RESUMO
BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.
Assuntos
Tratamento Conservador/estatística & dados numéricos , Corpos Estranhos/complicações , Reto/lesões , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Ferimentos não Penetrantes/epidemiologia , Adolescente , Adulto , Feminino , Corpos Estranhos/terapia , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Reto/diagnóstico por imagem , Reto/cirurgia , Estudos Retrospectivos , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/etiologia , Ferimentos não Penetrantes/terapia , Adulto JovemRESUMO
PURPOSE OF REVIEW: Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries. RECENT FINDINGS: Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization. SUMMARY: Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.
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Transtornos da Coagulação Sanguínea/terapia , Exsanguinação/terapia , Fraturas Ósseas/cirurgia , Ossos Pélvicos/cirurgia , Ressuscitação/métodos , Espaço Retroperitoneal/lesões , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/fisiopatologia , Transfusão de Sangue/métodos , Procedimentos Clínicos , Embolização Terapêutica/métodos , Exsanguinação/etiologia , Exsanguinação/fisiopatologia , Fixação de Fratura/métodos , Fraturas Ósseas/complicações , Hemodinâmica , Humanos , Ossos Pélvicos/lesões , Ossos Pélvicos/fisiopatologia , Taxa de SobrevidaRESUMO
BACKGROUND: Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA). METHODS: This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation. Upon MTP activation, patients were randomized to be managed either by an MTP goal directed by TEG or by CCA (ie, international normalized ratio, fibrinogen, platelet count). Primary outcome was 28-day survival. RESULTS: One hundred eleven patients were included in an intent-to-treat analysis (TEG = 56, CCA = 55). Survival in the TEG group was significantly higher than the CCA group (log-rank P = 0.032, Wilcoxon P = 0.027); 20 deaths in the CCA group (36.4%) compared with 11 in the TEG group (19.6%) (P = 0.049). Most deaths occurred within the first 6 hours from arrival (21.8% CCA group vs 7.1% TEG group) (P = 0.032). CCA patients required similar number of red blood cell units as the TEG patients [CCA: 5.0 (2-11), TEG: 4.5 (2-8)] (P = 0.317), but more plasma units [CCA: 2.0 (0-4), TEG: 0.0 (0-3)] (P = 0.022), and more platelets units [CCA: 0.0 (0-1), TEG: 0.0 (0-0)] (P = 0.041) in the first 2 hours of resuscitation. CONCLUSIONS: Utilization of a goal-directed, TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation.
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Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/terapia , Transfusão de Sangue/normas , Técnicas Hemostáticas , Ressuscitação/métodos , Tromboelastografia/métodos , Adulto , Colorado , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Centros de Traumatologia , Resultado do Tratamento , Ferimentos e Lesões/complicaçõesRESUMO
BACKGROUND: Trauma-induced coagulopathy (TIC) has been the subject of intense study for greater than a century, and it is associated with high morbidity and mortality. The Trans-Agency Consortium for Trauma-Induced Coagulopathy, funded by the National Health Heart, Lung and Blood Institute, was tasked with developing a clinical TIC score, distinguishing between injury-induced bleeding from persistent bleeding due to TIC. We hypothesized that the Trans-Agency Consortium for Trauma-Induced Coagulopathy clinical TIC score would correlate with laboratory measures of coagulation, transfusion requirements, and mortality. METHODS: Trauma activation patients requiring a surgical procedure for hemostasis were scored in the operating room (OR) and in the first ICU day by the attending trauma surgeon. Conventional and viscoelastic (thrombelastography) coagulation assays, transfusion requirements, and mortality were correlated to the coagulation scores using the Cochran-Armitage trend test or linear regression for numerical variables. RESULTS: Increased OR TIC scores were significantly associated with abnormal conventional and viscoelastic measurements, including hyperfibrinolysis incidence, as well as with higher mortality and more frequent requirement for massive transfusion ( p < 0.0001 for all trends). Patients with OR TIC score greater than 3 were more than 31 times more likely to have an ICU TIC score greater than 3 (relative risk, 31.6; 95% confidence interval, 12.7-78.3; p < 0.0001). CONCLUSION: A clinically defined TIC score obtained in the OR reflected the requirement for massive transfusion and mortality in severely injured trauma patients and also correlated with abnormal coagulation assays. The OR TIC score should be validated in multicenter studies. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.
