J Trauma
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A patient with a delayed aorto-right ventricular fistula and aortic valve injury after penetrating trauma is reported, and 17 similar additional cases from the literature reviewed. By examining the aortic root of adults with normal cardiac anatomy at autopsy, we defined the target area for these injuries as a 2 X 2 cm contact surface between the aorta above the right coronary cusp and the right ventricular outflow tract below the pulmonary valve. Five of the 18 patients required emergency exploration due to hemodynamic instability. ⋯ Patients with combination aortic valve and aortocardiac fistula injuries, more so than those with a single intracardiac lesion, fail with nonoperative management. Of the 18 patients, 17 underwent surgery. One of these died: the others did well during short-term followup (less than 1 year).
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Complete dislocation of the tarsal cuboid is presented along with regional anatomic considerations. Thorough literature search revealed only three other reported cases of dislocation of the tarsal cuboid. ⋯ It should be emphasized that A-P, lateral, and oblique X-rays should be obtained for injuries of the mid and forefoot. The rarity of such a dislocation is attributed to the structural integrity of the supporting ligamentous elements.
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The high cost of health care has become a nationwide concern and there are several national initiatives under way to reduce the rate of increase of these costs. Among the most recent initiatives has been the introduction of Medicare reimbursement based upon Diagnostic Related Groups (DRGs). This paper presents a retrospective analysis of the costs of care of burned patients admitted to the University of Alabama at Birmingham Burn Center and a profile of the financial impact of DRGs. ⋯ In 1983, if the care for Medicare patients had been reimbursed on the bases of DRG rates, the payment would have been $409,629 less than costs and $634,583 less than charges. This very unfavorable reimbursement is because DRG reimbursement is essentially a flat rate and for long lengths of stay costs are much greater than reimbursements. Specific policies on methods to correct this discrepancy are suggested.
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A retrospective analysis of 1,018 consecutive admissions with cutaneous burn injury over 32 months was carried out. Mortality probabilities as related to age, per cent TBSA burn, and presence of inhalation injury are presented. Incidence of and mortality from inhalation injury both rose with increasing burn area. The incidence of inhalation injury also rose with advancing age; mortality was lowest in the 5- to 14-year old age group and highest in those more than 59 years of age.
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Comparative Study
Fluid resuscitation after an otherwise fatal hemorrhage: I. Crystalloid solutions.
One half of deaths among trauma victims occur within 1 hour of injury and are due to rapid hemorrhage or CNS trauma. We developed a rapid hemorrhage model in unanesthetized swine to simulate human exsanguination. We compared the ability of four crystalloid solutions to prevent death after an otherwise fatal hemorrhage: normal saline (NS), Ringer's lactate (RL), Plasmalyte-A (PA), and Plasmalyte-R (PR). ⋯ Aortic blood (54 ml/kg) was removed in 15 minutes from 116 swine. The percentages of shed blood replaced were 14% in 5 minutes with NS, 100% in 20 minutes with NS, and 300% in 30 minutes with NS, RL, PA, or PR. We found that all mortalities were determined within 2 hours after hemorrhage and that RL provided the best survival rate of 67% (NS 300% = 50%, PR = 40%, and PA = 30%.) After an analysis of arterial blood gas, lactate, acid-base, heart rate, and aortic pressure measurements, we conclude that RL is the superior crystalloid solution because of its decreased chloride load (compared to NS) and because of the absence of acetate or magnesium (compared to PA and PR).