La ventana pericárdica es el estándar de oro en el diagnóstico de trauma cardiaco en heridas precordiales estando descritas diferentes vías de abordaje. El objetivo de este estudio es comparar las características clínicas, desenlaces y rendimiento diagnóstico de las vías subxifoidea vs. toracoscópica en pacientes con trauma precordial abierto.

Estudio observacional de cohortes, en un periodo de 56 meses, se recopilaron pacientes con heridas penetrantes en región precordial, hemodinámicamente estables que ingresaron al Servicio de Urgencias, a quienes se indicó la realización de ventana pericárdica para descartar lesiones cardiacas. Se compararon las características clínicas, desenlaces y el rendimiento diagnóstico de las pruebas.

Se incluyeron 256 pacientes, 93.4% ingresaron por herida por arma cortopunzante, 18.8% de las ventanas pericárdicas fueron vía toracoscópica, 20.8% resultaron positivas para hemopericardio y 11.5% de las subxifoideas, la mediana de la estancia hospitalaria fue 4 días, 16.0% presentaron complicaciones, 17.8% en pacientes abordados por vía subxifoidea y 8.3% vía toracoscópica siendo más frecuente el hemotórax coagulado, 15.2% fueron llevados a reintervención, la mayoría a toracoscopia para drenaje de hemotórax coagulado (62.5%), la mortalidad fue 1.6%, todos los casos en el grupo del abordaje subxifoideo. La sensibilidad de la ventana pericárdica subxifoidea fue 95.8% y la toracoscópica 90.9%, y la especificidad fue 99.5% y 100%, respectivamente.

El abordaje toracoscópico es una opción diagnóstica con rendimiento similar al subxifoideo. A pesar de establecer una disminución en la mediana de los días como usuarios de sonda de toracostomía, no se observó disminución en los días de estancia hospitalaria.

Mateus LJD, Guerrero AMB, Manrique AGB, Pastrana JPS, Falla OFH, Valencia-Ángel LI. Ventana Pericardica: Abordaje Subxifoideo vs. Toracoscopico En Trauma Precordial Abierto. Panam J Trauma Crit Care Emerg Surg 2017;6(3):135-141.

The pericardial window is the gold standard in the diagnosis of cardiac trauma in precordial wounds and different approaches are described. The aim of this study is to compare the clinical characteristics, outcomes, and diagnostic performance of subxiphoid vs. thoracoscopy in patients with open precordial trauma.

A 56-month observational study of cohorts collected patients with penetrating wounds in the precordial region was conducted. These patients were hemodynamically stable and admitted to the Emergency Department. They were asked to perform a pericardial window to rule out cardiac lesions. The clinical characteristics, outcomes, and diagnostic performance of the tests were compared.

A total of 256 patients were included in the study. Around 93.4% were injured by a sharp gunshot wound, 18.8% of the pericardial windows were thoracoscopic, 20.8% were positive for hemopericardium, and 11.5% were subxiphoid. The median length of hospital stay was 4 days, we had 16.0% complications, 17.8% in subxiphoid approach, and 8.3% in thoracoscopic patients, with coagulated hemothorax being the most frequent, 15.2% were submitted to reintervention, most of them thoracoscopy for clotted hemothorax drainage (62.5%), mortality was 1.6%, all cases in the subxiphoid group. The sensitivity of the subxiphoid pericardial window was 95.8% and thoracoscopic 90.9%, and the specificity was 99.5% and 100% respectively.

The thoracoscopic approach is a diagnostic option with subxiphoid-like performance. In spite of establishing a decrease in the median of the days as users of thoracostomy tube, no decrease was observed in the days of hospital stay.

El trauma es considerado un problema de salud pública. Es una de las patologías que generan mayor discapacidad y mortalidad a nivel de Latinoamérica y Colombia no es la excepción. El objetivo de este estudio fue describir las principales complicaciones del manejo quirúrgico de los pacientes con trauma penetrante de tórax en un hospital universitario en el sur de Colombia.

Estudio descriptivo observacional de los pacientes victimas de trauma penetrante de tórax que ingresaron entre enero de 2013 a marzo de 2015; Se evaluaron las variables clínicas, sociodemográficas, complicaciones, factores de riesgo y severidad de las lesiones; se realizó un análisis univariado, se calcularon medidas de tendencia central y de dispersión para las variables continuas, se utilizó la prueba de Chi² para medir significancia estadística en el software en línea R versión 2.15.2.

En total se analizaron 485 pacientes, 8,65% (42) desarrollaron alguna complicación; entre los pacientes en los que se registró algún tipo de complicación relacionada con el manejo quirúrgico del trauma penetrante de tórax, el empiema fue la principal complicación 59,52% (25), seguido por neumonía 28,57% (12), y SDRA 14,91% (5). La media de la edad fue de 34,2 ± 8,23 años, la media del ISS fue de 16,4 ± 2,91, el 88,1% de las lesiones fue por arma corto punzante, en 61,9% de los casos se presentó hemotórax, 30,95% neumotórax y en 7,14% se presentó neumo — hemotorax. La media de la estancia hospitalaria fue de 14,8 ± 2,45 días.

Las complicaciones postquirúrgicas del manejo en el trauma penetrante de tórax se presentan en un hospital universitario al sur de Colombia. El empiema postraumático es la principal complicación que se presenta en los pacientes con trauma penetrante de tórax, uno de los factores de riesgo más importante es el hemotorax coagulado el cual podría identificarse y tratarse a tiempo; evitando comorbilidades durante la estancia hospitalaria.

Trauma is considered a public health problem. It is one of the pathologies which leads to greater level of disability and mortality in Latin America, and Colombia is not an exception. The aim of this study was to describe the main complications of surgical management of patients with penetrating thoracic trauma in a university hospital in southern Colombia.

A descriptive study was conducted on patients who were the victims of penetrating chest trauma, admitted from January 2013 to March 2015. Clinical, sociodemographic, complications, risk factors, and severity of lesions were evaluated; univariate analysis was performed; measures of central tendency and dispersion for continuous variables were calculated; Chi-square test was used to measure statistical significance in the online software R version 2.15.2.

