Control de daños ortopédicos en pacientes politraumatizados pediátricos. Hospital Pediátrico "Eliseo Noel Caamaño" / Control of orthopedic damages in pediatric politraumatized patients. Pediatric Hospital "Eliseo Noel Caamaño"

RESUMEN Introducción: el control de daños en Ortopedia es aplazar la reparación definitiva de lesiones traumáticas, con el objetivo de la recuperación fisiológica deteriorada por lesiones y/o complicaciones que pueden poner en peligro la vida, realizando entonces procedimientos quirúrgicos sencillos, como una estabilización quirúrgica externa de las fracturas. Objetivo: determinar el comportamiento del control de daños ortopédicos en politraumatizados pediátricos. Materiales y método: se realizó un estudio observacional, descriptivo, prospectivo, de corte transversal, de enero del 2015 a diciembre del 2018. El universo estuvo constituido por 22 pacientes menores de 19 años de edad, politraumatizados en el período; la muestra por 15 pacientes, a los que se les aplicó control de daños ortopédicos, según criterios de selección. Resultados: se aplicó control de daños ortopédicos a 15 infantes. El más afectado fue el sexo masculino con el 73,3 %. Prevalecieron los traumatismos de los miembros inferiores con el 58,3 % y las fracturas cerradas con un 53,8 %. La osteomielitis crónica fue la complicación que predominó, en el 20 % de la muestra. En el 73,3 % de los casos se evaluó como satisfactoria la aplicación del control de daños ortopédicos en los politraumatizados. Conclusiones: a la totalidad de los traumatizados se le aplicó control de daños ortopédicos. Predominó el sexo masculino y el grupo de edad de 9 -14 años. Los miembros inferiores aportan la mayor cantidad con el fémur y la tibia. El control de daños ortopédicos se evaluó satisfactoriamente en la mayoría de los pacientes estudiados (AU).

ABSTRAC Introduction: the control of damages in Orthopedics is to postpone the definitive repair of traumatic lesions, with the objective of the physiologic recovery deteriorated by lesions and/or complications that can put in danger the life, carrying out simple surgical procedures, like an external surgical stabilization of the fractures at that time. . Objective: to determine the behavior of the orthopedic damage control in pediatric politraumatized patients. Material and method: a cross-sectional, prospective, descriptive, observational study was carried out from January 2015 to December 2018. The universe was formed by 22 patients younger than 19 years politraumatized in the period and the sample formed 15 patients; they underwent orthopedic damage control, according to the selection criteria. Results: the orthopedic damage control, was applied to 15 children. Male sex was the most affected one. Trauma in the lower limbs with 58.3 % and closed fractures with 53.8 prevailed. The predominating complication was chronic poliomyelitis in 20 % of the sample. The orthopedic damage control in politraumatized patients was assessed as successful in 73.3 % of the cases. Conclusions: the orthopedic damage control was applied to the total of traumatized patients. The male sex and the 9-14 years-old age group predominated. Lower limbs contributed with the biggest quantity of trauma, in femur and tibia. The orthopedic damage control was assessed as successful in most of studied patients (AU).

Alpha-tocopherol succinate- and AMD3100-mobilized progenitors mitigate radiation combined injury in mice.

