J Trauma
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One hundred nineteen patients suffered penetrating cardiac trauma over a 15-year period: 59 had gunshot wounds, 49 had stab wounds, and 11 had shotgun wounds. The overall survival rate was 58%. The most commonly injured structures were the ventricles. ⋯ We conclude that sternotomy provides superior exposure for cardiac repair in patients with penetrating anterior chest trauma. We feel it is the incision of choice in hemodynamically stable patients. Thoracotomy should be reserved for unstable patients requiring aortic cross-clamping, or when posterior mediastinal injury is highly suspected.
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Randomized Controlled Trial Clinical Trial
Surgical treatment of fracture-dislocations of the ankle joint with biodegradable implants: a prospective randomized study.
In a randomized study 43 patients with fracture-dislocations of the ankle joint were treated by open reduction and fixation with either steel or biodegradable implants. Results in both groups were favorable and the biodegradable material appears to be useful for some fracture-dislocations to obviate the need for a second operation.
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Comparative Study
Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics.
We sought to determine the reliability of the Glasgow Coma Scale (GCS) when used by emergency physicians and paramedics. We performed a prospective sequential trial in a classroom setting, with subjects blinded to others' scoring. Nineteen university-affiliated emergency physicians and 41 professional paramedics from an urban EMS system voluntarily participated. ⋯ Intrarater reliability (r1,2) for emergency physicians was 0.66 (p < 0.01) and for paramedics was 0.63 (p < 0.01). The GCS shows statistically significant reliability (i.e., significant agreement) between emergency physicians and emergency medical technician-paramedics. It also has a significant level of intrarater reliability.
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Comparative Study
Head CT scanning versus urgent exploration in the hypotensive blunt trauma patient.
In hypotensive blunt trauma patients with a diminished level of consciousness, it may be difficult to decide whether to proceed with immediate head CT scanning or urgent laparotomy or thoracotomy. The purpose of this study was to determine the frequency of emergency craniotomy and urgent laparotomy or thoracotomy in a group of 734 blunt trauma patients with initial hypotension (BP < 90 mm Hg systolic) admitted to the eight level I and II trauma centers in North Carolina. The mean initial systolic blood pressure was 64 +/- 26 mm Hg, and the mean Trauma Score was 8 +/- 5.8. ⋯ Overall hospital mortality for hypotensive blunt trauma patients was 36% (263 of 734). Although serious head injury occurs commonly (40%) in hypotensive blunt trauma patients, frequency of urgent laparotomy (21%) is 8.5 times greater than emergency craniotomy for intracranial hemorrhage (2.5%). This information may be used by trauma teams in prioritizing care for hypotensive blunt trauma patients.
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Although scores and other prehospital triage schema effectively identify injured patients who will benefit from trauma center care, those tools are relatively nonspecific. One consequence is overtriage--transport of less severely injured patients to trauma centers--with resulting expenditure of scarce resources on patients who do not benefit from an emergent and intensive response. We developed a tool that, during the prehospital phase, can sort inner-city trauma victims into those who will require ICU/OR services and those who will not. ⋯ Based on our initial experience with the two-tier response, the sorting criteria were revised and refined. The sensitivity of the current version of the two-tier criteria for predicting which trauma patients will require ICU/OR services during the first 24 hours of hospitalization approaches 95% (excluding misapplications of the tool) while avoiding urgent trauma team mobilization in 57% of patients triaged to our trauma center. Two-tiered trauma responses appear to be safe and may represent an important strategy for more effective distribution of increasingly scarce and costly resources.