The Journal of trauma (J Trauma Inj Infect Crit Care )

Publisher: American Association for the Surgery of Trauma; Eastern Association for the Surgery of Trauma; Trauma Association of Canada; Western Trauma Association


The Journal of Trauma® Injury, Infection, and Critical Care provides a specific focus on traumatic injury, as well as a wide range of subjects within this general field. Emphasizing clinical applications, techniques, and new developments in trauma care, each issue presents practical information of immediate use to the physician caring for critically injured patients.

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    Journal of Trauma, Injury, Infection, and Critical Care, The website
  • Other titles
    Journal of trauma (Online), The journal of trauma, Journal of trauma: injury infection, and critical care
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    Document, Periodical, Internet resource
  • Document type
    Internet Resource, Computer File, Journal / Magazine / Newspaper

Publications in this journal

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    ABSTRACT: Weaning from mechanical ventilation; trauma; pulmonary contusion
    The Journal of trauma 01/2014; 76(1):249.
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    ABSTRACT: BACKGROUND: Crush syndrome (CS) is characterized by ischemia/reperfusion-induced rhabdomyolysis and the subsequent onset of systemic inflammation. CS is associated with a high mortality, even when patients are treated with conventional therapy. We hypothesized that treatment of lethal CS rat model with dexamethasone (DEX) have therapeutic effects on the laboratory findings and clinical course and outcome. METHODS: To create a CS model, anesthetized rats were subjected to bilateral hind limb compression with rubber tourniquets for 5 hours and randomly divided into three groups as follows: saline-treated CS group, CS groups treated with low (0.1 mg/kg) and high doses (5.0 mg/kg) of DEX. Saline for the CS group or DEX for the DEX-treated CS groups was intravenously administered immediately before reperfusion. Under continuous monitoring and recording of arterial blood pressures, blood and tissue samples were collected for histologic and biochemical analysis at designated period before and after reperfusion. RESULTS: Ischemic compression of rat hind limbs reduced the nitrite content in the crushed muscle, and the subsequent reperfusion induced reactive oxygen species-mediated circulatory collapse and systemic inflammation, finally resulting in a mortality rate of 76% by 48 hours after reperfusion. A single injection of high-dose DEX immediately before reperfusion activated endothelial nitric oxide synthase (eNOS) by sequential phosphorylation through the nongenomic phosphoinositide 3-kinase (PI3K)-Akt-eNOS signaling pathway. DEX also exhibited anti-inflammatory effects by modulating proinflammatory and anti-inflammatory mediators, consequently suppressing myeloperoxidase activities and subsequent systemic inflammation, showing a complete recovery of the rats from lethal CS. CONCLUSION: These results indicate that high-dose DEX reduces systemic inflammation and contributes to the improved survival rate in a rat CS model.
    The Journal of trauma 05/2013;
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    ABSTRACT: BACKGROUND: Hemorrhage following traumatic injury is a leading cause of military and civilian mortality. Noncompressible torso hemorrhage (NCTH) has been identified as particularly lethal, especially in the prehospital setting. METHODS: All patients sustaining NCTH between August 2002 and July 2012 were identified from the UK Joint Theatre Trauma Registry. NCTH was defined as injury to a named torso axial vessel, pulmonary injury, solid-organ injury (Grade 4 or greater injury to the liver, kidney, or spleen) or pelvic fracture with ring disruption. Patients with ongoing hemorrhage were identified using either a systolic blood pressure of less than 90 mm Hg or the need for immediate surgical hemorrhage control. Data on injury pattern and location as well as cause of death were analyzed using univariate and multivariate analyses. RESULTS: During 10 years, 296 patients were identified with NCTH, with a mortality of 85.5%. The majority of deaths occurred before hospital admission (n = 222, 75.0%). Of patients admitted to hospital, survivors (n = 43, 14.5%) had a higher median systolic blood pressure (108 [43] vs. 89 [46], p = 0.123) and Glasgow Coma Scale (GCS) (14 [12] vs. 3 [0], p < 0.001) compared with in-hospital deaths (n = 31, 10.5%). Hemorrhage was the more common cause of death (60.1%), followed by central nervous system disruption (30.8%), total body disruption (5.1%), and multiple-organ failure (4.0%). On multivariate analysis, major arterial and pulmonary hilar injury are most lethal with odds ratio (95% confidence interval) of 16.44 (5.50-49.11) and 9.61 (1.06-87.00), respectively. CONCLUSION: This study demonstrates that the majority of patients sustaining NCTH die before hospital admission, with exsanguination and central nervous system disruption contributing to the bulk cause of death. Major arterial and pulmonary hilar injuries are independent predictors of mortality.