The purpose of this study was to elucidate the role of alpha-tocopherol succinate (TS)- and AMD3100-mobilized progenitors in mitigating combined injury associated with acute radiation exposure in combination with secondary physical wounding. CD2F1 mice were exposed to high doses of cobalt-60 gamma-radiation and then transfused intravenously with 5 million peripheral blood mononuclear cells (PBMCs) from TS- and AMD3100-injected mice after irradiation. Within 1 h after irradiation, mice were exposed to secondary wounding. Mice were observed for 30 d after irradiation and cytokine analysis was conducted by multiplex Luminex assay at various time-points after irradiation and wounding. Our results initially demonstrated that transfusion of TS-mobilized progenitors from normal mice enhanced survival of acutely irradiated mice exposed 24 h prior to transfusion to supralethal doses (11.5-12.5 Gy) of (60)Co gamma-radiation. Subsequently, comparable transfusions of TS-mobilized progenitors were shown to significantly mitigate severe combined injuries in acutely irradiated mice. TS administered 24 h before irradiation was able to protect mice against combined injury as well. Cytokine results demonstrated that wounding modulates irradiation-induced cytokines. This study further supports the conclusion that the infusion of TS-mobilized progenitor-containing PBMCs acts as a bridging therapy in radiation-combined-injury mice. We suggest that this novel bridging therapeutic approach involving the infusion of TS-mobilized hematopoietic progenitors following acute radiation exposure or combined injury might be applicable to humans.

Manejo inicial del politraumatizado / Initial management of politraumatized patient

Trauma is today the first cause of death in young population; Motor vehicle crashes (MVC’s) are the main specific cause. The initial approach of the trauma patient takes place in the prehospital and hospital environment, following a systematic evaluation and priorizing some systems above others. Primary evaluation (with the classic sequence: ABCDE), sets intervention priorities that ultimately target a reduction in trauma early mortality. The in-corporation of ultrasonography in the evaluation of the trauma patient, has been fundamental in searching for injuries that may have been overlooked in the primary evaluation. Injuries that compromise ventilation may cause hypoxemia and hemodynamic instability. Early bleed control is the main therapeutic target in the trauma patient with active hemorrhage, which leads to reduction of early mortality and also prevents future complications. Fluid resuscitation is the main intervention to restore tissue perfusion. Also, the use of transfusional therapy, permissive hypotension and tranexamic acid must also be considered. Emergency Ultrasound is today a fundamental instrument in the initial trauma patient evaluation, because it greatly contributes to the evaluation of ventilatory derangement and hemodynamic instability causes. Finally, one must remember that trauma is a dynamic process, and therefore reevaluating is imperative, especially because findings of neurological deficit or deterioration in time, will ultimately conduct to the diagnose of injuries that cause brain hypoperfusion...

A lei seca cumpriu sua meta em reduzir acidentes relacionados à ingestão excessiva de álcool? / Reducing accidents related to excessive alcohol intake? A retrospective study of polytraumatized patients undergoing surgery at a Brazilian University Hospital

OBJETIVO: avaliar se a Lei Seca cumpriu sua meta após três anos da promulgação. MÉTODOS: estudo retrospectivo dos pacientes com fraturas craniofaciais submetidos a tratamento cirúrgico em um hospital universitário, em dois períodos: antes (2005 a 2008) e após a implantação da lei (2008 a 2011). RESULTADOS:foram operados 265 pacientes (220 homens e 45 mulheres) nesse período sendo, 149 (56%) antes da lei e 116 (44%) após a lei, indicando redução no número de traumatismos (p=0,04). Houve predomínio da faixa etária entre 19 e 40 anos, em ambos os períodos. As principais causas dos traumas foram os acidentes automobilísticos, as agressões físicas e as quedas. O abuso de álcool foi identificado em 15,4% dos pacientes antes e 19% após a lei. A mandíbula e o complexo maxilozigomático foram os ossos mais acometidos. CONCLUSÃO:a redução no número de politraumatizados operados ficou aquém do esperado e almejado.

OBJECTIVE: To assess whether the Brazilian Driving Dry Law reached its goal after the three years following its enactment. METHODS: We onnducted a retrospective study of patients with craniofacial fractures who underwent surgery at a university hospital in two periods: before the Law (2005 to 2008) and after the Law (2008 to 2011). RESULTS: 265 patients (220 men and 45 women) were operated on during this period, 149 (56%) before and 116 (44%) after the Law, which indicates a reduction in the number of traumatisms (p=0.04). The age range between 19 and 40 years predominated in both periods. The main causes of traumas were car accidents, physical aggression and falls. Alcohol abuse was identified in 15.4% patients before and 19% patients after the enactment. The jaw and the maxillo-zygomatic complex were the most affected bones. CONCLUSION: The drop in the number of polytraumatized patients operated on at this institution in the three years following the Driving Dry Law was 22%, which is below the expected and desired percentage. These results must be compared to those of different services offering the same attendance type in order to compile data and enlarge statistics. The low index of reduction in the number of traumatisms and the report of alcohol abuse by several patients at the moment of trauma, even after the law, evidence the need of adopting stricter measures to control and punish violators.

