J Trauma
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The present trend towards conservative management of hemodynamically stable pediatric trauma patients may be increasing the risk of delay in the diagnosis of traumatic hollow viscus perforations (HVP). The purpose of this study is to determine whether there is a delay in the diagnosis of HVP because of expectant management. A survey of factors leading to diagnostic delay was also made and the value of current diagnostic tools were reevaluated. ⋯ There is an apparent delay in the diagnosis of traumatic HVP in this series. Signs of peritoneal irritation are the most consistent findings of HVP after blunt abdominal trauma in children. Persistence of abdominal signs indicates peritoneal lavage, which has a high diagnostic sensitivity for HVP compared to other diagnostic modalities.
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Provincial air ambulance transports of injured patients were quality reviewed prospectively to determine utilization and appropriateness of care. ⋯ A low overtriage rate was documented, raising concerns that the undertriage rate may be too high. Injured patients air transported without physician accompaniment more often received inappropriate care, suggesting that physician accompaniment is beneficial.
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To determine whether abnormal results of admission serum chemistry profiles (P7: sodium (Na), potassium (K), chloride (Cl), carbon dioxide content (CO2), blood urea nitrogen (BUN), creatinine (Cr), and glucose (GLU), amylase (AMY), and coagulation profiles (CP: prothrombin time (PT) and partial thromboplastin time (PTT) in trauma patients lead to clinical interventions, and to characterize frequency of abnormal results, we prospectively gathered laboratory data on 500 consecutive patients seen in our Level 1 trauma center. Clinicians were blinded to the study. ⋯ We conclude that information provided by routine admission chemistry and coagulation profiles in trauma patients seldom lead to clinical interventions. These tests should not be ordered routinely on admission in trauma patients.
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To determine actions of acute intoxication on pathophysiologic responses to trauma, anesthetized and ventilated mongrel pigs received a 20% solution of ethanol (EtOH) by an intravenous (IV group; 2 g/kg, n = 8) or an oral (PO group; 3 g/kg, n = 12 x 60 minutes) route of administration, or the lactated Ringer's vehicle (LR group; n = 12). After 60 minutes, all were subjected to soft tissue injury and 30 to 35% hemorrhage, 60-minute shock, and then resuscitation, with shed blood plus supplemental LR. After 3 days, host defense was challenged with Escherichia coli lipopolysaccharide (LPS); (1 microgram/kg x 30-minutes IV). ⋯ With IV, blood EtOH peaked at 275 mg/dL and then exponentially declined with a rate that was not influenced to a major extent by trauma or by anesthesia. Therefore: 1) EtOH absorption is impaired during trauma (in part because of reduced gut blood flow); 2) acute EtOH intoxication at the time of trauma altered neutrophils, plasma cortisol, and T4 lymphocytes during recovery and host defense to a superimposed LPS challenge. The apparently favorable effect of PO versus IV EtOH on the response to endotoxemia after trauma probably reflects differences in the kinetics of blood EtOH in the interval before reperfusion but a "first pass" effect (metabolism in the gut or liver) might also explain the data.
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Comparative Study
Different pattern of local and systemic release of proinflammatory and anti-inflammatory mediators in severely injured patients with chest trauma.
Excessive release of proinflammatory cytokines has been involved in pathogenesis of acute respiratory distress syndrome. ⋯ Highly increased concentrations of proinflammatory cytokines in BALF, but not in circulation, indicate a strong local inflammatory response early after multiple injuries combined with chest injury rather than severe systemic inflammation. In contrast, anti-inflammatory mechanisms seem to be activated locally and systemically.