J Trauma
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Comparative Study
Normal versus supranormal oxygen delivery goals in shock resuscitation: the response is the same.
Shock resuscitation is integral to early management of severely injured patients. Our standardized shock resuscitation protocol, developed in 1997 and implemented as a computerized intensive care unit (ICU) bedside decision support tool in 2000, used oxygen delivery index (Do I) > or = 600 mL/min/m as the intervention endpoint. In a recent publication, Shoemaker et al. refuted positive outcome effect of early supranormal Do (i.e., Do I > or = 600) resuscitation. In response to and because of ongoing concern for excessive volume loading, we decreased our Do I endpoint from 600 to 500. Our hypothesis was that by decreasing the Do I endpoint, less crystalloid would be administered. We compare resuscitation responses to the protocol with goals of Do I > or = 600 versus 500 in two patient cohorts. ⋯ Shock resuscitation using Do I > or = 500 was indistinguishable from Do I > or = 600 mL/min/m. Less volume loading was required to attain and maintain Do I > or = 500 than 600 using computerized protocol technology to standardize resuscitation during the first 24 ICU hours.
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There is no simple way to assess the injured patient after a loss of consciousness. Computed tomographic scanning is required to rule out anatomic injuries, and invasive intracranial pressure monitoring is needed for the patient with severe traumatic brain injury (TBI). We hypothesized that a noninvasive acoustic monitoring system could provide useful clinical data on the severity and progression of TBI. ⋯ Noninvasive monitoring of the injured brain can discriminate those patients who will have a poor clinical outcome from those who will do well. Further trials of the BAM are indicated.
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The paucity of information on the outcome of patients experiencing prehospital pulseless electrical activity (PEA) after blunt injury led to the present study. ⋯ If these grim results are corroborated by other investigators, consideration should be given to allowing paramedics to declare blunt trauma victims with PEA dead at the scene.
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In light of their potential for devastating consequences, a liberalized screening approach for blunt cerebrovascular injuries (BCVI) is becoming increasingly accepted. The "gold standard" for diagnosis of BCVI is arteriography; however, noninvasive diagnostic alternatives offer clear advantages. Recent series have demonstrated the ability of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) to identify BCVI, but have not compared their accuracy with arteriography. We hypothesized that CTA or MRA could reliably identify BCVI, obviating the need for arteriography. The purpose of this study was to determine the accuracy of CTA and MRA in identifying BCVI in asymptomatic patients. ⋯ CTA and MRA can identify BCVI, but they miss grade I, II, and III injuries. Future technical modifications may improve their accuracy. A prospective multicenter trial is warranted to define the capabilities and limitations of these noninvasive modalities. In the interim, arteriography remains the gold standard for diagnosis, but if arteriography is not available, CTA or MRA should be used to screen for BCVI in patients at risk.