Assuntos
Transtornos da Coagulação Sanguínea , Ferimentos e Lesões , Humanos , Transtornos da Coagulação Sanguínea/diagnóstico , Transtornos da Coagulação Sanguínea/etiologia , Coagulação Sanguínea , Hemorragia/etiologia , Hemostasia , Testes de Coagulação Sanguínea , Tromboelastografia/métodos , Ferimentos e Lesões/complicaçõesRESUMO
BACKGROUND: Many centers now perform surgical stabilization of rib fractures (SSRF). This single center study aimed to investigate temporal trends by year in patient selection, operative characteristics, and in-hospital outcomes We hypothesized that, over time, patient selection, time to SSRF, operative time, and in-hospital outcomes varied significantly. METHODS: A retrospective review of a prospectively maintained SSRF database (2010 to 2020) was performed. Patients were stratified by year in which they underwent SSRF. The primary outcome was operative time, defined in minutes from incision to closure. Secondary outcomes were patient and operative characteristics, and in-hospital outcomes. Multivariable regression analyses were performed to assess for temporal trends, corrected for confounders. The outcomes ventilator-, Intensive Care Unit-, and hospital-free days (VFD, IFD, and HFD, respectively) were categorized based on the group's medians, and complications were combined into a composite outcome. RESULTS: In total, 222 patients underwent SSRF on a median of one day after admission (P25-P75, 0-2). Patients had a median age of 54 years (P25-P75, 42-63), ISS of 19 (P25-P75, 13-26), RibScore of 3 (P25-P75, 2-5), and sustained a median of 8 fractured ribs (P25-P75, 6-11). In multivariable analysis, increasing study year was associated with an increase in operative time (p<0.0001). In addition, study year was associated with a significantly reduced odds of complications (Odds ratio [OR], 0.76; 95% Confidence Interval [95% CI], 0.63-0.92; p=0.005), VFD < 28 days (OR, 0.77; 95% CI, 0.65-0.92; p=0.003), IFD < 24 days (OR, 0.77; 95% CI, 0.66-0.91; p=0.002), and HFD < 18 days (OR, 0.64; 95% CI, 0.53-0.76; p<0.0001). CONCLUSION: In-hospital outcomes after SSRF improved over time. Unexpectedly, operative time increased. The reason for this finding is likely multifactorial and may be related to patient selection, onboarding of new surgeons, fracture characteristics, and minimally invasive exposures. Due to potential for confounding, study year should be accounted for when evaluating outcomes of SSRF.
Assuntos
Fraturas das Costelas , Hospitalização , Hospitais , Humanos , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/cirurgiaRESUMO
Introduction: Many patients utilize the Emergency Room (ER) for primary care, resulting in overburdened ERs, strained resources, and delays in care. To combat this, many centers have adopted a Trauma/Acute Care Surgery (TACS) service providing specialty surgeons whose primary work is the unencumbered surgical availability to emergency surgery patients. To evaluate our programs' efficacy, we investigated cholecystectomies as a common urgent procedure representative of services provided. We hypothesized that the adoption of a TACS service would result in improved access to care as evidence by decreased ER visits prior to cholecystectomy, improved time to cholecystectomy, and decreased hospital length of stay (LOS). Methods: All patients that underwent urgent cholecystectomy from January 1, 2018 to December 31, 2018 were reviewed. The unencumbered TACS surgeon was implemented on July 1, 2018. Prior ER visits involving biliary symptoms, time from admission to cholecystectomy, and hospital LOS were compared. Results: Of the 322 urgent cholecystectomies over the study period, 165 were performed prior and 157 following adoption of the TACS structure. The average number of ER visits for biliary symptoms prior to cholecystectomy decreased from 1.4 to 1.2 (p = 0.01). Time from admission to cholecystectomy was 28.3 hours and 27.3 hours respectively (p = 0.74). Average LOS decreased following the restructure (3.1 vs 2.5 days; p = 0.03). Conclusion: Implementation of an unencumbered TACS surgeon managing urgent surgical disease improves access to and delivery of surgical services for cholecystectomy patients in a safety net, level one trauma center. Further research is necessary to determine potential improvements in hospital cost and patient satisfaction.
Assuntos
Colecistectomia Laparoscópica , Cirurgiões , Colecistectomia/métodos , Serviço Hospitalar de Emergência , Humanos , Tempo de Internação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS: A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS: 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION: Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.
