J Trauma
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Although emergency department (ED) thoracotomy is performed only in selected adult trauma victims, it continues to be widely used in children. To evaluate if use of this liberal policy is justified in children, the charts of 23 pediatric trauma victims who underwent ED thoracotomy at our institution in the past 5 years were reviewed. Mechanism of injury was blunt trauma in 65% and penetrating injury in 35%. ⋯ This study demonstrates that children who arrive at the ED following blunt or penetrating trauma with no cardiac rhythm are unsalvageable and should not undergo ED thoracotomy. The burden of unreimbursed care for this procedure is not trivial. Indications for ED thoracotomy in pediatric trauma victims should therefore be the same as those currently used for adult trauma victims.
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A tamponade device for control of refractory liver bleeding is occasionally indicated. This report documents to our knowledge the first reported use of Foley catheter balloon tamponade for severe liver injury.
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We computed regression coefficients for TRISS analysis for all 4271 pediatric patients (aged 1 through 14 years) with complete data from the Major Trauma Outcome Study. We then compared predicted pediatric and adult TRISS survival probability norms. ⋯ The study confirmed that the TRISS adult blunt norm is highly discriminating and reliable in predicting survival probabilities for pediatric patients. Given that both norms were equally good predictors, and the importance of a consistent system to evaluate trauma care, the authors recommend the continued use of the adult blunt trauma norm for estimating survival probability in children.
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Comparative Study
Comparison of intraosseous, central, and peripheral routes of crystalloid infusion for resuscitation of hemorrhagic shock in a swine model.
Venous access is often a clinical dilemma in severely hypovolemic children. This study compares fluid resuscitation by central vein, peripheral vein, and the intraosseous route in a hemorrhagic shock model. Hampshire piglets were bled to a mean arterial pressure of 30 mm Hg. ⋯ There was no significant difference in mean arterial pressure, central venous pressure, cardiac output, pulmonary capillary wedge pressure, mixed venous oxygen saturation, or arterial oxygen saturation. Histologically, cellular washout and necrosis were found in bone marrow immediately adjacent to the intraosseous needle infusion site. For fixed-rate infusion, intraosseous crystalloid resuscitation is as efficacious as that delivered by peripheral or central venous routes in reversing hemorrhagic shock.
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Arterial injuries represent a formidable challenge to surgeons working in war zone conditions. A series of 23 consecutive patients with combat wounds from the Afghan conflict with acute arterial injury were treated at the ICRC hospital in Peshawar. ⋯ This was a highly significant statistical difference (Chi-square > 13.0, p < 0.005). We recommend attempting revascularization procedures only in patients seen within 12 hours of sustaining a military-type injury to an artery in an extremity.