摘要:

BackgroundAlthough not directly involved in designation per se, the American College of Surgeons (ACS) Committee on Trauma verification/consultation program in conjunction withResources for Optimal Care of the Injured Patienthas set the national standards for trauma care. This study analyzes the impact of a recent verification process on an academic health center.MethodsPerformance improvement data were generated monthly from the hospital trauma registry. Forty-seven clinical indicators were reviewed. Three study periods were defined for comparative purposes: PRE (January, June, October 1997), before verification/consultation; CON (April 1999–October 1999), after reorganization; and VER (November 1999–September 2000), from consultation to verification.ResultsStatistically significant (p< 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (< 120 minutes) improved in each study section (PRE, 21%; CON, 48%; VER, 76%). Enhanced nursing documentation correlated with improved clinical care such as early acquisition of head computed axial tomographic scans in neurologic injured patients (PRE, 66%; CON, 97%; VER, 95%). Intensive care unit length of stay (< 7 days) decreased (PRE, 87%; VER, 97.8%). Other transformations included increase in institutional morale with recognition of trauma excellence within the hospital and resurgence of the trauma research programs (60 institutional review board–approved projects).ConclusionThe ACS verification/consultation program had a positive influence on this developing academic trauma program. Preparation for ACS verification/consultation resulted in significant improvements in patient care, enhancement of institutional pride, and commitment to care of the injured patient.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundContinuing controversy surrounding the value of scene helicopter evacuation of urban trauma victims led to the present study.MethodsA retrospective review was performed of all patients brought to our trauma center from the injury scene by helicopter from 1990 to 2001.ResultsThe study included 947 consecutive patients, 911 with blunt trauma and 36 with penetrating injuries. The mean Injury Severity Score (ISS) was 8.9. Fifteen patients died in the emergency department, 312 patients (33.5%) were discharged home from the emergency department (mean ISS, 2.7), and 620 patients were hospitalized (mean ISS, 11.4). Three hundred thirty-nine of the hospitalized patients (54.7%) had an ISS ≤ 9; 148 patients had an ISS ≥ 16. Eighty-four patients (8.9%) required early operation, mostly for open extremity fractures; only 17 patients (1.8%) underwent surgery for immediately life-threatening injuries. For 54.7% of the patients, the helicopter was judged to be clearly faster than would have been possible by ground transport. In 140 additional patients (14.8%) with prolonged scene time, the helicopter was probably faster than ground ambulance. Considering faster transport time and either the need for early operation or hospitalization with an ISS ≥ 9 as advantageous, a maximum of 22.8% of the study population possibly benefited from helicopter transport.ConclusionThe helicopter is used excessively for scene transport of trauma victims in our metropolitan trauma system. New criteria should be developed for helicopter deployment in the urban trauma environment.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundShock resuscitation is integral to early management of severely injured patients. Our standardized shock resuscitation protocol, developed in 1997 and implemented as a computerized intensive care unit (ICU) bedside decision support tool in 2000, used oxygen delivery index (Do2I) ≥ 600 mL/min/m2as the intervention endpoint. In a recent publication, Shoemaker et al. refuted positive outcome effect of early supranormal Do2(i.e., Do2I ≥ 600) resuscitation. In response to and because of ongoing concern for excessive volume loading, we decreased our Do2I endpoint from 600 to 500. Our hypothesis was that by decreasing the Do2I endpoint, less crystalloid would be administered. We compare resuscitation responses to the protocol with goals of Do2I ≥ 600 versus 500 in two patient cohorts.MethodsA standardized protocol was used to direct bedside decisions for resuscitation of patients with major injury (Injury Severity Score > 15), blood loss (≥ 6 units of packed red blood cells), metabolic stress (base deficit ≥ 6 mEq/L), and no severe brain injury. The protocol logic is to attain and maintain Do2I ≥ a specified goal for the first 24 ICU hours using primarily blood and volume loading. Two cohorts were compared: Do2I ≥ 500 (18 patients admitted February–August 2001) versus Do2I ≥ 600 (18 patients admitted during 2000 age and gender matched with the Do2I ≥ 500 group). Data were analyzed using analysis of variance, &khgr;2, andttests (p< 0.05).ResultsBoth groups had similar demographics (age 30 ± 3 years; 78% men; Injury Severity Score 27 ± 3), hemodynamics, and severity of shock at start of resuscitation in the ICU. Resuscitation response was Do2I increase to ≥ 600 for both cohorts within ∼12 hours. Throughout the 24-hour ICU process, the Do2I ≥ 500 cohort received less lactated Ringer’s volume than the Do2I ≥ 600 cohort (total of 8 ± 1 vs. 12 ± 2 L;p< 0.05) and tended to receive less blood transfusion (total of 3 ± 1 vs. 5 ± 1 units of packed red blood cells).ConclusionShock resuscitation using Do2I ≥ 500 was indistinguishable from Do2I ≥ 600 mL/min/m2. Less volume loading was required to attain and maintain Do2I ≥ 500 than 600 using computerized protocol technology to standardize resuscitation during the first 24 ICU hours.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundAbdominal compartment syndrome has been reported to occur after fluid resuscitation in injured patients, even in the absence of intra-abdominal injuries. This report describes a set of patients who developed the secondary extremity compartment syndrome (SECS) in uninjured extremities after resuscitation for other injuries.MethodsThis study was a retrospective chart review of all trauma patients developing SECS at a Level I trauma center. Data are mean ± SD.ResultsFrom 1996 to 2001, 10 patients (8 men, age 31 ± 13 years, Injury Severity Score of 29 ± 17, and 3 with penetrating trauma) from a series of 11,996 trauma admissions developed SECS after resuscitation for other injuries. The mean number of extremities developing the SECS per patient was 3.1. This included compartment syndromes in 10 upper extremities and in 12 lower extremities that did not have any apparent injuries (i.e., contusions, fractures, or vascular injuries). After evaluation by the trauma team, abdominal silos were needed in 7 of the 10 patients also, and the mortality in patients with the SECS was 70%.ConclusionSECS is a rare complication of the postresuscitation systemic inflammatory response syndrome, is associated with significant morbidity, and may be a marker for mortality. SECS should be ruled out by measurement of compartment pressures in uninjured and injured extremities in patients with severe diffuse edema after resuscitation for injury.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundBase deficit (BD), as an endpoint for trauma resuscitation, has been extensively studied in the adult trauma patient but not in the pediatric population. We proposed that admission BD would correlate with outcomes after trauma in a pediatric population.MethodsThis study was a retrospective review of all patients admitted to the pediatric intensive care unit in an adult trauma center with pediatric commitment in whom an admission BD was available, over the 5-year period ending June 2001.ResultsA total of 65 patients formed the study population. Overall mortality was 20%. Patients who died were younger (6 ± 5 vs. 9 ± 5 years;p= 0.009), had lower Glasgow Coma Scale scores at admission (7 ± 5 vs. 10 ± 5;p< 0.0001), had higher Injury Severity Scores (24 ± 14 vs. 14 ± 9;p< 0.0001), and had lower Pediatric Trauma Scores (7 ± 4 vs. 10 ± 2;p< 0.0001). No patient with a BD less negative than −5 died, whereas 13 of 37 patients with a BD of −5 or higher died (37%) (p< 0.0001). Of the 13 patients who died, 8 never cleared their BD and died within 33 ± 18 hours of admission. Failure to clear BD was associated with 100% mortality. Five patients who normalized their BD died of isolated closed head injuries (time to death, 37 ± 18 hours;p= not significant). All surviving patients normalized their BD within 43 ± 41 hours of admission. Seventy-five percent of patients who survived (39 of 52) had a normal BD within 48 hours of admission.ConclusionAdmission BD in the pediatric trauma patient is a strong indicator of posttraumatic shock. An admission BD of ≤ −5 is predictive of severe injury and of poor outcome, with a 37% mortality in this series. Failure to clear BD is an extremely poor prognostic indicator.