J Trauma
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Criteria for defining the major trauma patient have been specified by physicians using Injury Patient Management Categories (PMCs), a computerized classification that can be used effectively with routinely collected discharge abstract data from non-trauma center hospitals as well as trauma centers. These criteria for major trauma not only include the more severe and complex single injuries, but also include criteria for identifying combinations of injuries that require tertiary level care. ⋯ In addition, unlike other measures that are generally limited to registries, PMC tertiary patient criteria differentiate major trauma patients at both trauma centers and non-trauma centers without additional data collection. Using this method thus facilitates trauma systems evaluation and patient outcome assessment.
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The results of 163 patients (49 SWs, 85 GSWs, 29 blunt trauma) who had resuscitative thoracotomy in the emergency room (ERT) were reviewed to reassess the indications for the procedure. The Revised Trauma Score (RTS) of the patients ranged from 0 to 3 in 138, 4 to 8 in 21, and greater than 8 in four. No patient with blunt trauma survived. ⋯ Two of the five patients (40%) with extremity vascular injuries survived after ERT was successful in restoring a cardiac rhythm. These data suggest that in patients without vital signs, ERT "directed" at potential cardiac injury based on thoracic penetration is an important prognostic prerequisite for survival. Emergency room thoracotomy is not beneficial in blunt trauma and its role in penetrating abdominal injuries remains unproven.
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Comparative Study
Cardiac output measurement in critical care patients: Thoracic Electrical Bioimpedance versus thermodilution.
Thoracic Electrical Bioimpedance (TEB) is a method for measuring cardiac performance which is noninvasive, continuous, has minimal technical requirements, and no patient risk. We used a commercially available TEB device to measure cardiac output in patients with thermodilution catheters in place. We compared the cardiac output measurements for the two modalities. ⋯ There was a strong correlation between COTD and COTEB (r = 0.91) and the regression slope was 0.91 with a Y intercept of 0.76. Cost analysis demonstrated that the use of TEB was approximately $600 less than thermodilution. Thoracic electrical bioimpedance measurement of cardiac output may offer a valuable alternative to the invasive measurement of the thermodilution catheter.
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Deaths from uncontrollable hemorrhage might be prevented by arresting the circulation under protective hypothermia to allow resuscitative surgery to repair these injuries in a bloodless field. We have shown previously that in hemorrhagic shock, circulatory arrest of 60 minutes under deep hypothermia (tympanic membrane temperature, Ttm = 15 degrees C) was the maximum duration of arrest that allowed normal brain recovery. We hypothesize that profound cerebral hypothermia (Ttm less than 10 degrees C) could extend the duration of safe circulatory arrest. ⋯ In the 20 dogs that followed protocol, best neurologic deficit scores (0% = normal, 100% = brain death) at 24-72 hours were 23% +/- 19% in group 1 and 12% +/- 8% in group 2 (p = 0.15). Overall performance categories and histologic damage scores were significantly better in group 2 (p = 0.04 and p less than 0.001, respectively). We conclude that profound cerebral hypothermia with CPB plus ice water immersion of the head can extend the brain's tolerance of therapeutic circulatory arrest beyond that achieved with deep hypothermia.
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Case Reports
Continuous arteriovenous rewarming: report of a new technique for treating hypothermia.
Survival is rare after major trauma if core temperature falls below 32 degrees C. Available rewarming methods are often ineffective. We utilized arterial and venous catheters to create a circulatory fistula through the heating mechanism of a modified commercially available counter-current fluid warmer to achieve simple, rapid extracorporeal rewarming.