J Trauma
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Vigorous intravenous fluid resuscitation has become widely accepted as the optimum management of hemorrhagic shock in trauma. There is now, however, sufficient evidence for this position to be reviewed. ⋯ It has been suggested that overresuscitation with intravenous fluids may worsen hemorrhage. This article discusses the possible adverse effects of "conventional" resuscitation and examines the evidence to support alternative treatment modalities.
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We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/systolic blood pressure) as covariates. ⋯ Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.
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We previously demonstrated that trauma patient volume affects attrition rate of Advanced Trauma Life Support (ATLS)-acquired skills. This study assesses the possible roles of age, gender, and practice specialty on attrition of these skills over 8 years. ⋯ Trauma patient volume is the most critical determinant of attrition rate of ATLS-acquired skills. Gender, age (at time of taking the course), and practice specialty do not alter this attrition rate.
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The most biomechanically stable relationship between the side plate of a compression hip screw (CHS) and retrograde intramedullary (IM) femoral nail has not been described in the literature. This becomes a clinical issue when treating supracondylar femur fractures with a retrograde nail in patients with a history of compression hip screw fixation of intertrochanteric fractures. The proximal end of the nail and the interlocking screws may act as a stress riser in the femoral diaphysis. The purpose of this study is to determine the biomechanical consequences of the amount of implant overlap between a CHS plate and retrograde IM femoral nail. ⋯ Strain patterns are altered by the degree of implant overlap in the proximal femoral diaphysis. Femora with uninstrumented intervals between retrograde nails and side plates fail at lower loads than femora without retrograde nails and those with kissing or overlapping implants. Kissing or overlapping instrumentation increases load to failure and creates a more biomechanically stable construct than gapped implants. The findings of this study suggest an overlapping implant orientation in the femur increases failure load at the implant interface.
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Evidence suggests that trauma centers treating high volumes of severely injured patients produce lower mortality rates than those with low volumes. However, the effect of individual surgeons' trauma caseload on outcomes has not been studied. This study compares outcomes between high-volume (HV) trauma surgeons admitting many patients with high injury severity, and low-volume (LV) surgeons treating fewer critical patients per year. ⋯ Within a single institution, mortality rates for patients treated by surgeons admitting many severely injured patients were not significantly different from low-volume surgeons' patients, although there was a trend toward higher mortality in the less active surgeons' patients in some subgroups.