J Trauma
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The aim of this study was to search for early inflammatory mediators in severely traumatized patients that could predict the occurrence of adult respiratory distress syndrome (ARDS). We measured sequential plasma levels of tumor necrosis factor (TNF), interleukin 1 (IL-1), interleukin 6 (IL-6), interleukin 8 (IL-8), complement fragment C3a, and endotoxin. In addition, we measured sequentially the values of hemodynamics, oxygen transport, and pulmonary function. ⋯ In both ARDS and nonARDS patients, no measurable quantities of TNF, IL-1, or endotoxin were found. We concluded that none of the mediators we measured reached their peaks before the onset of ARDS and none were found to be predictive of posttraumatic ARDS. However, these and other mediators may augment or intensify the development of ARDS.
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In a prospective study of 4,106 consecutive cases of initially asymptomatic stab wounds of the chest, 88% were successfully treated as outpatients after negative findings on a repeat chest x-ray film 6 hours after presentation, 12% of patients required tube thoracostomy for delayed pneumothoraces of hemothoraces, 0.2% required thoracotomy for delayed and continued bleeding or cardiac injuries, 1% of patients with small pneumothoraces (subjectively less than 20%) were observed, and 68% patients remained asymptomatic. The accuracy of the initial chest x-ray film was 95% overall, with a specificity of 99.9%. The negative predictive value of only 87.4% precludes the immediate outpatient management of these asymptomatic patients. ⋯ Asymptomatic patients with nonprogressive small pneumothoraces (less than 20%) not requiring a chest tube may be discharged after 48 hours of observation. Thirty-two percent of those observed for initially small pneumothoraces on chest x-ray films, had progression of their injuries and required tube thoracostomy. All patients should have close outpatient follow-up.
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Improvement in trauma patient outcome has been reported after Advanced Training Life Support training (ATLS) in the developing country of Trinidad and Tobago (T & T). The cognitive impact of ATLS training was assessed from pre-ATLS and post-ATLS performance of T & T physicians in multiple choice question tests and comparison with post-ATLS test performance among Nebraska physicians. Overall, improvement between the pre-test and post-test among the T & T physicians was 22.0% +/- 2.0%. ⋯ Attitudinal impact was assessed through 87 questionnaires from 50 physicians (92% response) and 37 nurses (89% response). Physicians (97.8% compared with 69.7%) were more aware of the ATLS training, and both groups (physicians, 77.3%; nurses, 69.6%) differentiated ATLS-trained physicians based on better resuscitation, more timely and appropriate consultation, greater confidence in trauma management, and improvement in trauma mortality and morbidity; all respondents recommended ATLS training for all emergency room physicians. The demonstrated positive cognitive and attitudinal effects very likely contributed to the improved post-ATLS trauma patient outcome.
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Twenty-four patients with Weber B and low Weber C displaced lateral malleolus fractures who underwent closed reduction and percutaneous internal fixation with an intramedullary, fully threaded, self-tapping screw were retrospectively reviewed. Nineteen of these patients were followed for an average of 63.4 weeks. A good radiographic reduction was obtained in 87.5% of patients, a fair reduction in 8.3%, and a poor reduction in 4.2%. ⋯ This closed technique also eliminates screw penetration of the ankle joint and damage to the peroneal tendons, which can be risks when a plate or lag screws are employed as internal fixation. Surgical time is also reduced and tourniquet use is optional. If an acceptable reduction cannot be obtained using this technique, open reduction and internal fixation should be performed.
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Ambient temperature-induced hypothermia noted in trauma patients is frequently accompanied by a bleeding diathesis despite "laboratory normal" coagulation values. To document this impression, the following experiment was conducted. Coagulation studies and platelet function studies were performed in ten minipigs during induced whole body hypothermia (40 degrees C to 34 degrees C) and rewarming. ⋯ Whole body hypothermia demonstrated abnormal bleeding time and PT (p < 0.001). Ambient temperature-induced hypothermia produced significant coagulation defects in a porcine model. Some of the coagulation defects were most pronounced during rewarming.