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

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe objective of this study was to describe a population of children admitted to a tertiary care pediatric hospital with severe trauma to identify key areas for injury prevention research, and programming.MethodsRetrospective chart review conducted on all children 0–17 years admitted to the Children’s Hospital of Eastern Ontario (CHEO) between April 1, 1996, and March 31, 2000, following acute trauma. Each record was reviewed and assigned an ISS using the AIS 1990 revision. All cases with an ISS > 11 were included in the study.ResultsThere were 2610 trauma cases admitted to CHEO over the study period. Of these, 237 (9.1%) had severe trauma (ISS > 11). Sixty-two percent were male. Twenty-nine percent were between the ages of 10 and 14 years, 27% between 5 and 9 years, 16% between 15 and 17 years, 15% between 1 and 4 years, and 13% less than 1 year old. The most common mechanisms of injury were due to motor vehicle traffic (39%), falls (24%), child abuse (8%), and sports (5%). Of those resulting from motor vehicle traffic, 53 (57%) were occupants, 22 (24%) were pedestrians, and 18 (19%) were cyclists. When combining traffic and nontraffic mechanisms, 26 (11% of all severe trauma cases) occurred as a result of cycling incidents. The most severe injury in 65% of patients was to the head and neck body region.ConclusionResearch efforts and activities to prevent severe pediatric trauma in our region should focus on road safety, protection from head injuries, avoidance of falls, and prevention of child abuse.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundWe hypothesized that hemorrhagic shock followed by the abdominal compartment syndrome (ACS) resulted in bacterial translocation (BT) from the gastrointestinal (GI) tract.MethodsNineteen Yorkshire swine (20–30 kg) were divided into two groups. In the experimental group, group 1 (n = 10), animals were hemorrhaged to a mean arterial pressure (MAP) of 25–30 mm Hg for a period of 30 minutes and resuscitated to baseline MAP. Subsequently, intra-abdominal pressure (IAP) was increased to 30 mm Hg above baseline by instilling sterile normal saline into the peritoneal cavity. The IAP was maintained at this level for 60 minutes. Acid/base status, gastric mucosal ph (pHi), superior mesenteric artery (SMA) blood flow, and hemodynamic parameters were measured and recorded. Blood samples were analyzed by polymerase chain reaction (PCR) for the presence of bacteria. Spleen, lymph node, and portal venous blood cultures were obtained at 24 hours. Results were analyzed by ANOVA and are reported as mean ± SEM. The second group was the control. These animals did not have the hemorrhage, resuscitation, or intra-abdominal hypertension (IAH) but were otherwise similar to the experimental group in terms of laparotomy and measured parameters.ResultsSMA blood flow in group 1 (baseline of 0.87 ± 0.10 l/min) decreased in response to hemorrhage (0.53 ± 0.10 l/min,p= 0.0001) and remained decreased with IAH (0.63 l/min ± 0.10,p= 0.0006) as compared to control and returned towards baseline (1.01 ± 0.5 l/min) on relief of IAH. pHi (baseline of 7.21 ± 0.03) was significantly decreased with hemorrhage (7.04 ± 0.03,p= 0.0003) and decreased further after IAH (6.99 ± 0.03,p= 0.0001) in group 1 compared to control, but returned toward baseline at 24 hours (7.28 ± 0.04). The mean arterial pH decreased significantly from 7.43 ± 0.01 at baseline to 7.27 ± 0.01 at its nadir within group 1 (p= 0.0001) as well as when compared to control (p= 0.0001). Base excess was also significantly decreased between groups 1 and 2 during hemorrhage (3.30 ± 0.71 vs. 0.06 ± 0.60,p= 0.001) and IAH (3.08 ± 0.71 vs. −1.17 ± 0.60,p= 0.0001). In group 1, 8 of the 10 animals had positive lymph node cultures, 2 of the 10 had positive spleen cultures, and 2 of the 10 had positive portal venous blood cultures for gram-negative enteric bacteria. Only 2 of the 10 animals had a positive PCR. In group 2, five of the nine animals had positive lymph node cultures, zero of the nine had positive spleen cultures, and one of the nine had positive portal venous blood cultures. Two of the nine animals had positive PCRs. There was no significant difference in cultures or PCR results between the two groups (Fisher’s exact test,p= 0.3).ConclusionIn this study, hemorrhage followed by reperfusion and a subsequent insult of IAH caused significant GI mucosal acidosis, hypoperfusion, as well as systemic acidosis. These changes did not appear to be associated with a significant bacterial translocation as judged by PCR measurements, tissue, or blood cultures.