A total of 485 patients were analyzed, 8.65% (42) developed some complications. Among patients with some type of complication related to the surgical management of penetrating chest trauma, empyema was the main complication 59.52% (25), followed by pneumonia 28.57% (12) and ARDS 14, 91% (5). The mean age was 34.2 ± 8.23 years, the mean ISS was 16.4 ± 2.91. Around 88.1% of the injuries were stabbing wounds, 61.9% cases presented hemothorax, 30.95% pneumothorax and 7,14% hemopneumothorax respectively. The average hospital stay was 14.8 ± 2.45 days.

Surgical complications after the operation in penetrating chest trauma are presented in a university hospital in southern Colombia. Posttraumatic empyema is the main complication that occurs in patients with penetrating chest trauma. One of the most important risk factor is coagulated hemothorax which could be identified and treated in time, avoiding comorbidities during the hospital stay.

Cuellar AM, Charry JD, Medina R, Chávarro O. Complicaciones del Manejo Quirúrgico De Los Pacientes Con Trauma Penetrante De Tórax En Un Hospital Universitario Al Sur De Colombia. Panam J Trauma Crit Care Emerg Surg 2017;6(3):142-145.

Analizar las características de los pacientes asistidos por ingesta de cuerpo extraño en el Departamento de Emergencia del Hospital Maciel y llegar al diseño de guías de actuación en el contexto de un equipo multidisciplinario.

Nuestra serie constó de 31 consultas por ingesta de cuerpo extraño. El 52% provenía de instituciones psiquiátricas y el 42% eran reclusos, un caso no pertenecía a ninguna de las 2 categorías. El 27,5% de las consulta se habían producido en las primeras 24hs desde la ingesta, el 24% de las ingestas se habían producido con más de una semana desde la ingesta y el resto oscilaba entra ambos tiempos evolutivos En cuanto a la conducta, en 12 casos se otorgó el alta sin mediar conducta activa endoscópica y/o quirúrgica. Se realizó una FGC en el 64% de los casos en los cuales se constató radiológicamente la ingesta de un cuerpo extraño, siendo efectivamente terapéuticas para la extracción de objetos a nivel gastroduodenal en el 67% de las mismas. De las 28 consultas por ingesta de CE 6 pacientes (21%) fueron operados. En 5 de ellos por falla de la extracción endoscópica, el restante se presentó como una peritonitis aguda. La ingesta de CE representa una patología de consulta frecuente en el Departamento de Emergencia. El manejo del mismo se realiza mediante un abordaje multidisciplinario que en el caso de nuestra serie mostró porcentajes de extracción endoscópica efectiva cercana al 70% comparable con otras series internacionales. El análisis de las características de la población analizada y el análisis de la evidencia científica publicada nos permite plantear un protocolo de actuación.

Trostchansky J, Masaferro G. Ingesta de Cuerpos Extraños Estudio Prospectivo Observacional. Conducta Terapéutica y Resultados. Panam J Trauma Crit Care Emerg Surg 2017;6(3):146-154.

To analyze the characteristics of assisted patients due to foreign body ingestion in the Department of Emergency of Maciel Hospital and the design of protocols of action in the context of a multidisciplinary team.

Our series had 31 patients who came for consultation because of foreign body ingestion; 52% came from psychiatric care institutions, 42% were prisoners of state prison, and one case did not belong to any of the previous categories. About 27.5% of consultations occurred within the first 24 hours after ingestion, 24% of consultations in the Department of Emergency occurred after more than 1 week from ingestion, and the rest oscillated between both evolutionary times. Regarding the therapeutic behavior performed, in 12 cases it was decided to discharge the patient without active endoscopic conduct or surgery. A FGC was performed in 64% of cases in which the intake of the foreign body was found radiologically. The FGC was effectively therapeutic for the extraction of objects at the gastroduodenal level in 67% of them. Of the 28 visits to the Department of Emergency for foreign body ingestion, 6 patients (21%) were operated. The reason for this surgery was the failure of endoscopic extraction in 5 of them, the remaining patient presented with acute peritonitis. Ingestion of foreign body represents a pathology of frequent consultation in the Department of Emergency. The management of this clinical situation is carried out through a multidisciplinary approach that, in the case of our series, showed percentages of effective endoscopic extraction close to 70%, comparable with other international series. The analysis of the characteristics of the population studied in our series and the analysis of the published scientific evidence allow us to define a protocol of action of this type of patients in our hospital.

To describe the results of a systematic, rapid, and effective method of communication for the definitive treatment of patients with severe traumatic bleeding.

The Red Wave was developed to improve communication between the emergency department and other strategical processes and to reduce the time from the arrival of severe traumatic hemorrhagic patient to a definitive treatment in the operating room.

On admission, the traumatized patient is seen by the nursing staff in the Red Room, who trigger a general bell indicating the arrival of a severe trauma patient.

The surgeon activates the red bell, which triggers an audible and visual alarm at strategic sectors of the hospital: operating center, transfusional agency, and laboratory, each one with its established sub-protocol. We defined as goals that the patient must arrive at the operating room in a maximum of 15 minutes after the Red Wave activation, with availability of blood and plasma in 20 minutes and blood tests collected at the same time. A light panel located in the surgical center turns off at each completed step, recording their time-responses.

From June through December 2015, we admitted 831 trauma patients in the Red Room of Hospital do Suburbio, predominantly young (67.9% younger than 40 years old) and male (77.5%). Blunt trauma was the predominant mechanism (79.2%), and the majority of patients had an revised trauma score (RTS) calculated at admission greater than 7 (86.5%).

We also evaluated, from September through December 2015, the attendance of 96 patients admitted with a diagnosis of hemorrhagic traumatic shock. The Red Wave was triggered in 39.6% of these cases. Gunshot wounds were the most frequent mechanism of trauma (86.5%), with a survival rate of 56.8%.

The goals for time-responses were met in most of the cases, with correctness of 81.6% for the patient arrival at the operating room, 81.6% for laboratory sampling, and 86.8% for blood and plasma availability by the transfusion agency.

