摘要:

Determinants of the wounding effects of a metallic projectile include the velocity, mass, shape, and stability of the missile, and whether it tumbles, deforms, or fragments within the body. The velocity, mass, shape, and stability influence its capability to penetrate through the skin, and the other factors influence the depth and volume of the wound. The energy lost into the tissues (kinetic energy deposition) is a greater determinant of potential wound volume than is the striking velocity, even though, because K.E. = 1/2 MV2, the potential striking K.E. is more strongly influenced by velocity than mass. The actual size and shape of the wound is influenced by tumbling, deformation, and fragmentation of the projectile and by the characteristics of the tissues and organs contacted. The pulsating temporary cavitation resulting from the passage of a high-velocity projectile produces blunt trauma that extends beyond the tissue actually contacted by the missile. The pulsation of the temporary cavitation with resulting strong negative pressure components permits contamination of the entire wound track of a perforating wound, with entrance of external contaminants from both the exit and the entrance sites. The extent and type of treatment required is determined more by the tissues and organs injured than by the characteristics of the wounding agent. Although extremity wounds from high-velocity projectiles may heal uneventfully, surgical exploration is indicated whenever there is a possibility of subfascial penetration, and obviously devascularized tissue should be excised. In circumstances in which contaminated devascularized tissue cannot be excised promptly or adequately, prophylactic topical antibacterial therapy (such as mafenide aqueous spray, which can penetrate through devascularized tissue) may prevent otherwise lethal infection.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

To elucidate the mechanism of persistent dyspnea after blunt chest trauma, we prospectively studied the pulmonary function of 18 patients with blunt chest trauma for 6 months. Nine of the patients had flail chest and 12 had pulmonary contusion (PC). Pulmonary function was evaluated using spirometry, arterial blood gas analysis, chest x-ray studies and CT scans. Functional residual capacity (FRC) remained significantly reduced throughout the 6 months in patients with PC. Such patients experienced a fall in Pao2when changed from a sitting position to a supine position and they had fibrous changes in the contused lung as demonstrated by CT scans at 6 months after injury. These findings were supported in an additional study of another 20 patients who had suffered PC 1 to 4 years previously. This study demonstrated that pulmonary function recovered within 6 months in patients without PC even with a residual deformity of the thoracic wall caused by flail chest, while patients with PC had decreased FRC and a fall in Pao2when moved to the supine position even several years after injury. This might be related to the persistent dyspnea seen after blunt chest trauma.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

A key element in the treatment of Adult Respiratory Distress Syndrome (ARDS) is improvement in oxygen delivery to match metabolic demands. Conventional modes of ventilation have decreased mortality (50%) very little. We have done a retrospective analysis of 30 surgical patients who were treated with pressure-controlled inverse ratio ventilation. Mortality was 10%. Arterial oxygenation improved from 40.8 ± 12.2 mm Hg to 13.8 ± 47.2 mm Hg, while Pco2decreased from 37.8 ± 7.6 mm Hg to 31.1 ± 5.9 mm Hg. Simultaneously, with the use of pressure-controlled inverse ratio ventilation, minute ventilation could be decreased by 30%, which may be secondary to increased O2delivery to the tissue. Our data indicate that pressure-controlled inverse ratio ventilation may be beneficial to surgical patients with ARDS.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

We conducted a 5-year follow-up study of a group of 461 consecutive trauma patients treated in our Intensive Care Unit from 1980 to 1983. The entry criteria (initial survival and severe injury: ISS ≥ 18) were fulfilled by 233 patients with a mean ISS of 29.3 and mean age of 35.6 years. Data on prehospital care, type and timing of surgery, and hospital and ICU stay were recorded during hospital discharge. The protocol strictly asked for a personal interview and a physical examination. Mailed questionnaires or phone interviews were not allowed. The areas of medical sequelae, aftercare, missed injuries, occupation, insurance, social integration, economics, legal aspects, and traffic involvement were covered.We were able to gather final information from 223 (95.6%) of the 233 cases. Forty-three patients (18.4%) died in the hospital, 13 patients (5.6%) died later, and 167 (76.5%) were eventually seen. Only 10 patients (4.4%) were lost to follow-up. Outcome was judged using the Glasgow Outcome Scale (GOS), which was compared with a GOS value given prospectively at the time of hospital discharge. Eighty-nine percent of the survivors were healthy or slightly disabled (GOS 5 and 4), 9% were severely disabled, and only 2% were in a persistent vegetative state. Outcome after 5 years was better than tentatively prognosed at the time of hospital discharge. Ninety-one patients with severe head injuries (AIS 4–5) were additionally tested using the Mini Mental State instrument. This test revealed normal mental functions in 77% and dementia, mostly of a minor degree, in 23% of the head-injured patients. Almost all the early deaths and two thirds of the late deaths were related to severe head injury. Seventy-nine percent of the survivors were working after 5 years. During the post-trauma period, patients experienced reduced social well-being and also changed professional and recreational activities. There appears to be extensive room for improvement in the posthospital recovery phase. We conclude that survivors of critical trauma have a very good chance, after 5 years, of regaining a high quality of life. All efforts at improving trauma survival and quality of trauma care are therefore worthwhile and deserve high priority.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

To help map the continuum from injury to return to full function, the Functional Independence Measure (FIM) was used in an acute care setting to identify and track disability, to focus rehabilitative efforts during the acute phase of care, and to help demonstrate what is truly important in getting patients back to full functional status. A total of 109 patients were assessed over a 13-month period. FIM scores were based on a patient's ability to routinely perform certain tasks in 18 areas of function and ranged from 1 to 7. The change in FIM scores from admission to discharge was used to determine those patients to be discharged home and those patients to be discharged to a rehabilitation facility. We conclude that the FIM is a very useful tool that produced a very good measure of a patient's total function, tracked progress or lack of it through acute hospitalization, and correctly categorized and quantitated dysfunction (both cognitive and physical) as discharge planning was being done.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

The necessity of including survivors with minor (ISS <10) injuries in a statewide trauma registry with a quality assurance focus was evaluated. During a 3-month period, data for 3,594 admissions to 28 trauma centers were entered into the registry. Of these admissions 1,696 patients (50.8% of patients studied) had an ISS <10. Of those, 10 (0.6%) were nonsurvivors and 67 (3.9%) had severe disability (66) or were in a persistent vegetative state (PVS) (1) at hospital discharge. Five nonsurvivors were 65 years of age or older. Four were injured in falls and one was an injured pedestrian. The disabled subset included a high percentage of older patients (61.2% ≥ 55). Minor falls, including those from a bed or chair or from the same level accounted for nearly one half (46.2%) of the disabling injuries. Fifty-one disabled patients had isolated extremity or pelvic fractures. Their hospital stays ranged from 1 to 42 days and averaged 13.0 days. The proportion of elderly in the United States is increasing substantially. Because of the significant risk of death or serious disability to elderly patients, even with minor injuries, we conclude it is appropriate to include data for elderly patients with an ISS <10 who meet other registry inclusion criteria. We also recommend the entry of data for patients with an ISS <10 and significant disability at discharge who qualify by other criteria. Exclusion of remaining patients with an ISS <10 would reduce qualifying cases by 38%.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Changes in the fibrinolytic system may lead to coagulation disorders in acute trauma patients. This study examined fibrin degradation by measuring D-dimer crosslinked fibrin degradation products (indicates hypercoagulability), plasminogen activators (fibrinolysis), and antithrombin III in 42 adult trauma patients and correlated these data with injury severity, types of injury, complications, and clinical tests of coagulation. Hypercoagulability and suppression of fibrinolysis were seen in most patients and were not correlated with severity of injury. These changes appeared most severe in patients with nervous system injury. Several patients with less severe injuries but evidence of hypercoagulability developed clinical evidence of pathologic thrombosis. Latex agglutination of D-dimer provides a rapid test of fibrinolysis that may be clinically useful in the management of trauma patients who cannot be easily studied for thrombosis.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

