RESUMEN

Hepatitis C virus (HCV) infection is associated with systemic inflammation and metabolic complications that might predispose patients to atherosclerosis. However, it remains unclear if HCV infection increases the risk of acute myocardial infarction (MI). To determine whether HCV infection is an independent risk factor for acute MI among adults followed in general practices in the United Kingdom (UK), a retrospective cohort study was conducted in The Health Improvement Network, from 1996 through 2008. Patients ≥18 years of age with at least 6 months of follow-up and without a prior history of MI were eligible for study inclusion. HCV-infected individuals, identified with previously validated HCV diagnostic codes (n = 4809), were matched on age, sex and practice with up to 15 randomly selected patients without HCV (n = 71 668). Rates of incident MI among patients with and without a diagnosis of HCV infection were calculated. Adjusted hazard ratios were estimated using Cox proportional hazards regression, controlling for established cardiovascular risk factors. During a median follow-up of 3.2 years, there was no difference in the incidence rates of MI between HCV-infected and -uninfected patients (1.02 vs 0.92 events per 1000 person-years; P = 0.7). HCV infection was not associated with an increased risk of incident MI (adjusted HR, 1.10; 95% confidence interval [CI], 0.67-1.83). Sensitivity analyses including the exploration of a composite outcome of acute MI and coronary interventions yielded similar results (adjusted HR, 1.16; 95% CI, 0.77-1.74). In conclusion, HCV infection was not associated with an increased risk of incident MI.

Asunto(s)

Hepatitis C Crónica/complicaciones , Infarto del Miocardio/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Reino Unido/epidemiología , Adulto Joven

RESUMEN

Prior studies found that hepatitis C virus (HCV) risk assessment and testing in primary care clinics were suboptimal. We aimed to determine the actual HCV testing rate among patients with HCV risk factors and to identify variables predictive of testing. In order to do so, we performed a prospective cohort study among patients seen in four urban primary care clinics. At the initial visit, patients were given a questionnaire that listed HCV risk factors and they were instructed to check 'yes' or 'no' if they did or did not have a risk factor, respectively. Patients then handed this questionnaire to their physician during their initial visit. Among those who acknowledged having a HCV risk factor via the questionnaire, we determined the subsequent HCV testing rate and calculated adjusted odds ratios (aOR) with 95% confidence intervals (CI) to identify variables predictive of testing. Of the 578 individuals who acknowledged having a HCV risk factor via the questionnaire, only 8% (46/578) were tested for HCV within 2 months of their initial visit. Among those tested, 11% (5/46) had a positive HCV antibody test result. The only variable predictive of HCV testing after adjusting for confounders was having a specific HCV risk factor identified and documented in the chart by physicians [16% (26/159) vs 5% (20/419); aOR 4.5, 95% CI 2.1-9.5]. In summary, 92% of patients with a HCV risk factor were not tested for HCV in the primary care setting, and efforts to improve such rates are clearly warranted.

Asunto(s)

Instituciones de Atención Ambulatoria , Hepacivirus/aislamiento & purificación , Hepatitis C/diagnóstico , Atención Primaria de Salud/métodos , Adulto , Estudios de Cohortes , Femenino , Investigación sobre Servicios de Salud , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Medición de Riesgo , Encuestas y Cuestionarios

RESUMEN

OBJECTIVE: To investigate the prevalence of cardiovascular risk factors in patients with primary hyperparathyroidism (PHPT) and to determine if they are gender specific. METHODS: This was a retrospective case control study. Three hundred and sixty-three men and women with PHPT and 363 age-, sex-, and body mass index (BMI)-matched controls with benign goiter were included in the study. We documented each patient's laboratory results along with the presence of any cardiovascular risk factors. Intra-operatively, the resected parathyroid adenomas were weighed and recorded. The data are expressed as the number of patients in each category and percentage of total patients in that group and the mean±SD. RESULTS: The prevalence of obesity, hypertension, hyperlipidemia, Type 2 diabetes, and coronary artery disease (CAD) is higher in PHPT patients compared to the general New Jersey population and age-, sex-, and BMI-matched goiter patients. Male PHPT patients tended to be more obese and were found to have heavier parathyroid adenomas compared to female patients (p<0.05). Additionally, a higher percentage of male PHPT patients were found to have higher rates of CAD (11.5%) and Type 2 diabetes (23.0%) compared to female patients (5.80% and 10.9%, respectively, p<0.05). CONCLUSIONS: There is a higher prevalence of metabolic disorders and CAD in PHPT patients. Male PHPT patients had larger parathyroid adenomas at the time of surgery and had a higher prevalence of obesity, Type 2 diabetes and CAD compared to female PHPT patients.