The Red Wave proved to be an effective protocol to systematize the initial treatment of patients with severe traumatic bleeding, improving communication between the strategic sectors involved, reducing the time-response of each service and making the definitive treatment of these patients faster and suitable.

Romeo AC, Cunha AG, Filho PS, Oliveira V, Moura T, Motta J, Mendes G, Cruz MR. Red Wave: Improving Care to Severe Trauma Victims. Panam J Trauma Crit Care Emerg Surg 2017;6(3):155-159.

Descrever resultados de meio de comunicação sistemático, rápido e efetivo para tratamento definitivo de pacientes com trauma hemorrágico grave.

A Onda Vermelha foi desenvolvida para melhorar a comunicação entre o departamento de emergência e outros setores estratégicos do hospital e reduzir o tempo entre a chegada do paciente com trauma hemorrágico grave e o tratamento cirúrgico definitivo.

O paciente traumatizado é avaliado na admissão pela enfermagem responsável pela sala vermelha que ativa campainha indicando a chegada de paciente traumatizado grave.

O cirurgião após avaliação do paciente aciona uma campainha vermelha que dispara um sinal sonoro e visual em setores estratégicos do hospital, cada um com seus sub-protocolos preestabelecidos. Definimos como objetivos a chegada do paciente ao centro cirúrgico em 15 minutos após o acionamento da Onda Vermelha, havendo disponibilidade de concentrado de hemácias e plasma fresco congelado e coleta de exames laboratoriais em 20 minutos. Uma luz do painel luminoso no centro cirúrgico apaga a cada etapa completada, gravando os tempos de resposta.

Entre Junho e Dezembro de 2015, 831 pacientes traumatizados foram admitidos na sala vermelha do Hospital do Subúrbio, predominantemente jovens (67,9% com menos de 40 anos) do gênero masculino (77,5%). O trauma contuso foi o mecanismo mais frequente (79,2%) e a maioria dos pacientes tiveram o RTS calculado na admissão maior que 7 (86,5%).

Avaliamos ainda, entre Setembro e Dezembro de 2015, o atendimento de 96 pacientes admitidos com choque hemorrágico traumático. A Onda Vermelha foi ativada em 39.6% destes casos. Ferimentos por arma de fogo foram mais frequentes nestes (86,5%), com uma taxa de sobrevida de 56,8%.

Os objetivos de tempo foram alcançados na maioria dos casos: 81,6% na chegada do paciente ao centro cirúrgico e coleta do laboratório e 86,8% na disponibilidade do concentrado de hemácias e plasma pela agência transfusional.

A Onda Vermelha mostrou-se protocolo efetivo para sistematização do tratamento inicial do paciente com choque hemorrágico, melhorando a comunicação entre os setores estratégicos envolvidos, reduzindo o tempo de resposta de cada setor e tornando o tratamento destes pacientes adequado e ágil.

This study aims to compare mortality prediction capabilities of three different physiological trauma scoring systems (TSS): Revised Trauma Score (RTS) Glasgow Coma Scale, Age, and Systolic Blood Pressure (GAP) and Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP).

A descriptive, cross-sectional study of trauma victims admitted to the emergency service between December-2013 and February-2014. Clinical and epidemiological information were gathered at admission and three TSS were calculated: RTS, GAP, and MGAP. The follow-up period to assess length of hospitalization and mortality lasted until August-2014. Two groups were created — survivals (S) and deaths (D) — and compared. P < 0.05 was considered statistically significant.

A total of 668 trauma victims were analyzed. The mean age was 37 ± 18 and 69.8% were males. Blunt trauma prevailed (90.6%). The mean scores of RTS, GAP, and MGAP for group S (n = 657; 98.4%) were 7.77 ± 0.33, 22.8 ± 1.7, and 27.4 ± 2.3 respectively (p < 0.001), whereas group D (n = 11, 1.6%) achieved mean scores of 4.57 ± 2.95, 13 ± 7, and 15.5 ± 7 (p < 0.001). Regarding the Receiver Operating Characteristics (ROC) analysis, the areas under the curve were 0.926 (RTS), 0.941 (GAP), and 0.981 (MGAP). The three TSS demonstrated significant mortality prediction capabilities (p < 0.001). There was no statistically significant difference between the three ROC curves (p = 0.138). The MGAP achieved the highest sensitivity (100%), while GAP and RTS sensitivities were 81.8% (59—100%), and 90.9% (73.9—100%) respectively (p < 0.001). The observed specificities were 96.2% (94.77—97.7%) for GAP, 91.6% (89.5—93.7%) for MGAP, and 87.2% (84.7—89.8%) for RTS (p < 0.001). Age (p = 0.049), Glasgow Coma Scale (GCS) (p < 0.001), and trauma mechanism (p < 0.001) were different between the two groups.

Most patients were young males and victims of blunt trauma. The three TSS demonstrated reliability regarding mortality prediction. The MGAP achieved the highest sensitivity and GAP was the most specific score, which may indicate a potential use of both as valuable alternatives to RTS.

Razente DM, Alvarez BD, Lacerda DAM, Biscardi JMDS, Olandoski M, Bahten LCV. Mortality Prediction in Trauma Patients using Three Different Physiological Trauma Scoring Systems. Panam J Trauma Crit Care Emerg Surg 2017;6(3):160-168.

Avaliar o poder preditivo de mortalidade de três scores de trauma (ST): Score de trauma revisado (RTS); escala de coma de Glasgow, idade e pressão arterial (GAP); e mecanismo, escala de coma de Glasgow, idade e pressão arterial (MGAP).

Estudo transversal e descritivo envolvendo vítimas de trauma admitidas no serviço de emergência entre Dezembro-2013 e Fevereiro-2014. Informações clínicas e epidemiológicas foram coletadas na admissão e três ST foram calculados: RTS, GAP e MGAP. Houve seguimento até Agosto-2014 para avaliar tempo de hospitalização e mortalidade. Dois grupos foram criados — sobreviventes (S) e óbitos (O) - e comparados. Significância estatística adotada: p < 0,05.

