Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 15.807
Filtrar
1.
Medicine (Baltimore) ; 99(10): e19411, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32150091

RESUMEN

The effects of the intercondylar notch morphology on predicting anterior crucaite ligament (ACL) injury in males were unknown. We aimed to determine the risk factors of the intercondylar notch on ACL injury, and evaluate the predictive effects of the morphological parameters on ACL injury in males. Sixty-one patients with ACL injury and seventy-eight patients with intact ACLs were assigned to the case group and control group respectively. The notch width (NW), bicondylar width, notch width index (NWI), notch height (NH), notch cross-sectional area (CSA), notch angle (NA) and notch shape were obtained from the magnetic resonance images of male patients. Comparisons were performed between the case and control groups. Logistic regression model and the receiver operating characteristic curve were used to assess the predictive effects of these parameters on ACL injury. The NW, NWI, NH, CSA and NA in the case group were significantly smaller than those in the control group on the coronal magnetic resonance images. The NW and NWI were significantly smaller, while no significant differences of the NH and CSA were found between the 2 groups on the axial images. There was no significant difference in the notch shape between the 2 groups. The maximum value of area under the curve calculated by combining all relevant morphological parameters was 0.966. The ACL injury in males was associated with NW, NH, NWI, CSA, and NA. These were good indicators for predicting ACL injury in males.


Asunto(s)
Lesiones del Ligamento Cruzado Anterior/diagnóstico por imagen , Adolescente , Adulto , Huesos/diagnóstico por imagen , Estudios de Casos y Controles , Humanos , Puntaje de Gravedad del Traumatismo , Articulación de la Rodilla/diagnóstico por imagen , Imagen por Resonancia Magnética , Masculino , Valor Predictivo de las Pruebas , Factores de Riesgo , Sensibilidad y Especificidad , Adulto Joven
2.
Medicine (Baltimore) ; 99(9): e19239, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32118728

RESUMEN

Despite the availability of a series of tests, detection of chronic traumatic osteomyelitis is still exhausting in clinical practice. We hypothesized that machine learning based on computed-tomography (CT) images would provide better diagnostic performance for extremity traumatic chronic osteomyelitis than the serological biomarker alone. A retrospective study was carried out to collect medical data from patients with extremity traumatic osteomyelitis according to the criteria of musculoskeletal infection society. In each patient, serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimer were measured and CT scan of the extremity was conducted 7 days after admission preoperatively. A deep residual network (ResNet) machine learning model was established for recognition of bone lesion on the CT image. A total of 28,718 CT images from 163 adult patients were included. Then, we randomly extracted 80% of all CT images from each patient for training, 10% for validation, and 10% for testing. Our results showed that machine learning (83.4%) outperformed CRP (53.2%), ESR (68.8%), and D-dimer (68.1%) separately in accuracy. Meanwhile, machine learning (88.0%) demonstrated highest sensitivity when compared with CRP (50.6%), ESR (73.0%), and D-dimer (51.7%). Considering the specificity, machine learning (77.0%) is better than CRP (59.4%) and ESR (62.2%), but not D-dimer (83.8%). Our findings indicated that machine learning based on CT images is an effective and promising avenue for detection of chronic traumatic osteomyelitis in the extremity.


Asunto(s)
Extremidades/lesiones , Osteomielitis/diagnóstico por imagen , Biomarcadores/sangre , Proteína C-Reactiva/metabolismo , China , Enfermedad Crónica , Bases de Datos Factuales , Femenino , Productos de Degradación de Fibrina-Fibrinógeno , Humanos , Puntaje de Gravedad del Traumatismo , Aprendizaje Automático , Masculino , Persona de Mediana Edad , Osteomielitis/sangre , Osteomielitis/diagnóstico , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X
3.
JAMA ; 323(6): 519-526, 2020 02 11.
Artículo en Inglés | MEDLINE | ID: mdl-32044942