Asunto(s)

Enfermedades Cardiovasculares/epidemiología , Hiperparatiroidismo Primario/epidemiología , Estudios de Casos y Controles , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Humanos , Hiperlipidemias/epidemiología , Hipertensión/epidemiología , Masculino , Persona de Mediana Edad , New Jersey/epidemiología , Obesidad/epidemiología , Neoplasias de las Paratiroides/epidemiología , Prevalencia , Estudios Retrospectivos , Factores de Riesgo

RESUMEN

Thyroid or parathyroid surgery may be performed using general anesthesia or regional anesthesia. Ninety-five (95) patients underwent thyroid or parathyroid surgery using general anesthesia (n=64) or bilateral superficial cervical plexus block with sedation (n=31) and completed a postoperative questionnaire regarding the perioperative experience. Patients undergoing parathyroid surgery under regional anesthesia (n=24) were more likely to experience better energy levels (p=0.012) and earlier return to work (p=0.045) postoperatively. Overall, 96% of patients undergoing either type of surgery with either type of anesthetic reported satisfaction with the anesthetic.

Asunto(s)

Anestesia de Conducción/métodos , Anestesia General/métodos , Glándulas Paratiroides/cirugía , Tiroidectomía/métodos , Adulto , Anciano , Plexo Cervical , Femenino , Humanos , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/métodos , Satisfacción del Paciente , Recuperación de la Función , Encuestas y Cuestionarios , Factores de Tiempo , Adulto Joven

RESUMEN

OBJECTIVES: This study aimed to use geographic information systems (GIS) that facilitate analysis of associations between location, environment and disease to document the non-random distribution of hepatitis C, identify infection cluster areas, and describe the demographic characteristics of those areas. METHODS: Spatial analysis was conducted of newly reported positive hepatitis C test results using the Connecticut Hepatitis C Reporting Database. A complete database of unduplicated hepatitis C laboratory reports that were sent to the Connecticut Department of Public Health during 1999 was created. Spatial filtering was used to eliminate random noise generated by sparsely populated towns or small number of cases per town. Cluster analysis was used to determine whether cases of hepatitis C virus (HCV) infection tend to occur closer in space to other cases than would be expected by chance alone. The demographic attributes of identified clusters of HCV-positive reports were examined. RESULTS: Areas with the highest concentration of HCV reports roughly correspond to the major metropolitan areas of Connecticut. Six significant clusters of HCV reports were identified in Connecticut. Four of the six clusters identified were located in the most densely populated and most urban areas of the state. All but one identified cluster had been described previously as areas of substantial injection drug use, as indicated by their designation as five of the sites of syringe exchange programmes in Connecticut. This finding suggests that geospatial analysis may assist in the identification of clusters that would not otherwise be suspected based on local demographics or other characteristics. CONCLUSIONS: These findings contribute significantly to the understanding of the state-specific epidemiology of HCV infection. This methodology can be applied wherever a similar database exists to enable the implementation of targeted prevention and educational campaigns to raise awareness of HCV risk factors, the importance of being tested, and treatment options.

Asunto(s)

Sistemas de Información Geográfica , Hepatitis C/epidemiología , Salud Pública/métodos , Análisis por Conglomerados , Connecticut/epidemiología , Humanos , Población Urbana