Analisaram-se 668 vítimas de trauma. Registrou-se média de idade de 37±18 anos, 69,8% sendo masculinos. Predominou o trauma contuso (90,6%). Para o grupo S (n = 657; 98,4%), as médias de RTS, GAP e MGAP foram, respectivamente, 7,77 ± 0,33, 22,8 ± 1,7 e 27,4 ± 2,3 (p < 0,001), enquanto o grupo O (n = 11, 1,6%) obteve médias de 4,57 ± 2,95, 13 ± 7 e 15,5 ± 7 (p < 0,001). A análise Receiver Operating Characteristics (ROC) revelou áreas abaixo da curva de 0,926 (RTS), 0,941 (GAP) e 0,981 (MGAP) (p<0,001). Todos os ST revelaram significativo poder preditivo de óbito (p < 0,001). As três curvas ROC não foram significativamente diferentes entre si (p = 0,138). MGAP atingiu a maior sensibilidade (100%), enquanto GAP e RTS obtiveram sensibilidades de 81,8% (59-100%) e 90,9% (73,9-100%). As especificidades foram de 96,2% (94,7-97,7%) para o GAP, 91,6% (89,5-93,7%) para o MGAP e 87,2% (84,7-89,8%) para o RTS. Idade (p = 0,049), escala de coma de Glasgow (p < 0,001) e mecanismo de trauma (p < 0,001) foram significativamente diferentes entre os dois grupos.

Observou-se predomínio de jovens masculinos, vítimas de trauma contuso. Os três ST demonstraram confiabilidade quanto à predição de óbito. MGAP atingiu a maior sensibilidade e GAP mostrou-se o mais específico, possivelmente indicando o uso de ambos como alternativas ao RTS.

Trauma registries contribute to improving trauma care, but their impact is highly dependent on the quality of the data. A simplified point of care pediatric trauma registry (PTR) was developed at the Centre for Global Surgery from the McGill University Health Centre (MUHC) for implementation in Low-middle income countries (LMICs). Pilot deployment was launched at a large urban trauma center in May 2016 in Santiago, Chile. Prior to deployment, we sought to identify missing data in existing trauma records in order to optimize PTR practicality and user benefit.

The project was approved by the local Institutional Review Board. Retrospective chart review was conducted on trauma patients below the age of 15 who were evaluated at the emergency room (ER) of Hospital Dr. Sotero del Rio (HSR) between January 1st and June 30th 2015. Data missingness was evaluated for each component of the PTR (demographics, mechanism, injury and outcomes). Potential independent predictors of data missingness were evaluated using multiple linear regression.

A total of 351 patients were included. Demographic data missingness ranged from 0% (age) to 95% (mode of arrival). Mechanism data missingness ranged from 6% (cause of injury) to 42% (site of injury). Injury physiology data missingness ranged from 37% (oxygen saturation) to 99% (respiratory rate). Interestingly, mean injury anatomy data missingness was significantly inferior to physiology data (0.6% vs. 78.6%, p < 0.05). Outcome data missingness reached 54% at 2 weeks.

In resource-limited settings, high quality data is essential to guide responsible resource allocation. We believe implementation of a simplified trauma registry has the potential to reduce data gaps for pediatric trauma patients by streamlining trauma data collection at point of care. This should include streamlined data collection with a short per-patient completion time, and should forego attempts to collect data at 2 weeks, which has proven unsuccessful.

St-Louis E, Roizblatt D, Deckelbaum DL, Baird R, Millán CV, Ebensperger A, Razek T. Identifying Pediatric Trauma Data Gaps at a Large Urban Trauma Referral Center in Santiago, Chile. Panam J Trauma Crit Care Emerg Surg 2017;6(3):169-176.

Los registros de trauma contribuyen a mejorar la atención traumatológica, pero su impacto depende en gran medida de la calidad de los datos. En el Centro de Cirugía Global del Centro de Salud de la Universidad de McGill se desarrolló un registro simplificado de trauma pediátrico en el punto de atención (PTR) para su implementación en países de ingresos medios bajos (LMIC, por sus siglas en inglés). El despliegue piloto fue lanzado en un gran centro de traumatología urbana en mayo de 2016 en Santiago, Chile. Antes del despliegue, se buscó identificar los datos faltantes en los registros de trauma existentes a fin de optimizar la practicidad PTR y el beneficio del usuario.

El proyecto fue aprobado por la Junta de Revisión Institucional local. Se realizó una revisión retrospectiva de los pronósticos de los pacientes con traumatismos menores de 15 años que fueron evaluados en la sala de urgencias del Hospital Dr. Sotero del Río entre el 1 de enero y el 30 de junio de 2015. Se evaluó la falta de datos para cada componente del PTR , Mecanismo, lesión y resultados). Los potenciales predictores independientes de la falta de datos se evaluaron mediante regresión lineal múltiple.

Se incluyeron 351 pacientes. La falta de datos demográficos osciló entre 0% (edad) y 95% (modo de llegada). La falta de datos del mecanismo osciló entre el 6% (causa de la lesión) y el 42% (sitio de la lesión). La falta de datos de la fisiología de lesiones osciló entre el 37% (saturación de oxígeno) y el 99% (frecuencia respiratoria). Curiosamente, los datos de anatomía de lesión media faltantes fueron significativamente inferiores a los datos fisiológicos (0,6% vs 78,6%, p <0,05). La falta de datos de resultados alcanzó el 54% a las 2 semanas.

En entornos de recursos limitados, los datos de alta calidad son esenciales para orientar la asignación responsable de recursos. Creemos que la implementación de un registro de trauma simplificado tiene el potencial de reducir las lagunas de datos para los pacientes pediátricos traumatizados mediante la racionalización de la recogida de datos de trauma en el punto de atención. Esto debería incluir una recolección de datos simplificada con un tiempo de finalización corto por paciente, y debería renunciar a los intentos de recopilar datos a las 2 semanas, lo que ha resultado infructuoso.

