J Trauma
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Comparative Study
Basic life support versus advanced life support for injured patients with an injury severity score of 10 or more.
To study the value of advanced life support (ALS) compared with basic life support (BLS) for penetrating and motor vehicle crash (MVC) patients, data were collected from eight hospitals over 24 months on 781 consecutive patients with Injury Severity Scores > or = 10 as well as on a subset of 219 hypotensive patients. Initial prehospital Revised Trauma Scores (RTSs) were compared with initial emergency department RTSs. Scene times, total prehospital times, and the use of a pneumatic antishock garment (PASG), intravenous fluids, and endotracheal intubation were also documented. ⋯ There were no differences between groups with respect to observed versus predicted mortality. Similar results were found in the hypotensive subset of patients. No benefit from the use of ALS for trauma patients with total prehospital times of less than 35 minutes was documented.
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Definitive laparotomy (DL) for penetrating abdominal wounding with combined vascular and visceral injury is a difficult surgical challenge. Physiologic derangements such as dilutional coagulopathy, hypothermia, and acidosis often preclude completion of the procedure. "Damage control" (DC), defined as initial control of hemorrhage and contamination followed by intraperitoneal packing and rapid closure, allows for resuscitation to normal physiology in the intensive care unit and subsequent definitive re-exploration. The purpose of the study was to compare the damage control technique with definitive laparotomy. ⋯ Resolution of coagulopathy (mean prothrombin time/partial thromboplastin time 19.5/70.4 to 13.3/34.9), normalization of acid-base balance (mean pH/HCO3 7.37/20.6 to 7.42/24.2), and core rewarming (mean 33.2 degrees C to 37.7 degrees C) were achieved. All patients had gastrointestinal procedures at reoperation (mean operative time, 4.3 hours). We conclude that damage control is a promising approach for increased survival in exsanguinating patients with major vascular and multiple visceral penetrating abdominal injuries.
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In 56 patients with multiple trauma with ISSs > or = 33 we prospectively collected data of seven scoring systems (ISS, TS, TRISS, GCS, PTS, APACHE II, SSS) and sequentially determined blood lactate concentrations. These data were analyzed in relation to the patients later developing adult respiratory distress syndrome (ARDS) and multiple organ failure (MOF). Twenty-two patients developed ARDS, and 18 developed MOF. ⋯ Surprisingly, APACHE II scores did not correlate with subsequent ARDS or MOF, nor did they show any significant relation with lactate concentrations at any time. By stepwise regression analysis ISS, SSS, and lactate level at day 3 were the most significant variables toward the development of ARDS and MOF. It is concluded that scoring systems directly grading the severity of groups of trauma patients have predictive value for late and remote complications such as ARDS and MOF, whereas scoring systems that grade the physiologic response to trauma--although clearly related to mortality--have no such predictive value.
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The effects of dual responses [Basic Life Support (BLS) and Advanced Life Support (ALS)] on the outcomes of trauma patients were evaluated. Outcomes included changes in physiologic measurements between the scene and the emergency department (ED), and survival to hospital discharge. Data for 2394 patients with penetrating, motor vehicle crash (MVC), or other blunt injuries were included. ⋯ Survival to hospital discharge among penetrating injury patients was negatively related to dual responses, whereas that among MVC patients was positively associated with dual responses. Parallel results were found for a subset of more severely injured patients. Future research should confirm and refine these results so that protocols for the appropriate use of dual response runs can be developed.
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Conventional management of adult respiratory distress syndrome (ARDS) with high minute ventilation, positive end-expiratory pressure (PEEP), and increased fractional inspired oxygen (FIO2) concentrations may worsen pulmonary injury. The intravascular oxygenator (IVOX) is a device made up of several hundred gas permeable hollow fibers that are inserted into the vena cava by femoral venous cutdown. Flow of gas through each fiber adds O2 and removes CO2 from the bloodstream. ⋯ Insertion of the IVOX decreased cardiac index and systemic oxygen delivery despite maximum fluid and inotropic support. Mortality was 80%. Although some gas exchange occurs, the current device does not allow a significant reduction in the level of mechanical ventilatory support and adversely affects systemic oxygen transport.