RESUMEN

OBJECTIVE: To determine whether physical examination alone or in combination with biochemical markers can accurately diagnose hypoperfusion. METHODS: Data from 264 consecutive surgical intensive care unit patients were collected by two intensivists and included extremity temperature, vital signs, arterial lactate, arterial blood gases, hemoglobin, and pulmonary artery catheter values with derived indices. Days of data were divided into data collected from patients with cool extremities (cool skin temperature [CST] group) versus warm extremities (warm skin temperature [WST] group). Values are means +/- SD. Comparisons between groups were made by two-tailed unpaired t test; significance was assumed for p < or = 0.05. RESULTS: There were 328 days of observations in the CST group versus 439 in the WST group. There were no differences (p > 0.05) between CST and WST data with regard to heart rate (107 +/- 14 vs. 99 +/- 19 beats/min), systolic blood pressure (118 +/- 24 vs. 127 +/- 28 mm Hg), diastolic blood pressure (57 +/- 14 vs. 62 +/- 15 mm Hg), pulmonary artery occlusion pressure (14 +/- 6 vs. 16 +/- 5 mm Hg), Fio2 (0.48 +/- 0.7 vs. 0.45 +/- 0.2), hemoglobin (8.8 +/- 1.6 vs. 9.3 +/- 1.3 g/dL), Pco2 (44.3 +/- 11.8 vs. 40.7 +/- 9.2 mm Hg), or Po2 (96.4 +/- 12.6 vs. 103.8 +/- 22.2 mm Hg). However, cardiac output (5.3 +/- 2.2 vs. 8.2 +/- 2.6 L/min), cardiac index (2.9 +/- 1.2 vs. 4.3 +/- 1.2 L/min/m2), pH (7.32 +/- 0.2 vs. 7.39 +/- 0.07), TCO2 (19.5 +/- 3.1 vs. 25.1 +/- 4.8 mEq/L), and Svo2 (60.2 +/- 4.4% vs. 68.2 +/- 7.8%) were all significantly lower (p < 0.05) in CST patients compared with WST patients. By comparison, lactate (4.7 +/- 1.5 vs. 2.2 +/- 1.6 mmol/L, p < 0.05) was significantly elevated in patients with cool extremities. CONCLUSION: Combining physical examination with serum bicarbonate and arterial lactate identifies patients with hypoperfusion as defined by low Svo2 and cardiac index. Hypoperfusion may occur despite supranormal cardiac indices. Patients with cool extremities and elevated lactate levels may benefit from a pulmonary artery catheter to guide but not initiate therapy.

Asunto(s)

Cuidados Críticos/métodos , Examen Físico/métodos , Choque/diagnóstico , Temperatura Cutánea , Algoritmos , Análisis de los Gases de la Sangre , Presión Sanguínea , Gasto Cardíaco , Árboles de Decisión , Diástole , Análisis Discriminante , Extremidades/irrigación sanguínea , Frecuencia Cardíaca , Hemoglobinas , Humanos , Ácido Láctico/sangre , Monitoreo Fisiológico/métodos , Traumatismo Múltiple/complicaciones , Oxígeno/sangre , Examen Físico/normas , Presión Esfenoidal Pulmonar , Resucitación , Estudios Retrospectivos , Sepsis/complicaciones , Choque/etiología , Choque/metabolismo , Choque/fisiopatología , Choque/terapia , Sístole

RESUMEN

RATIONALE AND OBJECTIVES: This study assessed the ability of a six-point trauma ultrasound (US) evaluation (a) to identify the presence of free fluid in the abdomen or pelvis, with computed tomography (CT) and laparotomy used as diagnostic standards and (b) to predict the presence of abdominal or pelvic injury, particularly injury requiring surgical intervention. MATERIALS AND METHODS: Of 156 patients who underwent US evaluation for free fluid after sustaining blunt and penetrating trauma, 147 were entered into the prospective study and underwent follow-up CT and/or laparotomy (n = 79), in-hospital observation, or outpatient examination. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of US for identifying abdominal or pelvic free fluid were 69%, 100%, 100%, 95%, and 95%, respectively. The corresponding values for predicting abdominal and pelvic injury on the basis of free fluid status alone were 57%, 99%, 80%, 96%, and 95%, respectively. Performing repeated US examinations in patients with deteriorating clinical status decreased the false-negative rate by 50%, increasing the sensitivity for free fluid detection to 85% and the negative predictive value to 97%. Similarly, the sensitivity and negative predictive value for detection of injury increased to 71% and 97%, respectively. A learning curve was also observed, with 67% of the false-negative findings occurring in the first 3 months of the 19-month study. CONCLUSION: A six-point trauma US evaluation can reliably identify abdominal and pelvic free fluid, which can be a reliable indicator of abdominal or pelvic injury. Scanning conditions must be optimized, and the approach to clinical management must be cautious.

