No abstract

No abstract

There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

Synopsis Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. As the primary injury cannot be undone, management strategies must therefore focus on preventing secondary injury by avoiding hypotension and hypoxia and maintaining appropriate cerebral perfusion pressure (CPP), which is a surrogate for cerebral blood flow (CBF). Cerebral perfusion pressure can be maintained by increasing mean arterial pressure (MAP), decreasing intracranial pressure (ICP), or both. MAP can be increased through a combination of pressors in the euvolemic state, although the ideal fluid in TBI patients is unknown. The goal should be euvolemia and avoidance of hypotension. Elevated intracranial pressure can be treated through an algorithmic approach utilization simple bedside maneuvers, hyperosmolar therapy, cerebral spinal fluid (CSF) drainage as well as pentobarbital coma and decompressive craniectomy in refractory cases. Mass lesions may require operative evacuation depending on size, exam findings, and ICP measurements. Although CPP may not be an ideal surrogate for cerebral blood flow and metabolic delivery, other modalities have not gained widespread use due to paucity of strong data. Other factors that deserve important consideration in the acute management of TBI patients are venous thromboembolism, stress ulcer, and seizure prophylaxis as well as nutritional and metabolic optimization.

Background-Race and socioeconomic disparities are pervasive and persist throughout our health care system. Inequities have also been identified in outcomes after trauma despite its immediate nature and the perceived equal access to emergent care.

This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Relative "trauma deserts" with decreased access to immediate care were found in certain areas of Chicago and adversely affected mortality from GSWs. These results may inform decisions about trauma systems planning and funding.

Background Race and socioeconomic disparities are pervasive and persist throughout our health care system. Inequities have also been identified in outcomes after trauma despite its immediate nature and the perceived equal access to emergent care. Objectives Our objective was to systematically evaluate the current literature on the association between trauma mortality and race, insurance status, and socioeconomic status. Our secondary objective was to assess data investigating potential mechanisms underlying these outcome disparities. Methods We performed a systematic review and random effects meta-analysis to examine the relationship between trauma and race, insurance, and socioeconomic disparities published between April 1990 and October 2011. The Cochrane Review Handbook and the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) statement were used as guides. Results Thirty-five studies were included in the final review. The current body of literature indicates that uninsured status is an independent negative predictor of trauma outcomes. Our meta-analysis corroborated this by demonstrating that uninsured patients were more likely to die than privately insured patients (OR 2.17 95% CI 1.51–3.11). Racial disparities in trauma outcomes are shown to be present and independent for black patients compared to whites. Our meta-analysis demonstrated that black race was associated with higher odds of death when compared with white race (OR 1.19 95% CI 1.09 – 1.31). Studies comparing Hispanic and white non-Hispanic patients’ post-trauma mortality outcomes, however, have provided conflicting results. Our meta-analysis found no significant difference in mortality comparing Hispanic patients with white patients (OR 1.08 95% CI 0.99–1.18) Conclusions Both race/ethnicity and insurance are clearly associated with disparate outcomes following trauma. These disparities are likely due to myriad factors across the trauma continuum of care: host factors, prehospital factors, hospital/provider factors, and factors associated with postacute care and rehabilitation. While there are many proposed mechanisms, we believe that there are several interventions that could be particularly effective in combatting trauma disparities. These include trauma prevention programs targeting vulnerable populations, expansion of healthcare coverage, relocation of trauma centers to better provide for vulnerable populations, and restructuring clinical training to address implicit biases. While much work still remains to fully elucidate the mechanisms underlying trauma disparities, we can and should now act to begin to reduce or eliminate these disparities that still plague our healthcare system. Level of Evidence Two.