J Trauma
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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.
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A series of 16 consecutive adults with femoral shaft fractures complicated by fracture-dislocations of the ipsilateral hip joint was prospectively studied. There were 11 posterior dislocations and five central dislocations. ⋯ Although an 18.8% (3 of 16) complication rate was noted, the outcome was satisfactory for all 16 hip joints. When such complicated combined injuries are sustained, the technique described here is the most reasonable treatment.
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We retrospectively reviewed the medical records and cervical films, computed tomographic (CT) scans, and tomographic studies of 216 consecutive patients with cervical injuries. A trauma series of roentgenograms--a cross-table lateral (CTL), a supine anteroposterior, and an open-mouth odontoid view--was performed in 100%; CT scanning was performed in 100%; and tomography was done in 9% of cases. We determined what percentage of the patients were asymptomatic initially in the emergency department; the total numbers of fractures, subluxations, and dislocations of the cervical spine in these patients; and what percentage of the cervical injuries were not detected with the plain films. ⋯ Of these 28, 17 were intoxicated or had mild closed head injuries; however, in 11 (5%) there was no clinical clue to their cervical injury other than a known injury mechanism. Prospectively, 67% of the fractures and 45% of the subluxations and dislocations were not detected by the CTL films, and 32% of the patients, over half of whom had unstable cervical injuries, were falsely identified as having normal spines. Prospectively, the trauma series improved the sensitivity of plain films for detecting cervical injuries but still did not detect 61% of the fractures and 36% of the subluxations and dislocations, and falsely identified 23% of the patients, half of whom had unstable cervical injuries, as having normal cervical spines.(ABSTRACT TRUNCATED AT 250 WORDS)
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A large number of laboratory tests are often ordered in the management of acutely burned patients. Administration of large volumes of fluid and frequent ventilator changes prompt many facilities to utilize ordering protocols. Forty-five consecutive acutely burned pediatric patients with burns measuring 25% or more of total body surface area (TBSA) sustained within 24 hours before admission were reviewed. ⋯ Of the four unexpected critical values obtained, two would have been picked up by our present standard noninvasive monitors. Six percent of estimated blood volume was used to perform laboratory tests. These results demonstrate that significant abnormal laboratory values are uncommon even in severely injured pediatric burn patients and that the ordering of these tests should be individualized based on patient examination and the use of noninvasive monitoring.
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The purpose of this study was to evaluate the ability of abdominal ultrasound (US) to detect intra-abdominal injuries that required surgical repair. We therefore retrospectively reviewed 353 patients with nontrivial blunt abdominal trauma. ⋯ Accuracy was 99.4%, the positive predictive value was 100%, and the negative predictive value was 99.4% (prior probability of disease was 7.65%). We believe that abdominal US should be considered an important tool and an integral part in the work-up of major trauma victims.