J Trauma
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The gut is considered an important target organ of injury after severe insult such as sepsis, trauma, and shock. The impact of bacterial translocation or mesenteric lymph on systemic inflammatory response and multiple organ damage has been investigated in animals, but dynamic changes in the gut flora and environment have not been fully clarified in critically ill patients. In the present study, we quantitatively evaluated changes in the gut microflora and environment in patients with severe systemic inflammatory response syndrome (SIRS). ⋯ The gut flora and environment are significantly altered in patients with severe SIRS. Abnormal gut flora and environment may affect systemic inflammatory response after severe insult.
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Assessment of the cervical spine (c-spine) in the obtunded blunt trauma patient remains a diagnostic dilemma. In 2002, our institution implemented a new c-spine clearance guideline utilizing c-spine computed tomography (CT) and magnetic resonance imaging (MRI). This study evaluates the safety and efficacy of this guideline. ⋯ In the obtunded patient, expeditious c-spine evaluation is important. Both missed injuries and prolonged unnecessary immobilization can result in adverse outcomes. This study confirms that c-spine CT, when used in combination with MRI, provides a safe and efficient method for c-spine clearance in this patient population. CT alone misses a statistically significant number of c-spine injuries.
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Emergency surgery patients are older, often critically ill, and at high risk of morbidity and mortality. We studied factors associated with issuance of a do-not-resuscitate (DNR) order and impact on morbidity and mortality in emergency surgery patients. ⋯ Female sex and, to a lesser extent, age were associated with issuance of DNR in series of patients who received emergency surgery. The association of DNR with female sex is an unexpected finding and may indicate clinician bias and necessitate the performance of further analysis.
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Comparative Study
National nosocomial infection surveillance system: from benchmark to bedside in trauma patients.
Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in the injured patient. Identification of those with VAP is important both in immediate clinical decision making as well as for the epidemiologic evaluation of the disease and benchmarking of rates across institutions with variable practice patterns. Despite this, controversy exists over the optimal method of VAP diagnosis. Many centers currently use invasive culture methods such as bronchoalveolar lavage (BAL) for diagnosis. Another diagnostic method, and the most common epidemiologic tool used to track VAP, is the definition employed by the National Nosocomial Infections Surveillance (NNIS) system. This relies on a combination of clinical and culture data. Our goal was to evaluate the accuracy of the NNIS definition as compared with BAL diagnosis in trauma patients. ⋯ Compared with strict bacteriologic criteria for VAP, the NNIS definition has good overall agreement and seems to have utility as an epidemiologic benchmarking tool in trauma patients. However, the NNIS definition has less utility as a bedside decision-making tool in this population, leading to under-treatment in a significant number of patients.
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To prospectively study the impact of implementing a computed tomographic angiography (CTA)-based screening protocol on the detected incidence and associated morbidity and mortality of blunt vascular neck injury (BVNI). ⋯ CTA screening increases the detected incidence of BVNI 8-fold, with rates similar to angiographically based screening protocols. CTA screening significantly decreases BVNI-related morbidity and mortality in an efficient manner, underlying its utility in the early diagnosis of this injury.