J Trauma
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Despite the demonstrated clinical benefits and decreased risks of injury recurrence, brief alcohol interventions are still not routine practice in trauma centers. Although alcohol and drugs play a significant role in trauma, few trauma specialists are aware of the potential benefits of interventions because alcohol treatment specialists have not widely disseminated their findings to other specialties. This article addresses some key obstacles that must be overcome to facilitate brief interventions as routine trauma practice. Included are discussions on training, cost and reimbursement factors, responsibility of the trauma surgeon, patient privacy and confidentiality issues, insurance laws and regulations, needed collaboration with partners, and research priorities and funding.
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"Off-label" use of human coagulation factor VIIa (FVIIa) is presently restricted to patients in extremis at our institution. Although bleeding will diminish in most patients, some will still die early as a result of irreversible shock and/or rebleeding. Futile administration of FVIIa significantly increases the economic burden of this expensive therapy and therefore limits its availability. On the basis of both human and in vitro studies, profound acidosis may be expected to predict lack of response. In addition, the depth of hemorrhagic shock, as defined by the degree of hypoperfusion over a given period of time, may be predictive of failure of FVIIa administration. We hypothesized that retrospective review of FVIIa use would identify variables associated with clinical futility. ⋯ Profound acidosis and coagulopathy may predict failure of FVIIa therapy. Depth of hemorrhagic shock, as described by the RTS, was also associated with futile administration. These variables should be considered as potential contraindications to the use of FVIIa. Earlier administration of FVIIa, before the development of massive blood loss and severe shock, may increase the rate of clinical response.
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There is clear evidence that trauma-related serious injuries and fatalities can be directly linked to alcohol misuse. Because alcohol is a factor in many motor vehicle crashes (the leading cause of death for persons up to age 49), the National Highway Traffic and Safety Administration has set a high priority on decreasing alcohol-related motor vehicle crash injuries. ⋯ Trauma centers are uniquely positioned to address this problem because of the high percentage of alcohol-impaired patients admitted after motor vehicle crashes. This article discusses the barriers to implementing alcohol screening and intervention programs in trauma centers from the trauma surgeon's perspective.
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To investigate whether multiple imputation (MI) of missing Glasgow Coma Scale (GCS) values generates more accurate GCS frequency distributions and less biased parameter estimates in logistic regression models predicting mortality than the standard procedure of excluding observations with missing GCS values. ⋯ MI is a valid solution to the problem of missing GCS data in trauma research. It allows the conservation of precious data observations and leads to unbiased estimates in consequent analyses. Analyses, which exclude observations with missing GCS data, provide biased results.