J Trauma
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Randomized Controlled Trial Clinical Trial
Ketoconazole prevents acute respiratory failure in critically ill surgical patients.
Effective prophylaxis against acute respiratory failure (ARDS) has not been established. This study investigated whether or not ketoconazole could prevent ARDS in critically ill surgical patients. Seventy-one Surgical Intensive Care Unit (SICU) patients without liver dysfunction received either ketoconazole (n = 35), 200 mg daily via the gastrointestinal tract, or placebo (n = 36), for 21 days or until discharge from the SICU, in a prospective, randomized, double-blind study. ⋯ The incidence of ARDS was decreased among ketoconazole patients compared to placebo (6% vs. 31%; p less than 0.01), as was median SICU stay (7.0 days vs. 15.5 days; p less than 0.05), and median SICU cost (+5,600. vs. +12,400.; p less than 0.05). Mortality is increased with ARDS after trauma and surgery. We conclude that ketoconazole prevents ARDS, shortens SICU stay, and lowers hospital costs.
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Case Reports
Dum-dums, hollow-points, and devastators: techniques designed to increase wounding potential of bullets.
When considering the kinetic energy formula (KE = 1/2 MV2) to estimate wounding potential of bullets, bullet velocity has assumed the premier role as the determinant of wounding capability. Particular characteristics of the bullet such as mass have assumed positions of secondary importance or have been largely ignored. ⋯ Dum-dum bullets, hollow-points, shot shells, and explosive bullets have been designed so as to cause delivery of greater kinetic energy to the victim. Surgeons managing gunshot wounds must be familiar with these types of bullets in order to properly care for the victims and to ensure their own safety during the process.
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Case Reports
Bullet embolus to the right hepatic vein after a gunshot wound to the heart and its percutaneous retrieval.
Bullet emboli are rare and their management when in the venous circulation is controversial. A 26-year-old female with a gunshot wound to the heart, followed by embolization of the bullet to the right hepatic vein, had successful percutaneous retrieval of the bullet via a catheter inserted through the right femoral vein.
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The Trauma Scores, CRAMS scales, and mechanisms of injury of 500 trauma patients were evaluated for their ability to identify a seriously injured patient. Serious injury was defined as one of the following: Injury Severity Score (ISS) greater than 15, or emergency-room Trauma Score less than or equal to 14, or injuries requiring greater than 3 days hospitalization, or death. ⋯ With these same mechanisms, the sensitivity of a CRAMS scale of less than or equal to 8 increased from 66% to 93%, with a specificity of 30%. The addition of these mechanisms of injury to standard field triage scoring appears to improve the identification of seriously injured patients while retaining an acceptable level of overtriage.
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The effects of acute head injury or subarachnoid hemorrhage on the cardiovascular system (CVS) are well known, but data are lacking on the effects of acute spinal cord injury (SCI) on the CVS. The clip compression SCI rat model was used to measure changes in the mean systemic arterial pressure (mSAP), cardiac output (CO), heart rate (HR), total peripheral resistance (TPR), and central venous pressure (CVP) after SCI. Three groups of five animals each were anesthetized with chloralose-urethane: one group underwent only the surgical procedures including laminectomy, and the other two received either a 2.3- or 53.0-gm injury at the T1 spinal cord segment for 1 minute. ⋯ Thus the CVS showed two major alterations after severe SCI: post-traumatic hypotension, and a parallel decline in CO. There were no major changes in TPR, HR, or CVP, although HR ultimately declined. These findings suggest that the decline in CO was not entirely due to decreased sympathetic tone, but may also have resulted from direct myocardial injury, similar to that demonstrated after head injury or subarachnoid hemorrhage.