J Trauma
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The severity and disparity of interpersonal violent injury is staggering. Fifty-three per 100,000 African Americans (AA) die of homicide yearly, 20 per 100,000 in Latinos, whereas the rate is 3 per 100,000 in Caucasians. With the ultimate goal of reducing injury recidivism, which now stands at 35% to 50%, we have designed and implemented a hospital-based, case-managed violence prevention program uniquely applicable to trauma centers. The Wraparound Project (WP) seizes the "teachable moment" after injury to implement culturally competent case management (CM) and shepherd clients through risk reduction resources with city and community partners. The purpose of this study was to perform a detailed intermediate evaluation of this multi-modal violence prevention program. We hypothesized that this evaluation would demonstrate feasibility and early programmatic efficacy. We looked to identify areas of programmatic weakness that, if corrected, could strengthen the project and enhance its effectiveness. ⋯ WP case managers served high-risk clients by developing trust, credibility, and a risk reduction plan. Cultural competency has been vital. Six of seven major needs were successfully addressed at least 50% of the time. The value of reporting these results has led WP to gain credibility with municipal stakeholders, who have now agreed to fund a third CM position. Intermediate evaluation provided a framework in our effort to achieve the ultimate goal of reducing recidivism through culturally competent CM and risk factor modification.
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Femoral shaft fractures are associated with acute respiratory distress syndrome (ARDS). The idea that primary intramedullary nailing increases the incidence of ARDS has theoretical support. Our approach to treating femoral fractures in patients with multiple traumatic injuries is to perform reamed nailing after adequate resuscitation has been shown by normalizing lactate plus optimized ventilatory and hemodynamic parameters. Damage control orthopedics (DCO) with primary external fixation usually is reserved for those rare patients who do not respond to resuscitation. Our hypothesis was that this approach yields a low rate of ARDS. ⋯ In the context of resuscitation before reamed intramedullary nailing of femoral shaft fractures, our rate of ARDS was lower (p < 0.001) than that of a similar study reported in the literature in which the DCO approach was used in up to 36% of patients (p < 0.001) and was more in keeping with previously reported rates of ARDS. This remained true despite frequent use of early reamed femoral nailing and infrequent use of DCO. An explanation for the discrepancy between the centers might be differences in preoperative resuscitation or medical care provided to treat shock.
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Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes. ⋯ Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.
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Multicenter Study
Relative bradycardia in hypotensive trauma patients: a reappraisal.
The inability to mount tachycardia (T) after trauma-related hypotension is labeled relative bradycardia (RB). The objective of this study was to examine RB incidence and prognosis in a large cohort of patients. ⋯ RB was common in hypotensive adult trauma patients; overall, it was associated with increased mortality. Patients older than 55 years and with a higher Glasgow coma scale score demonstrated decreased mortality with RB. When RB was further divided, a HR between 60 and 90 demonstrated a significant lower mortality compared with a HR <60 and to T.
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Blunt cerebrovascular injuries (BCVI) in trauma patients are rare but potentially devastating injuries, particularly if the diagnosis is delayed. Conventional angiography (CA) has been the screening and diagnostic modality of choice for identifying BCVI. With the advent of high-resolution computed tomography (CT), CT angiography has become a common modality for the screening of BCVI. A liberalized screening approach has suggested that cerebrovascular injuries are missed in many patients; however, no standard BCVI screening protocol exists. Early diagnosis of the BCVI can prevent long-term sequelae. ⋯ Neither 16- nor 64-slice CT angiography is as accurate as CA as a screening tool for BCVI.