RESUMO

BACKGROUND: Penetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure. CASE DESCRIPTION: A male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery. CONCLUSIONS: Penetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients.

Assuntos

Oxigenação por Membrana Extracorpórea , Pneumonectomia , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Masculino , Lesão Pulmonar/cirurgia , Lesão Pulmonar/etiologia , Adulto , Traumatismos Torácicos/cirurgia , Traumatismos Torácicos/complicações , Ferimentos Penetrantes/cirurgia , Hemotórax/etiologia , Hemotórax/cirurgia , Cuidados Pós-Operatórios/métodos

RESUMO

The shock index (SI) has been associated with predicting transfusion needs in trauma patients. However, its utility in penetrating thoracic trauma (PTTrauma) for predicting the Critical Administration Threshold (CAT) has not been well-studied. This study aimed to evaluate the prognostic value of SI in predicting CAT in PTTrauma patients and compare its performance with the Assessment of Blood Consumption (ABC) and Revised Assessment of Bleeding and Transfusion (RABT) scores. We conducted a prognostic type 2, single-center retrospective observational cohort study on patients with PTTrauma and an Injury Severity Score (ISS) > 9. The primary exposure was SI at admission, and the primary outcome was CAT. Logistic regression and decision curve analysis were used to assess the predictive performance of SI and the PTTrauma score, a novel model incorporating clinical variables. Of the 620 participants, 53 (8.5%) had more than one CAT. An SI > 0.9 was associated with CAT (adjusted OR 4.89, 95% CI 1.64-14.60). The PTTrauma score outperformed SI, ABC, and RABT scores in predicting CAT (AUC 0.867, 95% CI 0.826-0.908). SI is a valuable predictor of CAT in PTTrauma patients. The novel PTTrauma score demonstrates superior performance compared to existing scores, highlighting the importance of developing targeted predictive models for specific injury patterns. These findings can guide clinical decision-making and resource allocation in the management of PTTrauma.

Assuntos

Transfusão de Sangue , Traumatismos Torácicos , Humanos , Masculino , Feminino , Transfusão de Sangue/métodos , Adulto , Estudos Retrospectivos , Traumatismos Torácicos/terapia , Pessoa de Meia-Idade , Prognóstico , Escala de Gravidade do Ferimento , Ferimentos Penetrantes/terapia , Hemorragia/terapia , Hemorragia/etiologia , Hemorragia/diagnóstico , Choque/terapia , Choque/etiologia , Choque/diagnóstico

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is gaining popularity worldwide for managing hypotensive trauma patients. Vascular access complications related to REBOA placement have been reported, with some cases resulting in permanent morbidity. We aim to capitalize on the increase in literature to further describe and estimate the incidence of REBOA-associated vascular access complications in adult trauma patients. METHODS: We searched Medline, EMBASE, Scopus, and CINAHL for studies reporting vascular access complications of REBOA in adult trauma patients from inception to October 14, 2021. Studies reporting data from adult trauma patients who underwent REBOA insertion were eligible. Exclusion criteria included patients 15 years and younger, nontrauma patients, non-REBOA use, non-vascular access complications and patient duplication. Study data was abstracted using the PRISMA checklist and verified independently by three reviewers. Meta-analysis of proportions was performed using a random effects model with Freeman-Turkey double-arcsine transformation. Post hoc meta-regression by year of publication, sheath-size, and geographic region was also performed. The incidence of vascular access complications from REBOA insertion was the primary outcome of interest. Subgroup analysis was performed by degree of bias, sheath size, technique of vascular access, provider specialty, geographical region, and publication year. RESULTS: Twenty-four articles were included in the systematic review and the meta-analysis, for a total of 675 trauma patients who underwent REBOA insertion. The incidence of vascular access complications was 8% (95% confidence interval, 5%-13%). In post hoc meta-regression adjusting for year of publication and geographic region, the use of a smaller (7-Fr) sheath was associated with a decreased incidence of vascular access complications (odds ratio, 0.87; 95% confidence interval, 0.75-0.99; p = 0.046; R 2 = 35%; I 2 = 48%). CONCLUSION: This study provides a benchmark for quality of care in terms of vascular access complications related to REBOA insertion in adult trauma patients. Smaller sheath size may be associated with a decrease in vascular access complications. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level III.