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe use of open abdomen techniques in damage control laparotomy and abdominal compartment syndrome has led to development of several methods of temporary abdominal closure. All of these methods require creation of a planned hernia with later reconstruction in patients unable to undergo fascial closure in the early postoperative period. We review a method of late primary fascial closure, thus eliminating the need for delayed reconstruction in some patients.MethodsThe records of all patients managed with open abdomens over a 5-year period at a Level I trauma center were reviewed for injury characteristics, operative treatment, final abdominal closure type and timing, and outcome. Patients requiring open abdomen who were unable to undergo fascial closure in the early postoperative period were managed with a vacuum-assisted fascial closure (VAFC) technique. This allows for constant tension on the wound edges and facilitates late fascial closure. Patients managed with planned hernia (HERNIA group) were compared with those undergoing fascial closure ≥ 9 days after initial laparotomy (LATE group) for injury severity, fistula rate, and mortality. All patients in the LATE group underwent VAFC.ResultsFrom September 1996 to October 2001, 148 patients required management with an open abdomen. Fifty-nine underwent fascial closure, 37 of these before postoperative day 9 and 22 on or after day 9. Mean time to closure in the LATE group was 21 days (range, 9–49 days). Injury Severity Scores were similar in the HERNIA and LATE groups (26 vs. 30,p= 0.28), as were admission base deficit (−8.8 vs. −9.5,p= 0.71), number of fistulas (1 vs. 0,p= 0.99), and mortality (17% vs. 14%,p= 0.99).ConclusionVAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy. Complication rates do not differ from patients with planned hernia, and the need for future abdominal wall reconstruction is avoided.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundIn light of their potential for devastating consequences, a liberalized screening approach for blunt cerebrovascular injuries (BCVI) is becoming increasingly accepted. The “gold standard” for diagnosis of BCVI is arteriography; however, noninvasive diagnostic alternatives offer clear advantages. Recent series have demonstrated the ability of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) to identify BCVI, but have not compared their accuracy with arteriography. We hypothesized that CTA or MRA could reliably identify BCVI, obviating the need for arteriography. The purpose of this study was to determine the accuracy of CTA and MRA in identifying BCVI in asymptomatic patients.MethodsAsymptomatic patients meeting criteria for BCVI screening underwent arteriography, according to our institutional standard. A subset of patients requiring computed tomographic scanning underwent CTA; a subset of patients requiring magnetic resonance imaging underwent MRA. All of the studies were interpreted by radiologists in a blinded manner. Data were analyzed for sensitivity and specificity.ResultsForty-six patients underwent both CTA and arteriography. Of 23 with a normal CTA examination, 7 (30%) had BCVI on arteriography. Of 23 with an abnormal CTA examination, 8 (35%) had a normal arteriogram. The sensitivity, specificity, positive predictive value, and negative predictive value of CTA were 68%, 67%, 65%, and 70%, respectively. CTA missed 55% of grade I injuries, 14% of grade II injuries, and 13% of grade III injuries. Sixteen patients underwent both MRA and arteriography. One (11%) had a false-negative MRA result, and four (57%) had false-positive MRA results (75% sensitivity, 67% specificity, 43% positive predictive value, 89% negative predictive value).ConclusionCTA and MRA can identify BCVI, but they miss grade I, II, and III injuries. Future technical modifications may improve their accuracy. A prospective multicenter trial is warranted to define the capabilities and limitations of these noninvasive modalities. In the interim, arteriography remains the gold standard for diagnosis, but if arteriography is not available, CTA or MRA should be used to screen for BCVI in patients at risk.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThere is no simple way to assess the injured patient after a loss of consciousness. Computed tomographic scanning is required to rule out anatomic injuries, and invasive intracranial pressure monitoring is needed for the patient with severe traumatic brain injury (TBI). We hypothesized that a noninvasive acoustic monitoring system could provide useful clinical data on the severity and progression of TBI.MethodsTwenty-eight consecutive patients with severe TBI and an indication for invasive intracranial pressure monitoring were studied using the Brain Acoustic Monitor (BAM). Monitoring occurred for 1- to 3-hour time periods on the day of enrollment and each day until the patient’s condition stabilized. BAM signals were categorized on the basis of amplitude and positive-to-negative deflection ratio, and then compared with the patient’s clinical outcome.ResultsBAM signal correlated very strongly with clinical outcome: in 27 of 29 sessions with a normal signal, patients were discharged at a Glasgow Coma Scale score > 13, whereas in 36 of 42 sessions with an abnormal signal, the patient either died or left the hospital with a Glasgow Coma Scale score < 9 (p< 0.00001). The correlation between clinical outcome and initial BAM reading was even stronger: 10 of 10 patients with a normal signal did well, as compared with 3 of 18 patients with an abnormal signal.ConclusionNoninvasive monitoring of the injured brain can discriminate those patients who will have a poor clinical outcome from those who will do well. Further trials of the BAM are indicated.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe purposes of this study were to determine how clinically relevant levels of acute ethanol (EtOH) influence cerebral perfusion pressure (CPP), cerebral venous O2saturation (Scvo2), and systemic hemodynamics after fluid resuscitation from traumatic brain injury (TBI); and to test the hypothesis that the actions of EtOH on these variables are mediated by adenosine.MethodsAnesthetized swine were ventilated (Fio2= 0.4) and instrumented. In protocol 1, EtOH (3.5 g/kg, n = 11) or its vehicle (n = 17) was administered orally before TBI + 40% hemorrhage. At 90 minutes post-TBI, resuscitation consisted of shed blood + saline. In protocol 2, either saline (n = 15) or an adenosine-regulating agent (5-amino-4-imidazolecarboxamide riboside) in saline (1 mg/kg bolus + 12 mg/kg/h intravenously [i.v.]) (n = 5), was administered i.v. before TBI + 45% hemorrhage. At 90 minutes post-TBI, resuscitation consisted of saline only (three times shed blood volume). In protocol 3, EtOH was administered i.v. (1 g/kg; 20% vol/vol in saline) followed by either an adenosine receptor antagonist (theophylline, 10 mg/kg) or an adenosine uptake inhibitor (dipyridamole, 0.25 mg/kg).ResultsIn protocol 1, with no EtOH, 11 of 17 (65%) survived post-TBI hypotension. Mean arterial blood pressure, cardiac index, and mixed venous oxygen saturation were stable for 1 hour at 40% to 60% below their respective baselines, whereas lactate increased three- to fourfold (allp< 0.05). After fluid resuscitation, most variables rapidly corrected, but intracranial pressure was increased 10 to 15 mm Hg (p< 0.05). With EtOH, 9 of 11 (82%) survived post-TBI hypotension (p= 0.42 vs. no EtOH). After resuscitation from TBI, there were significant effects of EtOH on systemic hemodynamics (mean arterial pressure, cardiac index, mixed venous oxygen saturation), on CPP, on lactate, and on Scvo2at normo- and hypercapnia (allp< 0.05). The data from protocol 2 showed that essentially none of these changes were duplicated with an adenosine−regulating agent. In protocol 3, i.v EtOH produced small but significant changes in Scvo2, intracranial pressure, and lactate, at normo-, hyper-, and hypocapnia. Dipyridamole and theophylline tended to have opposite, albeit small and not statistically significant, effects on these variables relative to EtOH alone.ConclusionAcute EtOH (200–300 mg/dL) did not increase mortality after TBI + secondary hypotension, as long as cardiopulmonary support was provided. With EtOH, CPP was maintained and cerebral blood flow appeared to be adequate, if not excessive, with respect to cerebral metabolic demand, as judged by changes in Scvo2at normo-, hyper-, and hypocapnia. These changes were probably not mediated, but might have been modulated, by increases in endogenous adenosine.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID