摘要:

The efficacy of resuscitative emergency room thoracotomy (ERT), particularly in blunt injury, has been questioned. Wide application of the procedure may not be cost effective. The risk of exposure and lethal infection to medical personnel during ERT is considerable. For the past decade, the policy at this institution has been to perform ERT on all moribund patients sustaining penetrating torso injury and all patients sustaining blunt injury with any evidence of cardiac electrical activity. To evaluate whether such a liberal policy is currently justified, the charts of all patients undergoing ERT over a 4-year period were reviewed. One hundred twelve patients underwent ERT; 24 (21%) sustained penetrating injury, 88 (79%) blunt injury. The overall survival rate was 1.8%. Penetrating injury had a 4.2% survival and blunt injury 1.1%. No patients with CPR initiated at the scene and required throughout transport survived. In those patients with both blood pressure and spontaneous respirations present in the field, survival rate was 11.8%. Survival rate in patients manifesting sinus rhythm or ventricular fibrillation upon arrival at the ER was 6.4%. No survivors were noted among patients coming to the hospital with an idioventricular rhythm or asystole. The total hospital charges for patients undergoing ERT exceeded reimbursement by $59,565. Screening for HIV and hepatitis could be documented in only two patients; both were negative. Liberal performance of ERT has dismal results, incurs monetary loss, and affords a greater potential for exposure to lethal infection. Emergency room thoracotomy is justified only when vital signs or a resuscitatible cardiac rhythm are present in the field or ER and deteriorate shortly before thoracotomy. This policy maximizes survival while diminishing inappropriate expenditure of resources and risk to medical personnel.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Surgical treatment of concurrent orthopedic trauma in burn patients is controversial. During a 10-year period, 101 patients were treated for major fractures and burn injuries. Twenty-eight patients with 34 fractures were treated with early operative fixation. The mean TBS A burned was 20%. Ten fractures were open (4 grade I, 5 grade II, and 1 grade III) and 24 were closed. Seventy-five percent of patients had a definitive orthopedic procedure within 24 hours of burn. Intramedullary nails were used in 13, ORIF in 15, external fixation in 3, and percutaneous fixation in 4. Ten patients had burns overlying the fracture site and the surgical incision was made through burned tissue. Four were associated with open fractures. Two orthopedic complications occurred: nonunion of a femoral neck fracture and angulation of a tibial plateau fracture. The goal of orthopedic management in the polytrauma burn patient is to achieve early reduction to allow optimal wound care and early patient mobility. A team approach to patient selection and management is mandatory.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Experience with conservative management of solid viscus injuries from abdominal trauma in children has produced the impetus for a similar management in adults. To explore the implications of such a policy, we reviewed the records of 82 patients with hepatic injuries noted at laparotomy. Indications for laparotomy were positive findings on diagnostic peritoneal lavage (DPL) or CT scan, or a history of penetrating trauma. The liver injuries were graded according to severity: grade I, 19 patients; grade II, 20 patients (low severity = LS); grade III, 14 patients; grade IV, 6 patients (high severity = HS). Twenty-three injuries were not classified by the operating surgeon. Of the 53 patients with blunt hepatic trauma, 23 (43%) had concomitant injuries that required operative intervention. Twenty-nine patients had penetrating liver injuries. Fourteen (48%) had associated injuries requiring intervention. Patients most likely to have nonoperative management, those with grade I and grade II liver injuries (LS), comprised 48 of the total. In this subgroup there were 26 (54.2%) associated injuries requiring operative intervention. Shock could not be used as a factor to differentiate patients not requiring operative intervention. Nineteen of the LS patients requiring operative intervention secondary to associated injury were never in shock. In adult trauma victims positive DPL findings secondary to minor hepatic injuries that might not require operative intervention serve as a marker for associated injuries that do require operation. The risk of nonoperative management of hepatic injuries based upon radiologic diagnosis is not the result of complications from the hepatic injury. It is related to the delay in detecting significant associated injuries that are not detectable by current radiologic techniques. Exploratory laparotomy based on positive DPL or clinical findings should remain the method of choice in the treatment of abdominal injuries. Conservative treatment of abdominal trauma based upon a radiologic diagnosis of minor hepatic injuries risks delaying the treatment of significant associated injuries.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Diagnosis of cardiac injury in stable patients suffering penetrating precordial trauma has relied on observation, subxiphoid window, or exploratory thoracotomy. Previous reports have stressed the need for an alternative noninvasive diagnostic test. Although the use of echocardiography (ECHO) in this patient population has been suggested, to our knowledge no report thus far has presented extensive experience with this technique. We present our experience over 3 years with 36 patients in whom emergent ECHO was used as part of their initial work-up. Injuries included single stab wounds (17), multiple stab wounds (14), and gunshot wounds (5). Four patients (11%) had jugular venous distention, and 12 (33%) were tachycardic. None had a systolic blood pressure below 90 mm Hg. Four ECHOs (11%) were positive for pericardial effusion. No valvular abnormalities were detected. Three of the effusions were small and these patients were triaged to monitored beds and observed. All three effusions resolved on serial echocardiography. The fourth patient underwent an uneventful operative repair of a left ventricular laceration.Although the yield is low, emergent 2-D ECHO is a valuable tool in the triage of stable penetrating trauma patients when cardiac injury is suspected. Patients without effusion can be discharged or triaged to a ward bed. Small effusions can be observed in a monitored setting with serial examinations, while large effusions should be treated surgically. Echocardiography is less expensive than ICU admission and less invasive than either subxiphoid window or thoracotomy. There are no known complications associated with the procedure and it is recommended for emergent use when available.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

One hundred thirty (44.2%) of 294 patients hospitalized for trauma and admitted to the Surgical Intensive Care Unit for mechanical ventilation developed hospital-acquired bacterial pneumonia. The predominant pathogens isolated were gram-negative enteric bacilli (72%), but there was not an increase in mortality associated with gram-negative pneumonia compared with similar patients without pneumonia. Of the seven admission risk factors univariately associated with the development of acquired bacterial pneumonia, only emergent intubation (p< 0.001), head injury (p< 0.001), hypotension on admission (p< 0.001), blunt trauma as the mechanism of injury (p< 0.001), and Injury Severity Score (p< 0.001) remained significant after stepwise logistic regression. Not surprisingly, as mechanical ventilation is continued, the probability of pneumonia emerging increases. The consequences of hospital-acquired bacterial pneumonia are a significant seven-, five-, and two-fold increase in mechanically ventilated days, intensive care, and hospital stay, respectively. We conclude that the incidence of hospital-acquired pneumonia in injured patients admitted to the ICU for mechanical ventilation occurs in nearly half the patients, is associated with specific risk factors, and significantly increases morbidity but does not increase mortality.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

After a decade of intense fiscal scrutiny, appropriate utilization of intensive care resources remains controversial. In particular, the financial impact of patients transferred to a tertiary surgical intensive care unit (SICU) from a community hospital (interhospital) is unknown, especially when compared with elective (intrahospital) SICU admissions admitted from the tertiary center itself. We prospectively studied outcome and costs in 82 consecutive tertiary SICU admissions. Half were transferred acutely from community hospitals and half were transferred from within the hospital or postoperatively. Severity of illness (APACHE II) was scored on day 1, at the same time of the day (9:00–10:00 AM) and by one attending surgeon (BCB). Acute transfer patients had a significantly elevated mortality (36%) when compared with elective admissions (12%) (p< 0.05). When stratified by APACHE II score, acute transfers had twice the mortality for equivalent APACHE II scores (p< 0.05). Acute transfer patients with APACHE II scores greater than 19 had an 89% mortality; those nonsurvivors cost $128,652 each. From these results we conclude the following: (1) Acute transfer patients have a significantly elevated mortality when compared with elective intrahospital admissions with equivalent APACHE II day-1 scores; (2) patients transferred acutely to tertiary SICUs are significantly more costly, irrespective of outcome; (3) admission source (elective vs. acute transfer) should be seriously considered when evaluating patient outcome and cost in a SICU.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