RESUMEN

Importance: Following surgery to treat major trauma-related fractures, deep wound infection rates are high. It is not known if negative pressure wound therapy can reduce infection rates in this setting. Objective: To assess outcomes in patients who have incisions resulting from surgery for lower limb fractures related to major trauma and were treated with either incisional negative pressure wound therapy or standard wound dressing. Design, Setting, and Participants: A randomized clinical trial conducted at 24 trauma hospitals representing the UK Major Trauma Network that included 1548 patients aged 16 years or older who underwent surgery for a lower limb fracture caused by major trauma from July 7, 2016, through April 17, 2018, with follow-up to December 11, 2018. Interventions: Incisional negative pressure wound therapy (n = 785), which involved a specialized dressing used to create negative pressure over the wound, vs standard wound dressing not involving negative pressure (n = 763). Main Outcomes and Measures: The primary outcome measure was deep surgical site infection at 30 days diagnosed according to the criteria from the US Centers for Disease Control and Prevention. A preplanned secondary analysis of the primary outcome was performed at 90 days. The secondary outcomes were patient-reported disability (Disability Rating Index), health-related quality of life (EuroQol 5-level EQ-5D), surgical scar assessment (Patient and Observer Scar Assessment Scale), and chronic pain (Douleur Neuropathique Questionnaire) at 3 and 6 months, as well as other local wound healing complications at 30 days. Results: Among 1548 participants who were randomized (mean [SD] age, 49.8 [20.3] years; 561 [36%] were aged ≤40 years; 583 [38%] women; and 881 [57%] had multiple injuries), 1519 (98%) had data available for the primary outcome. At 30 days, deep surgical site infection occurred in 5.84% (45 of 770 patients) of the incisional negative pressure wound therapy group and in 6.68% (50 of 749 patients) of the standard wound dressing group (odds ratio, 0.87 [95% CI, 0.57 to 1.33]; absolute risk difference, -0.77% [95% CI, -3.19% to 1.66%]; P = .52). There was no significant difference in the deep surgical site infection rate at 90 days (11.4% [72 of 629 patients] in the incisional negative pressure wound therapy group vs 13.2% [78 of 590 patients] in the standard wound dressing group; odds ratio, 0.84 [95% CI, 0.59 to 1.19]; absolute risk difference, -1.76% [95% CI, -5.41% to 1.90%]; P = .32). For the 5 prespecified secondary outcomes reported, there were no significant differences at any time point. Conclusions and Relevance: Among patients who underwent surgery for major trauma-related lower limb fractures, use of incisional negative pressure wound therapy, compared with standard wound dressing, resulted in no significant difference in the rate of deep surgical site infection. The findings do not support the use of incisional negative pressure wound therapy in this setting, although the event rate at 30 days was lower than expected. Trial Registration: isrctn.org Identifier: ISRCTN12702354.


Asunto(s)
Vendajes , Fijación Interna de Fracturas , Fracturas Abiertas/cirugía , Extremidad Inferior/lesiones , Terapia de Presión Negativa para Heridas , Infección de la Herida Quirúrgica/prevención & control , Adolescente , Adulto , Femenino , Fijación Interna de Fracturas/efectos adversos , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Infección de la Herida Quirúrgica/epidemiología
4.
Am Surg ; 86(1): 8-14, 2020 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-32077410

RESUMEN

Studies demonstrate a significant variation in decision-making regarding withdrawal of life-sustaining treatment (WLST) practices for patients with severe traumatic brain injury (TBI). We investigated risk factors associated with WLST in severe TBI. We hypothesized age ≥65 years would be an independent risk factor. In addition, we compared survivors with patients who died in hospital after WLST to identify potential factors associated with in-hospital mortality. The Trauma Quality Improvement Program (2010-2016) was queried for patients with severe TBI of the head. Patients were compared by age (age < 65 and age ≥ 65 years) and survival after WLST (survivors versus non-survivors) at hospitalization discharge. A multivariable logistic regression model was used for analysis. From 1,403,466 trauma admissions, 328,588 (23.4%) patients had severe TBI. Age ≥ 65 years was associated with increased WLST (odds ratio: 1.76, confidence interval: 1.59-1.94, P < 0.001), whereas nonwhite race was associated with decreased WLST (odds ratio: 0.60, confidence interval: 0.55-0.65, P < 0.001). Compared with non-survivors of WLST, survivors were older (74 vs 61 years, P < 0.001) and more likely to have comorbidities such as hypertension (57% vs 38.5%, P < 0.001). Age ≥ 65 years was an independent risk factor for WLST, and nonwhite race was associated with decreased WLST. Patients surviving until discharge after WLST decision were older (≥74 years) and had multiple comorbidities.


