Uso de la tomografía corporal total en pacientes con heridas de arma de fuego y hemodinámicamente inestables: ¿Rompiendo paradigmas de atención inicial? / Whole-body computed tomography in hemodynamically unstable patients with gunshot wounds: A paradigm shift in trauma management?

Introducción. El objetivo del estudio fue analizar el impacto del uso de la tomografía corporal total en la evaluación de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables atendidos en un centro de referencia de trauma. Métodos. Se realizó un estudio analítico, retrospectivo, con base en un subanálisis del registro de la Sociedad Panamericana de Trauma ­ Fundación Valle del Lili. Se incluyeron los pacientes con trauma penetrante por proyectil de arma de fuego atendidos entre 2018 y 2021. Se excluyeron los pacientes con trauma craneoencefálico severo, trauma leve y en condición in extremis. Resultados. Doscientos pacientes cumplieron los criterios de elegibilidad, 115 fueron estudiados con tomografía corporal total y se compararon con 85 controles. La mortalidad intrahospitalaria en el grupo de tomografía fue de 4/115 (3,5 %) vs 10/85 (12 %) en el grupo control. En el análisis multivariado se identificó que la tomografía no tenía asociación significativa con la mortalidad (aOR=0,46; IC95% 0,10-1,94). El grupo de tomografía tuvo una reducción relativa del 39 % en la frecuencia de cirugías mayores, con un efecto asociado en la disminución de la necesidad de cirugía (aOR=0,47; IC95% 0,22-0,98). Conclusiones. La tomografía corporal total fue empleada en el abordaje inicial de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables. Su uso no se asoció con una mayor mortalidad, pero sí con una menor frecuencia de cirugías mayores.

Introduction. This study aims to assess the impact of whole-body computed tomography (WBCT) in the evaluation of patients with penetrating gunshot wounds (GSW) who are hemodynamically unstable and treated at a trauma referral center. Methods. An analytical, retrospective study was conducted based on a subanalysis of the Panamerican Trauma Society-FVL registry. Patients with GSW treated between 2018 and 2021 were included. Patients with severe cranioencephalic trauma, minor trauma, and those in extremis were excluded. Patients with and without WBCT were compared. The primary outcome was in-hospital mortality, and the secondary outcome was the frequency of major surgeries (thoracotomy, sternotomy, cervicotomy, and/or laparotomy) during initial care. Results. Two hundred eligible patients were included, with 115 undergoing WBCT and compared to 85 controls. In-hospital mortality in the WBCT group was 4/115 (3.5%) compared to 10/85 (12%) in the control group. Multivariate analysis showed that WBCT was not significantly associated to mortality (aOR: 0.46; 95% CI 0.10-1.94). The WBCT group had a relative reduction of 39% in the frequency of major surgeries, with an associated effect on reducing the need for surgery (aOR: 0.47; 95% CI 0.22-0.98). Conclusions. Whole-body computed tomography was employed in the initial management of patients with penetrating firearm projectile injuries and hemodynamic instability. The use of WBCT was not associated with mortality but rather with a reduction in the frequency of major surgery.

Risco de choque em pacientes com hemorragia grave: caracterização e atuação do enfermeiro do trauma / Risk of shock in patients with severe hemorrhage: characterization and the trauma nurse role / Riesgo de choque en pacientes con hemorragia severo: caracterización y actuación de enfermeras de trauma

Objetivo: Apresentar as características clínicas dos pacientes vítimas de trauma que necessitaram de transfusão emergencial para uma abordagem do Diagnóstico de Enfermagem "Risco de Choque"; descrever a atuação da equipe de Enfermeiros do Trauma nesse contexto. Métodos: Trata-se de um estudo descritivo, retrospectivo, de abordagem quantitativa. Os dados retratam o período de outubro de 2018 a dezembro de 2019, perfazendo um total de 447 pacientes com choque hemorrágico por trauma inseridos no Protocolo de Transfusão Maciça de um hospital público. Resultados: O "Risco de Choque" foi o diagnóstico de enfermagem prioritário nos pacientes com hemorragia grave por trauma. Houve predominância do sexo masculino, vítimas de politraumatismo em sua maioria, com idade entre 18 e 29 anos. 197 pacientes apresentaram líquido livre que foi detectado através do exame de ultrassom de emergência nos pacientes com trauma torácico ou abdominal. O Serviço de Atendimento Móvel de Urgência foi o meio utilizado por 378 pacientes para atendimento pré-hospitalar. Conclusão: A caracterização mostra a gravidade desses casos, com necessidade de transfusão maciça. O conhecimento desses fatores pela equipe multiprofissional de pacientes críticos com hemorragia grave associada ao trauma é fundamental, tornando-se necessária a abordagem do diagnóstico de enfermagem "risco de choque" pelo profissional Enfermeiro. (AU)

Objective: To present the clinical characteristics of the trauma patients who required emergency transfusion for an approach to the Nursing Diagnosis "Risk of Shock"; describe the role of the Trauma Nurses team in this context. Methods: This is a descriptive, retrospective study with a quantitative approach. The data portrays the period from October 2018 to December 2019, making up a total of 447 patients with traumatic hemorrhagic shock inserted in the Mass Transfusion Protocol of a public hospital. Results: There was a predominance of male subjects, victims polytrauma in that majority, aged between 18 and 29 years old. 197 patients had free fluid that was detected by emergency ultrasound examination in patients with chest or abdominal trauma. The Mobile Emergency Care Service was the resource used by 378 patients to the pre-hospital care. Conclusion: The characterization shows the severity of these cases, requiring massive transfusion. The knowledge of these factors by the multidisciplinary team of critically ill patients with severe hemorrhage associated with trauma is essential, making it necessary for the nursing professional to approach the nursing diagnosis "risk of shock". (AU)

Objetivo: Presentar las características clínicas de los pacientes traumatizados que requirieron transfusión urgente para el abordaje del Diagnóstico de Enfermería "Riesgo de Choque"; describir el papel del equipo de enfermeras de trauma en este contexto. Métodos: Se trata de un estudio descriptivo, retrospectivo con enfoque cuantitativo. Los datos retratan el período de octubre de 2018 a diciembre de 2019, lo que hace un total de 447 pacientes con choque hemorrágico traumático insertado en el Protocolo de Transfusión Masiva de un hospital público. Resultados: El "Riesgo de Choque" fue el diagnóstico de enfermería prioritario en los pacientes con hemorragia por trauma severo. Predominó el sexo masculino, mayoritariamente víctimas de politraumatismos, con edades comprendidas entre los 18 y 29 años. 197 pacientes tenían líquido libre que fue detectado por el examen de ultrasonido de emergencia con traumatismo torácico o abdominal. El Servicio Móvil de Atención de Emergencias fue el medio utilizado por 378 pacientes para la atención prehospitalaria. Conclusión: La caracterización muestra la gravedad de estos casos, requiriendo transfusión masiva. El conocimiento de estos factores por parte del equipo multidisciplinario de pacientes críticos con hemorragia severa asociada a trauma es fundamental, por lo que es necesario que el profesional de enfermería aborde el diagnóstico de enfermería "riesgo de shock". (AU)

Uso do ácido tranexâmico em usuários atendidos no serviço pré-hospitalar aéreo público do distrito federal / Use of tranexamic acid in users served in federal district public air pre-hospital service

Objective: to analyze the use of tranexamic acid (TXA) in the pre-hospital public air service in the Federal District. Method: descriptive study with cross-sectional design and quantitative approach. The study encompasses the documentary analysis of secondary data from the electronic medical records and attendance sheets of the Aeromedical Service (SA) of the Federal District (DF). Results: There was a reduction in the degree of shock and improvement in hemodynamic parameters from the Pre-Hospital (APH) to the in-hospital moment after using TXA. Conclusion: it was observed in the present study that the use of TXA associated with other hemorrhage control measures proved to be effective in improving the hemodynamic condition of patients. Volemic resuscitation of patients in the pre-hospital period and other measures to contain bleeding proved to be effective for resuscitation in severe degrees of shock. The administration of TXA in the APH occurred in the 1st hour of care with a dosage of 1g, with improvement.(AU)

Objetivo:analisar o uso do ácido tranexâmico (TXA) no serviço pré-hospitalar aéreo público do Distrito Federal. Método: estudo descritivo com delineamento transversal e abordagem. O estudo engloba a análise documental de dados secundários provenientes dos prontuários eletrônicos e fichas de atendimento do Serviço Aeromédico (SA) do Distrito Federal (DF). Resultados: O correu redução no grau de choque e melhora dos parâmetros hemodinâmicos do momento Pré-Hospitalar (APH) para o intra-hospitalar após uso do TXA. Conclusão: observou-se no presente estudo que o uso do TXA associado a outras medidas de controle de hemorragia mostrou-se eficaz para melhora da condição hemodinâmica dos pacientes. A reposição volêmica dos pacientes ainda no período pré-hospitalar e demais medidas para contenção de hemorragia mostraram-se efetiva para reanimação em graus severos de choque. A administração do TXA no APH ocorreu na 1ª hora do atendimento com dosagem de 1g com melhora nos dos parâmetros clínicos.(AU)

Objetivo: analizar el uso del ácido tranexámico (TXA) en el servicio público aéreo prehospitalario en el Distrito Federal. Método: estudio descriptivo con diseño transversal y enfoque cuantitativo. El estudio abarca el análisis documental de datos secundarios de las historias clínicas electrónicas y planillas de asistencia del Servicio Aeromédico (SA) del Distrito Federal (DF). Resultados: Hubo una reducción en el grado de shock y mejoría en los parámetros hemodinámicos desde el momento Pre-Hospitalario (HAP) hasta el intrahospitalario después de utilizar ATX. Conclusión: se observó en el presente estudio que el uso de ATX asociado a otras medidas de control de la hemorragia demostró ser eficaz en la mejoría del estado hemodinámico de los pacientes. La reanimación volémica de pacientes en el período prehospitalario y otras medidas para contener el sangrado demostraron ser efectivas para la reanimación en grados severos de shock. La administración de TXA en el HAP se produjo en la 1ª hora de atención con dosis de 1g, con mejoría de los parámetros clínicos.(AU)

Uso do ácido tranexâmico em usuários atendidos no serviço pré-hospitalar aéreo público do distrito federal / Uso de ácido tranexámico en usuarios atentidos en servicio prehospitalario del aire píblico del distrito federal / Use of tranexamic acid in users served in federal district public air pre-hospital service

Objetivo:analisar o uso do ácido tranexâmico (TXA) no serviço pré-hospitalar aéreo público do Distrito Federal. Método: estudo descritivo com delineamento transversal e abordagem. O estudo engloba a análise documental de dados secundários provenientes dos prontuários eletrônicos e fichas de atendimento do Serviço Aeromédico (SA) do Distrito Federal (DF). Resultados: O correu redução no grau de choque e melhora dos parâmetros hemodinâmicos do momento Pré-Hospitalar (APH) para o intra-hospitalar após uso do TXA. Conclusão: observou-se no presente estudo que o uso do TXA associado a outras medidas de controle de hemorragia mostrou-se eficaz para melhora da condição hemodinâmica dos pacientes. A reposição volêmica dos pacientes ainda no período pré-hospitalar e demais medidas para contenção de hemorragia mostraram-se efetiva para reanimação em graus severos de choque. A administração do TXA no APH ocorreu na 1ª hora do atendimento com dosagem de 1g com melhora nos dos parâmetros clínicos.(AU)

