J Trauma
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Multicenter Study Comparative Study
Pain as an indication for rib fixation: a bi-institutional pilot study.
In trauma patients, open reduction and internal fixation of rib fractures remain controversial. We hypothesized that patients who have open reduction and internal fixation of rib fractures would experience less pain compared with controls and thus require fewer opiates. Further, we hypothesized that improved pain control would result in fewer pulmonary complications and decreased length of stay. ⋯ The need for analgesia was significantly reduced after rib fixation in patients with multiple rib fractures. However, no difference in outcomes was observed when these patients were compared with matched controls in this pilot study. Further study is required to investigate these preliminary findings.
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Apnea (APN) and pneumothorax (PTX) are common immediately life-threatening conditions. Ultrasound is a portable tool that captures anatomy and physiology as digital information allowing it to be readily transferred by electronic means. Both APN and PTX are simply ruled out by visualizing respiratory motion at the visceral-parietal pleural interface known as lung sliding (LS), corroborated by either the M-mode or color-power Doppler depiction of LS. We thus assessed how economically and practically this information could be obtained remotely over a cellular network. ⋯ The emergent exclusion of APN-PTX can be immediately accomplished by a remote expert economically linked to almost any responder over cellular networks. Further work should explore the range of other physiologic functions and anatomy that could be so remotely assessed.
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Comparative Study
Spinal cord injury: outcomes of ventilatory weaning and extubation.
Spinal cord injury (SCI) carries potentially devastating respiratory implications depending on injury level. Optimal strategies for mechanical ventilation in this setting remain poorly described. We reviewed our experience of ventilatory weaning and extubation outcomes in this patient population. ⋯ Higher level of SCI correlates strongly with failure to wean and extubate; despite this, a subset of patients with high cord injury who can be safely weaned and extubated exists. A multicenter study is warranted to specifically identify patients with high SCI who merit weaning and extubation trials.
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Comparative Study
Talk and die revisited: bifrontal contusions and late deterioration.
Severe bifrontal contusions in an awake traumatic brain injury (TBI) patient is a challenging clinical picture, as they are prone to late deterioration. We evaluated our series of patients with severe bifrontal contusions, characterizing their clinical course and suggestions for management. ⋯ Awake patients with bifrontal contusions represent a unique cohort of TBI patients who are prone to rapid deterioration late in their clinical course. They have extensive frontal edema and mass effect, yet we were unable to find a correlation between edema volumes and incidence of deterioration. Based on this series and our experience in other TBI patients, we no longer utilize prophylactic infusions of hypertonic saline in the setting of TBI. We recommend managing these patients with intensive care unit admission and early intracranial pressure monitoring. If they do deteriorate despite these measures, rapid bifrontal decompression can lead to good functional outcomes.