Asunto(s)
Lesiones Traumáticas del Encéfalo/terapia , Privación de Tratamiento , Adulto , Factores de Edad , Anciano , Lesiones Traumáticas del Encéfalo/etnología , Lesiones Traumáticas del Encéfalo/mortalidad , Toma de Decisiones , Mortalidad Hospitalaria , Humanos , Puntaje de Gravedad del Traumatismo , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia
5.
Am Surg ; 86(1): 15-20, 2020 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-32077411

RESUMEN

The American College of Surgeons Committee on Trauma requires that trauma centers with greater than 10 per cent injured patients admitted to non-trauma services (NTSs) have processes to review these for appropriateness of care. We previously described an algorithm to determine the appropriateness of NTS admissions. Our objective was to determine if the outcome and process of care was similar between TS- and NTS-admitted patients. We conducted a retrospective analysis of our trauma registry. NTS-appropriate patients by algorithm were included. Differences between patients admitted to a TS and an NTS were compared. Nine hundred forty-one patients met the algorithm criteria as appropriate for the NTS; 694 were admitted to TS and 247 to NTS. Contact with TS was the most common association with admission to TS. NTS patients were older and had similar Injury Severity Scores, and a similar proportion had three or greater pre-existing comorbidities. NTS-admitted patients had similar risk for mortality and complications, but longer length of stay, and were less likely to have a desirable discharge disposition. Minimally injured elderly patients constitute most of NTS and a large proportion of TS admissions. NTS admission seems appropriate with respect to mortality and complications. Differences in the care process may have accounted for longer length of stay and differences in disposition destination.


Asunto(s)
Hospitalización , Centros Traumatológicos/organización & administración , Adulto , Anciano , Algoritmos , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos
6.
Am Surg ; 86(1): 35-41, 2020 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-32077414

RESUMEN

A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007-2015) or TNCs (2015-2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.


Asunto(s)
Transfusión Sanguínea/normas , Hemorragia/enfermería , Cuidados Intraoperatorios , Enfermeras Clínicas , Resucitación/enfermería , Heridas y Traumatismos/cirugía , Adulto , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Sistema de Registros , Estudios Retrospectivos , Centros Traumatológicos
10.
Am J Forensic Med Pathol ; 41(1): 5-10, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32000222

RESUMEN

Use of excessive force (UOEF) is an important and controversial topic but little is known about how injury severity is related to allegations of UOEF. We hypothesized that such complaints would be associated with more significant traumatic injuries. Emergency department records were searched for all individuals making UOEF complaints against an urban police department from 2010 to 2012. Demographic, diagnosis, and other medical data, including Injury Severity Score, were obtained. From police records, force used, suspect resistance and threat, and other call data were obtained. The same data were collected for a control group randomly chosen from all use-of-force events identified during the study period. Of the 235 complaints filed, 42 (18%) subjects had medical evaluation. The control group was significantly younger and more likely to be male; there was no significant difference in race or income. Major injuries were infrequent. No significant difference was found in Injury Severity Score or other medical variables between the 2 groups. Among the law enforcement variables, the only significant difference was a higher likelihood of psychiatric-related calls in the control group. The majority of patients alleging UOEF did not require immediate medical attention, and we found no relationship between injury severity and UOEF complaints.