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Síncope , Telemetria , Adulto , Humanos , Síncope/diagnóstico , Síncope/etiologia , Telemetria/efeitos adversos , Ecocardiografia , Testes Diagnósticos de Rotina/efeitos adversosRESUMO
BACKGROUND: Since the promulgation of emergency department (ED) thoracotomy>40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival. METHODS: Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively. RESULTS: During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge. CONCLUSION: Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.
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Ressuscitação/métodos , Toracotomia/estatística & dados numéricos , Ferimentos e Lesões/cirurgia , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/cirurgia , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ressuscitação/mortalidade , Ressuscitação/estatística & dados numéricos , Análise de Sobrevida , Traumatismos Torácicos/mortalidade , Traumatismos Torácicos/cirurgia , Toracotomia/mortalidade , Resultado do Tratamento , Estados Unidos , Ferimentos e Lesões/mortalidade , Ferimentos por Arma de Fogo/mortalidade , Ferimentos por Arma de Fogo/cirurgia , Ferimentos Perfurantes/mortalidade , Ferimentos Perfurantes/cirurgia , Adulto JovemRESUMO
Pelvic ring injuries presenting in hemorrhagic shock have historically had a mortality rate greater than 30%. To address this high mortality rate our institution has had a multi-disciplinary protocol for hemodynamically unstable pelvic ring injuries since 1993. In 2004, this protocol was revised to prioritize pre-peritoneal pelvic packing over angiography to rapidly control hemorrhage, reduce high-volume blood transfusions, and decrease the number of deaths from acute blood loss. This protocol has been successful in reducing deaths from hemorrhage by 30%. Despite the benefits of such a protocol, many trauma centers are not routinely stabilizing pelvic ring injuries or controlling pelvic hemorrhage. Subsequently, mortality rates remain high with a significant proportion of patients dying from acute blood loss. Trauma centers adhering to multi-disciplinary protocols that allow for rapid stabilization of the pelvis and simultaneous control of multiple sites of hemorrhage in hybrid operative suites are promising future directions for the management of patients with these lethal injuries.
Assuntos
Fraturas Ósseas , Ossos Pélvicos , Choque Hemorrágico , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Hemodinâmica , Hemorragia/terapia , Humanos , Ossos Pélvicos/diagnóstico por imagem , Ossos Pélvicos/cirurgia , Estudos Retrospectivos , Choque Hemorrágico/terapiaRESUMO
BACKGROUND: The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. METHODS: An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. RESULTS: Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. CONCLUSION: Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills. LEVEL OF EVIDENCE: Therapeutic, level V.
Assuntos
Aorta , Oclusão com Balão/métodos , Hemorragia/cirurgia , Ressuscitação/métodos , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Centros de Traumatologia , Resultado do Tratamento , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgiaRESUMO
BACKGROUND: The existence of primary fibrinolysis (PF) and a defined mechanistic link to the "Acute Coagulopathy of Trauma" is controversial. Rapid thrombelastography (r-TEG) offers point of care comprehensive assessment of the coagulation system. We hypothesized that postinjury PF occurs early in severe shock, leading to postinjury coagulopathy, and ultimately hemorrhage-related death. METHODS: Consecutive patients over 14 months at risk for postinjury coagulopathy were stratified by transfusion requirements into massive (MT) >10 units/6 hours (n = 32), moderate (Mod) 5 to 9 units/6 hours (n = 15), and minimal (Min) <5 units/6 hours (n = 14). r-TEG was performed by adding tissue factor to uncitrated whole blood. r-TEG estimated percent lysis was categorized as PF when >15% estimated percent lysis was detected. Coagulopathy was defined as r-TEG clot strength = G < 5.3 dynes/cm. Logistic regression was used to define independent predictors of PF. RESULTS: A total of 34% of injured patients requiring MT had PF, which was associated with lower emergency department systolic blood pressure, core temperature, and greater metabolic acidosis (analysis of variance, P < 0.0001). The risk of death correlated significantly with PF (P = 0.026). PF occurred early (median, 58 minutes; interquartile range, 1.2-95.9 minutes); every 1 unit drop in G increased the risk of PF by 30%, and death by over 10%. CONCLUSIONS: Our results confirm the existence of PF in severely injured patients. It occurs early (<1 hour), and is associated with MT requirements, coagulopathy, and hemorrhage-related death. These data warrant renewed emphasis on the early diagnosis and treatment of fibrinolysis in this cohort.
Assuntos
Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/fisiopatologia , Transfusão de Sangue/estatística & dados numéricos , Fibrinólise/fisiologia , Ferimentos e Lesões/complicações , Doença Aguda , Adulto , Transtornos da Coagulação Sanguínea/diagnóstico , Distribuição de Qui-Quadrado , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Sistemas Automatizados de Assistência Junto ao Leito , Estudos Prospectivos , Estatísticas não Paramétricas , Tromboelastografia , Fatores de Tempo , Ferimentos e Lesões/terapiaRESUMO
OBJECTIVE: To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP). DESIGN: Retrospective observational cohort study. SETTING: Level I academic trauma center. PATIENTS: Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring. INTERVENTION: Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87). MAIN OUTCOME MEASURE: Incidence of postoperative surgical site infections of the pelvic space. RESULTS: Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1-3 days) and 3.4 ± 3.7 days (range: 0-15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures. CONCLUSIONS: These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fixação Interna de Fraturas/efeitos adversos , Fraturas Ósseas/cirurgia , Técnicas Hemostáticas/efeitos adversos , Ossos Pélvicos/lesões , Infecção da Ferida Cirúrgica/epidemiologia , Adulto , Idoso , Placas Ósseas , Feminino , Consolidação da Fratura , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Rectal injuries have been historically treated with a combination of modalities including direct repair, resection, proximal diversion, presacral drainage, and distal rectal washout. We hypothesized that intraperitoneal rectal injuries may be selectively managed without diversion and the addition of distal rectal washout and presacral drainage in the management of extraperitoneal injuries are not beneficial. METHODS: This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 of all patients who sustained a traumatic rectal injury and were admitted to one of the 22 participating centers. Demographics, mechanism, location and grade of injury, and management of rectal injury were collected. The primary outcome was abdominal complications (abdominal abscess, pelvic abscess, and fascial dehiscence). RESULTS: After exclusions, there were 785 patients in the cohort. Rectal injuries were intraperitoneal in 32%, extraperitoneal in 58%, both in 9%, and not documented in 1%. Rectal injury severity included the following grades I, 28%; II, 41%; III, 13%; IV, 12%; and V, 5%. Patients with intraperitoneal injury managed with a proximal diversion developed more abdominal complications (22% vs 10%, p = 0.003). Among patients with extraperitoneal injuries, there were more abdominal complications in patients who received proximal diversion (p = 0.0002), presacral drain (p = 0.004), or distal rectal washout (p = 0.002). After multivariate analysis, distal rectal washout [3.4 (1.4-8.5), p = 0.008] and presacral drain [2.6 (1.1-6.1), p = 0.02] were independent risk factors to develop abdominal complications. CONCLUSION: Most patients with intraperitoneal injuries undergo direct repair or resection as well as diversion, although diversion is not associated with improved outcomes. While 20% of patients with extraperitoneal injuries still receive a presacral drain and/or distal rectal washout, these additional maneuvers are independently associated with a three-fold increase in abdominal complications and should not be included in the treatment of extraperitoneal rectal injuries. LEVEL OF EVIDENCE: Therapeutic study, level III.
Assuntos
Traumatismos Abdominais/cirurgia , Colostomia/métodos , Drenagem/métodos , Reto/lesões , Sociedades Médicas , Traumatologia , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/diagnóstico , Adulto , Feminino , Humanos , Masculino , Estudos Retrospectivos , Sigmoidoscopia , Índices de Gravidade do Trauma , Estados UnidosRESUMO
BACKGROUND: Chronic kidney disease (CKD) patients have increased rates of bleeding as well as thrombosis. Fibrinogen and platelets combine to generate a mature clot, but in CKD platelets are dysfunctional. Therefore, we hypothesize that CKD patients have increased clot strength due to elevated fibrinogen levels. METHODS: Retrospective review of CKD patients (n = 84) who had rTEG and fibrinogen levels measured. They were compared to healthy controls (n = 134). RESULTS: CKD patients had statistically significant increases in ACT, angle, MA and decreases in LY30 compared to controls. Fibrinogen levels were increased in CKD patients compared to reference range. Fibrinogen levels had a positive correlation with MA (rho = 0.709, p < 0.0001) in CKD patients. CONCLUSIONS: Patients with CKD manifest a coagulopathy consisting of delayed clot formation, but increased final clot strength and decreased clot breakdown. Furthermore, the elevated clot strength is mediated by increased fibrinogen levels in CKD patients.