    The Journal of trauma 01/2013; 75((2 Suppl 2)):S263-8.
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    ABSTRACT: BACKGROUND: Proximal traumatic lower-extremity amputation has become the signature injury of the war in Afghanistan. Casualties present in extremis and often require immediate operative control of arterial inflow to prevent exsanguination. This study evaluated the use of this strategy and its complications. METHODS: This is a retrospective analysis of case notes of UK service personnel, identified from the UK Joint Theatre Trauma Registry, who sustained traumatic lower-extremity amputation requiring suprainguinal vascular control, following improvised explosive device injury in Afghanistan, between July 2008 and December 2010. RESULTS: Fifty-one casualties were identified with a median Injury Severity Score (ISS) of 30. In 10 casualties, control was obtained via an extraperitoneal approach, and in 41, control was obtained via midline laparotomy and intraperitoneal (IP) approach. The most commonly controlled vessel in extraperitoneal control was the external iliac artery, and in IP control, the common iliac artery. Within the 41 patients who had IP control, 13 also required a therapeutic laparotomy, and 9 patients had bilateral injuries at the level of the proximal femur or higher. One patient, who had undergone IP control, experienced an injury to the common iliac vein, which was repaired. There were no other immediate complications recorded, and 39 casualties survived to discharge. CONCLUSION: This is the first study to characterize the methods of proximal control in high wartime lower-extremity amputees. Although some casualties will have abdominal injuries that necessitate laparotomy, the majority in our study did not; however, in the critically ill casualty, rapid proximal control is required. Novel methods of temporary hemorrhage control may reduce the need for, and burden of, cavity surgery.
    The Journal of trauma 01/2013; 75((2 Suppl 2)):S233-7.
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    ABSTRACT: Unintentional injuries are one of the leading causes of death in the United States. Many of these injuries are preventable, and unintentional firearm injuries, in particular, may be responsive to prevention efforts. We investigated the relationship between unintentional firearm death and urbanicity among adults. This study was a retrospective analysis of national death certificate data. Unintentional adult firearm deaths in the United States from 1999 to 2006 were identified using the Multiple Cause of Death Data files from the National Center for Health Statistics. Decedents were assigned to a county of death and classified along an urban-rural continuum defined by population density and proximity to metropolitan areas. Total unintentional firearm death rates by county were analyzed in adjusted analyses using negative binomial regression. A total of 4,595 unintentional firearm injury deaths of adults occurred in the United States during the study period (a mean of 574.4 per year). Adjusted rates of unintentional firearm death showed increases from urban to rural counties. Americans in the most rural counties were significantly more likely to die of unintentional firearm deaths than those in the most urban counties (relative rate, 2.16; 95% confidence interval, 1.44-3.21, p = 0.002). Rates of unintentional firearm death are significantly higher in rural counties than in urban counties. Prevention strategies should be tailored to account for both geographic location and manner of firearm injury. Epidemiologic study, level III.
    The Journal of trauma 09/2012; 73(4):1006-10.
  • The Journal of trauma 01/2012; 72(1):316-317.
  • The Journal of trauma 12/2011; 71(6):1921.
  • The Journal of trauma 12/2011; 71(6):1873-4.
  • The Journal of trauma 12/2011; 71(6):1925.
