30 results on '"Luchette, Fred A."'
Search Results
2. Novel Simulation for Training Trauma Surgeons.
- Author
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Aboud, Emad T., Krisht, Ali F., O'Keeffe, Terence, Nader, Remi, Hassan, Moustafa, Stevens, C. Melinda, Ali, Fahd, and Luchette, Fred A.
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- 2011
- Full Text
- View/download PDF
3. Small Bowel Injuries.
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Guarino, John, Hassett, James M., and Luchette, Fred A.
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- 1995
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4. Shotgun Wounds and Pellet Emboli.
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Yoshioka, Hiroaki, Seibel, Roger W., Pillai, Kumar, and Luchette, Fred A.
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- 1995
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5. PROSPECTIVE EVALUATION OF EPIDURAL VERSUS INTRAPLEURAL CATHETERS FOR ANALGESIA IN CHEST WALL TRAUMA.
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Luchette, Fred A., Radafshar, Shahyar M., Kaiser, Roger, Flynn, William, and Hassett, James M.
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- 1994
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6. Potential Role of the Advanced Surgical Skills for Exposure in Trauma (ASSET) Course in Canada.
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Ali, Jameel, Sorvari, Anne, Haskin, Danielle, Luchette, Fred, and Bowyer, Mark
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- 2011
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7. Training and certification in surgical critical care: a position paper by the Surgical Critical Care Program Directors Society.
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Alam HB, Chipman JG, Luchette FA, Shapiro MJ, Spain DA, and Cioffi W
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- Emergency Medicine education, Female, General Surgery education, Humans, Male, Physician Executives organization & administration, Program Evaluation, Societies, Medical, United States, Workforce, Certification organization & administration, Clinical Competence standards, Critical Care organization & administration, Critical Care standards, Education, Medical, Graduate organization & administration, Education, Medical, Graduate standards
- Abstract
Delivery of Surgical Critical Care in the United States is facing multiple challenges including increasing complexity of care, escalating costs, shortage of well-trained physicians, and controversies about appropriate training and credentialing methods. In this position paper, the Surgical Critical Care Program Directors Society discusses some of these important issues and suggests a number of possible solutions.
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- 2010
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8. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.
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Napolitano LM, Kurek S, Luchette FA, Anderson GL, Bard MR, Bromberg W, Chiu WC, Cipolle MD, Clancy KD, Diebel L, Hoff WS, Hughes KM, Munshi I, Nayduch D, Sandhu R, Yelon JA, Corwin HL, Barie PS, Tisherman SA, and Hebert PC
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- Adult, Evidence-Based Medicine, Humans, Critical Care standards, Erythrocyte Transfusion standards, Traumatology standards
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- 2009
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9. Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels.
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Hershberger RC, Aulivola B, Murphy M, and Luchette FA
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- Humans, Angioplasty, Aorta, Thoracic injuries, Blood Vessel Prosthesis Implantation, Carotid Artery Injuries surgery, Pulmonary Artery injuries, Stents
- Abstract
Background: Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times., Methods: A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma., Results: In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%., Conclusion: The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.
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- 2009
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10. Broken bones and orthopedist groans: can an acute care surgeon fix both?
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Endorf FW, Esposito TJ, Reed RL 2nd, Luchette FA, and Gamelli RL
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- Databases, Factual, Humans, Injury Severity Score, Prevalence, Time Factors, United States epidemiology, Fractures, Bone epidemiology, Fractures, Bone surgery
- Abstract
Background: Increasing reluctance of specialty surgeons to participate in trauma care has placed undue burden on orthopedic traumatologists at Level I trauma centers and prompted the exploration of an expanded role for general trauma surgeons in the initial management of select orthopedic injuries (OI) as an acute care surgeon. This study characterizes OI sustained by trauma patients (TPs) to analyze the feasibility of this concept., Methods: The National Trauma Data Bank was queried for specific information relating to the profile of OI. International Classification of Diseases-9th Revision codes were used to select patients for the study who sustained OI alone or in combination with other injuries as well as to determine body region of injury and a status of open or closed fractures. Skeletal Abbreviated Injury Scale scores were used to determine the severity of fractures, and International Classification of Diseases-9th Revision procedure codes were used to identify the nature of initial operative management., Results: Of the 1,130,093 patients studied, 557,541 (49%) had one or more reported OI. Open injuries constituted 11.4% of all OIs and occurred in 7.5% of all TPs. Distribution of OIs was 23% upper extremity (18% open) and 35% lower extremity (also 18% open). These represent a 15% and 22% occurrence in TP. Pelvic and acetabular fractures occurred in 13% of OI patients (4% open) and 6% of all TP. The mean skeletal Abbreviated Injury Scale of all OIs was 2.3. For upper extremities it was 2.2, for lower extremities and for pelvic or acetabular injuries it was 2.4. Closed reduction of joint dislocation was performed in 2% of OI and 1% of all TPs. Of these, 45% were on the hip, 8% on the knee, 15% on the ankle, 13% on the elbow, and 20% on the shoulder. The distribution of initial interventions for all patients with OI was irrigation and debridement (I&D) 13%, external fixator (ex-fix) application 25%, closed reduction 41%, and closed joint relocation 10%. Of all open injuries, 17% underwent I&D and 31% underwent ex-fix application. The median time to I&D or ex-fix application was 7.2 hours. One percent of these procedures were performed within 1 hour of hospital admission, 11% within 6 hours of hospital admission., Conclusion: OI occur in a significant portion of TP reported to the National Trauma Data Bank. They most commonly involve the lower extremities and are of moderate severity. Given this profile, it seems feasible to propose that some initial procedures can be mastered by nonorthopedic surgeons and that select OI management be within the purview of a properly trained and credentialed acute care surgeon.
