J Trauma
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Multicenter Study Clinical Trial
Nonoperative management of blunt splenic trauma: a multicenter experience.
The experience of six referral trauma centers with 832 blunt splenic injuries was reviewed to determine the indications, methods, and outcome of nonoperative management. During this 5-year period, 112 splenic injuries were intentionally managed by observation. There were 40 (36%) patients less than 16 years old and 72 adults. ⋯ This contemporary multicenter experience suggests that patients with Class I, II, or III splenic injuries after blunt trauma are candidates for nonoperative management if there is: 1) no hemodynamic instability after initial fluid resuscitation; 2) no serious associated abdominal organ injury; and 3) no extra-abdominal condition which precludes assessment of the abdomen. Strict adherence to these principles yielded initial nonoperative success in 98% of children and 83% of adults. Application of standard splenic salvage techniques to treat the patients with persistent hemorrhage resulted in ultimate splenic preservation in 100% of children and 93% of adults.
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Comparative Study
The declining incidence of fatal sepsis following thermal injury.
Successful management of burned patients requires effective prevention and management of infectious complications. This study reviews the incidence of fatal sepsis in our burn center and attempts to analyze factors which may predict septic mortality. From January 1, 1978, through May 31, 1988, 1,913 patients were admitted, with a mean age of 24.8 +/- 0.5 years, a mean burn size of 17.7 +/- 0.4% total body surface area (%TBSA), and a mean 10.1 +/- 0.5% TBSA full-thickness injury. ⋯ During the period 1983-1988, the incidence of septic mortality was 0.7%, which was significantly lower than the earlier half (1978-1982) of the study period (p less than 0.01). These data indicate that fatal infections are becoming increasingly uncommon after thermal injury. The reasons for this decline are probably multiple, and they include the widespread practice of early excision, and improvements in fluid resuscitation and the general medical care of burned patients.
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During a 6-year period, 14 consecutive children with penetrating craniocerebral gunshot wounds (GSW) were studied. Eleven patients were comatose on admission. Five had an admission Glasgow Coma Scale (GCS) score of 4 or less and developed clinical signs of brain death within 12 hours despite maximum therapeutic efforts. ⋯ There were four survivors. Neurobehavioral and intellectual functions were evaluated over a period of 1 to 2 years. Although serious cognitive deficits were noted, all survivors had sufficient functional recovery to warrant aggressive cardiopulmonary resuscitation and measures to control ICP in the management of comatose victims of craniocerebral GSW.
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Pulmonary contusion is the usual manifestation of lung parenchymal injury following blunt chest trauma. With rapid deceleration, however, parenchymal lacerations can result in cavities best termed post-traumatic pulmonary pseudocyst (PPP). This report discusses eight adult PPP cases encountered at the Denver General Hospital over the past 30 months. ⋯ Computed tomography of the chest was pursued in complicated patients and clearly influenced therapy. Three (38%) pseudocysts developed into lung abscesses; two required resection and the other responded to percutaneous drainage. Although previously described as a benign pediatric entity, in our adult experience, PPP may result in a recalcitrant lung abscess requiring aggressive intervention.
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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.