RESUMEN
BACKGROUND: Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. METHODS: An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as 'early', 'developing' and 'mature' time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. RESULTS: Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The "early" phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in 'elderly' (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. CONCLUSION: The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.
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Heridas no Penetrantes , Anciano , Servicio de Urgencia en Hospital , Humanos , Puntaje de Gravedad del Traumatismo , Resucitación , Estudios Retrospectivos , Toracotomía , Centros Traumatológicos , Heridas no Penetrantes/cirugíaRESUMEN
Phlegmasia cerulea dolens is an uncommon entity. We present a case of phlegmasia cerulea dolens secondary to an aortoiliac aneurysm that compressed the common iliac vein. Catheter-directed thrombolysis was not considered to be a suitable option, because the patient needed an urgent fasciotomy. The aneurysm was treated with a bifurcated stent graft and the thrombosed veins were opened with pharmacomechanical thrombectomy and recombinant tissue plasminogen activator. The reopened iliac veins, including an aneurysmal external iliac vein, were stented and fasciotomy was performed. Pharmacomechanical thrombectomy can be performed with a low dose of recombinant tissue plasminogen activator and allows for subsequent surgery.
RESUMEN
OBJECTIVES: To investigate the epidemiology of acute upper limb thromboembolism in a well-defined Norwegian population. METHODS: This study was a retrospective, single-center, observational population-based cohort study of acute upper limb thromboembolism. The study included all patients from the hospital's primary catchment area from January 2000 to December 2015. Age- and gender-adjusted incidence rates were calculated using population demographics from Statistics Norway. RESULTS: A total of 54 patients were identified, of which 49 were included in the analyses: 27 (55%) females (median age 83 years, range 40-96) and 22 (45%) males (median age 70 years, range 42-95) (P = .053). The adjusted incidence rate for the period was 1.6 patients per 100,000 inhabitants per year (95% confidence interval 1.2-2.2) and did not change significantly during the period studied. Atrial fibrillation was detected by electrocardiography in 30 (61%) patients; in this group, 10 patients were on warfarin but only two had an international normalized ratio > 1.9 and the remaining 20 were not anticoagulated. Altogether, 38 (78%) patients underwent surgery, 1 (2%) was treated with thrombolysis, and the remaining patients were treated conservatively; no amputations were performed. Four patients (8%) died within 30 days, and 12 of the surviving 45 patients (27%) had recurrent thromboembolism. CONCLUSION: The incidence rate was stable during the study period. Patients with upper limb thromboembolism due to atrial fibrillation were inadequately anticoagulated. One in four patients experienced a recurrent thromboembolic event. Lifelong anticoagulation should be considered in all patients with upper limb thromboembolism.
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Tromboembolia/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Fibrilación Atrial/complicaciones , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tromboembolia/tratamiento farmacológico , Extremidad SuperiorRESUMEN
BACKGROUND: The available literature on ruptured abdominal aortic aneurysms (rAAA) centers on survival after operation and commonly, reasons why some patients do not undergo surgery are not addressed. The aim of the present study is to examine, in a population-based cohort, the characteristics, stratification and time to death of patients admitted to hospital, but not undergoing operation for rAAA. METHODS: A retrospective, single-center study. All patients admitted to Stavanger University Hospital from the primary catchment area with rAAA on admission or in-hospital from 2000 to 2014 were included. RESULTS: Altogether 214 patients with rAAA were identified; 57 (27%) patients did not undergo surgery. The proportion of women was significantly higher (37 vs. 14%; p < .001) in patients not having surgery. The reasons for not undergoing operation were patient 'not fit for surgery' (30%), 'dying or agonal' at time of diagnosis (26%), 'did not want operation' (21%) and 'diagnosed at autopsy' (23%). Of the non-operated patients, 45 had rAAA on arrival to hospital, 12 had in-hospital rupture and 21 patients had previously been diagnosed with an abdominal aortic aneurysm. Non-operative treatment was uniformly fatal. The 45 patients with rAAA on arrival were scored using four scoring systems, the predicted mortality varied widely, and the median time from admission to death was 7.4 h (range 0-1337). CONCLUSION: In about half of patients, a decision not to operate was made by the consultant vascular surgeon or the patient. In the subgroup of patients not diagnosed until autopsy or having an in-hospital rupture, an earlier diagnosis might have altered the outcome.