Patients with severe polytrauma: management and imaging protocols.

Traumatic injuries can be severe and complex, requiring the coordinated efforts of a multidisciplinary team. Imaging tests play a fundamental role in rapid and accurate diagnosis. In particular, whole-body computed tomography (CT) has become a key tool. There are different CT protocols depending on the patient's condition; whereas dose-optimized protocols can be used in stable patients, time/precision protocols prioritizing speed at the cost of delivering higher doses of radiation should be used in more severe patients. In unstable patients who cannot be examined by CT, X-rays of the chest and pelvis and FAST or e-FAST ultrasound studies, although less sensitive than CT, enable the detection of situations that require immediate treatment. This article reviews the imaging techniques and CT protocols for the initial hospital workup for patients with multiple trauma.

Management of temperature control in post-cardiac arrest care: an expert report. / Manejo con control de temperatura en los cuidados posparada cardiaca: documento de expertos.

Targeted temperature management (TTM) through induced hypothermia (between 32-36 oC) is currently regarded as a first-line treatment during the management of post-cardiac arrest patients admitted to the Intensive Care Unit (ICU). The aim of TTM is to afford neuroprotection and reduce secondary neurological damage caused by anoxia. Despite the large body of evidence on its benefits, the TTM is still little used in Spain. There are controversial issues referred to its implementation, such as the optimal target body temperature, timing, duration and the rewarming process. The present study reviews the best available scientific evidence and the current recommendations contained in the international guidelines. In addition, the study focuses on the practical implementation of TTM in post-cardiac arrest patients in general and cardiological ICUs, with a discussion of the implementation strategies, protocols, management of complications and assessment of the neurological prognosis.

Risk and protective factors of secondary traumatic stress in Intensive Care Units: An exploratory study in a hospital in Madrid (Spain). / Factores de riesgo y protección del estrés traumático secundario en los cuidados intensivos: un estudio exploratorio en un hospital terciario de Madrid.

AIM: To propose a predictive model of secondary traumatic stress. DESIGN: A descriptive cross-sectional study was carried out. CONTEXT: The study was conducted in the Intensive Care Units of a hospital in Madrid (Spain). PARTICIPANTS: The sample comprised 103 health professionals. INTERVENTIONS: A series of questionnaires were created and completed by the participants. Network analysis and multiple regression were used for data analysis. VARIABLES OF INTEREST: Sociodemographic variables such as gender, years of experience and position, secondary traumatic stress, passion for work, work stressors, emotional effort, empathy and self-compassion were evaluated. RESULTS: The result identified the following: a) years of experience as a risk factor for compassion fatigue (ß=0.224 and P=0.029), and harmonious passion as a protector (ß=-0.363 and P=0.001); b) emotional effort and empathy as risk factors for shattered assumptions (ß=0.304 and P=0.004; ß=0.394 and P=0.000, respectively); and c), work stressors and empathy as risk factors for symptomatology (ß=0.189 and P=0.039; ß=0.395 and P=0.000, respectively), and years of experience as a protector (ß=-0.266 and P=0.002). CONCLUSIONS: This predictive model of secondary traumatic stress identifies protective factors which could be reinforced, such as harmonious passion, and risk factors which should be reduced, such as empathy and emotional effort, with a view to promoting quality of care and quality of life among these professionals.

Outcomes of very elderly trauma ICU patients. Results from the Spanish trauma ICU registry.

OBJECTIVE: To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry. DESIGN: A multicenter nationwide registry. Retrospective analysis. November 2012-May 2017. SETTING: Participating ICUs. PATIENTS: Trauma patients aged ≥80 years. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: The outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed. Comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value <0.05 was considered statistically significant. RESULTS: The mean patient age was 83.4±3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5±11.1, with a mean ICU stay of 7.45±9.9 days. The probability of survival based on the TRISS methodology was 69.8±29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury. CONCLUSIONS: Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury.

