摘要:

BackgroundTrauma registries frequently do not include the deaths of patients who do not get to trauma centers (TCs). Thus, complementary methods of monitoring the impact of trauma system initiatives should be considered. The objective of this study is to use National Highway Safety Traffic Administration's Fatality Analysis Reporting System (FARS) and New York State Department of Motor Vehicles data and to study the impact of state and regional initiatives over a 10-year period in the seven-county Hudson Valley New York (HV) region with one regional TC in Westchester County (WC) and to assess its face validity.MethodsFARS data for the United States (US), New York State (NY), the HV region, and WC were analyzed from 1987 to 1996. Trauma system initiatives included the following. Statewide: (1) TC standards (1989), (2) TC designation and funding (1990), (3) State Trauma Advisory Committee (1991), (4) BLS triage protocol and trauma registry (1993), and (5) quality improvement site surveys (1994). Regional: (1) one regional and two area TCs (1990), (2) helicopter services (1992 and 1994), (3) two additional area TCs, and (4) E 911 in all three counties (1995). The results were presented to the New York State Trauma Advisory Committee.ResultsAlthough nationally motor vehicle crash deaths/100,000 persons have plateaued since 1991, trauma system initiatives have been temporally associated with death rates continuing to diminish in New York, the HV, and WC. From 1987 to 1996, the HV death rate dropped from 17.00 to 9.45, a 44% drop; and the WC rate dropped from 12.51 to 7.05, a 44% drop compared with United States death rate drop of 16% (p < 0.005). The percentage of seriously injured trauma patients going to the trauma centers increased from 53% in 1990 to 72% in 1995 (p < 0.001). The STAC felt that the data reflected in part effects of New York State trauma system initiatives.ConclusionThe drops in motor vehicle crash death rates may reflect injury prevention as well as trauma system initiatives. Thus, although FARS and New York State Department of Motor Vehicles data cannot establish cause and effect relationships, it can monitor the aggregated impact of multiple initiatives. Taken together with increasing percentages of seriously injured trauma patients going to trauma centers and comparisons with national FARS data, the association of decreasing deaths with the implementation of a trauma system seems to have face validity.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundThe current literature defines the costs of trauma care in terms of hospital costs and charges. We sought to define the qualitative and quantitative labor costs of trauma care by measuring the various components of bedside care provided by surgeons at a community hospital.MethodsWe conducted a prospective time-and-motion study during the initial 24 hours of blunt trauma patients' stay in the hospital at a Level II trauma center. The services provided by two surgeons and one nurse practitioner were examined. All patients were resuscitated and seen initially by one of the physicians. Ten service elements (SEs) were defined, and total time (TT) spent was the sum of time spent on all service elements for that patient. We defined labor cost as TT. Data on Injury Severity Score (ISS), alcohol intoxication, length of stay, operative procedures, and injury mechanism were also collected. Data are in minutes as means +/- SEM. Analysis of linear correlation was by Pearson correlation coefficient, and intergroup comparison of means was by two-tailed t test.ResultsFifty-eight patients were studied. Mean ISS and length of stay were 11.8 +/- 3 and 4.6 +/- 3 days, respectively. A mean of seven SEs were provided per patient, and the number of SEs provided correlated directly with ISS (r = 0.75, p < 0.01). The mean TT spent was 171 +/- 9 minutes, and it correlated directly with ISS (r = 0.64, p < 0.01). For patients undergoing operative procedures by the trauma surgeon, the procedures consumed the greatest portion of TT: 73 +/- 6 minutes (24%). For patients not undergoing operative procedures, resuscitation and time spent in the radiology department consumed the majority of TT: 30 minutes for each SE (40% of TT). Serum ethanol was greater than 0.10 in 33 of 58 patients (57%), and these patients required significantly more TT (135 vs. 193 minutes; p < 0.05) than nonintoxicated patients.ConclusionA significant labor cost (TT) was required for the care of blunt trauma patients, and the majority of that cost was not spent in the operating room but involved the performance of cognitive services. Significant correlation existed between ISS and labor cost. The presence of ethanol intoxication significantly increased this commitment. These data might be of use in creating provider reimbursement schemes for trauma care. This methodology may have applications in the design of hospital systems for trauma care.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundThe importance of outcome after major injury has continued to gain attention in light of the ongoing development of sophisticated trauma care systems in the United States. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the 12-month and 18-month follow-ups in the TRP population and to examine the association of putative risk factors with functional outcome.MethodsBetween December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older; (2) Glasgow Coma Scale score on admission of 12 or greater; and (3) length of stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) Scale, an index sensitive to the well end of the functioning continuum (0 = death, 1.000 = optimum functioning). Follow-up at 12 months after discharge was completed for 806 patients (79%), and follow-up at 18 months was completed for 780 patients (74%). Follow-up contact at any of the study time points (6, 12, or 18 months) was achieved for 926 (88%) patients.ResultsThe mean age was 36 +/- 14.8 years, and 70% of the patients were male; 52% were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living together. The mean Injury Severity Score was 13 +/- 8.5, with 85% blunt injuries and a mean length of stay of 7 +/- 9.2 days. QWB scores before injury reflected the norm for a healthy adult population (mean, 0.810 +/- 0.171). At the 12-month follow-up, there were very high levels of functional limitation (QWB mean score, 0.670 +/- 0.137). Only 18% of patients followed at 12 months had scores above 0.800, the norm for a healthy population. There was no improvement in functional limitation at the 18-month follow-up (QWB mean score, 0.678 +/- 0.130). The majority of patients (80%) at the 18-month follow-up continued to have QWB scores below the healthy norm of 0.800. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days were significant independent predictors of 12-month and 18-month QWB outcome.ConclusionThis study demonstrates a prolonged and profound level of functional limitation after major trauma at 12-month and 18-month follow-up. This is the first report of long-term outcome based on the QWB Scale, a standardized quality-of-life measure, and provides new and provocative evidence that the magnitude of dysfunction after major injury has been underestimated. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days are significantly associated with 12-month and 18-month QWB outcome.