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe Institute of Medicine has recommended intraosseous (IO) infusion of 7.5% hypertonic saline (HTS) for combat casualties in shock. We tested the safety and efficacy of this recommendation in a long-term survival model of uncontrolled hemorrhagic shock using dehydrated swine.MethodsFourteen dehydrated Yorkshire swine had placement of a 12G needle in the right anterior tibia under isoflurane anesthesia. Uncontrolled hemorrhage was induced via left iliac artery and vein injury. Animals were kept in shock for 2 hours and then resuscitated over 2 hours with 5 mL/kg of 7.5% HTS given either as 10 small boluses (group I, n = 4) or two large boluses (group II, n = 6) to compare the physiologic response and blood loss. Control animals (group III, n = 4) received an equal volume of 0.9% saline IO and additional intravenous saline to equalize the salt load in all groups.ResultsThe three groups had similar physiologic responses, with no increase in blood loss following HTS resuscitation. However, between the second and fifth postresuscitation days, the 7.5% HTS resuscitated animals developed soft tissue necrosis or bone marrow necrosis of the right hind leg (group I, 100%; group II, 66.6%; group III, 0%).ConclusionHTS resuscitation effectively restored hemodynamic stability in dehydrated swine without increased bleeding from an uncontrolled vascular injury. However, IO infusion of HTS in this model was associated with a very high rate of local complications. Further investigations should be undertaken before IO use of 7.5% HTS in humans.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

PurposeThe purpose of this study was to determine whether gastric feeding tubes placed by the percutaneous endoscopic route resulted in fewer and less severe complications than open surgical gastrostomy (SG).MethodsCharts for all trauma patients admitted 1/94 to 12/98, which had an electively placed feeding tube, were individually reviewed. All tube-related complications were recorded. Of 8119 patients screened, 158 (1.9%) met inclusion criteria. Percutaneous endoscopic gastrostomies (PEGs) were placed in 95 (60.1%) and surgical gastrostomies in 63 (39.9%). Most patients (79.1%) had AIS 3 or greater head or spinal cord injury as the primary diagnosis leading to tube placement.ResultsOverall, SG patients were 5.4 times more likely than PEG patients to have a complication from their gastrostomy tube (95% CI, 2.1–13.8). They were 2.6 times more likely to have a major complication (internal leakage, dehiscence, peritonitis, and fistula), and 5.5 times more likely to have a minor complication (unplanned removal, dislodgment, external leak, skin infection, and nonfunction). The groups did not differ on ISS, ICU LOS, total LOS, or mortality (p> 0.05). Overall, a total of 39 individual complications related to tube placement were noted in 26 separate patients (PEG, 7; SG, 19). All four of the major complications requiring operative intervention were in the SG group. There were 31 minor complications, 8 in the PEG group and 27 in the SG group. Mean total charges for placement were also significantly lower in the PEG group than the SG group ($1271 vs. $2761,p< 0.001)ConclusionGastrostomy tubes placed via the percutaneous endoscopic route had a significantly lower complication rate than surgically placed tubes. In addition, the charges incurred for their placement were also significantly less. Based on the findings of this study, PEG should be considered as the method of choice for gastric feeding tube placement for trauma patients who do not have specific contraindications to the procedure.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe 372 cases of crush syndrome that followed the 1995 Hanshin-Awaji earthquake have provided a unique opportunity to investigate the long-term physical outcomes and to establish indications for specific treatments in such patients. The objectives of this study were to identify independent predictors of physical outcome in patients suffering from crush syndrome and to clarify the influence of fasciotomy on outcomes.MethodsSensory and motor functions were examined 2 years after the earthquake in 42 patients with a total of 58 compressed lower extremities. The influences of time to rescue, fasciotomy, and radical debridement on lower leg muscle strength were evaluated by stepwise regression analysis. Correlation between the time to