Evaluation of quality of care in trauma patients using international scoring systems. / Valoración de la calidad asistencial al traumatismo grave mediante comparación con estándares internacionales.

OBJECTIVE: To evaluate the ability of the TRISS and PS14 models to predict mortality rates in our medical system and population. DESIGN: A retrospective observational study was carried out over a 66-month period. BACKGROUND: The study was conducted in the Trauma Intensive Care Unit (ICU) of a third level hospital. PATIENTS: All severe trauma patients (Injury Severity Score≥16 and/or Revised Trauma Score <12) aged> 14 years were included. VARIABLES OF INTEREST: Medical care data were prospectively recorded. The "W" statistic (difference between expected and observed mortality for every 100 patients) and its significance were calculated for each model. Discrimination and calibration were evaluated by means of receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow test and GiViTI calibration belt, respectively. RESULTS: A total of 1240 patients were included. Survival at hospital discharge was 81.9%. The "W" scores for the TRISS, TRISS 2010 and PS14 models were+6.72 (P<.01), +1.48 (P=.08) and +2.74 (P<.01) respectively. Subgroup analysis revealed significant favorable results for some populations. The areas under the ROC curve for the TRISS, TRISS 2010 and PS14 models were 0.915, 0.919 and 0.914, respectively. There were no significant differences among them (P>.05). Both the Hosmer-Lemeshow test and GiViTI calibration belt demonstrated poor calibration for the three models. CONCLUSIONS: These models are suitable tools for assessing quality of care in a Trauma ICU, affording excellent discrimination but poor calibration. In our institution, survival rates higher than expected were observed.

Practical document on the management of hyponatremia in critically ill patients. / Documento práctico del manejo de la hiponatremia en pacientes críticos.

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient.

Prediction of massive bleeding in a prehospital setting: validation of six scoring systems. / Predicción de hemorragia masiva a nivel extrahospitalario: validación de seis escalas.

OBJECTIVE: To validate the diagnostic ability of six different scores to predict massive bleeding in a prehospital setting. DESIGN: Retrospective cohort. SETTING: Prehospital attention of patients with severe trauma. SUBJECTS: Subjects with more than 15 years, a history of severe trauma (defined by code 15 criteria), that were initially assisted in a prehospital setting by the emergency services between January 2010 and December 2015 and were then transferred to a level one trauma center in Madrid. VARIABLES: To validate: 1. Trauma Associated Severe Haemorrhage Score. 2. Assessment of Blood Consumption Score. 3. Emergency Transfusión Score. 4. Índice de Shock. 5. Prince of Wales Hospital/Rainer Score. 6. Larson Score. RESULTS: 548 subjects were studied, 76,8% (420) were male, median age was 38 (interquartile range [IQR]: 27-50). Injury Severity Score was 18 (IQR: 9-29). Blunt trauma represented 82,5% (452) of the cases. Overall, frequency of MB was 9,2% (48), median intensive care unit admission days was 2,1 (IQR: 0,8 - 6,2) and hospital mortality rate was 11,2% (59). Emergency Transfusión Score had the highest precisions (AUC 0,85), followed by Trauma Associated Severe Haemorrhage score and Prince of Wales Hospital/Rainer Score (AUC 0,82); Assessment of Blood Consumption Score was the less precise (AUC 0,68). CONCLUSION: In the prehospital setting the application of any the six scoring systems predicts the presence of massive hemorrhage and allows the activation of massive transfusion protocols while the patient is transferred to a hospital.

Rotational thromboelastometry (ROTEM) profile in a cohort of asystole donors. / Perfil de tromboelastometría rotacional (ROTEM) en una cohorte de asistolia no controlada.