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundPolymorphonuclear leukocytes (PMNL) play important roles in both host defenses and systemic inflammatory responses after insults. The objectives of this study are to examine the serial changes in PMNL priming and apoptosis in severely injured patients and to evaluate the impact of second hits on primed PMNL function and systemic vascular endothelial damage.MethodsTwenty-four severely injured patients (mean Injury Severity Score, 31.1 +/- 9.7) were included. Infections were seen as second hits after trauma in seven patients. Oxidative activity, phagocytosis, and apoptosis of PMNL from serial blood samples were measured by flow cytometry. Oxidative activity with no stimulus and with formylmethionyl-leucyl-phenylalanine (FMLP) were analyzed as the priming index and FMLP response, respectively. Interleukin (IL)-6, IL-10, PMNL elastase, and thrombomodulin concentrations in blood were also measured before and after the second hit.ResultsThe PMNL priming index was elevated from days 2 to 13, especially days 2 to 5 after injury. FMLP response was enhanced from days 2 to 21 after injury. Apoptosis of PMNL was inhibited for as long as 3 weeks after injury. Infections as second hits after trauma enhanced both the priming index and the FMLP response within 24 hours after diagnosis of infection and increased serum IL-6 concentrations. However, serum thrombomodulin levels were not affected by second hits. All patients with second hits survived.ConclusionSevere trauma stimulated acute-phase priming in PMNL and inhibited apoptosis. Infections after trauma induced second-hit priming in PMNL, but the unchanged serum levels of thrombomodulin suggest that priming per se may not cause systemic vascular endothelial damage.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundTissue injury from mechanical trauma often leads to secondary organ failure. Local accumulation of neutrophils and excessive release of toxic metabolites through inhibition of neutrophil apoptosis may be responsible for capillary leakage and irreversible damage of resident cells of injured tissues.MethodsThe purpose of this study was to examine the presence of apoptosis-inhibiting factors at the local site of tissue injury. Cerebrospinal fluid (CSF) from patients with severe head injury (n = 10; Abbreviated Injury Scale score, 4.5 +/- 0.2 points) and bronchoalveolar lavage fluid (BALF) from patients with serious chest trauma (n = 10; Abbreviated Injury Scale score, 4.1 +/- 0.1 points) were collected on days 1 and 3 after injury and compared with CSF (n = 5) and BALF (n = 16) obtained from patients undergoing elective orthopedic surgery. Neutrophils from healthy humans were incubated with 10% of CSF or BALF for 16 hours. Neutrophil apoptosis was determined by flow cytometric analysis of propidium iodide nuclear staining, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling, and May-Grunwald-Giemsa staining. Levels of granulocyte colony-stimulating factor (G-CSF) in CSF and BALF were measured with enzyme-linked immunosorbent assay.ResultsCSF and BALF from injured patients significantly inhibited spontaneous neutrophil apoptosis of healthy humans compared with control samples, whereas respiratory burst activity was enhanced (p < 0.05). Moreover, CSF and BALF from injured patients contained increased (p < 0.05) amounts of G-CSF. Neutralization of G-CSF in CSF and BALF from injured patients using monoclonal anti-G-CSF antibody markedly (p < 0.05) reduced the apoptosis-inhibiting effect of those body fluids and decreased the respiratory burst.ConclusionIn patients with severe head or chest injury, G-CSF acts locally as a strong inhibitor of spontaneous neutrophil apoptosis, which may cause an increased destructive potential of neutrophils present in injured tissues.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundNeutrophil sequestration in the lungs plays an important role in the development of acute respiratory distress syndrome. We previously reported that hypertonic saline resuscitation attenuated lung injury after hemorrhagic shock and lipopolysaccharide (LPS) by abolishing neutrophil CD11b upregulation. We investigated the mechanism underlying this effect.MethodsHuman neutrophils were exposed to LPS in the presence or absence of hypertonicity or SB203580 (p38 inhibitor). CD11b and CD14 were studied by immunofluorescence and p38 phosphorylation by immunoblotting.ResultsHypertonicity had no effect on CD11b or CD14, caused a weak p38 phosphorylation, and completely prevented the LPS-induced p38 phosphorylation and CD11b up-regulation. p38 inhibition also abrogated CD11b up-regulation by LPS.ConclusionMAPKp38 is important in CD11b regulation by LPS. The inhibitory effect of hypertonicity on the LPS-mediated effect may contribute to its protective anti-inflammatory effect observed in vivo. Transient hypertonicity might minimize organ injury in diseases characterized by neutrophil-mediated damage such as ARDS.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundGram-negative lipopolysaccharide (LPS) has been demonstrated to increase pulmonary capillary permeability as judged by the increased flow of protein-rich lymph from the lungs of sheep infused with LPS. This finding suggests that LPS-injured pulmonary capillaries might be less restrictive than uninjured capillaries to the filtration of large hetastarch molecules. Hetastarch has a broad molecular mass spectrum (35-1,500 kilodaltons (kDa)), and one way to test the restrictiveness of pulmonary capillaries is to measure the size of the largest hetastarch molecules that cross the microvascular barrier and enter the lymph. To evaluate the effects of LPS, we compared hetastarch molecular distributions in the lung lymph of normal and LPS-injured sheep.MethodsAdult sheep (38.2 +/- 0.8 kg) were surgically prepared for the collection of lung lymph, with study initiation after a 5- to 7-day recovery period. Hetastarch (6%) was infused (10 mL/kg) 24 hours before study to allow for stabilization of the hetastarch molecular distribution. On the day of study, LPS (Escherichia coli lipopolysaccharide, 2 [micro sign]g/kg; n = 6) was infused, and plasma and lymph samples were collected for 12 hours. An additional group of animals not infused with LPS (n = 6) served as controls. Hetastarch molecular distributions in plasma and lymph were measured by using high performance size exclusion chromatography.ResultsIn control sheep, the largest hetastarch molecules in lymph averaged 861 +/- 18 kDa (mean +/- SEM) (plasma, 1,065 +/- 18 kDa). In LPS-treated sheep, the largest hetastarch molecules in lymph averaged 845 +/- 19 kDa (not significant vs. normal) (plasma, 1,025 +/- 14 kDa). Hetastarch concentrations in plasma and lung lymph of normal sheep, respectively, were 0.61 +/- 0.05% and 0.34 +/- 0.07%. In LPS-treated sheep, hetastarch concentrations in plasma and lymph were 0.56 +/- 0.08 (not significant vs. normal) and 0.29 +/- 0.07, respectively (p <or=to 0.05). Lymph concentrations were lower after LPS because of increased lymph flows (19.9 +/- 5.4 mL/30 min, compared with 3.6 +/- 0.8 mL/30 min in normal sheep).ConclusionOur results suggest that LPS does not alter the diameter of the largest pores perforating the walls of pulmonary capillaries. Rather, the number of these pores in the capillary wall appears to be increased. This increase would explain why lymph flows rise after LPS with little change in the lymph protein concentration. Our results are also consistent with a filtration model in which capillaries are assumed to be perforated by small pores (protein reflection coefficient = 1) as well as large pores (protein reflection coefficient = 0).

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundTrauma care delivery in Canada, even in major trauma centers, usually devolves to the most involved service. For patients with multisystem injuries, this is not always optimal and aspects of care outside the domain of the primary service are apt to be overlooked. Trauma care is necessarily multidisciplinary, and to be optimal, appropriate integration of the care process and prioritization are required. The purpose of this study was to examine the impact on care in a busy provincial trauma center, after the introduction of a trauma program with a clinical trauma service, revised trauma protocols, and a dedicated trauma unit.MethodsData were collected prospectively before and during the introduction of the program. Aspects of care studied included trauma patient volume, compliance with trauma team activation and trauma consultation protocols, delays to the operating room for hypotension or open fractures, delays in disposition to the unit, average length of stay, and mortality based on Trauma and Injury Severity Score analysis. Data are presented summarized by quarter, one before and four after the introduction of the program. Variance tracking was introduced before the last quarter. Differences between preprogram and postprogram performance were assessed by using analysis of variance (asterisks indicates p < 0.05 compared with preprogram performance).ResultsTrauma unit average length of stay decreased from 10.15 days initially to 9.66 and 9.14* days at 6 and 12 months, reducing costs. Improved survival was demonstrated by Trauma and Injury Severity Score methodology with z score achieving significance compared with Major Trauma Outcome Study outcomes after program implementation.ConclusionTrauma care improvement can be achieved by a multidisciplinary team focusing on the process of care, developing a dedicated trauma service to manage the more seriously injured patients, collecting them onto a single unit, and initiating program management.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundThe incidence of swallowing dysfunction after brain injury is unknown. The efficacy of dysphagia therapy is also unknown. We reviewed our experience to define the incidence of swallowing dysfunction and efficacy of therapeutic intervention.MethodsPatients with brain injury sustained between January of 1996 and December of 1997 were reviewed. All were screened with trials of oral intake. Abnormal findings were confirmed with a videofluoroscopic swallow study. Standard therapies included diet, posture, and behavior modifications.ResultsA total of 47 patients were evaluated. Bedside evaluations were normal in 14 patients, 2 patients had overt aspiration and underwent gastrostomy, and 31 patients were referred for a videofluoroscopic swallow study (66%). The videofluoroscopic swallow study was abnormal in 22 of 31 patients (71%). Of these, 4 additional patients required gastrostomy, 13 patients had laryngeal penetration or minor aspiration responsive to dysphagia therapy and were fed. Five other patients had silent aspiration and were fed by means of nasogastric tube; these five patients responded to dysphagia therapy and were able to resume oral intake.ConclusionDysphagia is common after severe head injury. With formal swallowing service intervention, aspiration is avoided. Therapeutic interventions can be used to restore oral intake.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

