J Trauma
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Three weeks after a shotgun wound to the chest and abdomen, a patient developed acute ureteral colic caused by a migrating shotgun pellet. The pellet passed spontaneously. A search of the literature revealed 25 similar cases of this unusual complication of missile injuries to the abdomen. ⋯ Cases involving bullets and shrapnel fragments usually have had long latent periods after the initial injury and required surgery to remove the obstructing projectile. In contrast, cases of "buckshot colic" from shotgun pellets present earlier and often resolve with spontaneous passage of the pellet. The following report illustrates how conservative management can be successful in cases of "buckshot colic."
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Case Reports
Exclusion of aortic tear in the unstable trauma patient: the utility of transesophageal echocardiography.
The goal of this study was to investigate the value of biplanar transesophageal echocardiography (TEE) as a screening tool for aortic tear in unstable trauma patients. ⋯ The TEE procedure is valuable in identifying aortic injury in high-risk trauma patients who are too unstable to undergo transport to the aortography suite.
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The study is based on 44 preventable deaths occurring in a cohort of 360 patients with major trauma. These cases were reviewed by a committee of nine experts. The mean Injury Severity Score (ISS) was 28, and most cases had injuries to the head/neck (68%) and chest (64%). ⋯ Of the 34 patients that required direct transport at a level I trauma center, 50% were transferred to such a hospital. These results show significant prehospital delays and high rates of inappropriate IV line initiation and intubation in trauma patients receiving on-site care by physicians. We conclude that prehospital care protocols for trauma patients should emphasize prompt transport and specific on-site care algorithms.
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In June 1990, the Ministry of Health designated 11 hospitals throughout Ontario to be lead hospitals in trauma care. An integral part of a trauma system is the evaluation of care, in particular, outcome of the trauma patients. The Trauma and Injury Severity Score (TRISS) methodology, which offers a standard approach for evaluating outcomes for different populations of trauma patients, was used to determine if there was an improvement in outcomes after the designation of trauma centers of patients involved in motor vehicle crashes (ICD-9-CM, E810.0-825.9), with an Injury Severity Score > 12 for two 12-month periods: one predesignation (1989/1990) and one postdesignation (1992/1993). ⋯ When the bias introduced by patients intubated before arrival at the trauma center being excluded from TRISS analysis was removed, using a TRISS-like (as per Offner et al: J. Trauma 32:32, 1992) logistic regression equation that allows analysis of intubated patients, the improvement was even greater, with z = +1.34 predesignation and z = +2.97 postdesignation. Only the statistically significant z-score of the postdesignated year required the W-score to be calculated, W = +5.60.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
Traumatic chest lesions in patients with severe head trauma: a comparative study with computed tomography and conventional chest roentgenograms.
In patients with severe craniocerebral trauma, who need a continuous positive-pressure breathing, the detection of pulmonary and mediastinal traumatic lesions, especially pneumothorax, may alter the management. The aim of this study is to evaluate the efficiency and accuracy of conventional supine chest roentgenograms to detect the associated traumatic chest lesions in severe craniocerebral trauma and to compare their value as a diagnostic method for the identification of unsuspected lesions with a limited chest computed tomographic (CT) examination. Forty-seven consecutive patients with severe craniocerebral trauma underwent head CT and a prospective limited CT examination of the thorax in the same session. ⋯ The limited chest CT examination supplied additional information in 30% of patients. In 12.7% of patients, this information was clinically significant enough to alter the management. In patients with severe craniocerebral trauma evaluation of associated chest trauma by a supplementary limited chest CT, examination provides more and precise information about the size and severity of mediastinal and pulmonary lesions with a superior detectability of pneumothorax.