ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundThe ideal method of repairing serious small bowel injuries remains unknown. Prior reports suggest a higher rate of enteric anastomotic-related complications (EACs) with stapled posttraumatic bowel anastomosis but did not specifically focus on the small bowel or clarify fully the actual anastomotic construction.MethodsThis was a retrospective review of patients requiring surgical repair of small bowel perforations at a Level I urban American center (Detroit Receiving Hospital [DRH]) and a Canadian provincial trauma center (Vancouver Hospital and Health Sciences Center [VHHSC]). All patients requiring a primary repair and/or resection were included. Anastomoses were hand-sewn, stapled, or combined stapling and sewing with mucosal inversion. Leaks, anastomotic fistulae, and intra-abdominal abscesses were considered specific EACs. A sample size of 53 per group was obtained to detect a 17% difference at alpha = 0.05 (one-sided) and beta = 0.2.ResultsFull-thickness small bowel injuries were repaired in 232 patients (DRH, 165; VHHSC, 67). Injuries were penetrating at DRH (91.5%) and blunt at VHHSC (65.7%). Anastomotic repairs in 127 patients (158 anastomotic repairs [DRH, 113; VHHSC, 55]) were 64 (40.5%) stapled, 38 (24.1%) hand-sewn, and 56 (35.4%) combined. Also, 105 patients had 349 primary closures of an injury. Overall, there were 24 EACs. After anastomosis, there were 11 intra-abdominal abscesses: 6 after stapling, 3 after being sewn, and 2 after a combined construction. There were four small bowel anastomotic fistulae: three after stapled-only anastomosis and one after hand-sewing. After enteroenterostomy, the EAC rate was 10.2% per patient, or 8.4% per anastomosis. After primary repairs, one patient had an anastomotic fistula, which closed spontaneously, and 11 had intra-abdominal abscesses, yielding an EAC rate of 10.6% per patient or 3.4% per repair. A primary repair was significantly less likely to be associated with an EAC than any anastomosis (p= 0.035). No method of anastomosis was statistically safer in relation to EACs, whether analyzed by patient, by anastomosis, or by considering primarily either the use of a linear stapler or the principle of inverting the mucosal approximation. Only damage control procedures and associated pancreaticoduodenal injuries were identified as statistically significant predictors using multiple logistic regression analysis.ConclusionAnastomotic complications after enteroenterostomy or primary repair for trauma are uncommon regardless of the technique, but surgeons must be especially cautious during or after damage control. Primary repairs are desirable, but when anastomosis is unavoidable, the method of repair should reflect that with which the surgeon is the most comfortable.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundStandard rewarming methods for posttraumatic hypothermia are ineffective or require systemic heparinization. Centrifugal vortex blood pumps (CVBPs), heparin-bonded circuits, and, potentially, percutaneous access techniques, facilitate the institution of an extracorporeal circulation by noncardiac surgeons.MethodsSeven severely hypothermic patients requiring emergent operative intervention were rewarmed intraoperatively using the CVBP with heparin-bonded circuitry.ResultsPatients were critically ill (average Injury Severity Score of 43.5 [SD, 13.6] for the traumatized patients). The mean temperature before rewarming was 31.5°C (SD, 1.6°C). The CVBP outflow site was the common femoral vein in all patients, with the inflow into the superficial femoral artery (n = 2), contralateral common femoral vein (n = 2), and internal jugular vein (n = 3). The mean time to rewarm to 37°C was 73.3 (SD, 30.5) minutes. All patients survived the initial operation, although the ultimate survival was 43%.ConclusionNoncardiac surgeons can effectively use an extracorporeal rewarming strategy incorporating a heparin-bonded CVBP to rapidly rewarm hypothermic coagulopathic patients undergoing surgery.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundHypertonic saline/dextran (HSD) fluid resuscitation has been demonstrated to be effective in alleviating the adverse effects of hemorrhagic hypotension. The optimal dose of HSD has not been defined.MethodsThe comparative effectiveness of various dosages of HSD for the treatment of severe hemorrhage was investigated in conscious swine bled 46 mL/kg over 15 minutes, a lethal procedure. Five minutes after the completion of hemorrhage, animals were treated with 1, 2, 4, or 11.5 mL/kg HSD and observed over the next 96 hours.ResultsThe 11.5-mL dose resulted in 100% survival, which was statistically superior to the 1- and 2-mL doses but not the 4-mL dose. Survival incidences with 4, 2, and 1 mL/kg were 83%, 64%, and 13%, respectively.ConclusionIn terms of survival time, the 11.5- and 4-mL/kg doses were not significantly different. Therefore, optimum resuscitative effectiveness of HSD is achieved within the dose range of 4 to 11.5 mL/kg.