J Trauma
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Multicenter Study
Blunt traumatic thoracic aortic injuries: early or delayed repair--results of an American Association for the Surgery of Trauma prospective study.
The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes. ⋯ Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.
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Comparative Study
Predictors of posttraumatic deep vein thrombosis (DVT): hospital practice versus patient factors-an analysis of the National Trauma Data Bank (NTDB).
Trauma centers that perform more duplex ultrasounds report more deep vein thromboses (DVT). However, it is uncertain if this is due to variations in hospital practices or patient characteristics and case mix. We hypothesize that admission to trauma centers that use duplex ultrasound more frequently, independently predicts DVT reporting for individual patients, controlling for patient-level risk factors. ⋯ Trauma center ultrasound practice is an independent predictor of DVT diagnosis for individual patients, controlling for patient-level risk factors. Elevated DVT rates at these centers are due to surveillance bias. In the absence of standardized surveillance, hospital DVT rate is an inappropriate quality of care measure after trauma.
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Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate after high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The aim of this study was to assess the validity of the mangled extremity severity score (MESS), the only verified score, in a population of UK military patients with ballistic mangled extremity injuries. ⋯ The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have identified important factors in the management, in particular the need for early amputation, of the military mangled extremity.
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Physical assault is common in trauma patients. Penetrating injuries resulting from interpersonal violence have been well described in literature, but there have been few studies examining the injury patterns due to assaults with hands and feet or blunt instruments. ⋯ Injuries due to assault rarely require operative intervention and have a low risk of cervical spine or cord injuries. However, many result in traumatic brain injury. Patients older than 55 years tend to be more severely injured and at higher risk of mortality.
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Strict glycemic control has been shown to reduce both morbidity and mortality in critically ill surgical patients; however, overly aggressive management of hyperglycemia may also be associated with deleterious effects. We sought to characterize clinical outcomes associated with different levels of persistent hyperglycemia (PH) in a cohort of severely injured patients with trauma, when a strict glycemic control protocol (target glucose 80-110 mg/dL) was implemented. ⋯ Maintenance of daily maximum glucose values <145 mg/dL was independently associated with a survival benefit after injury. Patients with PH, despite aggressive insulin therapy, had a higher incidence of multiple organ failure and an associated higher risk of mortality. However, the strict glycemic control protocol in the current trauma cohort seems to have prevented the association of PH and infectious complications, which has been documented in prior studies. This analysis further validates the importance of strict glycemic control after injury, and highlights the need for further studies on the mechanism responsible for these findings.