Current Issue : January - March Volume : 2014 Issue Number : 1 Articles : 7 Articles
Background: We retrospectively reviewed the presentation, diagnosis, treatment, and outcomes of patients with\r\nclosed injury of the cervical trachea. We evaluated factors that improve diagnosis and treatment, reduce mortality,\r\nand avoid tracheal stenosis.\r\nMethods: We reviewed the clinical data of 17 patients with closed injury of the cervical trachea. All patients\r\nunderwent CT scanning or endoscopy, tracheal exploration, low tracheotomy, and tracheal repair.\r\nResults: In 12 patients, breathing, phonation, and swallowing functions had returned to normal at 2 weeks. In three\r\npatients, breathing and swallowing functions had recovered at 2 weeks, but hoarseness continued. In two patients,\r\ntracheal stenosis prevented extubation and required further surgery; in these patients breathing and swallowing\r\nfunctions had recovered at 6 months.\r\nConclusions: Closed injury of the cervical trachea may cause airway obstruction and is potentially life-threatening.\r\nEarly diagnosis and repair to restore structure and function are important to ensure survival and avoid tracheal\r\nstenosis....
Introduction: The trauma room at Oslo University Hospital- Ulleval is fully equipped for major damage control\r\nprocedures, in order to minimize delay to surgery. Since 2006, patients in need of immediate laparotomy have\r\nincreasingly been transferred to a dedicated trauma operating room (OR). We wanted to determine the decrease in\r\nnumber of procedures performed in the emergency department (ED), the effect on time from admission to\r\nlaparotomy, the effect on non-therapeutic laparotomies, and finally to determine whether such a change could be\r\nundertaken without an increase in mortality.\r\nMethods: Retrospective evaluation of haemodynamically unstable trauma patients undergoing laparotomy during\r\nthe period 2002ââ?¬â??2009. Based on time for protocol change Period 1 was defined as 2002ââ?¬â??2006 and Period 2 as\r\n2007ââ?¬â??2009. Significance was set at p < 0.05.\r\nResults: A total of 167 consecutive patients were included; 103 patients from Period 1 and 64 from Period 2. We found\r\na 42% decrease in ED laparotomies (p < 0.001). Median time to laparotomy increased from 24.0 to 34.0 minutes from\r\nPeriod 1 to Period 2 (p = 0.029). Crude mortality fell from 57% to 39%. The proportion of non-therapeutic laparotomies\r\nin the OR tended to be lower over the whole study period.\r\nConclusion: Moving this cohort of haemodynamically compromised trauma patients in need of emergency\r\nlaparotomy out of the ED to a dedicated OR resulted in longer median time to laparotomy, but did not increase\r\nmortality....
Background: Evaluation of emergency department (ED) performance remains a difficult task due to the lack of\r\nconsensus on performance measures that reflects high quality, efficiency, and sustainability.\r\nAim: To describe, map, and critically evaluate which performance measures that the published literature regard as\r\nbeing most relevant in assessing overall ED performance.\r\nMethods: Following the PRISMA guidelines, a systematic literature review of review articles reporting accentuated\r\nED performance measures was conducted in the databases of PubMed, Cochrane Library, and Web of Science.\r\nStudy eligibility criteria includes: 1) the main purpose was to discuss, analyse, or promote performance measures\r\nbest reflecting ED performance, 2) the article was a review article, and 3) the article reported macro-level\r\nperformance measures, thus reflecting an overall departmental performance level.\r\nResults: A number of articles addresses this studyââ?¬â?¢s objective (n = 14 of 46 unique hits). Time intervals and patientrelated\r\nmeasures were dominant in the identified performance measures in review articles from US, UK, Sweden\r\nand Canada. Length of stay (LOS), time between patient arrival to initial clinical assessment, and time between\r\npatient arrivals to admission were highlighted by the majority of articles. Concurrently, ââ?¬Å?patients left without being\r\nseenââ?¬Â (LWBS), unplanned re-attendance within a maximum of 72 hours, mortality/morbidity, and number of\r\nunintended incidents were the most highlighted performance measures that related directly to the patient.\r\nPerformance measures related to employees were only stated in two of the 14 included articles.\r\nConclusions: A total of 55 ED performance measures were identified. ED time intervals were the most\r\nrecommended performance measures followed by patient centeredness and safety performance measures. ED\r\nemployee related performance measures were rarely mentioned in the investigated literature. The studyââ?¬â?¢s results\r\nallow for advancement towards improved performance measurement and standardised assessment across EDs....