Asunto(s)

Traumatismos Abdominales/diagnóstico por imagen , Fracturas Óseas/diagnóstico por imagen , Huesos Pélvicos/lesiones , Pelvis/lesiones , Adulto , Algoritmos , Líquidos Corporales , Femenino , Humanos , Laparotomía , Masculino , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X , Ultrasonografía

RESUMEN

OBJECTIVE: To determine the contribution of the pulmonary antioxidant defense enzymes of the hexose monophosphate (HMP) shunt and glutathione systems to recovery from oxidant-mediated lung injury in an animal model shown to closely resemble the clinical syndrome of acute respiratory distress syndrome. DESIGN: Prospective, controlled laboratory study on phorbol myristate acetate (PMA)-induced lung injury in rabbits. SETTING: Animal research laboratory. SUBJECTS: Rabbits were injected with PMA (80 microg/kg) for 3 consecutive days. Control animals received normal saline. MEASUREMENTS AND MAIN RESULTS: Lungs were harvested at 24, 48, 72, and 96 hrs (n = 5/time point) after PMA injection or after the third injection of normal saline in control animals (n = 6). The cytosolic fraction from lung and bronchial alveolar lavage (BAL) fluid was used for measurements of HMP shunt and glutathione enzymes. Pulmonary activity peaked at 48 hrs post-PMA injury with a 40% increase in glucose-6-phosphate dehydrogenase activity and a 32% increase in 6-phosphogluconate dehydrogenase activity over control levels. BAL activity was maximal at 72 hrs with an increase of 98% in glucose-6-phosphate dehydrogenase and 346% in 6-phosphogluconate dehydrogenase activities. Glutathione peroxidase was maximally induced by 77% at 48 hrs in BAL and by 107% at 24 hrs in lung. Glutathione reductase activity did not increase significantly in either lung or BAL. CONCLUSIONS: The observed induction of the antioxidant enzymes in response to PMA suggests that both the HMP shunt and the glutathione systems contribute to the recovery phase of oxidant-mediated lung injury. The inability of natural host defenses to regenerate reduced glutathione may explain failure of recovery from acute respiratory distress syndrome and suggests an avenue for clinical intervention.

Asunto(s)

Glucosa Deshidrogenasas/biosíntesis , Glutatión Peroxidasa/biosíntesis , Vía de Pentosa Fosfato , Síndrome de Dificultad Respiratoria/metabolismo , Animales , Líquido del Lavado Bronquioalveolar/química , Inducción Enzimática , Masculino , Conejos , Síndrome de Dificultad Respiratoria/inducido químicamente , Síndrome de Dificultad Respiratoria/patología , Acetato de Tetradecanoilforbol/toxicidad

RESUMEN

OBJECTIVE: To apply case-matching methodology to a statewide trauma registry to identify for peer review one trauma center's patients with "unexpected" survival deaths, complications or prolonged length of stay in hospital (H-LOS) or in Intensive Care Unit (ICU-LOS). METHODS: Matching patients were defined by mechanism of injury, age, physiology and intubation status on emergency department admission, preexisting conditions, and the pattern and severity of anatomic injury. Matches for one trauma center's 1997 patients (TCP) were sought from other centers' patients (SWP) submitted to the statewide registry from October 1, 1993, though December 31, 1997. A minimum of 20 SWP matches was required for creating a matching group. TCP were compared with matching SWP for survival, H-LOS, and ICU-LOS and the occurrence of complications. Unexpected survivors and deaths identified by matching (by using the standard 50% cutpoint) were also evaluated by TRISS and the American College of Surgeon's Committee on Trauma. A patient whose complications occurred in less than 10% of matching patients or whose H-LOS or ICU-LOS exceeded the 90th percentile of its matching SWP were also designated for peer review. RESULTS: The potential matching pool included 69,660 SWP. At least one SWP match was found for 565 (92.9%) of the 608 TCPs. The average, median, and maximum number of matches were 917.6, 235, and 6,504 patients, respectively. The 451 patients with 20 or more SWP matches were further studied. Case matching and TRISS agreed on the identification of five unexpected deaths; the American College of Surgeon's Committee on Trauma agreed on four of five. Peer review included, however, that none of the deaths were clinically unexpected. Case matching identified 14 TCP with 29 complications; only 4 of those patients had undergone concurrent peer review. Retrospective review revealed two preventable and potentially seven preventable complications. There were 35 TCP patients with prolonged H-LOS and 24 with prolonged ICU-LOS. Peer review of those cases identified that complications and problems related to discharge planning contributed to the prolonged ICU-LOS (20.8% and 25.0%) and the H-LOS (20.% and 48.6%), respectively. CONCLUSION: Peer review of patients identified by case-matching methodology uncovered opportunities for system improvement that were missed by the concurrent performance improvement process. This method may also allow identification of anticipated H-LOS and ICU-LOS to promote earlier discharge.

