ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundThe Injury Severity Score (ISS) does not take into account multiple injuries in the same body region, whereas a New ISS (NISS) may provide a more accurate measure of trauma severity by considering the patient's three greatest injuries regardless of body region. The purpose of this study was to evaluate the ISS and NISS in patients with blunt trauma.MethodsConsecutive individuals treated from January of 1992 to September of 1996 at one institution were included if they had sustained blunt trauma and satisfied triage standards (n = 2,328). For each patient, we computed the ISS and the NISS to determine how often the two scores were identical or discrepant. Discrepant cases were then further analyzed using receiver operating characteristic curves to determine which score better predicted short-term mortality.ResultsThe mean ISS was 25 +/- 13, and the mean NISS was 33 +/- 18. The two predictive scores were identical in 32% of patients and discrepant in 68% of patients. Patients with identical scores had a lower mortality rate than patients with discrepant scores (10% vs. 13%; p < 0.02). In patients with discrepant scores, the area under the receiver operating characteristic curves was greater for the NISS than the ISS (0.852 vs. 0.799; p < 0.001), and greater amounts of discrepancy were associated with increasing rates of mortality (p < 0.001).ConclusionsThe NISS often increases the apparent severity of injury and provides a more accurate prediction of short-term mortality. The benefit associated with using the NISS rather than the ISS must be weighed against the disadvantages of changing a scoring system and the potential for still greater improvements.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundRecent attention concerning the adverse outcomes of blood transfusion has resulted in decreased blood product usage for nonemergency care. We hypothesized that there has also been a decrease in blood product use in the management of seriously injured adults.MethodsA retrospective review of institutional database records was conducted at a regional trauma center for adults admitted during 1991, 1993, and 1995. Data was analyzed for trends in amount, type, and timing of blood product use.ResultsA total of 1,738 patients were assessed, with 1,605 meeting inclusion. The three patient groups were similar, including injury severity (overall mean Injury Severity Score of 23.6), mechanism (88% blunt), and survival (87%). In 1991, 54% of the patients were transfused a total of 2,341 units of packed red blood cells (mean 4.67 units/pt treated) versus 42% of patients in 1995 (p < 0.0001) who received 2,018 packed red blood cells (mean 3.57 units/patient treated, p = 0.05). A significantly higher proportion of units was transfused in the first 24 hours of care in 1995 (64%) compared with 1991 (21%, p < 0.0001). A reduction in the use of universal donor type-O blood use was also found (1.21 vs. 0.65 units/patient transfused, p < 0.0001). Despite similar admission hemoglobin concentrations (124.1 vs. 125.3, not significant), significant reductions were found in the average 24-hour (109.2 vs. 103.8, p < 0.001), lowest (96.5 vs 92.1, p < 0.01) and discharge (115.8 vs. 110.5, p < 0.001) concentrations.ConclusionsBetween 1991 and 1995 there have been significant reductions in both the number of trauma patients receiving blood products and the total number of units transfused. These findings may reflect lower or abandoned hemoglobin transfusion triggers and increased awareness of complications related to transfusion.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundPart of the senior medical students' examination at the University of Toronto involves testing with simulated patient management. We compared the performance in these simulations of senior medical students who received Advanced Trauma Life Support (ATLS) training with those who did not receive ATLS training.MethodsThirty-two students (group I) completed a standard ATLS course, 12 students (group II) audited the ATLS course, and their performance in the trauma simulations was compared with 44 matched control students (group III) from the same class. Performance in the nontrauma patient simulation stations was also analyzed. The score on each station was standardized to a maximum of 20. The students were also graded on overall Approach (scale of 1 to 5) and pass status.ResultsThe mean scores (+/- SD, *p < 0.05 compared with other groups) were as follows: Trauma Station, 17.5 +/- 1.02* for group I, 11.76 +/- 0.72* for group II, and 14.67 +/- 0.54* for group III; Nontrauma Station, 13.05 +/- 0.95 for group I, 12.25 +/- 0.72 for group II, and 11.88 +/- 0.80 for group III; Approach, 4.45 +/- 0.50* for group I, 2.09 +/- 0.60* for group II, 3.50 +/- 0.67* for group III. The ATLS-trained and ATLS-audit students had higher scores in the trauma stations than the control group, with the highest scores being in the ATLS-trained group. All ATLS-trained students passed with 62.5% honors and 37.5% passing grades. The ATLS-audit group had 33.3% honors and 66.6% passing grades, compared with the control group who had 84.09% pass, 9.09% borderline, and 6.82% failure in the trauma stations.ConclusionsThe ATLS course, both complete and audit status, prepares students more appropriately for managing trauma patients as judged by trauma simulation scenarios. Consideration should be given for including ATLS as an integral part of the senior medical student curriculum.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundOngoing clinical trials have revived interest in hypertonic saline (HTS) for postinjury resuscitation; these studies have documented serum Na+or=to 170 mmol/L. Recent animal studies have shown that HTS enhances T-cell and monocyte function, but effects on the polymorphonuclear neutrophil (PMN) remain unclear. The postinjury lipid mediators platelet-activating factor (PAF) and leukotriene B4(LTB4) have been implicated in PMN priming for cytotoxicity, which is believed to be important in the pathogenesis of multiple organ failure. We hypothesized that HTS would stimulate PMN superoxide (O2-) and elastase release from PAF- and LTB4-primedPMNs.MethodsIsolated PMNs from five donors were primed for 5 minutes with 200 nmol/L PAF or 1 [micro sign]mol/L LTB4in Kreb's-Ringer's phosphate with dextrose at a Na+concentration of 140 mmol/L (normal serum Na+concentration), pelleted, and resuspended in Kreb's-Ringer's phosphate with dextrose for 10 minutes at a Na+concentration of 130 to 170 mmol/L. O2-generation was measured by superoxide dismutase-inhibitable reduction of cytochrome c and elastase release by cleavage of N-methoxysuccinyl-Ala-Ala-Pro-Val p-nitroanilide.ResultsHTS with Na+concentration up to 170 mmol/L had no significant effect on O2-production or elastase release from quiescent cells. Na+concentration of 160 and 170 mmol/L, however, activated PAF- and LTB4-primedPMNs for enhanced elastase release with no effect on O2-production.ConclusionIn clinically relevant concentrations, elevated Na+activates lipid-primed neutrophils for enhanced elastase degranulation. Consequently, the administration of HTS in the early postinjury resuscitation period, when PMNs are maximally primed, may activate PMN elastase release and thereby promote the development of multiple organ failure.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundAbdominal computed tomographic (CT) scans are used in the evaluation of blunt trauma. The purpose of this study was to determine if isolated intraperitoneal fluid seen on CT scan necessitates laparotomy.MethodsTrauma registry records of patients who underwent abdominal computed tomography from January 1994 through January 1997 were studied. Data were reviewed for age, gender, CT scan interpretation, associated injuries, and operative findings.ResultsAbdominal injury was identified in 126 patients. Seventy-eight patients had evidence of solid-organ injury and 17 patients had extraperitoneal injury. Isolated intraperitoneal fluid was identified in 31 patients. All patients with isolated fluid underwent laparotomy; 29 of these procedures (94%) were therapeutic. Bowel injuries occurred in 18 patients and mesenteric injuries in 8 patients. Five patients had intraperitoneal bladder rupture, and undetected solid-organ injuries were found in two patients. Other organs injured included the stomach, pancreas, ovary, and uterus.ConclusionExploratory laparotomy was therapeutic in 94% of patients. Isolated intraperitoneal fluid on CT scan after blunt trauma mandates laparotomy.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundIt has been demonstrated that surgeons and surgery residents, trained in the focused abdominal sonographic examination, are able to accurately and reliably evaluate trauma patients. Despite this, radiologists have objected to surgeon-performed sonography for several reasons. We set out to compare the accuracy of sonographic examinations performed by surgery residents and radiologists.MethodsA retrospective review of medical records of all trauma patients who received focused ultrasound examinations from January 1, 1995, through June 30, 1996, at one of two American College of Surgeons-verified Level I trauma centers in the same city was undertaken. Ultrasound examinations were performed by surgery residents at trauma center A (TCA) and by radiologists or radiology residents at trauma center B (TCB). Findings for each patient were compared with the results of computed tomography, diagnostic peritoneal lavage, operative exploration, or observation. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for each group of patients. Comparison of patient charges for the trauma ultrasound examinations at each of the trauma centers was also made.ResultsPatient populations at the two centers were similar except that the mean Injury Severity Score at TCB was higher than at TCA (11.74 vs. 9.6). Sensitivity, specificity, accuracy, or negative predictive value were not significantly different between the two cohorts. A significantly lower positive predictive value for examinations performed by surgery residents was noted and attributed to a lower threshold of the surgery residents to confirm their findings by computed tomography. Billing data revealed that the average charge for trauma sonography by radiologists (TCB) was $406.30. At TCA, trauma sonography did not generate a specific charge; however, a $20.00 sum was added to the trauma activation fee to cover ultrasound machine maintenance and supplies.ConclusionFocused ultrasound examination in the trauma suite can be as safely and accurately performed by surgery residents as by radiologists and radiology residents and should be a routine part of the initial trauma evaluation process.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundImplementation of Oregon's trauma system was associated with a reduction in the risk of death for hospitalized injured patients. An alternative explanation for improved outcome, however, is favorable concurrent temporal trends, e.g., new technologies and treatments.Patients and MethodsTo control for temporal trends, seriously injured hospitalized patients in Oregon and Washington were compared before either state had a trauma system (1985-1988) and when only the Oregon trauma system had been implemented (1990-1993). The study group consisted of hospitalized injured patients aged 16 to 79 years with one or more index injuries in six body regions, i.e., head, chest, spleen/liver, femur or pelvis fracture, and burns. Hospital discharge claims data were analyzed, converting International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis codes to Abbreviated Injury Scale scores and Injury Severity Scores using a conversion algorithm. Multivariate logistic regression models were used to estimate the differential risk-adjusted odds of death in Oregon compared with Washington after adjustment for demographics, injury type, and injury severity.Results15 compared with Washington (adjusted odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.70-0.91) after trauma system implementation in Oregon (1990-1993). Specifically, reductions in the risk of death were demonstrated for patients with head injuries (adjusted OR = 0.70, 95% CI = 0.59-0.82) or liver/spleen injuries (adjusted OR = 0.73, 95% CI = 0.54-0.99).ConclusionAssuming that the two states demonstrated similar concurrent temporal trends, the findings support the conclusion that improved outcomes among injured patients in Oregon may be attributed to the institution of a statewide trauma system.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundLong-term survival rate and functional status after trauma for one of the fastest growing segments of the population, patients 75 years and older, is poorly documented.MethodsTrauma patients 75 years and older who were discharged from our Level I trauma center between June 1988 and July 1992 (n = 279) were contacted by mail or phone. Public death records were used to identify patients who had died. A stepwise logistic regression analysis was performed to determine predictors of poor outcome (death within 6 months). Main outcome measures included mortality and self-assessed functional status.ResultsA minimum 4-year follow-up was obtained for 81% of the 279 study patients. The mean follow-up period was 5.4 +/- 1.1 years. Mean age at time of injury was 81 +/- 5 years (range, 75-101 years); mean Injury Severity Score was 9.4 +/- 7.7. At follow-up, 132 patients (47%) had died, 93 patients (33%) were contacted, and 54 patients (19%) could not be located. Twelve percent of patients survived less than 6 months after discharge. Poor survival was predicted by preexisting diseases (dementia, p = 0.001; hypertension, p = 0.02; and chronic obstructive pulmonary disease, p = 0.05) and not by age or severity of injury. The mean age of patients still living was 85 +/- 3.9 years (range, 79-99 years), and 77 of 93 patients were living in an independent setting (33 alone, 44 with spouse or family); of these, 57% reported no difficulties in performing 12 of 14 activities of daily living.ConclusionDespite higher than expected mortality after discharge, aggressive management of trauma patients 75 years and older is justified by the favorable long-term outcome.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID