J Trauma
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The quality of a trauma system can be assessed by the rate of preventable deaths. A random selected sample of 110 trauma patients was examined using both clinical and autopsy data. ⋯ The main failures of treatment were identified as errors and delays during the first phases of in-hospital assessment and care. An improvement in the pre-hospital phase will be almost useless if the quality of the definitive in-hospital management is not addressed.
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A three-year retrospective and prospective study was conducted in the North Coast EMS Region of California to evaluate the effectiveness of a rural trauma program and its impact on patient outcome. Two hundred sixty-six patients with major trauma were identified. Age, hospital and prehospital Trauma Scores (TS), Revised Trauma Scores (RTS), Injury Severity Scores (ISS), and Mechanism of Injury (MOI) were recorded. ⋯ Blunt trauma accounted for the majority of injuries (82.1%) and the primary cause was motor vehicle crashes (63.8%). The z (mortality) and M statistics were -2.33 (p = 0.020) and 0.66, respectively. Thus a significant improvement in survival rates resulted compared with MTOS baseline norms.
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Case Reports
Thoracic aortic dissection with renal artery involvement following blunt thoracic trauma: case report.
Blunt thoracic aortic injury most often occurs beyond the left subclavian artery with subsequent transection and exsanguination. We present a case of an unrestrained driver involved in a high-speed motor vehicle crash who had a traumatic mid-thoracic aortic dissection involving the orifices of both renal arteries, resulting in anuria. This diagnosis should be considered in the presence of anuria following chest trauma.
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Splanchnic ischemia, leading to intestinal mucosal damage, is thought to be common in patients after severe trauma. The adequacy of mucosal oxygenation can indirectly be determined by gastric intramucosal pH (pHi) measurement. We prospectively examined the posttraumatic gastric pHi values in 15 multiple trauma patients. ⋯ Although intestinal ischemia was expected to be a common condition in multiple trauma patients, no consistent pattern of abnormal pHi measurements in the direct posttraumatic course could be discovered. No correlation was found between initial pHi values (at 6 hours) and ISS, shock, and lactic acidosis or APACHE II scores on admission. It is concluded that monitoring gastric pHi is useful in severely injured patients admitted to the ICU.
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Complications in trauma care occur because of provider-related or patient disease-related events. Strictly defined standardized definitions of both types of complications are needed to develop strategies for problem resolution. The frequency and characteristics of 135 disease-related and provider-related complications were examined for a 3-year period in a level I university trauma service in all patients meeting Major Trauma Outcome Study (MTOS) criteria. ⋯ Errors in technique were attributed to inexperience, haste, unfamiliarity with devices, lack of developed institutional techniques, and failure of providers to use recognized endpoints. Errors in judgment were attributed to failure to access available patient information, proceeding despite available information, and failure to utilize available care guidelines. Further reduction in provider-related morbidity in an organized trauma system requires this type of analysis, which identifies the need to change the process of care through education or adjustment of protocols for standardization care delivery in addition to the traditional focus on outcomes.