped injury prevention opportunity.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundThe purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults.MethodsThrough the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively.ResultsFifteen percent of patients were 55 years of age or older. A similar proportion of patients ≥ 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients ≥ 55 was significantly greater than patients < 55 (43% vs. 23%). Patients ≥ 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%,p< 0.05) and failed NOM (29% vs. 12%,p= 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women ≥ 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (bothp< 0.05).ConclusionPatients ≥ 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women ≥ 55 had significantly greater mortality and failure of NOM than women < 55.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID