Injury
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Advanced Trauma Life Support guidelines recommend the use of a cannula 3 to 6 cm long to perform needle thoracocentesis for life-threatening tension pneumothorax. The chest wall thickness in the 2nd intercostal space, mid-clavicular line, was determined by ultrasound in 54 patients aged 18 to 55 years, and ranged from 1.3 to 5.2 cm (mean 3.2 cm). ⋯ As a 3 cm cannula would fail to reach the pleural cavity in over half of patients, we suggest that the recommended shortest length be increased to 4.5 cm. Unsuccessful needle thoracocentesis using a 4.5 cm cannula should be followed immediately by insertion of a longer cannula or a definitive chest drain.
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In this study, we have evaluated the performance of the Revised Trauma Score (RTS) as a triage instrument in the prehospital setting in The Netherlands. To this end we analysed prehospital and clinical data on 398 injured patients in an urban-rural area in the east of the Netherlands. Our study included injured patients aged over 15 who were alive at the time the ambulance arrived. ⋯ The specificity and the predictive value of a lowered RTS, however, were 94 per cent and 26 per cent respectively for all definitions used. The conclusion of this study is that the performance of the RTS in this study population is poorer than expected from earlier studies. The low prevalence of major injuries in the prehospital setting in The Netherlands and the distribution of case severity may possibly explain these results.
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The diagnosis of blunt abdominal injuries is one of the most difficult problems in the management of trauma. There is now better understanding of the diagnostic facilities available. Guidelines regarding the use of diagnostic peritoneal lavage, ultrasonography, or computed tomography scanning should be available in the Accident and Emergency department.
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Over a two and a half year period, 25 patients presenting to the Glasgow Royal Infirmary underwent emergency thoracotomy for suspected severe chest injuries. Eighteen (72 per cent) were performed in the Accident and Emergency (A&E) department and seven (28 per cent) in a fully equipped operating theatre after resuscitation. There were 23 men and 2 women. ⋯ Outcomes may be improved if appropriately trained hospital staff are immediately available and prehospital delays are minimized so that patients arrive sooner with signs of life still present. Ambulance paramedic interventions have little to offer these patients and may worsen the prognosis if they result in delayed transport to hospital. The emphasis placed on diagnosis and treatment of cardiac tamponade in Advanced Trauma Life Support programmes is appropriate and all staff involved in these cases should undergo this type of training.