American journal of surgery
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To assess the impact of ATLS education on early trauma management, charts of patients with an ISS of 14 or greater were reviewed for a 1 year period before and after ATLS training of emergency room trauma care providers. There were 50 patients in the before ATLS group, with a mean age of 41.6 years and an ISS of 29.8, and 71 patients in the after ATLS group, with a mean age of 40.6 years and an ISS of 30.6. Of those parameters evaluated as measures of early assessment, only rectal examination was found to be performed significantly more frequently after ATLS training. ⋯ In evaluating assessment and management parameters in the patients who died, no airway management errors were found in the after ATLS group; however, there were more missed injuries in this group. We have concluded that ATLS instruction failed to produce a quantifiable improvement in patient assessment or outcome. Further studies directed at assessing the retention rate for ATLS education and determining the impact on clinical performance are needed.
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Introducer insertion of a small caliber chest tube is easily mastered, fast, and nearly painless. Outpatient management of spontaneous pneumothorax with a 12 F. polyvinylchloride catheter and a Heimlich valve appears both safe and economical in a selected group of patients. Introducer chest tube insertion is well tolerated, in contrast to the discomfort experienced during insertion of chest tubes by means of blunt dissection or trocar. In addition, the high risk of injury to the lung or other viscera by trocars is avoided.
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This review of the literature has revealed that isotonic fluids, such as 0.9 percent sodium chloride and Ringer's lactate, are effective plasma volume expanders. Despite the continued use of a variety of colloid solutions in resuscitation, there is no good evidence to document a benefit of these solutions over the crystalloid solutions. The additional cost of colloid compared with crystalloid is another argument against colloid use. ⋯ Further evaluations are needed to verify the efficacy of this therapy. Finally, a recent National Institute of Health consensus panel identified the appropriate indications for fresh frozen plasma. They concluded that there is no indication for the use of fresh frozen plasma as a volume expander.
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The records of 82 patients treated with the Sengstaken-Blakemore tube for massive bleeding from esophageal varices have been reviewed. Initial control of hemorrhage was obtained in 78 patients (95 percent). Six patients suffered major nonfatal complications, including bronchial aspiration (five patients) and esophageal rupture (one patient). ⋯ Ninety-four percent of the patients were free of recurrent variceal bleeding, as proved by endoscopy, at 1 year, 90 percent at 5 years, and 77 percent at 10 years. This study shows that temporary use of the Sengstaken-Blakemore tube for the initial control of acutely bleeding esophageal varices is effective and relatively safe. In our experience, methods for the prevention of complications were early endotracheal intubation in patients under anesthesia, avoidance of traction on the tube, and a period of tamponade not exceeding 24 hours.