[Model aeroplanes: a not to be ignored source of complex injuries]. / Modellflug: Eine nicht zu unterschätzende Quelle für komplexe Verletzungen.

With the incidence of work-related injuries decreasing, we continue to observe an unchanged trend in leisure-related accidents. As in any other hobby, model flying devices bear the risk for accidents among builders and flyers ranging from skin lacerations to complicated and even life-threatening injuries. The fast-moving razor-sharp propeller blades predominantly cause trauma to the hands and fingers resulting in typical multiple parallel skin injuries also affecting structures deep to the dermis (e. g., tendons, vessels and nerves). The resultant clinical management involves complex reconstructive surgical procedures and prolonged rehabilitative follow-up. Improving the legal framework (e. g., warnings by the manufacturer) on the one hand, providing informative action and sensitising those affected on the other, should form a basis for an altered prevention strategy to reduce model flying device-related injuries in the future.

Reducing accidents related to excessive alcohol intake? A retrospective study of polytraumatized patients undergoing surgery at a Brazilian University Hospital.

OBJECTIVE: To assess whether the Brazilian Driving Dry Law reached its goal after the three years following its enactment. METHODS: We conducted a retrospective study of patients with craniofacial fractures who underwent surgery at a university hospital in two periods: before the Law (2005 to 2008) and after the Law (2008 to 2011). RESULTS: 265 patients (220 men and 45 women) were operated on during this period, 149 (56%) before and 116 (44%) after the Law, which indicates a reduction in the number of traumatisms (p=0.04). The age range between 19 and 40 years predominated in both periods. The main causes of traumas were car accidents, physical aggression and falls. Alcohol abuse was identified in 15.4% patients before and 19% patients after the enactment. The jaw and the maxillo-zygomatic complex were the most affected bones. CONCLUSION: The drop in the number of polytraumatized patients operated on at this institution in the three years following the Driving Dry Law was 22%, which is below the expected and desired percentage. These results must be compared to those of different services offering the same attendance type in order to compile data and enlarge statistics. The low index of reduction in the number of traumatisms and the report of alcohol abuse by several patients at the moment of trauma, even after the law, evidence the need of adopting stricter measures to control and punish violators.

[Domestic accidents involving women and first aid knowledge]. / Kadinlarin basina gelen ev kazalari ve ilk yardim bilgi düzeyleri.

BACKGROUND: Domestic accidents (DA) are preventable and untoward events occurring in a house, pool or garage. Those events constitute a major issue in the context of public health. The objective of this study was to highlight the characteristics of female involvement in DA and their level of knowledge regarding first aid. METHODS: Adult female relatives of patients presenting at the university-based emergency department within the six-month study period comprised the study sample. They were asked to answer a 23-item self-reported questionnaire, and the responses were analyzed. RESULTS: A total of 1017 women (mean age: 29.2±11.1 years) were enrolled in the study. Hand lacerations (n=924, 90.8%), sprain and contusions (n=904, 88.8%) and burns (n=803, 78.9%) were the most commonly reported types of DA. The children were reported to suffer mostly from hits, sprains and contusions (n=478, 91.7%), followed by falls and slipping (n=452, 86.7%). The telephone number of emergency medical services was recalled most frequently (n=871, 85.6%), while that of the poison control center was known least commonly (n=48, 4.7%). The group with the highest level of education had a significantly higher mean number of correct answers than that of the group with the lowest level of education (p=0.001). The knowledge level of the women who worked was significantly lower than that of the unemployed women (p=0.02). CONCLUSION: Extensive training of women on DA should be undertaken and the mass media should be utilized to achieve this goal.

Factors affecting mortality in patients with thorax trauma.

BACKGROUND: The purpose of this study was to define the epidemiologic properties and correlation of physiological and anatomical risk factors with the mortality rate among patients with thorax trauma and to ensure early prediction of severe trauma. METHODS: Files of 371 cases were retrospectively examined. Their initial state in the emergency department was analyzed in terms of mortality development. Age, gender, trauma mechanism, systolic blood pressure and respiration type on admission, accompanying injuries, thorax pathology, trauma scores, and treatment approaches in exitus and surviving cases were compared. Survival probabilities and unexpected mortality rates were computed using the Trauma Revised Score-Injury Severity Score (TRISS). RESULTS: Age, hypotension, pathologic respiration, blunt injury, accompanying injury, abdominal trauma, high Injury Severity Score (ISS), and low Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), and TRISS were the factors affecting mortality, and presence of blunt injuries, TRISS <85, ISS >22 and GCS <13 were found to be independent prognostic factors. The strongest factor indicating mortality was TRISS. Thirty-four of 307 cases with survival probability of over 50% died. CONCLUSION: In the presence of factors affecting mortality, patients with thorax trauma should be evaluated as being in a high-risk group and treatment strategies must be aggressive. Case analysis based on the TRISS model would further reveal the mistakes and may improve patient care.

Canadian Association of Pediatric Surgeons' position statement on the use of all-terrain vehicles by children and youth.

The goal of the Canadian Association of Pediatric Surgeons is to improve the surgical care of infants and children in Canada. Its areas of interest include all aspects of general and thoracic pediatric surgery with recognition of its unique responsibility to infants born with congenital anomalies and children with malignancies. Although its responsibility to pediatric trauma is not unique, that injury remains the number one cause of death of all children beyond infancy creates a pivotal role of this association in issues related to pediatric trauma. With modern methods of first aid, transportation, resuscitation, intensive care, and specialized surgical team effort, many of these seriously traumatized children can be saved. However, despite these advances in trauma care, it is recognized that the most important and ultimate approach to childhood injuries lies in the realm of prevention.

Injuries of the hand and forearm in young children caused by steam roller presses in laundries.

Fourteen children (median age 43 months, range 14-82 months; 7 girls and 7 boys) were treated for mangle injuries (one hot steam, and 13 cold roller presses) to the hand and forearm between 1996-2002 at the Department of Hand Surgery, Malmö, Sweden. All children had unilateral skin damage with avulsion or necrosis of skin in nine. Seven of the 14 had signs of compartment and carpal tunnel syndromes and three had fractures (phalanges or hamate bone). Initial treatment included fasciotomy, decompression, and skin revision with split skin grafts and later further skin cover, including one pedicled ulnar flap. IN eight the injuries healed uneventfully, while six had slight consequences (such as minor extension deficit of fingers or slight contracture of the scar). Ten of the 14 children came from immigrant families. Mangle injuries can be prevented through better supervision of children by parents when the mangle is being used, and dissemination of information of the potential hazards in relevant languages in residential areas with large immigrant populations.

Handlebar injuries in children: should we raise the bar of suspicion?

Injury prevention strategies for child bicyclists have focused on helmet use to prevent head trauma. Handlebars are another source of injury. A retrospective review from 2005 identified 385 admissions to a Level 1 pediatric trauma center of which 23 (5.9%) were pedal cyclists. Four cases (<1.0%) of handlebar injuries were identified. Three children (two bicyclists, one riding a scooter) sustained handlebar impact to the neck. All children with neck injuries had subcutaneous emphysema. Two of the children had pneumomediastinum, which after work-up was managed nonoperatively. One child had a tracheal injury requiring operative intervention. Another child was struck in the upper abdomen resulting in a traumatic abdominal wall hernia requiring emergent exploration and hernia repair. Discordance exists between the apparently minor circumstances of handlebar trauma and the severity of injury sustained by bicyclists. Recognizing the mechanism of handlebar-related injuries and maintaining a high index of suspicion for visceral injuries aids in the diagnosis. The incidence of these injuries is underestimated due to insufficient documentation of the circumstances of injury events and a lack of applicable E-codes specific for handlebar injury.

[Injury prevention as the physician's challenge]. / Prävention von Verletzungen als ärztliche Aufgabe.

In Germany, more than 9 million individuals yearly sustain injuries and more than 30,000 fatal injuries. Based on estimations, preventive measures could avoid more than one half of all accidents and could influence the other half of the accidents such that the injuries caused are minor. The aim of an initiative of the Study Group on Injury Prevention of the German Trauma Society (DGU) is a complete inventory of all prevention programs from different expert groups in Germany. A synopsis of the gathered knowledge should serve as a basis for further interdisciplinary preventive measures. The consistent interdisciplinary orientation of this program is a special characteristic including trauma surgery, orthopedics, pediatric surgery, pediatrics, sociology, legal medicine, psychology, sports medicine, geriatrics, anesthesiology, and others. Special attention was also directed to the age groups of children/adolescents and the elderly.

The silent epidemic of falls from buildings: analysis of risk factors.

This study wanted to search for potential risk factors associated with falls from windows and balconies in order to eventually improve prevention. All children under the age of 16 years suffering from head injuries/multiple trauma due to falls from windows or balconies treated over the last 7 years at the intensive care unit (ICU) of the University Children's Hospital Zürich were analysed retrospectively (group A). Fifty patients out of all children suffering from head injuries/multiple trauma due to other types of accidents in the same period were selected at random as controls (group B). Out of a total of 241 children with head injury and/or multiple trauma, 31 (13%) fell out of a building. Twenty-seven of these victims (87%) fell from the third floor or lower. Twenty-one of the falls (68%) occurred at home. Fifteen children (49%) climbed on a piece of furniture before falling. In almost 20% of the accidents dangerous balcony or house constructions led to the fall. Parents did not witness the fall, except for three cases (10%) with direct parental involvement (one mother jumped out with her child, two mothers threw their child out of the window). Two children (6%) attempted suicide. Children aged 0-5 years were predominantly represented (84%), and all six children who died were in this age group. There were significantly more patients with foreign nationalities and lower socio-professional categories in group A than in group B. In both groups, the accidents concerned the youngest child of the family in approximately 50% and happened mostly during summer evenings. There were no significant differences in injured systems and in injury severity between the two groups. This study identified young age, an immigrant family setting, low socio-professional category of the parents, dangerous house constructions, inappropriate furniture placement, and summertime evenings as risk factors for serious building falls in children. This information may foster focused prevention.

The epidemiology of the railway related casualties.

BACKGROUND: Railway related accidents and incidents account for 150-200 deaths per 100 million passengers annually in Turkey. The aim of this study was to evaluate the epidemiological aspects of these casualties. METHODS: The data about railway related casualties between January 1997 and December 2003 were retrospectively analyzed in Turkey. RESULTS: Railway related accidents and incidents resulted in 213,3 deaths per year per 100 million passengers during the study period. Train-pedestrian accidents caused highest number of mortality and level crossing accidents caused highest numbers of casualty. Furthermore, suicide attempts had highest mortality ratio in railway related accidents. The majority of the fatalities and injuries occurred in males for every type of incident and most of the injuries have taken place in the 25-60 age group. Summer time was the season with the highest number of fatalities and injuries. CONCLUSION: Measures should be taken to improve railway safety. These include prevention of direct exposure of pedestrians to the railway tracts and conditioning the level crossings.

Impacto del proyecto itersocietario de trauma en Rafaela: período 1996-2003 / Impact of trauma project in Rafaela city since 1996 to 2003

Antecedentes: El trauma o lesiones por causas extremas constituyen la primera causa de muerte en Argentina entre el primer año de vida y los 44. Objetivo: presentar la experiencia obtenida en la aplicación y desarrollo en Rafaela del Proyecto Intersocietario de Trauma (PIT) y su impacto en la comunidad. Diseño: Método operativo de investigación epidemiológico con transferencia de estrategias basadas en el análisis de circunatancias de ocurrencia. Lugar: Ciudad de Rafaela, Provincia de Santa Fé, Argentina. Población: 3040 víctimas politraumatizadas internadas en las instituciones médicas de Rafaela. Método: Incorporación y análisis de datos de pacientes, adultos y niños politraumatizados incorporados a un sistema de información durante el periodo octubre 1996-septiembre 1997. Elaboración de estrategias de prevención primaria basadas en el informe epidemiológico. Resultados: Promedio de edad 21,8 años (amplitud 0 a 98 años). El 73,4 por ciento de las víctimas tenia menos de 30 años de edad. Género: 65,2 por ciento fueron varones. De acuerdo a la Clasificación Internacional C10, las lesiones no intencionales representan el 95 por ciento del total. El 60 por ciento de los lesionados correspondieron a lesiones por "Otras causas externas de morbilidad y mortalidad" y dentro de éstas las caídas representaron el 43,3 por ciento. Los "Accidentes de Transporte" generaron el 35,6 por ciento de las lesiones. Las víctimas fallecidas por accidentes vehículares fueron 16 durante el año 1998, 13 en 1999, 12 en 2000, 13 en 2001, 6 en 2002 y 7 durante 2003. El número de internaciones de niños con lesiones por quemaduras fue de 68 durante el periodo 1993-1997 y de 50 para el período 1998-2001. Comentarios: El Proyecto Intersocietarios de Trauma (P.I.T.) en Rafaela, desarrolló un plan para la transferencia de conocimiento de las entidades científicas, mediante un proceso de autogestión comunitaria, destinado a generar programas de prevención primaria en lesiones de causa externas. La comunidad de Rafaela eligió realizar acciones de prevención sobre los accidentes de tránsito, tanto niños como en adultos. La detección del problema relacionado al aumento progresivo del número de niños internados por quemaduras generó medidas de prevención relacionadas con este tema. Los resultados obtenidos son muy estimulantes ya que se observó la franca disminución del número de accidentes...

Nutrição no paciente politraumatizado: parte 1: aspectos fisiopatológicos do paciente politraumatizado / Nutrition in politrauma patient: part 1: phisiopathological aspects in politrauma patient

Devido ao grande número de acidentes, as vítimas de truma se tornaram uma constante nos hospitais. Com o objetivo de melhor entender e atender o paciente politraumatizado, os autores abordam, em duas partes, os aspectos nutricionais do politrauma. Na primeira parte, envolvendo a definição de trauma, revêem sua fisiopatologia e suas respostas endócrinometabólicas. Além disso, apresentam o conceito de desnutrição e as alterações na cicatrização no desnutrido politraumatizado. Na segunda parte serão abordados os conceitos, as indicações e as contra-indicações da terapia de nutrição enteral no paciente politraumatizado.

Damage control surgery and intensive care.

The introduction and establishment of the 'damage control surgery' concept has led to increasing numbers of severely injured and unstable patients being presented to Intensive Care Units (ICU) for ongoing resuscitation. These patients present many challenges for the Intensive Care team and emphasise the need for a multidisciplinary approach to optimise trauma patient management. Multiple issues need to be addressed simultaneously while the overall aim is to rapidly achieve a physiological environment that will allow the best possible recovery. The 'lethal triad' of hypothermia, acidosis, and coagulopathy due to initial hypovolaemia require aggressive correction. From the outset ICU management must also attempt to minimise the complications of these injuries and the resuscitative process. This review will address some of the key issues relating to the care of these patients in the ICU.