The American surgeon
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The American surgeon · Nov 2009
Multicenter Study Comparative StudyDoes platelet administration affect mortality in elderly head-injured patients taking antiplatelet medications?
A significant portion of patients sustaining traumatic brain injury (TBI) take antiplatelet medications (aspirin or clopidogrel), which have been associated with increased morbidity and mortality. In an attempt to alleviate the risk of increased bleeding, platelet transfusion has become standard practice in some institutions. This study was designed to determine if platelet transfusion reduces mortality in patients with TBI on antiplatelet medications. ⋯ Of these patients, 166 received platelet transfusion and 162 patients did not. Patients who received platelets had a mortality rate of 17.5 per cent (29 of 166), whereas those who did not receive platelets had a mortality rate of 16.7 per cent (27 of 162) (P = 0.85). Transfusion of platelets in patients with TBI using antiplatelet therapy did not reduce mortality.
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The American surgeon · Nov 2009
ReviewGlucose control and its implications for the general surgeon.
In the face of these conflicting data, how should the practicing surgeon approach the issue of tight glucose control in their critically ill surgical patients? The answer to that question may well change over time as new data emerge. For now, however, it seems reasonable to conclude that tight glucose control to the normal range (80-110 mg/dL) in critically ill general surgery patients (i.e., the Van den Berghe model) is an intriguing but unproven hypothesis that needs to be confirmed by prospective randomized trials in different ICUs and in a relevant patient population. It is quite possible, and probably likely, that levels of hyperglycemia that were previously thought to be inconsequential (180-200 mg/dL) may be harmful when sustained over prolonged periods of time and that better glucose control in the ICU than previously practiced is merited. ⋯ These factors need to be accounted for in daily clinical practice and their roles need to be better understood in future clinical trials. At present, it seems reasonable to attempt to control blood glucose levels in critically ill general surgery patients to moderate levels that avoid deleterious hypoglycemia but have been associated with encouraging clinical results until better data emerge. Until that time, the clinician will need to attempt to balance the potentially detrimental effects of hyperglycemia with the risk of hypoglycemia carefully until future trials involving general surgery patients are completed to clarify this issue.
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The American surgeon · Nov 2009
Comparative StudyThe incidence and clinical significance of pneumomediastinum found on computed tomography scan in blunt trauma patients.
With the increased use of chest computed tomography (CT) scan in the initial evaluation of major trauma, findings that were not seen on a chest radiograph (CXR) are increasingly identified. Pneumomediastinum (PM) seen on CXR in blunt trauma patients is considered worrisome for airway and/or esophageal injury. The purpose of this study was to determine the incidence and clinical significance of PM found on CT in blunt trauma patients. ⋯ No patients had tracheobronchial or esophageal injuries. In this study, PM seen on CT was found to have little clinical significance other than as a marker for severe blunt trauma. No patients with airway or esophageal injuries were seen in any of the PM patients.
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The American surgeon · Nov 2009
Comparative StudyInjury location dictates utility of digital rectal examination and rigid sigmoidoscopy in the evaluation of penetrating rectal trauma.
Penetrating pelvic injuries (specifically rectal) pose a difficult diagnostic challenge. Although management of these injuries, once recognized, can be straightforward, the consequences of a missed injury can be devastating. The purpose of this study was to evaluate the utility of digital rectal examination (DRE) and rigid sigmoidoscopy (RS) as screening tests for penetrating rectal injuries. ⋯ RS proved better than DRE for diagnosis. The greatest benefit was observed with EP injuries. The possibility of a missed IP injury associated with a negative screen should prompt exploration if clinical suspicion is high.
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The American surgeon · Nov 2009
Comparative StudyCritical evaluation of pulmonary contusion in the early post-traumatic period: risk of assisted ventilation.
This study attempts to accurately quantify pulmonary contusion and predict those patients most likely to require assisted ventilation early in their hospital course. Patients admitted to a Level I trauma center were evaluated for pulmonary contusion by helical CT scan. Scans were reviewed by a single radiologist who attempted to accurately quantify contusion as a percentage of total lung volume. ⋯ Of patients sustaining <20 per cent contusion, only 7 of 92 (8%) required assisted ventilation versus 24 of 60 (40%) sustaining >20 per cent contusion. Pulmonary contusion is a significant injury especially when contusion volume exceeds 20 per cent of total lung volume. With accurate measurement of contusion, we can identify those patients at high risk of requiring assisted ventilation early in their hospital course.