J Trauma
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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.
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Comparative Study
HSPTX protects against hemorrhagic shock resuscitation-induced tissue injury: an attractive alternative to Ringer's lactate.
Conventional fluid resuscitation with Ringer's lactated (RL) activates neutrophils and causes end-organ damage. We have previously shown that HSPTX, a combination of small volume hypertonic saline (HS) and pentoxifylline (PTX), a phosphodiesterase-inhibitor, downregulates in vitro neutrophil activation and proinflammatory mediator synthesis. Herein, we hypothesized that HSPTX decreases end-organ injury when compared with RL in an animal model of hemorrhagic shock. ⋯ HSPTX, a small volume resuscitation strategy with marked immunomodulatory potential led to a marked decrease in end-organ damage. HSPTX is an attractive alternative to RL in hemorrhagic shock resuscitation.
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Fluid resuscitation remains a fundamental component of early burn care management. However, recent studies suggest that excessive volumes of resuscitation are being administered. Overresuscitation results in negative sequelae including abdominal and extremity compartment syndromes. Elevated intraocular pressure (IOP) has been described as another potentially devastating effect of massive fluid resuscitation in trauma patients. The orbit, similar to the abdomen and extremity, is a compartment, limited to expansion from edema anteriorly by the eyelids and orbital septum, and posteriorly by the bony orbital walls. The purpose of this study was to review the incidence of elevated IOP in a series of patients with major burn injury. ⋯ Massive fluid resuscitation following burn injury can result in orbital compartment syndrome requiring lateral canthotomy. Early diagnosis and treatment of orbital compartment syndrome should be incorporated into the management of patients with major burn injury receiving large fluid resuscitation volume.