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundOur goal was to evaluate computed tomographic (CT) scans of the chest as a means of stratifying smoke inhalation injury (SII) severity.MethodsTwenty anesthetized sheep underwent graded SII: group I, no smoke; group II, 5 smoke units; group III, 10 units; and group IV, 16 units. CT scans were obtained at 6, 12, and 24 hours after injury. Each quadrant of each slice was scored subjectively: 0 = normal, 1 = interstitial markings, 2 = ground-glass appearance, and 3 = consolidation. The sum of all scores was the radiologist’s score (RADS) for that scan. Computerized analysis of three-dimensional reconstructed scans was also performed, based on Hounsfield unit ranges: hyperinflated, −1,000 to −900; normal, −899 to −500; poorly aerated, −499 to −100; and nonaerated, −99 to +100. The fraction of abnormal lung tissue (FALT) was computed from poorly aerated, nonaerated, and total volumes. Mean gray-scale density (DENS) was also computed.ResultsSII resulted in severity- and time-related changes in oxygenation (alveolar-arterial gradient), ventilation (respiratory rate-pressure product), DENS, FALT, and RADS. Ordinal logistic regression generated a predictive model for severity of injury (r2= 0.623,p= 0.001), retaining RADS at 24 hours and rejecting the other variables.ConclusionAt 24 hours, CT scanning enabled SII severity stratification; qualitative evaluation (RADS) outperformed current semiautomated methods (DENS, FALT).

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundSide air bags (SABs) have been introduced in an attempt to reduce the risk of injury in near-side-impact motor vehicle collisions (MVCs). The impact of SABs on MVC-related mortality and morbidity has yet to be evaluated with a large population-based study. The objective of this study was to assess the effectiveness of SABs in reducing the risk of injury or death in near-side-impact MVCs.MethodsA retrospective study investigated outboard front seat occupants involved in police-reported, near-side-impact MVCs using data from the General Estimates System (1997–2000). The risk of MVC-related nonfatal and fatal injury for occupants of vehicles with and without SABs was compared.ResultsFront seat occupants of vehicles with SABs had a risk of injury similar to that of occupants of vehicles without SABs (risk ratio [RR], 0.96; 95% CI confidence interval [CI], 0.79–1.15). Adjustment for the potentially confounding effects of age, gender, seat belt use, seating position, damage severity and location, and vehicle body type did not meaningfully affect the association (RR, 0.90; 95% CICI, 0.76–1.08).ConclusionsThere is no association between the availability of SABs and overall injury risk in near-side-impact MVCs. Future research is necessary to determine the effectiveness of SABs in preventing the injuries for which they were specifically designed.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundDetermination of nonsurvival in trauma patients is difficult because valid prognostic indicators are lacking. It was hypothesized that patients presenting with a Glasgow Coma Score (GCS) of 3 as well as fixed and dilated (FD) pupils do not have a reasonable chance of survival.MethodsFrom 1999 through 2001, adult trauma patients (age, >14 years) admitted with a GCS of 3 were reviewed. Patients receiving paralytic agents before initial assessment were excluded from analysis. Fixed and dilated pupils were defined as being 4 mm or more in diameter bilaterally and nonreactive to light. In this study, the FD patients were evaluated for survival, resuscitative measures, surgical procedures, length of hospital stay, and organ donation. The non-FD patients were evaluated for survival and length of hospital stay.ResultsOf the 137 patients evaluated with a GCS of 3, 104 had FD pupils and 33 did not. In the FD group, there were no survivors. On arrival, 28 (37.3%) of the patients were declared dead, and no further interventions were undertaken. Of the 76 patients (62.7%) who underwent further resuscitation, which included 53 surgical procedures, 30 died in the resuscitation bay, 39 within 24 hours, 4 within 48 hours, 2 within 72 hours, and 1 on day 6. There were 18 (23.7%) organ donors. Of the 33 patients without FD pupils, 11 (33%) survived to discharge (mean hospital stay, 21.4 days). Of the 22 nonsurvivors (67%), 10 died in the resuscitation bay, 8 within 24 hours, 1 within 48 hours, 1 on day 4, and 2 on day 6.ConclusionsPatients presenting with a GCS of 3 and FD pupils have no reasonable chance for survival. A significant percentage of these patients can be salvaged for organ donation. This information should be used in deciding to pursue aggressive resuscitation efforts and in discussing prognosis with family. Patients with a GCS of 3 who are not FD should be aggressively resuscitated because many of these patients survive to discharge.