Asunto(s)
Puntaje de Gravedad del Traumatismo , Policia , Heridas y Traumatismos/epidemiología , Adulto , Estudios de Casos y Controles , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Trastornos Mentales/epidemiología , Persona de Mediana Edad , Estudios Retrospectivos , Trastornos Relacionados con Sustancias/epidemiología , Washingtón/epidemiología
11.
Bone Joint J ; 102-B(1): 102-107, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888364

RESUMEN

AIMS: Trochlear dysplasia is a significant risk factor for patellofemoral instability. The Dejour classification is currently considered the standard for classifying trochlear dysplasia, but numerous studies have reported poor reliability on both plain radiography and MRI. The severity of trochlear dysplasia is important to establish in order to guide surgical management. We have developed an MRI-specific classification system to assess the severity of trochlear dysplasia, the Oswestry-Bristol Classification (OBC). This is a four-part classification system comprising normal, mild, moderate, and severe to represent a normal, shallow, flat, and convex trochlear, respectively. The purpose of this study was to assess the inter- and intraobserver reliability of the OBC and compare it with that of the Dejour classification. METHODS: Four observers (two senior and two junior orthopaedic surgeons) independently assessed 32 CT and axial MRI scans for trochlear dysplasia and classified each according to the OBC and the Dejour classification systems. Assessments were repeated following a four-week interval. The inter- and intraobserver agreement was determined by using Fleiss' generalization of Cohen's kappa statistic and S-statistic nominal and linear weights. RESULTS: The OBC showed fair-to-good interobserver agreement and good-to-excellent intraobserver agreement (mean kappa 0.68). The Dejour classification showed poor interobserver agreement and fair-to-good intraobserver agreement (mean kappa 0.52). CONCLUSION: The OBC can be used to assess the severity of trochlear dysplasia. It can be applied in clinical practice to simplify and standardize surgical decision-making in patients with recurrent patella instability. Cite this article: Bone Joint J 2020;102-B(1):102-107.


Asunto(s)
Inestabilidad de la Articulación/clasificación , Luxación de la Rótula/clasificación , Articulación Patelofemoral/lesiones , Adolescente , Adulto , Niño , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Inestabilidad de la Articulación/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Luxación de la Rótula/diagnóstico por imagen , Articulación Patelofemoral/diagnóstico por imagen , Recurrencia , Estudios Retrospectivos , Adulto Joven
12.
Bone Joint J ; 102-B(1): 26-32, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888373

RESUMEN

AIMS: Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. METHODS: We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman's correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting. RESULTS: The mean follow-up was 11.4 months (3 to 31). The mean time to union was 9.7 months (3 to 21), the mean number of operations was 2.8 (1 to 11), the mean time in hospital was 17.7 days (5 to 84), the mean length of treatment was 92.7 days (5 to 730), the mean number of admissions was 1.7 (1 to 6), and the mean functional score (Lower Extremity Functional Score (LEFS)) was 60.13 (33 to 80). There was a significant correlation between the GHS and each of the outcome measures. A predictive model was generated from which the GHS could be used to predict the various outcome measures. CONCLUSION: The GHS can be used to predict the outcome of patients who present with an open fracture of the tibia. Our model generates a numerical value for each outcome measure that can be used in clinical practice to inform the treating team and to advise patients. Cite this article: Bone Joint J 2020;102-B(1):26-32.


Asunto(s)
Fracturas Abiertas/cirugía , Fracturas de la Tibia/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Fijación de Fractura/estadística & datos numéricos , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del Tratamiento , Adulto Joven
13.
J Surg Res ; 246: 544-549, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31635832

RESUMEN

BACKGROUND: Teamwork is a critical element of trauma resuscitation. Assessment tools such as T-NOTECHS (Trauma NOn-TECHnical Skills) exist, but correlation with patient outcomes is unclear. Using emergency department thoracotomy (EDT), we sought to describe T-NOTECHS scores during resuscitations. We hypothesized that patients undergoing EDT whose resuscitations had better scores would be more likely to have return of spontaneous circulation (ROSC). METHODS: Continuously recording video was used to review all captured EDTs over a 24-mo period. We used a modification of the validated T-NOTECHS instrument to measure five domains on a 3-point scale (1 = best, 2 = average, 3 = worst). A total T-NOTECHS score was calculated by one of three reviewers. The primary outcome was ROSC. ROSC was defined as an organized rhythm no longer requiring internal cardiac compressions. Associations between variables and ROSC were examined using univariate regression. RESULTS: Sixty-one EDTs were captured. Nineteen patients had ROSC (31%) and 42 (69%) did not. The median T-NOTECHS score for all resuscitations was 8 [IQR 6-10]. As demographic and injury data (age, gender, mechanism, signs of life) were not associated with ROSC in univariate analysis, they were not considered for inclusion in a multivariable regression model. The association between overall T-NOTECHS score and ROSC did not reach statistical significance, but examination of the individual components of the T-NOTECHS score demonstrated that, compared to resuscitations that had "average" (2) or "worst" (3) scores on "Assessment and Decision Making," resuscitations with a "best" score were 5 times more likely to lead to ROSC. CONCLUSIONS: Although the association between overall T-NOTECHS scores and ROSC did not reach statistical significance, better scores in the domain of assessment and decision making are associated with improved rates of ROSC in patients arriving in cardiac arrest who undergo EDT. LEVEL OF EVIDENCE: Level IV Therapeutic/Care Management.


Asunto(s)
Toma de Decisiones Clínicas/métodos , Paro Cardíaco/terapia , Grupo de Atención al Paciente/organización & administración , Grabación en Video , Heridas y Traumatismos/terapia , Adulto , Competencia Clínica , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Paro Cardíaco/etiología , Paro Cardíaco/mortalidad , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Pennsylvania , Resucitación/métodos , Toracotomía/métodos , Centros Traumatológicos/organización & administración , Heridas y Traumatismos/complicaciones , Heridas y Traumatismos/diagnóstico
14.
J Surg Res ; 246: 490-498, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31635838

RESUMEN

BACKGROUND: Burn patients are at high risk of infection, and as sepsis contributes significantly to morbidity and mortality, early diagnosis is essential. Procalcitonin (PCT) is a biomarker released in response to inflammation and specifically bacterial infection. This study aimed to determine the value of PCT as a diagnostic biomarker of sepsis in burns patients in Johannesburg, South Africa. MATERIALS AND METHODS: All adult patients admitted to two burns intensive care units in Johannesburg over a 3-year study period were included in a retrospective data review. Records of 178 patients were accessible and reviewed. RESULTS: The most significant risk factor for sepsis was percentage total body surface area burned (P = 0.012). A rise in PCT was a significant biomarker for bacterial infection in the early phase after a burn (P = 0.03) but not after day eight. PCT correlated with C-reactive protein as a biomarker for sepsis (P < 0.001), but not with other biomarkers. The mean PCT in patients who died was significantly higher on every study day until death compared with those who remained alive (P < 0.02, consistently). Patients on inotropes also had a significantly increased PCT level (P = 0.0001), as did those who were not discharged from intensive care unit by day 14. CONCLUSIONS: PCT may be useful as an adjunct biomarker of infection in burn patients and has potential as a predictive biomarker of early discharge.


Asunto(s)
Quemaduras/complicaciones , Polipéptido alfa Relacionado con Calcitonina/sangre , Sepsis/diagnóstico , Adulto , Biomarcadores/sangre , Quemaduras/sangre , Quemaduras/diagnóstico , Proteína C-Reactiva/análisis , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Sepsis/sangre , Sepsis/etiología , Sudáfrica , Adulto Joven
15.
J Surg Res ; 246: 605-613, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31668435

RESUMEN

BACKGROUND: Platelet function tests such as thrombelastography platelet mapping and impedance aggregometry have demonstrated universal platelet dysfunction in trauma patients. In this study, we introduce the measurement of platelet contraction force as a test of platelet function. We hypothesize that force will correlate with established coagulation tests such as thrombelastography, demonstrate significant differences between healthy subjects and trauma patients, and identify critically ill trauma patients. METHODS: Blood samples were prospectively collected from level 1 trauma patients at initial presentation, assayed for force of and time to contraction and compared with thrombelastography. Blood from healthy subjects was assayed to establish a reference range. Results from trauma patients were compared with healthy controls and trauma patients that died. RESULTS: The study includes one hundred trauma patients with mean age 45 y, 74% were male, and median injury severity score of 14 ± 12. Patients that survived (n = 90) demonstrated significantly elevated platelet contraction force compared with healthy controls (n = 12) (6390 ± 2340 versus 4790 ± 470 µN, P = 0.043) and trauma patients that died (n = 10) (6390 ± 2340 versus 2860 ± 1830 µN, P = 0.0001). Elapsed time to start of platelet contraction was faster in trauma patients that survived compared with healthy controls (660 ± 467 versus 1130 ± 140 s, P = 0.0022) and those that died (660 ± 470 versus 1460 ± 1340 s, P < 0.0001). CONCLUSIONS: In contrast with all existing platelet function tests reported in the literature, which report platelet dysfunction in trauma patients, contractile force demonstrates hyperfunction in surviving trauma patients and dysfunction in nonsurvivors. Platelet contraction reflects platelet metabolic reserve and thus may be a potential biomarker for survival after trauma. Contractile force warrants further investigation to predict mortality in severely injured trauma patients.


Asunto(s)
Trastornos de las Plaquetas Sanguíneas/diagnóstico , Plaquetas/fisiología , Heridas y Traumatismos/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Coagulación Sanguínea/fisiología , Trastornos de las Plaquetas Sanguíneas/sangre , Trastornos de las Plaquetas Sanguíneas/etiología , Trastornos de las Plaquetas Sanguíneas/fisiopatología , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Pruebas de Función Plaquetaria/métodos , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Curva ROC , Tromboelastografía , Heridas y Traumatismos/sangre , Heridas y Traumatismos/diagnóstico , Heridas y Traumatismos/mortalidad , Adulto Joven
16.
J Surg Res ; 246: 476-481, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31668607

RESUMEN

INTRODUCTION: Rib fractures are a major problem in trauma patients, and the associated pain is not well understood. Measuring total pain experience, duration, and intensity could facilitate comparisons of treatments. This study was intended to evaluate the feasibility of quantifying pain over the course of an admission and identify factors associated with increased pain experience in adults with rib fractures. METHODS: Patients admitted to a level I trauma center with rib fractures between 2015 and 2017 were included. Maximum pain score (verbal or nonverbal) was captured for each hospital day. Total pain was defined as the sum of the area under the curve (AUC) of the max pain scores plotted against time. A general linear model was used to determine demographic, injury, and clinical predictors of the pain AUC. RESULTS: We identified 3713 patients. Increased pain experienced (greater AUC) was associated with age group 40-59 y compared with 18-39 y (B = 6.1, P = 0.002); Injury Severity Score 9-14 (B = 11.5, P < 0.001) and ≥16 (B = 36.9, P < 0.0001); patients with flail chest versus multiple rib fractures (B = 17.1, P < 0.001); and patients who underwent rib fixation (B = 20.7, P = 0.004). Decreased pain experience was observed for male gender (B = -3.7, P = 0.032) and blunt mechanism of injury (B = -13.7, P < 0.0001). CONCLUSIONS: This study demonstrates the feasibility of measuring patients' total pain experience over the duration of their admission. Pain is a subjective but relevant measure of patients' experience. Our study identifies a number of predictive factors, some expected and some unexpected. Increased overall experience pain following fixation may be the result of severe pain before intervention.