Objective: to analyze the use of tranexamic acid (TXA) in the pre-hospital public air service in the Federal District. Method: descriptive study with cross-sectional design and quantitative approach. The study encompasses the documentary analysis of secondary data from the electronic medical records and attendance sheets of the Aeromedical Service (SA) of the Federal District (DF). Results: There was a reduction in the degree of shock and improvement in hemodynamic parameters from the Pre-Hospital (APH) to the in-hospital moment after using TXA. Conclusion: it was observed in the present study that the use of TXA associated with other hemorrhage control measures proved to be effective in improving the hemodynamic condition of patients. Volemic resuscitation of patients in the pre-hospital period and other measures to contain bleeding proved to be effective for resuscitation in severe degrees of shock. The administration of TXA in the APH occurred in the 1st hour of care with a dosage of 1g, with improvement in the clinical parameters.(AU)

Objetivo: analizar el uso del ácido tranexámico (TXA) en el servicio público aéreo prehospitalario en el Distrito Federal. Método: estudio descriptivo con diseño transversal y enfoque cuantitativo. El estudio abarca el análisis documental de datos secundarios de las historias clínicas electrónicas y planillas de asistencia del Servicio Aeromédico (SA) del Distrito Federal (DF). Resultados: Hubo una reducción en el grado de shock y mejoría en los parámetros hemodinámicos desde el momento Pre-Hospitalario (HAP) hasta el intrahospitalario después de utilizar ATX. Conclusión: se observó en el presente estudio que el uso de ATX asociado a otras medidas de control de la hemorragia demostró ser eficaz en la mejoría del estado hemodinámico de los pacientes. La reanimación volémica de pacientes en el período prehospitalario y otras medidas para contener el sangrado demostraron ser efectivas para la reanimación en grados severos de shock. La administración de TXA en el HAP se produjo en la 1a hora de atención con dosis de 1g, con mejoría de los parámetros clínicos(AU)

Effect of SAM junctional tourniquet on respiration when applied in the axilla: A swine model / 中华创伤杂志(英文版)

PURPOSE@#SAM junctional tourniquet (SJT) has been applied to control junctional hemorrhage. However, there is limited information about its safety and efficacy when applied in the axilla. This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model.@*METHODS@#Eighteen male Yorkshire swines, aged 6-month-old and weighing 55 - 72 kg, were randomized into 3 groups, with 6 in each. An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery. Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume. Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied. In Group I, the swine spontaneously breathed, while SJT was applied for 2 h with a pressure of 210 mmHg. In Group II, the swine were mechanically ventilated, and SJT was applied for the same duration and pressure as Group I. In Group III, the swine spontaneously breathed, but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression. The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands. After then, a temporary vascular shunt was performed in the 3 groups to achieve resuscitation. Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution. Tb and T0 represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock, respectively. T30, T60, T90 and T120, denote 30, 60, 90, and 120 min after T0 (hemostasis period), while T150, and T180 denote 150 and 180 min after T0 (resuscitation period). The mean arterial pressure and heart rate were monitored through the right carotid artery catheter. Blood samples were collected at each time point for the analysis of blood gas, complete cell count, serum chemistry, standard coagulation tests, etc., and thromboelastography was conducted subsequently. Movement of the left hemidiaphragm was measured by ultrasonography at Tb and T0 to assess respiration. Data were presented as mean ± standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method. All statistical analyses were processed using GraphPad Prism software.@*RESULTS@#Compared to Tb, a statistically significant increase in the left hemidiaphragm movement at T0 was observed in Groups I and II (both p < 0.001). In Group III, the left hemidiaphragm movement remained unchanged (p = 0.660). Compared to Group I, mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement (p < 0.001). Blood pressure and heart rate rapidly increased at T0 in all three groups. Respiratory arrest suddenly occurred in Group I after T120, which required immediate manual respiratory assistance. PaO2 in Group I decreased significantly at T120, accompanied by an increase in PaCO2 (both p < 0.001 vs. Groups II and III). Other biochemical metabolic changes were similar among groups. However, in all 3 groups, lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH. The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis. The coagulation function test did not show statistically significant differences among three groups at any time point. However, D-dimer levels showed a more than 16-fold increase from T120 to T180 in all groups.@*CONCLUSION@#In the swine model, SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation. Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency. Therefore, mechanical ventilation could be necessary before SJT removal.

Choc hémorragique péri-opératoire au Centre Hospitalier Universitaire Androva, Mahajanga, Madagascar

Introduction : Le choc hypovolémique est une défaillance circulatoire aiguë et critique, mettant rapidement en jeu le pronostic vital. L'objectif de l'étude était de déterminer les aspects épidémio-cliniques et la prise en charge du choc hémorragique periopéraoire au centre hospitalier de Mahajanga. Méthodes : Il s'agit d'une étude rétrospective, descriptive, observationnelle et monocentrique réalisée dans le service de Réanimation Chirurgicale du CHU PZaGa de Mahajanga, sur une période de 52 mois. Les données socio-démographiques, les paramètres cliniques périopératoires, la prise en charge médico-chirurgicale, l'évolution et les retentissements organiques de l'état de choc hémorragique ont été les paramètres étudiés. Résultats : Nous avons collecté 6896 dossiers des patients, dont 70 cas de choc hémorragique ont été recensés (1,02%) pour tout type de chirurgie ; 62 dossiers ont été retenus dans l'étude. La majorité des cas était du genre féminin (87,10%). Les pathologies gynéco-obstétricales étaient la principale source de l'état de choc de (77,4%), dont 59,4% d'hémorragie du post-partum. L'insuffisance rénale aiguë était la principale atteinte viscérale (61%, n=38) suivie de 10% (n=6) des cas des troubles neurologiques. Tous les patients ont bénéficié d'une oxygénothérapie, et d'un remplissage vasculaire par des cristalloïdes et 3,2% ont eu des colloïdes. Les substances vasoactives utilisées étaient l'éphédrine 41,9%, suivie de l'adrénaline 27,4% et de la noradrénaline 17,7%. Vingt-sept virgule quarante pourcent de nos patients étaient décédés, et la cause la plus incriminée était la coagulopathie par défibrination. Conclusion: Les hémorragies obstétricales constituent la première cause de choc hémorragique ; le taux de mortalité reste encore élevé.

