J Trauma
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Comparative Study
Triage and trauma workload in mass casualty: a computer model.
The aim of this study was to quantitatively analyze the impact of hospital triage on the workload of trauma teams in the Emergency Department during a mass casualty incident, using a computer model. ⋯ This study introduces innovative tools for quantitative analysis of hospital triage in mass casualty incidents and shows how triage accuracy and mode affect the ability of trauma teams to cope with heavy casualty loads. These tools can be used to optimize the hospital response to future threats.
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Shock index (SI) is recognized to be a more reliable early indicator of hemorrhage than traditional vital signs. Acute traumatic brain injury (TBI) can be associated with autonomic uncoupling and may therefore alter the reliability of SI in patients with combined TBI and peripheral hemorrhage. The aim of this study was to evaluate the performance of SI when acute TBI of mild and moderate severity were associated with progressive simple hemorrhage. ⋯ SI significantly underestimated underlying hemorrhage in the presence of acute TBI of moderate severity where attenuation of the biphasic heart rate and blood pressure response was also most pronounced.
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Comparative Study
Ventilator-associated pneumonia is more common and of less consequence in trauma patients compared with other critically ill patients.
Ventilator-associated pneumonia (VAP) incidence is used as a quality measure. We hypothesized that patient and provider factors accounted for the higher incidence of VAP in trauma patients compared with other critically ill patients. ⋯ The incidence of VAP is greatest among trauma patients at our institution. The increased use of bronchoalveolar lavage, the earlier onset of VAP, and the higher incidence of gram-negative pneumonias suggest that both patient and provider factors may influence this phenomenon. VAP was associated with increased mortality in the nontrauma group only. These factors should be considered before VAP is applied as a quality indicator.
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Critical care-trained trauma surgeons are the ideal care provider for severely injured patients. This "captain of the ship" (COS) assumes complete responsibility of the patient, from initial resuscitation to eventual discharge. Unlike American College of Surgeons-verified Level I centers, many nonacademic, community hospital trauma centers use a more fragmented approach, with care in the intensive care unit (ICU) delegated to a committee of multiple specialists. We hypothesized that dedicated trauma intensivists as COS in a community hospital could improve ICU outcome. ⋯ A trauma intensivist-driven model can be successfully adopted in a nonacademic community trauma program, without the need for a residency program. A decentralized ICU care model produces inefficiencies, diminishes the role of the trauma service, and decreases the overall throughput of trauma patients.
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Comparative Study
Clot-inducing minerals versus plasma protein dressing for topical treatment of external bleeding in the presence of coagulopathy.
Previous studies identified WoundStat (WS, smectite) and Combat Gauze (CG, kaolin-coated gauze) as the most effective available agents for controlling arterial bleeding with potential utility in casualty care. Tissue sealant properties of WS suggested its potential advantage over clot-promoting CG for treating coagulopathic bleeding. This study compared the efficacy of CG and WS with a fibrinogen-based (FAST) dressing to control bleeding in coagulopathic animals. ⋯ The tissue sealant property of WS is apparently mediated by clot formation in the wound; therefore, it was ineffective under coagulopathic conditions. CG was partially effective in maintaining blood pressure up to 1 hour after application. FAST dressing showed the highest efficacy because of the exogenous delivery of concentrated fibrinogen and thrombin to the wound, which bypasses coagulopathy and secures hemostasis.