J Trauma
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Randomized Controlled Trial Comparative Study Clinical Trial
Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma.
Severe blunt chest trauma can produce multiple rib fractures, flail segments, and pulmonary contusions. All of these injuries produce pain and diminished pulmonary function. The effectiveness of intrapleural and epidural administration of bupivacaine was prospectively evaluated in 19 patients with severe chest trauma. ⋯ Vital capacity, FIO2, minute ventilation, and respiratory rate were not affected. Mild hypotension was a common complication with epidural catheters. We conclude that continuous epidural analgesia is superior to intrapleural block and significantly improves tidal volume and negative inspiratory pressure.
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The control of hemorrhage in hypothermic patients with platelet and clotting factor depletion is often impossible. Determining the cause of coagulopathic bleeding (CB) will enable physicians to appropriately focus on rewarming, clotting factor repletion, or both. ⋯ Assays performed at 37 degrees C underestimate coagulopathy in hypothermic patients. The effect of hypothermia on NC and DC is not different, indicating the lack of a synergistic effect. Normalization of clotting requires both rewarming and clotting factor repletion.
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We report a new variant of subdural hygroma previously undocumented in the literature. A 29-year-old man had a skull mass and a progressive headache of 6 to 7 years duration. ⋯ This lesion is unique because: (1) the subdural hygroma was limited by an adhesion between the dura and the arachnoid; (2) the actual communication between the subdural hygroma and the subarachnoid space was clearly identified; and (3) localized bulging of the skull is exceptional for a subdural hygroma. Differentiation from more common cystic lesions such as congenital arachnoid cysts, traumatic arachnoid cysts, intradiploic arachnoid cysts, and chronic subdural hematomas is discussed.
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There is a current trend toward nonsurgical therapy for small, minimally symptomatic acute subdural hematomas (ASDH), but data supporting such a scheme have been lacking. We evaluated 83 patients with minimally symptomatic ASDH (Glasgow Coma Scale scores of 11-15) and found 58 managed nonsurgically (70%) and 25 managed with craniotomy (30%). Patients managed without surgery had a lower incidence of focal neurologic deficits (12% vs. 40%; p < .01), open cisterns (90% vs. 28%; p < .001), and small (< or = 1 cm) ASDHs (92% vs. 62%; p < .001). ⋯ Six percent of patients managed nonsurgically developed chronic SDH requiring craniotomy. We conclude that unless the hematoma is causing clinical evidence of intracranial hypertension or significant neurologic dysfunction, there appears to be no advantage in evacuating the clot. Selected patients with ASDH and GCS scores of 11-15 can safely be managed without craniotomy.
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Restrictions on the operative domain of general surgeons threaten the viability of trauma surgery as a career choice. Our study hypothesis is that an experienced trauma surgeon can provide definitive care for life-threatening thoracic trauma. This analysis is based on clinical outcomes at an ACS-verified level I center in which there are more than 3000 trauma admissions managed annually under the direction of four academic trauma surgeons. ⋯ Sixteen of our 18 patients lived and none developed paraplegia. In summary, excluding patients who arrived dead, survival for penetrating cardiac wounds was 94% and for blunt thoracic aortic tears 89%. In conclusion, these data support our contention that trauma surgeons can render definitive care for thoracic injuries with survival rates comparable to those reported by cardiothoracic surgeons.