J Trauma
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The Glasgow Coma Scale (GCS) has been shown to be a valuable tool in assessing the neurologic and physiologic status of critically ill patients. Unfortunately, the GCS requires assessment of the verbal response of the patient and this can be blocked by intubation. The purpose of this study was to assess the ability of a regression model based upon the eye and motor components of the GCS to accurately predict the verbal response of the GCS. The primary hypothesis was that the verbal response could be derived from the motor and eye responses of the GCS. ⋯ The GCS is a useful tool in the intensive care unit and a critical part of the APACHE II assessment of patient acuity. GCS has been shown to be a useful tool in its own right as a predictor of outcome in the critically ill. Its use is limited with intubation. (See Segatore M, Way C: Heart Lung 21:548, 1992; and Lieh-Lai MW, Theodorou AA, Sarnaik AP, et al: J Pediatr 120:195, 1992.) The present study demonstrates that a relatively simple regression model can use the eye and motor components of the GCS to predict the expected verbal component of the GCS, thus allowing the calculation of the GCS sum score in intubated patients.
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Case Reports
Chronic volar dislocation of the metacarpophalangeal joint of the thumb: a case report and review of the literature.
A 61-year-old man sustained a chronic volar dislocation of the metacarpophalangeal joint of the thumb. He did not present for treatment until he experienced recently progressive joint pain 2 year after injury. Arthrodesis of the metacarpophalangeal joint was performed to correct the deformity of the thumb because of its extensive tissue scarring and erosion of the articular cartilage of the metacarpal head. Six weeks of splint immobilization followed by a physiotherapy program allowed the patient to resume his daily activities with his right hand.
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The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. ⋯ For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.
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Limited cardiac reserve, secondary to coronary disease, may be associated with end organ morbidity. In this study, we investigate the significance of anemia in the pathogenesis of this phenomenon. ⋯ These data suggest that with limited cardiac reserve, anemia may compromise aerobic splanchnic circulation. These observations may further our understanding of the pathogenesis of cholecystitis, gastric stress ulcers, ileal endotoxin translocation, and ischemic colitis in critically ill patients with coronary artery disease.
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Using a standardized liver injury model of uncontrolled hemorrhage, we tested the effect of different fluid resuscitation regimens on hemodynamics, oxygen delivery, oxygen consumption, bleeding volume, and fluid resuscitation requirements. Rats were randomized into three bolus resuscitation groups 15 minutes after liver injury: lactated Ringer's solution (LR, n = 10), hypertonic saline (HS, n = 10), and hypertonic sodium acetate (HA, n = 10). In all resuscitation groups, a 4 mL/kg bolus was first infused at a rate of 0.4 mL/min. ⋯ Animals in the HS group had significantly higher oxygen extraction ratios at the conclusion of the experiment. The use of different bolus fluids for the resuscitation of uncontrolled hemorrhage resulted in significant differences in hemodynamics, oxygen metabolism, and blood loss even when subsequent resuscitation was the same in all groups. Results from large vessel injury animal models and clinical studies of patients with penetrating trauma may not apply to solid parenchymal injuries.