RESUMEN
PURPOSE: The purpose of this study was to review patients who failed to survive blunt trauma and to determine whether there is a relationship between specific facial fracture patterns and death. PATIENTS AND METHODS: This was a retrospective record review of patients with facial fractures admitted to a level I trauma center between January 1, 1993 and December 31, 1996. Records were reviewed for gender, age, injury severity score (ISS), Glasgow Coma Scale (GCS), revised probability of survival (RPS), cause of death, and facial fracture pattern. Facial fracture patterns were grouped as lower face (mandible), midface (maxilla, zygoma, nose, and orbits), and upper face (frontal bone). Causes of death were grouped into neurologic, visceral, combined neurologic and visceral, and other. Surviving and nonsurviving groups were compared. Parametric data were analyzed with a pooled or separate variance t-test, nonparametric data with a Mann-Whitney U-test, and categorical variables with a chi-square test (P < or = .05). The odds ratio with corresponding 95% confidence intervals was used to show the association between facial fracture patterns and death. RESULTS: During the 4-year period, 6,117 patients were admitted with blunt trauma, 661 (11%) of whom had facial fractures. Those who died were more likely to be older than those who survived, with a lower GCS, lower RPS, and higher ISS. Although there was a male predominance in the patient population, there was no gender difference between those who died and those who survived. Surviving patients were more likely to have only isolated mandible injuries. Nonsurvivors were more likely to have isolated midface fractures or combinations of midface and other facial fractures. The odds ratio showed a 13 to 75 times greater risk of patients dying of neurologic injury with patterns other than isolated mandible injury than with any mid- or upper-facial fracture patterns. CONCLUSIONS: Compared with survivors, nonsurviving patients with facial fractures were older and had a lower GCS, higher ISS, and lower RPS. Nonsurviving patients had a dramatic predilection for mid- and upper-facial fracture patterns and death of neurologic injury.
Asunto(s)
Huesos Faciales/lesiones , Fracturas Craneales/mortalidad , Traumatismos del Sistema Nervioso/mortalidad , Heridas no Penetrantes/mortalidad , Adulto , Causas de Muerte , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Ohio/epidemiología , Estudios Retrospectivos , Estadísticas no Paramétricas , Sobrevivientes/estadística & datos numéricosRESUMEN
This study was done in order to evaluate the effect of the timing of fixation for acetabular and pelvic ring fractures on patient outcome. Demographic, clinical and outcome data for 5821 trauma patients admitted from January 1993 through January 1996 were retrospectively reviewed. Pelvic fractures were classified according to Young and Burgess. Patients who had fixation within 24 h of admission were compared with those who had later operation. Main outcome measures were Multiple Organ Dysfunction Score according to Moore, hospital and intensive care unit length of stay and discharge disposition. Out of 416 patients with pelvic fractures, one hundred patients had fracture fixation [90 open reduction and internal fixation, 10 external fixation]. There were 59 acetabular fractures and 41 pelvic ring fractures. The overall mortality was 4%. Early fixation of acetabular fractures was associated with lower MODS (p < 0.006) and decreased total length of stay (p < 0.026). Length of hospital stay was also less with early fixation of pelvic ring fractures (p < 0.04). Functional outcome was improved in early fixation of acetabular fractures with a greater proportion of patients being discharged home rather than to rehabilitation or skilled care (p = 0.05). Patients who underwent early repair of acetabular and pelvic ring fractures had a shorter length of hospital stay compared to those with late fixation. Patients with early repair of acetabular fractures had significantly less organ dysfunction and exhibited improved functional outcome.