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Transtornos da Coagulação Sanguínea/diagnóstico , Testes de Coagulação Sanguínea , Falência Renal Crônica/sangue , Adulto , Estudos de Casos e Controles , Colorado , Feminino , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Diálise Renal , Estudos Retrospectivos , TromboelastografiaRESUMO
BACKGROUND: Chest CT is more sensitive than a chest X-ray (CXR) in diagnosing rib fractures; however, the clinical significance of these fractures remains unclear. OBJECTIVES: The purpose of this study was to determine the added diagnostic use of chest CT performed after CXR in patients with either known or suspected rib fractures secondary to blunt trauma. METHODS: Retrospective cohort study of blunt trauma patients with rib fractures at a level I trauma center that had both a CXR and a CT chest. The CT finding of ≥ 3 additional fractures in patients with ≤ 3 rib fractures on CXR was considered clinically meaningful. Student's t-test and chi-square analysis were used for comparison. RESULTS: We identified 499 patients with rib fractures: 93 (18.6%) had CXR only, 7 (1.4%) had chest CT only, and 399 (79.9%) had both CXR and chest CT. Among these 399 patients, a total of 1,969 rib fractures were identified: 1,467 (74.5%) were missed by CXR. The median number of additional fractures identified by CT was 3 (range, 4 - 15). Of 212 (53.1%) patients with a clinically meaningful increase in the number of fractures, 68 patients underwent one or more clinical interventions: 36 SICU admissions, 20 pain catheter placements, 23 epidural placements, and 3 SSRF. Additionally, 70 patients had a chest tube placed for retained hemothorax or occult pneumothorax. Overall, 138 patients (34.5%) had a change in clinical management based upon CT chest. CONCLUSIONS: The chest X-ray missed ~75% of rib fractures seen on chest CT. Although patients with a clinical meaningful increase in the number of rib fractures were more likely to be admitted to the intensive care unit, there was no associated improvement in pulmonary outcomes.
RESUMO
BACKGROUND: Attempts are made with emergency department thoracotomy (EDT) to salvage trauma patients who present to the hospital in extremis. The EDT allows for relief of cardiac tamponade, internal cardiac massage, and proximal hemorrhage control. Minimally invasive techniques, such as endovascular hemorrhage control (EHC) are available, but their noninferiority to EDT remains unproven. Before adopting EHC, it is important to evaluate the current outcomes of EDT. We hypothesized that EDT survival has improved during the last 4 decades, and outcomes stratified by pre-hospital CPR and injury patterns will provide benchmarks for success-to-rescue and survival outcomes for patients in extremis. STUDY DESIGN: Consecutive trauma patients undergoing EDT from 1975 to 2014 were prospectively observed as part of quality improvement. Predicted probabilities of survival were adjusted for pre-hospital CPR, mechanism of injury, injury pattern, patient demographics, and time period of EDT using logistic regression. Success-to-rescue was defined as return of spontaneous circulation with blood pressure permissive for transfer to the operating room. RESULTS: There were 1,708 EDTs included, with an overall 419 (24%) success-to-rescue patients and 106 survivors (6%), and 1,394 (79%) of these patients had pre-hospital CPR and 900 (54%) had penetrating wounds. The most common injury patterns were chest (29%), multisystem with head (27%), and multisystem without head (21%). Penetrating injury was associated with higher survival than blunt trauma (9% vs 3% p < 0.001). Success-to-rescue increased from 22% in 1975 to 1979 to 35% over the final 5 years (p < 0.001); survival increased from 5% to 14% (p < 0.001). CONCLUSIONS: Outcomes of EDT have improved over the past 40 years. In the last 5 years, STR was 35% and overall survival was 14%. These prospective observational data provide benchmarks to define the role of EHC as an alternative approach for patients arriving in extremis.
Assuntos
Benchmarking , Serviço Hospitalar de Emergência , Parada Cardíaca/terapia , Hemorragia/terapia , Ressuscitação/métodos , Toracotomia , Ferimentos e Lesões/complicações , Adulto , Idoso , Procedimentos Endovasculares , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ressuscitação/mortalidade , Ressuscitação/normas , Toracotomia/mortalidade , Toracotomia/normas , Resultado do Tratamento , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Refinement of criteria for both screening and initiation of empiric therapy in ventilator-associated pneumonia (VAP) will minimize antibiotic overuse. We hypothesized that variables within the commonly used Clinical Pulmonary Infection Score (CPIS) have unfavorable test performance characteristics. METHODS: Consecutive bronchoalveolar lavage (BAL) cultures obtained from surgical intensive care unit patients were abstracted (2009-2012). Ventilator-associated pneumonia was defined as ≥10(5) cfu/mL. The CPIS both without (CPISclinical) and with (CPISclinical+GS) the result of gram stain (GS) was calculated. Test performance characteristics for the sample, as well as several subgroups, were compared. RESULTS: One thousand thirteen lower respiratory tract cultures from 492 patients were analyzed; 438 (43.2%) of cultures were classified as VAP, and 310 of 492 patients (62.4%) had ≥1 episode of VAP. Both CPISclinical and CPISclinical+GS had poor discrimination for VAP (Receiver-operating characteristic area under the curve=0.55 and 0.66, respectively). Sensitivity of CPISclinical using a threshold of >6 was 21%; the lowest threshold for CPISclinical for which the sensitivity was at least 85% was 3. The highest sensitivity among the individual CPIS components was new CXR infiltrate (91.1%). Among the subset of cultures sent during the early VAP window (days intubated 2-5), organisms on GS had a sensitivity of 93.3%. The CPISclinical, CPISclinical+GS, organisms, and neutrophils on GS parameters all became less accurate in both the late VAP window and when screening for recurrent VAP. Every case of VAP had at least one of the following: 1) fever; 2) new CXR infiltrate, or 3) organisms on GS. CONCLUSION: In this series of BALs, traditional screening tools for VAP missed the majority of microbiological confirmed cases. Screening based on either new CXR infiltrate or fever yielded an acceptably high sensitivity. The only scenario identified in which empiric antibiotics could be withheld safely was the absence of organisms on GS in the early VAP window.
Assuntos
Unidades de Terapia Intensiva , Pneumonia Associada à Ventilação Mecânica/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Pneumonia Associada à Ventilação Mecânica/microbiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/microbiologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença , Escarro/microbiologia , Traqueia/microbiologia , Adulto JovemRESUMO
BACKGROUND: The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown. METHODS: Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours. RESULTS: Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance). CONCLUSIONS: Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.
Assuntos
Traumatismos Abdominais/complicações , Transfusão de Sangue/métodos , Trombofilia/prevenção & controle , Ferimentos não Penetrantes/complicações , Traumatismos Abdominais/sangue , Traumatismos Abdominais/diagnóstico , Adulto , Coagulação Sanguínea , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Masculino , Estudos Retrospectivos , Tromboelastografia , Trombofilia/sangue , Trombofilia/etiologia , Fatores de Tempo , Ferimentos não Penetrantes/sangue , Ferimentos não Penetrantes/diagnósticoRESUMO
BACKGROUND: Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. METHODS: Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. RESULTS: A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). CONCLUSION: While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study. LEVEL OF EVIDENCE: Prognostic study, level III.
Assuntos
Extubação/métodos , Respiração Artificial/métodos , Traumatismos da Medula Espinal/terapia , Centros de Traumatologia , Desmame do Respirador/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Traumatismos da Medula Espinal/mortalidade , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: In vitro data suggest that erythrocytes undergo storage time-dependent degradation, eventuating in hemolysis. We hypothesize that transfusion of old blood, as compared with newer blood, results in a smaller increment in hematocrit. METHODS: We performed an analysis of packed red blood cell transfusions administered in the surgical intensive care unit. Age of blood was analyzed as continuous, dichotomized at 14 days (old vs new), and grouped by weeks old. RESULTS: A total of 136 U of packed red blood cells were given to 52 patients; 110 (80.9%) were 14 days old or more. A linear, inverse correlation was observed between the age of blood and the increment in hematocrit (r(2) = -.18, P = .04). The increment in hematocrit was greater after transfusion of new as compared with old blood (5.6% vs 3.5%, respectively; P = .005). A linear relationship also was observed between the age of transfused blood in weeks and the increment in hematocrit (P = .02). CONCLUSIONS: There is an inverse relationship between the age of blood and the increment in hematocrit. The age of blood should be considered before transfusion of surgical patients with intensive care unit anemia.