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundTransporting all trauma patients to regional trauma centers is inefficient; however, the bypass of nearer, nondesignated hospitals in deference to regional trauma centers decreases mortality in the severely injured. One approach to improving efficiency is to allow the initial assessment of selected patients at lower level (Level III/IV) designated centers. We set out to evaluate whether patients initially assessed at these centers and then transferred to a Level I facility were adversely affected by delays to definitive care.MethodsThis is a retrospective cohort study in which the primary exposure being evaluated is initial assessment at a Level III or IV trauma center before transport to a Level I center in an urban setting. The outcomes in this transfer cohort were compared with outcomes in patients transported directly from the scene to a Level I center (direct cohort). The outcomes of interest were mortality, length of stay, and hospital charges. Multivariate analyses were used to adjust for differences in baseline characteristics across these two cohorts.ResultsCrude length of stay was comparable, whereas mortality was lower and charges were 40% higher in the transfer cohort (n = 281) compared with the direct cohort (n = 4,439). After adjusting for confounders, mortality and length of stay were similar and total charges were significantly greater in the transferred patients.ConclusionInterfacility transfers in a mature urban trauma system do not appear to impact on clinical outcome. However, transfer patients use significantly greater resources as measured by hospital charges. This effect is likely because of the nature of their injuries or, alternatively, delays in reaching definitive care.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundMild traumatic brain injury (MTBI), alone or in combination with other injuries, is frequently present in trauma patients requiring hospital admission. A survey was conducted to characterize the current practices of identification and management of patients with MTBI at Level I trauma centers in the United States.MethodsSurveys were mailed to trauma program managers at 68 verified Level I trauma centers.ResultsThirty-five (51.4%) centers responded, representing 24 states. Multiple terms are used synonymously with MTBI, and less than half (45%) of centers formally evaluate all trauma patients with MTBI. Patients identified with MTBI discharged from the emergency department are referred for further evaluation at only 34% of centers. There is no consistent practice for determining which hospitalized patients with MTBI are formally evaluated, who performs the evaluations, or which evaluation tool(s) are used. Patients with MTBI and cognitive deficits are referred to a variety of specialists after discharge.ConclusionThere is currently no standard practice for defining, evaluating, or managing MTBI at Level I trauma centers. A consistent definition of MTBI and its management could promote recognition of MTBI; facilitate data collection, analysis, and comparison; and provide guidelines for activity modification during recovery.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundThe burden of childhood injury is often described using vital statistics for mortality and hospital admissions as a measure of morbidity. Hospital admissions, however, reflect the process of care and do not directly measure children’s functional disability. The purpose of this study was to determine the influence of mechanism of injury on the functional outcome 6 months after injury in children in an inpatient trauma unit of a pediatric referral hospital.MethodsA retrospective cohort of 357 children aged 2 to 15 with an Injury Severity Score (ISS) > 12 was studied to determine the relationship between mechanism of injury (based onInternational Classification of Diseases, Ninth Revisione-code) and functional outcome 6 months after hospital discharge. Wee Functional Independence Measure (WeeFIM) was used to assess functional outcome. Any child with a WeeFIM score less than the maximum (of 126) attainable was classed as requiring assistance, and the relative risk of requiring assistance at 6 months was calculated for each injury mechanism. Poisson regression analysis was used to assess the importance of mechanism of injury, after adjusting for age, gender, ISS, and a primary diagnosis of central nervous system (CNS) injury.ResultsMechanism of injury had a significant effect on the functional outcome at 6 months: 72% of pedestrians, 64% of cyclists struck by cars, and 59% of injured motor vehicle occupants required assistance during daily activities. By contrast, only 27% of those injured playing sports and 22% of cyclists injured without motor vehicle involvement required assistance. The relative risk of children requiring assistance was similar with or without adjustment for age, gender, ISS, and CNS injury.ConclusionMechanism of injury is significantly associated with requiring assistance 6 months postdischarge, even after controlling for age, injury severity, and the presence of a CNS injury. These data are important both when discussing the prognosis for an individual patient and also when considering the population impact of childhood injuries.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID