RESUMO
BACKGROUND: Currently, several initiatives have emerged to empower the public to act as immediate responders in front of hemorrhaging victims. We aimed to evaluate the effectiveness of implementing the Stop the Bleed campaign and the association between the instructors' background and the theoretical and practical competences achieved by the participants in Latin America. METHODS: Medical students and general surgeons taught both allied health students and nonallied health students at a local university; the training had a master class followed by a practical component and a written test, as well as tourniquet placement was tested. RESULTS: 265 individuals received the training, and data were available for 243. Of these, 126 (52.07%) were women and the median age was 21 (IQR: 20-22) years. 121 (49.79%) were trained by general surgeons (group A) and 122 (50.21%) by medical students (group B). After the training, more than 98% of all participants perceived that they would most likely be capable of aiding correctly a bleeding victim by applying direct pressure and more than 90% of them felt confident in being able to apply a tourniquet. There were no statistically significant differences among both groups when comparing their post-training competence evaluations [Theoretical test score: group A = 5 (IQR: 4-5); group B = 5 (IQR: 4-5); P = 0.41] and [Practical competency of tourniquet deployment: group A = 119 (66.39%) versus group B = 120 (65.83%); P = 0.93]. CONCLUSIONS: The Stop the Bleed campaign can be effectively implemented in Latin America, and it can be taught by prequalified medical students without altering the learning objectives of the course.
Assuntos
Educação não Profissionalizante/organização & administração , Primeiros Socorros/métodos , Conhecimentos, Atitudes e Prática em Saúde , Hemorragia/terapia , Técnicas Hemostáticas/instrumentação , Participação da Comunidade , Feminino , Primeiros Socorros/instrumentação , Implementação de Plano de Saúde , Humanos , América Latina , Masculino , Fatores de Tempo , Torniquetes , Adulto JovemRESUMO
Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.
El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.
Assuntos
Anastomose Cirúrgica/métodos , Consenso , Enterostomia , Intestino Grosso/lesões , Intestino Delgado/lesões , Ferimentos Penetrantes/cirurgia , Adulto , Colômbia , Enterostomia/estatística & dados numéricos , Feminino , Hemorragia/etiologia , Hemorragia/cirurgia , Humanos , Intestino Grosso/cirurgia , Intestino Delgado/cirurgia , Laparotomia , Masculino , Ilustração Médica , Estudos Retrospectivos , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/cirurgia , Ferimentos Penetrantes/classificação , Ferimentos Penetrantes/complicações , Adulto JovemRESUMO
Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.
La resucitación en el control de daños debe iniciarse lo más rápido posible después de presentado el evento traumático para evitar descompensación metabólica y aumento de la mortalidad. El objetivo de este artículo es sustentar nuestro enfoque respecto a la atención prehospitalaria y presentar nuestra experiencia en la implementación de la iniciativa "Stop the Bleed" en Latinoamérica. La atención prehospitalaria es la fase Cero de la resucitación del control de daños. Por medio de la implementación de la iniciativa "Stop the Bleed" se identificó que el personal prehospitalario tiene una mejor percepción sobre el uso de técnicas hemostáticas como el torniquete que el personal hospitalario. Se recomienda el uso de torniquetes como medida de control de sangrado en extremidades. El manejo de líquidos debe realizarse usando cristaloides a bajos volúmenes, con bolos de 250 mL para cumplir el principio de la hipotensión permisiva con un rango entre 80 y 90 mm Hg de presión arterial sistólica. Se deben realizar medidas para evitar la hipotermia como el uso de sábanas térmicas o paso de líquidos calientes. Estas medidas no deben retrasar en ningún momento el tiempo de traslado para recibir la atención hospitalaria. En conclusión, la atención prehospitalaria es el paso inicial para garantizar las primeras medidas de control de sangrado y de resucitación hemostática de los pacientes. Realizar intervenciones tempranas sin acortar el tiempo de traslado a la atención hospitalaria son las claves para aumentar la tasa de supervivencia.
Assuntos
Serviços Médicos de Emergência/métodos , Hemorragia/prevenção & controle , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Algoritmos , Volume Sanguíneo , Temperatura Corporal , Hemorragia/etiologia , Humanos , Escala de Gravidade do Ferimento , Ferimentos e Lesões/complicaçõesRESUMO
BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging option for hemorrhage control, but its use is limited in scenarios such as penetrating chest trauma. The aim of this study was to describe the use of REBOA as a resuscitative adjunct in these cases with major hemorrhage and to propose a new clinical management algorithm. METHODS: This was a prospective, observational study conducted at a single Level I trauma center in Colombia. We included all patients older than 14 years with severe trauma who underwent REBOA from January 2015 to December 2019. Patients received REBOA if they were in hemorrhagic shock and were unresponsive to resuscitation. RESULTS: A total of 56 patients underwent REBOA placement of which 37 had penetrating trauma and 23 had chest trauma. All patients were hemodynamically unstable upon arrival to the emergency department, with a median systolic blood pressure of 69 mm Hg (interquartile range [IQR], 57-90 mm Hg) and median Injury Severity Score was 25 (IQR, 25-41). All REBOAs were deployed and inflated in zone 1, median inflation time was 40 minutes (IQR, 26-55 minutes), and no adverse neurologic outcomes were observed. Fifteen patients had REBOA and a median sternotomy. Eleven patients had concomitant abdominal wounds. Overall mortality was 28.6%, and there was no significant difference between penetrating versus blunt trauma patients (21.6% vs. 42.1%, p = 0.11). The survival rate of thoracic injured patients was similar to the predicted survival (65.2% vs. 63.3%). CONCLUSION: Resuscitative endovascular balloon occlusion of the aorta can be used safely in penetrating chest trauma, and the implementation of a REBOA management algorithm is feasible with a well-trained multidisciplinary team. LEVEL OF EVIDENCE: Therapeutic, level V.
Assuntos
Aorta/lesões , Oclusão com Balão , Protocolos Clínicos , Procedimentos Endovasculares/métodos , Choque Hemorrágico/terapia , Traumatismos Torácicos/complicações , Ferimentos Penetrantes/complicações , Traumatismos Abdominais/complicações , Adulto , Algoritmos , Colômbia , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Índices de Gravidade do Trauma , Ferimentos não Penetrantes/complicações , Adulto JovemRESUMO
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.
Assuntos
Tomografia Computadorizada Multidetectores/métodos , Traumatismo Múltiplo/diagnóstico por imagem , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/diagnóstico por imagem , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores/instrumentação , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/terapia , Taxa de Sobrevida , Fatores de Tempo , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Adulto JovemRESUMO
BACKGROUND: This study aimed to determine the critical threshold of systolic blood pressure (SBP) for aortic occlusion (AO) in severely injured patients with profound hemorrhagic shock. METHODS: All adult patients (>15 years) undergoing AO via resuscitative endovascular balloon occlusion of the aorta (REBOA) or thoracotomy with aortic cross clamping (TACC) between 2014 and 2018 at level I trauma center were included. Patients who required cardiopulmonary resuscitation in the prehospital setting were excluded. A logistic regression analysis based on mechanism of injury, age, Injury Severity Score, REBOA/TACC, and SBP on admission was done. RESULTS: A total of 107 patients underwent AO. In 57, TACC was performed, and in 50, REBOA was performed. Sixty patients who underwent AO developed traumatic cardiac arrest (TCA), and 47 did not (no TCA). Penetrating trauma was more prevalent in the TCA group (TCA, 90% vs. no TCA, 74%; p < 0.05) but did not modify 24-hour mortality (odds ratio, 0.51; 95% confidence interval, 0.13-2.00; p = 0.337). Overall, 24-hour mortality was 47% (50) and 52% (56) for 28-day mortality. When the SBP reached 60 mm Hg, the predicted mortality at 24 hours was more than 50% and a SBP lower than 70 mm Hg was also associated with an increased of probability of cardiac arrest. CONCLUSION: Systolic blood pressure of 60 mm Hg appears to be the optimal value upon which AO must be performed immediately to prevent the probability of death (>50%). However, values of SBP less than 70 mm Hg also increase the probability of cardiac arrest. LEVEL OF EVIDENCE: Therapeutic study, level IV.
Assuntos
Oclusão com Balão/efeitos adversos , Parada Cardíaca/terapia , Mortalidade Hospitalar , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/complicações , Adulto , Aorta Abdominal , Aorta Torácica , Pressão Sanguínea , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/fisiopatologia , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Análise Multivariada , Estudos Prospectivos , Ressuscitação/efeitos adversos , Centros de Traumatologia , Ferimentos e Lesões/fisiopatologia , Adulto JovemRESUMO
BACKGROUND: Serious complications related to groin access have been reported with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). We performed a systematic review and meta-analysis to estimate the incidence of complications related to groin access from the use of REBOA in adult trauma patients. METHODS: We identified articles in MEDLINE and EMBASE. We reviewed all studies that involved adult trauma patients who underwent the placement of a REBOA and included only those that reported the incidence of complications related to groin access. A meta-analysis of proportions was performed. RESULTS: We identified 13 studies with a total of 424 patients. REBOA was inserted most commonly by trauma surgeons or emergency room physicians. Information regarding puncture technique was reported in 12 studies and was available for a total of 414 patients. Percutaneous access and surgical cutdown were performed in 304 (73.4%) and 110 (26.5%) patients, respectively. Overall, complications related to groin access occurred in 5.6% of patients (n = 24/424). Lower limb amputation was required in 2.1% of patients (9/424), of which three cases (3/424 [0.7%]) were directly related to the vascular puncture from the REBOA insertion. A meta-analysis that used the logit transformation showed a 5% (95% CI 3%-9%) incidence of complications without significant heterogeneity (LR test: χ = 0.73, p = 0.2, Tau-square = 0.2). In a second meta-analysis, we used the Freeman-Tukey double arcsine transformation and found an incidence of complications of 4% (95% CI 2%-7%) with low heterogeneity (I = 16.3%). CONCLUSION: We found that the incidence of complications related to groin access was of 4-5% based on a meta-analysis of 13 studies published worldwide. Currently, there are no benchmarks or quality measures as a reference to compare, and thus, further work is required to identify these benchmarks and improve the practice of REBOA in trauma surgery. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.
Assuntos
Aorta/cirurgia , Procedimentos Endovasculares/instrumentação , Ferimentos e Lesões/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica/estatística & dados numéricos , Aorta/lesões , Aorta/patologia , Oclusão com Balão/efeitos adversos , Oclusão com Balão/métodos , Feminino , Virilha/anatomia & histologia , Virilha/patologia , Humanos , Incidência , Complicações Intraoperatórias/epidemiologia , Extremidade Inferior/patologia , Extremidade Inferior/cirurgia , Masculino , Pessoa de Meia-Idade , Punções/efeitos adversos , Punções/métodos , Ressuscitação/métodos , Choque Hemorrágico/complicações , Choque Hemorrágico/epidemiologia , Choque Hemorrágico/mortalidade , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapiaRESUMO
ABSTRACT Introduction: Amyand's hernia (appendix trapped within an inguinal hernia) is a rare clinical condition that groups two common surgical diseases: acute appendicitis and inguinal hernia. Its preoperative diagnosis is difficult, so it should be considered in cases of inguinal hernia before an inflammatory process occurs in the appendix to avoid complications. Although there is no consensus on its treatment, current classifications serve as a guide for a timely surgical resolution. Case presentation: A 57-year-old male patient from the southern coast of Ecuador consulted the emergency department of a secondary level health care institution due to a 24-hour history of painful and irreducible mass in the right inguinal region associated with hyporexia. The patient was diagnosed with incarcerated inguinal hernia and underwent a right inguinal hernioplasty, during which the appendix and cecum were found inside the hernia sac. Hernioplasty and appendectomy were performed using the Lichtenstein technique. The patient was discharged in good conditions and did not have any complications at 8- and 15-day follow-up. Conclusions: Amyand's hernia is increasingly reported. It is difficult to diagnose preoperatively due to its nonspecific symptoms. When suspected, imaging studies help its visualization and guide an individualized and early treatment, together with the current classifications of this type of hernias.
RESUMEN Introducción. La hernia de Amyand es una condición clínica infrecuente que agrupa a dos patologías quirúrgicas habituales: apendicitis aguda y hernia inguinal; en esta entidad el apéndice vermiforme se encuentra en el interior del saco de una hernia inguinal. Su diagnóstico preoperatorio es difícil, por lo que debe tenerse en cuenta en casos de hernia inguinal antes de que se presente un proceso inflamatorio, el cual puede traer más complicaciones; además, aunque no existe un consenso para el manejo según las clasificaciones actuales, estas sirven de guía para una resolución quirúrgica oportuna. Presentación del caso. Hombre de 57 años procedente de la costa sur de Ecuador, quien consultó al servicio de emergencias de una institución de segundo nivel de atención por un cuadro clínico de 24 horas de evolución que inició con la aparición de una masa dolorosa e irreductible en la región inguinal derecha asociada a hiporexia. El paciente fue diagnosticado con hernia inguinal incarcerada y se le practicó una hernioplastia inguinal derecha en la que se encontró el apéndice y el ciego dentro del saco herniario; durante este procedimiento también se realizó apendicectomía y hernioplastia con técnica de Lichtenstein. El paciente fue dado de alta en buenas condiciones y en controles posteriores, a los 8 y 15 días de la cirugía, no presentó complicaciones. Conclusiones. La hernia de Amyand es una entidad cada vez más frecuente que tiene un difícil diagnóstico preoperatorio debido a su cuadro clínico inespecífico. Ante la sospecha de esta patología se deben realizar estudios de imagenología que ayuden a su visualización y orienten, junto con las clasificaciones actuales de este tipo de hernias, un manejo individualizado y temprano.
RESUMO
Abstract Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.
Resumen El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.
RESUMO
Abstract Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.