Predictores de mortalidad precoz en pacientes con trauma complejo hemorrágico / Early mortality predictors in patients with complex hemorrhagic trauma

RESUMEN Fundamento: El trauma complejo es un problema de salud a nivel mundial y cuando es de tipo hemorrágico la mortalidad es superior a los otros tipos de traumas complejos. Objetivo: Determinar las variables predictoras de mortalidad precoz en pacientes hospitalizados con trauma complejo hemorrágico en una institución hospitalaria del segundo nivel de atención en Cuba. Metodología: Se realizó un estudio transversal en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, durante 6 años. Se incluyeron 207 pacientes. Las variables se agruparon en sociodemográficas, enfermedades crónicas asociadas, mecanismo lesional, tipo de trauma, localización topográfica, tiempo entre admisión hospitalaria, diagnóstico y tratamiento, complicaciones precoces, tratamiento médico y quirúrgico, y mortalidad precoz. Se elaboró un árbol de decisión mediante el método Chaid exhaustivo, la variable dependiente fue la mortalidad por trauma complejo hemorrágico. Resultados: Predominaron los pacientes del sexo masculino (85 %), con 60 años y menos (83 %), con trauma contuso (57.5 %) y politraumatizados (42.5 %). Predominaron también los que presentaron acidosis metabólica (66.7 %), coagulopatía aguda (44.4 %), hipotermia (41.5 %). El 30 % de los pacientes falleció precozmente. El árbol de decisión tuvo una sensibilidad de 82.3 %, una especificidad de 97.2 % y un porcentaje global de pronóstico correcto del 92.8 %. Se identificaron 4 variables predictores de mortalidad: hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante. Conclusiones: La probabilidad más alta de fallecer precozmente durante un trauma complejo hemorrágico se da entre pacientes con hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante.

ABSTRACT Background: Complex trauma is a worldwide health problem and when hemorrhagic, mortality is higher than other types of complex trauma. Objective: To determine predictive variables of early mortality in hospitalized patients with complex hemorrhagic trauma in a second care level hospital in Cuba. Methodology: A cross-sectional study was conducted at Camilo Cienfuegos Provincial General Hospital in Sancti Spíritus, for 6 years. 207 patients were included. The variables were grouped into sociodemographic, associated chronic diseases, injury mechanism, type of trauma, topographic location, time between hospital admission, diagnosis and treatment, early complications, medical and surgical treatment, and early mortality. A decision tree was developed using the exhaustive Chaid method, the dependent variable was mortality due to complex hemorrhagic trauma. Results: Male patients (85 %), 60 years and younger (83 %), with blunt trauma (57.5 %) and polytraumatized patients (42.5 %) predominated. Those who presented metabolic acidosis (66.7 %), acute coagulopathy (44.4 %), and hypothermia (41.5 %) also predominated. 30 % of patients died early. The decision tree had a sensitivity of 82.3 %, a specificity of 97.2 % and an overall percentage of correct forecast of 92.8 %. Four variables that predicted mortality were identified: hypothermia, metabolic acidosis, acute coagulopathy, and penetrating trauma. Conclusions: The highest probability of early dying during a complex hemorrhagic trauma occurs among patients with hypothermia, metabolic acidosis, acute coagulopathy and penetrating trauma.

Hemotórax mortal secundario a lesiones de arterias intercostales posteriores: Reporte de caso / Fatal hemothorax secondary to posterior intercostal artery injuries: case report

Resumen La lesión de la arteria intercostal es un diagnóstico diferencial poco sospechado. Puede complicarse con una inestabilidad hemodinámica por un hemotórax o un hematoma intratorácico, lo que contribuye a su morbilidad y mortalidad. Se reporta el caso de un paciente de 61 años sin antecedentes patológicos conocidos que acudió al servicio de urgencias por dolor asociado a dificultad respiratoria posterior a un trauma torácico cerrado por caída de 8 días de evolución. Los estudios de imagen revelaron un hemotórax derecho, que ameritó la colocación de un tubo pleural. Se realizó una laparotomía exploratoria sin evidencia de hemorragias ni colecciones intrabdominales, y que posteriormente falleció. En el examen de necropsia se evidenciaron fracturas del noveno y décimo arco costal posterior derecho, asociado a un hematoma. El hemotórax secundario a la lesión de la arteria intercostal es poco frecuente, pero es una emergencia que requiere un diagnóstico asertivo y una intervención oportuna.

Abstract Intercostal artery injury is a poorly suspected differential diagnosis. It can be complicated by hemodynamic instability due to hemothorax or intrathoracic hematoma, which contributes to morbidity and mortality. We report the case of a 61-year-old patient with no pathological history known, who was presented to the emergency department for pain associated with respiratory distress following a blunt chest trauma due to a fall 8 days earlier. The Imaging studies revealed a right hemothorax, which required the placement of a pleural tube. An exploratory laparotomy was performed without evidence of bleeding or intra-abdominal collections, and he subsequently died. The necropsy examination revealed fractures of the ninth and tenth right posterior costal arch, associated with a posterior costal hematoma. The hemothorax that is secondary to an intercostal artery injury is rare, but it is an emergency that requires assertive diagnosis and timely intervention.