Assuntos

Oclusão com Balão , Procedimentos Endovasculares , Choque Hemorrágico , Adulto , Humanos , Estudos Retrospectivos , Aorta/lesões , Ressuscitação/métodos , Oclusão com Balão/efeitos adversos , Oclusão com Balão/métodos , Incidência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia , Choque Hemorrágico/epidemiologia

RESUMO

BACKGROUND: Previous observational studies showed higher rates of abdominal wall closure with the use of hypertonic saline in trauma patients with abdominal injuries. However, no randomized controlled trials have been performed on this matter. This double-blind randomized clinical trial assessed the effect of 3% hypertonic saline (HS) solution on primary fascial closure and the timing of abdominal wall closure among patients who underwent damage control laparotomy for bleeding control. METHODS: Double-blind randomized clinical trial. Patients with abdominal injuries requiring damage control laparotomy (DCL) were randomly allocated to receive a 72-h infusion (rate: 50 mL/h) of 3% HS or 0.9 N isotonic saline (NS) after the index DCL. The primary endpoint was the proportion of patients with abdominal wall closure in the first seven days after the index DCL. RESULTS: The study was suspended in the first interim analysis because of futility. A total of 52 patients were included. Of these, 27 and 25 were randomly allocated to NS and HS, respectively. There were no significant differences in the rates of abdominal wall closure between groups (HS: 19 [79.2%] vs. NS: 17 [70.8%]; p = 0.71). In contrast, significantly higher hypernatremia rates were observed in the HS group (HS: 11 [44%] vs. NS: 1 [3.7%]; p < 0.001). CONCLUSION: This double-blind randomized clinical trial showed no benefit of HS solution in primary fascial closure rates. Patients randomized to HS had higher sodium concentrations after the first day and were more likely to present hypernatremia. We do not recommend using HS in patients undergoing damage control laparotomy. Trial registration The trial protocol was registered in clinicaltrials.gov (identifier: NCT02542241).

Assuntos

Traumatismos Abdominais , Hipernatremia , Humanos , Laparotomia/métodos , Hipernatremia/etiologia , Estudos Retrospectivos , Fáscia , Traumatismos Abdominais/cirurgia

RESUMO

PURPOSE: To evaluate the diagnostic performance of lung ultrasound (LUS) in screening for SARS-CoV-2 infection in patients requiring surgery. METHODS: Patients underwent a LUS protocol that included a scoring system for screening COVID-19 pneumonia as well as RT-PCR test for SARS-CoV-2. The receiver operator characteristic (ROC) curve was determined for the relationship between LUS score and PCR test results for COVID-19. The optimal threshold for the best discrimination between non-COVID-19 patients and COVID-19 patients was calculated. RESULTS: Among 203 patients enrolled (mean age 48 years; 82 males), 8.3% were COVID-19-positive; 4.9% were diagnosed via the initial RT-PCR test. Of the patients diagnosed with SARS-CoV-2, 64.7% required in-hospital management and 17.6% died. The most common ultrasound findings were B lines (19.7%) and a thickened pleura (19.2%). The AUC of the ROC curve of the relationship of LUS score with a cutoff value >8 versus RT-PCR test for the assessment of SARS-CoV-2 pneumonia was 0.75 (95% CI 0.61-0.89; sensitivity 52.9%; specificity 91%; LR (+) 6.15, LR (-) 0.51). CONCLUSION: The LUS score in surgical patients is not a useful tool for screening patients with potential COVID-19 infection. LUS score shows a high specificity with a cut-off value of 8.

Assuntos

COVID-19 , Masculino , Humanos , Pessoa de Meia-Idade , SARS-CoV-2 , Pulmão/diagnóstico por imagem , Teste para COVID-19 , Ultrassonografia/métodos

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a damage control tool with a potential role in the hemodynamic resuscitation of severely ill patients in the civilian pre-hospital setting. REBOA ensures blood flow to vital organs by early proximal control of the source of bleeding. However, there is no consensus on the use of REBOA in the pre-hospital setting. This article aims to perform a systematic review of the literature about the feasibility, survival, indications, complications, and potential candidates for civilian pre-hospital REBOA. METHODS: A literature search was conducted using Medline, EMBASE, LILACS and Web of Science databases. Primary outcome variables included overall survival and feasibility. Secondary outcome variables included complications and potential candidates for endovascular occlusion. RESULTS: The search identified 8 articles. Five studies described the use of REBOA in pre-hospital settings, reporting a total of 47 patients in whom the procedure was attempted. Pre-hospital REBOA was feasible in 68-100% of trauma patients and 100% of non-traumatic patients with cardiac arrest. Survival rates and complications varied widely. Pre-hospital REBOA requires a coordinated and integrated emergency health care system with a well-trained and equipped team. The remaining three studies performed a retrospective analysis identifying 784 potential REBOA candidates. CONCLUSIONS: Pre-hospital REBOA could be a feasible intervention for a significant portion of severely ill patients in the civilian setting. However, the evidence is limited. The impact of pre-hospital REBOA should be assessed in future studies.

