J Trauma
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Hemorrhagic shock and closed head injury often accompany severe trauma. Hypertonic saline may be beneficial in these patients, but few have examined its properties when sufficient volume is infused to achieve sustained resuscitation. Solutions of 6% NaCl (HS), 0.9% NaCl (NS), 6% hetastarch (HE), and whole blood (WB) were used to resuscitate swine in hemorrhagic shock (MAP less than 30 mm Hg). ⋯ ICE fell markedly in the HS group, [a decrease of 12 +/- 2 vs. a rise of 5 +/- 3 (HE), 2 +/- 3 (NS), and 6 +/- 3 (WB) mm Hg/ml; p = 0.0005]. This improvement was even more dramatic in the presence of an epidural mass [a fall of 21 +/- 3 vs. no change (HE, WB) and a rise of 4 +/- 3 (NS) mm Hg/ml; p = 0.0005]. For hemorrhage accompanied by severe head injury, resuscitation with HS may benefit victims by decreasing ICP and diminishing the effects of an intracranial mass.
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Human immunodeficiency virus (HIV) infection rates among 1,497 consecutive adult trauma victims triaged from rural and urban sectors to a statewide trauma center in Baltimore were studied. Those studied were 71.7% men, 77.4% whites, 63.2% vehicular trauma victims, 11.2% assault victims, and 25.7% other trauma victims. Non-Baltimoreans predominated (86.0%) and 32.7% were 25 to 39 years of age. ⋯ Significantly higher infection rates were seen in men (1.96% vs. 0.95%; p less than 0.02), non-whites (4.13% vs. 0.95; p less than 0.005), assault victims compared with vehicular and other trauma victims (5.99% vs. 1.06% vs. 1.30%, respectively; p less than 0.001), and Baltimore City residents (3.81% vs. 1.32%; p less than 0.03). Among those 25 to 39 years of age, 68.0% of the HIV infections were noted. Results suggest that HIV infection rates among trauma center patients are a reflection of the patient population served.
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Pulmonary contusion is the usual manifestation of lung parenchymal injury following blunt chest trauma. With rapid deceleration, however, parenchymal lacerations can result in cavities best termed post-traumatic pulmonary pseudocyst (PPP). This report discusses eight adult PPP cases encountered at the Denver General Hospital over the past 30 months. ⋯ Computed tomography of the chest was pursued in complicated patients and clearly influenced therapy. Three (38%) pseudocysts developed into lung abscesses; two required resection and the other responded to percutaneous drainage. Although previously described as a benign pediatric entity, in our adult experience, PPP may result in a recalcitrant lung abscess requiring aggressive intervention.
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As trauma systems have developed and board-certified in-house surgeons are now immediately available, enthusiasm has returned for thoracotomy as part of initial resuscitation. This study evaluated the impact of thoracotomy by board-certified surgeons during the resuscitative phase of treatment. ⋯ Survivors of penetrating injury had a probability of survival (Ps) of 0.48. Most patients suffering penetrating deaths had severe and advanced physiologic derangements at the time of admission despite similar anatomic injuries to survivors.
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Comparative Study
The declining incidence of fatal sepsis following thermal injury.
Successful management of burned patients requires effective prevention and management of infectious complications. This study reviews the incidence of fatal sepsis in our burn center and attempts to analyze factors which may predict septic mortality. From January 1, 1978, through May 31, 1988, 1,913 patients were admitted, with a mean age of 24.8 +/- 0.5 years, a mean burn size of 17.7 +/- 0.4% total body surface area (%TBSA), and a mean 10.1 +/- 0.5% TBSA full-thickness injury. ⋯ During the period 1983-1988, the incidence of septic mortality was 0.7%, which was significantly lower than the earlier half (1978-1982) of the study period (p less than 0.01). These data indicate that fatal infections are becoming increasingly uncommon after thermal injury. The reasons for this decline are probably multiple, and they include the widespread practice of early excision, and improvements in fluid resuscitation and the general medical care of burned patients.