J Trauma
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The charts of 175 patients who underwent emergency thoracotomy (ET) in the emergency room (ER) between 1972 and 1978 were reviewed to determine the efficacy of this procedure. Seven cases of nontraumatic cardiac arrest were excluded from analysis. Although 150 patients were transported to the ER within 1 hour of injury, 60% either had no vital signs (91 cases) or were agonal (20 cases) on admission to the ER. ⋯ Survival rates were higher for patients with stab wounds (40%), pericardial tamponade (38%), and injury to the heart (30%), or lungs (57%). A cost-benefit analysis revealed that total benefits were 2.4 times greater than total costs. Performing early thoracotomy in the ER is a life-saving measure for a substantial number of trauma patients who present to the ER in extremis.
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On 21 May 1975 a chartered bus carrying 51 members of a student choir rolled from a sharply curved freeway off-ramp and fell 22 feet, landing on its roof, which collapsed. Twenty-nine passengers died (25 before extrication) and 22, plus the driver, survived. An analysis of factors leading up to the accident reveals several contributing causes, among them inadequate design of the ramp, poor warning signs, driver inexperience with the bus, and deficient bus maintenance. ⋯ Problems with organization at the scene, triage, and communications among agencies involved in the rescue and receiving hospitals contributed to confusion in the transport of victims, although it appears this had little impact on outcome. An analysis of the accident allows several lessons to be learned which might prevent, or reduce, the fatalities from future accidents involving multipassenger vehicles, and other disasters with 10 to 25, or more than 25 fatalities. In the present report ten of 25 killed were judged possibly salvageable with immediate extrication.
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A case of traumatic disruption of the manubriosternal joint in the absence of rib fractures has been seen. The manubrium was displaced posteriorly on the sternum. Treatment by observation only was followed by a satisfactory outcome with new bone being laid down to produce a false joint.
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Neurologic recovery occurred in a 3-year-old patient following immersion hypothermia and prolonged cardiopulmonary resuscitation. Recognition of hypothermia in the near-drowning victim is imperative for appropriate resuscitative efforts. Intensive care monitoring (intracranial pressure, pulmonary artery catheterization) facilitates patient management and optimum neurologic recovery.
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Deficiency of opsonic alpha 2 surface binding (SB) glycoprotein (cold-insoluble globulin, plasma fibrinectin) is related to depressed reticulendothelial function as well as to multiple organ failure after tissue injury and sepsis. Cryoprecipitate (250 ml), extracted from 10 units of human plasma, was infused over 60 minutes into 11 hypo-opsonemic patients with decreased renal function. Cardiac output, mean arterial pressure, creatinine clearance, and limb blood flow were measured before and at intervals of 14 to 20, 35 to 44, and 60 to 66 hours following cryoprecipitate infusion. ⋯ Limb blood flow increased significantly at 4 hours and returned to control values by 35 to 44 hours. Thus cryoprecipitate infusion to critically ill trauma and surgical patients with depressed renal function may improve glomerular filtration rate independently of mean arterial pressure or cardiac output. This improved renal function may be related to increased reticuloendothelial clearance of blood-borne particulates and/or improved microcirculatory function and lends support to the concept that RES failure may be involved in the etiology of multiple organ failure secondary to combined tissue injury and sepsis.