Assuntos

Oclusão com Balão , Procedimentos Endovasculares , Choque Hemorrágico , Aorta , Oclusão com Balão/métodos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Hospitais , Humanos , Ressuscitação/métodos , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia

RESUMO

Abstract While reading the novella "Chronicle of a Death Foretold" by the Colombian Nobel Laureate Gabriel García-Marquez, we were surprised to realize that the injuries sustained by the main character could have been successfully treated had he received modern trauma care in which REBOA may have been considered. This is a discussion of Mr. Nasar's murder to explore whether he could have been saved by deploying REBOA as a surgical adjunct to bleeding control and resuscitation. In reading García-Marquez's novel we noted the events that unfolded at the time of Santiago Nasar's murder. To contextualize the claim that Mr. Nasar could have survived, had his injuries been treated with REBOA, we explored and illustrated what could have done differently and why. On the day of his death, Mr. Nasar sustained multiple penetrating stab wounds. Although he received multiple stab wounds to his torso, the book describes seven potentially fatal injuries, resulting in hollow viscus, solid viscus, and major vascular injuries. We provided a practical description of the clinical and surgical management algorithm we would have followed in Mr. Nasar's case. This algorithm included the REBOA deployment for hemorrhage control and resuscitation. The use of REBOA as part of the surgical procedures performed could have saved Mr. Nasar's life. Based on our current knowledge about REBOA in trauma surgery, we claim that its use, coupled with appropriate surgical care for hemorrhage control, could have saved Santiago Nasar's life, and thus prevent a death foretold.

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Resumen Leyendo la novela "Crónica de una muerte anunciada" del Nobel de Literatura Gabriel García Márquez, nos sorprendió reconocer que las heridas provocadas al personaje principal se habrían podido tratar exitosamente en un centro de trauma moderno donde hubieran optado por REBOA. Hacemos referencia al asesinato del señor Nasar para explorar la posibilidad de que se hubiera podido salvar de haberse utilizado REBOA como adyuvante de la cirugía para reanimación y control de la hemorragia. En la lectura de la novela de García Márquez tomamos nota de los sucesos que tuvieron lugar en el momento del asesinato de Santiago Nasar. Para contextualizar la afirmación de que Nasar habría podido sobrevivir si le hubieran manejado sus heridas con REBOA, exploramos e ilustramos lo que habría podido hacerse de otra manera y porqué. El día en que murió, el señor Nasar sufrió múltiples heridas por arma blanca y si bien muchas de ellas fueron en el torso, el libro describe siete heridas mortales que comprometieron los órganos sólidos, además de lesiones vasculares mayores. Presentamos una descripción práctica del algoritmo para el manejo clínico y quirúrgico que habríamos seguido en el caso del señor Nasar. Este algoritmo incluye el uso de REBOA para el control de la hemorragia y la reanimación, el cual, como parte de los procedimientos quirúrgicos realizados, habría podido salvarle la vida a la víctima. Basados en nuestro conocimiento actual acerca del uso de REBOA en la cirugía de trauma, planteamos que, junto con la atención quirúrgica apropiada para controlar la hemorragia, este procedimiento habría podido salvarle la vida a Santiago Nasar y, por tanto, evitar una muerte anunciada.

Assuntos

Pâncreas Divisum

RESUMO

PURPOSE: General surgeons, anesthesiologists, obstetricians and gynecologists (ob-gyns), and orthopedic surgeons are the vital disciplines to provide emergency surgery within a healthcare system. This paper aims to examine the relationship (if any) between multidimensional poverty (MDP) and GDP per-capita with the emergency surgery workforce density in Colombia. METHODS: We performed an ecological study, where the observation units were the 32 Colombian departments. The total numbers of general surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons were obtained from the "Registro Unico Nacional de Talento Humano en Salud" (ReTHUS) registry. The 2020 population projections, the incidence of MDP and the GDP per capita were obtained from the Colombian National Administrative Department of Statistics. A spearman's correlation coefficient was calculated to measure the strength of the correlations between the surgical workforce density with MDP and GDP per-capita. RESULTS: There were significant moderate inverse linear correlations between the incidence of multidimensional poverty and workforce density. The correlation coefficients for the incidence of multidimensional poverty and the workforce density were - 0.5273, - 0.5620, - 0.4704, and - 0.4612 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. Conversely, the correlation coefficients for the GDP per-capita and the workforce density were 0.4045, 0.3822, 0.4404, and 0.3742 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. CONCLUSION: This study found that Colombian trauma and emergency surgery workforce density was inversely and directly correlated with multidimensional poverty and GDP per-capita levels, respectively. The relationship of these economic indicators with the surgical capacity deserves further investigation.

Assuntos

Ginecologia , Cirurgiões , Colômbia/epidemiologia , Humanos , Pobreza , Recursos Humanos

RESUMO

BACKGROUND: The use of resuscitative endovascular balloon of the aorta (REBOA) is a useful strategy for bleeding control in placenta accreta spectrum (PAS) management. The incidence of complications associated with this procedure is variable. We report three cases of arterial thrombosis associated with REBOA, and we also analyze the factors that facilitated its occurrence. CASE REPORT: Three women with PAS, presented common femoral and external iliac arterial thrombosis after REBOA use. Among the contributing factors probably associated with thrombosis, we identified the absence of ultrasound guidance for vascular access and the not using of heparin during aortic occlusion. CONCLUSIONS: REBOA use is not exempt from complications and must be performed by experienced groups applying strategies to reduce the risks of complications.

Assuntos

Oclusão com Balão , Procedimentos Endovasculares , Placenta Acreta , Choque Hemorrágico , Trombose , Aorta , Feminino , Humanos , Gravidez , Ressuscitação

RESUMO

IMPORTANCE: The effect of high-flow oxygen therapy vs conventional oxygen therapy has not been established in the setting of severe COVID-19. OBJECTIVE: To determine the effect of high-flow oxygen therapy through a nasal cannula compared with conventional oxygen therapy on need for endotracheal intubation and clinical recovery in severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS: Randomized, open-label clinical trial conducted in emergency and intensive care units in 3 hospitals in Colombia. A total of 220 adults with respiratory distress and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of less than 200 due to COVID-19 were randomized from August 2020 to January 2021, with last follow-up on February 10, 2021. INTERVENTIONS: Patients were randomly assigned to receive high-flow oxygen through a nasal cannula (n = 109) or conventional oxygen therapy (n = 111). MAIN OUTCOMES AND MEASURES: The co-primary outcomes were need for intubation and time to clinical recovery until day 28 as assessed by a 7-category ordinal scale (range, 1-7, with higher scores indicating a worse condition). Effects of treatments were calculated with a Cox proportional hazards model adjusted for hypoxemia severity, age, and comorbidities. RESULTS: Among 220 randomized patients, 199 were included in the analysis (median age, 60 years; n = 65 women [32.7%]). Intubation occurred in 34 (34.3%) randomized to high-flow oxygen therapy and in 51 (51.0%) randomized to conventional oxygen therapy (hazard ratio, 0.62; 95% CI, 0.39-0.96; P = .03). The median time to clinical recovery within 28 days was 11 (IQR, 9-14) days in patients randomized to high-flow oxygen therapy vs 14 (IQR, 11-19) days in those randomized to conventional oxygen therapy (hazard ratio, 1.39; 95% CI, 1.00-1.92; P = .047). Suspected bacterial pneumonia occurred in 13 patients (13.1%) randomized to high-flow oxygen and in 17 (17.0%) of those randomized to conventional oxygen therapy, while bacteremia was detected in 7 (7.1%) vs 11 (11.0%), respectively. CONCLUSIONS AND RELEVANCE: Among patients with severe COVID-19, use of high-flow oxygen through a nasal cannula significantly decreased need for mechanical ventilation support and time to clinical recovery compared with conventional low-flow oxygen therapy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04609462.

Assuntos

COVID-19/complicações , Intubação Intratraqueal/estatística & dados numéricos , Oxigenoterapia/métodos , Oxigênio/uso terapêutico , Insuficiência Respiratória/terapia , Idoso , Idoso de 80 Anos ou mais , COVID-19/terapia , Estado Terminal/mortalidade , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/instrumentação , Respiração Artificial , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , SARS-CoV-2 , Fatores de Tempo , Resultado do Tratamento

RESUMO

Abstract Introduction: Although the peace process in Colombia resulted in a significant reduction in the number of anti-personnel mines across the country, there are no reliable data on the effects of this phenomenon on outcomes for patients who were victims of these devices. Objective: The objective of this study was to assess mortality from landmine injuries before and during the Colombian peace process. Furthermore possible associations between peace negotiations and mortality were explored. Methods: For this study, we used the "Colombian Victims of Antipersonnel Mines Injuries registry" (MAP/MUSE database) data from 2002 to 2018. This registry was launched in 2001 by the government of Colombia with the aim of prospectively and systematically collect information on all the cases of anti-personnel mine injuries in the country. The period between 2002-2012 was classified as the pre-negotiation period (período de guerra), and 2014-2018 as the peace negotiations period, with 2013 classified as a washout year. Multivariate logistic regression was used to explore the association between peace negotiations and mortality among anti-personnel landmine injured individuals. Results: A total of 10306 landmine injury cases were registered. Of these, 1180 (11.4%) occurred in the peace-negotiation period. Mortality was significantly lower during the period of peace negotiations. After adjusting for sex, age group, race, active duty soldier status, rural area, and geographic Departamentos case volumes, the peace negotiation period was found to be associated with lower risk-adjusted odds of mortality after suffering a landmine injury (OR= 0.6, 95% CI, 0.5-0.7; p<0.001). Conclusions: Our findings suggest an association between the period of peace negotiation and a lower likelihood of mortality among victims of anti-personnel landmines.

