J Trauma
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Trauma room lateral cervical spine radiographs (LCSR) may improve the safety of intubation and transportation of multiply injured patients by providing earlier recognition of spinal vertebral injuries. We prospectively evaluated 60 consecutive trauma admissions to determine the impact of clearance of cervical spine radiographs on patient care. Fifty-three patients had no cervical spine injury (CSI). ⋯ LCSR failed to identify three of the seven acute CSI (all three had C7 fractures). The spine-injured were managed with cervical collars and no new neurologic injury developed. We conclude that: 1) LCSRs do not appear to alter urgent management of multiply injured patients during resuscitation and transportation; 2) chest radiographs and emergency investigations should not be delayed by repeated LCSR in the trauma room as it may be difficult to fully exclude CSI in many trauma patients; 3) we support the current ATLS guidelines, which suggest that all patients should be presumed to have an unstable CSI until the presence of cervical injury has been excluded.
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All cases of penetrating extremity trauma (PET) seen at an urban trauma center were prospectively studied to determine the accuracy and safety of physical examination as the sole mode of evaluation for vascular injury. All patients with PET producing obvious or "hard" signs of vascular injury underwent immediate surgery. All asymptomatic proximity wounds were observed in hospital for 24 hours before discharge to outpatient followup. ⋯ Every patient taken immediately to surgery for hard signs had major arterial injury requiring repair, for a 100% positive predictive value for physical examination. No mortality or morbidity were related to protocol management. These results to date support prior reports of a negligible incidence of significant vascular injury following clinically occult proximity PET, and further suggest that the overall predictive value of physical examination of PET for vascular injury approaches 100%.
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Severe thermal injury results in impairment of granulocyte production and function. The ability to improve the functional capacity of neutrophils could contribute to a reduced morbidity and mortality from sepsis following thermal injury. Previous studies from this laboratory have shown that rhG-CSF increases the number of femoral marrow granulocyte progenitor cells and circulating neutrophils as well as the survival rate following burn wound infection. ⋯ The presence of a burn wound infection caused no further impairment of chemotaxis. Administration of rhG-CSF to animals with a burn wound infection resulted in improved chemotaxis compared with sham, burned, and burned/infected animals. The beneficial effect of G-CSF following burn wound infections from this and previous studies appears to be a combination of expanded numbers of myeloid elements and preservation of their function.
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Randomized Controlled Trial Comparative Study Clinical Trial
Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures.
To evaluate the efficacy of opiate administration regimens, 32 patients with multiple rib fractures were prospectively randomized to receive either continuous epidural (ED) or continuous intravenous (IV) infusions of fentanyl. Dosage was titrated to individual subjective pain relief. Ventilatory function tests (VFTs), arterial blood gases (ABGs), and visual analog scores were obtained before and after the institution of analgesia. ⋯ Side effects were similar between the groups, with pruritus being more pronounced with ED fentanyl administration. The data demonstrate that the continuous ED fentanyl method offers excellent relief of pain and improvement in ventilatory function and has distinct advantages over IV fentanyl administration with respect to changes in ABGs and MIP. The continuous infusion of epidural opiates should be the preferred analgesic method for patients at high risk of developing pulmonary complications following multiple rib fractures.
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The value of the TRISS method for interhospital comparisons of trauma care was studied using data for 5,616 consecutive patients from three trauma centers and five community hospitals. Z-scores were used to compare mortality rates. ⋯ Remedies to the first two of these limitations can be addressed within the present TRISS method. A remedy for the third requires a new method.