Puntajes VII Ortopedia infantil / Scores VII Pediatric orthopedics

El Comité Editorial quiere brindar a sus lectores una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la Ortopedia y Traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definiendo su uso e incluyendo bibliografía original y actualizada. Nivel de Evidencia: V

The Editorial Committee wants to provide its readers with an update on the commonly used scales. The use of tables and scales is a widespread practice in Orthopedics and Traumatology. The measurement and quantification of clinical, functional, and radiographic aspects has become an essential tool for decision-making in different aspects of healthcare activity. We carry out a review of the most used scales, defining their use and including original and updated literature. Level of Evidence: V

Impact of the lactate dehydrogenase in association with the International Staging System prognostic score in multiple myeloma patients treated in real life

Abstract Introduction Multiple myeloma is characterized by proliferation of clonal plasma cells. The identification of prognostics factors to identify patient's risk is important. Among the studied factors, it was identified of relevant importance the lactic dehydrogenase. Objectives To evaluate the impact of the value of DHL in combination with the score ISS in the medium patients overall survival (OS). Methods It is a retrospective cohort with 252 patients with MM recently-diagnosed that attendance in the institution of the study. Results To evaluate the association between DHL and ISS, we found 6 new groups to be analyzed: ISS I and normal DHL with medium overall survival not reached, and with DHL loud with medium OS of 69,8 months, ISS II and normal DHL with medium overall survival of 78,8 months and with DHL loud with medium OS of 73,9 months, ISS III and normal DHL with medium overall survival of 46,7 months and with DHL loud with medium OS of 45,5 months. Conclusion Through the association of ISS I and normal DHL, ISS III and high DHL and others combinations, we build a new score with superior impact prognostic in our population treated in real life.

Puntajes VI / Scores VI

El Comité Editorial quiere brindar a sus lectores una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la Ortopedia y Traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definiendo su uso e incluyendo bibliografía original y actualizada. Nivel de Evidencia: V

The Editorial Committee wants to provide its readers with an update on the commonly used scales. The use of tables and scales is a widespread practice in Orthopedics and Traumatology. The measurement and quantification of clinical, functional, and radiographic aspects has become an essential tool for decision-making in different aspects of healthcare activity. We carry out a review of the most used scales, defining their use and including original and updated literature. Level of Evidence: V

Characteristics of injuries resulting from falls from height in the construction industry

INTRODUCTION@#Falls from heights contribute to 34% of fatal accidents in Singapore. Of these, 51% of the accidents occur in the construction industry. This retrospective review, of all persons falling from heights in the construction industry from 2006 to 2012 and attending a major hospital, analysed injury patterns and related them to mechanisms and contributory factors.@*METHODS@#Information collected included injury and casualty characteristics, safety measures, pre-existing medical conditions and clinical outcomes.@*RESULTS@#Of 1,085 patients, 951 were male with a mean age of 39.8 years, mean height of 165.9 cm and mean weight of 69.7 kg. Most of the casualties fell between 0800 and 2000 hours. Among the severely injured patients, 2.4% had head injuries, 54.9% had chest injuries and 39.2% had abdominal and pelvic injuries. For these casualties, the mortality rate was 60.8%. For patients with less than major trauma, the commonest injuries were in the lower limbs (41.8%), upper limbs (40.8%) and spine (22.2%). All the casualties survived. Falls from scaffolding, formwork and platforms were the most common causes of severe injuries (41.1%). Safety helmets and harnesses were reported to be used in 1.8% and 4.1% of instances of falls, respectively.@*CONCLUSION@#Studying the patterns of injuries following falls at construction sites has the potential for injury prevention through safe practices, use of safety equipment and targeted training.

