J Trauma
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An instrument was developed using routinely available field data to identify the sizable subgroup of stable vehicular trauma victims initially triaged to the trauma center by mechanism indicators alone who are in reality at minimal risk for serious injury. The six most common vehicular mechanism indicators seen at a level I trauma center were evaluated: rollover, head-on greater than 30 mph, intrusion, prolonged extrication, other death in same vehicle, and ejection. Review of 1235 consecutive trauma team activations yielded 349 victims with a qualifying vehicular mechanism. ⋯ Retrospectively, use of this instrument would have excluded 56% of the MI group from unproductive trauma team referral, but nearly none of the SI group. We conclude that an identifiable subset of trauma patients referred by vehicular mechanism criteria alone could be safely evaluated on arrival in the emergency department as a form of secondary triage rather than by referral to the trauma team. The use of an appropriate exclusionary instrument can still preserve the sensitivity of trauma team activation for severely injured victims.
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Assessment of splanchnic perfusion by gastric intramucosal pH (pHi) adds to the information provided by systemic indicators of oxygen transport. ⋯ Uncorrected splanchnic malperfusion is associated with a higher incidence of organ dysfunction and mortality. Gastric tonometry supplements information provided by systemic indicators of oxygen transport during resuscitation of critically ill trauma patients.
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We devised a protocol to prospectively manage stab wounds to the back with the hypothesis that the triple contrast computed tomographic (CT) scan is an effective means of detecting occult injury in these patients. All wounds to the back in hemodynamically stable adults were locally explored. All patients with muscular fascial penetration underwent triple contrast CT scanning utilizing oral, rectal, and IV contrast. ⋯ Two CT scans documented significant injury and led to surgical exploration and therapeutic celiotomies. Although triple contrast CT scanning was able to detect occult injury in patients with stab wounds to the back it did so at considerable cost and the results rarely altered clinical care. Therefore, its routine use in these patients is not recommended.
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Multicenter Study
Death in the operating room: an analysis of a multi-center experience.
To characterize causes of death in the operating room (OR) following major trauma, a retrospective review of admissions to eight academic trauma centers was conducted to define the etiology of death and challenges for improvement in outcome. Five hundred thirty seven OR deaths of 72,151 admissions were reviewed for mechanism of injury, physiologic findings, resuscitation, patterns of injury, surgical procedures, cause of death, and preventability. Blunt injuries accounted for 61% of all injuries, gunshot wounds (GSW) accounted for 74% of penetrating injuries. ⋯ Recurrent injury patterns judged as the primary cause of patient death included head/neck injury (16.4%), chest injury (27.4%), and abdominal injury (53.4%). Actual cause of death was bleeding (82%), cerebral herniation (14.5%), and air emboli (2.2%). A different strategy for improved outcome was identified in 54 patients with the following conclusions: (1) delayed transfer to the OR remains a problem with significant BP deterioration during delay, particularly following interfacility transfer; (2) staged injury isolation and repair to allow better resuscitation and warming may lead to improved results; (3) combined thoraco-abdominal injuries, particularly with thoracic aortic disruption, often require a different sequence of management; (4) aggressive evaluation of retroperitoneal hematomas is essential; (5) OR management of severe liver injuries remains a technical challenge with better endpoints for packing needed; and (6) resuscitative thoracotomy applied to OR patients in extremis from exsanguination offers little.
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Comparative Study
Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma?
Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities in the evaluation of patients with suspected blunt abdominal trauma (BAT). Diagnostic peritoneal lavage is fast and accurate but associated with complications. Computed tomography is also accurate, yet requires that patients be stable and transportable. ⋯ Six injuries were missed but only one was felt to be significant. If US had been used in all 200 patients, 199 would have had appropriate care. We conclude US is reliable in the detection of free intraperitoneal fluid and may be used in place of DPL or CT.