J Trauma
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A case of blunt extraperitoneal rupture of the right hemidiaphragm and an accompanying abnormal hepatobiliary scan that revealed the rupture are presented. Associated major injuries, the fact that right-sided ruptures have less immediate herniation, and plugging of the defect by the liver are difficulties that can be encountered in establishing the diagnosis. Most diagnostic tests are not helpful and about half of these ruptures are found at laparotomy or thoracotomy. All should be closed surgically.
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Recent years have seen a renewed interest in the use of hypertonic-hyperoncotic solutions as plasma volume expanders for the treatment of hemorrhagic hypotension. In particular, a number of studies in experimental animals have addressed the efficacy and safety of small-volume infusions of 7.5% NaCl/6% dextran 70 (HSD). ⋯ In the few human field trials completed to date, HSD has been shown to be potentially beneficial in hypotensive trauma patients who require surgery or have concomitant head injury. Extensive toxicologic evaluations and lack of reports of adverse effects in the human trials indicate that, at the proposed therapeutic dose of 4 mL/kg, HSD should present little risk.
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Seventy adult and pediatric patients with blunt splenic injury were managed nonsurgically using previously published clinical criteria without regard to the appearance of the spleen on computed tomographic (CT) scans. Seven patients (10%) who underwent delayed surgery were considered failures of nonsurgical therapy; all recovered after total splenectomy. Two radiologists, blinded to patient outcome, retrospectively reviewed the admission CT scans of all 70 patients and graded them according to three published scoring systems. ⋯ No failures occurred in patients under age 17 years. Our data support the hypothesis that properly selected patients can be safely observed regardless of the magnitude of splenic injury on CT scans. A decision to undergo early exploration should be based on clinical criteria, including the patient's age and associated injuries.
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Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990--post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The frequency of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access (i.v.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies (%) were 83.5 vs. 65.3 for ET, 97.3 vs. 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. ⋯ Of the patients with severe chest injuries (AIS > or = 3) 87.7% had chest tubes post ATLS (94.4% in ER) compared with 48.1% pre ATLS (3.2% in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS.(ABSTRACT TRUNCATED AT 250 WORDS)
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The accuracy and reliability of the relationship between arterial and end-tidal carbon dioxide (PETCO2 and PaCO2), expressed as the gradient, P(a-ET)CO2, was assessed with 171 comparisons in nine mechanically ventilated trauma patients. The P(a-ET)CO2 was 14 +/- 11 mm Hg. (mean +/- standard deviation.) The positive correlation between PaCO2 (44 +/- 10 mm Hg) and PETCO2 (30 +/- 10 mm Hg) for the study population (reflected by r = 0.64, p = 0.001; but r2 = 0.41) indicated statistical significance, but only 40% of the changes reflected a linear relationship. ⋯ Changes in PETCO2 erroneously predicted the PaCO2 changes in 27% of comparisons with 15% false decreases and 12% false increases. Trends in P(a - ET)CO2 magnitude are not reliable, and concordant direction changes in PETCO2 and PaCO2 are not assured.