Puntajes V. Columna Vertebral / Scores V. Spine

El Comité Editorial quiere brindar a los lectores de la RAAOT una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la ortopedia y traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definimos su uso e incluimos bibliografía original y actualizada. Nivel de Evidencia: V

The Editorial Committee wants to provide its readers with an update on the commonly used scales. The use of tables and scales is a widespread practice in Orthopedics and Traumatology. The measurement and quantification of clinical, functional, and radiogra-phic aspects have become an essential tool for decision-making in different aspects of healthcare activity. We carry out a review of the most used scales, defining their use and including original and updated literature. Level of Evidence: V

Puntajes III / Scores III

El Comité Editorial quiere brindar a sus lectores una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la Ortopedia y Traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definiendo su uso e incluyendo bibliografía original y actualizada. Nivel de Evidencia: V

The Editorial Committee wants to provide its readers with an update on the commonly used scales. The use of tables and scales is a widespread practice in Orthopedics and Traumatology. The measurement and quantification of clinical, functional, and radiographic aspects has become an essential tool for decision-making in different aspects of healthcare activity. We carry out a review of the most used scales, defining their use and including original and updated literature. Level of Evidence: V

Puntajes IV / Scores IV

El Comité Editorial quiere brindar a los lectores de la RAAOT una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la ortopedia y traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definimos su uso e incluimos bibliografía original y actualizada. Nivel de Evidencia: V

The Editorial Committee wants to provide its readers with an update on the commonly used scales. The use of tables and scales is a widespread practice in Orthopedics and Traumatology. The measurement and quantification of clinical, functional, and radiographic aspects have become an essential tool for decision-making in different aspects of healthcare activity. We carry out a review of the most used scales, defining their use and including original and updated literature. Level of Evidence: V

Puntajes II / Scores II

El Comité Editorial quiere brindar a sus lectores una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la Ortopedia y Traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definiendo su uso e incluyendo bibliografía original y actualizada. Nivel de Evidencia: V

The Editorial Committee wants to provide its readers with an update on the commonly used scales. The use of tables and scales is a widespread practice in Orthopedics and Traumatology. The measurement and quantification of clinical, functional, and radiographic aspects have become essential tools for decision-making in different aspects of healthcare activity. We carried out a review of the most used scales, defining their use and including original and updated literature. Level of Evidence: V

Puntajes I / Scores I

El Comité Editorial quiere brindar a sus lectores una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la Ortopedia y Traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definiendo su uso e incluyendo bibliografía original y actualizada. Nivel de Evidencia: V

The Editorial Committee wants to provide its readers with an update on the commonly used scales. The use of tables and scales is a widespread practice in Orthopedics and Traumatology. The measurement and quantification of clinical, functional, and radiographic aspects have become an essential tool for decision-making in different aspects of healthcare activity. We carry out a review of the most used scales, defining their use and including original and updated literature. Level of Evidence: V

Early changes within the lymphocyte population are associated with the long term prognosis in severely injured patients / 北京大学学报(医学版)

OBJECTIVE@#To investigate the relationship between early lymphocyte responses and the prognosis in severely injured patients.@*METHODS@#Consecutive patients with severe trauma who were treated in Peking University People's Hospital Trauma Medical Center between June 2017 and June 2020 were enrolled in this restropective chart-review study. According to the responses of lymphocyte after severe injury, the patients were divided into three groups, group 1: lymphopenia-returned to normal; group 2: persistent lymphopenia; group 3: never lymphopenic, and the outcome of 28 d were recorded. Clinical data such as gender, age, base excess, mechanism of injury, Glasgow coma scale (GCS), injury severity score (ISS) and massive blood transfusion were collected. Perform statistical analysis on the collected clinical data to understand the trend of lymphocyte changes in early trauma and the relationship with prognosis. In order to eliminate the interference of age, stratification was carried out according to whether the age was ≥ 65 years old, in different age groups, they were grouped according to whether the length of stay was ≥ 28 d, and the relationship between lymphocyte trend and length of stay was discussed.@*RESULTS@#A total of 83 patients were included, 66 males and 17 females. The main injury mechanisms were traffic accident injuries and high-altitude fall injuries. The average ISS was (30±11) points. 65 patients had lymphopenia on the day of injury, 32 of them returned to normal on the 5th day, and the rest did not recover; the other 18 patients had normal lymphocyte levels after injury. Patients which are failure to normalize lymphopenia within the first 5 days following admission was related with the long hospitalization time and higher 28 d mortality rate. After further stratification by age, failure to normalize lymphopenia within the first 5 days following admission in the elderly group (age ≥65 years) was a risk factor for prolonged hospital stay (≥28 d), P=0.04. While in younger group, a high level of neutrophils within the first 5 d following admission was a risk factor for bad outcome.@*CONCLUSION@#A failure to normalize lymphopenia in severely injured patients is associated with significantly higher mortality and longer hospital stay. This study reveals lymphocytes can be used as a reliable indicator for the prognostic evaluation.