BACKGROUND: Hypoperfusion plays a central role in shock states, and has been proposed as a coagulopathy trigger. The study of the rotational thromboelastometry (ROTEM) profile during cardiac arrest could offer new insights to the role of hypoperfusion in coagulation during shock states. OUTCOME: To describe the ROTEM profile in a cohort of asystole donors and elucidate the incidence of hyperfibrinolysis. DESIGN: A prospective observational study was carried out in 18 patients consecutively admitted to the ICU after out-of-hospital non-recovered cardiac arrest (CA). Initial rhythm and time between CA and admission were recorded. Conventional coagulation and ROTEM (EXTEM, APTEM, FIBTEM) tests were performed within 30minutes after blood sample collection. SCOPE: An asystole donor reference hospital. PARTICIPANTS: Patients admitted to the ICU after out-of-hospital non-recovered CA. RESULTS: The median age was 50years, and 14 of the patients were men (77.8%). The time from CA to hospital admission expressed as the median (interquartile range) was 91minutes (75-104). The results of the routine tests were: INR 1.25 (1.19-1.34), aPTT 55s (45-73) and fibrinogen 161mg/dl (95-295). For the ROTEM APTEM assay the results were: CT 126s (104-191), CFT 247s (203-694). Hyperfibrinolysis criteria were recorded in 15 patients (83.3%). In addition, MCF improved in APTEM versus EXTEM. Prolonged CA times were associated to lower fibrinogen levels and lower values for MCF FIBTEM (P<.05). CONCLUSIONS: The ROTEM assays revealed severe alterations of the clot formation parameters and a high incidence of hyperfibrinolysis.

Handover in Intensive Care. / Traspaso de información en Medicina Intensiva.

Handover is a frequent and complex task that also implies the transfer of the responsibility of the care. The deficiencies in this process are associated with important gaps in clinical safety and also in patient and professional dissatisfaction, as well as increasing health cost. Efforts to standardize this process have increased in recent years, appearing numerous mnemonic tools. Despite this, local are heterogeneous and the level of training in this area is low. The purpose of this review is to highlight the importance of IT while providing a methodological structure that favors effective IT in ICU, reducing the risk associated with this process. Specifically, this document refers to the handover that is established during shift changes or nursing shifts, during the transfer of patients to other diagnostic and therapeutic areas, and to discharge from the ICU. Emergency situations and the potential participation of patients and relatives are also considered. Formulas for measuring quality are finally proposed and potential improvements are mentioned especially in the field of training.

Does a history of psychoactive substances abuse play a role in the level of pain of the patient with severe trauma? / ¿Influyen los antecedentes de consumo de sustancias psicótropas en el nivel de dolor del paciente con traumatismo grave?

OBJECTIVE: To analyse the influence of psychotropic substance use on the level of pain in patients with severe trauma. DESIGN: Longitudinal analytical study. SCOPE: Intensive Care Unit (ICU) of Trauma and Emergencies. PATIENTS: severe trauma, non-communicative and mechanical ventilation >48hours. Two groups of patients were created: users and non-users of psychotropic substances according to medical records. INTERVENTIONS: Measurement of pain level at baseline and during mobilization, using the Pain Indicator Behaviour Scale. VARIABLES: demographic characteristics, pain score, sedation level and type and dose of analgesia and sedation. RESULTS: Sample of 84 patients, 42 in each group. The pain level in both groups, during mobilisation, showed significant differences p=0.011, with a mean of 3.11(2.40) for the user group and 1.83(2.14) for the non-user group. A relative risk of 2.5 CI (1,014-6,163) was found to have moderate / severe pain in the user group compared to the non-user group. The mean dose of analgesia and continuous sedation was significantly higher in the user group: P=.032 and P=.004 respectively. There was no difference in bolus dose of analgesia and sedation with P=.624 and P=.690 respectively. CONCLUSIONS: Patients with a history of consumption of psychoactive substances show higher levels of pain and experience a higher risk of this being moderate/severe compared to non-users despite receiving higher doses of analgesia and sedation infusion. Key words: pain, multiple trauma, drug users.