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- 2008
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11. Medicare's "Global" terrorism: where is the pay for performance?
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Reed RL 2nd, Luchette FA, Esposito TJ, Pyrz K, and Gamelli RL
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- Humans, Insurance, Health, Reimbursement, Surgical Procedures, Operative economics, United States, Wounds and Injuries surgery, Current Procedural Terminology, General Surgery economics, Medicare, Reimbursement, Incentive, Relative Value Scales
- Abstract
Background: Medicare and Medicaid Services (CMS) payment policies for surgical operations are based on a global package concept. CMS' physician fee schedule splits the global package into preoperative, intraoperative, and postoperative components of each procedure. We hypothesized that these global package component valuations were often lower than comparable evaluation and management (E&M) services and that billing for E&M services instead of the operation could often be more profitable., Methods: Our billing database and Trauma Registry were queried for the operative procedures and hospital lengths of stay for trauma patients during the past 5 years. Determinations of preoperative, intraoperative, and postoperative payments were calculated for 10-day and 90-day global packages, comparing them to CMS payments for comparable E&M codes., Results: Of 90-day and 10-day Current Procedural Terminology codes, 88% and 100%, respectively, do not pay for the comprehensive history and physical that trauma patients usually receive, whereas 41% and 98%, respectively, do not even meet payment levels for a simple history and physical. Of 90-day global package procedures, 70% would have generated more revenue had comprehensive daily visits been billed instead of the operation ($3,057,500 vs. $1,658,058). For 10-day global package procedures, 56% would have generated more revenue with merely problem-focused daily visits instead of the operation ($161,855 vs. $156,318)., Conclusions: Medicare's global surgical package underpays E&M services in trauma patients. In most cases, trauma surgeons would fare better by not billing for operations to receive higher reimbursement for E&M services that are considered "bundled" in the global package payment.
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- 2008
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12. Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critically ill patients.
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Abood GJ, Davis KA, Esposito TJ, Luchette FA, and Gamelli RL
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- Adult, Aged, Body Composition, Clinical Competence, Female, Humans, Judgment, Male, Middle Aged, Prospective Studies, Radiography, Thoracic, Sensitivity and Specificity, Catheterization, Central Venous adverse effects, Critical Illness
- Abstract
Background: Central venous catheterization (CVC) is routine in the management of critically ill patients. However, this procedure has complications, generally mandating a postprocedural chest radiograph (CXR) to confirm adequate position and to rule out procedure-related complications. We sought to determine whether clinician judgment could reliably predict complications and malpositioning after CVC placement, thus obviating the need for a postprocedural CXR on all lines placed., Methods: Prospective observational study of patients undergoing central line placement in the trauma, surgical, and burn intensive care units during a 12-month period. After placement, a questionnaire addressing comorbidities and the technical aspects of the procedure was completed by the clinician placing the line. The clinical impression regarding line placement was then compared with the findings on a postprocedural CXR., Results: In 147 patients, 209 CVCs were performed (mean age of 52 +/- 21 years). The population was 52% burn and 48% trauma or general surgery patients. The subclavian position was used in 78%. Ninety four percent of CVCs were without complication, whereas 3% were malpositioned and 2% resulted in pneumothorax (one delayed diagnosis at 24 hours). The incidence of complications was associated with level of training of the physician placing the line as well as the number of attempts necessary to access the vein. Clinical judgment correctly identified malpositioning in 20% of cases, and pneumothorax in 67% of cases. The person placing the line thought 68% of the CVCs were uncomplicated (corresponding complication rate 2.3%), whereas 25% thought they were technically difficult (corresponding complication rate 1%), and the remainder thought either they were associated with complications or technically not feasible, all with corresponding complications. Overall, clinical judgment had a sensitivity of 71%, specificity of 44%, positive predictive value of 97%, and negative predictive value of 6%, for an overall accuracy of only 70%., Conclusion: Clinical judgment does not reliably predict malpositioning after CVC or the presence of postprocedural complications. Chest X-ray after CVC placement in the critically ill should remain the standard of care.
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- 2007
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13. Nutritional gain versus financial gain: The role of metabolic carts in the surgical ICU.
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Davis KA, Kinn T, Esposito TJ, Reed RL 2nd, Santaniello JM, and Luchette FA
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- Adult, Aged, Critical Illness, Female, Humans, Male, Middle Aged, Predictive Value of Tests, Reproducibility of Results, Wounds and Injuries therapy, Calorimetry, Indirect, Critical Care economics, Energy Metabolism physiology, Nutritional Requirements, Rest physiology, Wounds and Injuries metabolism
- Abstract
Background: Adequate nutritional replacement of critically ill and injured patients is of paramount importance, as it decreases infectious morbidity and mortality. However, multiple methods of determining nutritional requirements exist, including mathematical formulas, weight based calculations, and the use of metabolic cart measurements, the latter of which is associated with significant labor and equipment costs. We hypothesized that metabolic cart measurements, despite increasing the cost of care, would more accurately determine nutritional requirements in a critically ill population than formulaic or weight-based calculations., Methods: Consecutive metabolic cart measurements were prospectively obtained on 59 critically ill surgery and trauma patients, and compared with predicted values as determined by the Harris-Benedict equation and weight-based calculations. Comparison was made to actual resting energy expenditure data acquired via indirect calorimetry data obtained from serial metabolic carts., Results: There were 59 patients who formed the study population, with 37% of the population having two or more metabolic cart readings (total number of cart readings was 106). There was no statistically significant difference between the metabolic cart results, the predicted resting energy expenditure as calculated by the Harris-Benedict equation adjusted with a factor of 1.5, and a weight based calculation at 30 kcal/kg adjusted body weight. Metabolic requirements were stable over time (4-48 days) without significant variation. Nutritional parameters, as evaluated by the visceral proteins prealbumin and transferrin significantly increased with time in injured patients., Conclusions: Either 30 kcal/kg adjusted body weight or the resting energy expenditure calculated from the Harris-Benedict equation multiplied by 1.5 adequately predicts the nutritional requirements of critically ill surgery and trauma patients. The addition of metabolic cart data does not provide any additional information in the determination of caloric needs in the critically ill and injured patient. In this population, omission of metabolic cart data would have saved 33,000 dollars without adversely affecting patient outcome.
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- 2006
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14. Socioeconomic factors, medicolegal issues, and trauma patient transfer trends: Is there a connection?
- Author
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Esposito TJ, Crandall M, Reed RL, Gamelli RL, and Luchette FA
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- Humans, Illinois, Injury Severity Score, Insurance Coverage, Insurance, Health, Insurance, Liability, Patient Transfer legislation & jurisprudence, Retrospective Studies, Socioeconomic Factors, Triage organization & administration, Wounds and Injuries mortality, Patient Transfer trends, Wounds and Injuries therapy
- Abstract
Background: A number of forces have come together to effect a perceived change in the volume and nature of transfers to Level I trauma centers recently. These may have little to do with the actual clinical need. This study seeks to verify whether a change in the profile of trauma transfers has occurred and to characterize the nature of any changes., Methods: Retrospective review of state trauma registry data from 1999 through 2003 including day and time of transfer, Injury Severity Score (ISS), primary ICD-9, payor status, and mortality. The transfer group (TTP) was compared with the general population of trauma patients (ATP) and variables trended. Analysis employed descriptive statistics and logistic regression. Average malpractice insurance premium charges and measures of subspecialty surgeon participation in trauma care were also trended., Results: During the study period ATP increased by 6% and TTP by 34%. The majority of transfers were from Level II to Level I trauma centers. Mean ISS increased from 9.1 to 10.0 (1.2%) in ATP and from 11.3 to 12.8 (2%) in TTP. The mortality rate over time was essentially unchanged for both groups; 4% ATP versus 5% TTP. Proportion of self-pay patients in each group remained relatively static between 20% to 25%. The number of patients with head injury (HI) increased by 14%, their transfer rate increased by 44%. Orthopedic injury (OI) prevalence increased 25% whereas transfers increased by 48%. Mean ISS increased from 13.7 to 14.8 and 11.1 to 12.9, respectively. The variables most significant for predicting transfer were arrival at initial emergency department between 3:00 pm and 7:00 am and OI or HI. Concomitantly, the mean malpractice insurance premium paid by general, orthopedic, and neurosurgeons each rose by approximately 90% during the study period. Waivers of regulatory compliance were requested by 28% of trauma centers (72% Level II) with 39% of requests related to lack of neurosurgery services., Conclusion: During the study period, a disproportionate increase in TTP occurred in comparison to ATP. This finding is more pronounced in patients with HI and OI. Findings do not appear attributable to changes in severity or proportion of self payors. The ISS of TTP is below 16. Concomitantly, there was a precipitous rise in malpractice premiums and a functional decrease in neurosurgeons. This suggests a multifactorial reluctance or inability of initial hospitals to care for patients they are theoretically capable of treating, placing undo burden on Level I centers.
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- 2006
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15. Trauma surgeons practice what they preach: The NTDB story on solid organ injury management.
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Hurtuk M, Reed RL 2nd, Esposito TJ, Davis KA, and Luchette FA
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- Adolescent, Adult, Aged, Aged, 80 and over, Case-Control Studies, Child, Child, Preschool, Female, General Surgery trends, Humans, Infant, Infant, Newborn, Kidney injuries, Logistic Models, Male, Middle Aged, Retrospective Studies, Survival Rate, Trauma Severity Indices, United States epidemiology, Wounds and Injuries epidemiology, Wounds and Injuries mortality, Wounds and Injuries therapy, Wounds, Nonpenetrating epidemiology, Wounds, Nonpenetrating mortality, Wounds, Nonpenetrating therapy, Liver injuries, Spleen injuries
- Abstract
Background: Recent studies advocate a nonoperative approach for hepatic and splenic trauma. The purpose of this study was to determine whether the literature has impacted surgical practice and, if so, whether or not the overall mortality of these injuries had changed., Methods: The American College of Surgeons' National Trauma Data Bank (NTDB 4.0) was analyzed using trauma admission dates ranging from 1994 to 2003. All hepatic and splenic injuries were identified by ICD-9 codes. As renal trauma management has not changed during the study period, renal injuries were included as a control. Nonoperative management (NOM) rates and overall mortality were determined for each organ. Proportions were compared using chi analysis with significance set at p < 0.05., Results: There were 87,237 solid abdominal organ injuries reported and included: 35,767 splenic, 35,510 hepatic, 15,960 renal injuries. There was a significant (p < 0.00000000005) increase in percentage of NOM for hepatic and splenic trauma whereas renal NOM remained stable for the study period. Despite an increase in NOM for splenic and hepatic injuries, mortality has remained unchanged., Conclusions: This study demonstrates that the management of hepatic and splenic injuries has significantly changed in the past 10 years with no appreciable effect on mortality. NOM has become the standard of care for the management of hepatic and splenic trauma. The NTDB can be used to monitor changes in trauma care in response to new knowledge regarding improved outcomes.
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- 2006
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16. Predictors of the need for nephrectomy after renal trauma.
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Davis KA, Reed RL 2nd, Santaniello J, Abodeely A, Esposito TJ, Poulakidas SJ, and Luchette FA
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- Adolescent, Adult, Blood Pressure physiology, Blood Transfusion, Child, Humans, Needs Assessment, Retrospective Studies, Shock, Hemorrhagic etiology, Trauma Severity Indices, Wounds, Nonpenetrating complications, Wounds, Nonpenetrating physiopathology, Wounds, Penetrating complications, Wounds, Penetrating physiopathology, Kidney injuries, Nephrectomy, Wounds, Nonpenetrating therapy, Wounds, Penetrating therapy
- Abstract
Background: Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma., Methods: This is a retrospective review of renal injuries admitted over a 12-year period to a Level I trauma center., Results: Ninety-seven patients (73% male) sustained a kidney injury (mean age, 27 +/- 16; mean Injury Severity Score, 13 +/- 10). Of the 72 blunt trauma patients, 5 patients (7%) underwent urgent nephrectomy, 3 (4%) had repair and/or stenting, and 89% were observed despite a 29% laparotomy rate for associated intraabdominal injuries in this group. Twenty-five patients with penetrating trauma underwent eight nephrectomies (31%), one partial nephrectomy, and two renal repairs. Regardless of the mechanism of injury, patients requiring nephrectomy were in shock, had a higher 24-hour transfusion requirement, and were more likely to have a high-grade renal laceration (all p < 0.05). Bluntly injured patients requiring nephrectomy had more concurrent intraabdominal injuries (p < 0.0001). Overall, patients after penetrating trauma were more severely injured, had higher 24-hour transfusion requirements, and a higher nephrectomy rate (all p < 0.05). Despite a higher injury severity in the penetrating group, however, mortality was higher in the bluntly injured group (p < 0.0001). Univariate predictors for nephrectomy included: revised trauma score, injury severity score, Glasgow Coma Scale score, shock on presentation, renal injury grade, and 24-hour transfusion requirement. No patient with a mild or moderate renal injury required nephrectomy, whereas 6 of 12 (50%) grade 4 injuries and 7 of 8 (88%) grade 5 injuries required nephrectomy. Multiple logistic regression analysis confirmed penetrating injury, renal injury grade, and Glasgow Coma Scale score as predictive of nephrectomy., Conclusion: Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.
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- 2006
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17. Ventilator-associated pneumonia, like real estate: location really matters.
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Eckert MJ, Davis KA, Reed RL 2nd, Esposito TJ, Santaniello JM, Poulakidas S, Gamelli RL, and Luchette FA
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- Adolescent, Adult, Female, Humans, Injury Severity Score, Male, Middle Aged, Retrospective Studies, Risk Factors, Wounds and Injuries therapy, Emergency Medical Services, Emergency Service, Hospital, Hospitalization, Intubation, Intratracheal, Pneumonia etiology, Ventilators, Mechanical adverse effects
- Abstract
Introduction: Previous work has demonstrated an increased risk of ventilator-associated pneumonia (VAP) in trauma patients after prehospital (field) intubation as compared with emergency department (ED) intubations. However, this population was not compared with patients intubated as inpatients, making data interpretation difficult. We sought to further examine predictors for the development of VAP after trauma., Methods: A 10-year retrospective review of all patients mechanically ventilated greater than 24 hours after injury was performed., Results: In all, 1,628 patients were identified, of which 1,213 (75%) were intubated as inpatients and 415 were emergently intubated (353 ED, 62 field). Overall, those intubated emergently were younger (p = 0.03) and less injured as seen by higher Glasgow Coma Scale scores (p = 0.0002), lower Injury Severity Scores (p = 0.01) and higher Revised Trauma Scores (p < 0.0001). Despite a lower injury severity, those patients emergently intubated were more likely to develop pneumonia as 22% of ED intubations and 15% of field intubations developed pneumonia, as compared with the inpatient rate of 6.5%. Pneumonia after field intubation was more likely to be community-acquired (p < 0.0001) with a significantly lower percentage of infecting enteric gram-negative rods (p < 0.0001) as compared with the inpatient and ED groups. Forward logistic regression analysis (with VAP = 1) identified inpatient intubation as protective against VAP (odds ratio 0.28, 95% CI = 0.2-0.4). Backwards logistic regression analysis further identified both field airway (odds ratio 2.29, 95% CI = 1.1-4.9) and ED airway (odds ratio 3.61, 95% CI = 2.5-5.2) as predictive of VAP., Conclusions: Compared with a population of trauma patients as inpatients, and excluding those patients mechanically ventilated less than 24 hours, patients intubated in the ED or field have a higher incidence of pneumonia, despite equivalent or lower injury severity.
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- 2006
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18. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information.
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Esposito TJ, Ingraham A, Luchette FA, Sears BW, Santaniello JM, Davis KA, Poulakidas SJ, and Gamelli RL
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- Adolescent, Adult, Aged, Aged, 80 and over, Child, Child, Preschool, Female, Gastrointestinal Hemorrhage etiology, Health Status Indicators, Humans, Infant, Male, Middle Aged, Physician's Role, Predictive Value of Tests, Prospective Studies, Spinal Cord Injuries etiology, Urethral Obstruction etiology, Digital Rectal Examination, Gastrointestinal Hemorrhage diagnosis, Spinal Cord Injuries diagnosis, Urethral Obstruction diagnosis, Wounds and Injuries complications
- Abstract
Background: Performance of digital rectal examination (DRE) on all trauma patients during the secondary survey has been advocated by the Advanced Trauma Life Support course. However, there is no clear evidence of its efficacy as a diagnostic test for traumatic injury. The purpose of this study is to analyze the value of a policy mandating DRE on all trauma patients as part of the initial evaluation process and to discern whether it can routinely be omitted., Methods: Prospective study of patients treated at a Level I trauma center. Clinical indicators other than DRE (OCI) denoting gastrointestinal bleeding (GIB), urethral disruption (UD), or spinal cord injury (SCI) were sought and correlated with DRE findings suggesting the same. Impression of the examining physician as to the need and value of DRE was also studied. Patients with a Glasgow Coma Scale Score (GCS) of 3 and pharmacologically paralyzed were excluded from the SCI analyses. UD analysis included only males., Results: In all, 512 cases were studied (72% male, 28% female) ranging in age from 2 months to 102 years. Thirty index injuries were identified in 29 patients (6%), 17 SCI (3%), 11 GIB (2%), and 2 UD (0.4%). DRE findings agreed positively or negatively with one or more OCI of index injuries in 93% of all cases (92% seeking SCI, 90% seeking GIB, 96% seeking UD). Overall, negative predictive value of DRE was the same as that of OCI, 99% (SCI 98% versus 99%, GIB, 97% versus 99%, UD both 100%). Positive predictive value for DRE was 27% and for OCI 24% (SCI 47% versus 44%, GIB 15% versus 18%, UD 33% versus 6%). Efficiency of DRE was 94% and OCI was 93%. For confirmed index injuries, indicative DRE findings were associated with 41% and OCI 73% (SCI 36% versus 79%, GIB 36% versus 73%, UD 50% versus 100%). OCIs were present in 81% of index injury cases. In all index injury cases where OCIs were absent, positive DRE findings were also absent. DRE was felt to give additional information in 5% of all cases and change management in 4%. In cases where the clinician felt DRE was definitely indicated (29%) it reportedly gave no additional information in 85% and changed management in 11%., Conclusion: DRE is equivalent to OCI for confirming or excluding the presence of index injuries. When index injuries are demonstrated, OCI is more likely to be associated with their presence. DRE rarely provides additional accurate or useful information that changes management. Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous. Elimination of routine DRE from the secondary survey will presumably conserve time and resources, minimize unpleasant encounters, and protect patients and staff from the potential for further harm without any significant negative impact on care and outcome.
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- 2005
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19. Pain management guidelines for blunt thoracic trauma.
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Simon BJ, Cushman J, Barraco R, Lane V, Luchette FA, Miglietta M, Roccaforte DJ, and Spector R
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- Analgesics, Opioid administration & dosage, Catheters, Indwelling, Comorbidity, Humans, Nerve Block, Pain Measurement, Risk Assessment, Thoracic Injuries complications, Thoracic Injuries surgery, Thoracic Surgical Procedures, Wounds, Nonpenetrating complications, Wounds, Nonpenetrating surgery, Analgesia, Epidural methods, Pain Management, Thoracic Injuries therapy, Wounds, Nonpenetrating therapy
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- 2005
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20. Combined percutaneous and angiographic thrombosis of a traumatic hepatic artery pseudoaneurysm in a child.
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Malaisrie SC, Borge MA, Glynn L, Santaniello JM, Esposito TJ, Davis KA, and Luchette FA
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- Aneurysm, False diagnostic imaging, Aneurysm, False etiology, Humans, Infant, Male, Thrombosis drug therapy, Ultrasonography, Abdominal Injuries complications, Aneurysm, False therapy, Hemostatics therapeutic use, Hepatic Artery diagnostic imaging, Thrombin therapeutic use, Wounds, Nonpenetrating complications
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- 2005
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21. Old fashion clinical judgment in the era of protocols: is mandatory chest X-ray necessary in injured patients?
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Sears BW, Luchette FA, Esposito TJ, Dickson EL, Grant M, Santaniello JM, Jodlowski CR, Davis KA, Poulakidas SJ, and Gamelli RL
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- Accidental Falls, Adolescent, Adult, Aged, Aged, 80 and over, Child, Preschool, Clinical Competence, Female, Humans, Infant, Judgment, Male, Mediastinum diagnostic imaging, Middle Aged, Prospective Studies, Rib Fractures diagnostic imaging, Sensitivity and Specificity, Thoracic Injuries diagnostic imaging, Clinical Protocols, Decision Making, Radiography, Thoracic statistics & numerical data, Wounds and Injuries diagnostic imaging
- Abstract
Background: The ATLS Course advocates that injured patients have a chest x-ray (CXR) to identify potential injuries. The purpose of this study was to correlate clinical indications and clinician judgment with CXR results to ascertain if a selective policy would be beneficial., Methods: Patients treated at a Level I trauma center over 12 months were prospectively evaluated. Before obtaining a CXR, signs, symptoms, and history suggestive of thoracic injury were identified. Additionally, a trauma surgeon (TS) recorded whether in their judgment a CXR was clinically indicated. These findings were compared with final CXR diagnoses. The sensitivity of individual clinical indicators, combinations of clinical indicators, and TS judgment for CXR abnormalities were calculated with a 95% confidence interval., Results: During the twelve-month study period, data were acquired on 772 patients (age 0-102 years). Seventy percent were male and 86.0% were injured by blunt force. Only 29% (N = 222) of the patients manifested one or more of the clinical indicators (signs and symptoms). The negative predictive value for the TS judgment was 98.2% which was superior to the clinical indicators. Reliance on the opinion of the TS to determine the need for a CXR would have eliminated 49.9% of CXRs and avoided hospital and radiologist reading charges totaling $100,078.22., Conclusion: Mandatory CXR for all trauma patients has a low yield for abnormal findings. A selective policy relying on surgical judgment guided by clinical indicators is safe and efficacious while reducing cost and conserving resources.
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- 2005
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22. Ventilator-associated pneumonia in injured patients: do you trust your Gram's stain?
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Davis KA, Eckert MJ, Reed RL 2nd, Esposito TJ, Santaniello JM, Poulakidas S, and Luchette FA
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- Adult, Analysis of Variance, Anti-Bacterial Agents therapeutic use, Bronchoalveolar Lavage methods, Bronchoalveolar Lavage standards, Cross Infection drug therapy, Cross Infection etiology, Cross Infection mortality, Female, Gram-Negative Bacterial Infections drug therapy, Gram-Negative Bacterial Infections etiology, Gram-Negative Bacterial Infections mortality, Gram-Positive Bacterial Infections drug therapy, Gram-Positive Bacterial Infections etiology, Gram-Positive Bacterial Infections mortality, Hospital Mortality, Humans, Illinois epidemiology, Length of Stay statistics & numerical data, Male, Middle Aged, Multiple Trauma complications, Multiple Trauma epidemiology, Multiple Trauma therapy, Patient Selection, Pneumonia, Bacterial drug therapy, Pneumonia, Bacterial etiology, Pneumonia, Bacterial mortality, Predictive Value of Tests, Retrospective Studies, Trauma Centers, Cross Infection diagnosis, Gentian Violet, Gram-Negative Bacterial Infections diagnosis, Gram-Positive Bacterial Infections diagnosis, Phenazines, Pneumonia, Bacterial diagnosis, Respiration, Artificial adverse effects, Sputum microbiology
- Abstract
Background: The results of sputum or bronchoalveolar lavage (BAL) fluid Gram's stain have been used to guide presumptive antibiotic therapy for ventilator-associated pneumonia (VAP) in injured patients, despite reported variability in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Our aim was to evaluate the utility of Gram's stain of BAL fluid in the diagnosis of VAP., Methods: We conducted a retrospective chart review of all mechanically ventilated trauma patients who developed pneumonia over a 5-year period in whom Gram's stain and final culture data were available., Results: One hundred fifty-five records with complete data sets were reviewed. VAP was diagnosed by Centers for Disease Control and Prevention criteria and confirmed by BAL and quantitative culture in all patients. Overall accuracy of Gram's stain in diagnosing VAP for any organism was 88% (137 true-positives). When assessed for the ability to predict pneumonia caused by a specific organism, the accuracy decreased significantly, with only 63% of Gram-negative VAPs and 72% of Gram-positive VAPs accurately identified by Gram's stain. However, the absence of Gram-positive organism of Gram's stain excludes Gram-positive VAP in 80% of patients., Conclusion: All trauma patients should be covered presumptively for gram-negative organisms, as they encompass 70% of infections, but are not reliably identified by Gram's stain. As 88% of VAP can be identified by the presence of any organism on Gram's stain, it may be useful in the early diagnosis of VAP but cannot reliably be used to guide presumptive therapy.
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- 2005
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23. Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia--a multi-center trial.
- Author
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Maxwell RA, Campbell DJ, Fabian TC, Croce MA, Luchette FA, Kerwin AJ, Davis KA, Nagy K, and Tisherman S
- Subjects
- Adolescent, Adult, Chest Tubes, Device Removal, Double-Blind Method, Female, Follow-Up Studies, Hemopneumothorax etiology, Hemopneumothorax physiopathology, Humans, Injury Severity Score, Logistic Models, Male, Middle Aged, Multivariate Analysis, Prospective Studies, Reference Values, Risk Assessment, Thoracic Injuries complications, Thoracic Injuries surgery, Thoracostomy methods, Trauma Centers, Treatment Outcome, Antibiotic Prophylaxis, Cefazolin therapeutic use, Empyema, Pleural prevention & control, Hemopneumothorax surgery, Pneumonia, Bacterial prevention & control, Thoracostomy adverse effects
- Abstract
Objective: To determine whether presumptive antibiotics reduce the risk of empyema or pneumonia following tube thoracostomy for traumatic hemopneumothorax., Methods: A prospective, randomized, double-blind trial was performed comparing the use of cefazolin for duration of tube thoracostomy placement (Group A) versus 24 hours (Group B) versus placebo (Group C)., Results: A total of 224 patients received 229 tube thoracostomies. Logistic regression analysis revealed that duration of tube placement and thoracic acute injury score were predictive of empyema (p <0.05). Empyema tended to occur more frequently in patients with penetrating injuries (p=0.09). chi analysis showed pneumonia occurred significantly more frequently in blunt than penetrating injuries (p <0.05). Presumptive antibiotic use did not significantly effect the incidence of empyema or pneumonia, although no empyemas occurred in Group A., Conclusions: The incidence of empyema was low and the use of presumptive antibiotics did not appear to reduce the risk of empyema or pneumonia.
- Published
- 2004
- Full Text
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24. Urgent airways after trauma: who gets pneumonia?
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Eckert MJ, Davis KA, Reed RL 2nd, Santaniello JM, Poulakidas S, Esposito TJ, and Luchette FA
- Subjects
- Adolescent, Adult, Age Distribution, Cohort Studies, Emergency Treatment, Female, Humans, Incidence, Injury Severity Score, Intubation, Intratracheal methods, Male, Middle Aged, Predictive Value of Tests, Probability, Prognosis, Regression Analysis, Retrospective Studies, Risk Assessment, Sex Distribution, Survival Analysis, Tracheostomy methods, Trauma Centers, Wounds and Injuries diagnosis, Intubation, Intratracheal adverse effects, Pneumonia, Bacterial epidemiology, Pneumonia, Bacterial etiology, Tracheostomy adverse effects, Wounds and Injuries epidemiology, Wounds and Injuries therapy
- Abstract
Background: Several risk factors, including emergent intubation, severe head injury, shock, blunt trauma, and high severity of injury, have been identified as risk factors for the development of pneumonia after trauma. This study assesses the contribution of emergent intubation to the development of pneumonia after injury., Methods: A retrospective review of all trauma patients requiring intubation or cricothyroidotomy in the Emergency Department (ED) or in the pre-hospital area (field) over a 41/2 year period., Results: 571 patients comprised the study population. Of these, 80% had airways established in the ED, while 20% were intubated in the field. Field intubation was associated with a lower Glasgow Coma Scale (GCS) score (p <0.0001) and more severe injury (p <0.0001), particularly to the chest and extremities.Twenty-five percent of the population developed pneumonia. Patients diagnosed with pneumonia were older (p=0.009), and had a higher ISS (p <0.0001), lower GCS score, (p <0.008), longer ICU and hospital length of stay (p < 0.0001). Injuries to the head, thorax and extremities were more common (p < 0.05) and more severe (p <0.05) in patients developing pneumonia. The incidence of pneumonia after field airway was significantly higher (35% versus 23%, p=0.048).Multiple logistic regression analysis identified field intubation, age, AIS-head, and AIS-extremity as independent risk factors for pneumonia., Conclusion: Pre-hospital but not ED intubation is an independent risk factor for the development of post-traumatic pneumonia. Other predictors include the severity of injury, specifically head and extremity injuries.
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- 2004
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25. Ten year experience of burn, trauma, and combined burn/trauma injuries comparing outcomes.
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Santaniello JM, Luchette FA, Esposito TJ, Gunawan H, Reed RL, Davis KA, and Gamelli RL
- Subjects
- Adolescent, Adult, Age Distribution, Aged, Burn Units, Burns therapy, Burns, Inhalation diagnosis, Burns, Inhalation mortality, Burns, Inhalation therapy, Child, Combined Modality Therapy, Critical Care methods, Female, Follow-Up Studies, Humans, Injury Severity Score, Logistic Models, Male, Middle Aged, Multiple Trauma therapy, Multivariate Analysis, Predictive Value of Tests, Registries, Retrospective Studies, Risk Assessment, Sex Distribution, Survival Analysis, Trauma Centers, Treatment Outcome, Burns diagnosis, Burns mortality, Cause of Death, Multiple Trauma diagnosis, Multiple Trauma mortality
- Abstract
Background: Percent total body surface area (TBSA) burn, inhalation injury (INH), and age all have been shown to be independent predictors of mortality in burn victims. Little is known regarding patients sustaining combined thermal and mechanical injuries in relation to either injury sustained in isolation or with regard to these variables. This descriptive study profiles the 10-year experience of a single American Burn Association/American College of Surgeons verified Level I trauma and burn center and the treatment of this patient population., Methods: A retrospective review of all burn and trauma patients admitted between 1990 and 2000. Patients were divided into three groups; Burn only (B), Trauma only (T), and combined Burn/Trauma (B/T). Groups were compared with respect to age, TBSA burn, length of stay (LOS), Injury Severity Score (ISS), INH and mortality. These groups were then compared with B, T and B/T patients from the National Burn Repository (NBR) and National Trauma Data Bank (NTDB). Student's t test and chi tests were performed, as well as multiple logistic regression to identify independent predictors of mortality. p <0.05 was considered significant., Results: Through our trauma registry, 24,093 patients were identified (T=22,284, B=1717 and B/T=92). When comparing B and T, there was no difference in age, LOS, ISS, or mortality to those patients in the NBR or NTDB. B/T patients showed significantly increased percentage with INH (B/T=44.5% versus 11%), increased LOS (B/T=18 days versus 13.7 B and 5.3 T) and increased mortality (B/T=28.3% versus 9.8% B and 4.3% T). B/T were also significantly older (B/T=40.1 years versus 31.0 B and 35.1 T). When these variables are compared with the NBR and the NTDB benchmarks, mortality (28.3% versus 11.6% NBR and 7.0% NTDB) and ISS (23 versus 11.7 NTDB) were significantly higher with no difference in age (40.1 versus 33.4 NTDB, 35.9 NBR), LOS (18 days versus 23.3 NBR) or TBSA (20.8% versus 19.5% NBR). Multiple logistic regression comparing TBSA, age, ISS and INH of survivors versus non-survivors identified only ISS as an independent predictor of mortality., Conclusion: B combined with T presents a rare injury pattern that has a synergistic effect on mortality. Physicians and caregivers should be aware of a 2-3 fold increase in the incidence of INH in this population, and increased mortality despite similar TBSA burned when compared with patients with B as the sole mechanism; ISS appears to be an independent predictor of mortality in this combined injury pattern.
- Published
- 2004
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26. Guidelines for emergency tracheal intubation immediately after traumatic injury.
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Dunham CM, Barraco RD, Clark DE, Daley BJ, Davis FE 3rd, Gibbs MA, Knuth T, Letarte PB, Luchette FA, Omert L, Weireter LJ, and Wiles CE 3rd
- Subjects
- Glasgow Coma Scale, Humans, Injury Severity Score, Emergency Medical Services, Guidelines as Topic, Intubation, Intratracheal, Wounds and Injuries classification, Wounds and Injuries therapy
- Published
- 2003
- Full Text
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27. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial.
- Author
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Fakhry SM, Watts DD, and Luchette FA
- Subjects
- Humans, Intestinal Perforation epidemiology, Intestinal Perforation mortality, Multicenter Studies as Topic, Prevalence, Registries, Retrospective Studies, United States epidemiology, Wounds, Nonpenetrating epidemiology, Wounds, Nonpenetrating mortality, Intestinal Perforation diagnosis, Intestine, Small injuries, Trauma Centers statistics & numerical data, Wounds, Nonpenetrating diagnosis
- Abstract
Objectives: Blunt SBI is infrequent and its diagnosis may be difficult, especially in the face of confounding variables. The purpose of this study was to evaluate methods for making the diagnosis of blunt SBI., Methods: Patients with blunt small bowel injury (SBI) were identified from the registries of 95 trauma centers for a 2-year period (1998-1999). Patients with SBI (cases) were matched by age and Injury Severity Score with a blunt trauma patient receiving an abdominal workup who did not have SBI (controls)., Results: Logistic regression models were unable to differentiate SBI with perforation from SBI without perforation. Thirteen percent of patients with documented perforating SBI had normal abdominal computed tomographic scans preoperatively., Conclusion: Alone or in combination, current diagnostic approaches lack sensitivity in the diagnosis of perforated SBI. Improvements in diagnostic methods and approaches are needed to ensure the prompt diagnosis of this uncommon but potentially devastating injury.
- Published
- 2003
- Full Text
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28. Preliminary report on the safety of heparin for deep venous thrombosis prophylaxis after severe head injury.
- Author
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Kim J, Gearhart MM, Zurick A, Zuccarello M, James L, and Luchette FA
- Subjects
- Abbreviated Injury Scale, Adult, Age Distribution, Aged, Anticoagulants adverse effects, Cerebral Hemorrhage chemically induced, Cerebral Hemorrhage diagnosis, Comorbidity, Drug Monitoring, Head Injuries, Closed diagnosis, Head Injuries, Closed therapy, Heparin adverse effects, Humans, Middle Aged, Neurologic Examination, Retrospective Studies, Risk Factors, Time Factors, Tomography, X-Ray Computed, Trauma Centers, Treatment Outcome, Anticoagulants therapeutic use, Head Injuries, Closed complications, Heparin therapeutic use, Safety, Thromboembolism etiology, Thromboembolism prevention & control, Venous Thrombosis etiology, Venous Thrombosis prevention & control
- Abstract
Background: Prophylaxis for venous thromboembolism (VTE) in head injured patients has avoided heparin products because of concern for exacerbating intracranial bleeding. The purpose of this study was to evaluate the safety of unfractionated heparin (UFH) for VTE prophylaxis after traumatic brain injury., Methods: We retrospectively evaluated the early use of UFH in patients sustaining a severe closed head injury (Abbreviated Injury Scale score > 3) from January 1, 2000, through December 31, 2000. Two groups were formed on the basis of the timing of UFH administration: within 72 hours of admission (Early group), or after the third day of hospitalization (Late group), if at all. Intracranial bleeding related to UFH administration was assessed by computed tomographic scan of the head and/or clinical examination., Results: Sixty-four of 76 patients with intracranial blood on admission head computed tomographic scan fulfilled study criteria. Seventy-three percent (n = 47) were in the Early group and 27% (n = 17) were in the Late group. None of the Early group had an increase in intracranial bleeding or deterioration on neurologic examination as a result of UFH administration. However, there was no statistical difference in VTE events between the two groups., Conclusion: Early use of UFH in the severe head injured patient does not increase bleeding complications.
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- 2002
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29. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group.
- Author
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Rogers FB, Cipolle MD, Velmahos G, Rozycki G, and Luchette FA
- Subjects
- Anticoagulants therapeutic use, Bandages standards, Evidence-Based Medicine, Heparin therapeutic use, Humans, Phlebography standards, Research Design standards, Risk Factors, Sensitivity and Specificity, Thromboembolism diagnosis, Traumatology standards, Ultrasonography, Doppler standards, Vena Cava Filters standards, Venous Thrombosis diagnosis, Multiple Trauma complications, Thromboembolism etiology, Thromboembolism prevention & control, Traumatology methods, Venous Thrombosis etiology, Venous Thrombosis prevention & control
- Published
- 2002
- Full Text
- View/download PDF
30. Hypoxia is not the sole cause of lactate production during shock.
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Luchette FA, Jenkins WA, Friend LA, Su C, Fischer JE, and James JH
- Subjects
- Analysis of Variance, Animals, Epinephrine pharmacology, Ethanol pharmacology, Lactic Acid blood, Male, Microdialysis, Ouabain pharmacology, Rats, Rats, Sprague-Dawley, Regional Blood Flow drug effects, Hypoxia metabolism, Lactic Acid biosynthesis, Shock, Hemorrhagic metabolism, Sodium-Potassium-Exchanging ATPase metabolism
- Abstract
Background: Traditionally, elevated blood lactate after hemorrhage is interpreted as tissue hypoperfusion, hypoxia, and anaerobic glycolysis. The severity and duration of the increase in blood lactate correlate with death. Recent in vitro studies indicate that epinephrine stimulates lactate production in well-oxygenated skeletal muscle by increasing activity of the Na+-K+-adenosine triphosphatase (ATPase), which derives a significant amount of adenosine triphosphate from glycolysis. Using in vivo microdialysis, we tested whether inhibiting the Na+-K+ pump with ouabain could reduce muscle lactate production during local exposure, via the microdialysis probe, to epinephrine or during hemorrhage in rats., Methods: Microdialysis catheters were placed in the muscle of both thighs of pentobarbital-anesthetized male Sprague-Dawley rats (275-350 g) and perfused (1 microL/min) with Krebs-phosphate buffer (pH 7.4) containing ethanol (5 mmol/L) to permit assessment of changes in local blood flow. To inhibit the Na+-K+-ATPase, ouabain (2-3 mmol/L) was added to the perfusate of one leg. In one series of studies, epinephrine was added to the perfusate. In another series, rats were hemorrhaged to a mean arterial pressure of 45 mm Hg for 30 minutes, followed by resuscitation with shed blood and 0.9% sodium chloride. Dialysate fractions were analyzed for lactate and ethanol fluorometrically., Results: Lactate rose during epinephrine exposure or during hemorrhage and resuscitation. Treatment with ouabain reduced dialysate lactate concentration significantly in both series of studies. Local blood flow was reduced by either epinephrine or hemorrhage, but returned toward baseline afterward. Ouabain had no apparent effect on local blood flow., Conclusion: Increased Na+-K+ATPase activity during epinephrine treatment or hemorrhage contributes to muscle lactate production. Hypoxia is not necessarily the sole cause of hyperlactatemia during and after hemorrhagic shock.
- Published
- 2002
- Full Text
- View/download PDF
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