El trauma craneoencefálico (TCE) continúa siendo la principal causa de morbimortalidad entre pacientes con trauma, la discapacidad y el compromiso cognitivo corresponde a la principal afectación configurando pronóstico a largo plazo.

Se realizó un estudio prospectivo tipo cohortes/casos y controles donde se incluyeron los pacientes con TCE severo (Escala Coma de Glasgow <8 y/o TAC anormal) que ingresaron a la unidad de cuidados intensivos Adultos durante 6 meses; se buscó determinar los desenlaces relacionados con el TCE en términos de mortalidad y discapacidad.

Se encontraron 32 pacientes, más del 90% hombres, la mayoría con estabilidad hemodinámica al ingreso, se practicó neurocirugía en el 40% de los pacientes, aunque todos tenían indicación de monitoria de presión intracraneana solo se realizó en el 6% de los pacientes. El puntaje en la escala de desenlaces de Glasgow presento una mediana de 3 (RIC = 225 puntos). Se clasifico la severidad de la discapacidad en buena recuperacion 9,3%, discapacidad moderada 31,25%, discapacidad severa-muerte hasta en un 25%. Se determino que que un puntaje en la ECG se relacionaba con un GOS mas bajo; la neumonía aspirativa fue la principal complicación extracraneal, la mortalidad global correspondió a un 34.4%.

El TCE continua afectando de manera especial a las poblaciones jóvenes, con una alta incidencia de consecuencias discapacitantes y alta mortalidad, los centros de trauma deben implementar protocolos mas estrictos para promover la prevención y reforzar la aplicación de recomendaciones mundiales para mejores resultados en términos supervivencia y calidad de vida.

El trauma craneoencefálico, continua configurándose como la principal causa de morbimortalidad y discapacidad en adultos jovenes, con esta investigación se busca conocer y describir los datos epidemiológicos relevantes con respecto al desenlace de dicho trauma, conocimiento que es clave en el proceso de enseñanza buscando ofrecer mejores y mas efectivos abordajes en el momento de verse enfrentado a un trauma craneoencefálico.

Traumatic brain injury (TBI) remains to be the leading cause of morbidity and mortality among patients with trauma, disability and neurocognitive commitment corresponds to the main affectation and set the long-term prognosis of these patients.

It was performed a prospective cohort/cases and controls study, where all the patients with severe TBI (Glasgow Coma Scale (GCS) < 8 and/or abnormal CT scan) were admitted into the adult intensive care unit (ICU) for 6 months to determine the outcomes related to TBI in terms of mortality and disability.

Thirty-two patients, more than 90% men, most with hemodynamic stability at admission; neurosurgery was practiced in 40% of patients. Although all had indication of intracranial pressure (ICP), monitoring was only performed in 6% of the patients. The score on the Glasgow outcome scale presented a median of 3 (IQR = 2p5 points). The severity of disability in good recovery was 9.3%, moderate disability 31.25%, and severe-dead disability was up to 25%. It was determined that a GCS score was associated with a lower GOS; aspiration pneumonia as the main extracranial complication was presented, overall mortality fell to 34.4% with only 12.5% of organ donors.

The TBI continues to affect especially young populations with a high incidence of disabling consequences and high mortality. The trauma centers should implement more strict protocols to promote prevention and to strengthen the implementation of global recommendations for better results in terms of survival and quality of life.

Traumatic brain injury continues being the main cause of morbidity and disability in young adults. This research seeks to know and describes the relevant epidemiological data regarding the outcome of this trauma, a knowledge that is key in the teaching process seeking better and more effective approaches at the moment of approach traumatic brain injury.

Rubio MA, Rubio JJ, Lozano A, Ruiz J, Sanjuan J, Botache WF. Estado Funcional De Los Pacientes Con Trauma Craneo Encefalico Criticamente Enfermos. Panam J Trauma Crit Care Emerg Surg 2017;6(3):177-181.

La definición de Berlin de politrauma (2014) combina la severidad lesional con al menos uno de cinco complementos (edad, TAS, GCS, KPTT o EB).

Hasta ahora hay insuficiente información sobre cómo afecta esta nueva definición la identificación de los grupos con mayor mortalidad. El objetivo de este trabajo fue evaluar la performance de esta definición comparándola con otras mediciones.

Análisis retrospectivo observacional de ingresos prospectivos al Registro de Trauma de Fundación Trauma en 10 hospitales entre 2010-2016. Los criterios de inclusión fueron edad > 15 años y tener información completa para el cálculo de los índices. Los pacientes se compararon según las definiciones de politrauma (PT), trauma múltiple (Tmult), trauma mayor por ISS (TM_ISS) y trauma mayor por NISS (TM_NISS). Se analizaron medidas de performance.

Se analizaron 259 hechos con PT, 802 con Tmult, 1349 con TM_ISS y 2143 con TM_NISS. El grupo PT resultó heterogéneo, con una mortalidad entre 44% y 71% según diferentes combinaciones de complementos. El 75% tuvo lesiones por transporte y el 76% tuvo al menos una lesión encefálica AIS > 2. El desenlace estuvo relacionado con el estado al ingreso, por impacto fisiológico (RTS) y por severidad lesional (ISS-NISS). La relación O/E para sobrevida por TRISS fue 0.73.

La comparación con las otras definiciones mostró diferencias estadísticamente significativas en mortalidad pero no en ISS, NISS ni RTS. La evaluación de performance mostró que TM_NISS tuvo la mayor sensibilidad y el mayor VPN, mientras que PT tuvo el mayor VPP. Como medida global, TM_ISS tuvo una precisión superior al resto (89%) y una especificidad de 97%.

La definición de PT para identificación de pacientes con mayor riesgo de muerte no mostró ser superior a otras definiciones de uso corriente. Consideramos que la definición de PT necesita ser validada en estudios multicéntricos antes de recomendarse como un nuevo standard.

Monteverde E, Bosque L, Lartigue B, Maciá E, Barbaro C, Ortiz C, Ginzburg E, Neira J. Evaluación de la Nueva Definición de Politrauma en una Cohorte de Pacientes de 10 Hospitales Argentinos. Panam J Trauma Crit Care Emerg Surg 2017;6(3):182-189.

Berlin definition of polytrauma from 2014 combines injury severity with at least one of five ancillary parameters (age, systolic blood pressure, Glasgow coma score, coagulopathy and acidosis). Until now there is insufficient evidence of this definition's capability to identify higher risk of mortality patients. The objective of this investigation was to evaluate this definition's performance to identify severely injured patients as compared with other current measures.

Retrospective observational analysis was done on prospectively admitted patients to Fundación Trauma Registry in 10 Argentine hospitals between 2010 and 2016. The inclusion criteria were age > 15 years and complete data for scores calculation. Patients were compared across four definitions: polytrauma, multiple trauma (MulT), major trauma by major trauma_injury severity score (MT_ISS), and by major trauma_new injury severity score (MT_NISS). Performance measures were applied.

We identified 2143 cases meeting MT_NISS definition, 1349 for MT_ISS, 802 for MulT and 259 for polytrauma. Polytrauma group was heterogenous, with a mortality rate ranging from 44% to 71% (resulting from different component combinations). About 75% were transport-injured and 76% had at least one AIS3+ head injury. Hospital outcome was related to condition at admission, physiologic impact revised trauma score (RTS) and injury severity (ISS-NISS). Observed to predicted survival ratio method trauma and injury severity score (TRISS) was 0.73. The comparison with the other definitions showed statistically significant differences in mortality but not in ISS, NISS, and RTS. Performance evaluation showed that MT_NISS had the highest sensibility and negative predictive value and polytrauma had the highest predictive value (PPV). MT_ISS had the highest precision (89%) and a specificity of 97%.

Polytrauma definition used to identify patients with the highest probability of death did not show any benefit when compared with other current measures. We consider that this definition needs to be validated in multicentric studies before being recommended as a new standard.

Análise, através de amostragem, dos aspectos envolvidos na condução dos pacientes laparostomizados.

Estudo prospectivo tipo série de casos. Há mais de 15 anos o serviço tem aprimorado seu protocolo em relação à laparostomia. De março/2014 a março/2016, 60 pacientes foram conduzidos em laparostomia no serviço de cirurgia geral e do trauma do Hospital Pronto Socorro João XXIII (HPSJXXIII) da Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), objeto desse estudo.

A maioria dos pacientes era jovem, média de idade de 33 anos e do sexo masculino 50 (83%). O mecanismo de trauma mais frequente foi o penetrante 32 (53%). O ISS maior que 16, observado em 80% dos casos, define alto percentual de pacientes graves. A instabilidade hemodinâmica foi detectada em 39 (65%) pacientes e 24 (40%) foram encaminhados ao centro cirúrgico em caráter de emergência. O controle de danos foi realizado em 53 (88%) das laparostomias. Ao final da primeira intervenção, a Bolsa de Bogotá foi o fechamento temporário do abdome realizado em 100% dos casos dos laparostomizados. Curativo com pressão negativa foi realizado em 13 (22%) dos pacientes. Algum tipo de complicação abdominal ocorreu em 36 (60%) dos casos. A fístula intestinal foi a complicação mais grave, observada em 8 (13%) pacientes. O óbito foi o desfecho final em 27 (45%) pacientes do estudo.

Nos últimos anos, a análise dos laparostomizados tem aguçado preocupação na condução desses pacientes no serviço. A morbimortalidade é significativa e cada vez mais há evidências de que os vieses no controle de danos acabam influenciando decisivamente nos resultados. A complacência na indicação dos procedimentos de controle de danos deve ser reavaliada nos serviços de trauma.

O crescimento do “damage control” aumentou muito a indicação de laparostomias. O abdome aberto tem benefícios bem estabelecidos no manejo de pacientes instáveis, porém, associa-se a grandes complicações e a um alto índice de morbimortalidade. É necessário maiores discussões acerca do tema e desenvolvimento de protocolos específicos, cada vez mais concisos, levando-se em conta os recursos humanos e materiais de cada instituição.

Constantino GDC, Drumond DAF, de Oliveira RM, de Souza Araújo AB. Laparostomias No Hospital João XXIII: Análise Das Indicações e Resultados. Panam J Trauma Crit Care Emerg Surg 2017;6(3):190-200.

To analyse the aspects involved in the management of laparostomized patients by sampling.

A prospective study of a series of cases was conducted. For more than 15 years, the service has improved its protocol regarding laparostomy. From March 2014 to March 2016, 60 patients were submitted to laparostomy in the General Surgery and Trauma's Service of the Hospital Pronto Socorro João XXIII (HPSJXXIII) of the Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), as object of this study.

The majority of patients (50 [83%]) were young male and the mean age was 33 years. The predominant mechanism of trauma was penetrating 32 (53%). The injury severity score (ISS) greater than 16, observed in 80% of the cases, defines a high percentage of critical patients. Hemodynamic instability was detected in 39 (65%) patients and 24 (40%) were referred to the operating room as emergencies cases. The damage control method was performed in 53 (88%) of the laparostomies. At the end of the first intervention, the Bolsa de Bogotá was the temporary closure of the abdomen performed in 100% of the laparostomized cases. Negative pressure wound therapy was performed in 13 (22%) patients. Some kind of abdominal complication occurred in 36 (60%) cases. Intestinal fistula was the most severe complication observed in 8 (13%) patients. Death was the final outcome in 27 (45%) patients in the study.

In the last years, the study of laparostomized patients has driven interest in the management of these patients in our service. Morbidity and mortality are significant among these cases and there is growing evidence that the damage control method and its biases ultimately influences outcomes. Compliance in the indication of damage control procedures should be reevaluated in trauma services.

The growth of “damage control” has greatly increased the indication of laparostomies. The open abdomen has well-established the benefits in managing unstable patients, but it is associated with major complications and a high morbidity and mortality rate. Further discussion on this topic and development of specific, increasingly concise protocols are required, taking into account the human and material resources of each institution.

Elucidar as características e o padrão epidemiológico dos acidentes com escorpião no ano de 2015 atendidos em um hospital de trauma terciário.

