J Trauma
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A sample of 360 severely injured patients was selected from a cohort of 8007 trauma victims followed prospectively from the time of injury to death or discharge. A case referent study was used to test the association between on-site care, total prehospital time, and level of care at the receiving hospital with short-term survival. ⋯ Total prehospital time over 60 minutes was associated with a statistically significant adjusted relative odds of dying (OR = 3.0). The results of this study support the need for regionalization of trauma care and fail to show a benefit associated with ALS.
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Fractures of the clavicle and scapula are usually treated conservatively. After malunion functional results are usually good, however, function and shoulder contour can be improved by corrective osteotomies.
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Case Reports
Traumatic intramyocardial dissection secondary to significant blunt chest trauma: a case report.
The case of a patient with delayed mitral regurgitation and right coronary artery traumatic injury in association with intramyocardial dissection without rupture or pseudoaneurysm is presented. These findings evolved secondary to blunt chest trauma and were confirmed by cardiac ultrasound scanning, magnetic resonance imaging, and cardiac catheterization. Successful surgical correction was facilitated with this combination of diagnostic testing.
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Physicians, fearful of an increase in the incidence of intubation mishaps (IMs) and pulmonary complications (PUCs), have been reluctant to use paralysis and intubation (PI) outside the OR. This study examines the correlations between PI, IM, and PUC. Since 1987, we have used PI when complex injury or combative behavior warranted. ⋯ There was no statistical relationship between IM and PUC (Fisher's exact test). However, patients with PUCs had a significantly higher AIS-chest score (2.9 +/- 1.7 vs. 0.9 +/- 1.5) (p < 0.0005, Student's t test) and ISS (27.3 +/- 9.6 vs. 14.5 +/- 10.8) (p < 0.0005, Student's t test). In our hands, PI is associated with low morbidity, no mortality, and can be safely used to facilitate injury management or to control combative behavior.
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Although scores and other prehospital triage schema effectively identify injured patients who will benefit from trauma center care, those tools are relatively nonspecific. One consequence is overtriage--transport of less severely injured patients to trauma centers--with resulting expenditure of scarce resources on patients who do not benefit from an emergent and intensive response. We developed a tool that, during the prehospital phase, can sort inner-city trauma victims into those who will require ICU/OR services and those who will not. ⋯ Based on our initial experience with the two-tier response, the sorting criteria were revised and refined. The sensitivity of the current version of the two-tier criteria for predicting which trauma patients will require ICU/OR services during the first 24 hours of hospitalization approaches 95% (excluding misapplications of the tool) while avoiding urgent trauma team mobilization in 57% of patients triaged to our trauma center. Two-tiered trauma responses appear to be safe and may represent an important strategy for more effective distribution of increasingly scarce and costly resources.