J Trauma
-
Long-duration blasts are an increasing threat with the expanded use of thermobaric and other novel explosives. Other potential long-duration threats include large explosions from improvised explosive devices, weapons caches, and other explosives including nuclear explosives. However, there are very few long-duration pulmonary blast injury assessments, and use of short-duration exposure injury metrics is inappropriate as the injury mechanism for long-duration exposures is likely different from that of short-duration exposures. ⋯ New injury risk assessment curves were determined for both incident and reflected pressure conditions for reflecting surface and free-field exposures. Position dependent injury risk curves were also determined. The resulting curves are an improvement to existing assessments, because they use actual data to demonstrate theoretical assumptions on the injury risk.
-
Two prospective randomized trauma trials have shown recombinant factor VIIa (rFVIIa) to be safe and to decrease transfusion requirements. rFVIIa is presently used in 22% of massively transfused civilian trauma patients. The US Military has used rFVIIa in combat trauma patients for five years, and two small studies of massively transfused patients described an association with improved outcomes. This study was undertaken to assess how deployed physicians are using rFVIIa and its impact on casualty outcomes. ⋯ In military casualties, rFVIIa is used in the most severely injured patients based on physician selection rather than on guideline criteria. Use of rFVIIa is not associated with an improvement in survival or an increase in complications. The undetected bias of physician selection of patients for treatment with rFVIIa, likely, has an impact on case matching to achieve equivalence similar to that of randomized control studies. This inability to match populations, thus, prevents definitive interpretation of this study and others studies of similar design. This problem emphasizes the need to develop entry criteria to identify patients who could potentially benefit from use of rFVIIa and the need to subsequently perform efficacy studies.
-
Comparative Study
Cranioplasty after postinjury decompressive craniectomy: is timing of the essence?
The appropriate timing of cranioplasty after decompressive craniectomy for trauma is unknown. Potential benefits of delayed intervention (>6 weeks) for reducing the risk of infection must be balanced by persistent altered cerebrospinal fluid dynamics leading to hydrocephalus. We reviewed our recent 5-year experience in an effort to improve patient throughput and develop a rational decision making plan. ⋯ In our experience, the prior practice of delayed cranioplasty (3-6 months postdecompressive craniectomy), requiring repeat hospital admission, does not seem to lower postcranioplasty infection rates nor the need for cerebrospinal fluid diversion procedures. Our current practice emphasizes cranioplasty during the initial hospital admission, as soon as there is resolution on computed tomography scan of brain swelling outside of the cranial vault with concurrent clinical examination. This occurs as early as 2 weeks postcraniectomy and should lower the overall cost of care by eliminating the need for additional hospital admissions.
-
Comparative Study
S-100B in serum and urine after traumatic head injury in children.
Children with head trauma are frequently seen in many emergency units. The clinical evaluation of these patients is difficult for a number of reasons and improved diagnostic tools are needed. S-100B, a protein found in glial cells, has previously been shown to be a sensible marker for brain damage after head injury in adults, but few studies have focused on its use in children. ⋯ Serum S-100B values within 6 hours after head trauma in children were significantly higher in patients with intracranial pathology compared with those without intracranial complications. Identification of these high-risk patients already in the emergency department is of major importance, and we suggest that S-100B could be a valuable diagnostic tool in addition to those used in clinical practice today.
-
Comparative Study
Trauma center designation correlates with functional independence after severe but not moderate traumatic brain injury.
The mortality of traumatic brain injury (TBI) continues to decline, emphasizing functional outcomes. Trauma center designation has been linked to survival after TBI, but the impact on functional outcomes is unclear. The objective was to determine whether trauma center designation influenced functional outcomes after moderate and severe TBI. ⋯ ACS trauma center designation is significantly associated with FI and IE after severe, but not moderate TBI. Prospective study is warranted to verify and explore factors contributing to this discrepancy.