Asunto(s)
Acetábulo/lesiones , Fijación de Fractura/métodos , Fracturas Óseas/cirugía , Huesos Pélvicos/lesiones , Acetábulo/cirugía , Adolescente , Adulto , Protocolos Clínicos , Femenino , Fracturas Óseas/clasificación , Fracturas Óseas/mortalidad , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Huesos Pélvicos/cirugía , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: The treatment for splenic injury is evolving to an increased use of nonoperative management. We studied patients with blunt injury to the spleen to determine the overall success with splenic salvage and the reason that adults and children have different outcomes. METHODS: Patient records were reviewed retrospectively for information and parameters that may influence outcome. Patients were categorized by age and type of management. RESULTS: Two hundred sixty-seven patients (222 adults; 45 children < 16 years old) with blunt splenic trauma were treated over a 7.5-year period. Adults had a significantly higher injury severity score (ISS; 27.2 +/- 0.9 vs 19.9 +/- 2.0; P < .05), splenic injury score (SIS; 2.8 +/- 0.1 vs 2.3 +/- 0.1; P < .01), and mortality rate (11.7% vs 2.2%; P < .05) compared with children. Eighty-six adults and 3 children had emergent operation; 23 patients had splenorrhaphy. Nonoperative management was selected initially in 178 patients; 83% (105 adults and 42 children) were treated successfully. The ISS and SIS of patients in whom nonoperative management failed were different from those patients in whom treatment was successful (ISS, 27.5 +/- 2.1 vs 20.6 +/- 1.0; SIS, 3.6 +/- 0.2 vs 2.1 +/- 0.1; P < .05) but were similar to those patients who needed initial emergent operation. Adults and children who had successful nonoperative management had similar ISSs (21.4 +/- 1.1 vs 18.4 +/- 2.0) and SISs (2.0 +/- 0.1 vs 2.3 +/- 0.1). Overall splenic salvage was achieved in 64% of patients (57% of adults and 96 % of children). Salvage increased from 50% to 85% during the study period. CONCLUSIONS: Splenic preservation is possible in most adults and children with blunt injury with the appropriate use of both operative salvage and nonoperative treatment. The higher salvage rate and decreased need for operation in children is due to their lower severity of overall injury and splenic injury. Operative salvage has become less common in adults because more patients are selected for nonoperative management.
Asunto(s)
Bazo/lesiones , Bazo/cirugía , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/terapia , Adolescente , Adulto , Presión Sanguínea , Niño , Femenino , Frecuencia Cardíaca , Hematócrito , Hemoperitoneo/cirugía , Mortalidad Hospitalaria , Humanos , Masculino , Selección de Paciente , Estudios Retrospectivos , Insuficiencia del Tratamiento , Heridas no Penetrantes/mortalidadRESUMEN
STUDY OBJECTIVE: To determine the effectiveness, safety, and resource allocation of a 2-specialty, 2-tiered triage and trauma team activation protocol. METHODS: We conducted a 6-month retrospective analysis of a 2-specialty, 2-tiered trauma team activation system at an urban Level I trauma center. Based on prehospital data, patients with a high likelihood of serious injury were assigned to triage category 1 and patients with a low likelihood of serious injury were assigned to category 2. Category 1 patients were immediately evaluated by both emergency medicine and trauma services. Category 2 patients were evaluated initially by emergency medicine staff with a mandatory trauma service consultation. Main outcomes measured included mortality, need for emergency procedures, need for emergency surgery, complications, and discharge disposition. Potential physician-hours saved were calculated for category 2 cases. RESULTS: Five hundred sixty-one patients were assigned a triage classification (272 to category 1 and 289 to category 2). Category 1 patients had a higher mortality rate (95% confidence interval [CI] for difference of 15.9%, 11.1% to 20.7%, P < .0001), need for emergency surgery (10.7% versus 1.4%, 95% CI for difference of 9.3%, 5.2% to 13.4%; P < .0001), need for emergency procedures (89% of total procedures, 95% CI 83% to 95%; P < .0001), and discharges to rehabilitation facilities (95% CI for difference of 15.1%, 9.3% to 21.0%; P < .0001). The 2-tiered response system saved an estimated 578 physician-hours of time for the trauma service over the study period. CONCLUSION: This evaluation tool effectively predicts likelihood of serious injury, mortality, need for emergency surgery, and need for rehabilitation. Patients with a low likelihood of serious injury may be initially evaluated by the emergency medicine service effectively and safely, thus allowing more efficient use of surgical personnel.
