J Trauma
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Deer hunting is a popular activity in much of the United States. In West Virginia, over 350,000 people each year actively hunt deer. Although injuries and deaths caused by shooting-related incidents have declined, hunting injuries caused by falls from deer stands have not. We present a retrospective study from January 1994 through December 1999 to determine the number of and trauma resulting from deer stand-related incidents in West Virginia. ⋯ Injuries from deer stand falls are a significant cause of morbidity and mortality in this state. This is the largest series of hunting-related deer stand injuries reported in the current literature. Other states have successfully implemented prevention programs that have resulted in a reduction of these types of injuries. Our data emphasize the need to establish and promote preventative education programs for hunters using tree stands.
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We have evaluated our recent experience as a Level I trauma center to test the hypothesis that preinjury anticoagulation adversely affects the morbidity and mortality of trauma patients with an intracranial injury. ⋯ These data indicate that the trauma patient with preinjury anticoagulation such as warfarin or even aspirin who has an intracranial injury has a four- to fivefold higher risk of death than the nonanticoagulated patient. The efficacy of reversing the anticoagulant effect at the time of hospital admission remains to be evaluated.
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TRISS has reigned as the preeminent trauma outcome prediction model for 20 years. Despite this endorsement, the calibration of TRISS has been poor in most data sets where it has been examined. We hypothesized that the lack of calibration of TRISS was because of the inappropriate mathematical specification of the model that TRISS is based on, rather than the predictors in the model. In particular, we hypothesized that the nonlinearity of the Injury Severity Score (ISS) in the log odds of death was responsible for the poor calibration of TRISS, and further, that this nonlinearity could be corrected by the simple addition of an ISS squared term to the TRISS model. ⋯ The TRISS model for outcome prediction currently uses ISS in a mathematically inappropriate way that impairs the calibration, but not the discrimination, of its predictions. If TRISS is to continue as the prediction standard for trauma, a quadratic ISS term must be added to the model. In the future, outcome prediction models should undergo thorough statistical modeling and evaluation before being released. Injury severity descriptors other than ISS (such as ASCOT, ICISS, or NISS) may require other modeling techniques to optimize the calibration of survival models that use these injury scores.
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Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies. ⋯ Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.