Protocolo de transfusão maciça: experiência no atendimento ao trauma / Massive transfusion protocol: experience in trauma care

Introdução: O trauma é uma das principais causas de morte no mundo e a hemorragia é responsável por 30% a 40% da mortalidade relacionada ao trauma. O estabelecimento de um protocolo de transfusão maciça (PTM) oferece oportunidade de medidas preventivas de controle de danos ao doente com choque hemorrágico grave. Objetivo: analisar dados epidemiológicos dos pacientes submetidos ao PTM em instituição de referência em trauma. Métodos: estudo quantitativo, envolvendo pacientes submetidos ao PTM no período de janeiro a dezembro de 2018. Dados sanguíneos, identificação do paciente, local do trauma, tipo de acidente, informações clínicas e desfecho foram obtidos por meio de revisão de prontuários e informações coletadas no núcleo transfusional do hospital. A análise estatística foi feita com o programa Statistical Package for the Social Sciences (SPSS) versão 23. Resultados: 306 pacientes foram avaliados, houve predominância do sexo masculino e idade de 18 a 30 anos. 55,9% dos pacientes eram procedentes de Fortaleza. O grupo sanguíneo predominante foi O, a maioria fator Rh positivo. O tórax foi o local mais comum de trauma. A maioria dos casos foi relacionada a trauma penetrante, sendo 53,6% por armas de fogo e 8,5% por armas brancas. As medianas do Escore ABC, de concentrado de hemácias e de plasma fresco usados foram de 2. 29,7% tiveram óbito em 24 horas e apenas o local do trauma - abdome - revelou-se como fator protetor para esse desfecho. Conclusão: observou-se a inexistência de associações significativas entre as variáveis do protocolo e o desfecho clínico de óbito.

Introduction: Trauma is one of the main causes of death in the world and hemorrhage is responsible for 30% to 40% of trauma-related mortality. The establishment of a massive transfusion protocol (TMP) offers the opportunity for preventive measures to control damage to the patient with severe hemorrhagic shock. Objective: to analyze epidemiological data of patients submitted to the MTP in a trauma reference institution. Methods: this is a study retrospective with a quantitative approach, involving patients undergoing MTM from January to December 2018. Blood data, patient identification, trauma site, accident type, clinical information and outcome were obtained through review of medical records and information collected at the hospital transfusion center. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) version 23. Results: 306 patients were evaluated, there was a predominance of males and ages from 18 to 30 years. 55.9% of the patients were from Fortaleza. The predominant blood group was O, being the majority with Rh positive factor. The thorax was the most common site of trauma. Most cases were related to penetrating trauma, being 53.6% for firearms and 8.5% for white weapons. Median ABC score, concentration of red blood cells and fresh plasma used were 2. 29.7% were dead in 24 hours and only the trauma site - abdomen - was revealed as a protective factor for this outcome. Conclusion: it was observed, after completing the study, the inexistence of significant associations between the protocol variables and the clinical death outcome.

Sangre total leucorreducida y filtro ahorrador de plaquetas preserva su función hemostática por 21 días: ¿La resucitación hemostática podría ser una realidad en Colombia? / Leukoreduced whole blood and platelet-sparing filter preserves its hemostatic function for 21 days: Could hemostatic resuscitation become a reality in Colombia?

Introducción. La resucitación hemostática es una estrategia para compensar la pérdida sanguínea y disminuir el impacto de la coagulación inducida por trauma. Debido a que la disponibilidad de transfundir una razón equilibrada de hemocomponentes es difícil de lograr en el entorno clínico, la sangre total ha reaparecido como una estrategia fisiológica, con ventajas logísticas, que le permiten ser accesible para iniciar tempranamente la resucitación hemostática. El objetivo de este estudio fue evaluar las propiedades celulares, coagulantes y viscoelásticas de la sangre total almacenada por 21 días. Métodos. Las unidades de sangre total fueron obtenidas de 20 donantes voluntarios sanos. Se procesaron mediante un sistema de leucorreducción ahorrador de plaquetas y fueron almacenadas en refrigeración (1-6°C) sin agitación. Se analizaron los días 0, 6, 11 y 21. Las bolsas fueron analizadas para evaluar las líneas celulares, niveles de factores de coagulación y propiedades viscoelásticas mediante tromboelastografía. Resultados. El conteo eritrocitario y la hemoglobina se mantuvieron estables. El conteo de plaquetas tuvo una reducción del 50 % al sexto día, pero se mantuvo estable el resto del seguimiento. Los factores de coagulación II-V-VII-X, fibrinógeno y proteína C se mantuvieron dentro del rango normal. La tromboelastografía mostró una prolongación en el tiempo del inicio de la formación del coágulo, pero sin alterar la formación final de un coágulo estable. Conclusiones. La sangre total leucorreducida y con filtro ahorrador de plaquetas conserva sus propiedades hemostáticas por 21 días. Este es el primer paso en Colombia para la evaluación clínica de esta opción, que permita hacer una realidad universal la resucitación hemostática del paciente con trauma severo.

Background. Hemostatic resuscitation is a strategy to compensate blood loss and reduce the impact of trauma-induced coagulopathy. However, balanced resuscitation presents challenges in its application in the clinical setting. Whole blood has re-emerged as a physiologic strategy with logistical advantages that offer the opportunity for early initiation of hemostatic resuscitation. The study aims to evaluate the cellular, coagulation, and viscoelastic properties of whole blood preserved for 21 days. Methods. Whole blood units were donated by 20 healthy volunteers. These units were processed using a platelet-sparing leukoreduction filtration system. Units were stored under refrigeration (1-6°C) without agitation and were sampled on days 0, 6, 11, 16, and 21. The units were tested to assess its cellular properties and coagulation factors levels. In addition, viscoelastic features were tested using tromboelastography.Results. Red blood cells count and hemoglobin levels remained stables. Platelet count had a 50% reduction on day 6, and then remained stable for 21 days. Factors II-V-VII-X, fibrinogen, and protein C remained within normal range. Tromboelastrography test showed that the reaction time of clot formation is prolonged, but the final clot formation is not altered. Conclusion. Whole blood retains its hemostatic properties for 21 days. This is the first step to evaluate the use of whole blood in the resuscitation protocols for Colombia allowing hemostatic resuscitation become a universal reality.

