Evaluation of initial base deficit as a prognosticator of outcome in the pediatric trauma population.

Although the utility of the base deficit as an indicator of hypoperfusion and physiologic derangement in adults is well established, its value in the assessment of children is not as clear. The purpose of this study was to evaluate this tool with regard to injury severity, infectious morbidity, and outcome in a pediatric trauma population. A retrospective review of a 6-year period of the database of our level 1 pediatric trauma center was performed. One hundred seventeen severely injured children requiring mechanical ventilation were identified. Initial base deficit, Injury Severity Score, time to correction of this abnormality, ventilator days, infectious morbidity, and mortality were obtained and compared. Of the 117 patients included in this study, 30 patients were identified with an initial BD of less than or equal to -8 mEq/L and were placed into group 1. Group 2 consisted of the remaining 87 patients who presented with a base deficit (BD) of greater than -8 mEq/L. An admission base deficit of -8 mEq/L or less corresponded to a probability of mortality of 23 per cent as opposed to only 6 per cent with a BD greater than -8. Patients in group 1 remained on mechanical ventilation 9.4 +/- 8.1 days, whereas patients in group 2 remained ventilated 6.5 +/- 6.4 days; an increase of nearly 145 per cent. Likewise, the number of infectious complications rose 26 per cent with a worsening initial base deficit from 17 per cent of group 2 patients to 43 per cent of group 1 patients. We conclude that a high initial base deficit in injured children predicts a higher incidence of infectious complications and a less favorable outcome. This readily available laboratory study can identify those children most at risk of potentially preventable complications.

Video assessment of trauma response: adherence to ATLS protocols.

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

Complications of 32% dextran-70 in 10% dextrose. A case report.

BACKGROUND: Thirty-two percent dextran-70 in 10% dextrose is a useful distention medium for hysteroscopic surgery. However, the side effects profile is considerable. CASE REPORT: A young woman underwent hysteroscopic evaluation for menorrhagia. Postoperatively, she suffered severe noncardiogenic pulmonary edema, disseminated intravascular coagulopathy and acute anuric renal failure. CONCLUSION: Precautions must be taken when using 32% dextran-70 in 10% dextrose to avoid its potentially life-threatening complications.

Management of trauma in the elderly patient.

Injuries among the elderly are a common occurrence and, as the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly sustain the same injuries that younger people do; however, because of a variety of age-related processes, the elderly suffer more severe consequences from these injuries. Epidemiologic factors and physiologic processes are used to explain the "susceptibility" of the elderly population to traumatic injuries. Recommendations for initial resuscitation and management of specific injuries are presented along with general principles of injury prevention and rehabilitation. The socioeconomic cost of trauma in the elderly is discussed in terms of physical disabilities and financial burdens.

CT detection of occult pneumothorax in multiple trauma patients.

Chest injuries are the cause of death in 25% of trauma fatalities, and a major contributing factor in an additional 50%. Pneumothorax, the second most common chest injury, may often be initially overlooked. Administration of anesthesia and mechanical ventilation may produce enlargement of a pneumothorax and clinical deterioration. We reviewed 90 trauma patients who had been admitted with a diagnosis of pneumothorax or who had developed pneumothoraces after hospital admission. In 35 cases (38.8%), initial supine chest x-ray study failed to detect a pneumothorax, and the diagnosis was made on CT scan of the chest or abdomen performed within 2 hours of admission. In 15 of these cases (42.8%), identification of the pneumothorax on CT scan resulted in alterations in management, including chest tube placement in 10 patients and intensified monitoring in 5 patients. Failure to identify pneumothoraces in trauma patients may lead to deterioration and significant complications in patients requiring anesthesia or mechanical ventilation. CT scan may facilitate identification in these cases.