J Trauma
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A multidisciplinary concurrent audit of the quality of medical care within a trauma system was carried out by a committee of physicians, nurses, and health officials representing trauma centers, nontrauma hospitals, and the public agency administrating the trauma system. Care was audited with regard to timeliness and appropriateness of diagnosis and therapy. Complications were classified as being due to an error in diagnosis, judgment, or technique. ⋯ Complications or protocol violations occurred in 595 of 6,564 surviving trauma patients (9.1%). During the first 12 months of system operation, 7,200 person-hours were required to perform the audit. Personnel costs alone for audit in the first year were $300,420.
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Our experience with 56 patients who sustained massive transfusion exceeding two times their estimated blood volume is reviewed. Survival was 39% for the entire group, which included six cases of blunt multiple trauma and seven nontraumatic surgical emergencies, and 51% for the subgroup who sustained penetrating trauma. Six patients arrived without detectable vital signs, but half of them left the hospital alive. ⋯ Pulmonary morbidity was rare among penetrating trauma patients in spite of an average of 35 units of blood transfusion. Acute respiratory failure developed in a subgroup with penetrating trauma who received an average of 59 units of blood; blunt trauma patients developed acute respiratory failure at an average transfusion volume of 35 units. The 77% mortality among patients who developed coagulopathy, and our inability to predict in advance which patients will develop serious clinical bleeding, argue strongly in favor of an aggressive approach toward prophylaxis in these patients in spite of the theoretical risk of disease transmission from the additional units of platelets and frozen plasma required.
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The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. ⋯ One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.
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A 28-year-old male developed tension pneumopericardium following penetrating paraxiphoid injury to the pericardial space. We found no previous reports of this unique problem. Pneumopericardium associated with penetrating chest trauma warrants thorough exploratory surgery to rule out direct cardiac injury.
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The activities of a trauma service in a university hospital were analyzed to test the hypothesis that operative caseload alone does not adequately measure the trauma experience of a surgical resident. Over a 2-year period, 378 victims of major trauma (blunt in 79%) were admitted to the service. Only 41% of them required a major operation by the Trauma Service. ⋯ A trauma service in a university center manages significant numbers of patients with multisystem injuries who never undergo a general surgical procedure. This experience constitutes such an important component of surgical education in trauma that it should be recognized by agencies accrediting residents and training programs. Completion of surgical residency should also imply competence in critical care of surgical patients.