Asunto(s)

Investigación sobre Servicios de Salud/métodos , Tiempo de Internación/estadística & datos numéricos , Análisis por Apareamiento , Traumatismo Múltiple/complicaciones , Traumatismo Múltiple/terapia , Evaluación de Procesos y Resultados en Atención de Salud/organización & administración , Proyectos de Investigación , Gestión de la Calidad Total/organización & administración , Centros Traumatológicos/normas , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Humanos , Lactante , Persona de Mediana Edad , Traumatismo Múltiple/mortalidad , Revisión por Expertos de la Atención de Salud , Pennsylvania/epidemiología , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia

RESUMEN

OBJECTIVE: To review the development of an integrated trauma program at two separate campuses brought about by the merger of two medical-affiliated hospitals, each with an integrated program and a common trauma administrator, medical director, and educational coordinator. Each campus has an associate trauma medical director for on-site administrative management, a nurse coordinator, and a registrar. The integration resulted in a reduction of 1.5 full-time equivalents and "cost" savings by consolidated use of the helicopter, outreach, prevention, research, and educational programs. Regular "integration meetings," ad hoc committees, and video-linked conferences were used to institute common quality improvement programs, morbidity and mortality discussions, policies, and clinical management protocols. Reaccreditation by an outside agency, elimination of duplicated services, and maintenance of pre-merger clinical volume results. CONCLUSION: This integrated trauma program may serve as a model in this era of individual hospitals merging into large health care delivery networks.

Asunto(s)

Prestación Integrada de Atención de Salud/organización & administración , Instituciones Asociadas de Salud/organización & administración , Programas Médicos Regionales/organización & administración , Centros Traumatológicos/organización & administración , Acreditación/organización & administración , Ahorro de Costo , Toma de Decisiones en la Organización , Investigación sobre Servicios de Salud , Humanos , Modelos Organizacionales , Philadelphia , Estudios Retrospectivos , Facultades de Medicina/organización & administración , Gestión de la Calidad Total/organización & administración

RESUMEN

New Food and Drug Administration guidelines allow research to be done under an "exception to informed consent." These guidelines mandate advance public disclosure (PD) but provide no specifics for how to accomplish this task. This report outlines the history of informed consent in emergency care situations, highlights the Food and Drug Administration regulations for an exception to informed consent, and describes a stepwise approach with specific details of a PD program for a study using a blood substitute. This descriptive report can serve as a guideline for subsequent emergency care investigators in the development of a strategic plan for PD.

Asunto(s)

Participación de la Comunidad , Tratamiento de Urgencia/normas , Guías como Asunto , Experimentación Humana/ética , Consentimiento Informado/legislación & jurisprudencia , Política Organizacional , Revelación de la Verdad , United States Food and Drug Administration/legislación & jurisprudencia , Algoritmos , Sustitutos Sanguíneos/uso terapéutico , Árboles de Decisión , Humanos , Pennsylvania , Investigación/normas , Resucitación/métodos , Choque Hemorrágico/terapia , Factores de Tiempo , Centros Traumatológicos , Estados Unidos

RESUMEN

This pilot study was carried out to determine whether converting from a two-tier to a three-tier in-hospital trauma triage system improves the efficiency of emergency department (ED) care and minimizes inappropriate triage. Patients at an urban, Level 1 trauma centre were triaged using either a two-tier (months 1-3; n = 197) or three-tier (months 4-6; n = 240) trauma response system. Patients were assessed for triage type, age, sex, injury severity score, Glasgow coma score, post-ED disposition, total ED time, survival, complication rate, probability of survival and unexpected death. Comparisons were made by ANOVA table analysis; significance was assumed for p < 0.05. Two-tier (n = 197) and three-tier patients (n = 240) were matched with respect to mean age, sex, mean injury severity score, mean Glasgow coma score, post-ED disposition, survival and probability of survival. Two-tier patients were triaged to give 20% alerts [criteria = physiological derangement (PD) and/or injury mechanism (MOI)] and 80% consults; three-tier patients were triaged as 20% category I (criteria = PD), 18% category II (criteria = MOI) and 62% consults. Total ED time decreased from two-tier (3.98 +/- 2.81 h) to three-tier triage (3.53 +/- 2.14 h, p = 0.001). There was no difference between two-tier alert and three-tier category I times (2.09 +/- 1.64 vs. 1.95 +/- 1.75 h; p = 0.72). Category II patients (3.28 +/- 1.98 h; p = 0.009) spent less time in the ED than did two-tier consults (4.36 +/- 2.65 h). The mean ED three-tier consult time significantly decreased as well (3.95 +/- 2.42 h, p = 0.008 vs. two-tier consult). Complications per patient were unchanged from two-tier to three-tier triage (0.17 +/- 0.52 vs. 0.12 +/- 0.48; p = 0.15). Under-triage (5%) and over-triage (7.5%) were minimal under three-tier triage. It is concluded that using a three-tier triage system results in an increase in the early involvement of the trauma service while decreasing emergency department time and minimizing over-triage.

