J Trauma
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Randomized Controlled Trial Clinical Trial
Hemodynamic and ventilatory effects associated with increasing inverse inspiratory-expiratory ventilation.
Increasing the percentage of inspiratory time during mechanical ventilation (i.e., inverse inspiratory-expiratory (I:E) ventilation) is frequently used to improve oxygenation in patients with acute respiratory distress syndrome; however, an optimal I:E ratio is unknown. ⋯ These findings demonstrate the effectiveness of increasing inspiratory time to improve oxygenation, yet to the detriment of ventilation. This suggests that within the parameter confines of this study, the preferential I:E ratio is a balance between oxygen demands and ventilatory requirements.
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Comparative Study
Predicting survival, length of stay, and cost in the surgical intensive care unit: APACHE II versus ICISS.
Risk stratification of patients in the intensive care unit (ICU) is an important tool because it permits comparison of patient populations for research and quality control. Unfortunately, currently available scoring systems were developed primarily in medical ICUs and have only mediocre performance in surgical ICUs. Moreover, they are very expensive to purchase and use. We conceived a simple risk-stratification tool for the surgical ICU that uses readily available International Classification of Diseases, Ninth Revision, codes to predict outcome. Called ICISS (International Classification of Disease Illness Severity Score), our score is the product of the survival risk ratios (obtained from an independent data set) for all International Classification of Diseases, Ninth Revision, diagnosis codes. ⋯ Because ICISS is both more accurate and much less expensive to calculate than APACHE II score, ICISS should replace APACHE II score as the standard risk stratification tool in surgical ICUs.
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In 1987, the article "The Demographics of Trauma in 1995" (DT95) attempted to predict the future needs of trauma centers based on changing population distributions. This article foresaw a relative increase in the number of injuries to the elderly and a relative decrease in total injuries. Based on these predictions, the paper recommended increasing the capabilities of existing trauma centers rather than developing new facilities. We compared these predictions to actual experience to validate this use of demographic data in trauma system planning. ⋯ Demographic projections assist in predicting the number and type of future injuries. Sociologic and economic factors also need to be considered in any predictive determinations of the true demand for trauma centers.
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The study of both short-term and long-term outcomes after major trauma has become an increasingly important focus of injury research because of the improved survival rates attributable to the evolution of sophisticated trauma care systems. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the discharge and 6-month follow-up time points in the TRP population and to examine the association of putative risk factors with functional outcome. ⋯ Postinjury functional limitation is a clinically significant complication in trauma patients at discharge and a 6-month follow-up. The QWB yields a more sensitive assessment of functional status than traditional ADL instruments. Postinjury depression, PTSD, serious extremity injury, and length of stay are significantly associated with 6-month QWB outcome.
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Ensuring an unobstructed airway and adequate oxygenation are first priorities in the resuscitation of the trauma patient. In situations of difficult endotracheal intubation, rapid sequence protocols frequently include the use of paralytic agents and cricothyrotomy for airway management. Recent literature findings suggest that the prehospital use of cricothyrotomy is too frequent. The purpose of this study was (a) to evaluate the efficacy of a rapid sequence intubation protocol without the use of paralytic agents, and (b) to determine the need for cricothyrotomy by using this protocol in the field. ⋯ Experienced emergency medical services personnel can effectively perform endotracheal intubation with narcotic analgesics without the use of paralytic agents in the field. With proper training for field airway management, cricothyrotomy in the field can be reduced to a few indications with high success rates.