实体化创伤中心建设提升严重创伤救治能力

为明确实体化创伤中心建设对提升严重创伤救治能力的作用,笔者以兴义市创伤中心实体化建设后所取得的初步成效,从院内多学科团队建设及核心能力维护、创伤救治流程优化、创伤时间节点质量控制与持续改进等方面进行介绍,为实体化创伤中心建设提供借鉴和参考。     

Shotgun Wounds: Nationwide Trends in Epidemiology,Injury Patterns,and Outcomes from US Trauma Centers

BackgroundShotguns represent a distinct form of ballistic injury because of projectile scatter and variable penetration. Due in part to their rarity, existing literature on shotgun injuries is scarce.ObjectiveThis study defined the epidemiology, injury patterns, and outcomes after shotgun wounds at a national level.MethodsPatients with shotgun injury were identified from the National Trauma Data Bank (2007–2014). Transferred patients and those with missing procedure data were excluded. Demographics, injury data, and outcomes were collected and analyzed. Categorical variables are presented as number (percentage) and continuous variables as median (interquartile range).ResultsShotgun wounds comprised 9% of all firearm injuries. After exclusions, 11,292 patients with shotgun injury were included. The median age was 29 years (21–43) and most were male (n = 9887, 88%). Most injuries occurred in the South (n = 4092, 36%) and among white patients (n = 4945, 44%). The median Injury Severity Score was 9 (3–16). Overall in-hospital mortality was 14% (n = 1341), with 669 patients (7%) dying in the emergency department. Assault was the most common injury intent (n = 6762, 60%), followed by accidental (n = 2081, 19%) and self-inflicted (n = 1954, 17%). The lower and upper extremities were the most commonly affected body regions (n = 4071, 36% and n = 3422, 30%, respectively), while the head was the most severely injured (median Abbreviated Injury Scale score 4 [2–5]).ConclusionsIn the United States, shotgun wounds are an infrequent mechanism of injury. Shotgun wounds as a result of interpersonal violence far outweigh self-inflicted and accidental injuries. White men in their 20s in the southern parts of the country are most commonly affected and thereby delineate the high-risk patient population for injury by this mechanism at a national level.     

Increased activation of the fear neurocircuitry in children exposed to violence

Most studies investigating the effect of childhood trauma on the brain are retrospective and mainly focus on maltreatment, whereas different types of trauma exposure such as growing up in a violent neighborhood, as well as developmental stage, could have differential effects on brain structure and function. The current magnetic resonance imaging study assessed the effect of trauma exposure broadly and violence exposure more specifically, as well as developmental stage on the fear neurocircuitry in 8‐ to 14‐year‐old children and adolescents (N = 69). We observed reduced hippocampal and increased amygdala volume with increasing levels of trauma exposure. Second, higher levels of violence exposure were associated with increased activation in the amygdala, hippocampus, and ventromedial prefrontal cortex during emotional response inhibition. This association was specifically observed in children younger than 10 years. Finally, increased functional connectivity between the amygdala and brainstem was associated with higher levels of violence exposure. Based on the current findings, it could be hypothesized that trauma exposure during childhood results in structural changes that are associated with later risk for psychiatric disorders. At the same time, it could be postulated that growing up in an unsafe environment leads the brain to functionally adapt to this situation in a way that promotes survival, where the long‐term costs or consequences of these adaptations are largely unknown and an area for future investigations.     

损伤控制外科手术治疗严重腹部创伤的临床效果研究

目的探讨损伤控制外科手术治疗严重腹部创伤的效果。方法30例严重腹部创伤患者随机分为两组各15例,实验组施行损伤控制外科手术,对照组施行常规外科手术,比较两组的手术情况、并发症发生率以及病死率。结果实验组的手术确诊时间、住院时间均显著短于对照组,输血量、并发症发生率均显著低于对照组(P<0.05)。两组的病死率比较,差异无统计学意义(P>0.05)。结论损伤控制外科手术治疗严重腹部创伤效果显著,可控制患者病情,降低并发症发生率和病死率。     

眼外伤前房出血的治疗方法及临床疗效分析

目的 探讨眼外伤所致前房出血的治疗方法以及临床治疗效果。方法 回顾性分析90例(90眼)外伤性前房出血患者的临床资料,分析治疗方法以及临床治疗效果。结果 Ⅰ级前房出血吸收时间为1~5 d,Ⅱ级前房出血吸收时间为5~10 d,Ⅲ级前房出血吸收时间为7~15 d。其中继发出血9例,继发青光眼19例, 2例出血未完全吸收继续治疗恢复良好。所有继发青光眼病例于前房出血吸收后眼压均恢复正常。积血吸收后视力<0.1者4例, 0.1~0.5者20例, 0.6~1.0者21例,>1.0者45例。结论 挫伤性前房出血经有效合理药物治疗可使出血得到吸收,保守治疗可获得良好的治疗效果,对一些复杂的、继发出血的病例,采取积极、恰当的治疗措施可避免视力的严重损害,视力可得到恢复,病情得到缓解或治愈。     

“I'm Leaving”: Factors That Impact Against Medical Advice Disposition Post-Trauma

BackgroundDischarge against medical advice (AMA) is an important, yet understudied, aspect of health care—particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs.ObjectiveThe goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment.MethodsWe performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status.ResultsUninsured (odds ratio [OR] 2.72; 95% confidence interval [CI] 2.58–2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37–2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02–1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52–0.75), Asian (OR 0.59; 95% CI 0.49–0.69), and Hispanic (OR 0.80; 95% CI 0.75–0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury.ConclusionsInsurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.