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D Fortlage

Publications and source records attributed to D Fortlage.

13 recordsLinked to original sources
PubMed2001

Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center.

INTRODUCTION: We present our experience in the management of penetrating pancreatic injuries, focusing on factors related to complications and death. METHODS: Retrospective trauma registry-based analysis of 62 consecutive patients with penetrating pancreatic injuries during an 11-year period. Overall injury severity was assessed by the injury severity score (ISS) and the penetrating abdominal trauma index (PATI). Pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS). Complications were characterised using standardised definitions. Mortality was recorded as early (within 48 h after admission) and late (after 48 h). RESULTS: Thirty patients suffered gunshot wounds and 24 had grade I pancreatic injuries. Shotgun and gunshot wounds were more destructive than stab wounds (higher PATI, number of intraabdominal injuries and mortality). Seventeen patients died. Most deaths occurred within 1 h after admission due to massive bleeding and severe associated injuries. Only one death was potentially related to the pancreatic injury. Mortality rate also correlated with pancreatic injury grading. Sixty-one patients had associated intraabdominal injuries. Combined pancreaticoduodenal injuries were present in 13 patients, and five died. Simple drainage was the most common procedure performed. Pancreas-related complications were found in 12 out of 47 patients who survived more than 48 h; intraabdominal abscess (n=7) that was associated with colon injuries, and pancreatic fistula (n=5). CONCLUSION: An approach based on injury grade and location is advised. Routine drainage is recommended; distal resection is indicated in the presence of main duct injury, and the management of severe injuries will be tailored according to the overall physiologic status, presence of associated injuries, and duodenal viability. Morbidity and mortality is mainly due to associated injuries.

Abdominal Abscess↗
PubMed2001

The 15-year evolution of an urban trauma center: what does the future hold for the trauma surgeon?

BACKGROUND: Safer cars, decreased violence, and nonoperative management have changed the trauma patient's nature. We evaluated changes in a Level I trauma center over 15 years and considered their effect on trauma surgeons. METHODS: From January 1985 through August 1999, 16,799 trauma registry patients were analyzed for mechanism of injury, Injury Severity Score, and procedures. RESULTS: Mean Injury Severity Score decreased from 15.9 to 10.7 and length of stay fell from 8.0 days to 5.9 days. There were significant decreases in penetrating trauma admissions and percentage of patients with Abbreviated Injury Scale score > 3 for head, chest, and abdomen. Frequency of craniotomy, thoracotomy, and laparotomy dropped dramatically. CONCLUSION: Significant decreases in injury severity, penetrating violence, and operations have occurred over 15 years. These changes will have profound effects on the practice of trauma surgeons and on surgical education.

Abdominal Injuries↗
PubMed1998

Trauma in pregnancy: maternal and fetal outcomes.

OBJECTIVE: Pregnancy imposes significant physiologic demands that may confuse and complicate the evaluation, resuscitation, and definitive management of pregnant women who sustain trauma. Accurate prediction of fetal outcome after trauma remains elusive. The objective of this study was to characterize patterns of injury in pregnant women, to determine if pregnancy affects maternal morbidity and mortality after trauma, and to identify predictors of fetal death. METHODS: We performed a retrospective, case-control analysis of all injured pregnant patients admitted to the Trauma Service at the University of California San Diego Medical Center from 1985 to 1995. RESULTS: We identified 114 injured pregnant patients. Motor vehicle crashes accounted for 70% of injuries, and of these, 46% of patients were not using seat belts or helmets. Violence accounted for 12% of injuries. Injured pregnant women with Injury Severity Scores > 8 demonstrated similar mortality, morbidity, and length of stay to matched nonpregnant control patients. Pregnant women were more likely to sustain serious abdominal injury and were less likely to sustain severe head injury. Identified risk factors for fetal loss include maternal death, overall maternal injury severity, the presence of severe abdominal injury, and the presence of hemorrhagic shock. CONCLUSION: There appears to be a group of pregnant women in San Diego at high risk for traumatic injury who should be targeted for preventative strategies including improved seat belt use. Pregnancy does not increase mortality or morbidity after trauma but influences the pattern of injury. Maternal death, high Injury Severity Score, serious abdominal injury, and hemorrhagic shock are risk factors for fetal loss.

Abdominal Injuries↗
PubMed1997

Is operating room resuscitation a way to save time?

BACKGROUND: Direct admission to the operating room (OR) can shorten the time to incision. A protocol for operating room resuscitation was established with patient triage based on (1) cardiac arrest, (2) hypotension unresponsive to field fluid resuscitation, or (3) uncontrolled external hemorrhage. METHODS: Operating room resuscitation over 11 years was reviewed to determine whether the triage criteria correctly identified patients requiring operation. Survival was analyzed and compared with the probability of survival (Ps) determined at the scene. RESULTS: Operating room resuscitation patients were more likely to require a major operation regardless of mechanism of injury. Of 476 patients with penetrating injury, 170 patients had persistent low blood pressure (<90 mm Hg), and 146 (85.9%) of these required major operative intervention. The mean time to incision in this group was 21.7-67.5 minutes less than for patients not receiving OR resuscitation. Observed survival was significantly greater than that predicted for this group. CONCLUSIONS: Field triage criteria are able to reliably identify patients who require immediate major operative intervention. Direct admission to the OR results in a more timely initiation of operative therapy for patients requiring emergency surgical procedures.

Adult↗
PubMed1996

The ongoing challenge of retroperitoneal vascular injuries.

BACKGROUND: Retroperitoneal vascular injury remains one of the most frequent causes of death following abdominal trauma. A risk analysis of the association between potential outcome predictors and mortality following abdominal aorta and inferior vena cava injuries was performed. METHODS: Eighty-nine patients sustaining abdominal aortic or inferior vena cava injury were concurrently evaluated for a 10-year period and retrospectively reviewed. A multiple logistic regression model evaluated the following variables:presence of shock on admission, base deficit (< -10 or > or = -10), classification by the organ injury scale (OIS), blood transfusion, crystalloid infusion, total infusion volume, associated injuries, site of injury, and presence of retroperitoneal tamponade. RESULTS: Overall mortality for all injuries was 57%. Excluding all death on arrival (DOA) patients, the mortality rate decreased to 45.7%. Death following abdominal aortic injuries was significantly associated with free bleeding in the peritoneal cavity, acidosis, and an injury in the suprarenal location (OIS > 4). For inferior vena cava injuries and combined abdominal aortic and inferior vena cava injuries, death was associated with free bleeding, the suprarenal location (OIS = 4), and the presence of shock on admission as well. CONCLUSIONS: Despite advances in transport and resuscitation, mortality of aortic and vena cava injuries remains unchanged. Shock on admission, bleeding without retroperitoneal tamponade, acidosis, and the suprarenal location each play a significant role in mortality. Immediate identification associated with a rapid surgical approach are the only factors that may improve survival of such devastating injuries.

Adolescent↗
PubMed1994

Analysis of recurrent process errors leading to provider-related complications on an organized trauma service: directions for care improvement.

