Current opinion in critical care
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Patients with penetrating abdominal trauma are at risk of harboring life-threatening injuries. Many patients are in need of emergent operative intervention. However, there are clearly patients who can be safely managed nonoperatively. This review evaluates the literature to identify management guidelines for patients with penetrating abdominal trauma. ⋯ Shock, evisceration, and peritonitis warrant immediate laparotomy following penetrating abdominal trauma. Thoracoabdominal stab wounds should be further evaluated with chest X-ray, ultrasonography, and laparoscopy or thoracoscopy. Wounds to the back and flank should be imaged with CT scanning. Anterior abdominal stab wound victims can be followed with serial clinical assessments. The majority of patients with gunshot wounds are best served by laparotomy; however, select patients may be managed expectantly.
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To review the current care of the patient with an injured spleen. ⋯ Nonoperative management (NOM) is the standard of care for the hemodynamically stable patient with an isolated blunt splenic injury. Splenic salvage can be safely increased, even in higher grade injuries, with the use of angioembolization. Patients managed nonoperatively are successfully discharged as early as 1-2 days for low-grade injuries and as early as 3-4 days for higher grade. Safe management of the patient with blunt splenic injury requires careful selection for NOM, meticulous monitoring and follow-up.
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Blunt cerebrovascular injuries (BCVI) are a rare but potentially devastating injury with stroke rates up to 50%. Over the past decade, the recognition and subsequent management of these injuries has undergone a marked evolution. This review will focus on the rationale for BCVI screening, imaging options, and treatment modalities. ⋯ Cerebrovascular injuries (CVI) are now diagnosed in approximately 1% of blunt trauma patients. The recognition of a clinically silent period allows for injury screening based upon mechanism of trauma and the patient's injury pattern. Following identification of injuries in asymptomatic patients, prompt initiation of antithrombotic therapy reduces the incidence of stroke.
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Significant changes in the management of patients, with possible or documented injuries to peripheral arteries, have occurred over the last 20 years. ⋯ The care of patients with injured peripheral arteries has remained the same in some areas; however, lessons from the battlefield, new imaging technology, the safety of nonoperative management, use of temporary intraluminal shunts, and better recognition of postrepair compartment syndromes have had a significant impact on current management.
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Acute kidney injury (AKI) is a major clinical problem in hospitalized patients. Effective treatment and early diagnosis of this syndrome are not currently available. This review focuses on recent studies examining the biological characteristics and the diagnostic and prognostic value of a novel biomarker--neutrophil gelatinase-associated lipocalin (NGAL)--in the two major patient populations at risk for AKI. ⋯ NGAL appears to fulfill many characteristics of an appropriate 'real-time' biomarker for AKI detection.