CrossRef Listing of Deleted DOIs

Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso. We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a pre-hospital systolic blood pressure of < or = 90 mm Hg. The study setting was a city with a single centralized system of pre-hospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room. Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04). The mean estimated intraoperative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23 percent) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30 percent) in the immediate-resuscitation group (P = 0.08). The duration of hospitalization was shorter in the delayed-resuscitation group. For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.

To compare the efficacy of methylprednisolone administered for 24 hours with methyprednisolone administered for 48 hours or tirilazad mesylate administered for 48 hours in patients with acute spinal cord injury. Double-blind, randomized clinical trial. Sixteen acute spinal cord injury centers in North America. A total of 499 patients with acute spinal cord injury diagnosed in National Acute Spinal Cord Injury Study (NASCIS) centers within 8 hours of injury. All patients received an intravenous bolus of methylprednisolone (30 mg/kg) before randomization. Patients in the 24-hour regimen group (n=166) received a methylprednisolone infusion of 5.4 mg/kg per hour for 24 hours, those in the 48-hour regimen group (n=167) received a methylprednisolone infusion of 5.4 mg/kg per hour for 48 hours, and those in the tirilazad group (n=166) received a 2.5 mg/kg bolus infusion of tirilazad mesylate every 6 hours for 48 hours. Motor function change between initial presentation and at 6 weeks and 6 months after injury, and change in Functional Independence Measure (FIM) assessed at 6 weeks and 6 months. Compared with patients treated with methylprednisolone for 24 hours, those treated with methylprednisolone for 48 hours showed improved motor recovery at 6 weeks (P=.09) and 6 months (P=.07) after injury. The effect of the 48-hour methylprednisolone regimen was significant at 6 weeks (P=.04) and 6 months (P=.01) among patients whose therapy was initiated 3 to 8 hours after injury. Patients who received the 48-hour regimen and who started treatment at 3 to 8 hours were more likely to improve 1 full neurologic grade (P=.03) at 6 months, to show more improvement in 6-month FIM (P=.08), and to have more severe sepsis and severe pneumonia than patients in the 24-hour methylprednisolone group and the tirilazad group, but other complications and mortality (P=.97) were similar. Patients treated with tirilazad for 48 hours showed motor recovery rates equivalent to patients who received methylprednisolone for 24 hours. Patients with acute spinal cord injury who receive methylprednisolone within 3 hours of injury should be maintained on the treatment regimen for 24 hours. When methylprednisolone is initiated 3 to 8 hours after injury, patients should be maintained on steroid therapy for 48 hours.

Despite numerous studies analyzing this topic, specific advantages of helicopter transport of blunt polytrauma patients as compared with ground ambulances have not yet been identified unequivocally. Four possible pathways in 403 polytrauma patients (Injury Severity Score [ISS] > 16) who were in reach of the helicopter emergency medical service (HEMS) Dresden were analyzed as follows: HEMS-UNI group (n = 140), transfer by HEMS into a university hospital; AMB-REG group (n = 102), transfer by ground ambulance into a regional (Level II or III) hospital; AMB-UNI group (n = 70), transfer by ground ambulance into the university hospital; and INTER group (n = 91), transfer by ground ambulance into a regional hospital, followed by transfer to the university hospital. Scores used were the ISS and the TRISS. Tests used for statistical analysis included chi2 and Fisher's tests. Statistical significance was set at p > 0.05. Age, gender, and mean ISS (range, 33.3-35.6) revealed extensive homogeneity of the groups. Mortality of the AMB-REG group was almost doubled (41.2%) compared with HEMS-UNI (22.1%) patients (p = 0.002). The AMB-UNI group displayed the lowest mortality (15.7%, p = not significant). TRISS analysis (PRE-Chart) revealed identical outcome for AMB-UNI and HEMS-UNI patients. Rescue time averaged 90 +/- 29 minutes for HEMS-UNI patients, 68 +/- 25 minutes for AMB-UNI patients, and 69 +/- 26 minutes for the AMB-REG group. Primary transfer by HEMS into a Level I trauma center reduces mortality markedly. In principle, this benefit can be attributed to superior preclinical therapy, primary admission to a Level I trauma center, or both. However, the identical probability of survival of the AMB-UNI and HEMS-UNI groups in this and comparable studies does not confirm generally better survival rates on account of a more aggressive on-site approach.