Background: Delayed admission to appropriate care has been shown increase mortality following traumatic brain\r\ninjury (TBI). We investigated factors associated with delayed admission to a hospital with neurosurgical expertise in\r\na cohort of TBI patients in the intensive care unit (ICU).\r\nMethods: A retrospective analysis of all TBI patients treated in the ICUs of Helsinki University Central Hospital was\r\ncarried out from 1.1.2009 to 31.12.2010. Patients were categorized into two groups: direct admission and delayed\r\nadmission. Patients in the delayed admission group were initially transported to a local hospital without\r\nneurosurgical expertise before inter-transfer to the designated hospital. Multivariate logistic regression was utilized\r\nto identify pre-hospital factors associated with delayed admission.\r\nResults: Of 431 included patients 65% of patients were in the direct admission groups and 35% in the delayed\r\nadmission groups (median time to admission 1:07h, IQR 0:52ââ?¬â??1:28 vs. 4:06h, IQR 2:53ââ?¬â??5:43, p <0.001). In multivariate\r\nanalysis factors increasing the likelihood of delayed admission were (OR, 95% CI): male gender (3.82, 1.60-9.13),\r\nincident at public place compared to home (0.26, 0.11-0.61), high energy trauma (0.05, 0.01-0.28), pre-hospital\r\nphysician consultation (0.15, 0.06-0.39) or presence (0.08, 0.03-0.22), hypotension (0.09, 0.01-0.93), major extra cranial\r\ninjury (0.17, 0.05-0.55), abnormal pupillary light reflex (0.26, 0.09-0.73) and severe alcohol intoxication (12.44, 2.14-72.38).\r\nA significant larger proportion of patients in the delayed admission group required acute craniotomy for mass lesion\r\nwhen admitted to the neurosurgical hospital (57%, 21%, p< 0.001). No significant difference in 6-month mortality was\r\nnoted between the groups (p= 0.814).\r\nConclusion: Delayed trauma center admission following TBI is common. Factors increasing likelihood of this were:\r\nmale gender, incident at public place compared to home, low energy trauma, absence of pre-hospital physician\r\ninvolvement, stable blood pressure, no major extra cranial injuries, normal pupillary light reflex and severe alcohol\r\nintoxication. Focused educational efforts and access to physician consultation may help expedite access to appropriate\r\ncare in TBI patients....
Despite ongoing controversial expert discussions the European Medicines Agency (EMA) recently recommended to\r\nsuspend marketing authorisations for hydroxyethyl starch. This comment critically evaluates the line of arguments.\r\nBasically, the only indication for a colloid is intravascular hypovolemia. Crystalloid use appears reasonable to\r\ncompensate ongoing extracellular losses beyond. In the hemodynamically instable patient this leads to the\r\ndistinction between an initial resuscitation phase where colloids might be indicated and a crystalloidal maintenance\r\nphase thereafter. It is important to bear this in mind when reevaluating the studies the EMA referred to in the\r\ncontext of its recent decision: i) VISEP compared ringer�s lactate to 10% HES 200/0.5 in septic patients and found an\r\nincreased incidence of renal failure in HES receivers. Unfortunately, study treatment was started only after initial\r\nstabilization with HES, randomizing hemodynamically stable patients into a rational (crystalloids) and an irrational\r\n(high dose starch until ICU discharge) maintenance treatment. ii) 6S compared ringer�s acetate to 6% HES 130/0.42\r\nfor fluid resuscitation in septic patients and found an increased need of renal replacement therapy and a higher\r\nmortality in the HES group. However, patients of both groups were again randomized only after initial stabilization\r\nwith colloids, the actual comparison was, therefore, again rational vs. irrational. Beyond that, the documentation is\r\npartly fragmentary, leaving many important questions around the fate of the patients unanswered. iii) CHEST\r\nrandomized ICU patients to receive saline or 6% HES 130/0.4 for fluid resuscitation. Actually, despite partly discussed\r\nin a different way, this trial showed no relevant differences in outcome.\r\nIn all, two studies showed what happens to septic patients if starches are used in a way we do not observe in daily\r\npractice. The third one actually proves their safety. The benefit of perioperative goal-directed preload optimization\r\nusing starches is unquestioned. Taking these informations into account, the recommendation of the EMA starches\r\nto be generally dangerous remains mysterious and incomprehensible. An authority being able to dictate behavior\r\nshould stand clear from oppressively ending a worldwide expert discussion and step back into the role of the\r\nobserver until science achieves an agreement....
