J Trauma
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Comparative Study
Head CT scanning versus urgent exploration in the hypotensive blunt trauma patient.
In hypotensive blunt trauma patients with a diminished level of consciousness, it may be difficult to decide whether to proceed with immediate head CT scanning or urgent laparotomy or thoracotomy. The purpose of this study was to determine the frequency of emergency craniotomy and urgent laparotomy or thoracotomy in a group of 734 blunt trauma patients with initial hypotension (BP < 90 mm Hg systolic) admitted to the eight level I and II trauma centers in North Carolina. The mean initial systolic blood pressure was 64 +/- 26 mm Hg, and the mean Trauma Score was 8 +/- 5.8. ⋯ Overall hospital mortality for hypotensive blunt trauma patients was 36% (263 of 734). Although serious head injury occurs commonly (40%) in hypotensive blunt trauma patients, frequency of urgent laparotomy (21%) is 8.5 times greater than emergency craniotomy for intracranial hemorrhage (2.5%). This information may be used by trauma teams in prioritizing care for hypotensive blunt trauma patients.
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One hundred nineteen patients suffered penetrating cardiac trauma over a 15-year period: 59 had gunshot wounds, 49 had stab wounds, and 11 had shotgun wounds. The overall survival rate was 58%. The most commonly injured structures were the ventricles. ⋯ We conclude that sternotomy provides superior exposure for cardiac repair in patients with penetrating anterior chest trauma. We feel it is the incision of choice in hemodynamically stable patients. Thoracotomy should be reserved for unstable patients requiring aortic cross-clamping, or when posterior mediastinal injury is highly suspected.
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Although scores and other prehospital triage schema effectively identify injured patients who will benefit from trauma center care, those tools are relatively nonspecific. One consequence is overtriage--transport of less severely injured patients to trauma centers--with resulting expenditure of scarce resources on patients who do not benefit from an emergent and intensive response. We developed a tool that, during the prehospital phase, can sort inner-city trauma victims into those who will require ICU/OR services and those who will not. ⋯ Based on our initial experience with the two-tier response, the sorting criteria were revised and refined. The sensitivity of the current version of the two-tier criteria for predicting which trauma patients will require ICU/OR services during the first 24 hours of hospitalization approaches 95% (excluding misapplications of the tool) while avoiding urgent trauma team mobilization in 57% of patients triaged to our trauma center. Two-tiered trauma responses appear to be safe and may represent an important strategy for more effective distribution of increasingly scarce and costly resources.
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We retrospectively reviewed the medical records and cervical films, computed tomographic (CT) scans, and tomographic studies of 216 consecutive patients with cervical injuries. A trauma series of roentgenograms--a cross-table lateral (CTL), a supine anteroposterior, and an open-mouth odontoid view--was performed in 100%; CT scanning was performed in 100%; and tomography was done in 9% of cases. We determined what percentage of the patients were asymptomatic initially in the emergency department; the total numbers of fractures, subluxations, and dislocations of the cervical spine in these patients; and what percentage of the cervical injuries were not detected with the plain films. ⋯ Of these 28, 17 were intoxicated or had mild closed head injuries; however, in 11 (5%) there was no clinical clue to their cervical injury other than a known injury mechanism. Prospectively, 67% of the fractures and 45% of the subluxations and dislocations were not detected by the CTL films, and 32% of the patients, over half of whom had unstable cervical injuries, were falsely identified as having normal spines. Prospectively, the trauma series improved the sensitivity of plain films for detecting cervical injuries but still did not detect 61% of the fractures and 36% of the subluxations and dislocations, and falsely identified 23% of the patients, half of whom had unstable cervical injuries, as having normal cervical spines.(ABSTRACT TRUNCATED AT 250 WORDS)
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A retrospective review of 756 blunt trauma cases at a level I trauma center was conducted to determine the role of thoracolumbar (TL) spine roentgenograms in the management of asymptomatic patients. Thoracolumbar spine films were obtained on 106 patients. The charts from 99 patients were available for thorough review. ⋯ Of the 20 patients in whom the clinical examination was equivocal, one (5%) had radiographic evidence of TL spine injury. We conclude that physical examination is reliable for assessing the TL spine, and that in the absence of clinical evidence of injury, TL spine films are unnecessary. In patients with equivocal examinations, TL spine films should be obtained because 7% (one of 15) of the injuries were identified in this group.