Complications in trauma care occur because of provider-related or patient disease-related events. Strictly defined standardized definitions of both types of complications are needed to develop strategies for problem resolution. The frequency and characteristics of 135 disease-related and provider-related complications were examined for a 3-year period in a level I university trauma service in all patients meeting Major Trauma Outcome Study (MTOS) criteria. Provider-related complications were analyzed for recurrent process errors to be targeted for corrective action. Complication events occurred in 2764 of 3327 patients, with provider-related complications in 759. Twenty-three percent (175) of complications were judged unjustified and 16 patterns of recurrent process-of-care errors were identified. Delay in trauma team activation was caused by insensitivity of field triage protocols and inadequate recognition of injury patterns. Delays in diagnosis or surgery were caused by inadequate performance of standard work-up, inadequate recognition of injury severity by providers, diagnostic procedure interpretation errors, and errors in prioritizing the order of diagnostic procedures. Errors in technique were attributed to inexperience, haste, unfamiliarity with devices, lack of developed institutional techniques, and failure of providers to use recognized endpoints. Errors in judgment were attributed to failure to access available patient information, proceeding despite available information, and failure to utilize available care guidelines. Further reduction in provider-related morbidity in an organized trauma system requires this type of analysis, which identifies the need to change the process of care through education or adjustment of protocols for standardization care delivery in addition to the traditional focus on outcomes.

Adult↗
PubMed1993

In-house board-certified surgeons improve outcome for severely injured patients: a comparison of two university centers.

The benefit derived from in-house board-certified attending surgeons (IHBCS) staffing trauma centers has recently been questioned. We compared the outcomes and provider-related complications of patients with severe injuries who were treated at two university trauma centers, one with IHBCS, and one with PGY-4 or PGY-5 residents in house (RIH). The RIH center had a significantly longer resuscitation time (160 vs. 58.8 minutes; p < 0.01). Except in cases of vascular injury, the odds ratio of dying at the RIH institution was significantly greater in all groups when the variables of transport time, Revised Trauma Score, and ISS were controlled. Errors in judgment were significantly more likely to have been made at the RIH institution in all groups. It is concluded that the management and ultimate outcome are significantly improved when IHBCS are involved with the resuscitation and early care of specific cohorts of severely injured patients.

Adult↗
PubMed1993

A risk analysis of pulmonary complications following major trauma.

Varying institutional definitions and degrees of surveillance limit awareness of the true incidence of posttraumatic pulmonary complications. Prospective review with standardized definitions of 25 categories of pulmonary complications was applied to a university level I trauma service over 3 years to establish the true incidence. Potential injury-related predictors of individual complications were determined using multiple logistic regression analysis and adjusted odds ratios were calculated, thereby controlling for the effect of other covariants. Significance was attributed to p < 0.05. Of 3289 patients meeting MTOS criteria, pulmonary complications occurred in 368 (11.2%). Pulmonary complications account for one third of all disease complications. Significant associations with pneumonia included age, the presence of shock on admission, significant head injury, and surgery to the head and chest. Significant risk for atelectasis occurred in patients with blunt injury mechanism, ISS > 16, shock on admission, and severe head injury. Risks for development of respiratory failure included age > 55 years, the mechanism of "pedestrian struck", and the presence of significant head injury. Risk factors for ARDS included surgery to the head and a Trauma Score < 13 on arrival. Significant predictors for pulmonary embolism included ISS > 16, shock on admission, and extremity and pelvis injuries. The true incidence of pulmonary complications is established with this kind of analysis and focuses attention on (1) groups at high risk for developing complications, (2) groups for which current therapeutic modalities are still ineffective, and (3) defining the need to refocus on prospective research rather than ineffective processes of care.

Adult↗
PubMed1992

An evaluation of provider-related and disease-related morbidity in a level I university trauma service: directions for quality improvement.

As the number of preventable trauma-related deaths plateaus as a result of trauma system development, new directions for quality improvement in trauma care must come from analyzing morbidity with standardized methods to establish thresholds for provider-related and disease-specific complications. To establish such thresholds and determine priorities for improvements in quality all trauma patients who died, who were admitted to the ICU or OR, who were hospitalized for more than 3 days, or who were interfacility transfers to an academic trauma service, were concurrently evaluated for 1 year. All complication events were defined, reviewed, tabulated, and classified using 135 categories of complications. These categories were subdivided into provider-specific and disease-specific complications. Provider-related complications were classified as justified or unjustified to allow identification of events with a potential for improvement. A total of 1108 patients were admitted (mean ISS, 17); there were 97 deaths. Three potentially preventable deaths were identified, 857 complication events were identified, and 285 provider-related complications were responsible for errors with potential for improvement in 59 events (21%). Disease-specific morbidity was primarily related to infection; pneumonia accounted for 36% of all infectious complications and systemic infection for only 8.6% of infectious complications. Organ failure and other major systemic complications occurred in 2%-8% of patients. This type of analysis forms the basis on which to determine thresholds of provider-specific and disease-specific morbidity in a trauma hospital and serves as a guide to direct efforts toward continuous quality improvement.

Adult↗
PubMed1990

The trauma triage rule: a new, resource-based approach to the prehospital identification of major trauma victims.

STUDY OBJECTIVE: To develop a new trauma decision rule. DESIGN: Retrospective clinical review. SETTING: Level I trauma center. TYPE OF PARTICIPANTS: 1,004 injured adults. MEASUREMENTS AND MAIN RESULTS: A new trauma decision rule was derived from 1,004 injured adult patients using a new operational definition of major trauma. The rule, termed the Trauma Triage Rule, defines a major trauma victim as any injured adult patient whose systolic blood pressure is less than 85 mm Hg; whose motor component of the Glasgow Coma Score is less than 5; or who has sustained penetrating trauma of the head, neck, or trunk. Using the operational definition of major trauma, the rule had a sensitivity of 92% and a specificity of 92% when tested on the 1,004-patient cohort. CONCLUSION: The Trauma Triage Rule may significantly reduce overtriage while only minimally increasing undertriage. This approach must be validated prospectively before it can be used in the prehospital setting.

Adolescent↗
PubMedDate not supplied

Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews.

The use of prehospital tube thoracostomy (TT) for the treatment of suspected tension pneumothorax (TPtx) in trauma patients is controversial. A study is presented that reviews a 6-year experience with the use of needle catheter aspiration (NA) and chest tubes performed in the field by air medical personnel. Prehospital flight charts and hospital records from 207 trauma patients who underwent one or both of these procedures in the field were retrospectively reviewed. The clinical indications used to determine treatment are presented for both procedures. Improvement in clinical status of patients observed by flight personnel were similar for both treatment groups (54% for NA, 61% for TT). Thirty-two (38%) of the TT patients had failed NA attempts prior to chest tube placement. Average time on scene (T.O.S.) was significantly greater for the TT group (25.7 min versus 20.3 min for NA group). Fewer patients were pronounced dead on arrival (D.O.A.) with TT treatment compared to NA alone (7% versus 19%, respectively). Injury severity scores, number of hospital complications, length of stay (L.O.S.), and total hospital costs were not different between the two groups. There were no cases of lung damage or empyema formation associated with prehospital TT treatment. Overall mortality was similar for both groups. From these data, we conclude that NA is a relatively rapid intervention in the treatment of suspected TPtx in the prehospital setting; however, TT is an effective adjunct for definitive care without increasing morbidity or mortality. A better understanding of the physiology of intrapleural air masses is needed to determine the most effective decompression requirements prior to aeromedical transport.

Adolescent↗
PubMedDate not supplied

Intubation techniques in the helicopter.

The purpose of this study is an analysis of 630 field intubations of trauma patients by flight personnel of the San Diego Life Flight program. We compared nasotracheal intubation to rapid sequence induction orotracheal intubation and noninduced orotracheal intubation. We measured success of intubation route, complications, and overall patient outcome. Flight records, quality assurance flight procedure data, and hospitalization data from the San Diego Trauma Registry were reviewed over a 4-year period, from 1988 to 1991. The results of our study show that rapid sequence induction orotracheal intubation has a higher success rate, fewer complications, and a better patient outcome compared to noninduced orotracheal intubation and blind nasotracheal intubation. We recommend that rapid sequence induction oral intubation be the standard method for prehospital airway management in trauma patients.

Adult↗