Estudo epidemiológico, retrospectivo e descritivo, a partir de dados de notificação de acidentes escorpiônicos do Sistema de Informação de Agravos de Notificação (SINAN) sendo a coleta de dados feita por meio da Unidade de Toxicologia da instituição (CEATOX) e Núcleo Hospitalar de Epidemiologia (NUHEPI), referentes ao ano de 2015.

No ano de 2015, 2652 vítimas de acidentes com escorpiões receberam auxílio médico no pronto atendimento do hospital de trauma em questão. Deste número, 1721 (64,9%) eram do sexo masculino. A capital, Fortaleza, era o município de residência de 2.465 (92,9%) dos pacientes. As regiões corpóreas mais acometidas foram pé e mão, ambos com 885 (33,4%) dos casos. Não foi necessária a infusão de soro antiescorpiônico em nenhuma ocasião. Ademais, em 2647 (99,8%) o acidente foi categorizado como leve.

Essa amostragem demonstra a ainda grande prevalência dessa causa externa de trauma no estado do Ceará, condição essa que pode acarretar risco de lesão grave de membros e complicações graves, incluindo o óbito. O agravo está, também, estreitamente relacionado com questões ambientais e com a falta de conhecimento da população sobre os aspectos da prevenção, tornando o profissional de saúde um agente transformador na redução dos índices e redução da demanda hospitalar pelos casos.

Embora a maior parte dos acidentes com escorpião seja classificada como leve, alguns indivíduos, principalmente crianças e idosos, podem evoluir com quadros graves que terminem em óbito. Tornam- se assim imperativos tanto a implementação de medidas preventivas como o correto manejo clínico de cada caso.

Farias ACC, Alves ODC, de Oliveira TC, da Silva FJC, Terceiro DA, Bizerril RO, Arantes EP, Olímpio FP, Soeiro GO, Furtado AFV. Aspectos epidemiológicos dos acidentes com escorpião no ano de 2015 atendidos em um hospital de referência. Panam J Trauma Crit Care Emerg Surg 2017;6(3):201-208.

The aim of the study is to analyze the epidemiological aspects of scorpion bites assisted in an emergency hospital in 2015.

Retrospective and descriptive study was based on notification data of scorpion accidents in the Sistema de Informação de Agravos de Notificação (SINAN). The data was gathered from the toxicological unit of the hospital and Núcleo Hospitalar de Epidemiologia (NUHEPI), for the year 2015.

In 2015, total 2652 patients victims of scorpion accidents, received medical assistance. Out of this total number, 1721 (64.9%) were males. Fortaleza, the capital, was the city where 2465 (92.9%) patients lived. The most affected body parts were the hand and the foot equally, each part responsible for 885 (33.4%) of the cases. The administration of antiscorpionic serum was not necessary in any of the victims, and in 2647 cases (99.8%), the accidents were classified as mild.

This sample shows that this external trauma case is still very prevalent in Ceará, which can bring risks of major limb damage and serious complications, including death. Unfavorable environment condition and poor knowledge about prevention measures make the injury easier to occur. Hence, health professionals have an important task to spread information regarding preventive methods among the people, and consequently there will be reduction in injury rates and hospital demands.

Although the major part of scorpion accidents was mild, children and elderly people can evolve to life-threatening conditions and death. Therefore, prevention methods and appropriate medical conduction of the cases are essential.

To report on the clinical course of a patient who received penetrating shrapnel to the heart and colon.

Penetrating missiles to the heart is a highly lethal incident, particularly, when associated with other serious injuries.

This is the case of a 29-year-old male soldier, who sustained multiple shrapnel injuries caused by an explosive device in the war zone. Shrapnel penetrated the cecum and another lodged in the interventricular septum of the heart. Surprisingly, the patient was stable enough to undergo a staged procedure, where he was subjected to limited right hemicolectomy first, followed by open heart surgery to extract the cardiac shrapnel twelve hours later. His convalescence was uneventful and was discharged in a good condition.

With timely intervention and close collaboration between the concerned clinicians in specialized centers, patients with penetrating shrapnel to vital structures, including the heart, could have a successful outcome.

Critical thinking is needed to prioritize which injuries to deal with first, in patients with near lethal injuries.

Rabie ME, Gallo R, Refaie MA, Asmary MA. Survival after penetrating Shrapnel to the Heart and Colon: Which Injuries to tackle First? Panam J Trauma Crit Care Emerg Surg 2017;6(3):209-213.

Reportar el curso clínico de un paciente que recibió esquirlas penetrantes al corazón y colon.

Misiles penetrantes en el corazón es un incidente altamente letal, especialmente cuando se asocia con otras lesiones serias.

un soldado masculino de 29 años de edad, que sufrió múltiples heridas de esquirlas causadas por un artefacto explosivo en la zona de guerra. Una de las esquirlas penetró el intestino ciego y otra alojada en el septo interventricular del corazón. Sorprendentemente, el paciente estaba lo suficientemente estable como para someterse a un procedimiento de etapas, donde fue sometido a hemicolectomía derecha limitada en primer lugar, seguido por cirugía a corazón abierto para extraer la esquirla cardiaca doce horas más tarde. Su convalecencia fue sin incidentes y fue dado de alta en buenas condiciones.

Con la intervención oportuna, y estrecha colaboración entre los médicos tratantes, en centros especializados, pacientes con esquirlas penetrantes a estructuras vitales, incluyendo el corazón, puden tener un resultado exitoso.

Con pensamiento crítico, es necesario priorizar qué lesiones tratar primero, en pacientes con lesiones letales.

Soto AP, Huizar JAR, Rosas AIH, Vazquez AH, de Leon OHG. Lesión Vascular de Cuello en Paciente Pediátrico Secundario a Mordedura de Perro. Reporte de Caso. Panam J Trauma Crit Care Emerg Surg 2017;6(3):214-218.

