J Trauma
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To examine the role of early excision and grafting in the preservation of maximal function of hands with deep dermal burns, we prospectively evaluated 164 burned hands in consecutively admitted patients (mean age, 29 years; mean burn size, 37% of body surface). All hands with burn depths of second degree, deep second degree, or third degree above the level of the tendons and joint capsules were assessed preoperatively, intraoperatively, and at discharge from the hospital. Patients were treated by excision and grafting in the first or second postburn week, by delayed grafting alone, or by allowing primary healing. ⋯ While early excision and grafting of hands with third-degree burns tended to produce poorer results than did initial nonoperative care and late grafting, the differences are just outside the range of significance. Early excision and grafting of selected third-degree injuries of the hands may be indicated in patients with small total body surface burns in order to shorten hospital stay. However, early surgical intervention in patients with massive burns should be directed toward area coverage, not toward hand excision.
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Cervical spine immobilization devices are widely used to stabilize the cervical spine and prevent neurologic deficits associated with unstable fractures. In order to quantitate their efficacy we measured controlled cervical spine motion in three axes, using six different immobilization methods in 25 volunteers instructed to actively move their necks as much as possible in the directions of flexion, extension, rotation, and lateral bending while lying supine. Control measurements were made with no device and measurements were repeated following immobilization with: soft collar (SC), hard collar (HC), extrication collar (EC), Philadelphia collar (PC), bilateral sandbags joined with 3-inch cloth tape across the forehead (ST), and the combination of sandbags, tape, and the Philadelphia collar (ST/PC). ⋯ PC was not significantly better than the other two types of hard collars, except in limiting extension. ST immobilization was significantly better than any of the other four methods used alone, for all four movements. The addition of PC to ST was significantly more effective in reducing extension only.
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The indiscriminate application of thoracotomy in the resuscitation of trauma has recently been challenged. Since 1 May 1974 400 consecutive trauma patients have undergone resuscitative thoracotomy in our Emergency Departments (ED). The mechanism of injury was blunt in 195 (49%) patients, gunshot wound in 147 (37%), and stab wound in 58 (14%) Upon arrival in the ED, 352 (88%) patients had no obtainable blood pressure (BP), 334 (84%), fixed pupils, and 315 (798%) failed to exhibit agonal respirations or other waning signs of life. ⋯ There were no survivors with intact neurologic function among: 150 patients sustaining blunt trauma and arriving in the ED without signs of life (BP, pupil reactivity, respiratory effort); or 87 patients with penetrating torso injuries who had no signs of life at the scene. Following thoracotomy, in the absence of cardiac tamponade, there were no intact survivors of 124 patients without cardiac activity or of aortic occlusion. We believe the above factors should militate against initiating resuscitative thoracotomy in the ED or in deciding to continue heroic measures following thoracotomy.