J Trauma
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Comparative Study
Abbreviated Injury Scale does not reflect the added morbidity of multiple lower extremity fractures.
To determine if patients with multiple lower extremity fractures have worse outcomes than do patients with isolated femur fractures, and to determine if the Abbreviated Injury Scale (AIS) should distinguish between single and multiple lower extremity fractures. ⋯ Although AIS and ISS appropriately reflect the impact of extraskeletal injuries in patients with femur fractures, they do not adequately reflect the increased morbidity associated with multiple lower extremity fractures. The AIS-Extremity Score may need to be upgraded for multiple long bone fractures of the lower extremities.
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Comparative Study Clinical Trial
Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma.
Although there is an interest in emergent abdominal sonography (EAS), the clinical utilization of EAS in North America is minimal. The purpose of this study was to develop a new diagnostic algorithm for blunt abdominal injury based on a prospective blinded comparison of EAS, diagnostic peritoneal lavage (DPL), and computed tomography (CT). EAS (+ = fluid, - = no fluid) was performed before the DPL or CT, in 400 patients with a mean Injury Severity Score of 26; 293 had a CT and 107 had a DPL. ⋯ Based on these results, a diagnostic algorithm was developed using EAS as a screening test with selective use of DPL and CT. Emergent abdominal sonography performed by clinician sonographers is a rapid and accurate test for peritoneal fluid in blunt trauma victims, and the need for laparotomy in patients with a negative EAS is rare. Our study supports the routine use of EAS as a screening test in a diagnostic algorithm for the evaluation of blunt abdominal trauma.
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Review Comparative Study
The Injury Severity Score is unable to differentiate between poor care and severe injury.
The Injury Severity Score (ISS) has been the most frequently used tool for stratifying injured patients. The primary hypothesis of this study was that ISS fails to differentiate between severe injury and mismanagement. ⋯ This study demonstrates a fact that should be recognized by all who rely upon the ISS for comparing quality of care: ISS fails to differentiate severe injury from mismanagement of injury. Because the ISS mixes outcome data with injury severity, ISS incorrectly assigns increased severity to the lesser injuries of mismanaged patients. These findings have important implications for use of the ISS in quality of care assessments.
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There are few large series of the long-term results of severe devascularized, open fractures to the lower extremity. Therefore, we retrospectively reviewed our experience with 35 consecutively admitted patients who sustained Gustilo Type IIIC injuries and who presented to our Reimplantation Center between 1984 and 1987. To our knowledge, this group of patients represents the largest series of this injury reported to date. ⋯ Subsequent management included liberal use of microsurgical free transplantation to overcome soft tissue defects; bone grafting as soon as infection and soft tissue coverage permitted and delayed wound closure. Our approach differs in that definitive wound closure is avoided for 4 to 6 weeks to allow resolution of myonecrosis secondary to initial ischemia and subsequent reperfusion injury. Contraindications to this aggressive revascularization approach are poor patient health before injury, completely severed limb, segmental tibial loss greater than 8 cm, ischemia time greater than 6 hours, and severance of the posterior tibial nerve.
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Comparative Study
Predicting the need to pack early for severe intra-abdominal hemorrhage.
To determine if the decision to pack for hemorrhage could be refined. ⋯ Patients who suffer severe injury, hypothermia, refractory hypotension, coagulopathy, and acidosis need early packing if they are to survive. Failure to control hemorrhage is related to severity of injury and delay in the use of pack tamponade. A specific protocol that mandates packing when parameters reach a critical limit should be considered.