J Trauma
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During a 7-year period (1980-1987), 161 patients underwent emergency thoracotomy for penetrating lung injuries. Of these, 25 (15%) had injuries involving central pulmonary (hilar) vascular structures. Anterolateral thoracotomies were performed in 14 patients because of unstable vital signs (ten) or cardiac arrest (four), and only two (14%) of these patients survived. ⋯ Eight of the 14 deaths were clearly due to blood loss, which was treated with an average of 19.5 units of blood. However, in six of the earlier deaths with much less blood loss, air emboli may have been a factor, but was unproven. Early vascular control at the hilum for central lung injuries seems to be needed not only to stop the bleeding but also to prevent systemic air emboli.
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A 9-month prospective study was conducted in Salt Lake County to evaluate the efficacy of a field trauma triage system using the CRAMS score. Before the triage system was implemented trauma victims were taken to the nearest appropriate hospital. Post-implementation, trauma victims with field CRAMS scores of 1 through 6 were triaged to the Level I Trauma Center. ⋯ The study patients with CRAMS scores of 4 or less had lower mortality when cared for at the Level I Trauma Center (p = 0.013). We conclude that trauma patients who are severely injured (CRAMS less than or equal to 4) have a significantly higher rate of survival if taken to the Level I Trauma Center. The use of the CRAMS triage system appears to be an effective approach toward improving trauma care in Salt Lake County.
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Esophageal perforation from external blunt trauma is an exceedingly rare injury. Since 1900, including our five cases, we found 96 reported cases. The most common cause was violent vehicular trauma. ⋯ There were 24 (38%) infectious complications directly related to the esophageal perforation. In 21 of these, there was a delay in diagnosis. There were five (9.4%) deaths due to sepsis from the esophageal perforation.
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The base deficit (BD), is a potentially useful indicator of volume deficit in trauma patients. To evaluate BD as an index for fluid resuscitation, the records of 209 trauma patients with serial arterial blood gases (ABG's) were reviewed. The patients were grouped according to initial BD: mild, 2 to -5; moderate, -6 to -14; and severe, less than -15. ⋯ The MAP decreased significantly and the volume of fluid required for resuscitation increased with increasing severity of BD group. A BD that increased (became more negative) with resuscitation was associated with ongoing hemorrhage in 65%. The data suggest that the BD is a useful guide to volume replacement in the resuscitation of trauma patients.
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Trauma patients obtunded as a result of head injury, hypotension, alcohol, or drugs have an unreliable physical examination which may lead to errors or delays in diagnosis. To define the extent of routine radiologic survey needed in patients with a depressed level of consciousness, the records of 789 adults with blunt injuries and a Glasgow Coma Score (GCS) of 10 or less on admission were reviewed. Major skeletal injury (MSI), was defined as one or more fractures or dislocations of the axial spine, pelvis, hip, or long bones of the lower extremity. ⋯ Patients suffering falls (18%) and assaults (2%) had a decreased incidence of MSI (p less than 0.01). The high incidence of potentially occult MSI in obtunded patients after blunt trauma demonstrated by this data suggests the need for routine radiologic survey including the axial spine, pelvis and long bones of the lower extremity. Mechanism of injury, CRAMS, TS, and GCS may be useful in the early identification of a particularly high-risk group.