J Trauma
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Comparative Study
Right ventricular end-diastolic volume as a measure of preload.
Right ventricular (RV) end-diastolic volume index (RVEDVI) measured by a modified thermodilution pulmonary artery catheter has been proposed as an improved measure of cardiac preload, compared with pulmonary capillary wedge pressure (PCWP). This study compared the correlation of RVEDVI and PCWP with cardiac index (CI) to determine which parameter better reflected ventricular preload. Modified thermodilution catheters were placed in 38 critically ill patients. ⋯ In individual patients, a significant, uncorrected correlation (p < 0.05) was found between RVEDVI and CI in 27 of the 38 patients, whereas 11 patients had a significant correlation between PCWP and CI. RVEDVI correlated more closely with CI than did PCWP, even after correlation for mathematical coupling. In both the group as a whole and in individual patients, RVEDVI was a better indicator of cardiac preload.
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Comparative Study
A prospective study of emergent abdominal sonography after blunt trauma.
In North America, the role of emergent abdominal sonography [ultrasonography (US)] after blunt trauma requires further definition. The purpose of this prospective study was to compare US to the gold standards, diagnostic peritoneal lavage (DPL), and computed tomography (CT), in a population of adults after blunt trauma. In 206 adults who required either CT or DPL to assess possible abdominal injury, US was performed, before DPL or CT, and was aimed at the detection of intraperitoneal fluid. ⋯ Of the six false-negative USs, only one required surgery. The US examinations required 2.6 +/- 1.4 min. Emergent abdominal sonography is an accurate, rapid test for the presence of intraperitoneal fluid in adult blunt trauma victims and in these patients may prove valuable as a screening test for abdominal injury.
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Comparative Study
Limiting initial resuscitation of uncontrolled hemorrhage reduces internal bleeding and subsequent volume requirements.
We tested the hypothesis that full or "standard resuscitation" (SR) with lactated Ringer's solution (LRS) results in increased bleeding in uncontrolled hemorrhagic shock, compared with a "limited prehospital resuscitation" (LPR) regimen and a control group of "no resuscitation" (NR). Cardiac output was used as physiological endpoint for resuscitation. Twenty swine had 25 mL/kg of blood withdrawn during a 30-minute controlled hemorrhage, followed by a 20-minute "prehospital" resuscitation regimen was conducted in three groups: the SR group (n = 6), LRS infused as needed to restore cardiac index (CI) to 100% baseline; the LPR group (n = 8), with resuscitation using LRS to 60% of baseline CI, with volume limited to 10 mL/kg; and the NR group (n = 6). ⋯ Peritoneal blood volume was significantly higher in the SR group (20.6 +/- 5.6 mL/kg), versus the LPR (7.3 +/- 1.3 mL/kg; p < 0.05) and NR groups (3.0 +/- 0.9 mL/kg; p < 0.05). Crystalloid and whole blood requirements during the intraoperative resuscitation phase were significantly higher in the SR group (193 +/- 16.0 and 9.0 +/- 2.5 mL/kg), than in LPR (111.8 +/- 15.6 and 4.5 +/- 1.8 mL/kg; p < 0.05) and NR groups (128.5 +/- 32.3 and 3.9 +/- 2.3 mL/kg; p < 0.05). In the presence of uncontrolled hemorrhagic shock, LPR and NR can significantly reduce internal hemorrhage and subsequent intraoperative crystalloid and blood requirements.
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Health care reform will affect the relationship of trauma centers to health maintenance organizations and other managed care plans. We studied Kaiser Permanente Medical Center (Kaiser) members admitted to the Trauma Center at San Francisco General Hospital (SFGH) to determine: (1) variables predicting transfer from SFGH to a Kaiser Hospital (repatriation), (2) the length of hospital stay (LOS), and (3) the cost of their care. The SFGH trauma registry provided data on 7,794 patients admitted before 1994. ⋯ A relatively small number of severely injured patients account for a large percentage of costly trauma care. Analyses of patient subsets are necessary for trauma centers to negotiate suitable relationships with managed care plans. A prospective study is needed to examine the cost efficiency of early transfer of managed care patients.
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Comparative Study
Evolution of management of major hepatic trauma: identification of patterns of injury.
Nonoperative management of hemodynamically stable patients following blunt hepatic trauma identified by computed tomography (CT) has been reported in up to 20% of patients presenting with hepatic injury, predominantly low grade. We reviewed 128 consecutive adult patients sustaining blunt hepatic trauma with the hypothesis that severe hepatic injuries (grades III to V) could be safely managed nonoperatively and to determine anatomic pattern and severity of hepatic injuries. Sixty-two of the 128 patients (47%) went directly for laparotomy, based on physical findings or positive peritoneal lavage. ⋯ However, the majority of patients with grade V injuries were unstable, and 92% required laparotomy. Twenty-six of 46 patients treated nonoperatively (56%) had injury to the posterior segment of the right lobe of the liver or a "split liver." In retrospect, only 33% of patients with hepatic injury required laparotomy for therapy of the liver injury. Hemodynamic stability and anatomic pattern of injury on presentation were important factors in successful nonoperative management of hepatic injury.