ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundBy geographic necessity, rural trauma patients must be initially stabilized at local community hospitals before transfer for definitive care. In this study, it was hypothesized that telemedicine consults with trauma surgeons from a Level I trauma center online while the patient was still in the community hospital ED could positively affect care.MethodsFour community hospital emergency departments in upstate New York and Vermont were equipped with dual cameras with remote control capability. Three trauma surgeons’ homes were wired and equipped with telemedicine systems. Protocols were developed for the initiation of a telemedicine consult.ResultsThere were 26 telemedicine consults over an 8-month period. The telemedicine population was significantly more severely injured and had a higher mortality than the general trauma population admitted to the Level I trauma center. In two cases, it was felt that the telemedicine consultation was potentially lifesaving. On follow-up, more than 80% of the referring providers felt that the telemedicine consult improved care.ConclusionTelemedicine provides a virtual online trauma surgeon to assist with the resuscitation and stabilization of the major trauma patient in a small community hospital. These preliminary results show a positive impact on rural trauma patient care at the local community hospital.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundWith the increasing use of high-resolution diagnostic techniques, minimal aortic injuries (MAI) are being recognized more frequently. Recently, we have used nonoperative therapy as definitive treatment for patients with MAI. The current study examines our institutional experience with these patients from July 1994 to June 2000.MethodsAll patients suspected of blunt aortic injury (BAI) by screening helical CT (HCT) underwent confirmatory aortography with or without intravascular ultrasound (IVUS). MAI was defined as a small (<1 cm) intimal flap with minimal to no periaortic hematoma.ResultsOf the 15,000 patients evaluated by screening HCT, 198 (1.3%) were suspected of having BAI. BAI was confirmed in 87 (44%), and 9 (10%) of these had MAI. The initial aortogram was considered normal in five of the MAI patients. The correct diagnosis was made by IVUS (four patients), and video angiography (one patient). One MAI patient had surgery, and two (22%) died of causes not related to the aortic injury. Follow-up studies were done on the six MAI patients that were discharged. In two, the flap had completely resolved, and in one it remained stable. The remaining three patients formed small pseudoaneurysms.ConclusionTen percent of BAI diagnosed with high resolution techniques have MAI. These intimal injuries heal spontaneously and hence may be managed nonoperatively. However, the long-term natural history of these injuries is not known, and hence caution should be exercised in using this form of treatment.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundImproved outcomes following lung injury have been reported using “lung sparing” techniques.MethodsA retrospective multicenter 4-year review of patients who underwent lung resection following injury was performed. Resections were categorized as “minor” (suture, wedge resection, tractotomy) or “major” (lobectomy or pneumonectomy). Injury severity, Abbreviated Injury Scale (AIS) score, and outcome were recorded.ResultsOne hundred forty-three patients (28 blunt, 115 penetrating) underwent lung resection after sustaining an injury. Minor resections were used in 75% of cases, in patients with less severe thoracic injury (chest AIS scores “minor” 3.8 ± 0.9 vs. “major” 4.3 ± 0.7,p= 0.02). Mortality increased with each step of increasing complexity of the surgical technique (RR, 1.8; CI, 1.4–2.2): suture alone, 9% mortality; tractotomy, 13%; wedge resection, 30%; lobectomy, 43%; and pneumonectomy, 50%. Regression analysis demonstrated that blunt mechanism, lower blood pressure at thoracotomy, and increasing amount of the lung resection were each independently associated with mortality.ConclusionBlunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While “minor” resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundConstruction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries.MethodsUsing a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed.ResultsA total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08–infinity,p= 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96–7.57,p= 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89–4.86,p= 0.076).ConclusionAnastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundA Level I trauma center recently underwent a policy change wherein airway management of the