Resumen La resucitación en el control de daños debe iniciarse lo más rápido posible después de presentado el evento traumático para evitar descompensación metabólica y aumento de la mortalidad. El objetivo de este artículo es sustentar nuestro enfoque respecto a la atención prehospitalaria y presentar nuestra experiencia en la implementación de la iniciativa "Stop the Bleed" en Latinoamérica. La atención prehospitalaria es la fase Cero de la resucitación del control de daños. Por medio de la implementación de la iniciativa "Stop the Bleed" se identificó que el personal prehospitalario tiene una mejor percepción sobre el uso de técnicas hemostáticas como el torniquete que el personal hospitalario. Se recomienda el uso de torniquetes como medida de control de sangrado en extremidades. El manejo de líquidos debe realizarse usando cristaloides a bajos volúmenes, con bolos de 250 mL para cumplir el principio de la hipotensión permisiva con un rango entre 80 y 90 mm Hg de presión arterial sistólica. Se deben realizar medidas para evitar la hipotermia como el uso de sábanas térmicas o paso de líquidos calientes. Estas medidas no deben retrasar en ningún momento el tiempo de traslado para recibir la atención hospitalaria. En conclusión, la atención prehospitalaria es el paso inicial para garantizar las primeras medidas de control de sangrado y de resucitación hemostática de los pacientes. Realizar intervenciones tempranas sin acortar el tiempo de traslado a la atención hospitalaria son las claves para aumentar la tasa de supervivencia.
Assuntos
Humanos , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Serviços Médicos de Emergência/métodos , Hemorragia/prevenção & controle , Ferimentos e Lesões/complicações , Volume Sanguíneo , Temperatura Corporal , Algoritmos , Escala de Gravidade do Ferimento , Hemorragia/etiologiaRESUMO
Introducción. La tomografía corporal (TC) total en la evaluación de pacientes con trauma grave, puede ser una herramienta eficaz y segura para decidir entre un tratamiento quirúrgico y uno no quirúrgico, pero aún no son claras las implicaciones diagnósticas y los riesgos asociados con esta técnica.Métodos. Se incluyeron pacientes mayores de 15 años con trauma grave que fueron sometidos a TC total. Se evaluaron la seguridad, la efectividad y la eficiencia por medio de los parámetros de incidencia de nefropatía inducida por los medios de contraste, dosis total de radiación por paciente, proporción de casos en los que la TC total cambió el manejo, y el retraso en el diagnóstico. Resultados. Se incluyeron 263 pacientes, 83 % sufrieron trauma cerrado y 17 % sufrieron trauma penetrante. La gravedad de la lesión fue mayor en estos últimos y, sin embargo, el trauma cerrado con inestabilidad hemodinámica se presentó con mayores grados de choque. El 65 % de los pacientes recibió tratamiento selectivo no operatorio. Entre los subgrupos, no hubo diferencias significativas en el tiempo entre el ingreso a la sala de urgencias y la toma de la TC total (p=0,96) y, en la mayoría de los casos, el tiempo entre la práctica de la TC total y el diagnóstico de presencia o ausencia de heridas fue menor de 25 minutos. La mediana de radiación total estuvo por debajo de 20 mSv en todos los grupos. No hubo diferencias significativas en la mortalidad (p=0,17). Conclusión. La TC total es una herramienta segura y eficiente para decidir entre un tratamiento quirúrgico y uno no quirúrgico en los casos de trauma grave, independientemente del mecanismo de la lesión o la estabilidad hemodinámica al ingreso
Introduction: Total body tomography (CT) in the evaluation of patients with severe trauma may be an effective and safe tool to decide between a surgical or non-operative management, but the diagnostic implications and risks associated with this technique are still unclear.Methods: Patients older than 15 years with severe trauma who underwent total CT were included. Safety, effectiveness and efficiency were evaluated through the parameters of incidence of contrast-induced nephropathy, total radiation dose per patient, proportion of cases in which the total CT changed the management, and the delay in the diagnosis.Results: 263 patients were included, 83% presented with blunt trauma and 17% with penetrating trauma. The severity of the injury was higher in the latter, however, the blunt trauma with hemodynamic instability presented with higher degrees of shock. Non-operative management was selected in 65% of patients. Among the subgroups, there was no significant difference in the time between admission to the emergency room and taking the total CT (p=0.96), and in most cases, the time between the total CT and the diagnosis of presence or absence of injury was less than 25 minutes. The median total radiation was below than 20 mSv in all groups. There were no significant difference in mortality (p=0.170. Conclusion: Total CT is a safe and efficient tool to decide between a surgical and a non-operative management in patients with severe trauma, regardless of the mechanism of injury or hemodynamic stability at admission
Assuntos
Humanos , Ferimentos e Lesões , Tomografia , Diagnóstico , Tratamento ConservadorRESUMO
Introducción. El objetivo de este estudio fue evaluar si la laparotomía de control de daños con ligadura y reconstrucción intestinal diferida, en pacientes con peritonitis secundaria a compromiso de víscera hueca, reduce el número de ostomías. Métodos. Se incluyeron todos los pacientes menores de 18 años de edad que ingresaron a la clínica con sospecha de peritonitis de origen no traumático y que se sometieron a laparotomía entre enero del 2003 y diciembre del 2018. Se evaluaron las características sociodemográficas, comorbilidades, escalas de gravedad fisiológica, técnicas de reconstrucción intestinal y resultados clínicos. Resultados. Se incluyeron 306 pacientes, distribuidos en tres grupos: 1) 120 (39,2 %) sometidos a resección y anastomosis, 2) 87 (28,4 %) sometidos a ostomía, y 3) 99 (32,3 %) sometidos inicialmente a ligadura intestinal. Los pacientes sometidos a ligadura intestinal presentaron mayor compromiso fisiológico al ingreso a la unidad de cuidado intensivo, con puntuación APACHE II: 14 (rango intercuartílico, RIC=10-18) en el grupo 1, 13 (RIC=11-18) en el grupo 2, y 18 (RIC=14-24) en el grupo 3 (p<0,01). Sin embargo, más de la mitad se reconstruyeron en la siguiente laparotomía: anastomosis mecánica (16/99; 16,1 %), anastomosis manual (49/99; 49,5 %), ostomía (34/99; 34,3 %). Además, estos pacientes sometidos a ligadura intestinal tuvieron un número significativamente mayor de nuevas laparotomías, y de días de asistencia respiratoria mecánica, de estancia en la unidad de cuidado intensivo y de estancia hospitalaria. No hubo diferencias estadísticamente significativas en la mortalidad entre los subgrupos: (grupo 1=19 (15,8 %), grupo 2=16 (18,4 %), grupo 3=19 (19,2 %) (p=0,79). Conclusión. En este estudio, se logró evitar la ostomía como técnica de reconstrucción definitiva en más de la mitad de los pacientes con peritonitis que se sometieron a laparotomía de control de daños con ligadura intestinal
Introduction. The objective of this study was to evaluate if the damage control laparotomy with ligation and delayed intestinal reconstruction (DR), in patients with peritonitis secondary to compromised hollow viscera, reduces the number of ostomies.Methods. All patients under 18 years of age who entered the clinic with suspected non-traumatic peritonitis and who underwent laparotomy between January 2003 and December 2018 were included. Sociodemographic characteristics, comorbidities, severity scales physiological, intestinal reconstruction techniques and clinical results were evaluated.Results. A total of 306 patients were included, divided into three groups: 1) 120 (39.2 %) underwent resection and anastomosis, 2) 87 (28.4 %) underwent ostomy, and 3) 99 (32.3 %) underwent initial to intestinal ligation. Patients undergoing intestinal ligation presented greater physiological compromise upon admission to the intensive care unit, with an APACHE II score: 14 (interquartile range, IQR= 10-18) in group 1, 13 (IQR = 11-18) in the group 2, and 18 (IQR = 14-24) in group 3 (p<0.01). However, more than half were reconstructed in the following laparotomy: mechanical anastomosis (16/99; 16.1 %), manual anastomosis (49/99; 49.5 %), ostomy (34/99; 34.3 %). Also, they had a significantly greater number of new laparotomies, and of days of mechanical respiratory assistance, of stay in the intensive care unit and of hospital stay. There were no statistically significant differences in mortality between the subgroups: group 1= 19 (15.8 %), group 2= 16 (18.4 %), group 3= 19 (19.2 %) (p= 0.79). Conclusion. In this study, it was possible to avoid the ostomy as the definitive reconstruction technique in more than half of the patients with peritonitis who underwent damage control laparotomy with intestinal ligation
Assuntos
Humanos , Laparotomia , Peritonite , Estomia , Reanimação CardiopulmonarRESUMO
Abstract Purpose: The objective of this study was to evaluate the implementation of a new single-pass whole-body computed tomography Protocol in the management of patients with severe trauma. Methods: This was a descriptive evaluation of polytrauma patients who underwent whole-body computed tomography. Patients were divided into three groups: 1. Blunt trauma hemodynamically stable 2. Blunt trauma hemodynamically unstable and 3. Penetrating trauma. Demographics, whole-body computed tomography parameters and outcome variables were evaluated. Results: Were included 263 patients. Median injury severity score was 22 (IQR: 16-22). Time between arrival to the emergency department and completing the whole-body computed tomography was under 30 minutes in most patients [Group 1: 28 minutes (IQR: 14-55), Group 2: 29 minutes (IQR: 16-57), and Group 3: 31 minutes (IQR: 13-50; p= 0.96)]. 172 patients (65.4%) underwent non-operative management. The calculated and the real survival rates did not vary among the groups either [Group 1: TRISS 86.4% vs. real survival rate 85% (p= 0.69); Group 2: TRISS 69% vs. real survival rate 74% (p= 0.25); Group 3: TRISS 93% vs. real survival rate 87% (p= 0.07)]. Conclusion: This new single-pass whole-body computed tomography protocol was safe, effective and efficient to decide whether the patient with severe trauma requires a surgical intervention independently of the mechanism of injury or the hemodynamic stability of the patient. Its use could also potentially reduce the rate of unnecessary surgical interventions of patients with severe trauma including those with penetrating trauma.
Resumen Introducción: El objetivo de este estudio fue evaluar la implementación de un nuevo protocolo de tomografía computarizada corporal total para el manejo de pacientes con trauma severo. Métodos: Este estudio es una evaluación descriptiva de pacientes que recibieron tomografía computarizada corporal total. Los pacientes fueron divididos en 3 grupos: 1. Trauma cerrado hemodinámicamente estables, 2. Trauma cerrado hemodinámicamente inestables y 3. Trauma penetrante. Se evaluaron las características demográficas, parámetros relacionados con la técnica y los desenlaces de los pacientes. Resultados: Se incluyeron 263 pacientes. La mediana del puntaje de severidad de la lesión fue 22 (RIQ: 16-22). El tiempo entre el ingreso a urgencias y completar la tomografía corporal total fue menor a 30 minutos en la mayoría de pacientes [Grupo 1: 28 minutos (RIQ: 14-55), Grupo 2: 29 minutos (RIQ: 16-57), y Grupo 3: 31 minutos (RIQ: 13-50; p= 0.96). 172 pacientes (65.4%) recibieron manejo no operatorio. Las tasas de supervivencia calculadas y reales no difirieron entre ninguno de los grupos [Grupo 1: TRISS 86.4% vs. Tasa real de supervivencia 85% (p= 0.69); Grupo 2: TRISS 69% vs. Tasa real de supervivencia 74% (p= 0.25); Grupo 3: TRISS 93% vs. Tasa real de supervivencia 87% (p= 0.07)]. Conclusión: Este nuevo protocolo de tomografía corporal total de un solo pase fue seguro, efectivo y eficiente para definir si los pacientes con trauma severo requieren o no una intervención quirúrgica. Su uso podría reducir la tasa de intervenciones quirúrgicas innecesarias en estos pacientes incluyendo los que se presentan con trauma penetrante.
Assuntos
Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/diagnóstico por imagem , Traumatismo Múltiplo/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos , Fatores de Tempo , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/terapia , Escala de Gravidade do Ferimento , Taxa de Sobrevida , Tomografia Computadorizada Multidetectores/instrumentaçãoRESUMO
Introducción. La maniobra de reanimación mediante el denominado "balón de reanimación endovascular de aorta"(Resuscitative Endovascular Balloon Occlusion of the Aorta, REBOA), es un procedimiento para obtener el control proximal de la hemorragia. Nuestra hipótesis es que puede usarse como una maniobra emergente para el manejo del choque hemorrágico y como una intervención para prevenir la aparición de hemorragia masiva en los pacientes en riesgo. Materiales y métodos. Se recolectaron los datos de una cohorte prospectiva de pacientes entre el 2014 y 2018 en un centro de trauma de nivel I del suroccidente colombiano. Los datos se presentaron, de acuerdo con su distribución de normalidad, en medias y desviaciones estándar o medianas y rangos intercuartílicos. Resultados. Se incluyeron 70 pacientes, 27 considerados en riesgo de choque hemorrágico (mujeres embarazadas con placentación anormal) y 43 con choque hemorrágico (pacientes de trauma sometidos a cirugía y oclusión aórtica con balón). En el primer grupo, ningún paciente requirió transfusión masiva y no se reportaron muertes. En el último, hubo aumento significativo de la presión arterial sistémica después del procedimiento de 50,1 ± 22,5 a 107 mm Hg (rango: 87-129) y la mortalidad fue del 30,2 %. Conclusión. Esta muestra de pacientes sometidos a reanimación mediante oclusión aórtica con REBOA es la más grande reportada hasta ahora en Latinoamérica. Esta es una herramienta eficaz para el manejo de pacientes en choque hemorrágico o en riesgo de uno
Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a procedure that involves placement of an endovascular balloon in the aorta to obtain proximal control of hemorrhage. We hypothesize that the REBOA can be used as an emergent maneuver for the management of patients with hemorrhagic shock and as a prophylactic intervention to prevent the appearance of massive hemorrhage in populations at risk. Methods: Data were collected from a prospective cohort of patients in the period between 2014 and 2018, at a level I trauma center in Southwestern Colombia. The data was presented according to their distribution of normality, in means and standard deviations or medians and interquartile ranges. Results: Seventy patients were included, 27 considered at risk of hemorrhagic shock (pregnant women with abnormal placentation) and 43 with hemorrhagic shock (trauma patients undergoing surgery and REBOA). In the first group, no patient required massive transfusion and no deaths were reported. In the latter, there was a significant increase in blood pressure [SBP pre-REBOA: 50.1 ± 22.5, post-REBOA SBP: 107 (87-129)] and mortality was 30.2%. Conclusion: Our experience in the use of REBOA is the largest reported in Latin America. This is an effective tool for the management of patients at or at risk of hemorrhagic shock
Assuntos
Humanos , Procedimentos Endovasculares , Transfusão de Sangue , Reanimação Cardiopulmonar , Oclusão com BalãoRESUMO
INTRODUCCIÓN: El neumomediastino es la presencia de aire en el mediastino, tiene incidencia variable que oscila entre 1/80 000 y 1/42 000 a nivel mundial, genera una diversidad de características clínicas, puede ser secundario a entidades torácicas o extra torácicas; dentro de las causas extratorácicas, podemos asociarlo a procedimientos dentales siendo de vital importancia considerar la posibilidad y la asociación a dichos procedimientos para su diagnóstico y tratamiento adecuado. CASO CLÍNICO: Paciente de sexo femenino de 23 años, que 24 horas previas a su ingreso, se realizó procedimiento dental tipo exodoncia del tercer molar inferior izquierdo, en el que se usó instrumental manual y neumático, que debió ser suspendido; la paciente presentó dolor intenso más dificultad respiratoria, posterior a ello dolor torácico opresivo, mandibular y en cuello de lado izquierdo, acompañado de enfisema subcutáneo en hemicara izquierda, cuello bilateralmente y subclavicular izquierdo. EVOLUCIÓN: Paciente es ingresada con diagnóstico de neumomediastino secundario a procedimiento dental para tratamiento antibiótico de amplio espectro y vigilancia, durante su hospitalización por tres días permanece estable, afebril con mejoría clínica general. CONCLUSIÓN: El neumomediastino es una complicación poco frecuente tras intervenciones odontológicas, se debe sospechar por el uso de instrumental neumático que disecan los tejidos blandos faciales, del cuello y tórax; la paciente tuvo una evolución favorable en base al diagnóstico y tratamient
BACKGROUND: Neumomediastinum is defined as the presence of air in the mediastinum, It has variable incidence that oscillates between 1/80000 and 1/420000, generates a diversity of clinical characteristics. It can be secondary to thoracic or extra thoracic entities, within extrathoracic causes; it can be associated with dental procedures, being of vital importance consider the possibility and the association to this procedure to get to an adequate diagnosis and treatment. CASE REPORT: A 23-year-old female patient who, 24 hours prior to admission, underwent a dental procedure such as a third-molar left third molar extraction, in which manual instruments and pneumatics dental lathe were used, which had to be suspended; the patient presented severe pain plus respiratory difficulty, after that she presented oppressive chest pain, mandibular and left side neck, accompanied by subcutaneous emphysema in the left side of the face, neck bilaterally and left subclavicular EVOLUTION: The patient was hospitalize with a diagnosis of neumomediastinum secondary to dental procedure to receive treatment with broad spectrum antibiotic and surveillance, during her hospitalization for three days she remains stable, afebrile with general clinical improvement. CONCLUSIONS: The neumomediastinum is a rare complication after odontological interventions. It should be suspected when pneumatic instrument lathe are used that dissect facial, neck and thorax soft tissues; the patient had a favorable evolution based on the diagnosis and early treatment proposed by the doctors according to the patients symptoms.
Assuntos
Humanos , Feminino , Enfisema Subcutâneo/complicações , Administração de Caso , Enfisema Mediastínico/diagnóstico , Cirurgia Bucal/instrumentaçãoRESUMO
Introducción. La hemorragia no controlada es la principal causa prevenible de muerte en trauma. No hay precedentes locales que estimen el efecto de estrategias de prevención que involucren al público en la atención inicial de las víctimas. Objetivo. Evaluar si es factible implementar programas de entrenamiento para el control prehospitalario básico del sangrado en pacientes de trauma, en un país de bajos a medianos ingresos. Métodos. Cirujanos y estudiantes de medicina se encargaron de desplegar el curso "Stop the bleed" en estudiantes universitarios del suroccidente colombiano. Se hizo una evaluación antes y después de hacer el entrenamiento. Se usó la prueba t de Student y un análisis de regresión logística ordinal, para determinar los factores que estuvieron asociados a obtener mejores puntajes en la evaluación del curso. Resultados. Se entrenaron 265 estudiantes, con una edad media de 21,4 ± 4 años, de los cuales 136 (51,5 %) eran mujeres. Después de recibir el entrenamiento un participante tuvo 15,6 veces la oportunidad de obtener mayor puntaje de calificación con respecto al periodo preentrenamiento [IC95%: 15,1-16,2 (p<0,001)], 99,4 y 95,2 %, respectivamente, estarían dispuestos a tomar medidas y colocar un torniquete a una víctima de sangrado (p<0,001). Conclusión. Es factible para los países con recursos limitados hacer el entrenamiento en control básico del sangrado. Este se puede llevar a cabo de manera eficaz, tanto por instructores con un bagaje amplio en técnicas de control del sangrado como por instructores con menor nivel de formación, pero con un entrenamiento adecuado
