摘要:

The ability of the Pediatric Trauma Score (P.T.S.) to predict injury severity and mortality was evaluated by analysis of its relationship with the Injury Severity Score (I.S.S.) of 615 children entered into the National Pediatric Trauma Registry (N.P.T.R.). Mean age was 8.2 years and mortality was 3.5%. Mean I.S.S. of survivors was 8.1 in comparison to 59.7 for nonsurvivors. Linear regression coefficient determined from analysis of these variables produced a slope of —3.7 with a statistically significant correlation of P.T.S. to I.S.S. (p<0.001; r2=0.89). Analysis of the mortality for each cohort of patients with the same P.T.S. identified three categories of mortality potential. Children whose P.T.S. was greater than 8 had a 0% mortality. Children whose P.T.S. was between 0 and 8 had an increasing mortality related to their decreasing P.T.S. (r2=0.86), and children whose P.T.S. was below 0 had 100% mortality. This study documents the direct linear relationship between P.T.S. and injury severity, and confirms the P.T.S. as an effective predictor of both severity of injury and potential for mortality.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

In order to test the hypothesis that outcome from blunt traumatic injury is different for children and adults, a statistical method based on the TRISS Index was used to compare patient outcomes after blunt injury among three pediatric populations (N=594 children: ages 0—3, ages 0—8, and ages 0-14) and an adult population (N=7,809: ages 15—54 inclusive). There was no statistical difference in predicted outcome between these populations. Using a methodology that accounts for both anatomic injury description and physiologic response (TRISS), the survival probability function does not appear to be age dependent below 54 years.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

Since the initial hour after injury is the most crucial time for trauma patients, resuscitation technique is of vital importance. Standardized courses for first-hour management (ATLS) have been widely accepted. A teaching format based upon video recording of every resuscitation has been developed. Tapes are reviewed by the staff and by the individuals involved in a particular resuscitation. In a weekly resuscitation review conference, actual footage is presented to the trauma team members, specific aspects of a resuscitation are critiqued, and supplemental didactic information is presented.Legal problems have been avoided by making the review and conference a part of the quality assurance process. Patient anonymity is preserved by positioning the video camera at the foot of the resuscitation bed. Tapes are erased after each conference.Video recording allows analysis of: 1)prioritiesduring the resuscitation; 2)cognitiveintegration of the workup by the teamleader; 3)physicalintegration of the workup by the teamleader; 4) teammemberadherence to assigned responsibilities, resuscitation time, errors or breaks in technique; and 5) behavior change over time.In 3½ years, more than 2,500 resuscitations have been recorded. Over a 3-month period, average resuscitation time todefinitive caredecreased for age- and injury severity-matched patient groups cared for by one team. Resuscitations have become more efficient and adherence to assigned responsibilities better. Weekly review of resuscitation contributes to improved technique and trauma care.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

In the past 5 years, 72 moribund patients have undergone resuscitative thoracotomy (RT) at the Medical University of South Carolina: 62 patients underwent the procedure before the adoption of a policy of mandatory rapid transport (scoop and run) for penetrating and unstable victims of trauma by our EMS system (Group I). Group II is comprised of ten patients who underwent RT following adoption of this policy. Resuscitation was successful in three patients in Group I (4.8%) and there were only two survivors (3.2%). In contrast, resuscitation was successful in two of ten patients in Group II (20%) and there was one survivor (10%). Nineteen patients in Group I (31%) were in traumatic full arrest on the scene, all of whom died. Twenty-five patients in Group I (40%) had a measurable pulse and/or blood pressure when EMS personnel arrived at the scene and subsequently “died” before their arrival at the trauma center. RT was also uniformly unsuccessful in this subgroup. Eighteen patients in Group I (29%) suffered cardiac arrest following their arrival at the hospital. Three of these patients (16.6%) were successfully resuscitated and two (11%) survived to leave the hospital. There were four traumatic full arrests in Group II (40%) and all four died. Only two patients in Group II (20%) lost their vital signs in transport and both died. Four patients in Group II (40%) suffered cardiac arrest after arrival at the hospital. Two of these patients (50%) were successfully resuscitated and one left the hospital (25%). The average time spent on the scene by EMS was 37 minutes, 15 seconds, in Group I and the average transport time was 13 minutes, 15 seconds. Thus the total mean field time was 50 minutes, 30 seconds, in this group. In the group of patients transported after the adoption of the scoop and run policy, 9 minutes, 30 seconds, were spent on the scene in the average case and the mean transport time was 13 minutes (22 minutes, 30 seconds, total field time). The authors conclude that RT is rarely successful in patients presenting to the emergency department with no vital signs. A significant number of potentially salvageable patients suffer loss of vital signs during prolonged transport. Thus, the overwhelming priority in prehospital management of the severely injured should be delivery of these patients to the emergency department with the least possible time in the field.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

This study assessed the injury severity, patient outcome, the cost of care, and the economic impact of Medicare DRG payment policies on patients referred to a Level I trauma center. Only 11 of 283 admitted traumatized patients were Medicare patients. Yet, these 11 Medicare patients left the trauma center with a deficit of $249,601. No significant differences were found between the Medicare and non-Medicare groups for Trauma Score, CRAMS Score, Glasgow Coma Score, Injury Severity Score, ICU or hospital length of stay, disability, or mortality. Under DRG's, Medicare payments ($4,237 ± 2,351/ patient) have fallen to 20% of prior cost-based Medicare reimbursements ($21,542 ± 34,170/patient), are providing only 16% of hospital costs ($26,928 ± 42,713/patient), and are significantly (p<0.0001) less than non-Medicare reimbursements ($15,288 ± 17,111/patient). Despite the high financial losses occurring when the trauma center treats referred traumatized Medicare patients, when all referred Medicare and non-Medicare patient trauma reimbursements are combined, overall trauma revenues have declined by only 4.3% under DRG's. If Medicare DRG payments were to be adopted by all third-party payers, reimbursement ($5,058 ± 4,090/patient) would be significantly (p<0.0001) less than current hospital reimbursements ($14,801 ± 16,537/patient) and costs ($16,121 ± 17,624/patient). These results indicate that although high financial losses result when caring for traumatized Medicare patients, DRG's have not had a major financial effect upon centers receiving referred trauma patients because of the low numbers of admitted traumatized Medicare patients. However, if third-party payers were to enact the Medicare payment system, devastating economic losses would be inflicted upon major trauma centers.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

In order to better understand the pathophysiologic changes in the immediate postoperative period after total hip replacement surgery and to distinguish alterations due to the surgical operation from those due to bed rest, we examined rheologic parameters and red cell metabolism of patients before, 1 day after, and 5 to 6 days after total hip replacement and compared the results to those obtained from normal volunteers placed at bed rest for 5 days. Bed rest in the control group led to increases in hematocrit, mean corpuscular hemoglobin concentration, red cell DPG and ATP levels, and plasma concentrations of total proteins, globulins, and fibrinogen, with attendant increases in whole blood viscosity, plasma viscosity, blood viscosity, relative blood viscosity with hematocrit adjusted to 45 %, and viscometric aggregation index, and the viscosity of red cell suspensions in Ringer's solution at 45% hematocrit decreased at low shear rate. The patient group, despite the postoperative lowering of their hematocrit, mean corpuscular hemoglobin concentration, and total plasma proteins and a consequent decrease of whole blood viscosity, revealed disproportionate increases in blood viscosity, relative blood viscosity, and viscometric aggregation index. These rheologic changes, which reflect an enhanced red cell aggregability, may contribute to complications of thrombophlebitis. Enforced inactivity, when superimposed on the effects of trauma, blood loss, transfusion with bank blood, and the lowflow state, would exaggerate these rheologic problems. The results suggest that management of total hip replacement patients should include hemorrheologic considerations (e.g., preoperative intentional hemodilution) and early postoperative activity.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

Treatment with thromboxane (Tx) synthase inhibitors or free radical scavengers has been shown to afford protection from renal ischemia. Since free radicals are closely associated with thromboxane (Tx) synthesis, this study examines the thesis that free radical scavengers inhibit formation of Tx. Anesthetized rats (n=42) underwent right nephrectomy. By random choice, before 45 min of left renal pedicle clamping, rats received: 0.5 ml dextrose placebo IV (n=6); the hydroxyl radical scavenger dimethyl-thiourea (DMTU), 500 mg/kg IV (n=10); or the superoxide scavenger superoxide dismutase (SOD), 24,000 Sigma Units (SU)/kg IV (n=12). This dose of SOD was repeated before release of the clamp. Treatment with DMTU and SOD decreased plasma TxB2 levels following 5 min of reperfusion from 2,480 pg/ml in dextrose treated controls to 1,155 pg/ml (p<0.01) and 1,419 pg/ml (p<0.03), respectively. At 24 hr, DMTU and SOD therapy decreased creatinine from 3.0 mg/dl in controls to 1.6 mg/dl (p<0.01) and 2.1 mg/dl (p<0.05), respectively. At 24 hr, DMTU but not SOD decreased left renal weight from 113 to 94% (p<0.0003) of the weight of the previously removed right kidney, and histologically prevented acute tubular necrosis (p<0.05). In nephrectomized but nonischemic sham control rats (n=7) plasma TxB2 and 6- keto-PGF1,,concentrations were 757 pg/ml and 82 pg/ml, creatinine level 0.9 mg/dl and kidney weight 94% of the previously removed right kidney. Sham rats treated with DMTU (n=4) or SOD (n=3) had similar values of creatinine but TxB2levels were decreased to 225 pg/ml (p<0.05) and 262 pg/ ml (p<0.05), respectively. In a second study, platelet-rich plasma (PRP) was incubated with DMTU 10-6to 10-4M (n=7) or SOD 10.8 to 1,080 SU (n=7). Treated PRP was activated with ADP for 1 min, centrifuged, and the supernatant assayed for TxB2. At the highest dose DMTU and SOD decreased supernatant TxB2from 12.0 to 2.5 ng TxB2/108 pits (p<0.004) and 19.9 to 7.3 ng TxB2/108 pits (p<0.05), respectively. Inhibition of TxB by DMTU and SOD was dose dependent. These data indicate that the salutary effects of DMTU and SOD in minimizing renal ischemic injury may be by the direct antagonism of free radicals as well as by an indirect effect on Tx synthesis.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

The purpose of this study was to determine if alcohol worsens arrhythmias produced by nonpenetrating cardiac impact. Twenty-three dogs were studied. Twelve underwent nonpenetrating cardiac impact alone at 12 m/sec with a contact compression of 2 cm. Eleven underwent cardiac impact after having received intravenous alcohol (blood level of 197 ± 37 mg/100 ml) (mean ± SD). Three dogs experienced ventricular fibrillation immediately after impact and died: of these, two underwent impact alone and one underwent impact following ethanol. These three dogs were eliminated from the study. All of the dogs had some form of complex arrhythmia during the first 10 minutes of observation, the average cumulative duration of which during the first 10 minutes following trauma was greater among dogs that received ethanol. No complex arrhythmias other than ventricular premature contractions or ventricular tachycardia were observed after the first 10 minutes following impact. During the first 2 hours of observation following cardiac impact, dogs that received alcohol before trauma showed more single premature ventricular contractions (p<0.03), couplets (p<0.01), triplets (p<0.02), runs of 4-20 beats (p<0.05), and total number of premature ventricular contractions (p<0.05) than dogs that underwent trauma alone. Following the first 10 minutes, ventricular irritability increased with time until approximately 1 hour, and then there was a gradual reduction of the frequency of arrhythmias in both dogs that received alcohol and those that did not. In conclusion, nonpenetrating cardiac impact in dogs that previously received ethanol was associated with greater ventricular irritability than in dogs that underwent impact alone.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

FTCH is a recently developed material which consists of a collagen fleece containing fibrinogen, thrombin, and aprotinin integrated into its surface. FTCH is highly effective in sealing of tissues and in establishing hemostasis. We evaluated FTCH in experimentally produced liver (n=6) and splenic (n=12) injuries in 18 adult mongrel dogs. The stability of the parenchymal seal of the splenic injuries was tested by splenic tissue pressure elevation after temporary ligation of the splenic vein. No breakthrough bleeding occurred up to a parenchymal pressure of 16.3 ± 5 mm Hg. Complete hemostasis was easily achieved in all animals before closure. When the dogs were re-explored postoperatively at intervals of either 14 or 30 days, there was no gross evidence of recurrent bleeding. Histologic examinations demonstrated a partially regenerated capsule covering an unspecific fibrovascular granulation tissue and progressive resorption of FTCH without significant inflammatory response. We conclude the following: FTCH provides adequate hemostatic control of experimental liver and splenic injuries. FTCH has excellent tissue compatibility and can be applied easily and safely to hemorrhaging parenchymal wounds. It will not replace adequate surgical techniques, but could be useful as a quickly available and easily applicable hemostatic means in diffuse or acute bleeding of liver and spleen.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

ICP in 233 patients with severe head injuries was monitored utilizing a subarachnoid catheter technique. The relationships between initial ICP and GCS, between initial ICP and GOS, between maximal ICP and GCS, and between maximal ICP and GOS were examined statistically. The correlation was significant in each case, but particularly so between maximal ICP and GOS. Thus morbidity and mortality may be dependent upon maximal ICP. Catheterization of the subarachnoid space presents little difficulty using a Tuohy needle for epidural anesthesia as an introducer. Though the catheter is very fine (1.0 mm in outer diameter), failure of waveform occurred in only 2.1% of all patients. The procedure can be easily performed at the bedside, is safe, inexpensive, and useful for the management of severe head injuries. Meningitis was recognized in 4.7% of all patients.

ISSN:0022-5282    

出版商:OVID    

年代:1988

数据来源: OVID