J Trauma
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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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Randomized Controlled Trial Clinical Trial
Use of low molecular weight heparin in preventing thromboembolism in trauma patients.
To investigate the safety and effectiveness of low molecular weight heparin (LMWH) in preventing deep venous thrombosis (DVT) in high-risk trauma patients, compared with mechanical methods of prophylaxis. ⋯ The administration of LMWH is a safe and extremely effective method of preventing DVT in high-risk trauma patients. When heparin is contraindicated, aggressive attempts at mechanical compression are warranted.
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Determine whether severe injury results in decreased plasma antithrombin (AT) activity and whether this decreased AT activity is associated with thromboembolic complications. ⋯ AT activity was depressed in critically injured patients. Patients with head injury developed supranormal AT activity. The risk factors for AT deficiency mimicked those for thromboembolism. Patients with decreased AT activity were at increased risk for thromboembolic complications. Given heparin's dependence on AT, these data call into question the use of unmonitored heparin thromboembolism prophylaxis.
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Multicenter Study
Continuous use of standard process audit filters has limited value in an established trauma system.
To evaluate the ability of five quality assurance/ quality improvement audit filters to identify opportunities for improvement in patient care in a mature trauma system. ⋯ The non-death process based audit filters that we evaluated in our trauma system documented adherence to care process standards but found few opportunities for quality improvement, suggesting that audit filters should be periodically evaluated and changed when their goals have been accomplished.