Background: uncontrolled hemorrhage is the leading cause of preventable death in trauma. There are no local precedents that estimate the effect of prevention strategies that involve the public in the initial care of victims. Our objective was to evaluate if it is feasible to implement training programs for the basic control of prehospital bleeding in trauma patients, in a low to a middle-income country. Methods: Surgeons and medical students deploying the Stop the bleed course in a Colombian southwestern university, evaluation was performed before and after the training. A T-test and an ordinal logistic regression analysis were used to determine the factors associated with better scores in the course evaluation. Results: of the 265 students, were women 136 (51.5%), age was 21.4± 4. After receiving the training, a participant had 15.6 times the chance of obtaining a higher score than the pre-training period [95% CI: 15.1-16.2 (p <0.001)]. 99.4% and 95.2% respectively, would be willing to take actions and place a tourniquet on a bleeding victim (p <0.001). Conclusion: in a low to a middle-income country is feasible to perform the Bleeding Control Basic training. This can be done effectively by instructors with a broad background in bleeding control techniques as well as by instructors with less experience, but with adequate training
Assuntos
Humanos , Hemorragia , Ferimentos e Lesões , Emergências , Educação da PopulaçãoRESUMO
INTRODUCCIÓN: El feocromocitoma es una neoplasia neuroendocrina localizada en la médula adrenal, llamado paraganglioma cuando su ubicación es extraadrenal. Su incidencia anual es de 2-8 por millón de personas, sin predilección de sexo. Su cuadro clínico se caracteriza por: cefalea, diaforesis, taquicardia e hipertensión arterial. El tratamiento es la resección quirúrgica con una preparación preoperatoria multidisciplinaria. CASO CLÍNICO: Se trata de una paciente de 36 años, femenina con antecedentes de hipertensión arterial de un año de evolución, acompañado de cefalea, pérdida de peso, dolor abdominal, diaforesis, malestar general y otros; hospitalizada por varias ocasiones debido a crisis hipertensivas. Tensión arterial 180/120 mmHg, Frecuencia cardíaca 90/min, Índice de masa corporal 19.2 Kg/m2. Abdomen: masa palpable en hipocondrio y flaco izquierdos de aproximadamente 10 cm, no doloroso a la palpación. EVOLUCIÓN: Dentro de los exámenes complementarios, la determinación de catecolaminas en plasma fueron normales, en la tomografía computarizada se evidenció una masa retroperitoneal que involucraba riñón y suprarrenal izquierdos; ante la persistencia de hipertensión, se realiza la resección de la neoplasia por laparotomía más nefrectomía izquierda, flebotomía de cava inferior y transversectomía. Como complicación en el postoperatorio inmediato presentó hemoperitoneo requiriendo relaparotomía con esplenectomía, además adquirió neumonía la cual fue superada satisfactoriamente y fue dada el alta médica en buenas condiciones. CONCLUSIONES: El feocromocitoma es una patología infrecuente y compleja, cuya resolución quirúrgica es mandatoria, con una preparación prequirúrgica multidisciplinaria para disminuir al máximo la morbimortalidad y con un seguimiento a largo plazo en todos los casos.(AU)
INTRODUCTION: Pheochromocytoma is a neuroendocrine tumor located in the adrenal medulla or paraganglioma when its location is extraadrenal. The annual incidence is 2-8million people, no sex predilection. Clinical symptoms are characterised by: headache, diaphoresis,tachycardia, and hypertension. The treatment is surgical resection with a multidisciplinary preoperative preparation. CASE REPORT: This isa36 year old female patient,withahistory of hypertension forayear,accompanied by headache, weight loss, abdominal pain, diaphoresis, malaise and others; hospitalized for several times due to hypertensive crises. BP: 180/120 mmHg; HR: 90 per minute; BMI 19.2 kg / m2. Abdomen: palpablemass in upper quadrant and left flank of approximately 10 cm, not painful on palpation. EVOLUTION: About the examinations, the plasma catecholamines tests were normal and the CT scan showed a retroperitoneal mass which involved kidney and adrenal on left side. At the persistence of hypertension, the resection of the tumor was performed by laparotomy; also was performed left nephrectomy, phlebotomy of inferior cava and the resection ofthe transverse colon. Inthe immediatepostoperativeperiod,thepatientpresentedhemoperitoneumandasplenectomy was performed; also contracted pneumonia which was successfully treated. She left the hospital in good condition. CONCLUSIONS: The Pheochromocytoma is an infrequent and complex disease, whose surgical treatment is mandatory. A multidisciplinary preoperative preparation is important to reduce the morbidity andmortality associated and the follow-upmust be long termin all cases.(AU)