Mortalidade materna: perfil clínico e epidemiológico de uma maternidade pública do Amazonas / Maternal mortality: clinical and epidemiological profile of a public maternity hospital in Amazonas

Objetivo: Avaliar o perfil clínico e epidemiológico das mortes maternas ocorridas em uma maternidade pública de Manaus no período de janeiro de 2016 a dezembro de 2019. Métodos: Trata-se de um estudo do tipo descritivo e retrospectivo realizado a partir de dados contidos em prontuários médicos do Serviço de Arquivo Médico e Estatística (SAME) da Maternidade Ana Braga na cidade de Manaus-AM. A amostra foi constituída por pacientes admitidas na Maternidade Ana Braga e que evoluíram com óbito no ciclo gravídico puerperal, que consiste em grávidas, em trabalho de parto, que deram à luz ou que abortaram dentro de um período de até 42 dias. Resultados: Foram avaliados 29 prontuários de pacientes que foram a óbito no ciclo gravídico puerperal. Essas mulheres tinham entre 14 e 42 anos de idade. Quanto à escolaridade, 56,3% delas tinham ensino médio. Quanto à etnia, as mulheres negras e pardas representaram a maioria, as solteiras, o maior percentual. No óbito materno, observou-se que 10 mulheres realizaram menos de seis consultas pré-natal, a principal via de parto foi a cesariana e o choque séptico foi o mais prevalente como causa de morte. Conclusão: Esse resultado sugere a necessidade de avaliação do acesso oportuno das gestantes à assistência pré-natal, ao parto e ao puerpério adequada, além de melhorias na promoção de políticas públicas que busquem a redução da mortalidade materna.(AU)

Objective: To evaluate the clinical and epidemiological profile of maternal deaths that occurred in a public maternity hospital in Manaus from January 2016 to December 2019. Methods: This is a descriptive and retrospective study carried out based on data contained in medical records doctors from the Medical Archive and Statistics Service (SAME) of the Ana Braga Maternity Hospital in the city of Manaus-AM. The sample consisted of patients admitted to the Ana Braga Maternity Hospital and who died in the pregnancy-puerperal cycle, which consists of pregnant women, in labor, who gave birth or who aborted within a period of up to 42 days. Results: Were evaluated 29 records of patients who died in the pregnancy-puerperal cycle, these women were between 14 and 42 years old, and 56.3% had high school education. As for ethnicity, black and brown women represented the majority, single women the highest percentage. In maternal death, it was observed that 10 women had less than six prenatal consultations, the main mode of delivery was cesarean section and septic shock was the most prevalent cause of death. Conclusion: This result suggests the need to assess the timely access of pregnant women to adequate prenatal care, childbirth and postpartum care, in addition to improvements in the promotion of public policies that seek to reduce maternal mortality.(AU)

Gravidez heterotópica espontânea: implicações de um diagnóstico tardio / Spontaneous heterotopic pregnancy: implications of a late diagnosis

A gestação heterotópica é uma entidade rara, principalmente se resultante de concepção natural. O diagnóstico é ultrassonográfico, porém a gestação intrauterina concomitante contribui para a dificuldade propedêutica. Neste relato de caso, a detecção foi tardia, a ultrassonografia não identificou a gestação heterotópica e apenas durante a avaliação intraoperatória, por meio de uma cirurgia de emergência devido a choque hemorrágico, houve o reconhecimento. A suspeita de uma gestação heterotópica deve ser sempre aventada quando sinais clínicos típicos (sangramento, dor abdominal) estão presentes, mesmo na ausência de fatores de risco ou imagens anômalas na ecografia. Assim, uma intervenção precoce menos invasiva pode ser realizada, reduzindo a morbimortalidade materna e do feto intrauterino. Este relato de caso destaca uma situação incomum dentro dessa patologia rara: diagnóstico tardio, apenas no segundo trimestre de gestação, sem evidência prévia ultrassonográfica, certificada apenas durante o intraoperatório. O manejo cirúrgico preciso permitiu a manutenção da gravidez intrauterina.(AU)

Heterotopic pregnancy is a rare entity, especially if it is resulted from natural conception. The diagnosis is ultrasonographic, but the concomitant intrauterine pregnancy contributes to the propaedeutic difficulty. In this case report, the detection was late, the ultrasonography did not identify heterotopic pregnancy and, only during intraoperative evaluation through emergency surgery, exploratory laparotomy, there was recognition. The suspicion of a heterotopic pregnancy should always be raised when typical clinical signs (bleeding, abdominal pain) are present, even in absentia of risk factors or anomalous images on ultrasound. Thus, a less invasive early intervention can be performed, reducing maternal and intrauterine fetus morbimortality. This case report highlights an unusual situation within this rare pathology: late diagnosis, only in the second trimester of pregnancy, without previous ultrasound evidence, certified only during the intraoperative period. Precise surgical management allowed the maintenance of intrauterine pregnancy.(AU)

Revisión sistemática y metaanálisis sobre eficacia de las drogas vasoactivas en el shock hemorrágico en animales / Systematic review and meta-analysis on the efficacy of vasoactive drugs in hemorrhagic shock in animals

The objective of this review was to evalúate the efficacy of the use of vasoactive drugs in the initial resuscitation of hemorrhagic shock in animals. The search was developed using the databases: Cochrane Central Register of Controlled Trials, PUBMED, MEDLINE, EMBASE, the database was also included: Clinical Trial.gov; no date restriction of publication or language. We included randomized controlled clinical trials in animals that compared the use of vasoactive drugs with any other resuscitation strategy for hemorrhagic shock. The analysis was developed using of review manager version 5.4, with the random effects model and the Mantel Haenszel method for dichotomous data. Statistical heterogeneity was evaluated with the statisgraph I. The strength of evidence was assessed for each outcome according to the statements of the working group for the classification of the quality of the evidence (GRADE). 18 trials (n = 533 participant) were included in this meta-analysis. Compared with control, vasopressors were associated with lower relative risk of mortality during initial resuscitation from hae- morrhagic shock, with an overall risk estimate of 0.53 (0.39, 0.71) 95% confidence interval. There is evidence of the efficacy of vasopressors in resuscitation hemorrhagic shock in animals, this is of moderate to low quality; Therefore, it is necessary to develop and implement randomized clinical trials that allow an evaluation of the efficacy and safety of these drugs in humans for their use systematically in patients with hemorrhagic shock.

