J Trauma
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There is, at present, little literature to guide one in the management of a patient with a gunshot wound to the chest with normal vital signs, physical examination, and as a normal chest X-ray. The present study followed up 357 patients as outpatients at 48 hours, then 1 and 3 months. ⋯ The wound infection rate was only 1.5% with or without antibiotics, showing that prophylactic antibiotics are probably not warranted if good surgical wound care is practised. We conclude that patients with gunshot wounds to the chest with normal vital signs, physical examinations, and normal X-rays can be reasonably treated as outpatients after 4 hours of observation, at the physician's discretion.
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To determine limitations in survival and problems of single and multiple organ failure (SOF, MOF) following trauma in Bavaria, we reviewed 433 consecutive patients with multiple injuries treated at the Klinikum Grosshadern from 1978 through 1982. Most patients were young and were injured in traffic accidents. The overall mortality was 18% (78 deaths): 38 deaths were due to CNS injuries (49%), six from miscellaneous causes (7%), 15 associated with SOF (19%), and 19 associated with MOF (25%). ⋯ The temporal sequence of organ failure was lung, clotting system, kidney, and liver. Sepsis was ultimately the cause of death in eight MOF patients (42%). Earlier pulmonary and cardiovascular support beginning at the scene of the accident, and prevention and better treatment of head injury, respiratory failure, and sepsis are critical factors for increasing survival after injury.
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Since 1975, more than one thousand children with life-threatening injuries have been preferentially transported to our statewide Regional Pediatric Trauma Center by helicopter or city ambulance. Initial care is provided by emergency medical technicians with special instruction in the handling of pediatric trauma. More than half the children admitted to our service were injured in motor vehicle/pedestrian or motor vehicle/bicycle accidents. ⋯ Between January 1976 and December 1979, 46 children with coma of longer than 24 hours' duration were treated in the Pediatric Intensive Care Unit. The mortality rate was still high (38%) but employing intracranial monitoring and aggressive control of brain edema, 88% of the survivors had a good recovery without major motor or intellectual defects. The large volume of cases allows for development and evaluation of new techniques in trauma management and invaluable experience in the training of general surgical residents, pediatricians, and emergency physicians.
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Two surviving patients with traumatic hemipelvectomy are presented. Rapid transport, aggressive initial resuscitation, and attention to detail in the rehabilitation phase are necessary for the successful management of these patients. ⋯ There is need to include this entity in the existing classifications of pelvic fractures. Hemipelvectomy is proposed as an alternative in the management of the severe unilateral open pelvic fracture with uncontrollable bleeding.
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Fourteen thermally injured patients with severe inhalation injury were sequentially studied with the thermal-green dye double indicator dilution technique of extravascular lung water (EVLW) measurement. Eight females and six males (average age, 49 years, and average thermal burn, 37% body surface) were studied for 2-31 days postinjury. All were burned in a closed space, had facial burns, soot in their sputum, and a mean carboxyhemoglobin level of 30%. ⋯ The remaining four cases of permeability edema occurred 4-24 days postinjury and resulted from burn wound or pulmonary sepsis. We thus conclude that increases in EVLW after thermal and inhalational injury are primarily caused by systemic or pulmonary sepsis, and have a delayed onset. Early increases in EVLW may be a result of the chemical toxicity of inhaled gases but are very uncommon, moderate in degree, and are seen only with the severest cases of inhalation injury.