RESUMO
INTRODUCTION: Trauma primarily affects the economically active population, causing social and economic impact. The non-operative management of solid organ injuries aims to preserve organ function, reducing the morbidity and mortality associated with surgical interventions. The aim of study was to demonstrate the epidemiological profile of patients undergoing non-operative management in a trauma hospital and to evaluate factors associated with mortality in these patients. METHODS: This is a historical cohort of patients undergoing non-operative management for solid organ injuries at a Brazilian trauma reference hospital between 2018 and 2022. Included were patients with blunt and penetrating trauma, analyzing epidemiological characteristics, blood transfusion, and association with the need for surgical intervention. RESULTS: A total of 365 patients were included in the study. Three hundred and forty-three patients were discharged (93.97%), and the success rate of non-operative treatment was 84.6%. There was an association between mortality and the following associated injuries: hemothorax, sternal fracture, aortic dissection, and traumatic brain injury. There was an association between the need for transfusion and surgical intervention. Thirty-eight patients required some form of surgical intervention. CONCLUSION: The profile of patients undergoing non-operative treatment consists of young men who are victims of blunt trauma. Non-operative treatment is safe and has a high success rate.
Assuntos
Ferimentos não Penetrantes , Humanos , Masculino , Feminino , Adulto , Brasil/epidemiologia , Pessoa de Meia-Idade , Adulto Jovem , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Ferimentos não Penetrantes/epidemiologia , Adolescente , Estudos Retrospectivos , Transfusão de Sangue/estatística & dados numéricos , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Idoso , Centros de TraumatologiaRESUMO
Resumen Objetivo: Presentar dos casos en que se empleó como soporte la circulación extracorpórea (CEC) durante cirugía por traumatismo torácico con lesión de grandes vasos del tórax (TTLGV). Materiales y Método: Se presentan dos casos con TTLGV en que se empleó cirugía con CEC. Resultados: Caso 1; hombre de 31 años con TTLGV por cuerpo extraño (tubo pleural) intracavitario del tronco de la arteria pulmonar izquierda, con entrada a través de parénquima pulmonar, en que se realizó cirugía abierta para retiro de cuerpo extraño más toractotomía pulmonar utilizando CEC como soporte. Caso 2; hombre de 21 años con TTLGV contuso y lesión de aorta en unión sino tubular, en que se realizó cirugía abierta y reemplazo de aorta ascendente con prótesis y uso CEC como soporte. Discusión: El uso de CEC como soporte es una alternativa para sustituir la función cardíaca y/o pulmonar durante cirugías excepcionales de reparación de TTLGV. Conclusión: El uso de técnicas de asistencia circulatoria como soporte durante la cirugía de reparación de TTLGV ocurre en casos muy seleccionados, siendo una alternativa ante lesiones particularmente complejas.
Aim: To present two cases of thoracic trauma with great vessel injury (TTGVI) surgeries where extracorporeal circulation (ECC) was employed. Materials and Method: Two TTGVI cases are presented and ECC during surgery was used in both. Results: Case 1; 31-year-old man with TTGVI due to an intracavitary foreign body (pleural tube) in the left pulmonary artery trunk, which entered through lung parenchyma. An open surgery was performed to remove the foreign body with pulmonary tractotomy using ECC as support. Case 2; 21-year-old man with blunt TTGVI and aortic injury at sinotubular junction. An open surgery with ascending aorta prosthesis replacement was performed, using ECC as support. Discussion: The use of ECC as support is an alternative to replace cardiac and/or pulmonary function during exceptional TTGVI reparation surgeries. Conclusión: The use of circulation assist techniques as support during TTGVI repair surgery occurs in highly selected cases, being an alternative to face very complex injuries.
Assuntos
Humanos , Masculino , Adulto , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/terapia , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/terapia , Traumatismos Torácicos/cirurgia , Ferimentos não Penetrantes/cirurgia , Diagnóstico por Imagem/métodos , Radiografia , Tomografia Computadorizada por Raios XRESUMO
Blunt abdominal trauma occurs in 20% of polytraumatized patients, of which approximately 5% may have mesenteric lesions. We present a case of a woman suffering from a blunt abdominal trauma, who underwent computed tomography with evidence of hematoma on the right flank, which was controlled by angioembolization of the superior mesenteric artery. Treatment of mesenteric lesions will be determined according to the hemodynamic status of the patient, since in view of stability, a choice can be made between open surgery and embolization, but in case of instability, laparotomy is recommended.
