J Trauma
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We devised a protocol to prospectively manage stab wounds to the back with the hypothesis that the triple contrast computed tomographic (CT) scan is an effective means of detecting occult injury in these patients. All wounds to the back in hemodynamically stable adults were locally explored. All patients with muscular fascial penetration underwent triple contrast CT scanning utilizing oral, rectal, and IV contrast. ⋯ Two CT scans documented significant injury and led to surgical exploration and therapeutic celiotomies. Although triple contrast CT scanning was able to detect occult injury in patients with stab wounds to the back it did so at considerable cost and the results rarely altered clinical care. Therefore, its routine use in these patients is not recommended.
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Hypothermia prolongs clotting times when the tests are performed at hypothermic temperatures, in contrast to standard clinical tests performed at 37 degrees C. The relative impact of hypothermia on plasma clotting factor activity was investigated by determining the specific clotting factor deficiencies required to produce an equivalent effect. ⋯ The clotting times for each temperature with undiluted ARP were compared with the clotting times at 37 degrees C obtained with FDP dilution. Hypothermia at temperatures below 33 degrees C produces a coagulopathy that is functionally equivalent to significant (< 50% of normal activity) factor-deficiency states under normothermic conditions, despite the presence of normal clotting factor levels.
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Despite numerous advances, the mortality from adult respiratory distress syndrome (ARDS) remains high. Traditional ventilator management in ARDS has been to maintain normal PaCO2 by positive pressure ventilation (PPV). However, high levels of PPV may worsen the lung injury by alveolar overdistension. Permissive hypercapnia (PHC) has been proposed as an alternative method of ventilation, but hypercapnia may affect the hemodynamics of a hyperdynamic, critically ill patient. The purpose of this study was to determine the effect of PHC on ventilator requirement, arterial oxygenation, and hemodynamic performance in patients with severe ARDS. ⋯ Permissive hypercapnia by V(t) reduction: (1) decreased Ve, PAP, and Pplat without a change in mean airway pressure, static compliance or arterial oxygenation; (2) caused a mild partially compensated acidosis; and (3) does not adversely affect pulmonary vascular resistance, systemic vascular resistance, cardiac index, or systemic oxygen delivery and consumption.
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Multicenter Study
Death in the operating room: an analysis of a multi-center experience.
To characterize causes of death in the operating room (OR) following major trauma, a retrospective review of admissions to eight academic trauma centers was conducted to define the etiology of death and challenges for improvement in outcome. Five hundred thirty seven OR deaths of 72,151 admissions were reviewed for mechanism of injury, physiologic findings, resuscitation, patterns of injury, surgical procedures, cause of death, and preventability. Blunt injuries accounted for 61% of all injuries, gunshot wounds (GSW) accounted for 74% of penetrating injuries. ⋯ Recurrent injury patterns judged as the primary cause of patient death included head/neck injury (16.4%), chest injury (27.4%), and abdominal injury (53.4%). Actual cause of death was bleeding (82%), cerebral herniation (14.5%), and air emboli (2.2%). A different strategy for improved outcome was identified in 54 patients with the following conclusions: (1) delayed transfer to the OR remains a problem with significant BP deterioration during delay, particularly following interfacility transfer; (2) staged injury isolation and repair to allow better resuscitation and warming may lead to improved results; (3) combined thoraco-abdominal injuries, particularly with thoracic aortic disruption, often require a different sequence of management; (4) aggressive evaluation of retroperitoneal hematomas is essential; (5) OR management of severe liver injuries remains a technical challenge with better endpoints for packing needed; and (6) resuscitative thoracotomy applied to OR patients in extremis from exsanguination offers little.
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Comparative Study
Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma?
Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities in the evaluation of patients with suspected blunt abdominal trauma (BAT). Diagnostic peritoneal lavage is fast and accurate but associated with complications. Computed tomography is also accurate, yet requires that patients be stable and transportable. ⋯ Six injuries were missed but only one was felt to be significant. If US had been used in all 200 patients, 199 would have had appropriate care. We conclude US is reliable in the detection of free intraperitoneal fluid and may be used in place of DPL or CT.