J Trauma
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Comparative Study
Limiting initial resuscitation of uncontrolled hemorrhage reduces internal bleeding and subsequent volume requirements.
We tested the hypothesis that full or "standard resuscitation" (SR) with lactated Ringer's solution (LRS) results in increased bleeding in uncontrolled hemorrhagic shock, compared with a "limited prehospital resuscitation" (LPR) regimen and a control group of "no resuscitation" (NR). Cardiac output was used as physiological endpoint for resuscitation. Twenty swine had 25 mL/kg of blood withdrawn during a 30-minute controlled hemorrhage, followed by a 20-minute "prehospital" resuscitation regimen was conducted in three groups: the SR group (n = 6), LRS infused as needed to restore cardiac index (CI) to 100% baseline; the LPR group (n = 8), with resuscitation using LRS to 60% of baseline CI, with volume limited to 10 mL/kg; and the NR group (n = 6). ⋯ Peritoneal blood volume was significantly higher in the SR group (20.6 +/- 5.6 mL/kg), versus the LPR (7.3 +/- 1.3 mL/kg; p < 0.05) and NR groups (3.0 +/- 0.9 mL/kg; p < 0.05). Crystalloid and whole blood requirements during the intraoperative resuscitation phase were significantly higher in the SR group (193 +/- 16.0 and 9.0 +/- 2.5 mL/kg), than in LPR (111.8 +/- 15.6 and 4.5 +/- 1.8 mL/kg; p < 0.05) and NR groups (128.5 +/- 32.3 and 3.9 +/- 2.3 mL/kg; p < 0.05). In the presence of uncontrolled hemorrhagic shock, LPR and NR can significantly reduce internal hemorrhage and subsequent intraoperative crystalloid and blood requirements.
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The availability of unreamed interlocked nails for fixation of tibia fractures has raised the issue of what effect reaming the intramedullary canal has on the clinical outcome after tibial nailing. A retrospective review was performed of all tibial fractures treated with interlocking nailing at the authors' institution over the past 5 years in order to compare reamed and unreamed nailing. Forty-five nailings were identified of which 38 had adequate follow-up information to be considered healed or non-united at 1 year. ⋯ Patellofemoral complications were more common in unreamed nailings. Although this study is limited by retrospective, nonrandom design, it raises questions about the routine use of unreamed nailing with regard to healing potential and other postoperative complications. Further study is warranted.
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The purpose of this study was to determine the frequency and significance of computed tomographic (CT) scan-detected pneumoperitoneum in blunt abdominal trauma. We retrospectively reviewed 118 consecutive CT scans of the abdomen in blunt abdominal trauma patients (mean Injury Severity Score 24), performed at our Regional Trauma Unit over a 12-month period. Seven (5.9%) patients had intra-abdominal extraluminal air. ⋯ In the setting of blunt abdominal trauma pneumoperitoneum does not necessarily indicate hollow viscus injury. It frequently is secondary to other etiologies, especially dissection of interstitial air from the chest, as suggested in this study. The decision for laparotomy should be based on a combination of the clinical findings, CT scan results, or other diagnostic tests such as peritoneal lavage.
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Tension pneumothorax and hemothorax are life-threatening emergencies that require immediate treatment. Field stabilization of trauma patients often requires rapid surgical drainage of these injuries but inevitably delays departure for hospital. Conventional treatment involves the insertion of a chest drain but we describe a modified technique of simple thoracostomy that is faster and simpler to perform and avoids the risks associated with insertion of the chest drain. Following use of a simple thoracostomy as an alternative to chest drain insertion in 45 patients at the roadside, this technique appears to have important advantages over conventional techniques and warrants further clinical evaluation.
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Comparative Study
Evolution of management of major hepatic trauma: identification of patterns of injury.
Nonoperative management of hemodynamically stable patients following blunt hepatic trauma identified by computed tomography (CT) has been reported in up to 20% of patients presenting with hepatic injury, predominantly low grade. We reviewed 128 consecutive adult patients sustaining blunt hepatic trauma with the hypothesis that severe hepatic injuries (grades III to V) could be safely managed nonoperatively and to determine anatomic pattern and severity of hepatic injuries. Sixty-two of the 128 patients (47%) went directly for laparotomy, based on physical findings or positive peritoneal lavage. ⋯ However, the majority of patients with grade V injuries were unstable, and 92% required laparotomy. Twenty-six of 46 patients treated nonoperatively (56%) had injury to the posterior segment of the right lobe of the liver or a "split liver." In retrospect, only 33% of patients with hepatic injury required laparotomy for therapy of the liver injury. Hemodynamic stability and anatomic pattern of injury on presentation were important factors in successful nonoperative management of hepatic injury.