J Trauma
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Ensuring an unobstructed airway and adequate oxygenation are first priorities in the resuscitation of the trauma patient. In situations of difficult endotracheal intubation, rapid sequence protocols frequently include the use of paralytic agents and cricothyrotomy for airway management. Recent literature findings suggest that the prehospital use of cricothyrotomy is too frequent. The purpose of this study was (a) to evaluate the efficacy of a rapid sequence intubation protocol without the use of paralytic agents, and (b) to determine the need for cricothyrotomy by using this protocol in the field. ⋯ Experienced emergency medical services personnel can effectively perform endotracheal intubation with narcotic analgesics without the use of paralytic agents in the field. With proper training for field airway management, cricothyrotomy in the field can be reduced to a few indications with high success rates.
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Wound management in open pelvic fractures has used fecal diversion, debridement, and closure by secondary intention to prevent pelvic sepsis. Colostomy care and takedown adds to the morbidity and resource utilization of this approach. We reviewed our experience to determine if a selective approach to fecal diversion based on wound location was possible. ⋯ No patients with anterior wounds and an intact fecal stream developed pelvic sepsis. Colostomy may not be necessary in all patients with open pelvic fracture. Protocols using fecal diversion based on wound location appear to be safe and may decrease resource utilization and subsequent morbidity related to colostomy closure.
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Some patients who survived severe hemorrhagic shock (HS) seem to exhibit persistent subtle neurobehavioral deficits. This finding is of concern if limited hypotensive fluid resuscitation is applied in hypotensive victims with penetrating trauma. This study was designed to determine whether subtle brain damage would occur in rats after severe prolonged HS. We hypothesized that rats surviving HS with mean arterial pressure (MAP) controlled at 40 mm Hg for 60 minutes would recover with slight permanent brain damage in terms of cognitive function without morphologic loss of neurons and that rats surviving HS with MAP at 30 mm Hg for 45 minutes (60 minutes were not tolerated) would have grossly abnormal brain function and loss of neurons. ⋯ HS at MAP 40 mm Hg for 60 minutes or MAP 30 mm Hg for 45 minutes does not cause subtle functional or histologic brain damage in surviving rats. Controlling MAP at 30 mm Hg carries a risk of sudden cardiac arrest. These data suggest that limited fluid resuscitation, to maintain MAP at about 40 mm Hg, as recommended for victims of penetrating trauma with uncontrolled HS, is safe for the brain.
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Although several retrospective studies have been published concerning nonoperative management of minor liver and spleen injuries, few studies have prospectively analyzed the results of nonoperative management for higher-grade liver and spleen injuries. Is it possible to manage extensive hepatic or splenic injuries with hemoperitoneum nonoperatively? The current study was conducted to evaluate the safety of nonoperative management of blunt hepatic and splenic trauma with significant hemoperitoneum in hemodynamically stable patients regardless of injury severity. ⋯ We suggest that nonoperative management may be undertaken successfully in appropriately designed areas with close observation for the hemodynamic stable patient.
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To evaluate functional recovery after suture of the sciatic nerve after missile injury. ⋯ We advocate exploration of the sciatic nerve at any level within 3 months if no spontaneous recovery occurs after a missile injury. We do not advocate exploration of the sciatic nerve at the buttock level if only peroneal function is lost except in children.