J Trauma
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Outcome in patients with traumatic brain injury (TBI) is often affected by secondary insults including posttraumatic cerebral infarction (PTCI). The incidence of PTCI after TBI was previously reported to be 2% with no mortality impact. We suspected that recent advances in imaging modalities and treatment might affect incidence and outcome. We sought to define the incidence and mortality impact of PTCI. We also identified risk factors associated with PTCI. ⋯ The incidence of PTCI in patients with severe TBI is higher after severe brain injury than previously thought. PTCI has a significant impact on mortality and LOS. The presence of a blunt cerebral vascular injury, the need for craniotomy, or treatment with factor VIIa are risk factors for PTCI. Recognition of this secondary brain insult and the associated risk factors may help identify the group at risk and tailor management of patients with severe TBI.
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Military operations, mass casualty events, and remote work sites present unique challenges to providers of immediate medical care, who may lack the necessary skills for optimal clinical management. Moreover, the number of patients in these scenarios may overwhelm available health care resources. Recent applications of closed-loop control (CLC) techniques to critical care medicine may offer possible solutions for such environments. ⋯ Some potential advantages of CLC in patient management include limiting task saturation when there is simultaneous demand for cognitive and active clinical intervention, improving quality of care through optimization of the titration of medications, conserving limited consumable supplies, preventing secondary insults in traumatic brain injury, shortening the duration of mechanical ventilation, and achieving appropriate goal-directed resuscitation. The uses of CLC systems in critical care medicine have been increasingly explored across a wide range of therapeutic modalities. This review will provide an overview of control system theory as applied to critical care medicine that must be considered in the design of autonomous CLC systems, and introduce a number of clinical applications under development in the context of deployment of such applications to austere environments.
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Comparative Study
Computed tomography alone for cervical spine clearance in the unreliable patient--are we there yet?
Injuries to the cervical spine (CS) occur in 2% to 6.6% of blunt trauma patients. Studies have suggested that computed tomography (CT) alone is sufficient for CS clearance in unreliable patients based on follow-up magnetic resonance (MR) imaging not altering management. We hypothesized that an admission cervical spine CT with no acute injury-using new CT technology-is not sufficient for CS clearance in an unreliable patient. ⋯ Newer generation CT continues to miss CS injuries in unreliable patients. MR changed the management in 7.9% of patients having had an admission CT with no acute injury. Thus, we recommend continued use of MR for CS clearance in the unreliable patient and ongoing evaluation as the quality of CT imaging continues to evolve.
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An epidemiologic profile of traumatic brain injury (TBI) in Australia and New Zealand was obtained following the publication of international evidence-based guidelines. ⋯ In Australia and New Zealand, mortality and favorable neurologic outcomes after TBI were similar to published data before the advent of evidence-based guidelines. A high incidence of prehospital secondary brain insults and an ageing population may have contributed to these outcomes. Strategies to improve outcomes from TBI should be directed at preventive public health strategies and interventions to minimize secondary brain injuries in the prehospital period.
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The evolving discipline of acute care surgery as an expansion of trauma surgery is undergoing intense critique. As we envision this new paradigm of surgical practice, an evaluation of our current status across the nation's trauma centers is an essential step. The purpose of this study is to determine the practice patterns of trauma surgeons at major trauma centers throughout the United States. ⋯ The model of the acute care surgeon is attractive and timely, but only a limited number of trauma surgeons currently practice this proposed range of operative procedures; even fewer surgeons have an elective surgical practice to maintain key operative skills. Fellowship training programs need to incorporate vascular and thoracic procedures to enable the specialty of acute care surgery.