J Trauma
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Randomized Controlled Trial
A randomized prospective trial of airway pressure release ventilation and low tidal volume ventilation in adult trauma patients with acute respiratory failure.
Airway pressure release ventilation (APRV) is a mode of mechanical ventilation, which has demonstrated potential benefits in trauma patients. We therefore sought to compare relevant pulmonary data and safety outcomes of this modality to the recommendations of the Adult Respiratory Distress Syndrome Network. ⋯ For patients sustaining significant trauma requiring mechanical ventilation for greater than 72 hours, APRV seems to have a similar safety profile as the LOVT. Trends for APRV patients to have increased ventilator days, ICU LOS, and ventilator-associated pneumonia may be explained by initial worse physiologic derangement demonstrated by higher Acute Physiology and Chronic Health Evaluation II scores.
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The occurrence of discharge to home shortly after transfer from another hospital, also termed "secondary overtriage," needs to be analyzed in trauma patients because it helps to assess the efficiency of triage and transfer criteria. The extent of secondary overtriage and factors associated with it remain largely undescribed. ⋯ Secondary overtriage is more common in pediatric patients than in adults. The underlying causes of this occurrence need to be further investigated (e.g., fear of litigation and uneven distribution of resources). There are significant direct and indirect costs associated with these occurrences that must be considered as we identify areas of potential cost savings in our nation's health care.
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Trauma surgery is perceived to have high malpractice risk. Unsolicited patient complaints (UPCs) can predict increased malpractice risk. An ex ante analysis of UPCs was performed to determine the risk profile for trauma surgeons compared with nontrauma surgeons. ⋯ TS are at increased risk of UPCs compared with NTS, but this risk is still largely borne by a minority of TS. UPCs seem to be a reasonable proxy for malpractice risk, so targeted interventions for TS associated with disproportionate shares of UPCs may reduce patient dissatisfaction and, perhaps, malpractice claims.
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Advances in care such as damage control surgery, hemostatic resuscitation, protocol-driven cerebral perfusion management, and lung-protective ventilation have promised to improve survival after major trauma. We examined injury severity, mortality, and preventability in a mature trauma system during a 12-year period to assess the overall benefits of these and other improvements. ⋯ Survival after severe trauma and survival benchmarked against predicted risk improved significantly at our center during the past 12 years despite generally increasing age and worsening injuries. Advances in trauma care have kept pace with an aging population and greater severity of injury, but overall survival has not improved.