Non-fatal Bihemispheric Penetrating Brain Injury from a Crossbow Arrow with Good Clinical Outcome: Case Report

Crossbow injuries to the head have seldom been reported in the literature, and they represent a unique type of penetrating brain injury (PBI) in which a low-velocity arrow results in an intracranial fragment larger than most high-velocity projectiles, usually with a lethal outcome.We present the case of a 34-year-oldman who attempted suicide with a self-inflicted cranial injury from a crossbow arrow, with a right parietal point of entry and a palpable subcutaneous tip in the left parietal region. The emergency team reported a Glasgow coma scale (GCS) score of 15, and the patient was brought sedated and intubated. Computed tomography (CT) imaging scans showed that the arrow crossed both parietal lobes, with mild subarachnoid hemorrhage and small cerebral contusions adjacent to its intracranial path. Careful retrograde removal of the penetrating arrow was performed in the CT suite, followed by an immediate CT scan, which excluded procedure-related complications. The patient woke up easily and was discharged 3 days later withmild left hand apraxia and no other neurologic deficits. To the best of our knowledge, there are no similar case reports describing both good clinical outcome and rapid discharge after a bihemispheric PBI. Individualizing the management of each patient is therefore crucial to achieve the best possible outcome as PBI cases still represent a major challenge to practicing neurosurgeons worldwide.

Firearm-associated ocular injuries: analysis of national trauma data / Lesões oculares relacionadas a armas de fogo: análise de dados nacionais de traumas nos EUA

ABSTRACT Purpose: The United States of America has the highest gun ownership rate of all high-income nations, and firearms have been identified as a leading cause of ocular trauma and visual impairment. The purpose of this study was to characterize firearm-associated ocular injury and identify at-risk groups. Methods: Patients admitted with firearm-associated ocular injury were identified from the National Trauma Data Bank (2008-2014) using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes and E-codes for external causes. Statistical analysis was performed using the SPSS 24 software. Significance was set at p<0.05. Results: Of the 235,254 patients, 8,715 (3.7%) admitted with firearm-associated trauma had ocular injuries. Mean (standard deviation) age was 33.8 (16.9) years. Most were males (85.7%), White (46.6%), and from the South (42.9%). Black patients comprised 35% of cases. Common injuries were orbital fractures (38.6%) and open globe injuries (34.7%). Frequent locations of injury were at home (43.8%) and on the street (21.4%). Black patients had the highest risk of experiencing assault (odds ratio [OR]: 9.0; 95% confidence interval [CI]: 8.02-10.11; p<0.001) and street location of injury (OR: 3.05; 95% CI: 2.74-3.39; p<0.001), while White patients had the highest risk of self-­inflicted injury (OR: 10.53; 95% CI: 9.39-11.81; p<0.001) and home location of injury (OR: 3.64; 95% CI: 3.33-3.98; p<0.001). There was a steadily increasing risk of self-inflicted injuries with age peaking in those >80 years (OR: 12.01; 95% CI: 7.49-19.23; p<0.001). Mean (standard deviation) Glasgow Coma Scale and injury severity scores were 10 (5.5) and 18.6 (13.0), respectively. Most injuries (53.1%) were classified as severe or very severe injury, 64.6% had traumatic brain injury, and mortality occurred in 16% of cases. Conclusion: Most firearm-associated ocular injuries occurred in young, male, White, and Southern patients. Blacks were disproportionally affected. Most firearm-associated ocular injuries were sight-­threatening and associated with traumatic brain injury. The majority survived, with potential long-term disabilities. The demographic differences identified in this study may represent potential targets for prevention.

