ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundNonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults.MethodsA total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended &khgr;2test. Data are expressed as mean ± SD; a value ofp< 0.05 was considered significant.ResultsA total of 38.5% of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p< 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p< 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum.ConclusionIn this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundIt has previously been shown that elderly patients have a worse prognosis than their younger counterparts after sustaining blunt trauma. This is due in part to a higher incidence of comorbid conditions as well as less physiologic reserve in an elderly population sustaining largely blunt trauma. We compared the outcome after penetrating trauma in elderly patients to matched “younger” patients to determine whether they had a similarly poor prognosis.MethodsElderly patients (≥65 years) were identified from our trauma registry. Sex, mechanism of injury, and Abbreviated Injury Score/Injury Severity Score were determined from the registry. Patients presenting with traumatic arrest were excluded. The registry was then searched for patients aged 15 to 40 years with the same sex, mechanism of injury, and Abbreviated Injury Score in each region. A chart review was then performed to determine additional details of their hospital stay. The two groups were then compared using Student’sttest and Fisher’s exact &khgr;2test, as appropriate.ResultsEighty-five elderly patients (OLD group) were admitted with penetrating trauma between 1983 and 1998. They were compared with 85 matched young patients (YOUNG group). Each group included 66 male and 19 female patients. In each group, gunshot wounds occurred in 45.9%, stab wounds in 52.9%, and shotgun wounds in 1.2% of patients. The average Injury Severity Score in each group was 5.5 ± 5.6 (range, 1–29) and the regional Abbreviated Injury Scores were likewise equal in both groups. The OLD patients had an average hospital stay of 6.9 ± 9.1 days compared with 4.3 ± 5.7 days in the YOUNG patients (p< 0.05). Twenty-seven OLD patients spent 7.3 ± 9.2 days in the intensive care unit compared with 19 YOUNG patients who stayed 3.4 ± 3.2 days (p< .05). A total of 91 comorbidities were identified in 58 OLD patients compared with 18 in 15 YOUNG patients (p< .0001). Eighty-six invasive procedures were performed in the OLD group compared with 96 in the YOUNG group (p= not significant). Nineteen OLD patients (22.3%) and 15 YOUNG patients (17.6%) suffered one or more complications, including death (p= not significant). A total of 91% of surviving OLD patients were discharged to home compared with 100% of surviving YOUNG patients (p< .01).ConclusionElderly patients who sustain penetrating trauma have more comorbidities than their younger counterparts. This may account for their longer hospital stay and lesser ability to be discharged home. These patients do not have an increased complication rate and should continue to be managed aggressively.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo evaluate the necessity of abdominal screening beyond physical examination in awake and alert blunt trauma patients who require emergent extra-abdominal trauma surgery.MethodsData from an urban Level I trauma center was reviewed for all blunt trauma patients who underwent extra-abdominal emergency procedures during the period from January 1995 through August 1998. Awake and alert patients (Glasgow Coma Scale [GCS] score ≥ 14) with negative abdominal physical examination results who underwent extra-abdominal emergent surgery were entered in the study. All patients entered were older than 14 years of age, hemodynamically stable, and underwent further abdominal evaluation with computed tomographic scan or diagnostic peritoneal lavage after the decision for extra-abdominal surgical intervention. Emergent surgery occurred within 8 hours of admission. Data was collected for results of diagnostic studies, hemodynamic status, mechanism of injury, indications for operative intervention, and admission blood ethanol (EtOH) levels.ResultsA total of 210 patients with an average age of 33 years (range, 14–92 years) were entered in the study. The most common mechanism of injury was motor vehicle crash (67%). Sixty-six (32%) patients presented with EtOH levels > 100 mg/dL; 181 (86%) patients presented with a GCS score of 15, and 29 (14%) presented with a GCS score of 14. The majority of surgical procedures were orthopedic (86%). Diagnostic peritoneal lavage was performed in 55 (26%) patients, and computed tomographic scans were obtained in 155 (74%) patients. Three (1.4%) intraperitoneal injuries were diagnosed in the study population. Two of the injuries were stable grade 1 liver injuries, and missed diaphragmatic injury was diagnosed on postadmission day 1.ConclusionBefore emergent extra-abdominal trauma surgery, abdominal evaluation with physical examination is sufficient to identify surgically significant abdominal injury in the awake and alert blunt trauma patient. Screening with additional studies does not impact patient outcome.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundThe purpose of this study was to test whether polynitroxylation (PN) improved the therapeutic profile of hemoglobin-based oxygen-carrying compounds (HBOCs) that were unpolymerized (&agr;&agr;Hb) or 70% polymerized (polyHb) in a clinically relevant model that combines pulmonary injury and reperfusion. To our knowledge, four different HBOC formulations have never been compared in the same trauma model.MethodsAnesthetized, ventilated swine (n = 45) received a unilateral lung contusion + 25% hemorrhage. After 60 minutes, 250 mL of either PN&agr;&agr;Hb (n = 5), &agr;&agr;Hb (n = 10), PNpolyHb (n = 6), polyHb (n = 5), or normal saline (NaCl, n = 10) was administered for 20 minutes, followed by standard crystalloid resuscitation for 30 minutes, and supplemental crystalloid as required for 6 hours to maintain heart rate <100 beats/min and mean arterial pressure >70 mm Hg.ResultsNine of 45 deaths occurred before resuscitation. Survival time was 395 minutes with NaCl versus 303 minutes with &agr;&agr;Hb (p= 0.03) or 238 minutes with PN&agr;&agr;Hb (p= 0.04). With both polymerized HBOCs, survival was 480 minutes (polyHb vs. &agr;&agr;Hb,p= 0.005; PNpolyHb vs. PN&agr;&agr;Hb,p= 0.006). All HBOCs were pressors (allp< 0.05) and all reduced the supplemental fluid required to maintain systemic hemodynamics during resuscitation (allp< 0.05). By 90 minutes postresuscitation, cardiac index was 112% of baseline with NaCl (p< 0.02), but was 78% with &agr;&agr;Hb (p= not significant), 63% with PN&agr;&agr;Hb (p< 0.01), 79% with PNpolyHb (p< 0.01), and 67% with polyHb (p< 0.02). Relative to NaCl, no HBOC altered trauma-induced neutrophilia, thrombocytopenia, or the trauma-induced increases in bronchoalveolar lavage protein or bronchoalveolar lavage neutrophils.ConclusionAfter resuscitation from chest trauma, we observed the following: (1) all HBOCs reduced fluid requirements and increased right and left ventricular afterload versus NaCl, which further compromised an already marginal cardiac performance; (2) mortality was less with polyHbs relative to &agr;&agr;Hb, but the pressor action was unchanged; (3) the pressor action was less with polynitroxylated compounds relative to the unmodified HBOC, but this chemical modification had no effect on mortality; and (4) the pressor action of HBOCs must be attenuated by strategies other than polymerization or polynitroxylation for these compounds to be safe, effective resuscitants in humans.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundTo develop and validate an artificial neural network (ANN) for predicting survival of trauma patients based on standard prehospital variables, emergency room admission variables, and Injury Severity Score (ISS) using data derived from a regional area trauma system, and to compare this model with known trauma scoring systems.Patient Population:The study was composed of 10,609 patients admitted to 24 hospitals comprising a seven-county suburban/rural trauma region adjacent to a major metropolitan area. The data was generated as part of the New York State trauma registry. Study period was from January 1993 through December 1996 (1993–1994: 5,168 patients; 1995: 2,768 patients; 1996: 2,673 patients).MethodsA standard feed-forward back-propagation neural network was developed using Glasgow Coma Scale, systolic blood pressure, heart rate, respiratory rate, temperature, hematocrit, age, sex, intubation status, ICD-9-CM Injury E-code, and ISS as input variables. The network had a single layer of hidden nodes. Initial network development of the model was performed on the 1993–1994 data. Subsequent models were generated using the 1993, 1994, and 1995 data. The model was tested first on the 1995 and then on the 1996 data. The ANN model was tested against Trauma and Injury Severity Score (TRISS) and ISS using the receiver operator characteristic (ROC) area under the curve [ROC-A(z)], Lemeshow-Hosmer C-statistic, and calibration curves.ResultsThe ANN showed good clustering of the data, with good separation of nonsurvivors and survivors. The ROC-A(z) was 0.912 for the ANN, 0.895 for TRISS, and 0.766 for ISS. The ANN exceeded TRISS with respect to calibration (Lemeshow-Hosmer C-statistic: 7.4 for ANN; 17.1 for TRISS). The prediction of survivors was good for both models. The ANN exceeded TRISS in nonsurvivor prediction.ConclusionAn ANN developed for trauma patients using prehospital, emergency room admission data, and ISS gave good prediction of survival. It was accurate and had excellent calibration. This study expands our previous results developed at a single Level I trauma center and shows that an ANN model for predicting trauma deaths can be applied across hospitals with good results

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundInjured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting.MethodsA retrospective review of trauma patients (August 1996–January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival.ResultsFifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 ± 5.4 days (n = 37).ConclusionsImplementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundGut ischemia followed by reperfusion (I/R) is implicated as a prime initiating event in the mechanism of multiple organ failure after trauma and hemorrhagic shock. Several lines of evidence indicate that macrophages are involved in this prime event. Our purpose was to evaluate hydrogen peroxide (H2O2) and tumor necrosis factor (TNF) production and phagocytosis by lung macrophages in a gut I/R model of multiple organ failure in rats.MethodsIn the experimental group (I/R), Wistar rats (n = 35) were anesthetized and subjected to a median laparotomy, and the superior mesenteric artery was clamped for 45 minutes followed by 60 minutes of reperfusion. In the control group (LAP) (n = 37), animals underwent sham laparotomy. After the period of reperfusion, bronchoalveolar lavage (BAL) was performed and the resulting BAL cells were assayed for H2O2production using the horseradish peroxidase-mediated red phenol oxidation method. TNF release was determined using the L929 cells bioassay. Zymosan phagocytosis by BAL macrophages was quantitated using phase microscopy.ResultsH2O2release in BAL cells of I/R rats (19.90 ± 7.98 nmol/L/2 × 105cells) is statistically higher than in the LAP group (10.92 ± 5.01 nmol/L per 2 × 105cells) (p = 0.0155), and the TNF production by BAL cells of the I/R group (38.09 ± 20.79 units per 106cells) was significantly higher than that of LAP rats (17.16 ± 13.35 units per 106cells) (p = 0.0281). Phagocytic activity of BAL macrophages of I/R rats was not statistically different from LAP animals.ConclusionThese results suggest that BAL macrophage play a role in the mechanism of acute lung injury after trauma and hemorrhagic shock.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundRegional pediatric trauma centers (PTC) were established to optimize the care of injured children. However, because of the relative shortage of PTC, many injured children continue to be treated at adult trauma centers (ATC). As a result, a growing controversy has evolved regarding the impact of PTC and ATC on outcome for injured children.MethodsA retrospective analysis of 13,351 injured children entered in the Pennsylvania Trauma Outcome Study between 1993 and 1997 was conducted. Patients were stratified according to mechanism of injury, injury severity, specific organ injury, and type of trauma center: PTC; Level I ATC (ATC I); Level II ATC (ATC II); or ATC with added qualifications to treat children (ATC AQ). Mortality was the major outcome variable measured.ResultsMost injured children were treated at a PTC or ATC AQ. The majority of children below 10 years of age were admitted to PTC. Patients treated at PTC and ATC had similar injury severity as determined by median Injury Severity Score, mean Revised Trauma Score, and Glasgow Coma Scale. Overall survival was significantly better at PTC and ATC AQ compared with ATC I and ATC II. Survival for head, spleen, and liver injuries was significantly better at PTC compared with ATC AQ, ATC I, or ATC II. Children who sustained moderate or severe head injuries were more likely to undergo neurosurgical intervention and have a better outcome when treated at a PTC. Despite similar mean Abbreviated Injury Scores for spleen and liver, significantly more children underwent surgical exploration (especially splenectomy) for spleen and liver injuries at ATC compared with PTC.ConclusionChildren treated at PTC or ATC AQ have significantly better outcome compared with those treated at ATC. Severely injured children (Injury Severity Score > 15) with head, spleen, or liver injuries had the best overall outcome when treated at PTC. This difference in outcome may be attributable to the approach to operative and nonoperative management of head, liver, and spleen injuries at PTC.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveThe majority of early trauma deaths are attributable to uncontrolled hemorrhage from truncal sites. A hemorrhage-control technique that reduced bleeding in the prehospital phase of treatment without requiring manual compression may improve the outcome of these patients. We conducted this preliminary study to determine whether an expanding fibrin sealant foam (FSF) would reduce bleeding from a severe liver injury even during resuscitation.MethodsRats (n = 31; 291 ± 5 g; 37.4 ± 0.3°C; mean ± SEM), underwent a 60 ± 5% excision of the median hepatic lobe. The animals received one of three treatments: (1) FSF, (2) immunoglobulin G placebo foam (IgGF), or (3) no treatment. All animals were resuscitated with 40°C lactated Ringer’s solution at 3.3 mL/min/kg to a mean arterial pressure of 100 mm Hg. Total blood loss, mean arterial pressure, and resuscitation volume were recorded for 30 minutes. A qualitative measure of foam coverage and adherence to the cut liver edge was recorded.ResultsThe total blood loss was less (p< 0.01) in the FSF group (21.2 ± 5.0 mL/kg) than in either IgGF (41.4 ± 4.3 mL/kg) or the no treatment group (44.6 ± 4.7 mL/kg), which did not differ. The resuscitation volume was not different. The amount of foam used in the treated groups, 9.1 ± 1.0 g in the FSF group and 10.0 ± 1.0 g in the IgGF group, did not differ. Survival for 30 minutes was not different among groups. There was no difference in the amount of cut liver covered by either foam, but the clots were more adherent (p< 0.05) in the FSF group than in the IgGF group.ConclusionIn rats with a severe liver injury, spraying fibrin foam directly on the cut liver surface decreased blood loss when compared with placebo foam and no treatment. This pilot study suggests a future possible treatment for noncompressible truncal hemorrhage.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID