J Trauma
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Resuscitation with hypertonic saline/dextran (HSD) has been suggested to be efficacious in patients who have traumatic brain injury and are hypotensive. We undertook a cohort analysis of individual patient data from previous prospective randomized double-blinded trials to evaluate improvements in survival at 24 hours and discharge after initial treatment with HSD in patients who had traumatic brain injury (head region Abbreviated Injury Score > or = 4) and hypotension (systolic blood pressure < or = 90 mm Hg). ⋯ Patients who have traumatic brain injuries in the presence of hypotension and receive HSD are about twice as likely to survive as those who receive standard of care.
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Preservation of a high cerebral perfusion (mean arterial) pressure to prevent ischemia has become the primary focus during treatment of severe head trauma because ischemia is favored as a triggering mechanism behind intracellular brain edema development and poor outcome. A high cerebral perfusion pressure, however, simultaneously may increase the hydrostatic vasogenic edema. The present paper evaluates the mechanisms behind the vasogenic edema by analyzing the physiologic hemodynamic mechanisms controlling the volume of a tissue that is enclosed in a rigid shell, possesses capillaries permeable for solutes, and has depressed autoregulation. ⋯ We contend that in the long run, the interstitial volume in such a tissue can be reduced only through reduction in arterial inflow pressure providing an otherwise optimal therapy to improve microcirculation. Therefore we argue, in contrast to the conventional view, that antihypertensive and antistress therapy may be of value by reducing the interstitial tissue volume during treatment of brain edema, and that the problem with ischemia during such therapy can be handled when considering an otherwise optimal intensive care. These physiologic principles of interstitial tissue volume regulation form the basic concept for the "Lund therapy" of severe head injuries, which is a new and controversial therapy of posttraumatic brain edema.
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Pulmonary contusion is a common lesion occurring in patients sustaining severe blunt chest trauma. Alveolar hemorrhage and parenchymal destruction are maximal during the first 24 hours after injury and then usually resolve within 7 days. ⋯ Respiratory distress is common after lung trauma, with hypoxemia and hypercarbia greatest at about 72 hours. Although management of patients with pulmonary contusion is supportive, pneumonia and adult respiratory distress syndrome with long-term disability occur frequently.
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Although the indications for video-assisted thoracic surgery (VATS) have expanded rapidly, especially in the areas of therapeutic and operative procedures, its role in the definite surgical treatment of chest trauma is not clear. From July 1994 to December 1995, 56 patients with hemothorax or posthemothorax complications resulting from chest trauma received thoracic surgery. Their ages ranged from 17 to 71 years. ⋯ Twelve of the 50 patients treated with VATS would have otherwise had to undergo thoracotomy. Our results indicate that VATS can be safely used in hemodynamically stable patients with no cardiovascular or great vessel injury, sparing many patients the pain and morbidity associated with thoracotomy. Additionally, use of VATS may reduce the likelihood of posthemothorax complications by allowing early direct inspection of the chest wall, because VATS has a lower associated risk and can be performed with a lower index of suspicion than can standard thoracotomy.
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Review Case Reports
Aortic dissection after trauma: case report and review of the literature.