RESUMO Objetivo: Os Estados Unidos têm a maior taxa de posse de armas de fogo de todos os países de alta renda e essas armas foram identificados como uma das maiores causas de trauma ocular e deficiência visual. O objetivo deste estudo foi caracterizar as lesões oculares associadas a armas de fogo e identificar grupos de risco. Métodos: Foram identificados pacientes hospitalizados com lesões oculares associadas a armas de fogo no período de 2008 a 2014, a partir do Banco de Dados Nacional de Trauma (National Trauma Data Bank), usando os códigos de diagnósticos da CID9MC e códigos "E" para causas externas. A análise estatística foi efetuada usando o programa SPSS. O nível de significância considerado foi de p<0,05. Resultados: De um total de 235.254 pacientes hospitalizados com trauma associado a armas de fogo, 8.715 (3,7%) tinham lesões oculares. A média de idade foi de 33,8 (DP 16,9) anos. A maioria foi de homens (85,7%), brancos (46,6%) e da região Sul (42,9%); 35% dos pacientes eram negros. As lesões mais comuns foram fraturas de órbita (38,6%) e lesões de globo aberto (34,7%). Os locais mais frequentes foram a residência (43,8%) e a rua (21,4%). Pacientes negros tiveram maior probabilidade de sofrer agressões (RP=9,0, IC 95%=8,02-10,11; p<0,001) e da ocorrência ser na rua (RP=3,05, IC 95%=2,74-3,39; p<0,001), enquanto pacientes brancos tiveram maior probabilidade de lesões autoprovocadas (RP=10,53, IC 95%=9,39-11,81; p<0,001) e da ocorrência ser na residência (RP=3,64, IC 95%=3,33-3,98; p<0,001). A probabilidade de lesões autoprovocadas aumentou com a idade de forma consistente, atingindo o máximo em pacientes com mais de 80 anos (RP=12,01, IC 95%=7,49-19,23; p<0,001). A pontuação média na escala de coma de Glasgow foi 10 (DP 5,5) e na escala de severidade da lesão foi 18,6 (DP 13,0). A maioria das lesões (53,1%) foi classificada como severa ou muito severa. Dentre os pacientes, 64,6% tiveram lesão cerebral traumática e 16% evoluíram a óbito. Conclusão: A maior parte das lesões oculares relacionadas a armas de fogo ocorreu em pacientes jovens, do sexo masculino, brancos e sulistas. Negros foram afetados desproporcionalmente. A maior parte das lesões oculares relacionadas a armas de fogo apresentou riscos à visão e foi associada a lesões cerebrais traumáticas. A maioria dos pacientes sobreviveu, mas com potencial para invalidez no longo prazo. As diferenças demográficas identificadas podem ser potencialmente alvos de ações preventivas.

Non-operative management of blunt splenic trauma: evolution, results and controversies / Tratamento não operatório do trauma esplênico: evolução, resultados e controvérsias

ABSTRACT The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.

RESUMO O baço é um dos órgãos mais frequentemente afetados no trauma abdominal contuso. Desde os trabalhos de Upadhyaya, o tratamento do trauma esplênico vem sofrendo importantes modificações. Atualmente, é consenso que todo trauma esplênico que se apresenta com estabilidade hemodinâmica pode ser tratado inicialmente de forma não operatória, desde que o serviço possua estrutura adequada e o paciente não apresente outras condições que indiquem exploração da cavidade abdominal. Entretanto, vários tópicos permanecem controversos no que diz respeito ao tratamento não operatório (TNO) do trauma esplênico. A angioembolização esplênica é uma ferramenta de grande auxílio no TNO, porém não há consenso sobre suas indicações precisas. Não há uma definição na literatura a respeito da forma como o TNO deve ser conduzido, tampouco a respeito da periodicidade do controle hematimétrico, do limiar de transfusão que define falha do TNO, de quando iniciar a profilaxia contra tromboembolismo venoso, da necessidade de exames de imagem de controle, do período de repouso no leito, e de quando é seguro indicar alta hospitalar. O objetivo desta revisão é analisar de forma crítica a literatura a respeito desse tema, expondo o estado da arte no TNO do trauma esplênico.

Trauma Quality Indicators' usage limitations in severe trauma patients / Limitações do uso de filtros de qualidade para avaliação do atendimento em vítimas de trauma grave

ABSTRACT Purpose: to analyze the relation between Trauma Quality Indicators (QI) and death, as well as clinical adverse events in severe trauma patients. Methods: analysis of data collected in the Trauma Register between 2014-2015, including patients with Injury Severity Score (ISS) > 16, reviewing the QI: (F1) Acute subdural hematoma drainage > 4 hours with Glasgow Coma Scale (GCS) <9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours; (F4) Admission-laparotomy time greater than 60 min in hemodynamically instable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time > 6 hours; (F10) Surgery > 24 hours. T the chi-squared and Fisher tests were used to calculate statistical relevance, considering p<0.05 as relevant. Results: 127 patients were included, whose ISS ranged from 17 to 75 (28.8 + 11.5). There were adverse events in 80 cases (63%) and 29 died (22.8%). Twenty-six patients had some QI compromised (20.6%). From the 101 patients with no QI, 22% died, and 7 of 26 patients with compromised QI (26.9%) (p=0.595). From the patients with no compromised QI, 62% presented some adverse event. From the patients with any compromised QI, 18 (65.4%) had some adverse event on clinical evolution (p=0.751). Conclusion: the QI should not be used as death or adverse events predictors in severe trauma patients.

