J Trauma
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It has been suggested that fluid resuscitation for the prehospital management of hypotensive trauma victims increases bleeding. In a model of uncontrolled hemorrhage induced by complete splenic laceration with a hilar vascular injury, we hypothesized that small-volume hypertonic saline or large-volume lactated Ringer's solution may provide sustained hemodynamic benefits despite promoting increases in intra-abdominal bleeding. ⋯ No-fluid resuscitation in uncontrolled hemorrhage from splenic rupture resulted in a low-flow state, whereas resuscitation with small volumes of HSD or large volumes of LR produced hemodynamic benefits without significant increases in bleeding.
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Prehospital trauma patient field intubations and paralyzations, using neuromuscular blocking agents before emergency department respiratory and neurologic assessments are made, bias assessments and outcome evaluations using probability-of-survival models, such as TRISS and A Severity Characterization of Trauma (ASCOT). We present a newly developed "TRISS-like" probability-of-survival model for intubated blunt- and penetrating-injured patient assessment. ⋯ Study findings suggest that the new TRISS-like model should be used to assess both blunt- and penetrating-injured intubated patients. Use of this new model provides an analytical method for addressing a significant limitation of both the standard TRISS and ASCOT models, which are not applicable to intubated injured patient assessment. In addition, use of this model will complement TRISS/ASCOT assessments of nonintubated trauma patients and thus permit appropriate assessments for both intubated and nonintubated injured patient study populations.
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Coagulopathy and hemorrhage are known contributors to trauma mortality; however, the actual relationship of prothrombin time (PT) and partial thromboplastin time (PTT) to mortality is unknown. Our objective was to measure the predictive value of the initial coagulopathy profile for trauma-related mortality. ⋯ The incidence of coagulation abnormalities, early after trauma, is high and they are independent predictors of mortality even in the presence of other risk factors. An initial abnormal PT increases the adjusted odds of dying by 35% and an initial abnormal PTT increases the adjusted odds of dying by 326%.
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The presence of a surgeon at the initial assessment and care of the trauma patient has been the focal point of trauma center designation. However, for Level I verification, the American College of Surgeons Committee on Trauma currently does not require the presence of an attending trauma surgeon in the hospital (IH), provided senior surgical residents are immediately available. Likewise, the state of Missouri does not mandate an IH presence of the attending trauma surgeon but requires senior (postgraduate year 4 or 5) level surgical residents to immediately respond, with a 20-minute response time mandated for the attending surgeon if IH or out of the hospital (OH). Nevertheless, some claim that IH coverage by attending surgeons provides better care for seriously injured patients. ⋯ As long as initial assessment and care is provided by senior level IH surgical residents and as long as the attending surgeon responds in a defined period of time (if OH) to guide critical decision-making, the IH presence of an attending surgeon has not been shown in this retrospective study to improve care of the critically injured patient.
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There are many reasons for hypotension in trauma patients with multiple injuries; one uncommon source is facial fractures. The treatment algorithm is volume replacement and local control of the bleeding. A retrospective study was undertaken to evaluate the treatment of patients with life-threatening hemorrhage secondary to facial fractures, and to develop a treatment algorithm. ⋯ The incidence of severe hemorrhage secondary to facial fractures is rare; however, it can be life threatening. When common modalities of treatment such as pressure, packing, and correction of coagulopathy fail to control the hemorrhage, transcatheter arterial embolization offers a safe alternative to surgical control.