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    ABSTRACT: Recent studies have demonstrated that black patients receive substandard care compared with white patients across healthcare settings. The purpose of this study was to evaluate the association of race on the management (salvage vs. amputation) of traumatic lower extremity open fractures. Data analysis was conducted using the American College of Surgeon's National Trauma Data Bank. Open tibial and fibular (OTFF) and open femoral (OFF) fractures among adults above the age of 18 were identified by International Classification of Diseases, 9th Revision codes. Injuries were identified as amputated based on the presence of one of three types of knee amputations. Statistical analysis included logistic regression stratified for sex, age, race, mechanism of injury, severity, and insurance type. From the National Trauma Data Bank, 10,082 OFF and 22,479 OTFF were identified. Amputation rates were 3.1% for OFF and 4.2% for OTFF. With age stratification, the ratio of amputation odds for blacks to amputation odds for whites (i.e., the Racial Odds for Amputation Ratio [ROAR]) demonstrated a significant interaction between black and age in both the OFF (p = 0.028) and OTFF (p = 0.008) groups. In younger patients, a lower ROAR (p = 0.016) favored salvage in blacks, while the ROAR in older patients favored amputation in blacks (p = 0.013). The higher prevalence of penetrating injuries in blacks only accounted for 12.7% of the lower ROAR among younger adults. There exists a racial disparity in the management of lower extremity open fractures. Older blacks have greater odds of amputation that is not explained by mechanism. In contrast, younger blacks have lower odds for amputation that is only partially explained by mechanism of injury.
    The Journal of trauma 12/2011; 71(6):1732-6.
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    ABSTRACT: Although avoiding hypotension is a primary focus after trauma, elevated systolic blood pressure (SBP) is frequently disregarded. The purpose of this study was to determine the association between elevated admission SBP and delayed outcomes after trauma. The Los Angeles County Trauma System Database was queried for all patients between 2003 and 2008 with blunt injuries who survived for at least 2 days after admission. Demographics and outcomes (pneumonia and mortality) were compared at various admission SBP subgroups (≥160 mm Hg, ≥170 mm Hg, ≥180 mm Hg, ≥190 mm Hg, ≥200 mm Hg, ≥210 mm Hg, and ≥220 mm Hg). Patients with moderate-to-severe traumatic brain injury (TBI), defined as head Abbreviated Injury Score ≥3, were then identified and compared with those without using multivariable logistic regression. Data accessed from 14,382 blunt trauma admissions identified 2,601 patients with moderate-to-severe TBI (TBI group) and 11,781 without moderate-to-severe TBI (non-TBI group) who were hospitalized ≥2 days. Overall mortality was 2.9%, 7.1% for TBI patients, and 1.9% for non-TBI patients. Overall pneumonia was 4.6%, 9.5% for TBI patients, and 3.6% for non-TBI patients. Regression modeling determined SBP ≥160 mm Hg was a significant predictor of mortality in TBI patients (adjusted odds ratio [AOR], 1.59; confidence interval [CI], 1.10-2.29; p = 0.03) and non-TBI patients (AOR, 1.47; CI, 1.14-1.90; p = 0.003). Similarly, SBP ≥160 mm Hg was a significant predictor for increased pneumonia in TBI patients (AOR, 1.79; CI, 1.30-2.46; p = 0.0004), compared with non-TBI patients (AOR, 1.28; CI, 0.97-1.69; p = 0.08). In blunt trauma patients with or without TBI, elevated admission SBP was associated with worse delayed outcomes. Prospective research is necessary to determine whether algorithms that manage elevated blood pressure after trauma, especially after TBI, affect mortality or pneumonia.
    The Journal of trauma 12/2011; 71(6):1689-93.
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    ABSTRACT: In trauma patients, open reduction and internal fixation of rib fractures remain controversial. We hypothesized that patients who have open reduction and internal fixation of rib fractures would experience less pain compared with controls and thus require fewer opiates. Further, we hypothesized that improved pain control would result in fewer pulmonary complications and decreased length of stay. This is a retrospective bi-institutional matched case-control study. Cases were matched 1:2 by age, injury severity Score, chest abbreviated injury severity score, head abbreviated injury severity score, pulmonary contusion score, and number of fractured ribs. The daily total doses of analgesic drugs were converted to equianalgesic intravenous morphine doses, and the primary outcome was inpatient narcotic administration. Sixteen patients between July 2005 and June 2009 underwent rib fixation in 5 ± 3 days after injury using an average of 3 (1-5) metallic plates. Morphine requirements decreased from 110 mg ± 98 mg preoperatively to 63 ± 57 mg postoperatively (p = 0.01). There were no significant differences between cases and controls in the mean morphine dose (79 ± 63 vs. 76 ± 55 mg, p = 0.65), hospital stay (18 ± 12 vs. 16 ± 11 days, p = 0.67), intensive care unit stay (9 ± 8 vs. 7 ± 10 days, p = 0.75), ventilation days (7 ± 8 vs. 6 ± 10, p = 0.44), and pneumonia rates (31% vs. 38%, p = 0.76). The need for analgesia was significantly reduced after rib fixation in patients with multiple rib fractures. However, no difference in outcomes was observed when these patients were compared with matched controls in this pilot study. Further study is required to investigate these preliminary findings.
    The Journal of trauma 12/2011; 71(6):1750-4.
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    ABSTRACT: Trauma centers are more frequently evaluating patients who are receiving anticoagulant or prescription antiplatelet (ACAP) therapy at the time of injury. Because there are reports of delayed intracranial hemorrhage (ICH) after blunt trauma in this patient group, we evaluated patients receiving ACAP with a head computed tomography (CT) on admission (CT1) followed by a routine repeat head CT (CT2) in 6 hours. We hypothesized that among patients with no traumatic findings on CT1 and a normal or unchanged interval neurologic examination, the incidence of clinically significant delayed ICH would be zero. We retrospectively reviewed adult blunt trauma patients admitted to our Level I trauma center from January 2006 to August 2009 who were receiving preinjury ACAP therapy. We reviewed medications, mechanism of injury, head CT results, and outcomes. Demographic data, injury severity scores, international normalized ratio, and neurologic examinations were recorded. We determined the incidence of delayed ICH on CT2 for patients with a negative CT1. Five hundred patients qualified for the protocol. Of these, 424 patients (85%) had a negative CT1. Among these patients, mean age was 75 years; 210 (50%) were male. Fall from standing was the most common mechanism of injury found in 357 patients (84%). Warfarin alone was taken in 68%, clopidogrel alone in 24%, and other agents in 2%. Six percent of patients were taking two agents. Mean international normalized ratio for patients on warfarin was 2.5. Among patients with a negative CT1, CT2 was obtained in 362 patients (85%) and was negative in 358 patients (99%). Four patients (1%) with a negative CT1 had a positive (n = 3) or equivocal (n = 1) CT2. All the changes on CT2 were minor and had either resolved or stabilized on third head CT. Of the four patients with positive or equivocal CT2, none had a change in neurologic examination; however, two had symptoms that could be attributed to head injury. Three were discharged home and one died of cardiac disease unrelated to head trauma. The incidence of delayed ICH in our study was 1%. However, none of the delayed findings were clinically significant. Among patients on ACAP therapy with a negative CT1 and a normal or unchanged neurologic examination, a routine CT2 is unnecessary. We recommend a period of observation to recognize those patients with symptoms that could be due to delayed ICH.
    The Journal of trauma 12/2011; 71(6):1600-4.
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    ABSTRACT: The pernicious individual and societal effects of exposure to violence highlight the importance of understanding factors related to trauma perpetration. Little research has investigated the phenomenon of accidental perpetration of serious injury and death, or considered the relationship between perpetration and trauma exposure. This study uses data from the National Comorbidity Survey-Replication to examine the demographic correlates and characteristics of both intentional and accidental perpetration of trauma, as well as the relationship of these types of perpetration to exposure to traumatic events. Participants were 83 individuals who had accidentally perpetrated trauma and 120 individuals who had intentionally perpetrated trauma. Findings indicated that men were more likely than women to report having intentionally, compared to accidentally, perpetrated trauma. Intentional and accidental perpetration of trauma were both associated with high levels of psychologic disorders, although those who had intentionally perpetrated trauma were more likely to report symptoms of posttraumatic stress disorder compared with those who had accidentally perpetrated trauma. Intentional perpetrators were more likely to have experienced interpersonal trauma in adulthood and childhood compared to accidental perpetrators. Interpersonal and sexual trauma was likely to precede any kind of trauma perpetration. Findings suggest that accidental, as well as intentional, perpetration of serious injury or death frequently occurs in the context of trauma and violence. Both types of perpetration are related to psychopathology. Potential mechanisms underlying the relationship between trauma exposure, psychopathology, and perpetration are discussed. Further research is needed to elucidate pathways from trauma exposure to perpetration and mental disorder.
    The Journal of trauma 12/2011; 71(6):1821-8.
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    ABSTRACT: An increasing number of minimal aortic injuries (MAIs) are being identified with modern computed tomography (CT) imaging techniques. The optimal management and natural history of these injuries are unknown. We have adopted a policy of selective multidisciplinary nonoperative management of MAI. This study examines our experience with these patients from July 2004 to June 2009. Retrospective chart review of all blunt trauma patients who underwent chest CT angiography to evaluate for blunt aortic injury (BAI) was undertaken. All patients deemed to have a MAI were managed nonoperatively, and those with a severe aortic injury underwent repair. Data collected included age, mechanism of injury, Injury Severity Score, type and location of aortic injury, intensive care unit length of stay (LOS), overall LOS, ventilator days, disposition, and mortality. In addition, all BAIs were graded according to the Presley Trauma Center CT Grading System of Aortic Injury. Forty-seven patients with BAI were identified. Thirty-two were classified as severe injuries, and 15 were considered MAI (32%). Nineteen underwent operative repair, 13 underwent endovascular stent graft repair, and 15 were managed nonoperatively. The average Injury Severity Score was 31 ± 10, and the average age was 44 ± 20 with no significant difference across treatment groups. There was no difference in overall or intensive care unit LOS. The nonoperative group had a shorter duration of ventilator days (1.1 vs. 4.28, p = 0.02). There were five deaths, none in the nonoperative group. None of these patients required subsequent intervention. All nonoperative patients had follow-up imaging at median of 4 days; on CT chest angiography, five injuries had resolved, eight had stable intimal flaps or pseudoaneurysm, and two had no detectable injury on subsequent aortogram. Almost one-third of our BAI were safely managed nonoperatively. Patients with MAI should be considered for selective nonoperative management in a multidisciplinary approach with close radiographic follow-up. We recommend that patients with MAIs should be considered for selective nonoperative management.
    The Journal of trauma 12/2011; 71(6):1519-23.
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    ABSTRACT: Topical hemostatic agents have generated intense research interest in recent years, prompted in part by the demands of wartime medicine. Numerous animal studies demonstrate variable degrees of efficacy of a variety of agents; however, little clinical data are available in severely traumatized patients. This report describes 30 consecutive uses of the modified rapid deployment hemostat (MRDH) during combat operations in Operation Iraqi Freedom. In a prospective observational fashion, traumatized patients presenting to a combat support hospital or a forward surgical team with difficult to control hemorrhage (due to anatomy, limited resources, or tactical environment) had the MRDH applied to severely bleeding wounds. Basic demographics, wounding mechanism, wound characteristics, circumstances, and efficacy were recorded. Presence of a clinical coagulopathy was also noted. Thirty hemostatic bandages were applied to 19 patients with a wide variety of wounds. All but one application occurred in the operating room. The demographics were mean age 27 years (range, 9-55 years), 95% male, 68% penetrating or fragmentation, and four casualties had a clinical coagulopathy. Hemostasis was achieved following application of the hemostatic agent in 16 of 19 wounds. Rebleeding occurred upon removal in three cases. In all cases, the patient failed conventional interventions at hemostasis before the hemostat was applied. This is the single largest description of the clinical efficacy of the MRDH and the first description during combat operations. The MRDH bandage was an effective hemostat for temporarily controlling hemorrhage in difficult circumstances. Caution should be exercised when removing the dressing as rebleeding may occur.
    The Journal of trauma 12/2011; 71(6):1775-8.
  • The Journal of trauma 12/2011; 71(6):1925.
  • The Journal of trauma 12/2011; 71(6):1880-4.

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