J Trauma
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Comparative Study
Computer protocol facilitates evidence-based care of sepsis in the surgical intensive care unit.
Care of sepsis has been the focus of intense research and guideline development for more than two decades. With ongoing success of computer protocol (CP) technology and with publication of Surviving Sepsis Campaign (SSC) guidelines, we undertook protocol development for management of sepsis of surgical intensive care unit patients in mid-2006. ⋯ Our comprehensive sepsis protocol has enabled rapid and consistent implementation of evidence-based care, and, implemented as a bedside CP, contributed to decreased mortality rate for management of surgical sepsis.
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Comparative Study
Prehospital hypotension in blunt trauma: identifying the "crump factor".
Trauma activation for prehospital hypotension in blunt trauma is controversial. Some patients subsequently arrive at the trauma center normotensive, but they can still have life-threatening injuries. Admission base deficit (BD)≤-6 correlates with injury severity, transfusion requirement, and mortality. Can admission BD be used to discriminate those severely injured patients who arrive normotensive but "crump," (i.e., become hypotensive again) in the Emergency Department? The purpose is to determine whether admission BD<-6 discriminates patients at risk for future bouts of unexpected hypotension during evaluation. ⋯ Blunt trauma patients with repeat episodes of hypotension have significantly greater mortality. Patients with transient field hypotension and a BD≤-6 are more than twice as likely to have repeat hypotension (crump). This study reinforces the need for early arterial blood gases and trauma team involvement in the evaluation of these patients. Patients with BD≤-6 should have early invasive monitoring, liberal use of repeat FAST exams, and careful resuscitation before computed tomography scanning. Surgeons should have a low threshold for taking such patients to the operating room.
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Comparative Study
Crush syndrome and acute kidney injury in the Wenchuan Earthquake.
The Wenchuan Earthquake resulted in calamitous destruction and massive death. We report the characteristics of crush syndrome (CS) and acute kidney injury (AKI) brought by the earthquake, which took place in a mountainous area. ⋯ Although the mountains hampered rescue actions, causing more loss of life, CS and AKI were still common and life-threatening events in the Wenchuan Earthquake. Most patients with CS and/or AKI had severe complications, especially hyperkalemia.
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Historically, minimally to moderately displaced clavicular fractures have been managed nonoperatively. However, there is no clear evidence on whether clavicular fractures can progressively displace following injury and whether such displacement might influence decisions for surgery. ⋯ We have demonstrated that a significant proportion of clavicle fractures (27% of our operative cases over a 5-year period) are minimally displaced at presentation, but are unstable and demonstrate progressive deformity during the first few weeks after injury. Because of this experience, we recommend close monitoring of nonoperatively managed clavicular fractures in the early postinjury period. A prudent policy is to obtain serial radiographic evaluation for 3 weeks, even for initially, minimally displaced clavicle fractures.