Asunto(s)

Servicio de Urgencia en Hospital/normas , Centros Traumatológicos/organización & administración , Triaje/métodos , Adulto , Anciano , Servicio de Urgencia en Hospital/organización & administración , Femenino , Mal Uso de los Servicios de Salud , Hospitales Universitarios , Humanos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Philadelphia , Proyectos Piloto , Tasa de Supervivencia , Índices de Gravedad del Trauma

RESUMEN

Thoracic trauma victims commonly sustain visceral pleural injury with resultant pneumothorax. These injuries usually respond to standard tube thoracostomy decompression and drainage. However, a subset of these patients develop recurrent and/or loculated pneumothoraces or pneumatoceles that are not readily accessible by tube thoracostomy. Percutaneous catheter drainage of these collections provides a safe and reliable method of management in critically ill patients.

Asunto(s)

Neumotórax/etiología , Traumatismos Torácicos/cirugía , Heridas no Penetrantes/cirugía , Adulto , Drenaje , Humanos , Masculino , Persona de Mediana Edad , Neumotórax/diagnóstico por imagen , Neumotórax/terapia , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/terapia , Recurrencia , Respiración Artificial , Síndrome de Dificultad Respiratoria/etiología , Tomografía Computarizada por Rayos X , Traqueostomía

RESUMEN

A novel strategy using videotape recordings of initial trauma resuscitations was incorporated into the quality assurance program at a level 1 trauma center. Described are the process of taping the resuscitations, the multidisciplinary nature of the resuscitation team, the security measures taken to assure patient confidentiality, and the review process involved. The videotape review process was incorporated into a multidisciplinary educational trauma conference. The videotapes were used to evaluate the adherence to Advanced Trauma Life Support (ATLS) resuscitation protocols. Resident performance in six aspects of the ATLS resuscitation process were specifically highlighted on each videotape and graded for adherence to preestablished standards. The videotape process allowed an unblased, indisputable accurate documentation of the sequential application of the protocols of evaluation and resuscitation espoused in the ATLS course. We found 23% overall deviation from ATLS resuscitation principles, with at least one aspect of the resuscitation deviating from expected ATLS performance in 64% of the patients. In addition to documenting adherence to ATLS principles, this study illustrated the impact of the videotape review process on the education of eight senior residents in surgery.

Asunto(s)

Competencia Clínica , Medicina de Emergencia/educación , Internado y Residencia , Resucitación , Grabación de Cinta de Video , Heridas y Lesiones/terapia , Protocolos Clínicos , Estudios de Evaluación como Asunto , Humanos , Garantía de la Calidad de Atención de Salud

RESUMEN

Presented is a case of a thoracic gunshot wound resulting in descending thoracic aortic and biventricular cardiac injuries. Successful management of these wounds allowed the development of an unusual and previously undescribed complication of thoracic trauma--thoracic compartment syndrome. The clinical features, therapy, and potential sequelae of thoracic compartment syndrome are presented with a review of the literature.

Asunto(s)

Síndromes Compartimentales/etiología , Complicaciones Posoperatorias/etiología , Traumatismos Torácicos/cirugía , Heridas por Arma de Fuego/cirugía , Adolescente , Humanos , Masculino

RESUMEN

We present a patient who developed a gastric bezoar following extensive penetrating abdominal trauma. Bezoar pathogenesis, diagnosis, and endoscopic therapy are highlighted. Additionally, alternative therapeutic modalities are explored with a review of the literature. Combination endoscopic lavage fragmentation/extraction presents a safe method of bezoar resolution.