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Resumen Introducción: Aunque el proceso de paz colombiano produjo una reducción en la cantidad de minas antipersona en el país, no hay estimativos sobre el efecto de este fenómeno en los desenlaces de los pacientes víctimas de estos artefactos. Objetivo: Nuestro objetivo fue evaluar la mortalidad por minas antipersona antes y durante la negociación del proceso de paz en Colombia. Además, exploramos posibles asociaciones entre las negociaciones de paz y la mortalidad. Métodos: Para este estudio utilizamos los datos del "Registro de víctimas colombianas de lesiones de minas antipersona" (base de datos MAP / MUSE) de 2002 a 2018. Este registro fue lanzado en 2001 por el gobierno de Colombia con el objetivo de recolectar información de manera prospectiva y sistemática de los casos de trauma por minas antipersona en el país. Clasificamos el período comprendido entre 2002 y 2012 como el período previo a la negociación (período de guerra), el comprendido entre 2014 y 2018 como el período de negociaciones de paz y el año 2013 como período de "depuración". Se utilizaron modelos de regresión logística multivariados para explorar las asociaciones entre las negociaciones de paz y la mortalidad. Resultados: Se registraron un total de 10306 casos de lesiones por minas antipersona. De estos, 1180 (11.4%) ocurrieron en el período de negociación de paz. La mortalidad fue significativamente menor durante el período de negociaciones de paz. El análisis de regresión logística multivariado determinó que el período de negociación de paz se asoció con una menor probabilidad de mortalidad después de sufrir una lesión por minas antipersona (OR = 0,6, IC 95%, 0,5-0,7; p <0,001). Conclusiones: Nuestros hallazgos sugieren una asociación entre el período de negociación de paz y una menor probabilidad de mortalidad entre las víctimas de las minas antipersona.

Assuntos

Humanos , Masculino , Adolescente , Guerra , Ferimentos e Lesões , Mortalidade , Artefatos , Amputação Cirúrgica , Militares , Alprostadil , Análise de Regressão , Colômbia , Atenção à Saúde , Governo , Mineração , Categorias de Trabalhadores

RESUMO

PURPOSE: The purpose of this study was to examine the association of REBOA and mortality in a group of patients with penetrating trauma to the torso, treated in a level-I trauma center from Colombia. METHODS: In a retrospective cohort study, patients with penetrating trauma, requiring emergency surgery, and treated between 2014 and 2018, were included. The decision to use or not use REBOA during emergent surgery was based on individual surgeon's opinion. A propensity score (PS) was calculated after adjusting for age, clinical signs on admission (systolic blood pressure, cardiac rate, Glasgow coma scale), severe trauma in thorax and abdomen, and the presence of non-compressive torso hemorrhage. Subsequently, logistic regression for mortality was adjusted for the number of red blood cells (RBC) transfused within the first six hours after admission, injury severity score (ISS), and quintiles of PS. RESULTS: We included 345 patients; 28 of them (8.1%) were treated with REBOA. Crude mortality rates were 17.9% (5 patients) in REBOA group and 15.3% (48 patients) in control group (p = 0.7). After controlling for RBC transfused, ISS, and the PS, the odds of death in REBOA group was 78% lower than that in the control group (odds ratio [OR] 0.20, 95% confidence interval [95%CI] 0.05-0.77, p = 0.01). CONCLUSION: We found that, when compared to no REBOA use, patients treated with REBOA had lower risk-adjusted odds of mortality. These findings should be interpreted with caution and confirmed in future comparative studies, if possible.

Assuntos

Oclusão com Balão , Procedimentos Endovasculares , Aorta , Humanos , Escala de Gravidade do Ferimento , Ressuscitação , Estudos Retrospectivos

RESUMO

PURPOSE: Although Damage Control Thoracic Surgery (DCTS) has become a provocative alternative to treat patients with chest injuries who are critically ill and physiologically depleted, the management approaches of chest-packing and the measurement of clinically relevant outcomes are not well established. In this paper, we systematically reviewed the available knowledge and evidence about intra-thoracic packing during DCTS for trauma patients. We furthermore inform on the management approaches, surgical strategies, and mortality associated with this intervention. METHODS: We identified articles in MEDLINE and SCOPUS. We reviewed all studies that included trauma patients with chest injuries and managed with intrathoracic packing during DCTS. Studies were eligible if the use of intrathoracic packing in trauma populations was reported. RESULTS: We identified 14 studies with a total of 211 patients. Overall, intrathoracic packing was used in 131 trauma patients. Packing was most commonly used to arrest persistent coagulopathic bleeding or oozing either from raw surfaces or repaired structures and in conjunction with other operative techniques. Pneumonectomy was a deadly intervention; however, one study reported survivors when pneumonectomy was deferred. CONCLUSION: Packing is a feasible, reliable and potentially effective complementary method for hemorrhage control. Therefore, we recommend that packing can be used liberally as a complement to rapid lung-sparing techniques.