RESUMO Objetivo: analisar relação entre comprometimento de Filtros de Qualidade (FQ) com complicações e mortalidade entre vítimas de trauma grave. Métodos: análise dos dados coletados para o Registro de Trauma entre 2014 e 2015, sendo incluídos os traumatizados com Injury Severity Score (ISS) > 16 e analisados os FQ: (F1) drenagem de Hematoma Subdural Agudo (HSA) > 4 horas com Escala de Coma de Glasgow (ECG) <9, (F2) transferência da sala de emergência sem via aérea definitiva e com ECG<9, (F3) reintubação traqueal em até 48 horas, (F4) tempo entre admissão e laparotomia exploradora maior que 60 minutos em pacientes instáveis com foco abdominal, (F5) reoperação não programada, (F6) laparotomia > 4 horas, (F7) fratura de diáfise de fêmur não fixada, (F8) tratamento não operatório em Ferimento por Arma de Fogo (FAF) abdominal, (F9) tempo entre admissão e tratamento de fraturas expostas de tíbia > 6 horas, (F10) operação > 24 horas. Testes de Chi quadrado e Fisher para a análise estatística, considerando significativo p<0,05, foram usados. Resultado: foram incluídos 127 pacientes com ISS entre 17 a 75 (28,8 + 11,5). As complicações ocorreram em 80 casos (63%) e 29 morreram (22,8%). Vinte e seis pacientes apresentaram algum FQ comprometido (20,6%). Dos 101 doentes sem FQ comprometido, 22% faleceram, o que ocorreu em 7 dos 26 doentes com comprometimento dos FQ (26,9%) (p=0,595). Dos doentes sem FQ comprometido, 62% tiveram alguma complicação. Entre os pacientes com FQ comprometido, 18 (65,4%) tiveram complicações (p=0,751). Conclusão: os FQs não devem ser utilizados como preditor de mortes ou complicações evitáveis nas vítimas de traumas graves.

Surgical treatment in hepatic trauma: factors associated with hospitalization time / Trauma hepático com tratamento operatório: fatores associados ao aumento do tempo de hospitalização

ABSTRACT Objective: the aim of this study was to identify associated factors with the increased length of hospital stay for patients undergoing surgical treatment for liver trauma, and predictors of mortality as well as the epidemiology of this trauma. Methods: retrospective study of 191 patients admitted to the Cajuru University Hospital, a reference in the treatment of multiple trauma patients, between 2010 and 2017, with epidemiological, clinicopathological and therapeutic variables analyzed using the STATA version 15.0 program. Results: most of the included patients were men with a mean age of 29 years. Firearm injury represents the most common trauma mechanism. The right hepatic lobe was injured in 51.2% of the cases, and hepatorraphy was the most commonly used surgical correction. The length of hospital stay was an average of 11 (0-78) days and the length of stay in the intensive care unit was 5 (0-52) days. Predictors for longer hospital stay were the mechanisms of trauma, hemodynamic instability at admission, number of associated injuries, degree of liver damage and affected lobe, used surgical technique, presence of complications, need for reoperation and other surgical procedures. Mortality rate was 22.7%. Conclusions: the study corroborated the epidemiology reported by the literature. Greater severity of liver trauma and associated injuries characterize patients undergoing surgical treatment, who have increased hospital stay due to the penetrating trauma, hemodynamic instability, hepatic packaging, complications and reoperations.

RESUMO Objetivo: identificar fatores associados ao aumento do tempo de hospitalização de pacientes submetidos a tratamento cirúrgico por trauma hepático e descrever preditores de mortalidade, assim como a epidemiologia desse trauma. Métodos: estudo retrospectivo de 191 pacientes admitidos no Hospital Universitário Cajuru, referência no atendimento de politraumatizados, no período entre 2010 e 2017, com variáveis epidemiológicas, clinicopatológicas, terapêuticas analisadas por meio do programa STATA versão 15.0. Resultados: maioria dos pacientes incluídos eram homens com média de idade de 29 anos. Ferimento por arma de fogo representou o mecanismo de trauma mais comum. O lobo hepático direito foi lesado em 51,2% dos casos e hepatorrafia foi a correção cirúrgica mais empregada. O tempo de internamento hospitalar foi em média de 11(0-78) dias e o tempo de internação em unidade de terapia intensiva de 5 (0-52) dias. Preditores de maior tempo de hospitalização foram mecanismo de trauma, instabilidade hemodinâmica à admissão, número de lesões associadas, grau da lesão hepática e lobo acometido, técnica cirúrgica empregada, presença de complicações, necessidade de reoperação e outros procedimentos cirúrgicos. Taxa de mortalidade foi de 22,7%. Conclusões: o estudo corroborou a epidemiologia descrita na literatura. Maior gravidade do trauma hepático e das lesões associadas caracterizam os pacientes submetidos ao tratamento cirúrgico, que apresentam aumento de tempo de hospitalização devido a trauma penetrante, instabilidade hemodinâmica, tamponamento hepático, complicações e reoperações.

Puntaje predictivo de resultado en la cirugía reconstructiva de miembros inferiores. Ensayo preliminar / Predictive outcome score in lower limb reconstructive surgery. Preliminary test

Introducción: Las secuelas postraumáticas en los miembros son un cuadro de muy difícil abordaje por la gravedad de las lesiones, la falta de protocolos de tratamiento y especialmente por la elección de la mejor alternativa. El objetivo de este estudio fue analizar el resultado del tratamiento reconstructivo con un puntaje prequirúrgico diseñado para tal fin y evaluar su predictibilidad de resultado. Materiales y métodos: Se realizó un análisis retrospectivo de tipo cohorte de los resultados del tratamiento con fijación externa en 32 pacientes con secuela traumática de la pierna en los últimos siete años que fueron estadificados con un puntaje preoperatorio elaborado para tal fin y comparado con el resultado obtenido con la tabla de resultados de la ASAMI con dos años de seguimiento mínimo. Resultados:Se obtuvo una relación directa entre la estadificación prequirúrgica y el resultado final. Dicha relación se ve reflejada en el alto porcentaje de excelentes resultados en pacientes de bajo riesgo (50%) y una tasa del 60% de malos resultados en pacientes de alto riesgo. Conclusiones: La evidencia actual es contradictoria y se discute cuál es la mejor opción de tratamiento. Los pacientes considerados de alto riesgo tienen un alto porcentaje de malos resultados y tal vez no se beneficien con la cirugía reconstructiva. Nivel de Evidencia: IV

Introduction: Post-traumatic sequelae in the limbs are a very difficult condition to approach due to the severity of the injuries and the lack of treatment protocols, which considerably hinder the choice of the best treatment alternative. The objective of this study was to analyze the outcomes of reconstructive treatment with a pre-surgical score designed ad-hoc and to evaluate its predictability. Materials and methods: A retrospective cohort-type analysis of the outcomes of external fixation treatment was performed in 32 patients with traumatic leg sequelae in the last 7 years who were staged with a pre-operative score designed ad-hoc. This was compared with the results obtained with the ASAMI score with a minimum 2-year follow-up. Results: We obtained a direct relationship between pre-surgical staging and the final outcome. This relationship is reflected by obtaining a high percentage of excellent outcomes in low-risk patients (50%) and 60% of poor outcomes in high-risk patients. Conclusions: The current evidence is contradictory and there is controversy over which is the best treatment option. We found that high-risk patients have a high percentage of poor outcomes and may not benefit from reconstructive surgery. Level of Evidence: IV

Pattern of injuries due to wild animal attack among patients presenting to the emergency department: A retrospective observational study / 中华创伤杂志(英文版)

