J Trauma
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The effects of injury with hemorrhagic shock on the clotting and fibrinolytic systems were studied serially in 22 patients receiving 21 +/- 13 transfusions and 1.26 +/- 0.58 L of fresh frozen plasma (FFP) during operation (OR). The PT, aPTT, thrombin time (TT), fibrinogen (FI), factors V (FV) and VIII (FVIII), fibrin(ogen) split products (FSP) and fibrin monomers were measured in OR and after OR at 6 and 15 hours, days 2 and 4, and at convalescence (25 days). The TT, PT, and aPTT were were prolonged in OR and reflected the low FI, FV, and FVIII, respectively. ⋯ Later factor restoration likely reflects enhanced hepatic synthesis, factor half-life, capillary selectivity retaining large molecular weight factors, and intravascular relocation from abundant extravascular stores. Throughout this biphasic response, the clotting times reflect factor levels. Fibrinolysis contributes little to these changes.
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As trauma systems have developed and board-certified in-house surgeons are now immediately available, enthusiasm has returned for thoracotomy as part of initial resuscitation. This study evaluated the impact of thoracotomy by board-certified surgeons during the resuscitative phase of treatment. ⋯ Survivors of penetrating injury had a probability of survival (Ps) of 0.48. Most patients suffering penetrating deaths had severe and advanced physiologic derangements at the time of admission despite similar anatomic injuries to survivors.
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We reviewed our experience with tracheal and bronchial trauma from 1977 to 1988. There were 22 patients with tracheobronchial injuries treated in this period. Seventeen (77%) of the injuries were due to penetrating trauma and five (23%) were due to blunt trauma. ⋯ Two patients with blunt chest trauma and small bronchial tears were treated nonoperatively with good results. All three deaths (14% mortality rate) were due to associated injuries. We conclude that patients with penetrating tracheobronchial injuries should be managed by surgical exploration and primary repair, although selected patients with blunt injury may be treated nonoperatively.
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Traumatic hemipelvectomy is a catastrophic injury resulting from violent blunt shearing forces which cause massive skin, bone, and soft-tissue destruction. The initial extent of the injury as well as the complexity of the consequent problems is staggering. As such it constitutes one of the major challenges seen by trauma surgeons. ⋯ The University of California at Davis General Surgery Trauma Service admitted 9,369 major trauma victims from June 1985 to May 1988. During this 3-year period eight patients sustained a traumatic hemipelvectomy, of whom three survived. Given the complexity, yet rarity, of this injury, a review of the world literature was undertaken to compile collective experiences to aid surgeons in the management of this injury.
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Comparative Study
Emergency Department thoracotomy in children--a critical analysis.
Recent clinical reviews have helped to clarify the role of Emergency Department (E. D.) thoracotomy in critically injured adults. However, guidelines in the pediatric population remain ill defined. ⋯ Blunt trauma, the predominant mechanism of lethal injuries in children, had a dismal outcome, with only 2% salvage and no survivors when vital signs were absent. This study demonstrates a similar outcome for E. D. thoracotomy in children compared to adults, and supports a selective policy of liberal use in penetrating injury irrespective of physiologic status but limited in those arriving lifeless following blunt trauma.