Assuntos

Traumatismos Torácicos , Cirurgia Torácica , Procedimentos Cirúrgicos Torácicos , Bandagens , Hemorragia , Humanos , Traumatismos Torácicos/cirurgia

RESUMO

BACKGROUND: Our objective was to identify possible associations between clinical and laboratory variables and the risk of developing acute kidney injury (AKI) in severely injured patients admitted to the intensive care unit (ICU) for whom creatine kinase (CK) levels were available. METHODS: For this retrospective observational study, we analyzed adult trauma patients admitted to the ICU from 2011 to 2015 at Fundación Valle del Lili (FVL) University Hospital. Our primary outcome was the incidence of AKI. Multivariate regression analysis was used to assess risk factors for this outcome. RESULTS: A total of 315 patients were included. The trauma mechanisms were blunt (n = 130), penetrating (n = 66) and blast (n = 44) trauma. The median (interquartile range, IQR) of injury severity score (ISS) was 21 (16-29). AKI developed in 75 patients (23.8%). Multivariate regression analysis revealed that the thoracic abbreviated injury scale (AIS) value (median (IQR) in the AKI group: 3 (0-4)), Acute Physiology and Chronic Health Evaluation (APACHE II) score (median (IQR) in the AKI group: 18 (10-27)), CK greater than 5000 U/L, lactic acid concentration at admission, and dobutamine administration were independently associated with AKI. CONCLUSION: We found that age, APACHE II score, thoracic trauma, lactic acidosis, and dobutamine administration were independently associated with AKI. Trauma surgeons need to be aware of the increased odds of AKI if one of these factors is identified during the evaluation and treatment of injured patients.

Assuntos

Injúria Renal Aguda/sangue , Ferimentos e Lesões/complicações , APACHE , Acidose Láctica/complicações , Acidose Láctica/fisiopatologia , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/fisiopatologia , Adulto , Colômbia/epidemiologia , Creatina Quinase/análise , Creatina Quinase/sangue , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Logísticos , Masculino , Estudos Retrospectivos , Fatores de Risco , Ferimentos e Lesões/sangue , Ferimentos e Lesões/epidemiologia

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries' income based on the World Bank Country and Lending Groups. METHODS: We used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality. RESULTS: A total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36­1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63­3,33; p = 0.3). CONCLUSION: There is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide.

Assuntos

Oclusão com Balão/métodos , Procedimentos Endovasculares/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Adulto , Países Desenvolvidos , Países em Desenvolvimento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Sistema de Registros , Choque Hemorrágico/mortalidade , Análise de Sobrevida , Ferimentos e Lesões/mortalidade

RESUMO

PURPOSE: The objective of this study was to evaluate the implementation of a new single-pass whole-body computed tomography Protocol in the management of patients with severe trauma. METHODS: This was a descriptive evaluation of polytrauma patients who underwent whole-body computed tomography. Patients were divided into three groups: 1. Blunt trauma hemodynamically stable 2. Blunt trauma hemodynamically unstable and 3. Penetrating trauma. Demographics, whole-body computed tomography parameters and outcome variables were evaluated. RESULTS: Were included 263 patients. Median injury severity score was 22 (IQR: 16-22). Time between arrival to the emergency department and completing the whole-body computed tomography was under 30 minutes in most patients [Group 1: 28 minutes (IQR: 14-55), Group 2: 29 minutes (IQR: 16-57), and Group 3: 31 minutes (IQR: 13-50; p= 0.96)]. 172 patients (65.4%) underwent non-operative management. The calculated and the real survival rates did not vary among the groups either [Group 1: TRISS 86.4% vs. real survival rate 85% (p= 0.69); Group 2: TRISS 69% vs. real survival rate 74% (p= 0.25); Group 3: TRISS 93% vs. real survival rate 87% (p= 0.07)]. CONCLUSION: This new single-pass whole-body computed tomography protocol was safe, effective and efficient to decide whether the patient with severe trauma requires a surgical intervention independently of the mechanism of injury or the hemodynamic stability of the patient. Its use could also potentially reduce the rate of unnecessary surgical interventions of patients with severe trauma including those with penetrating trauma.

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INTRODUCCIÓN: El objetivo de este estudio fue evaluar la implementación de un nuevo protocolo de tomografía computarizada corporal total para el manejo de pacientes con trauma severo. MÉTODOS: Este estudio es una evaluación descriptiva de pacientes que recibieron tomografía computarizada corporal total. Los pacientes fueron divididos en 3 grupos: 1. Trauma cerrado hemodinámicamente estables, 2. Trauma cerrado hemodinámicamente inestables y 3. Trauma penetrante. Se evaluaron las características demográficas, parámetros relacionados con la técnica y los desenlaces de los pacientes. RESULTADOS: Se incluyeron 263 pacientes. La mediana del puntaje de severidad de la lesión fue 22 (RIQ: 16-22). El tiempo entre el ingreso a urgencias y completar la tomografía corporal total fue menor a 30 minutos en la mayoría de pacientes [Grupo 1: 28 minutos (RIQ: 14-55), Grupo 2: 29 minutos (RIQ: 16-57), y Grupo 3: 31 minutos (RIQ: 13-50; p= 0.96). 172 pacientes (65.4%) recibieron manejo no operatorio. Las tasas de supervivencia calculadas y reales no difirieron entre ninguno de los grupos [Grupo 1: TRISS 86.4% vs. Tasa real de supervivencia 85% (p= 0.69); Grupo 2: TRISS 69% vs. Tasa real de supervivencia 74% (p= 0.25); Grupo 3: TRISS 93% vs. Tasa real de supervivencia 87% (p= 0.07)]. CONCLUSIÓN: Este nuevo protocolo de tomografía corporal total de un solo pase fue seguro, efectivo y eficiente para definir si los pacientes con trauma severo requieren o no una intervención quirúrgica. Su uso podría reducir la tasa de intervenciones quirúrgicas innecesarias en estos pacientes incluyendo los que se presentan con trauma penetrante.

Assuntos

Tomografia Computadorizada Multidetectores/métodos , Traumatismo Múltiplo/diagnóstico por imagem , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/diagnóstico por imagem , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores/instrumentação , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/terapia , Taxa de Sobrevida , Fatores de Tempo , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Adulto Jovem

RESUMO

INTRODUCTION: Trauma teams (TTs) improve outcomes in trauma patients. A multidisciplinary TT was conformed in September 2015 in a tertiary level I trauma university hospital in southwestern Colombia, a middle-income war-influenced country. OBJECTIVE: To evaluate the impact of a TT in admission-tomography and admission-surgery times as well as mortality in a tertiary center university hospital in a middle-income country war-influenced country. MATERIAL AND METHODS: Retrospective analytical study. Patients older than 17 years admitted to the emergency room 15 months prior and 15 months after the TT implementation were included. Patients prior to the TT implementation were taken as controls. No exclusion criteria. Four hundred sixty-four patients were included, 220 before the TT implementation (BTT) and 244 after (ATT). Demographic data, trauma characteristics, admission-tomography, and admission-surgery time interval as well as mortality were recorded. Requirement of CT scan or surgery was based on physician decision. The analysis was made on Stata 15.1®. Categorical variables were described as quantities and proportions, and continuous variables as mean and standard deviation or median and interquartile range (IQR). Categorical variables were compared using χ2 or Fisher's test and continuous variables using Student's T test or Wilcoxon-Mann-Whitney. A multiple logistic regression model was created to evaluate the impact of being treated in the ATT group on mortality, adjusted by age, trauma severity, and physiological response upon admission. RESULTS: The admission-tomography time interval was 56 min (IQR 39-100) in the BTT group and 40 min (IQR 24-76) in the ATT group, p < 0.001. The admission-surgery time interval was 116 min (IQR 63-214) in the BTT group and 52 min (IQR 24-76) in the ATT group, p < 0.001. Mortality in the BTT group was 18.1% and 13.1% in the ATT group. Adjusted OR was 0.406 (0.215-0.789) p = 0.006 CONCLUSIONS: A trauma team conformation in a war-influenced middle-income country is feasible and reduces mortality as well as admission-surgery and admission-tomography time intervals in trauma patients.

RESUMO

Abstract Purpose: The objective of this study was to evaluate the implementation of a new single-pass whole-body computed tomography Protocol in the management of patients with severe trauma. Methods: This was a descriptive evaluation of polytrauma patients who underwent whole-body computed tomography. Patients were divided into three groups: 1. Blunt trauma hemodynamically stable 2. Blunt trauma hemodynamically unstable and 3. Penetrating trauma. Demographics, whole-body computed tomography parameters and outcome variables were evaluated. Results: Were included 263 patients. Median injury severity score was 22 (IQR: 16-22). Time between arrival to the emergency department and completing the whole-body computed tomography was under 30 minutes in most patients [Group 1: 28 minutes (IQR: 14-55), Group 2: 29 minutes (IQR: 16-57), and Group 3: 31 minutes (IQR: 13-50; p= 0.96)]. 172 patients (65.4%) underwent non-operative management. The calculated and the real survival rates did not vary among the groups either [Group 1: TRISS 86.4% vs. real survival rate 85% (p= 0.69); Group 2: TRISS 69% vs. real survival rate 74% (p= 0.25); Group 3: TRISS 93% vs. real survival rate 87% (p= 0.07)]. Conclusion: This new single-pass whole-body computed tomography protocol was safe, effective and efficient to decide whether the patient with severe trauma requires a surgical intervention independently of the mechanism of injury or the hemodynamic stability of the patient. Its use could also potentially reduce the rate of unnecessary surgical interventions of patients with severe trauma including those with penetrating trauma.

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Resumen Introducción: El objetivo de este estudio fue evaluar la implementación de un nuevo protocolo de tomografía computarizada corporal total para el manejo de pacientes con trauma severo. Métodos: Este estudio es una evaluación descriptiva de pacientes que recibieron tomografía computarizada corporal total. Los pacientes fueron divididos en 3 grupos: 1. Trauma cerrado hemodinámicamente estables, 2. Trauma cerrado hemodinámicamente inestables y 3. Trauma penetrante. Se evaluaron las características demográficas, parámetros relacionados con la técnica y los desenlaces de los pacientes. Resultados: Se incluyeron 263 pacientes. La mediana del puntaje de severidad de la lesión fue 22 (RIQ: 16-22). El tiempo entre el ingreso a urgencias y completar la tomografía corporal total fue menor a 30 minutos en la mayoría de pacientes [Grupo 1: 28 minutos (RIQ: 14-55), Grupo 2: 29 minutos (RIQ: 16-57), y Grupo 3: 31 minutos (RIQ: 13-50; p= 0.96). 172 pacientes (65.4%) recibieron manejo no operatorio. Las tasas de supervivencia calculadas y reales no difirieron entre ninguno de los grupos [Grupo 1: TRISS 86.4% vs. Tasa real de supervivencia 85% (p= 0.69); Grupo 2: TRISS 69% vs. Tasa real de supervivencia 74% (p= 0.25); Grupo 3: TRISS 93% vs. Tasa real de supervivencia 87% (p= 0.07)]. Conclusión: Este nuevo protocolo de tomografía corporal total de un solo pase fue seguro, efectivo y eficiente para definir si los pacientes con trauma severo requieren o no una intervención quirúrgica. Su uso podría reducir la tasa de intervenciones quirúrgicas innecesarias en estos pacientes incluyendo los que se presentan con trauma penetrante.

Assuntos

Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/diagnóstico por imagem , Traumatismo Múltiplo/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos , Fatores de Tempo , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/terapia , Escala de Gravidade do Ferimento , Taxa de Sobrevida , Tomografia Computadorizada Multidetectores/instrumentação

RESUMO

BACKGROUND: There is evidence in favor of using the ultrasound as the primary screening tool in looking for an occult cardiac injury. We report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country. METHODS: Data were collected prospectively. We included all consecutive patients 14 years and older who presented to the Emergency Trauma Unit with (1) penetrating injuries to the precordial area and (2) a systolic blood pressure ≥ 90 mmHg (hemodynamically stable). The main outcome measures were sensitivity, specificity, and positive and negative predictive values of ultrasound compared with those of the pericardial window, which was the standard test. RESULTS: A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions. CONCLUSION: We found that ultrasound was 79% sensitive and 92% specific for the diagnosis of occult penetrating cardiac wounds. However, it should be used with caution in patients with injuries to the cardiac zone and simultaneous left hemothorax.

Assuntos

Traumatismos Cardíacos/diagnóstico por imagem , Ultrassonografia , Ferimentos Penetrantes/diagnóstico por imagem , Adulto , Pressão Sanguínea , Procedimentos Cirúrgicos Cardíacos , Técnicas de Diagnóstico por Cirurgia , Serviço Hospitalar de Emergência , Reações Falso-Negativas , Feminino , Traumatismos Cardíacos/fisiopatologia , Traumatismos Cardíacos/cirurgia , Hemotórax/complicações , Hemotórax/diagnóstico por imagem , Humanos , Masculino , Técnicas de Janela Pericárdica , Valor Preditivo dos Testes , Estudos Prospectivos , Ferimentos Penetrantes/fisiopatologia , Ferimentos Penetrantes/cirurgia , Adulto Jovem

RESUMO

In designing and implementing a peer support writing group for junior researchers at our home institution, we saw an opportunity to advance the understanding of this intervention as a valuable tool for future physician-scientists. We, therefore, performed a scoping literature review of the available literature on peer support writing groups in clinical disciplines to learn what has been described about this topic. We paid specific attention to the characteristics, implementation, and impact of these groups on the academic development of medical/healthcare scientists. We performed a scoping literature review following the conceptual framework proposed by Arksey and O'Malley. We included studies describing the characteristics, implementation, and impact/effects of peer support writing groups in clinical disciplines. All the information extracted was summarized descriptively to chart the available literature on peer support writing groups in clinical disciplines. We identified a total of 369 articles, of which six were finally included. The absolute number of papers published increased considerably after the participation in the peer support writing groups. The subjective comments of the participating individuals highlighted the positive effects of these groups on the academic productivity of attendees. Available information shows a significant increase in the absolute number of publications and a positive perception between individuals participating in peer support writing groups. Stakeholders should implement this strategy in their home academic institutions.