We developed a new technique, extracorporeal venovenous rewarming (EVR), to rewarm hypothermic patients in the intensive care unit or operating room. We compared this method with the active external (standard) techniques of warming blankets; heated ventilator circuits, intravenous fluids, and gastric and peritoneal lavage; and cardiopulmonary bypass. The EVR technique warmed patients' blood or additional blood products and crystalloids to 40°C at 150–400 mL/min and allowed survival from a core temperature of 31.1°C after massive injury. The EVR technique rewarmed patients more rapidly than standard techniques and may be most appropriate in patients with multisystem trauma when rapid correction of hypothermia-related hypovolemia, coagulopathy, and arrhythmia is necessary. Cardiopulmonary bypass is required in severely hypothermic patients with cardiac arrest. Standard techniques can be used when these immediately life-threatening conditions are not present.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

To determine the effect of admission body weight on blunt trauma victims, a chart review of all patients >12 years of age admitted to Sentara Norfolk General Hospital between January 1 and July 31, 1987 was undertaken. The charts of 351 patients were reviewed; 184 records contained admission height and weight. These 184 patients made up the study group and age, gender, injuries, Injury Severity Score (ISS), ventilator days (VD), complications, length of stay (LOS), and outcome were noted. Body Mass Index (BMI) (weight (kg)/(height (m))2, was calculated for each patient. The average ISS was 21.87 (range, 1–66) and the average BMI was 25.15 kg/m2(range, 16–46 kg/m2). The overall mortality for the population was 9%. The population was grouped according to BMI: average (<27 kg/m2), overweight (27–31 kg/m2), and severely overweight (>31 kg/m2). The mortality of 5.0% and 8.0% in the average and overweight groups was not different. The severely overweight group had a higher mortality at 42.1% compared with the other two groups (p< 0.0001). The groups did not differ in age, ISS, LOS, nor VD. Age, BMI, and ISS were subjected to regression analysis. By this method BMI and ISS were independent determinants of outcome (p< 0.0001). There was an increase in complications, mainly pulmonary problems, in the SO group (p< 0.05). The three groups were subdivided into survivors and nonsurvivors. The nonsurvivors had a longer average LOS at 26.6 days compared with nonsurvivors in the overweight (5.0 days) or severely overweight (8.62 days) groups (p< 0.007). The severely overweight group was characterized by a rapid deterioration and demise that was unresponsive to intervention. ISS did not differ among nonsurvivors. Among survivors the severely overweight group had a lower ISS, 9.73. This was different from the overweight group (21.57) and from the average group (20.21) (p< 0.04).

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

To characterize trauma patients who die unexpectedly on the ward (unexpected ward deaths = UWDs), 1,011 trauma-related deaths occurring at a level I trauma center over a 10-year period were reviewed for location of death. Seventy-four deaths occurred on the non-ICU trauma ward (i.e., nonmonitored med-surg floor). Fifty patients were “do not resuscitate” (expected deaths). Twenty-four patients (mean age, 58.0 years) died unexpectedly (2.4% of trauma-related deaths). The majority had a central nervous system injury or a precipitating event that occurred at night. Twelve (50%) of the UWDs were determined by peer review to be potentially preventable and were the result of delayed diagnosis (n = 6), aspiration (n = 3), or cardiorespiratory arrest (n = 3). We conclude that unexpected trauma center deaths related to events occurring on the non-ICU trauma ward (2.4% of trauma deaths) occur mostly at night in older, neurologically impaired patients and that half of these deaths may be potentially preventable. Increased awareness of this issue and an environment for direct patient observation may reduce the number of these potentially preventable deaths.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID