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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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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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.
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We studied the effect of deferoxamine (DFO) infused after burns on hemodynamic stability as well as local and systemic inflammation and oxidant-induced lipid peroxidation. Eighteen anesthetized sheep were given a 40% of total body surface burn and fluid resuscitated to restore oxygen delivery (DO2) and filling pressures to baseline values. Animals were resuscitated with lactated Ringer's (LR) alone or LR plus 1,500 ml of a 5% hetastarch complexed with DFO (8 mg/ml). ⋯ Burn tissue edema, measured as protein-rich lymph flow, was significantly increased with the administration of DFO compared with the other groups. We conclude that DFO used for burn resuscitation prevents systemic lipid peroxidation and decreases the vascular leak in nonburn tissues while also increasing O2 utilization. Resuscitation with hetastarch-DFO may accentuate burn tissue edema, possibly by increased perfusion of burn tissue.
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Some measures of the efficacy of fluid resuscitation after hemorrhage are blood volume restitution (BVR) and attenuation of the neuroendocrine response. We compared the effectiveness of resuscitation with 0.9% NaCl and 3.0% NaCl in chronically prepared awake dogs after 30% hemorrhage. Each dog was bled on four occasions and resuscitated by four protocols: 1) full resuscitation (infusion to return and maintain mean arterial pressure (MAP) at control +/- 10 mm Hg) with 3.0% NaCl (HS); 2) full resuscitation with 0.9% NaCl (NS); 3) under-resuscitation with a volume of 0.9% NaCl equal to the subject's previous 3.0% NaCl requirement (SV); and 4) no fluid therapy (NR). ⋯ Resuscitation with HS incurs an intracellular water debt which is aggravated by a saline diuresis. Hormonal attenuation is linked either to BVR (ACTH, cortisol) or to MAP restoration (renin, AVP). Thus the optimal resuscitation regimen may consist of initial infusion of hypertonic saline followed by sufficient hypotonic solution to restore interstitial fluid volume and normal cellular hydration.