Asunto(s)

Traumatismos Abdominales/complicaciones , Bezoares/etiología , Estómago , Heridas por Arma de Fuego/complicaciones , Adulto , Bezoares/diagnóstico , Bezoares/terapia , Traumatismos por Explosión/complicaciones , Femenino , Lavado Gástrico , Gastroscopía , Humanos , Estómago/lesiones , Succión

RESUMEN

The role of pulmonary fibroblasts (PFBs) in early adult respiratory distress syndrome is poorly understood. To investigate PFB cellular function in acute lung injury, New Zealand rabbits (2 to 3 kg) were given either three daily doses of phorbol myristate acetate (PMA; 65 micrograms/kg, IV), a potent stimulator of oxygen radical formation, or saline (control). On day 4, the lungs were harvested, subjected to enzymatic digestion, and PFBs isolated via serial subculture. Proliferation was assessed via 6-hour pulsed [3H]thymidine incorporation and by creating 5-day growth curves. Confluent PFB cultures were assessed for collagen production and total protein production, as well as interleukin (IL)-1 alpha secretion. Qualitative comparisons using transmission electron micrography were also made. There were no differences between PFBs harvested from control versus PMA-treated animals in terms of growth rates, total protein, and IL-1 alpha production. However, there was a significant difference in collagen production, with the PMA-treated animals' PFBs producing 35% more collagen than controls. Transmission electron micrography revealed PMA fibroblasts to be smaller (two to three times), have more dark staining granules, and have hypertrophied smooth endoplasmic reticulum--all consistent with increased metabolic activity. This suggests that pulmonary fibrosis, a late development in adult respiratory distress syndrome, may be triggered during the acute phase of lung injury. The increase in collagen synthesis is not related to PFB proliferation or the secretion of IL-1 alpha.

Asunto(s)

Fibroblastos/fisiología , Enfermedades Pulmonares/patología , Enfermedad Aguda , Animales , Colágeno/biosíntesis , Modelos Animales de Enfermedad , Fibroblastos/patología , Fibroblastos/ultraestructura , Interleucina-1/aislamiento & purificación , Enfermedades Pulmonares/inducido químicamente , Enfermedades Pulmonares/fisiopatología , Masculino , Microscopía Electrónica , Proyectos Piloto , Biosíntesis de Proteínas , Conejos , Acetato de Tetradecanoilforbol

RESUMEN

OBJECTIVE: To determine the safety of percutaneous central venous access when used for trauma resuscitation and whether the initial hemodynamic status of the patient or the site of placement affects the ease or success of line placement. METHOD: Consecutive major-trauma patients were managed using a resuscitation protocol guiding intravenous line use. Percutaneous peripheral venous access was initially attempted in all patients. If this approach was unsuccessful or proved to be inadequate for volume resuscitation, venous access was attempted using central venous catheter-introducer sets. The site of the central venous access was determined by protocol. For thoracic injury, access was via the ipsilateral subclavian vein (SCV), the ipsilateral internal jugular vein (IJV), or the femoral vein. For suspected mediastinal injury, access was via the contralateral SCV or IJV, or the femoral vein. For abdominal or flank injury, access was via the SCV or IJV only. Multiple central venous access sites were used at the discretion of the trauma team. RESULTS: Central venous access was successful at 144 of 147 sites (99%) used in 122 patients during the study period. There was only one major complication (rate = 0.7%; 95% CI 0.0-3.8%). Mean catheter placement time was 1.9 minutes, and cannulation occurred with a mean of 1.8 needle passes. Most patients (81/122) were hypotensive (blood pressure < or = 90 torr) at the time of line placement, including 44 who were in cardiac arrest and four awake patients who had no obtainable blood pressure. Neither the access site nor the presence of hypotension was associated with the mean time to obtain central venous access, the mean number of attempts, or the complication rate. CONCLUSION: Percutaneous central venous access is relatively safe and reliable for gaining intravenous access when resuscitating trauma patients, when used in a center where physicians are experienced in the technique. Consideration should be given to expanding the use of central venous access in trauma resuscitation.

Asunto(s)

Venodisección/métodos , Cateterismo Venoso Central/métodos , Heridas y Lesiones/terapia , Adulto , Venodisección/efectos adversos , Protocolos Clínicos , Femenino , Vena Femoral , Hemodinámica , Humanos , Venas Yugulares , Masculino , Estudios Prospectivos , Resucitación , Vena Subclavia , Factores de Tiempo , Heridas y Lesiones/fisiopatología