El objetivo de esta revisión fue evaluar la eficacia del uso de drogas vasoactivas en la resucitación inicial del hemorrágico en animales. La búsqueda fue desarrollada usando las bases de datos: Cochrane Central Register of Controlled Trials, PUBMED, MEDLINE, EMBASE, fue incluida además la base de datos: Clinical Trial.gov; sin restricción por fecha de publicación o idioma. Se incluyeron ensayos clínicos controlados y aleatorizados en animales que compararon el uso de drogas vasoactivas con cualquier otra estrategia de resucitación del hemorrágico. El análisis fue desarrollado con el uso de review manager versión 5.4, con el modelo de efectos aleatorios y el método de Mantel Haenszel para datos dicotómicos. Heterogeneidad estadística fue evaluada con el estadígrafo I. La fuerza de la evidencia fue evaluada para cada resultado acorde a las declaraciones del grupo de trabajo para la clasificación de la calidad de la evidencia (GRADE). 18 ensayos (n = 533 participante) fueron incluidos en este metaanálisis. Comparado con el control, los vasopresores fueron asociados con menor riesgo relativo de mortalidad durante la reanimación inicial del hemorrágico, con una estimación global del riesgo de 0,53 (0,39, 0,71) intervalo de confianza de 95%. Existe evidencia de la eficacia de los vasopresores en la reanimación inicial del hemorrágico en animales, esta es de calidad moderada a baja; por lo que, es necesario desarrollar e implementar ensayos clínicos aleatorizados que permitan una evaluación de la eficacia y seguridad de estas drogas en humanos para su uso de manera sistemática en pacientes con hemorrágico.

"Packing" torácico en urgencias torácicas / Thoracic packing in thoracic emergencies

RESUMEN El control de daños es un procedimiento en tres etapas en pacientes con riesgo vital. Primera etapa: laparotomía abreviada para el control de sangrados y contaminación. Segunda etapa: en cuidados críticos para corregir alteraciones fisiológicas y tercera etapa: con resolución definitiva de las lesiones. Se describió el empaquetamiento (packing) torácico como adaptación del empaquetamiento abdominal como procedimiento contemporizador y hemostático. El objetivo fue presentar nuestra experiencia con la cirugía de empaquetamiento torácico y mostrar su utilidad en la cirugía de control de daños en tórax. Las lesiones traumáticas de tórax pueden ir desde lesiones de leve entidad hasta lesiones graves que amenacen la vida del paciente. La decisión de empaquetar el tórax se adopta al tomar contacto con un paciente "in extremis". En conclusión, el empaquetamiento torácico se muestra eficaz para el control del sangrado en pacientes que no admiten medidas definitivas para él.

ABSTRACT Damage control is defined as an approach with 3 stages in patients with life-threatening injuries. Stage I: abbreviated laparotomy for hemorrhage and contamination control. Stage II: intensive care management to correct physiologic abnormalities; and stage III: definitive repair of injuries. Thoracic packing, an adaptation of abdominal packing, was described as a temporary procedure for hemostatic control. The aim of this study is to report our experience with thoracic packing and show its usefulness in thoracic damage control surgery. Traumatic chest injuries vary from minor trauma to life-threatening injuries. The decision to perform thoracic packing is made during the contact with a critically ill patient. In conclusion, packing is effective for bleeding control in critically ill patients who are not suitable for definitive treatment.

Hipotensión permisiva en trauma / Permissive hypotension in trauma

Resumen Introducción: El shock hemorrágico es una de las causas más comunes de muerte en pacientes con trauma debido a que pone en marcha un círculo vicioso de mecanismos que incluyen hipotermia, acidosis y coagulopatía. Para mitigar estos efectos, se han propuesto estrategias de control de daños, incluido el aporte controlado de líquidos con hipotensión permisiva contemplando metas en la presión arterial sistólica para mantener una adecuada perfusión de los tejidos. Objetivo: Conocer información actualizada acerca del manejo de la hipotensión permisiva en pacientes con trauma. Metodología: Se buscó información en las bases de datos Web-of-Science y Scopus de los últimos cinco años. El resultado arrojó un total de 118 artículos de los cuales se tomaron 30, según los criterios de inclusión y exclusión. Resultados: Todos los artículos consideran el uso de la hipotensión permisiva como una buena opción para el manejo de los pacientes con trauma e hipotensión, sin embargo, difieren en qué momento es adecuado utilizarlo y en qué condiciones se debe realizar. Conclusiones: Si bien la hipotensión permisiva se ha convertido en uno de los pilares fundamentales en el manejo prehospitalario del paciente con trauma, se requieren estudios investigativos en humanos para soportar cuándo y cómo debe utilizarse.

Abstract Introduction: Hemorrhagic shock is one of the most common causes of death in trauma patients, because it sets in motion a vicious cycle of mechanisms, including hypothermia, acidosis, and coagulopathy. To mitigate these effects, damage control strategies have been proposed, including the controlled intake of fluids with permissive hypotension, contemplating goals in systolic blood pressure, and thus, maintaining adequate tissue perfusion. Objective: The present research aimed to review the literature in search of updated information about the management of permissive hypotension in patients with trauma. Methodology: Information was searched in the Web-of-Science and Scopus databases in the last five years. The result yielded a total of 118 articles, of which 30 were taken according to the inclusion and exclusion criteria. Results: All the articles consider the use of permissive hypotension as a good option for the management of patients with trauma and hypotension, however, they differ when it is appropriate to use it and under what conditions it should be performed. Conclusions: Although permissive hypotension has become one of the fundamental pillars in the prehospital management of the patient with trauma, research studies in humans are required to support when and how it should be used.