trauma patient is under the auspices of Emergency Medicine (EM) rather than Anesthesiology.MethodsWe prospectively collected data on 11 months of EM intubations (EMI) since this policy change and compared them to the last year of Anesthesia-managed intubations (ANI) to answer the following questions: (1) Is intubation of trauma patients being accomplished effectively by EM? (2) Has there been a change in complication rates since the policy change? (3) How does the complication rate at our trauma center compare with other institutions?ResultsEM residents successfully intubated trauma patients on their first attempt 73.7% of the time compared with 77.2% ANI. The overall success rates, i.e., securing the airway within three attempts, were 97.0% (EMI) and 98.0% (ANI). The airway was successfully secured by EMI 100% of the time while a surgical airway was performed in two ANIs.ConclusionEM residents and staff can safely manage the airway of trauma patients. There is no statistically significant difference in peri-intubation complications. The complication rate for EDI (33%) and ANI (38%) is higher than reported in the literature, although the populations are not entirely comparable.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundHemorrhagic shock-induced splanchnic hypoperfusion has been implicated as a priming event in the two event model of multiple organ failure (MOF). We have previously shown that early postinjury neutrophil (PMN) priming identifies the injured patient at risk for MOF. Recent in vitro studies have demonstrated that postshock mesenteric lymph primes isolated human neutrophils. We hypothesize that lymphatic diversion before hemorrhagic shock abrogates systemic PMN priming and subsequent lung injury.MethodsSprague-Dawley rats (n ≥ 5 per group) underwent hemorrhagic shock (MAP 40 mm Hg × 30 min) and resuscitation (shed blood + 2× crystalloid) with and without mesenteric lymphatic duct diversion. Sham animals underwent anesthesia and laparotomy. Whole blood was taken 2 hours after resuscitation, heparinized, and incubated for 5 min at 37°C. Surface expression of CD11b (a marker for PMN priming) was determined by flow-cytometry compared with isotype controls. In addition, lung myeloperoxidase (MPO) was measured for PMN sequestration, and Evans blue lung leak was assessed in the bronchoalveolar lavage fluid in sham, and shock ± lymph diversion animals.ResultsHemorrhagic shock resulted in increased surface expression of PMN CD11b relative to sham (23.8 ± 6.7 vs. 9.9 ± 0.6). Mesenteric lymphatic diversion before hemorrhagic shock abrogated this effect (8.0 ± 2.6). Lung PMN accumulation, as assessed by MPO, was greater in the lungs of nondiverted (113 ± 14 MPO/mg lung) versus sham (55 ± 4 MPO/mg lung,p< 0.05); lymph diversion reduced lung PMNs to control levels (71 ± 6.5 MPO/mg lung,p< 0.05). Evans blue lung leak was 1.6 times sham in the hemorrhagic shock group; this was returned to sham levels after lymph diversion (p< 0.05).ConclusionPost-hemorrhagic shock mesenteric lymph primes circulating PMNs, promotes lung PMN accumulation, and provokes acute lung injury. Lymphatic diversion abrogates these pathologic events. These observations further implicate the central role of mesenteric lymph in hemorrhagic shock-induced lung injury. Characterizing the PMN priming agents could provide insight into the pathogenesis of postinjury MOF and ultimately new therapeutic strategies.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundPostinjury small bowel ileus is poorly characterized and may be an important factor in intolerance to enteral nutrition (EN). We, therefore, placed jejunal manometry catheters in high-risk trauma patients. Our hypothesis was that the presence of “fasting migrating motility complex (MMC)” activity and conversion to a “fed pattern” at goal rate of EN would be present in those patients who tolerate jejunal feeding.MethodsAfter obtaining baseline fasting manometry pressure tracings, jejunal feeding was advanced stepwise to a set goal while tolerance was monitored and intolerance was treated by a standard approach.ResultsOf the 10 study patients, 7 were able to be maintained on EN. Five (50%) had “fasting MMCs” and had good tolerance to early advancement of EN. The remaining five patients did not exhibit “fasting MMCs” and four had poor tolerance to early advancement of EN. Overall, nine patients reached goal rate of EN of which four converted to a “fed pattern.” This, however, was not associated with later tolerance to EN.ConclusionEN is feasible following severe traumatic shock. Surprisingly, half of the patients had fasting MMCs. This requires intact neural and motor function and was associated with good tolerance of early EN.

ISSN:0022-5282    

出版商:OVID    

年代:2001

数据来源: OVID