J Trauma
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Ventilator-associated pneumonia (PN) is difficult to distinguish from trauma-induced systemic inflammatory response syndrome (SIRS), especially in patients with multiple injuries. Previous work using bronchoscopy and quantitative cultures demonstrated significant bacterial growth in about one-third of patients with clinical evidence of PN. In this prospective study, antibiotic therapy for PN was based solely on quantitative bronchoalveolar lavage (BAL) cultures. ⋯ SIRS, which can mimic PN, is common in trauma patients. These entities can be distinguished by bronchoscopy with BAL. Basing antibiotic therapy solely on quantitative BAL cultures is efficacious in trauma patients.
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Case Reports
Exclusion of aortic tear in the unstable trauma patient: the utility of transesophageal echocardiography.
The goal of this study was to investigate the value of biplanar transesophageal echocardiography (TEE) as a screening tool for aortic tear in unstable trauma patients. ⋯ The TEE procedure is valuable in identifying aortic injury in high-risk trauma patients who are too unstable to undergo transport to the aortography suite.
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The study is based on 44 preventable deaths occurring in a cohort of 360 patients with major trauma. These cases were reviewed by a committee of nine experts. The mean Injury Severity Score (ISS) was 28, and most cases had injuries to the head/neck (68%) and chest (64%). ⋯ Of the 34 patients that required direct transport at a level I trauma center, 50% were transferred to such a hospital. These results show significant prehospital delays and high rates of inappropriate IV line initiation and intubation in trauma patients receiving on-site care by physicians. We conclude that prehospital care protocols for trauma patients should emphasize prompt transport and specific on-site care algorithms.
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Upper extremity injuries are commonly seen in the sport of in-line skating. The use of protective equipment, including wrist splints, has been advocated as a means to decrease both the incidence and severity of upper extremity injuries in this sport. We report on four cases of open forearm fractures in the in-line skaters that occurred adjacent to the proximal border of the wrist splints. ⋯ The splint and distal forearm may act as a single unit to convert the impact from the level of the wrist to a torque moment, with the fulcrum located at the proximal border of the splint. The energy from the fall is then dissipated by the fracturing of the forearm bones at this level. These cases suggest that the use of wrist splints may be associated with their own specific set of injury patterns.
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Case Reports
Management of thoracic duct injury associated with fracture-dislocation of the spine following blunt trauma.
Thoracic duct injuries accompanying blunt thoracic trauma are rare. A significant number of these lesions, however, are associated with fracture-dislocation of the spine. In this report, we discuss the surgical management of chylothorax in this setting.