J Trauma
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Clinical Trial
Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve.
Although sonographic screening for blunt abdominal trauma is gaining acceptance, standards for implementation, training, credentialing, and quality control remain to be established. ⋯ This experience with the de novo implementation of a trauma US program suggests that the training and credentialing requirements in this study are sufficient to provide surgeon ultrasonographers with acceptable competence in US diagnosis of blunt abdominal trauma.
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Deep venous thrombosis (DVT) and pulmonary embolism (PE) are considered to be a major source of morbidity and mortality among trauma patients. Several reports have identified high-risk patients with recommendations for management ranging from frequent duplex scanning to placement of prophylactic inferior vena cava (IVC) filters. We reviewed our experience with a large trauma population to determine whether such approaches are justified. ⋯ Although these patients were at increased risk for thromboembolic events, the overall incidence of DVT was still extremely low with no apparent PE deaths. In our patient population, aggressive screening and prophylactic IVC filters would not have benefited 95% of "high-risk" patients without DVT and would not have prevented any deaths. We could not identify any population, except perhaps venous injuries, where such expensive and potentially harmful maneuvers seemed justified. Our experience with DVT and PE does not support either aggressive screening or prophylactic IVC filters as the standards of care.
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Most prognostic indices for severely injured patients are based on anatomical findings and the vital signs. The posttraumatic organ failure, however, is thought to be triggered by the initial inflammatory response. The objective of this study was to evaluate the correlation between the early activation of inflammation and the rate of organ failure and death. ⋯ These data show that the degree of the initial inflammatory response corresponds with the development of posttraumatic organ failure. Besides anatomically and physiologically based trauma scores, these parameters might be used as indicators for the injury severity.
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Scapulothoracic dissociation is an infrequent injury with a potentially devastating outcome. The diagnosis has heretofore relied on the radiographic description of the forequarter disruption. Recent experience with four patients at a single trauma center, along with review of 54 injuries adequately described in the literature, indicates a broader spectrum of injury. ⋯ Identification of this injury requires clinical suspicion, based upon the injury mechanism and physical findings, to accurately assess the degree of trauma to musculoskeletal, neurologic, and vascular structures. Based upon these clinical findings, a rational approach to diagnostic techniques, injury classification, and appropriate surgical intervention can be achieved. Outcome is dependent on early recognition of the subset of patients with injuries amenable to surgical treatment and rehabilitation.
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Comparative Study
Comparison of the Injury Severity Score and ICD-9 diagnosis codes as predictors of outcome in injury: analysis of 44,032 patients.
Appropriate stratification of injury severity is a critical tool in the assessment of the treatment and the prevention of injury. Since its inception, the Injury Severity Score (ISS) has been the generally recognized "gold standard" for anatomic injury severity assessment. However, there is considerable time and expense involved in the collection of the information required to calculate an accurate ISS. In addition, the predictive power of the ISS has been shown to be limited. Previous work has demonstrated that the anatomic information about injury contained in the International Classification of Diseases Version 9 (ICD-9) can be a significant predictor of survival in trauma patients. The goal of this study was to utilize the San Diego County Trauma Registry (SDTR), one of the nation's leading trauma registries, to compare the predictive power of the ISS with the predictive power of the information contained in the injured patients' ICD-9 diagnoses codes. It was our primary hypothesis that survival risk ratios derived from patients' ICD-9 diagnoses codes would be equal or better predictors of survival than the Injury Severity Score. The implications of such a finding would have the potential for significant cost savings in the care of injured patients. ⋯ The present study confirms previous work showing that survival risk ratios derived from injured patients' ICD-9 diagnoses codes are as good as or better than ISS as predictors of survival.