BackgroundWe have previously shown a sequence of events after unilateral pulmonary contusion that suggests the release of blood-borne prostanoid mediators and that culminates in refractory bilateral pulmonary failure.PurposeTo determine the role of platelet-derived thromboxane and endothelial-derived prostacyclin in the primary and secondary injury after unilateral blunt chest trauma, and to determine whether pretreatment with the cyclooxygenase inhibitor indomethacin alters the progression of secondary injury.MethodsAnesthetized, ventilated (FIO2= 0.50) pigs received a unilateral, blunt injury to the right thorax (n = 20) or sham injury (n = 5) and were monitored for 24 hours. Either indomethacin (5 mg/kg IV; n = 10) or its saline vehicle (n = 10) were administered 15 minutes before injury. Serial bronchoalveolar lavages of each lung were analyzed for protein and neutrophil (polymorphonuclear neutrophil (PMN)) content.ResultsContusion caused profound hypoxemia; PaO2partially recovered within 1 hour of injury to 50% of baseline. Thereafter, worsening hypoxemia required positive end-expiratory pressure. With indomethacin compared with vehicle, PaO2was higher at any given level of positive end-expiratory pressure (p < 0.05). There was an early increase in serial bronchoalveolar lavage protein on the injured side (peak at 2 hours), with a delayed pulmonary capillary leak on the contralateral side (peak at 6 hours), which correlated with increasing PMN infiltration; this was reduced by 40 to 60% with indomethacin (p < 0.05). Thromboxane peaked within 1 hour after contusion at 800% baseline, then fell off rapidly. This peak preceded the maximal increase in permeability and was completely blocked by indomethacin. Prostacyclin slowly rose to 300% baseline by 3 hours and remained elevated; this change was blocked by indomethacin for 18 hours.ConclusionsContusion of the right thorax induced a delayed pulmonary capillary leak in the left lung, which reflects a progressive secondary inflammatory response. Elevations in thromboxane and prostacyclin preceded progressive bilateral PMN infiltration. Indomethacin blocked thromboxane and prostacyclin and attenuated, but did not prevent, the progression to pulmonary failure. Overall, these data suggest that prostanoids are released soon after unilateral contusion and initiate an inflammatory response in both lungs that is sustained by PMN infiltration.

ISSN:0022-5282    

出版商:OVID    

年代:1999

数据来源: OVID