J Trauma
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Elderly trauma patients have a higher incidence of medical comorbidities when compared with their younger cohorts. Currently, the minimally accepted criteria established by the Committee on Trauma for the highest level of trauma activation (Level I) does not include age as a factor. Should patients older than 60 years with multiple injuries and/or a significant mechanism of injury be considered as part of the criteria for Level I activation? Would these patients benefit from a higher level of activation? ⋯ Patients with an ISS between 0 and 15 are often triaged to Level II activation. Our data would suggest that patients older than 60 years should be a criterion for the highest level of trauma activation.
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Plate fixation is frequently used to repair clavicle fractures, but over drilling can cause subclavian neurovascular bundle damage. The aims of this study were to investigate the anatomic relationship between the clavicle and subclavian neurovascular bundle and to determine safe drilling angles and depths. ⋯ We have used magnetic resonance imaging to determine safe drilling directions and depth for plate-screw fixation of the clavicle. On confirmation, these findings could be used in the clinical setting to reduce the risk of inadvertent iatrogenic subclavian neurovascular bundle injury during surgical clavicle fracture repair.
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The Trauma Quality Improvement Project has demonstrated significant variations in risk-adjusted mortality rates across the designated trauma centers. It is not known whether the outcome differences are related to provider-level clinical decision making. We hypothesized that centers with good outcomes undertake critical operative interventions aggressively, thereby avoiding complications and deaths. ⋯ Trauma centers with higher risk-adjusted mortality rates are more likely to undertake operative interventions for solid organ injuries. Hence, there is a need to focus quality improvement efforts on medical decision-making and perioperative processes of care.
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Comparative Study
Impact of policy change on US Army combat transfusion practices.
Clinical practice guidelines (CPGs) are used to keep providers up-to-date with the most recent literature and to guide in decision making. Adherence is typically improved although many have a muted impact. In March 2006, the US Army issued a damage control resuscitation CPG, encouraging 1:1 plasma:red blood cell (RBC) transfusions and limiting crystalloid use. The objective of this study was to determine whether the CPG was associated with a change in the transfusion practices in combat-wounded patients. ⋯ MT patients are now receiving a higher FFP:RBC ratio and less crystalloid after implementation of the CPG. Additionally, patients are now presenting normothermic and have higher hemoglobin levels. All of these changes are consistent with the principles of damage control resuscitation. Changes in practice were associated with implementation of the CPG, maturity of the battlefield, and increased availability of products.
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Comparative Study
A large animal survival model (Sus scrofa) of extremity ischemia/reperfusion and neuromuscular outcomes assessment: a pilot study.
Extremity ischemia/reperfusion has been studied mostly in small-animal models with limited characterization of neuromuscular or functional outcome. The objective of this experiment was to report a large-animal survival model of extremity ischemia/reperfusion using circulating, electromyographic (EMG), gate, and histologic measures of injury and limb recovery. ⋯ This study reports a new large-animal survival model of extremity ischemia/reperfusion using circulating, functional, and histologic markers of neuromuscular recovery. Findings provide insight into an extremity ischemic threshold after which functional neuromuscular recovery is lost. Additional study is necessary to define this threshold and factors that may move it to a more or less favorable position in the setting of extremity injury.