The American surgeon
-
The American surgeon · Oct 2004
Necrotizing soft tissue infections: improved outcomes with modern care.
The outcome of necrotizing soft tissue infections (NSTI) remains unchanged despite advances in care. Reasons cited are changing patterns of causative factors, delays in diagnosis, and inadequate antibiotic coverage and surgical treatment. To document outcomes of NSTI after aggressive management and to identify risk factors of mortality and prolonged hospital stay, we reviewed all our patients with NSTI admitted from January 2000 to January 2002. ⋯ The patients who died had higher admission white blood cell counts (46 +/- 22 vs 22 +/- 10 x 10(3)/mm3, P = 0.01), higher admission pain score (8 +/- 1 vs 5 +/- 3, P = 0.02), longer intervals from admission to antibiotic administration (16 +/- 20 vs 6 +/- 12 hours, P = 0.02), and fewer surgical debridements (2.6 +/- 1.1 vs 3.6 +/- 1.7, P = 0.04). No independent risk factors of mortality or ICU admission were identified. We concluded that severe local pain and a significantly elevated white blood cell count on admission should alert the physician to the presence of severe infection and prompt the initiation of expeditious aggressive treatment.
-
Rhabdomyolysis (RHAB) is a known complication following blunt trauma. RHAB after penetrating trauma has not been studied. The objective of this study was to evaluate the incidence, risk factors, and complications of RHAB following penetrating trauma. ⋯ CK elevations and significant RHAB are common after penetrating trauma. Patients who sustain vascular and severe extremity injury as a result of their penetrating wounds are at high risk to develop significant RHAB, resulting in renal failure and prolonged ICU stay. Therefore, critically injured penetrating trauma patients should be routinely screened with CK levels.
-
The purpose of this study was to ascertain risk factors for death from trauma. The large cohort allows for simultaneous evaluation of known mortality risk factors along with controlling for factors to assess the influence of each independently. Individually, base deficit, temperature, hypotension, age, and injury severity have been shown to be associated with an increased risk of death. ⋯ The top four predictors of mortality in this group were partial thromboplastin time (OR 3.37, 95% CI: 2.51-4.52), positive head computed tomography result (OR, 2.47; 95% CI, 1.95-3.04), initial hemoglobin (OR, 1.69; 95% CI, 1.23-2.31), base deficit (OR, 1.62; 95% CI, 1.29-2.04), and trauma resuscitation bay systolic blood pressure (OR, 1.45; 95% CI, 1.11-1.88). We conclude that prognostic indicators of all-cause mortality after trauma, which remain independent in the presence of all other factors and are potentially treatable, included low hemoglobin, elevated prothrombin and partial thromboplastin time, low scene and trauma bay systolic pressure, and elevated base deficit. The independent indicators of mortality, which are untreatable, included head injury, increasing age, and Injury Severity Score.
-
The American surgeon · Sep 2004
Language barrier leads to the unnecessary intubation of trauma patients.
Airway evaluation in trauma patients is performed immediately upon patient contact, with communication being a vital component to this exam. Language and communication barriers may lead to the unnecessary placement of an artificial airway with resultant patient risk and elevation of health care costs. The objective of our study was to evaluate potentially preventable intubations in Spanish-speaking patients. ⋯ MOI, HDR, ISS, illicit substance use, alcohol use, and payer source were similar. GCS was statistically higher in the Spanish-speaking group (14 vs 12; P = 0.004). Language and communication barriers lead to potentially preventable intubations in trauma patients.
-
The Accreditation Council for Graduate Medical Education (ACGME) requires all programs to limit resident work hours to 80 hours per week with some programs allotted an extra 10 per cent for specific educational purposes. The purpose of this study was to evaluate data reflecting changes in resident schedules made in 2002-2003 to be compliant with ACGME requirements without compromising patient care or resident education. Surgery residents originally completed a work-hour survey in May 2002. ⋯ Twenty-four residents who were on our normal call schedule completed the survey. Fourteen per cent of junior residents, 33 per cent of senior residents, and 0 per cent of chief residents worked more than 88 hours per week. By making the changes described, we have substantially reduced the number of resident work-hours while maintaining our academic and patient care missions.