Background: The utility of advanced prehospital interventions for severe blunt traumatic brain injury (BTI) remains\r\ncontroversial. Of all trauma patient subgroups it has been anticipated that this patient group would most benefit\r\nfrom advanced prehospital interventions as hypoxia and hypotension have been demonstrated to be associated\r\nwith poor outcomes and these factors may be amenable to prehospital intervention. Supporting evidence is largely\r\nlacking however. In particular the efficacy of early anaesthesia/muscle relaxant assisted intubation has proved\r\ndifficult to substantiate.\r\nMethods: This article describes the design and protocol of the Head Injury Retrieval Trial (HIRT) which is a randomised\r\ncontrolled single centre trial of physician prehospital care (delivering advanced interventions such as rapid sequence\r\nintubation and blood transfusion) in addition to paramedic care for severe blunt TBI compared with paramedic care alone.\r\nResults: Primary endpoint is Glasgow Outcome Scale score at six months post injury. Issues with trial integrity resulting\r\nfrom drop ins from standard care to the treatment arm as the result of policy changes by the local ambulance system are\r\ndiscussed.\r\nConclusion: This randomised controlled trial will contribute to the evaluation of the efficacy of advance prehospital\r\ninterventions in severe blunt TBI....
Background: Coagulopathy often develops in patients with serious trauma and is correlated with the clinical\r\noutcome. The contribution of platelet activity and endothelial dysfunction to trauma-induced coagulopathy remain\r\nto be defined. The purpose of this study was to investigate the time courses of soluble P-selectin (sPsel, an index of\r\nplatelet activation) and von Willebrand factor (VWF, an index of endothelial dysfunction) in trauma patients and\r\nelucidate their relationship to coagulation parameter levels, the presence of coagulopathy, and patient outcome.\r\nMethods: This prospective observational study, which took place in a university hospital intensive care unit (ICU),\r\nincluded 82 severely injured trauma patients. The sPsel, VWF antigen, protein C, and factor VII levels were measured\r\nand routine coagulation tests were performed upon admission to ICU and daily within the first week. The 30-day\r\nmortality rate was also determined.\r\nResults: Thirty-seven (45.1%) patients developed coagulopathy upon admission to the ICU, and the 30-day\r\nmortality rate was 20.7% (n = 17). Both the admission sPsel and VWF levels were lower in patients with\r\ncoagulopathy than in those without (p < 0.05) and were significantly correlated with the protein C and factor VII\r\nlevels, respectively (all p < 0.05). The VWF levels were lower during the first 3 days and higher on day 7 after\r\nadmission in nonsurvivors than in survivors (all p < 0.05). No significant differences in sPsel levels were found\r\nbetween nonsurvivors and survivors on each day during the first week.\r\nConclusion: In severely injured trauma patients in the ICU, lower levels of sPsel and VWF on admission were\r\nassociated with the presence of coagulopathy and might not predict a better outcome. An increase in the VWF\r\nlevel at the end of the first week after admission to ICU was associated with increased 30-day mortality....
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