El trauma abdominal cerrado se presenta en el 20% de los pacientes politraumatizados, de los cuales aproximadamente el 5% pueden llegar a tener lesiones mesentéricas. Presentamos el caso de una mujer que sufre un traumatismo abdominal cerrado a la cual se le realizó tomografía computarizada con evidencia de un hematoma en el flanco derecho, que se logra controlar por angioembolización de la arteria mesentérica superior. El tratamiento de las lesiones mesentéricas se determinará según el estado hemodinámico del paciente, pues ante la estabilidad se puede escoger entre cirugía abierta y embolización, pero en caso de inestabilidad se recomienda la laparotomía.
Assuntos
Traumatismos Abdominais , Embolização Terapêutica , Ferimentos não Penetrantes , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico por imagem , Traumatismos Abdominais/terapia , Feminino , Humanos , Mesentério/diagnóstico por imagem , Mesentério/lesões , Estudos Retrospectivos , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/terapiaRESUMO
Resumen Introducción: La terapia endovascular ha demostrado ser una buena alternativa de tratamiento en las enfermedades arteriales y venosas. Asimismo, en trauma vascular periférico constituye una excelente opción, especialmente en sitios anatómicos difíciles de acceder y con lesiones complejas como seudoaneurismas, fístulas arteriovenosas (FAV) o la combinación de ambos, con numerosas ventajas. Objetivo: Evaluar los resultados del tratamiento endovascular en trauma vascular penetrante por agresiones y iatrogenias. Materiales y Método: Revisión retrospectiva de todos los pacientes con trauma vascular periférico sometidos a terapia endovascular. Resultados: Entre abril de 2011 y mayo de 2020 se trataron 30 pacientes, 28 hombres y 2 mujeres. Con edades fluctuantes entre 17 y 84 años. La causa del trauma fue 20 penetrantes y 10 iatrogenias. Los vasos afectados fueron arteria femoral superficial 6, femoral profunda 2, subclavia 9, axilar 1, poplítea 4, ilíacas 1, peronea 1, tibial anterior 5, tronco venoso braquiocefálico 1. Diecisiete pacientes fueron tratados con endoprótesis, 9 con embolización y 4 con cierre percutáneo en relación con catéteres arteriales en subclavia. No hubo mortalidad, pero dos pacientes requirieron reparación abierta: un seudoaneurisma poplíteo gigante y un seudoaneurisma de tibial anterior, en ambos se constató sección completa de ambas arterias. El seguimiento clínico ha sido entre 30 días y 3 años. Conclusiones: En esta serie de casos, la terapia endovascular en lesiones de trauma vascular periférico ofrece excelentes resultados con baja morbimortalidad y permeabilidad aceptable a corto y mediano plazo.
Introduction: Endovascular therapy has proven to be a good treatment alternative in arterial and venous diseases. Likewise, in peripheral vascular trauma it is an excellent option, especially in anatomical sites that are difficult to access and with complex lesions such as pseudoaneurysms, arteriovenous fistulas (AVFs) or the combination of both, with numerous advantages. Aim: To evaluate the results of endovascular treatment in trauma Penetrating vascular injury and iatrogenesis. Materials and Method: Retrospective review of all patients with peripheral vascular trauma undergoing endovascular therapy. Results: Between April 2011 and May 2020, 30 patients were treated, 28 men and 2 women. With fluctuating ages between 17 and 84 years. The cause of the trauma was 20 penetrating and 10 iatrogenic. The affected vessels were superficial femoral artery 6, deep femoral 2, subclavian 9, axillary 1, popliteal 4, iliac 1, peroneal 1, anterior tibial 5, brachiocephalic venous trunk 1. Seventeen patients were treated with endoprosthesis, 9 with embolization and 4 with percutaneous closure in relation to arterial catheters in the subclavian. There was no mortality but two patients required open repair: a giant popliteal pseudoaneurysm and an anterior tibial pseudoaneurysm in which both sections of both arteries were found to be complete. Clinical follow-up was between 30 days and 3 years. Conclusión: In this serie, endovascular therapy in peripheral vascular trauma lesions offers excellent results with low morbidity and mortality and acceptable patency in the short and medium term.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Artérias/lesões , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Procedimentos Endovasculares/métodos , Ferimentos não Penetrantes/diagnóstico , Ferimentos Penetrantes/diagnóstico , Prótese Vascular/estatística & dados numéricos , Estudos RetrospectivosRESUMO
OBJECTIVE: To identify the predictive capacity for mortality of the indexes Revised Trauma Score, Rapid Emergency Medicine Score, modified Rapid Emergency Medicine Score, and Simplified Acute Physiology Score III in blunt trauma victims hospitalized in an intensive care unit and compare their performance. METHOD: Retrospective cohort of patients with blunt trauma in an intensive care unit from medical records. Receiver Operating Characteristic and a 95% confidence interval of the area under the curve were analyzed to compare results. RESULTS: Out of 165 analyzed patients, 66.7% have received surgical treatment. The mortality in the intensive care unit and in the hospital was 17.6% and 20.6%, respectively. For the mortality in the intensive care unit, the area under the curve varied from 0.672 to 0.738; however, better results have been observed in surgical patients (0.747 to 0.811). Similar results have been observed for in-hospital mortality. In all analyses, the areas under the curve of the indexes presented no significant difference. CONCLUSION: The accuracy of the severity indexes was moderate, with an improved performance when applied to surgical patients. The four indexes presented a similar prediction for the analyzed outcomes.
Assuntos
Unidades de Terapia Intensiva , Ferimentos não Penetrantes , Mortalidade Hospitalar , Humanos , Curva ROC , Estudos Retrospectivos , Ferimentos não Penetrantes/terapiaRESUMO
The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.
Assuntos
Traumatismos Abdominais , Ferimentos não Penetrantes , Transfusão de Sangue , Hemodinâmica , Humanos , Escala de Gravidade do Ferimento , Estudos Retrospectivos , Baço/lesões , Resultado do Tratamento , Ferimentos não Penetrantes/terapiaRESUMO
BACKGROUND: Trauma is the leading cause of death and disability for individuals under age 55. Many severely injured trauma patients experience complicated clinical courses despite appropriate initial therapy. We sought to identify novel circulating metabolomic signatures associated with clinical outcomes following trauma. STUDY DESIGN: Untargeted metabolomics and circulating plasma immune mediator analysis was performed on plasma collected during 3 post-injury time periods (<6 hours [h], 6 h-24h, day 2-day 5) in critically ill trauma patients enrolled between April 2004 and May 2013 at UPMC Presbyterian Hospital in Pittsburgh, PA. Inclusion criteria were age ≥ 18 years, blunt mechanism, ICU admission, and expected survival ≥ 24 h. Exclusion criteria were isolated head injury, spinal cord injury, and pregnancy. Exploratory endpoints included length of stay (overall and ICU), ventilator requirements, nosocomial infection, and Marshall organ dysfunction (MOD) score. The top 50 metabolites were isolated using repeated measures ANOVA and multivariate empirical Bayesian analysis for further study. RESULTS: Eighty-six patients were included for analysis. Sphingolipids were enriched significantly (chi-square, p < 10-6) among the top 50 metabolites. Clustering of sphingolipid patterns identified 3 patient subclasses: nonresponders (no time-dependent change in sphingolipids, n = 41), sphingosine/sphinganine-enhanced (n = 24), and glycosphingolipid-enhanced (n = 21). Compared with the sphingolipid-enhanced subclasses, nonresponders had longer mean length of stay, more ventilator days, higher MOD scores, and higher circulating levels of proinflammatory immune mediators IL-6, IL-8, IL-10, MCP1/CCL2, IP10/CXCL10, and MIG/CXCL9 (all p < 0.05), despite similar Injury Severity Scores (p = 0.12). CONCLUSIONS: Metabolomic analysis identified broad alterations in circulating plasma sphingolipids after blunt trauma. Circulating sphingolipid signatures and their association with both clinical outcomes and circulating inflammatory mediators suggest a possible link between sphingolipid metabolism and the immune response to trauma.
Assuntos
Metaboloma , Esfingolipídeos/sangue , Ferimentos não Penetrantes/sangue , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Estado Terminal , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Estudos Longitudinais , Masculino , Metabolômica , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Prognóstico , Estudos Prospectivos , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/imunologia , Ferimentos não Penetrantes/terapia , Adulto JovemRESUMO
ABSTRACT The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.