One of the first reported cases of cervical trauma was in Homer's Iliad, when Achilles struck with a spear to the neck of Hector. Injuries in general are the main cause of death in the first four decades of life in Mexico City; neck trauma represents 5-10% of all traumas and of these 20% are associated with mortality when it comes to penetrating injuries.

From time immemorial man has been related with animals. In any of the relations alterations may arise in coexistence constituting specific accidents, such as it's the bites.

A higher proportion of them are in children of whom 50% of those affected are minors 1of 4 years (1-4 and 5-9 years). It seems clear that the lower the size of the victim, the more frequent are these bites in the neck, head and face, leading to the possible association of craniofacial fractures (appear in 25% of cases) and intracranial hemorrhages (12%). The indications for immediate surgical intervention after penetrating cervical injury include hemodynamic instability or significant external hemorrhage.

We present the case of a 6-year-old patient, attacked by family dog, causing injuries multiple, in neck, face, extremities and thorax. that conditioned a hypovolemic shock secondary to injuries of the external and internal jugular veins, that were repaired by vascular exploration.

Communities, and especially children, through of a culture of education for coexistence with animals, must know the risks of dog bites and way to prevent them: for example, do not approach dogs street and never leave a child unsupervised near a dog.

Systemic lupus erythematosus (SLE)-associated thrombocytopenia in pregnancy is a rare condition associated with potential harm to the mother, the fetus, and/or newborn, if the thrombocytopenia is severe (<50,000/mm³). Controversy persists regarding the role and the timing of splenectomy in patients with SLE-associated refractory immune thrombocytopenia in pregnancy. This report describes the use of splenectomy at the time of the cesarean section (CS) in a patient with refractory SLE-associated thrombocytopenia.

A 19-year-old gravida 2, para 1 woman with SLE-associated thrombocytopenia diagnosed at age 16 developed a platelet count of 10,000/mm³ at the 18th week of gestation. She had been asymptomatic until that point, except for a previous spontaneous abortion at the 8th week of gestation in 2008. During this admission she was treated initially with methylprednisolone and enoxaparin, but following an episode of epistaxis she received intravenous immunoglobulin (IVIG). She was discharged home with a platelet count of 52,000/mm³. She was readmitted on the 34th week of gestation with a platelet count of 15,000/mm³ unresponsive to steroids and IVIG; she underwent a CS and an open splenectomy. Following surgery, she continued to receive maintenance dose steroids. She had a partial response to the splenectomy (platelet count on discharge 63,000/mm³).

Splenectomy at the time of CS is a safe therapeutic option for women with SLE-associated refractory thrombocytopenia during pregnancy.

Granate M, Quaglia F, Petrone P, Cerciello G, Marini C, Martinelli P. Systemic Lupus Erythematosus-associated Thrombocytopenia in Pregnancy: Is Splenectomy Necessary at the Time of Delivery? Panam J Trauma Crit Care Emerg Surg 2017;6(3):219-223.

La trombocitopenia asociada al Lupus Eritematoso Sistémico (LES) en el embarazo es una afección rara asociada con daño potencial a la madre, al feto y/o al recién nacido, si la trombocitopenia es grave (<50.000/mm³). La controversia persiste con respecto al papel y el momento de la esplenectomía en pacientes con trombocitopenia inmune refractaria asociada al LES en el embarazo. Este informe describe el uso de la esplenectomía en el momento de la cesárea (CS) en un paciente con trombocitopenia refractaria asociada al LES.

Paciente femenina de 19 años de edad, con trombocitopenia asociada a LES diagnosticada a los 16 años, gravida 2, para 1, desarrolló un recuento de plaquetas de 10.000/mm³ a la 18° semana de gestación. Hasta ese momento había estado asintomática, excepto por un aborto espontáneo previo a la 8° semana de gestación en 2008. Durante esta admisión se trató inicialmente con metilprednisolona y enoxaparina pero tras un episodio de epistaxis recibió inmunoglobulinas intravenosas (IVIG). Fue dada de alta con un recuento de plaquetas de 52.000/mm³. Fue readmitida a la 34° semana de gestación con un recuento de plaquetas de 15.000/mm³ no responde a los esteroides y IVIG. Se sometió a un CS y una esplenectomía abierta. Después de la cirugía, continuó recibiendo dosis de mantenimiento de esteroides. Tuvo una respuesta parcial a la esplenectomía (recuento de plaquetas al alta 63.000/mm³).

La esplenectomía en el momento del CS es una opción terapéutica segura para las mujeres con trombocitopenia refractaria asociada al LES durante el embarazo.

A trombocitopenia associada ao Lupus Eritematoso Sistêmico (LES) na gravidez é uma condição rara associada a possíveis danos à mãe, ao feto e / ou ao recém nascido, se a trombocitopenia for grave (<50.000/mm³). A controvérsia persiste em relação ao papel e ao momento da esplenectomia em pacientes com trombocitopenia imune refratária associada ao LES na gravidez. Este relatório descreve o uso de esplenectomia no momento da cesariana (CS) em um paciente com trombocitopenia associada ao LES.

Paciente do sexo feminino, 19 anos, com trombocitopenia associada com LES diagnosticado aos 16 anos, grávida 2 a 1, desenvolveu uma contagem de plaquetas de 10.000/mm³ para a 18^a semana de gestação. Até então ele tinha sido assintomática, com excepção de um aborto espontâneo antes às 8 semanas de gestação em 2008. Durante esta admissão foi inicialmente tratada com metilprednisolona e enoxaparina mas após um episódio de epistaxe receberam imunoglobulina intravenosa (IVIG). Ele recebeu alta com uma contagem de plaquetas de 52.000/mm³. Ele foi readmitido no 34^a semana de gestação com uma contagem de plaquetas de 15.000/mm³ não responde aos esteróides e IVIG. Ele passou por uma CS e uma esplenectomia aberta. Após a cirurgia, ele continuou a receber uma dose de manutenção de esteróides. Ele teve uma resposta parcial a esplenectomia (contagem de plaquetas 63.000/mm³).

A esplenectomia no momento do CS é uma opção terapêutica segura para mulheres com trombocitopenia refratária associada ao LES durante a gravidez.