Asunto(s)
Tórax Paradójico/diagnóstico , Fijación Interna de Fracturas/efectos adversos , Dolor Musculoesquelético/diagnóstico , Dimensión del Dolor/métodos , Fracturas de las Costillas/complicaciones , Adolescente , Adulto , Factores de Edad , Estudios de Factibilidad , Femenino , Tórax Paradójico/etiología , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Masculino , Persona de Mediana Edad , Dolor Musculoesquelético/etiología , Estudios Retrospectivos , Fracturas de las Costillas/diagnóstico , Fracturas de las Costillas/cirugía , Índice de Severidad de la Enfermedad , Factores Sexuales , Factores de Tiempo , Centros Traumatológicos/estadística & datos numéricos , Adulto Joven
17.
J Trauma Acute Care Surg ; 88(2): 330-344, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31688831

RESUMEN

BACKGROUND: The objective of our study was to perform a systematic review and meta-analysis aimed at assessing the prevalence of inhalation injury in burn patients and its prognostic value in relation to in-hospital mortality. METHODS: We searched the PubMed and EMBASE databases for noninterventional studies published between 1990 and 2018 investigating in-hospital mortality predictors among burn patients.The primary meta-analysis evaluated the association between inhalation injury and mortality. A secondary meta-analysis determined the global estimate of the prevalence of inhalation injury and the rate of mortality. Random effects models were used, and univariate meta-regressions were used to assess sources of heterogeneity. This study is registered in the PROSPERO database with code CRD42019127356. FINDINGS: Fifty-four studies including a total of 408,157 patients were selected for the analysis. A pooled inhalation prevalence of 15.7% (95% confidence interval, 13.4%-18.3%) was calculated.The summarized odds ratio of in-hospital mortality secondary to an inhalation injury was 3.2 (95% confidence interval, 2.5-4.3). A significantly higher odd of mortality was found among the studies that included all hospitalized burn patients, those that included a lower proportion of male patients, those with a lower mean total body surface area, and those with a lower prevalence of inhalation injury. CONCLUSION: Despite our study's limitations due to the high risk of bias and the interstudy heterogeneity of some of our analyses, our results revealed a wide range of prevalence rates of inhalation injury and a significant association between this entity and in-hospital mortality in burn patients. However, this association is not significant if adjusted for disease severity. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.


Asunto(s)
Quemaduras/mortalidad , Mortalidad Hospitalaria , Lesión por Inhalación de Humo/epidemiología , Superficie Corporal , Quemaduras/diagnóstico , Humanos , Puntaje de Gravedad del Traumatismo , Prevalencia , Pronóstico , Análisis de Supervivencia
18.
J Trauma Acute Care Surg ; 88(2): 314-319, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31804417

RESUMEN

BACKGROUND: Timely angioembolization (AE) is known to improve outcomes of patients with hemorrhage resulting from pelvic fracture. The hybrid emergency room system (HERS) is a novel trauma resuscitation room equipped with a computed tomography scanner, fluoroscopy equipment, and an operating room setup. We hypothesized that the HERS would improve the timeliness of AE for pelvic fracture. METHODS: A retrospective medical record review of patients who underwent AE for pelvic fracture at our institution from April 2015 to December 2018 was conducted. Patients' demographics, location of AE, Injury Severity Score, Revised Trauma Score, probability of survival by the trauma and injury severity score (TRISS Ps) method, presence of interventional radiologists (IRs) upon patient arrival, time from arrival to AE, and in-hospital mortality were analyzed. These data were compared between patients who underwent AE in the HERS (HERS group) and in the regular angio suite (non-HERS group). RESULTS: Ninety-six patients met the inclusion criteria. The HERS group comprised 24 patients, and the non-HERS group, 72 patients. Interventional radiologists were more frequently present upon patient arrival in the HERS than non-HERS group (IRs, 79% vs. 22%, p < 0.01). The time from arrival to AE was shorter in the HERS than non-HERS group (median [range], 46 [5-75] minutes vs. 103 [2-690] minutes, p < 0.01). There were no differences in the rate of in-hospital mortality (13% vs. 15%, p = 0.52) between the two groups. Survivors in the HERS group had a lower probability of survival by the trauma and injury severity score (median [range], 61% [1%-98%] vs. 93% [1%-99%], p < 0.01) than survivors in the non-HERS group. CONCLUSION: The HERS improved the timeliness of AE for pelvic fracture. More severely injured patients were able to survive in the HERS. The new team building involving the addition of IRs to the traditional trauma resuscitation team will enhance the benefit of the HERS. LEVEL OF EVIDENCE: Therapeutic, level IV.


