The American surgeon
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The American surgeon · Apr 2010
Optimizing outcomes in emergency room thoracotomy: a 20-year experience in an urban Level I trauma center.
Emergency room thoracotomy (ERT) has remained a last resort tool of resuscitation in the management of patients with major trauma. The medical records of all patients undergoing ERT for penetrating chest trauma from January 1, 2000 through April 30, 2008 were retrospectively reviewed. The data from this study were added to data collected in two previous studies conducted at our institution for meta-analysis. ⋯ Overall survival in the 1995 group was 2.5 per cent, 1999 was 2.7 per cent, and 2008 was 7.8 per cent. The majority of the survival benefit occurs in patients who have electrical activity and a blood pressure when examined in the emergency department (Class III and IV). We intend to do future prospective research to further clarify the Class II patients when evaluating the type of rhythm shown on electrocardiogram tracing to move away from the generic pulseless electrical activity category.
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The American surgeon · Apr 2010
Case ReportsBuprenorphine maintenance therapy hinders acute pain management in trauma.
Buprenorphine is a mixed opiate receptor agonist-antagonist growing in popularity as an office-based treatment for opioid-dependent patients. It has high affinity, but only partial agonism at the micro-opioid receptor resulting in a ceiling analgesic effect. At higher doses, buprenorphine potentiates antagonism at the kappa-opioid receptor. ⋯ We present a case of a young multisystem trauma patient in whom adequate analgesia could not be achieved due to buprenorphine treatment before and through the early course of admission. Discontinuation of buprenorphine allowed for appropriate pain management and successful analgesia. Further education of acute care clinicians about buprenorphine pharmacology and careful selection of patients for buprenorphine maintenance therapy are needed to avoid delays of pain control in trauma patients.
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The American surgeon · Apr 2010
Computed tomography versus magnetic resonance imaging for evaluation of the cervical spine: how many slices do you need?
Controversy exists regarding the correlation between CT and MRI for evaluation of the cervical spine. We hypothesize that newer-generation CT scanners will improve diagnostic accuracy and may obviate the need for MRI in patients with a normal CT. We compared the missed injury rate of four-slice CT and 64-slice CT performed to evaluate the cervical spine. ⋯ The 64-slice CT missed no injuries (0%), whereas the four-slice CT missed all three (7%) of the ligamentous injuries (P = 0.03). Older-generation CT scanners miss clinically significant injuries in blunt trauma patients and should not be independently relied on to evaluate the cervical spine. The newer 64-slice CT scan does not appear to miss clinically significant cervical spine injuries and may allow clearance of the cervical spine in blunt trauma patients without the addition of an MRI.
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The American surgeon · Apr 2010
Concomitant rib fractures and minor liver or spleen injuries in blunt trauma: what is the potential for missed diaphragmatic injuries?
Nonoperative management (NOM) of blunt liver or spleen injuries (LSI) is widely accepted, but diaphragmatic injuries (DI) can be elusive. We hypothesize that rib fractures and minor LSI (RF+ minor LSI) are associated with DI. Patients with blunt injury undergoing exploratory laparotomy between January 1, 2000, and December 31, 2007, were identified from our registry. ⋯ RF + minor LSI are associated with DI even when there are no other operative injuries. Because NOM is increasingly accepted, the potential for missed DI exists. When high-quality imaging is not available or is equivocal, further studies should be considered.