Articles: trauma.
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In the past three decades there has been a significant clinical shift in the performance of emergency department thoracotomy (EDT), from a nearly obligatory procedure before declaring any trauma patient to select patients undergoing EDT. The value of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable. Its indiscriminate use, however, renders it a low-yield and high-cost procedure. ⋯ Conversely, patient outcome is relatively poor when EDT is done for blunt trauma; 2% survival in patients in shock and less than 1% survival with no vital signs. Patients undergoing CPR upon arrival to the emergency department should be stratified based upon injury and transport time to determine the utility of EDT. The optimal application of EDT requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences.
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In 2003, a multidisciplinary group of physicians formulated the first guidelines for the management of severe traumatic brain injury in infants and children. Initial treatment of these patients is focused on stabilization to prevent the occurrence of secondary insults such as hypotension and hypoxemia. However, this article focuses on the established and emerging therapies used in the intensive care unit management of intracranial hypertension--which represents the key target for contemporary therapy of this condition. ⋯ This includes first- and second-tier therapies. This article contains a brief synopsis of this critical pathway and discusses important new developments for the management of this condition. Key new developments include a better understanding of the optimal cerebral perfusion pressure target for intracranial pressure-directed therapy, with emerging evidence supporting the use of two therapeutic modalities, mild-moderate hypothermia and decompressive craniectomy.
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Therapeutic hypothermia is a potentially dangerous treatment with a very narrow therapeutic index. It is of proven benefit in certain conditions, including post ventricular fibrillation cardiac arrest and intermediate severity neonatal asphyxia. ⋯ While it is clear that hypothermia decreases intracranial pressure, a major phase III trial demonstrated no improvement in neurological outcomes with hypothermia, in an unselected group of patient with severe head injury. More focused phase III trials are underway but until the results are known this treatment should not be offered to patients outside the context of a clinical trial.