Asunto(s)
Grupo de Atención al Paciente/organización & administración , Triaje/organización & administración , Algoritmos , Distribución de Chi-Cuadrado , Servicio de Urgencia en Hospital/organización & administración , Asignación de Recursos para la Atención de Salud , Hospitales Urbanos/organización & administración , Humanos , Evaluación de Resultado en la Atención de Salud , Estudios Retrospectivos , Estadísticas no ParamétricasRESUMEN
PURPOSE: Traumatic occlusion of the internal carotid artery (ICA) is a rare complication of maxillofacial trauma or surgery. This investigation evaluated patient demographics, diagnostic methods, and effective therapeutic modalities associated with blunt carotid injury (BCI). PATIENTS AND METHODS: This was a retrospective analysis of patient records with an ICD-9-CM diagnosis of carotid injury conducted at MetroHealth Medical Center during the 24-month period between August 1993 and July 1995. Carotid injuries attributable to penetrating trauma were excluded. Age, gender, cause of injury, Glasgow Coma Scale score, Injury Severity Score, type and location of injury, concomitant injury, diagnostic methods, treatment modalities, and outcome were identified, recorded, and analyzed. RESULTS: During the 24-month period, 12 patients (seven males and five females) suffered BCI. These patients were divided into two groups based on cause of the problem. In group I, there were 3,214 blunt trauma patients admitted during the 2-year study, of which 10 patients had BCI, representing 0.31% of blunt trauma patients, and 1.2% of patients with head injuries. Seven patients presented with hemiplegia, two with cranial nerve palsy, and one with perceptual neglect. Ninety percent of the patients had associated injuries. Two patients had surgical intervention, three received anticoagulation, and five had only supportive care. Four of the 10 patients died, four had moderate neurologic deficits, and two survived with only minor neurologic deficits. In group II, two patients developed BCI after surgery. A 52-year-old woman had a carotid injury after right total temporomandibular joint replacement, and a 48-year-old man who underwent surgical removal of a third molar became hemiplegic postoperatively. The first patient recovered after anticoagulation, whereas the second patient, who received only supportive care, has severe neurologic deficits. CONCLUSIONS: BCI is an uncommon entity. It is usually recognized when a patient develops an unexplained neurologic deficit, most often hemiplegia, subsequent to trauma or surgery of the head, face, or neck. In the early stages, the diagnosis can be missed by carotid ultrasound or computed tomography. The injury is unrelated to Glasgow Coma Scale score. Symptoms may not develop for days after injury in 50% of patients. Anticoagulation appears to be the most beneficial therapeutic modality.
Asunto(s)
Traumatismos de las Arterias Carótidas , Heridas no Penetrantes/diagnóstico , Adolescente , Adulto , Anticoagulantes/uso terapéutico , Arteriopatías Oclusivas/diagnóstico , Arteriopatías Oclusivas/tratamiento farmacológico , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/cirugía , Artroplastia de Reemplazo/efectos adversos , Enfermedades de las Arterias Carótidas/diagnóstico , Enfermedades de las Arterias Carótidas/tratamiento farmacológico , Enfermedades de las Arterias Carótidas/etiología , Enfermedades de las Arterias Carótidas/cirugía , Causas de Muerte , Niño , Enfermedades de los Nervios Craneales/diagnóstico , Enfermedades de los Nervios Craneales/etiología , Traumatismos Craneocerebrales/diagnóstico , Femenino , Escala de Coma de Glasgow , Hemiplejía/diagnóstico , Hemiplejía/etiología , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Tercer Molar/cirugía , Traumatismo Múltiple , Examen Neurológico , Parálisis/diagnóstico , Parálisis/etiología , Trastornos de la Percepción/diagnóstico , Trastornos de la Percepción/etiología , Complicaciones Posoperatorias , Estudios Retrospectivos , Tasa de Supervivencia , Articulación Temporomandibular/cirugía , Extracción Dental/efectos adversos , Resultado del Tratamiento , Heridas no Penetrantes/tratamiento farmacológico , Heridas no Penetrantes/cirugíaRESUMEN
One of the hallmarks of modern trauma care is the teamwork concept. To achieve optimum outcome, severely injured patients are identified as early as possible and brought to hospitals with a broad range of capabilities. Although injury to the genitourinary system is not usually an immediate threat to life, a high morbidity rate may result if these injuries are not recognized early. Urologists provide an important strength of the complete trauma center. A cooperative relationship between the trauma surgeon and the urologist is essential for timely, orderly diagnosis and to help avoid missed injuries.