RESUMO O baço é um dos órgãos mais frequentemente afetados no trauma abdominal contuso. Desde os trabalhos de Upadhyaya, o tratamento do trauma esplênico vem sofrendo importantes modificações. Atualmente, é consenso que todo trauma esplênico que se apresenta com estabilidade hemodinâmica pode ser tratado inicialmente de forma não operatória, desde que o serviço possua estrutura adequada e o paciente não apresente outras condições que indiquem exploração da cavidade abdominal. Entretanto, vários tópicos permanecem controversos no que diz respeito ao tratamento não operatório (TNO) do trauma esplênico. A angioembolização esplênica é uma ferramenta de grande auxílio no TNO, porém não há consenso sobre suas indicações precisas. Não há uma definição na literatura a respeito da forma como o TNO deve ser conduzido, tampouco a respeito da periodicidade do controle hematimétrico, do limiar de transfusão que define falha do TNO, de quando iniciar a profilaxia contra tromboembolismo venoso, da necessidade de exames de imagem de controle, do período de repouso no leito, e de quando é seguro indicar alta hospitalar. O objetivo desta revisão é analisar de forma crítica a literatura a respeito desse tema, expondo o estado da arte no TNO do trauma esplênico.
Assuntos
Humanos , Ferimentos não Penetrantes/terapia , Traumatismos Abdominais , Baço/lesões , Transfusão de Sangue , Escala de Gravidade do Ferimento , Estudos Retrospectivos , Resultado do Tratamento , HemodinâmicaRESUMO
INTRODUCCIÓN: Los accidentes en bicicleta son una causa frecuente de trauma abdominal contuso en pediatría. En Chile no existen publicaciones científicas que traten sobre las lesiones abdominales por manubrio de bicicleta, su presentación y manejo. OBJETIVO: Describir tres casos clínicos de trauma abdominal contuso provocados por manubrio de bicicleta en niños, ilustrar las distintas lesiones observadas, sus formas de presentación y manejo. CASOS CLÍNICOS: 1) Paciente masculino, 11 años, consulta tras golpe con manubrio de bicicleta en epigastrio; en la Tomografía Computada (TC) de abdomen y pelvis se describió neumoretroperitoneo. Se realizó laparotomía exploradora, reparándose una perforación duodenal. 2) Paciente masculino, 14 años, consulta tras golpe en el hipocondrio izquierdo con el manubrio de la bicicleta; en la TC se evidenció fractura esplénica con múltiples laceraciones. Por la presencia de sangrado activo se trató con angioembolización, lográndose resolución de la lesión y viabilidad del órgano luego de 6 semanas de seguimiento. 3) Paciente masculino, 9 años, ingresó tras sufrir golpe con manubrio de bicicleta en el hipocondrio derecho. En TC se observó una laceración hepática, que fue manejada de forma expectante, con resolución de la lesión luego de 8 semanas de seguimiento. Todos los pacientes tuvieron una evolución favorable. CONCLUSIÓN: El trauma abdominal contuso por golpe con manubrio de bicicleta puede ser potencialmente grave en pacientes pediátricos, pudiendo afectar órganos sólidos y vísceras huecas. El manejo no quirúrgico cada vez es más utilizado, logrando altas tasas de éxito en pacientes estables. Los pacientes inestables o en los que se sospeche perforación de víscera hueca, requerirán cirugía como primera aproximación.
INTRODUCTION: Bicycle accidents are a frequent cause of blunt abdominal trauma in children. In Chile, there are no scientific articles about such accidents, their presentation and management. OBJECTIVE: The aim of this study is to describe three cases of blunt abdominal trauma due to handlebar injury in children, in order to illustrate the different kinds of lesions, their presentation, and management. CLINICAL CASES: 1) 11-year-old boy presented to Emergency Department (ED) after falling on a bi cycle handlebar, hitting his epigastric region. A CT scan showed signs of duodenal perforation. A la parotomy was performed and the duodenal perforation repaired. 2) 14-year-old boy seen at ED after a bicycle accident in which the handlebar hit him in the abdomen area. A CT scan showed a splenic injury with multiple lacerations and active bleeding that was treated with angioembolization. After 6 weeks of follow-up, he presented resolution of the lesion and viability of the spleen. 3) 9-year-old boy admitted due to a hit with the bicycle handlebar on the abdomen area. A CT scan showed a he patic injury that was managed with non-surgical procedures, achieving resolution of the lesion after 8 weeks of follow-up. CONCLUSION: Blunt abdominal trauma caused by handlebar can be potentially serious in pediatric patients, since it may affect solid and hollow abdominal viscera. Non-surgical ma nagement is becoming more used for stable patients, achieving high success rates. Unstable patients or those with suspicion of hollow viscera perforation will require surgery as first approach.
Assuntos
Humanos , Masculino , Criança , Adolescente , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/terapia , Ciclismo/lesões , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/terapia , Ferimentos não Penetrantes/etiologia , Tomografia Computadorizada por Raios X , Serviço Hospitalar de Emergência , Traumatismos Abdominais/etiologiaRESUMO
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.
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.