There is a widespread perception that many trauma centers are poorly reimbursed, and many hospitals that once cared for trauma victims no longer do so, primarily for financial reasons. The problem is blamed on both uninsured and underinsured patients, but data supporting this perception are lacking. To determine the validity of these perceptions and to better understand the nature of trauma center reimbursement, a survey was conducted. A questionnaire on the volume of trauma seen annually and the reimbursement experience for trauma center (TC) and hospital (HO) patient populations was mailed to representative but nonrandomly chosen trauma centers. Seventy-one surveys were mailed and 25 were returned (35%). There were 15 Level I and 10 Level II centers; 16 were urban, seven were suburban, and two were rural. Eighteen centers (72%) reported significant underfunding of the TC in contrast to the HO, and 11 indicated that they would not be able to continue their current level of TC services with present reimbursement. For Medicare patients, HO cost recovery rates averaged 93%, but recovery rates were only 64% for TCs. For Medicaid beneficiaries, the HO cost recovery rate averaged 85%, but it was only 49% for TCs. Thirty-one percent of TC patients had no insurance coverage at all, in contrast to only 9% of HO patients. An aggregate loss equal to 19.9% of total costs was reported by respondents. This survey, while not representative of trauma centers as a whole throughout the United States, does suggest that there is a basis for the perception of underfunding of trauma care and indicates that such underfunding results from the combination of adverse selection and disproportionate share. We also describe a new method for assessing and comparing trauma center reimbursement.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Colloid oncotic pressure (COP) and fluid shifts were studied in 43 septic (SS) patients and 33 injured (HS) patients (ISS = 48.2). During maximal postresuscitation fluid retention, plasma volume (PV/RISA), red cell volume (RBC/51Cr), inulin space (ECF), and COP were measured. Interstitial space (IFS), PV/IFS ratio, and correlation coefficients (r) were calculated. A subgroup of 22 SS patients and 22 HS patients of equal study weight were also compared. Septic patients had greater IFS expansion (17.6 L vs. 11.5 L) than HS patients who, by inference, had more intracellular expansion. Expansion of IFS in SS patients correlated (r= −0.76,p< 0.02) with reduced plasma COP; this was not seen in HS patients (r= −0.09,p> 0.35). In contrast, plasma COP correlated (r= 0.72,p< 0.001) with PV/RISA in HS patients but not in SS patients (r= 0.09,p> 0.35). We conclude: (1) SS patients with greater IFS expansion that correlates with reduced plasma COP likely have increased capillary permeability; and (2) HS patients with less IFS expansion that does not correlate with reduced plasma COP likely have maintained capillary permeability with altered IFS matrix configuration causing reduced protein exclusion.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

The purpose of this experiment was to determine in skin microvasculature the dose response to bradykinin (BRADY). Over a range 0, 0.2, 0.4, and 0.8 μg/kg/min BRADY was infused into the femoral artery of anesthetized dogs while lymph was collected from the hind paw. After 4 hours of continuous BRADY, venous pressure was increased 20 to 30 mm Hg by tightening a tourniquet around the thigh to further increase lymph flow and achieve a filtration-independent lymph–plasma ratio, for albumin (R Alb), immunoglobulin G (R IgG), and immunoglobulin M (R IgM). These proteins were measured with immunoelectrophoresis and immunodiffusion. MEAN ± SD,*p< 0.05, ANOVA, DIFFERENT FROM LOWER DOSE.BRADY caused a dose-related increase in microvascular permeability up to 0.4 μg/min. The increase in the lymph–plasma ratio for the large plasma proteins (IgM, molecular radius 110 Å) is of the same magnitude as for albumin, (molecular radius 36 Å), and this suggests BRADY increased the number but not the size of “large pores” in the microvascular memberane.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

We wanted to determine the effects of WEB 2086, a platelet activating factor (PAF) antagonist, in lipopolysaccharide (LPS) shock in anesthetized pigs. In a randomized study, LPS fromS. abortus equi, 2 μg/kg/h was given IV for six hours. Thirteen animals received LPS and WEB 2086, 10 mg/kg/h IV for 6.5 hours, beginning 30 minutes before LPS. Eleven septic controls received saline and LPS, three nonseptic controls received saline and WEB 2086, and three nonseptic controls received saline only. In six animals we investigated the effect of synthetic PAF in doses between 50 and 10,000 ng on arterial (AP) and pulmonary arterial (PAP) pressure before and during infusion of WEB 2086. The LPS-induced rise in PAP was reduced by WEB 2086 (p= 0.01) but not the decrease in AP. The LPS-induced leukopenia, hypoxia, increase in airway pressure, and release of plasminogen activator inhibitor were reduced by WEB 2086. Platelet activating factor produced an increase in PAP and a biphasic response in AP. All PAF dose response curves were shifted to the right by WEB 2086. Platelet activating factor was a pulmonary hypertensive agent and contributed to the LPS-induced respiratory alterations.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID