J Trauma
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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.
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During a 6-year period, 14 consecutive children with penetrating craniocerebral gunshot wounds (GSW) were studied. Eleven patients were comatose on admission. Five had an admission Glasgow Coma Scale (GCS) score of 4 or less and developed clinical signs of brain death within 12 hours despite maximum therapeutic efforts. ⋯ There were four survivors. Neurobehavioral and intellectual functions were evaluated over a period of 1 to 2 years. Although serious cognitive deficits were noted, all survivors had sufficient functional recovery to warrant aggressive cardiopulmonary resuscitation and measures to control ICP in the management of comatose victims of craniocerebral GSW.
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To ascertain morbidity and disability associated with vigorous attempts at limb salvage after lower extremity combined orthopedic and arterial injuries we reviewed more than 10,000 trauma admissions. Twenty-two patients (0.2%) suffered 14 blunt and eight penetrating lower extremity orthoarterial injuries. In all, more than 90 extremity operations were performed within 30 days of admission. ⋯ Tremendous effort was expended to achieve limb salvage in the patients of this review. Patients who underwent amputation had the more uneventful hospitalizations and the lower rates of disability. The notion that limb salvage need to be obtained in all patients at all costs may often lead to the triumph of technique and technology over reason.
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Randomized Controlled Trial Comparative Study Clinical Trial
Prospective, randomized trial of hypertonic sodium lactate versus lactated Ringer's solution for burn shock resuscitation.
We prospectively randomized 51 adult burned patients on admission to study fluid, electrolyte, and physiologic parameters during burn resuscitation with the use of hypertonic saline (HSL, Na 250 mEq/L, 514 mOsm) or lactated Ringer's solution (LR, Na 130 mEq/L, 268 mOsm). Patients suffered at least 20% total body surface area burns (BSA); the mean BSA injury was 36.7% BSA, with a range of 20 to 74% BSA. All patients were admitted to our Burn Center within at least 12 hours of injury. ⋯ Regression analysis was used to compare sodium intake (mEq/kg) and fluid intake (cc/kg) between the HSL and the LR groups in relation to % BSA. Our data show no advantage of HSL over conventional therapy with LR for burn resuscitation. We were not able to demonstrate decreased fluid requirements, improved tolerance of feedings, or decrease in per cent weight gain.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
Mortality of patients with head injury and extracranial injury treated in trauma centers.
The types and severity of injuries of 49,143 patients from 95 trauma centers were coded according to the 1985 version of the Abbreviated Injury Scale (AIS). This paper analyzes the causes, incidence, and mortality in 16,524 patients (33.6% of the trauma center patients) with injury to the brain or skull and compares them to patients without head injury. Relative to its incidence, patients with head injury composed a disproportionately high percentage (60%) of all the deaths. ⋯ The cause of death in head-injured patients was approximated and it was found that 67.8% were due to head injury, 6.6% to extracranial injury, and 25.6% to both. Head injury is thus associated with more deaths (3,010 vs. 1,972) than all other injuries and causes almost as many deaths (2,040 vs. 2,170) as extracranial injuries. Because of its high mortality, head injury is the single largest contributor to trauma center deaths.