Asunto(s)
Embolización Terapéutica/métodos , Servicio de Urgencia en Hospital/organización & administración , Fracturas Óseas/complicaciones , Hemorragia/terapia , Huesos Pélvicos/lesiones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Vías Clínicas/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Fracturas Óseas/diagnóstico , Fracturas Óseas/terapia , Hemorragia/etiología , Hemorragia/mortalidad , Mortalidad Hospitalaria , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente/organización & administración , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Tiempo de Tratamiento , Resultado del Tratamiento , Adulto Joven
19.
J Surg Res ; 246: 153-159, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31586889

RESUMEN

BACKGROUND: Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS). MATERIALS AND METHODS: We performed a retrospective cohort study at two level I pediatric trauma centers. INCLUSION CRITERIA: <15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics. RESULTS: We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82). CONCLUSIONS: Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.


Asunto(s)
Transporte de Pacientes/estadística & datos numéricos , Centros Traumatológicos/organización & administración , Triaje/organización & administración , Heridas no Penetrantes/diagnóstico , Heridas Penetrantes/diagnóstico , Niño , Preescolar , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Utilización de Instalaciones y Servicios/organización & administración , Utilización de Instalaciones y Servicios/normas , Utilización de Instalaciones y Servicios/estadística & datos numéricos , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/estadística & datos numéricos , Masculino , Admisión del Paciente/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Centros Traumatológicos/normas , Centros Traumatológicos/estadística & datos numéricos , Triaje/normas , Triaje/estadística & datos numéricos , Estados Unidos , Heridas no Penetrantes/terapia , Heridas Penetrantes/terapia
20.
J Surg Res ; 246: 182-189, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31593862

RESUMEN

BACKGROUND: Trauma patients with pelvic fractures have a high rate of venous thromboembolism (VTEs). The reason for this high rate is unknown. We hypothesize that fibrinolysis shutdown (SD) predicts VTE in patients with severe pelvic fracture. METHODS: Retrospective chart review of trauma patients who presented with pelvic fracture from 2007 to 2017 was performed. Inclusion criteria were injury severity score > 15, abdomen/pelvis abbreviated injury scale >/= 3, blunt mechanism, admission citrated rapid thrombelastography (TEG). Fibrinolytic phenotypes were defined by fibrinolysis on citrated rapid TEG as hyperfibrinolysis, physiologic lysis, and SD. Univariate analysis of TEG measurements and clinical outcomes, followed by multivariable logistic regression (MV) with stepwise selection, was performed. RESULTS: Overall, 210 patients were included. Most patients (59%) presented in fibrinolytic shutdown. VTE incidence was 11%. There were no significant differences in fibrinolytic phenotypes or other TEG measurements between those who developed VTE and those who did not. There was a higher rate of VTE in patients who underwent pelvic external fixation or resuscitative thoracotomy. On MV, pelvic fixation and resuscitative thoracotomy were independent predictors of VTE. CONCLUSIONS: In severely injured patients with pelvic fractures, there was a high rate of VTE and the majority presented in SD. However, we were unable to correlate initial SD with VTE. Ultimately, the high rate of VTE in this patient population supports the concept of implementing VTE chemoprophylaxis measures as soon as hemostasis is achieved.


Asunto(s)
Fibrinólisis/fisiología , Fracturas Óseas/complicaciones , Huesos Pélvicos/lesiones , Tromboembolia Venosa/epidemiología , Heridas no Penetrantes/complicaciones , Escala Resumida de Traumatismos , Adulto , Femenino , Fracturas Óseas/diagnóstico , Fracturas Óseas/fisiopatología , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tromboelastografía , Centros Traumatológicos/estadística & datos numéricos , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/fisiopatología , Heridas no Penetrantes/diagnóstico , Heridas no Penetrantes/fisiopatología
SELECCIÓN DE REFERENCIAS
DETALLE DE LA BÚSQUEDA