RESUMEN

OBJECTIVES: To determine the hemodynamic responses to blunt trauma with a closed-head injury and to investigate the effect that volume resuscitation has on intracranial pressure. DESIGN: Prospective study with retrospective analysis of patient data and hemodynamic responses. SETTING: Surgical intensive care unit at an inner-city, Level I trauma center. PATIENTS: Consecutive patients (n = 30) who sustained multiple system injury, including a closed-head injury that was severe enough to require intracranial pressure monitoring but not a craniotomy. INTERVENTIONS: All patients underwent invasive hemodynamic monitoring with percutaneous arterial and pulmonary arterial catheters. Serum lactate concentrations and hemodynamic and oxygen transport variables were measured every 4 hrs. Intracranial pressures and vital signs were recorded each hour. Attempts were made to achieve a state of nonflow-dependent oxygen consumption and a normal serum lactate concentration. MEASUREMENTS AND MAIN RESULTS: Despite being normotensive and neither tachycardiac nor oliguric, 80% of patients had evidence of inadequate tissue perfusion. Only 50% of the remaining patients had an adequate response to volume. The other 50% received vasodilating inotropic agents. Despite volume loading and the administration of inotropic agents, intracranial pressure did not increase. This observation was found in patients who showed clinically important intracranial pathology on computed tomography scan, as well as in all other patients. Intracranial pressure did not correlate with the amount of fluid or blood infused or with hemodynamic performance, but intracranial pressures did correlate with serum lactate concentrations. CONCLUSIONS: Many patients with diffuse blunt trauma closed-head injuries, even when they are normotensive, have evidence of impaired peripheral perfusion. Volume infusion and vasodilating inotropic support improve oxygen transport without increasing intracranial pressure. The observed relationship between intracranial pressure and the serum lactate concentration requires further study.

Asunto(s)

Traumatismos Craneocerebrales/terapia , Fluidoterapia , Traumatismo Múltiple/terapia , Resucitación , Vasodilatadores/uso terapéutico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Escala de Coma de Glasgow , Hemodinámica , Humanos , Unidades de Cuidados Intensivos , Presión Intracraneal/efectos de los fármacos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resucitación/métodos , Centros Traumatológicos , Población Urbana

RESUMEN

OBJECTIVE: To determine whether early invasive monitoring is necessary in young trauma patients. DESIGN: A prospective study. SETTING: Surgical intensive care unit (ICU) at an inner-city, Level I trauma center. PATIENTS: Thirty-nine patients < 40 yrs of age, who required operative therapy for penetrating trauma and who received > 6 units of intraoperative blood. INTERVENTIONS: Invasive hemodynamic monitoring, with percutaneous insertion of arterial and pulmonary artery catheters. Vital signs, hemodynamic and oxygen transport values, and laboratory tests were obtained at 1, 8, and 24 hrs postoperatively. Oxygen delivery was increased until a normal serum lactate concentration and a state of nonflow-dependent oxygen consumption were achieved. MEASUREMENTS AND MAIN RESULTS: Despite normal heart rate, blood pressure, and urine output, only five (15%) patients achieved an optimized state at 1 hr postoperatively. Of the other 34 patients, two patients achieved an optimized state with volume infusion alone and 32 (82%) patients required inotropes. Five (12%) patients never achieved an optimized state and died within hours of their arrival to the ICU. Two other patients achieved an optimized state but died of sepsis and organ failure. The other 32 (82%) patients achieved an optimized state within 24 hrs and survived. The hemodynamic values of survivors at 1 hr postoperatively showed a significantly lower pulmonary vascular resistance and serum lactate concentration, and a significantly higher oxygen delivery and mixed venous oxygen saturation, when compared with the values of nonsurvivors. At 24 hrs postoperatively, survivors also had a significantly lower pulmonary vascular resistance and serum lactate concentration, and significantly higher oxygen delivery than nonsurvivors. Survivors' oxygen consumption was also higher than the oxygen consumption of nonsurvivors. CONCLUSIONS: Our data demonstrate that young trauma patients have substantial but clinically occult myocardial depression after shock, and most of these patients require inotropes to optimize and clear circulating lactate. Early invasive monitoring is necessary to precisely define the adequacy of the cardiac response and to individually tailor therapy. Patients who do not optimize and clear their lactate within 24 hrs may not survive.

Asunto(s)

Traumatismos Abdominales/cirugía , Choque/mortalidad , Choque/fisiopatología , Traumatismos Torácicos/cirugía , Heridas por Arma de Fuego/cirugía , Heridas Punzantes/cirugía , Adolescente , Adulto , Hemodinámica , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Masculino , Cuidados Posoperatorios , Estudios Prospectivos , Choque/etiología