Asunto(s)
Traumatismo Múltiple , Sistema Urinario/lesiones , Fracturas de Cadera/diagnóstico , Humanos , Perineo/lesionesRESUMEN
We have found this setup to be most useful. For those surgeons who incorporate rectal irrigation as part of their treatment plan for patients with rectal injuries, we would recommend trial of this simple yet effective technique. The more senior anesthesia and nursing staff who have suffered through the vagaries of widespread fecal contamination from the beginning to the end of the operation rapidly become advocates of this procedure.
Asunto(s)
Canal Anal/lesiones , Perineo/lesiones , Recto/lesiones , Irrigación Terapéutica/métodos , Heridas Penetrantes/cirugía , Colon , HumanosRESUMEN
Autotransfusion is a potentially valuable tool in the resuscitation of hypovolemic trauma patients; its acceptance in this setting has been limited by fears of the induction of coagulopathic and septic complications. It has been inferred that the addition of a cell washing step would obviate these concerns but at the cost of speed. To assess the validity of these concerns, we have retrospectively compared two autotransfusion devices: one without (the modified Bentley device) and one with (the Baylor Rapid Autologous Transfusion system) a cell washing step, over a 48-month period. In the Bentley group (n = 13), the mean estimated blood loss was 8,423 ml and the mean amount of blood autotransfused was 1,826 ml. Overall, the device returned 0.54 units of whole blood for every unit of banked blood used. Sixty-two per cent of these severely injured individuals died. Among survivors, there was a 20 per cent incidence of significant complications. In the BRAT group (n = 13), the mean estimated blood loss was 11,177 ml and the mean amount of blood autotransfused was 3,681 ml. Overall, the device returned 0.82 units of washed, packed red blood cells for every unit of banked blood used. Overall mortality was 26 per cent, and 30 per cent of survivors had complications. While we have been unable to demonstrate an advantage of the cell washing step, there is no evidence that this step in this unit limited the rate or volume of autologous blood replacement.
Asunto(s)
Transfusión de Sangre Autóloga/normas , Traumatismo Múltiple/terapia , Adulto , Transfusión de Sangre Autóloga/instrumentación , Transfusión de Sangre Autóloga/métodos , Mortalidad Hospitalaria , Humanos , Indiana/epidemiología , Traumatismo Múltiple/diagnóstico , Traumatismo Múltiple/mortalidad , Estudios Retrospectivos , Tasa de Supervivencia , Centros Traumatológicos , Índices de Gravedad del TraumaRESUMEN
Lipid emulsion is a major caloric source in patients receiving total parenteral nutrition. Cleared by the Kupffer cells of the reticuloendothelial system (RES), lipid emulsion may adversely affect the RES function by decreasing its ability to remove blood-borne bacteria. This study evaluates and compares the blood clearance and organ localization of viable radiolabeled [35S] Escherichia coli following slow intraperitoneal (IP) and more rapid intravenous (IV) administration of a 20% fat emulsion (FE). Sixty male Sprague-Dawley rats weighing 150 g were placed in 6 experimental groups (10 rats per group). Group 1 received IP normal saline (3 mL/d for 3 days); group II received IP FE (20%) (4 g/kg/d for 3 days); and group III received normal saline IV (3 mL/d for 3 days). The remaining animals received a slow (15-minute) IV infusion of FE (4 g/kg/dose) prior to bacterial challenge: group IV at 4 hours; group V at 24 hours; and group IV at 4 and 24 hours. E coli (10(9)/mL) were injected via the tail vein. Blood samples were obtained for clearance study. At 10 minutes, tissue samples (50 to 100 mg) of liver, spleen, kidney, and lung were obtained and processed for liquid scintillation counting. Although rapid bacterial blood clearance was found in all the groups, there was a significant change in organ localization of bacteria. Normal distribution of bacteria in group I was as follows: liver 70.1% +/- 6.2%, spleen 5.2% +/- 1.2%, kidney 0.2% +/- 0.04%, and lung 1.6% +/- 0.6%. There was a slight increase in lung localization of bacteria in rats receiving IP FE (3.7% +/- 1.5%; P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)