J Trauma
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Large urban trauma centers care for injured children as well as adults in many areas of the country, but the quality of care in these hospitals has not been evaluated versus that available at pediatric trauma centers. The recent validation of TRISS methodology in pediatric populations allowed us to evaluate the quality of pediatric trauma care being provided in a level I trauma center treating injured patients of all ages. We reviewed the records of 353 injured children (aged 0-17 years) who were admitted to our trauma center over a 30-month period for the following data: demographics, mechanism of injury, initial physiologic status (RTS), surgical procedures required, need for intensive care, nature and severity of the injuries (ISS), and outcome. ⋯ The Z scores ranged from +0.32 for the children aged less than 2 years to +3.98 for the older age group (14-17 years). We conclude that the quality of care for pediatric trauma patients admitted to trauma centers that care for patients of all ages compares favorably with national standards. In most areas of the country, improvements in pediatric trauma care will likely come from addressing the special needs of injured children in general trauma centers rather than from developing separate pediatric facilities.
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A method for the reduction of anterior dislocations of the shoulder based on the Milch technique is presented. We have been using this method for the last 2 years (75 dislocations) with excellent results. The reduction is easy, produces minimal pain and discomfort for the patient, and the success rate is as high as 94.5%. The modified Milch technique is less troublesome for the patient and the physician and we strongly recommend it.
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Morbidity and mortality are doubled when hemorrhagic hypotension (HEM) accompanies a traumatic brain injury (TBI). Hemorrhagic hypotension initiates a "secondary" injury (SI) that has been attributed to ischemia, but this has not been confirmed in the laboratory. All previous studies have been of relatively short duration (less than 6 hours), allowing insufficient time to study the pathophysiology of SI, since maximal intracranial pressure (ICP) elevations may occur 16 to 20 hours after injury. ⋯ Hemorrhagic hypotension following TBI produced a significant and sustained reduction in cO2del associated with a lower cMRO2 and cO2ER, and higher ICP and CWC, than seen with lesion alone. This occurred despite adequate early restoration of sO2del. This confirms that cerebral ischemia is ongoing despite restoration of systemic hemodynamics.
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A patient with a stab wound to the back with suspected major vascular injury was evaluated by computed tomography instead of arteriography. The computed tomographic (CT) scan demonstrated no injury to the aorta, inferior vena cava, or esophagus, which were adjacent to the blade, and excluded a hematoma. The information from the CT scan made possible a less extensive surgical procedure than might have otherwise been necessary.
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A new concept of cerebral hemodynamic and metabolic physiology, cerebral hemodynamic reserve (CHR), was evaluated in 20 comatose adults with acute traumatic brain swelling who were undergoing continuous monitoring of the arteriojugular difference in oxyhemoglobin saturation, along with cerebral perfusion pressure and expired PCO2. The CHR was measured as the ratio of relative (percent) changes in cerebral oxygen extraction to relative changes in cerebral perfusion pressure during spontaneous increases in intracranial pressure. ⋯ It is concluded that cerebral hemodynamic reserve abnormalities very closely associate with signs of increased intracranial "tightness" on computed tomographic scans of the head. Cerebral hemodynamic reserve could therefore become an important guide in the functional evaluation and management of acute brain swelling (focusing on cerebral oxygenation and perfusion pressure) in a variety of predominantly diffuse acute intracranial disorders.