Asunto(s)
Infecciones por Coronavirus/epidemiología , Accesibilidad a los Servicios de Salud , Neumonía Viral/epidemiología , Centros Traumatológicos/organización & administración , Betacoronavirus , COVID-19 , Protocolos Clínicos , Colorado/epidemiología , Cuidados Críticos/organización & administración , Humanos , Quirófanos/organización & administración , Pandemias , Equipo de Protección Personal , Admisión y Programación de Personal , Guías de Práctica Clínica como Asunto , SARS-CoV-2 , Capacidad de Reacción , TelemedicinaRESUMEN
OBJECTIVE: To investigate the safety and feasibility of performing definitive fracture fixation in multiply injured patients in the presence of an open abdomen after laparotomy. DESIGN: Retrospective observational cohort study. SETTING: Level-I academic trauma center. PATIENTS: Adult polytrauma patients with the presence of an open abdomen after "damage control" laparotomy and associated major fractures of long bones, acetabulum, pelvis, or spine, requiring surgical repair (n = 81). INTERVENTION: Timing of definitive fracture fixation in relation to the timing of abdominal wall closure. MAIN OUTCOME MEASURE: Incidence of orthopedic surgical site infections. RESULTS: During a 15-year time window from January 1, 2000 until December 31, 2014, we identified a cohort of 294 consecutive polytrauma patients with an open abdomen after laparotomy. Surgical fixation of associated fractures was performed after the index laparotomy in 81 patients. In group 1 (n = 32), fracture fixation occurred significantly sooner despite a concurrent open abdomen, compared with group 2 (n = 49) with abdominal wall closure before fixation (mean 4.4 vs. 11.8 days; P = 0.01). The incidence of orthopaedic surgical site infections requiring a surgical revision was significantly lower in group 1 (3.1%) compared to group 2 (30.6%; P = 0.002). CONCLUSIONS: Definitive fracture fixation in the presence of an open abdomen is performed safely and associated with a significant decrease in clinically relevant surgical site infections, compared with delaying fracture fixation until abdominal wall closure. These data suggest that the strategy of imposing a time delay in orthopaedic procedures while awaiting abdominal wall closure is unjustified. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Traumatismos Abdominales/complicaciones , Fijación de Fractura/métodos , Traumatismo Múltiple , Traumatismos Abdominales/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Puntaje de Gravedad del Traumatismo , Laparotomía/métodos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Tiempo , Centros Traumatológicos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: A 2015 American Association for the Surgery of Trauma trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized that preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality. METHODS: In 2004, we initiated a PPP protocol for pelvic fracture hemorrhage. RESULTS: During the 11-year study, 2,293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age, 44 ± 2 years; Injury Severity Score (ISS), 48 ± 1.2). The lowest emergency department systolic blood pressure was 74 mm Hg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions before SICU admission compared with the 24 postoperative hours were 8 versus 3 units (p < 0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush.Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the operating room at 89 and 100 minutes after arrival, whereas 1 died 9 hours after arrival. CONCLUSIONS: PPP results in a shorter time to intervention and lower mortality compared with modern series using AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be used for pelvic fracture-related bleeding in the patient who remains unstable despite initial transfusion. LEVEL OF EVIDENCE: Therapeutic study, level IV.