J Trauma
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Traumatic hemipelvectomy is a catastrophic injury resulting from violent blunt shearing forces which cause massive skin, bone, and soft-tissue destruction. The initial extent of the injury as well as the complexity of the consequent problems is staggering. As such it constitutes one of the major challenges seen by trauma surgeons. ⋯ The University of California at Davis General Surgery Trauma Service admitted 9,369 major trauma victims from June 1985 to May 1988. During this 3-year period eight patients sustained a traumatic hemipelvectomy, of whom three survived. Given the complexity, yet rarity, of this injury, a review of the world literature was undertaken to compile collective experiences to aid surgeons in the management of this injury.
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Comparative Study
Emergency Department thoracotomy in children--a critical analysis.
Recent clinical reviews have helped to clarify the role of Emergency Department (E. D.) thoracotomy in critically injured adults. However, guidelines in the pediatric population remain ill defined. ⋯ Blunt trauma, the predominant mechanism of lethal injuries in children, had a dismal outcome, with only 2% salvage and no survivors when vital signs were absent. This study demonstrates a similar outcome for E. D. thoracotomy in children compared to adults, and supports a selective policy of liberal use in penetrating injury irrespective of physiologic status but limited in those arriving lifeless following blunt trauma.
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Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. ⋯ Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.
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Multicenter Study Clinical Trial
Nonoperative management of blunt splenic trauma: a multicenter experience.
The experience of six referral trauma centers with 832 blunt splenic injuries was reviewed to determine the indications, methods, and outcome of nonoperative management. During this 5-year period, 112 splenic injuries were intentionally managed by observation. There were 40 (36%) patients less than 16 years old and 72 adults. ⋯ This contemporary multicenter experience suggests that patients with Class I, II, or III splenic injuries after blunt trauma are candidates for nonoperative management if there is: 1) no hemodynamic instability after initial fluid resuscitation; 2) no serious associated abdominal organ injury; and 3) no extra-abdominal condition which precludes assessment of the abdomen. Strict adherence to these principles yielded initial nonoperative success in 98% of children and 83% of adults. Application of standard splenic salvage techniques to treat the patients with persistent hemorrhage resulted in ultimate splenic preservation in 100% of children and 93% of adults.
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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.