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:

IntroductionSince their inception, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS) have been suggested as measures of the quality of trauma care. In concept, they are designed to accurately assess injury severity and predict expected outcomes. ICISS, an injury severity methodology based on International Classification of Diseases, Ninth Revision, codes, has been demonstrated to be superior to ISS and TRISS. The purpose of the present study was to compare the ability of TRISS to ICISS as predictors of survival and other outcomes of injury (hospital length of stay and hospital charges). It was our hypothesis that ICISS would outperform ISS and TRISS in each of these outcome predictions.Methods"Training" data for creation of ICISS predictions were obtained from a state hospital discharge data base. "Test" data were obtained from a state trauma registry. ISS, TRISS, and ICISS were compared as predictors of patient survival. They were also compared as indicators of resource utilization by assessing their ability to predict patient hospital length of stay and hospital charges. Finally, a neural network was trained on the ICISS values and applied to the test data set in an effort to further improve predictive power. The techniques were compared by comparing each patient's outcome as predicted by the model to the actual outcome.ResultsSeven thousand seven hundred five patients had complete data available for analysis. The ICISS was far more likely than ISS or TRISS to accurately predict every measure of outcome of injured patients tested, and the neural network further improved predictive power.ConclusionIn addition to predicting mortality, quality tools that can accurately predict resource utilization are necessary for effective trauma center quality-improvement programs. ICISS-derived predictions of survival, hospital charges, and hospital length of stay consistently outperformed those of ISS and TRISS. The neural network-augmented ICISS was even better. This and previous studies demonstrate that TRISS is a limited technique in predicting survival resource utilization. Because of the limitations of TRISS, it should be superseded by ICISS.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundExperimental and clinical work has suggested that hypertonic saline (HTS) would be better than lactated Ringer's solution (LRS) for the resuscitation of patients with head injuries. No clinical study has examined the effect of HTS infusion on intracranial pressure (ICP) and outcome in patients with head injuries. We hypothesized that HTS infusion would result in a lower ICP and fewer medical interventions to lower ICP compared with LRS.Methods/DesignProspective, randomized clinical trial at two teaching hospitals.ResultsThirty-four patients were enrolled and were similar in age and Injury Severity Score. HTS patients had a lower admission Glasgow Coma Scale score (HTS: 4.7 +/- 0.7; LRS: 6.7 +/- 0.7; p = 0.057), a higher initial ICP (HTS: 16 +/- 2; LRS: 11 +/- 2; p = 0.06), and a higher initial mean maximum ICP (HTS: 31 +/- 3; LRS: 18 +/- 2; p < 0.01). Treatment effectively lowered ICP in both groups, and there was no significant difference between the groups in ICP at any time after entry. HTS patients required significantly more interventions (HTS: 31 +/- 4; LRS: 11 +/- 3; p < 0.01). During the study, the change in maximum ICP was positive in the LRS group but negative in the HTS group (LRS: +2 +/- 3; HTS: -9 +/- 4; p < 0.05).ConclusionAs a group, HTS patients had more severe head injuries. HTS and LRS used with other therapies effectively controlled the ICP. The widely held conviction that sodium administration will lead to a sustained increase in ICP is not supported by this work.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveThe effects of a bolus of 7.5% NaCl-6% dextran 70 (HSD) on cardiac contractility were evaluated in anesthetized sheep with hemorrhagic shock.BackgroundHSD has been shown to be effective at resuscitation in cases of hypovolemia caused by hemorrhage. Common hemodynamic findings after the injection of HSD in hemorrhagic shock are the restoration of cardiac output, increased blood pressure, and improvement of peripheral circulation. Some mechanisms by which HSD maintains circulation in hemorrhagic shock have been proposed: rapid shift of fluid from intracellular to extracellular space, improved peripheral perfusion, and increased cardiac contractility. Conflicting data exist, however, regarding the positive effect of HSD on cardiac contractility after hemorrhagic shock.MethodsHemorrhagic shock was induced by shedding mean blood volume of 31.4 mL/kg, and mean blood pressure was maintained at 50 mm Hg for 30 minutes. The HSD group (n = 6) received HSD (4 mL/kg), and the saline group (n = 6) received normal saline (40 mL/kg) after shock. Cardiac functions were measured in both groups using the left ventricular end-systolic pressure-volume relationship and preload recruitable stroke work during the experimental period: before shock, immediately after the resuscitation, and 2 hours after resuscitation.ResultsHemodynamic parameters in both groups demonstrated similar changes throughout the experimental period without significant difference between the two groups. Not only the slopes of end-systolic pressure-volume relationship and preload recruitable stroke work but also their placements did not result in any significant differences between the groups.ConclusionHSD seems to be an effective resuscitation fluid after hemorrhagic shock because the volume required to maintain circulation is smaller than that of normal saline. Our data, however, show that HSD does not enhance cardiac contractility after hemorrhagic shock.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background and ObjectiveRecent studies have shown that administration of the anterior pituitary hormone, prolactin, after hemorrhage restored the depressed immune responses that are observed under those conditions. Because metoclopramide (MCP) is known to increase prolactin secretion and ultimately plasma prolactin levels, we attempted to determine whether administration of metoclopramide after hemorrhage produces any beneficial effects on the depressed splenocyte and peritoneal macrophage immune function after severe hemorrhage.Design, Materials and MethodsMice were bled to and maintained at a mean arterial pressure of 35 mm Hg for 60 minutes, then adequately resuscitated and segregated into two groups. One group received saline vehicle; animals in the other group were treated with metoclopramide (100 micro g/100 g body weight, subcutaneously) before resuscitation. Two hours after saline or MCP injection, the animals were killed and macrophage as well as splenocyte cultures established. Plasma corticosterone levels were also measured.ResultsThe proliferative capacity of the splenocytes as well as their ability to release interleukin (IL)-2 and IL-3 in response to mitogen was markedly improved in animals that had hemorrhaged and that were treated with MCP compared with saline-injected mice. Moreover, the depressed splenic and peritoneal macrophage IL-1 and IL-6 release after hemorrhage was restored with MCP treatment. Furthermore, treatment with MCP prevented the increase in blood corticosterone levels seen after severe hemorrhage.ConclusionThese results support the concept that the immunosuppression after hemorrhage may be mediated by hormones from the hypothalamic-pituitary-adrenal axis. Furthermore, MCP may be a useful adjuvant in the treatment of the traumahemorrhagic shock-induced immunosuppression.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundPrevious studies indicate that after severe hemorrhage, immune functions are markedly depressed in males, whereas females do not show any depression. Although androgen depletion by castration of mice before soft-tissue trauma and hemorrhagic shock prevents the depression of cell-mediated immunity, it remains unknown whether testosterone per se is responsible for producing immune depression.MethodsFemale C3H/HeN mice were pretreated with 5 alpha-dihydrotestosterone (DHT) or vehicle for 20 days. The mice then underwent soft-tissue trauma (laparotomy) and hemorrhagic shock (blood pressure 35 +/- 5 mm Hg for 90 minutes) followed by adequate fluid resuscitation (shed blood and lactated Ringer's solution) or sham operation. Two groups of nontreated male C3H/HeN mice were included as controls: one group was subjected to hemorrhagic shock followed by resuscitation, and the second group underwent only sham operation. At 24 hours after trauma-hemorrhage and resuscitation, animals were killed, macrophages harvested from the peritoneum and spleen, and their ability to release interleukin (IL)-1 and IL-6 was evaluated. Plasma DHT, estradiol, and corticosterone levels were measured by radioimmunoassay.ResultsTreatment of female mice with DHT produces a significant increase in DHT levels that was comparable with those seen in nontreated male mice. Alternatively, estradiol levels in female mice were significantly depressed by DHT treatment to levels comparable with those observed in control males. In the vehicle-treated female mice, no depression of the macrophage function was evident after trauma hemorrhage. In contrast, testosterone-treated female mice that had experienced hemorrhage showed significant depression in splenic and peritoneal macrophage IL-1 and IL-6 production, comparable with the values seen in macrophages from male mice that had experienced hemorrhage.ConclusionsThese findings indicate that pretreatment of female mice with DHT depresses macrophage function after trauma-hemorrhage, which mimics the changes seen in normal male mice subjected to trauma-hemorrhage. We propose, therefore, that high testosterone and/or low estradiol levels are responsible for producing the immune depression in male mice after trauma-hemorrhage. Testosterone receptor blocking agents, e.g., flutamide, and/or estradiol administration should thus be useful adjuncts for preventing immune depression in male trauma patients.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Background and MethodsTo determine the current status and future direction of trauma care fellowships, a phone survey was conducted with the 45 program directors reporting information to the American Association for the Surgery of Trauma and the Eastern Association for the Surgery of Trauma.ResultsForty programs (89%) were operational, with 86 positions. The duration of the fellowship was 1 year for 16 (40%) and 2 or more years for 24 (60%). Accreditation Council for Graduate Medical Education accreditation (ACGME) (for surgical critical care) was held by 28 (70%). Mean salary was $39,600 at the first-year level. A funding shift from institutional to practice revenue sources is foreseen. Thirteen directors (32.5%) saw future recruitment potential as increasing and 11 (27.5%) saw it as decreasing.ConclusionThe essence, structure, and funding of trauma fellowships are changing. One-year exclusive trauma fellowships are being replaced by 1- to 2-year trauma or surgical critical care fellowships with Accreditation Council for Graduate Medical Education accreditation increasingly seen as essential. The challenge for fellowships in an era of budgetary constraints will be to provide adequate training in the full spectrum of tramatology within a reasonable time frame supported by a predictable funding mechanism.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundPrimary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown.ObjectiveTo determine the current preferences of American trauma surgeons for colon injury management.MethodsFour hundred forty-nine members of the American Association for the Surgery of Trauma were surveyed regarding their preferred management of eight types of colon wounds among three options: diverting colostomy (DC), primary repair (PR), or resection and anastomosis (RA). The influence of selected patient factors and surgeons' characteristics on the choice of management was also surveyed.ResultsSeventy-three percent of surgeons completed the survey. Ninety-eight percent chose PR for at least one type of injury. Thirty percent never selected DC. High-velocity gunshot wound was the only injury for which the majority (54%) would perform DC. More than 55% of the surgeons favored RA when the isolated colon injury was a contusion with possible devascularization, laceration greater than 50% of the diameter, or transection. Surgeons who managed five or fewer colon wounds per year chose DC more frequently (p < 0.001) and PR less frequently (p < 0.001) than surgeons who managed six or more colon wounds per year.ConclusionThe prevailing opinion of trauma surgeons favors primary repair or resection of colon injuries, including anastomosis of unprepared bowel. Surgeons who manage fewer colon wounds prefer colostomy more frequently.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveRecent literature suggests that patients who undergo emergent tube thoracostomy in the field are at increased risks for complications. This study evaluates indications, complications, and effectiveness of field placement of chest tubes by an aeromedical service.MethodsIn a prospective study, 624 consecutive patients with chest injuries (Abbreviated Injury Scale score 1-6) were included. All patients were treated at the scene by a physician-staffed aeromedical service and transported by air to a Level I trauma center. Indications, clinical findings before and after chest tube insertion, and subsequent radiologic diagnosis by chest roentgenography were documented prospectively.ResultsSeventy-six chest tubes (50 unilateral, 13 bilateral) were inserted laterally in 63 patients (10%) by blunt dissection. Clinical findings included pneumothorax in 30 patients and hemothorax in 18 patients. In 15 patients receiving field chest tubes, neither pneumothorax nor hemothorax was confirmed. Six patients (<1%) arrived at the trauma center with unsuspected pneumothoraces and required chest tube insertion. No tension pneumothoraces escaped field detection and treatment. Four chest tubes placed in the field required repositioning in the hospital because of malfunction or malpositioning. Radiologic findings excluded intraparenchymal tube placements in all patients. No pleural infections were observed in these 63 patients during their hospital stay. No antibiotics were administered as a result of prehospital chest tube placement.ConclusionPrehospital chest tube thoracostomy is safe, effective, and associated with low morbidity. Nontherapeutic chest tube placements occurred in 15 of 624 patients (2.4%); missed pneumothoraces occurred in 6 of 624 patients (<1%). Aggressive prehospital physician management of blunt chest trauma leads to an earlier treatment of potentially life-threatening injuries. Significant morbidity can be avoided by prompt pleural decompression using proper techniques.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID