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Am J Crit Care 2002 May;11(3):196; author reply 196
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PMID: 12022481, UI: 22017172
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PMID: 12022480, UI: 22017171
Am J Crit Care 2002 May;11(3):194, 196
PMID: 12022479, UI: 22017170
Am J Crit Care 2002 May;11(3):188, 191-2
PMID: 12022478, UI: 22017169
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Am J Respir Crit Care Med 2002 Dec 15;166(12 Pt 1):1534-6
PMID: 12471069, UI: 22358181
Anaesthesist 2002 Jun;51(6):485-8
Hachenburg, Germany.
PMID: 12391536, UI: 22277800
Arch Dis Child 2002 Dec;87(6):561-2
PMID: 12456577, UI: 22344124
Arch Dis Child 2002 Dec;87(6):560-1
PMID: 12456575, UI: 22344122
Arch Dis Child 2002 Dec;87(6):559; author reply 560
PMID: 12456573, UI: 22344120
Arch Dis Child 2002 Dec;87(6):559-60; author reply 560
PMID: 12456572, UI: 22344119
Crit Care Nurse 2002 Oct;22(5):60-9
Oregon Health & Science University (OHSU), Portland, Ore., USA.
PMID: 12382618, UI: 22270736
J Trauma 2002 Dec;53(6):1196-7; author reply 1197-8
PMID: 12478055, UI: 22366116
J Trauma 2002 Dec;53(6):1135-8
Department of Trauma, Cook County Hospital, Chicago, IL 60612, USA.
BACKGROUND: Chest radiographs are routine for patients presenting with blunt and penetrating chest trauma. The accuracy of physical examination in the diagnosis of hemopneumothorax in these patients is unclear. A prospective study was performed to define the utility of routine portable chest radiographs in 676 trauma patients. METHODS: Over 19 months (January 2000-July 2001), 676 patients who presented with penetrating or blunt chest trauma were interviewed and examined for signs and symptoms of hemopneumothorax. The incidence of chest pain or tenderness and tachypnea was noted and both lung fields were auscultated. A portable chest radiograph was then performed on all the patients. RESULTS: All the patients were hemodynamically stable. Five hundred twenty-three patients sustained blunt trauma, with seven hemopneumothoraces (1.3%). The negative predictive values of auscultation, pain or tenderness, and tachypnea were 99& to 100%. One hundred fifty-three patients sustained penetrating chest trauma. Of these injuries, 68 were gunshot wounds and 85 were stab wounds. Twenty-four (16%) of these patients had hemopneumothoraces. The sensitivities of auscultation, pain or tenderness, and tachypnea were 50%, 25%, and 32%, respectively. The negative predictive values of these tests were < 91%. CONCLUSION: Blunt chest trauma patients who are hemodynamically stable with a normal physical examination do not require a routine chest radiograph. In contrast, all victims of penetrating trauma require chest radiographs because many will have hemopneumothorax in the absence of clinical findings.
PMID: 12478040, UI: 22366101
J Trauma 2002 Dec;53(6):1073-7
DeWitt Daughtry Family Department of Surgery, University of Miami School of Medicine, Florida 33101, USA.
BACKGROUND: The purpose of this study was to determine the appropriate time interval between the removal of a chest tube and the chest radiograph (CXR). We hypothesized that a CXR obtained 1 hour after chest tube removal would exclude the presence of a recurrent pneumothorax. METHODS: Of 214 trauma intensive care unit patients with a chest tube during a 1-year period, 75 met entry criteria and underwent chest tube removal according to an institutional review board-approved prospective study protocol. Patients were undergoing positive-pressure ventilation, with an existing solitary chest tube, and had less than 150 mL of drainage on water seal over the previous day. After chest tube removal, serial CXRs were obtained at approximately 1, 10, and 36 hours. Demographic, chest tube, and ventilator data were collected. RESULTS: None of the patients experienced hemodynamic or respiratory deterioration after chest tube removal. There were nine pneumothoraces (12%). All pneumothoraces were present on the initial CXR after chest tube removal. Two patients (3%) required intervention for pneumothorax. Of the remaining seven small pneumothoraces, three resolved and four were unchanged on the third CXR. CONCLUSION: A CXR obtained within 1 to 3 hours after chest tube removal effectively identifies pneumothorax in mechanically ventilated patients.
PMID: 12478031, UI: 22366092
J Trauma 2002 Dec;53(6):1064-7
Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey 08903-0019, USA. hammond@umdnj.edu
BACKGROUND: The intent of the study was to document initial experience with human patient simulation, using a full-scale computerized mannequin, in evaluating cognitive performance among junior surgery residents. METHODS: This was an observational study of eight postgraduate year-2 surgery residents during initial critical care rotation that assessed their responses to three unknown scenarios using a human patient simulator. RESULTS: No resident successfully completed the first scenario. Of note was a reluctance to call for help until the scenario reached a critical stage. Subsequent performance improved in areas previously neglected. Resident acceptance of simulation scenarios as a teaching tool was excellent. CONCLUSION: The human patient simulator is a valuable tool in critical care education, identifying weaknesses both in individual student performance and in program content.
PMID: 12478029, UI: 22366090
J Trauma 2002 Dec;53(6):1058-63
Department of Surgery, University of Colorado Health Sciences Center, Denver 80262, USA. casey.calkins@uchsc.edu
BACKGROUND: Although postinjury multiple organ failure (MOF) is a well-described phenomenon in adults, the incidence of this syndrome in children is unknown. The purpose of this study was to describe the incidence, course, and severity of pediatric postinjury MOF. We hypothesized that the incidence and severity of postinjury MOF in children would be less when compared with adults. METHODS: Patients were retrospectively identified from the trauma registry of a regional pediatric trauma center and an adult Level I trauma center with pediatric commitment for a 3-year period. All trauma patients less than 16 years old who survived for longer than 24 hours and had an Injury Severity Score > 15 were eligible. An accepted MOF score was used. Categorical variables were compared by chi2 and continuous variables by t test. A value of p< 0.05 was considered statistically significant. RESULTS: Of 534 patients identified, 334 (63%) were admitted for evaluation of isolated head injury and excluded from further analysis. The rate of postinjury MOF in children was found to be only 3%, with a low (17%) mortality when compared with historical adult data (50%). CONCLUSION: The incidence of postinjury MOF in the child is less than in the adult, given equivalent injury severity. These observations solidify the contention that postinjury MOF is rare in children, and is less severe when it occurs. Delineating the mechanism(s) whereby children are protected from postinjury MOF may provide insight into the development of strategies to prevent MOF in other age groups as well as various disease states.
PMID: 12478028, UI: 22366089
J Trauma 2002 Dec;53(6):1048-52
Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA.
BACKGROUND: Venous thromboembolic disease remains a difficult problem in the trauma patient population. The purpose of this study was to delineate the incidence and natural history of below-knee deep venous thrombosis (BKDVT) in high-risk trauma patients. METHODS: Patients were stratified into risk categories (low, high, or very high) for deep venous thrombosis on the basis of an institutional practice management guideline and known risk factors. All at-risk patients received either sequential compression devices (SCDs) or subcutaneous heparin (SQH) compounds, and high-risk patients also underwent weekly surveillance by duplex scanning. Very-high-risk patients had prophylactic inferior vena cava (IVC) filter placement. This prospective, observational study examines the duplex results on all high-risk patients. Data regarding method of prophylaxis, the incidence of proximal propagation on serial duplex examinations, and changes in management (anticoagulation or IVC filter placement) were collected on the high-risk patients who developed a BKDVT. RESULTS: Between March 1997 and June 2001, 601 patients were stratified into the high-risk category and underwent a total of 1,109 duplex examinations. Eighty-five patients (14.1%) had 113 BKDVTs. These patients underwent a total of 212 duplex examinations; all patients developed their BKDVTs within 34 days. Weekly incidence was 40 (47.1%), 25 (29.4%), 15 (17.6%), 1 (1.2%), and 4 (4.7%) for weeks 1 through 5, respectively. SCDs, SQH compounds, and SCDs with SQH compounds were used on 73, 3, and 9 patients, respectively. In 4 of 85 (4.7%) patients, the BKDVT propagated proximally to an above-knee location in 4 to 8 days. Two of these patients were anticoagulated, and two underwent placement of an IVC filter. One patient (1.2%) with a BKDVT that had not propagated on duplex study developed a pulmonary embolus. CONCLUSION: Patients identified as high-risk by our practice management guideline had a 14.1% incidence of a BKDVT; 94.1% were diagnosed within the first 3 weeks of hospitalization. Proximal propagation occurred in 4.7% and led to changes in management. Serial duplex examination of the BKDVT alone, rather than systemic anticoagulation or IVC filter placement, appears to be a reasonable treatment alternative.
PMID: 12478026, UI: 22366087
N Engl J Med 2003 Jan 2;348(1):66-8
PMID: 12510046, UI: 22398311
N Engl J Med 2003 Jan 2;348(1):5-14
Faculty of Medicine, University of Calgary, Calgary, Alta, Canada. sandham@ucalgary.ca
BACKGROUND: Some observational studies suggest that the use of pulmonary-artery catheters to guide therapy is associated with increased mortality. METHODS: We performed a randomized trial comparing goal-directed therapy guided by a pulmonary-artery catheter with standard care without the use of a pulmonary-artery catheter. The subjects were high-risk patients 60 years of age or older, with American Society of Anesthesiologists (ASA) class III or IV risk, who were scheduled for urgent or elective major surgery, followed by a stay in an intensive care unit. Outcomes were adjudicated by observers who were unaware of the treatment-group assignments. The primary outcome was in-hospital mortality from any cause. RESULTS: Of 3803 eligible patients, 1994 (52.4 percent) underwent randomization. The base-line characteristics of the two treatment groups were similar. A total of 77 of 997 patients who underwent surgery without the use of a pulmonary-artery catheter (7.7 percent) died in the hospital, as compared with 78 of 997 patients in whom a pulmonary-artery catheter was used (7.8 percent)--a difference of 0.1 percentage point (95 percent confidence interval, -2.3 to 2.5). There was a higher rate of pulmonary embolism in the catheter group than in the standard-care group (8 events vs. 0 events, P=0.004). The survival rates at 6 months among patients in the standard-care and catheter groups were 88.1 and 87.4 percent, respectively (difference, -0.7 percentage point [95 percent confidence interval, -3.6 to 2.2]; negative survival differences favor standard care); at 12 months, the rates were 83.9 and 83.0 percent, respectively (difference, -0.9 percentage point [95 percent confidence interval, -4.3 to 2.4]). The median hospital stay was 10 days in each group. CONCLUSIONS: We found no benefit to therapy directed by pulmonary-artery catheter over standard care in elderly, high-risk surgical patients requiring intensive care. Copyright 2003 Massachusetts Medical Society
PMID: 12510037, UI: 22398302