J Trauma
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Meta Analysis Comparative Study
Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis.
Ruling out injuries of the cervical spine in obtunded blunt trauma patients is controversial. Although computed tomography (CT) readily demonstrates fractures and malalignment, it provides limited direct evaluation of ligamentous integrity, leading some to advocate a magnetic resonance imaging (MRI) in obtunded patients. Thus, the question remains: does adding an MRI provide useful information that alters treatment when a CT scan reveals no evidence of injury? ⋯ Reliance on CT imaging alone to "clear the cervical spine" after blunt trauma can lead to missed injuries. This study supports a role for the addition of MRI in evaluating patients who are obtunded, or unexaminable, despite a negative CT scan.
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Controversy continues as to the most safe and reliable method for clearing the cervical spine (C-spine) in a trauma patient who is rendered unable to participate in a clinical examination. Although magnetic resonance imaging (MRI) is the most sensitive test to detect soft-tissue injuries, it is impractical for routine use in every patient largely because of its cost and time of acquiescence. Recent studies have advocated the sole use of multidetector computed tomographic (MDCT) scans of the C-spine to decide if cervical collar immobilization can be discontinued. The current investigation retrospectively reviewed a series of MDCT scans obtained after an acute traumatic event that were used to direct treatment in the emergency department (ED) or intensive care unit. ⋯ C-spine clearance of patients without the ability participate in a clinical examination remains difficult. A multidisciplinary, algorithmic approach generally yields the most consistent results. However, our data highlight that reliance on a single imaging modality may lead to missed diagnosis of C-spine injuries. These data suggest that early involvement of the spine service for radiographic clearance may help identify occult injuries or suspicious findings necessitating further evaluation.
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After decompressive craniectomy for brain swelling, bone flaps need to be stored in a sterile fashion until cranioplasty. Temporary placement in a subcutaneous pocket (SP) and cryopreservation (CP) are the two commonly used methods for preserving bone flaps. Surgical site infection (SSI) is a serious complication of cranioplasty, and the storage method associated with a lower SSI incidence is favored. It is unclear, however, whether one storage method is superior to the other in terms of SSI prevention. ⋯ SP and CP may be equally efficacious for storage of bone flaps of non-TBI etiology; however, SP may be the storage method of choice for TBI. It remains to be verified in a prospective fashion whether SP is truly the better method of storing bone flaps in TBI.
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Experimental studies of uncontrolled hemorrhage demonstrated that permissive hypotension (PH) reduces blood loss, but its effect on clot formation remains unexplored. Desmopressin (DDAVP) enhances platelet adhesion promoting stronger clots. We hypothesized PH and DDAVP have additive effects and reduce bleeding in uncontrolled hemorrhage. ⋯ PH reduced bleeding and improved hemostasis compared with normotensive resuscitation. DDAVP given preshock exerted similar effects with normotensive resuscitation.
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Venous thromboembolism (VTE) causes major morbidity in adults after trauma, occurring in up to 50% of patients without prophylaxis. The incidence of VTE after trauma is lower in children. No study has measured the incidence of and risk factors for VTE in critically ill children after trauma. ⋯ VTE is not a rare event in critically ill children after trauma. Most patients developing thrombosis have multiple risk factors, including poor perfusion, immobility, and presence of a CVL.