The purpose of this study was to investigate the incidence of aspiration following extubation in critically ill trauma patients. This prospective pilot study included 20 consecutive trauma patients who required orotracheal intubation for at least 48 hours. All subjects underwent a bedside transnasal fiberoptic endoscopic evaluation of swallowing at 24 +/- 2 hr after extubation to determine objectively aspiration status. Aspiration was defined as the entry of a blue dyed material into the airway below the level of the true vocal folds, with silent aspiration occurring in the absence of any external behavioral signs such as coughing or choking. Aspiration was identified in 9 of 20 (45%) subjects and 4 of these 9 (44%) were silent aspirators. Therefore, silent aspiration occurred in 20% of the study population. Eight of the 9 (89%) aspirating subjects resumed an oral diet from 2-10 days (mean, 5 days) following extubation. All subjects had no evidence of pulmonary complications. It was concluded that trauma patients after orotracheal intubation and prolonged mechanical ventilation have an increased risk of aspiration. An objective assessment of dysphagia to identify aspiration may reduce the likelihood of pulmonary complications after extubation.
Early FF leads to greater fluid administration in patients with head injuries. Hypoxemia and hypotension, risk factors for secondary brain injury, may contribute to a poor neurologic outcome after early fixation. Prospective studies evaluating the impact of the timing of FF on head injury are indicated.
The safety and efficacy of low-molecular-weight heparin (LMWH) was compared with those of conventional unfractionated heparin (UH) in preventing deep venous thrombosis (DVT) in trauma patients with moderate injuries in a prospective double-blind, randomized trial at a level I trauma center. After informed consent, trauma patients meeting inclusion criteria (age > 45 or requiring > 2 days' bedrest) received LMWH or UH twice daily in a double-blind, randomized trial. Patients were excluded if they had severe brain injuries or bleeding injuries not accessible to hemostatic control (eg, severe visceral contusions). Clinical examination and weekly venous duplex ultrasound evaluations were performed to identify DVT. One hundred four patients were randomized, 53 to receive UH and 51 to receive LMWH; 32 UH and 34 LMWH patients completed the study (mean injury severity score [ISS] = 12). There were no significant differences between groups with regard to age, sex, ISS, mechanism of injury, or doses of drug given. Outcome measures such as length of stay in the surgical intensive care unit and hospital days were similar. There were two patients with DVT in the UH group, none in the LMWH group (p = 0.493 by Fisher's exact test). This was not a statistically significant difference. There were five major bleeding complications in each group. The incidence of DVT in injured patients receiving prophylaxis appears to be quite low if individuals such as those with severe head injury or visceral contusions are excluded. LMWH is not clearly beneficial when compared with UH in this moderate-risk trauma population.
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