J Trauma
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The purpose of this study was to develop a model that accurately predicts mortality among injured children based on components of the initial patient evaluation and that is generalizable to diverse acute care settings. Important predictive variables obtained in an emergency setting are frequently missing in even large national databases, limiting their effectiveness for developing predictions. In this study, a model predicting pediatric trauma mortality was developed using a national database and methods to handle missing data that may avoid biases that can occur restricting analyses to complete cases. ⋯ Using multiple imputation to handle missing data, a model predicting pediatric trauma mortality was developed that compared favorably with existing trauma scores. Application of these methods may produce predictive trauma models that are more statistically reliable and applicable in clinical practice.
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The devastating effects of hypotension on head-trauma-related mortality are well known. This study evaluates the systemic and cerebral hemodynamic responses to volume replacement with 3% hypertonic saline (HSS) or lactated Ringer's solution (LR), during the acute phase of hemorrhagic shock (HS) associated with traumatic brain injury (TBI). ⋯ In the event of severe head trauma and hemorrhagic shock, the use of HSS 3% and larger volumes of LR promote similar systemic and cerebral hemodynamic benefits. However, a lower ICP was observed after HSS 3% than after LR.
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Although there is substantial evidence supporting the benefits of an intensivist model of critical care delivery, the extent to which this model has been adopted by trauma centers across the United States is unknown. We set out to evaluate how critical care is delivered in Level I and II trauma centers and the extent to which these centers implement evidence-based patient care practices known to improve outcome. ⋯ The process of trauma center verification and designation should assure a high quality of trauma care. In keeping with these expectations of quality, the delivery of critical care services in trauma centers should evolve to a model that both includes the trauma surgeon in the care of the injured and allows for collaboration with a dedicated intensivist, who may or may not be a surgeon. The benefits of an intensivist model might be distinct from the utilization of evidence-based practices, suggesting that there might be incremental benefit in using these practices as markers of quality.
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Development of practice-based learning (PBL) is one of the core competencies required for resident education by the Accreditation Council for Graduate Medical Education, and specialty organizations including the American College of Surgeons have formed task forces to understand and disseminate information on this important concept. However, translating this concept into daily practice may be difficult. Our goal was to describe the successful application of PBL to patient care improvement with development of an algorithm for the empiric therapy of ventilator-associated pneumonia (VAP). ⋯ Application of the concept of PBL allowed for identification of local patterns of infection and development of an institution specific treatment algorithm that resulted in >80% adequate initial empiric coverage for VAP with a trend toward decreased mortality. PBL allows for alteration in practice based on local patterns and outcomes and has the potential to improve patient care.
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Skin stretching harnesses the same viscoelastic properties of the skin as expansion, with the difference that the forces are applied externally and not internally. An improvised system for wound closure is presented. ⋯ This system permits the closure of wounds not suitable for closure by primary intention and avoids the use of skin grafts or flaps.