fasciotomy and lower leg muscle strength was also analyzed.ResultsSevere disabilities related to the lower leg compartment were present in 47% (8/17) of patients who underwent fasciotomy and in 16% (4/25) of patients who did not. The anterior compartment was damaged more severely than the posterior compartment. Severe sensory and motor disturbances occurred at a higher rate in relation to anterior and posterior compartments that were treated by fasciotomy than in relation to those that were not. Stepwise regression analysis showed fasciotomy/debridement score to be an independent predictor of long-term lower leg muscle strength (R= 0.67,p< 0.0001) and showed time to rescue to be an independent predictor when debrided compartments were not included in the analysis (R= 0.36,p= 0.009). In all debrided anterior compartments, muscle contractility was completely abolished. There was a significant negative correlation between time to fasciotomy and lower leg muscle strength.ConclusionSecondary compartment syndrome affects physical outcome in crush syndrome patients. We obtained no evidence that fasciotomy improves outcome. Delayed rescue, delayed fasciotomy, and radical debridement may worsen the physical prognosis. Indications for fasciotomy in crush syndrome during the acute phase need further deliberation.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundTraumatic brain injury (TBI) is a leading cause of morbidity and mortality in trauma patients. Cerebral perfusion pressure (CPP) directed ICU management is recommended for patients with severe TBI. It, however, requires an invasive device to measure intracranial pressure (ICP). Transcranial cerebral oximetry is a noninvasive method utilizing near-infrared technology to indirectly measure cerebral saturation (Stco2).MethodsA prospective observational study was performed at a Level I trauma center. Data were collected hourly for the first 6 days on four patients with severe TBI. Each patient had ICP monitoring and Stco2(INVOS, Somanetics) assessed from each frontal lobe. CPP directed care was used.ResultsFour patients with TBI, with admission GCS scores of 4, 4, 7, and 8, all had subdural hematomas and contusions; three had subarachnoid hemorrhage (SAH); one had an epidural hematoma (the only death; day 6); two had craniotomies. In the first 48 hours when CPP ≥ 70, Stco2was 71 ± 9, while it was 61 ± 9 when CPP < 70 (p< 0.0001). This relationship was constant for all study days, withp< 0.0001. Moreover, CPP < 70 correlated with Stco2withr= 0.8l andr2= 0.66. Stco2≥75 was associated with CPP ≥ 70 96.4% of the time (95% CL, 94.3–98.5%). Stco2< 55 was associated with CPP < 70 68.2% of the time (95% CL, 57–79.4%). Also, 13.4% of observations with CPP ≥ 70 had Stco2< 60, suggesting the potential of cerebral ischemia in the face of “normal” CPP. The Stco2patches were user-friendly and not technically finicky.ConclusionIn this pilot study, Stco2correlated significantly with CPP. A Stco2≥ 75 suggests that CPP is adequate, while < 55 suggests an inadequate CPP. Although these results should be confirmed in a larger study, Stco2may serve as a noninvasive measurement of cerebral perfusion in the patient with a TBI or, at the very least, a sensitive indicator for the need to begin monitoring the ICP.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThis study assessed patients with traumatic brain injury (TBI) to determine whether prehospital and community hospital providers employed hyperventilation therapy inconsistent with consensus recommendation against its routine use.MethodsThis prospective analysis of 37 intubated TBI patients without herniation, undergoing helicopter transport to an urban Level I center, entailed flight crews’ noting of assisted ventilation rate (AVR) and end-tidal carbon dioxide (ETco2) upon their arrival at trauma scenes or community hospitals.A priori-set levels of AVR and ETco2were used to assess frequency of guideline-inconsistent hyperventilation, and Fisher’s exact and Kruskal-Wallis tests assessed association between guideline-inconsistent hyperventilation and manual vs. mechanical ventilation mode.ResultsInappropriately high AVR and low ETco2were seen in 60% and 70% of patients, respectively. Manual ventilation was associated with guideline-inconsistent hyperventilation assessed by AVR (p= 0.038) and ETco2(p= 0.022).ConclusionPrehospital and community hospital hyperventilation practices are not consistent with consensus recommendations for limitation of hyperventilation therapy.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID