Critical care medicine
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The most common bleeding and clotting problems in post-traumatic states are reviewed. The normal response of the coagulation system and the fibrinolytic system to trauma is described; this response must be considered when studying the abnormal situations. The laboratory tests need not be numerous or sophisticated but they must be repeated often enough to understand and interpret the data. A proper understanding of these abnormalities forms the rational basis for the correct choice of therapy, and is of utmost importance in the management of post-traumatic patients.
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Critical care medicine · Nov 1975
Comparative StudyThe therapeutic intervention scoring system. An application to acutely ill cancer patients.
The Therapeutic Intervention Scoring System (TISS) has been introduced (Cullen DJ, Civetta JM, Briggs BA, et al: Therapeutic intervention scoring system: A method for quantitative comparison of patient care. Crit Care Med 2:57-60, 1974) at the Massachusetts General Hospital as a means of quantifying the medical and nursing care required by critically ill patients. The method has been instituted in the Intensive Care Unit of Memorial Cancer Center to evaluate its applicability to patients who develop life-threatening complications of their disease or its treatment. ⋯ This average compares closely with that of postcardiac surgery patients (31.8 points), the group that required the most care of all patients in the initial study. The results indicate the usefulness of this sytem in evaluating severity of illness, predicting survival, and assessing cost benefits. It has proven to be a simple and accurate method of assessment when simple and accurate method of assessment when applied to this patient population, but certain modifications seem warranted and have been suggested herein.
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Nine variables were studied in 56 patients to analyze hemodynamic patterns of critically ill and shock patients. The variables were central venous pressure, mean arterial pressure, heart rate, cardiac index, left ventricular stroke work, strok index, total peripheral resistance, arteriovenous oxygen difference, and oxygen consumption. We observed six patterns; three with low cardiac index (hypodynamic) and three with high cardiac index (hyperdynamic). ⋯ Group IID: High cardiac index and increased arteriovenous oxygen difference in patients with sepsis and stable hemodynamic conditions. Groups IIE and IIF: Increased cardiac index and normal or increased arteriovenous oxygen difference in septic patients, who were hemodymamically unstable or in shock. These hemodynamic observations were found to be useful for understanding physiological compensations, for deciding on therapy, and in evaluating the effectiveness of therapy.
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Critical care medicine · Sep 1975
A system-structured medical record for intensive care patient documentation.
The problem-oriented approach to the medical record has aroused a long overdue interest in the structuring of the medical case file. Clinical information in the traditional record is source-structured and time-sequenced, whereas the problem-oriented system differs by being a problem-structured record retaining still a chronologic sequence. We have found that in acute illness the multiplicity of interacting pathophysiologic processes makes premature application of the problem-oriented approach cumbersome and unwieldy. ⋯ Some used the simple cataloguing of events and data as a substitute for clinical judgment and decision making, focusing more upon style rather than content of the medical record. By using a rigid physiologic system-structured "problem" list and a modification of the SOAP (Subjective Objective, Assessment, Plan) subdivision, we have improved the documentation of our intensive care patients. The summary of the patient's stay in the intensive care unit is structured with active and inactive problems, this summary to be further used as the permanent problem list.