PURPOSE@#The human-wildlife conflicts (HWCs) causing nuisances and injuries are becoming a growing public health concern over recent years worldwide. We aimed to study the demographic profile, mode of injury, pattern of injury, and outcome of wild animal attack victims presented to the emergency department.@*METHODS@#This retrospective cross-sectional study was conducted in the emergency department of a tertiary-care hospital in Eastern India. Data were retrieved from the medical records from May 2017 to May 2021. Patients of all ages and genders attacked by wild animals and secondary injuries were included in this study. Patients with incomplete data, injuries due to the attack of stray and domestic animals and trauma due to other causes were excluded. Demographic profile, mode of injury, the pattern of injury, injury severity score (ISS), radiological pattern, and outcome were recorded. Statistical analysis with R (version 3.6.1.) was conducted.@*RESULTS@#A total of 411 wild animal attack victims were studied, of which 374 (90.9%) were snakebite injuries and 37 (9.1%) were wild mammalian (WM) attack injuries. The mean age of WM attack victims was 46 years, and the male-to-female ratio was 4:1. Elephant attack injury (40.5%) was the most common WM attack injury reported. Most WM attacks (43.2%) occurred between 4:00 a.m. to 8:00 a.m. The median ISS was 18.5 (13-28), where 54.2% of patients had polytrauma (ISS>15). Elephant attack was associated with a higher ISS, but the difference was not significant compared to other animal types (p = 0.2). Blunt trauma was common pattern of injury in the elephant attack injury cases. Lacerations and soft tissue injuries were common patterns in other animal attacks. Among snakebites, neurotoxic was the most common type (55.4%), and lower extremity was the most common site involved.@*CONCLUSION@#The young male population is the major victim of HWCs; and elephant is the most common animal involved. There is a need to design scientifically sound preventive strategies for HWCs and to strengthen the preparedness in health establishments to manage victims effectively.

Damage control resuscitation: REBOA as the new fourth pillar / Resucitación en control de daños: REBOA, el cuarto pilar

Abstract Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm "The Fourth Pillar": Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA.

Resumen La resucitación en control de daños busca combatir la descompensación metabólica del paciente severamente traumatizado mediante tres ejes: la hipotensión permisiva, la resucitación hemostática y la cirugía de control de daños. El objetivo de este artículo es hacer una revisión de la historia de la resucitación en control de daños y la cirugía de control de daños proponiendo un nuevo paradigma basado en los recientes avances de la tecnología endovascular. Un puente ha sido creado entre el manejo prehospitalario y el control del sangrado, descrito antes de la etapa I de la cirugía de control de daños, que es la inclusión y colocación de un REBOA. Esta es una herramienta adicional en el control de la hemorragia y de soporte en la resucitación hemodinámica de los pacientes con trauma severo de tipo cerrado y/o penetrante. Por lo que se propone un nuevo paradigma "El cuarto pilar": Hipotensión permisiva, resucitación hemostática, cirugía de control de daños y REBOA.

Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding! / Control de Daños Prehospitalario: ¡Para Los Cristaloides, Para La Hipotermia Y…! ¡Para El Sangrado!

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.

Whole blood for blood loss: hemostatic resuscitation in damage control / Sangre total: la nueva alternativa en la resucitación hemostática

Abstract Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.

Resumen El choque hemorrágico y sus complicaciones son la principal causa de muerte en los pacientes con trauma. La resucitación en control de daños ha demostrado una disminución en la mortalidad y mejoría en el manejo del paciente. La resucitación hemostática consiste en la recuperación del volumen con hemoderivados como glóbulos rojos, plasma, crioprecipitado y plaquetas, en proporciones de 1:1:1:1. Sin embargo, esta demanda de hemo componentes podría no aplicarse para toda Latinoamérica u otros países de medianos y bajos ingresos. Las principales barreras para la implementación de esta estrategia serían la escasa disponibilidad de bancos de sangre y de hemoderivados insuficientes para contar con un protocolo de transfusión masiva. Una propuesta para superar estas barreras es el uso de sangre total fresca fría para la resucitación hemostática de los pacientes exsanguinados. Ecuador ha sido pionero en la implementación de esta estrategia con una experiencia ya de seis años, en que han demostrado que la sangre total tiene ventajas sobre la terapia de hemo componentes incluyendo, pero no limitando, la trasfusión de sangre con una razón fisiológica de componentes, fácil transporte y transfusión, menor volumen de anticoagulantes y aditivos trasfundidos al paciente, y menor exposición a donantes. La sangre total es una herramienta con un potencial reemergente que puede ser implementado en centros de trauma civil con óptimos resultados y menor demanda técnica.