Transfusão maciça em pacientes vítimas de trauma: uma coorte não concorrente / Massive transfusion in trauma patients: a non-concurrent cohort study

As causas externas estão entre os principais motivos de óbito no mundo e, dentre elas, o trauma se destaca por causar óbitos e incapacitações permanentes. A perda sanguínea maciça é a principal causa de morte evitável no trauma. Nos casos de hemorragias volumosas, a transfusão maciça de hemocomponentes pode ser necessária; entretanto aspectos sobre o procedimento são controversos na literatura. No Brasil, estudos sobre a transfusão maciça, ainda que escassos, ressaltam a elevada mortalidade e a necessidade de maior conhecimento de enfermeiros e equipes sobre a transfusão. Assim, este estudo objetivou analisar os aspectos epidemiológicos das transfusões maciças em pacientes vítimas de trauma, em um hospital referência neste tipo de atendimento em Belo Horizonte, Minas Gerais. Trata-se de um estudo de coorte não concorrente, em que foram analisados os registros de transfusão maciça de 110 pacientes vítimas de trauma, com idade superior a 18 anos, admitidos no período compreendido entre janeiro de 2019 e junho de 2020. Os dados foram obtidos por meio dos registros da agência transfusional do hospital e dos prontuários dos pacientes. Para a análise, foi empregada a estatística descritiva e inferencial, utilizando frequência simples e acumulada, medidas de tendência central e dispersão, análise de perdas de informações, bem como estatística Kappa, estimativa de incidência, estatística de Kaplan-Meier e teste log-rank. Em 78,18% dos casos houve a ocorrência de trauma contuso, provocado por colisões (40,00%) e atropelamentos (18,18%). O maior número de pacientes era do sexo masculino com mediana da idade de 36,5 anos. As Unidades de Suporte Avançado do Serviço de Atendimento Móvel de Urgência conduziram 45,37% das vítimas ao hospital. À admissão, a mediana dos dados dos pacientes indicava alteração do sensório (Escala de Coma de Glasgow 13), pressão arterial sistólica limítrofe (90 mmHg) e taquicardia (110 BPM). Ocorreram 45 óbitos, sendo 19,09% em até 6 horas após a admissão, 12,73% entre 6 e 24 horas e 9,09% após 24 horas da admissão. Infecção, sepse e insuficiência renal aguda foram complicações mais relatadas na internação, sendo os mais acometidos os pacientes vítimas de trauma contuso com traumatismo cranioencefálico. No momento da alta, os pacientes apresentavam alguma limitação, demanda de cuidado ou recomendação de acompanhamento ou nova cirurgia. Em 77,27% dos casos o protocolo de transfusão de emergências foi acionado, e a mediana do tempo entre a admissão e a primeira dispensação de hemocomponente foi de 19 minutos. Índice de choque (com ponto de corte de 0,9) e a escala Assessment of Blood Consumption (com ponto de corte de 2,0) tiveram uma concordância moderada (42,77%/ p<0,001), pelo Teste de Kappa, para predizer a necessidade de transfusão maciça. A incidência de óbitos foi de 40,90%, sendo a densidade para esse grupo de pacientes de 13,57 (10,13-18,17 IC95%) por mil pessoas-dia. A probabilidade de óbitos foi maior entre pacientes que não fizeram uso de plaquetas e ácido tranexâmico, não havendo diferença estatisticamente significativa em relação aos que não usaram tais substâncias. Identificou-se que a probabilidade de óbito dentre os pacientes que fizeram uso de volumes iguais ou superiores a 10 unidades de concentrado de hemácias foi superior àqueles pacientes que usaram volumes menores deste hemocomponente (p <0,05). A análise evidenciou que as vítimas de trauma submetidas à transfusão maciça são homens jovens, com quadro grave e com maior probabilidade de evoluir à óbito quando recebem volumes de concentrado de hemácias superiores a 3000ml. Os resultados fornecem informações que contribuem para a avaliação e acompanhamento destes pacientes, tais como sinais de gravidade e fatores a serem observados em sua evolução e que podem determinar maior probabilidade de óbito. Os dados reforçam, ainda, a importância do cuidado do ambiente pré-hospitalar após a alta.

External causes are among the main reasons off mortality in the world, with trauma accounting for a great number of deaths and permanent disability. Massive blood loss is the leading cause of preventable death in trauma. In cases of massive hemorrhages, massive transfusion of blood components may be necessary, however aspects about this procedure are controversial in the literature. Thus, this study aimed to analyze the epidemiological aspects of massive transfusions in trauma patients admitted in a hospital that is recognized for trauma care in Belo Horizonte, Minas Gerais. This is a non-concurrent cohort study, in which records of massive transfusions of 110 trauma patients aged over 18 years, admitted between january 2019 and june 2020, were analyzed. Data were obtained through the records of the hospital's transfusion agency and the patients' charts. For data analysis, descriptive and inferencial statistics were used, using simple and accumulated frequency, measures of central tendency and dispersion, analysis of information loss, as well as Kappa statistics, incidence estimation and Kaplan-Meier statistics and log-test. rank. In 78.18% of the cases there was the occurrence of blunt trauma, caused by most of the time by collisions (40.00%) and being run over (18.18%). The largest number of patients was male with a median age of 36.5 years. The Advanced Support Units of the Serviço de Atendimento Móvel de Urgência, was responsible for 45.37% of transport of the victims to the hospital. At admission, the median of patient data indicated sensory alteration (Glasgow Coma Scale 13), hypotension (90 mmHg) and tachycardia (110 BPM). There were 45 deaths, 19.09% within 6 hours of admission, 12.73% between 6 and 24 hours after admission, and 9.09% after 24 hours of admission. Infection, sepsis, and acute renal failure were the most reported complications during hospitalization, with patients suffering from blunt trauma with traumatic brain injury being the most affected. At the time of discharge, the patients had some limitation, demand for care or recommendation for follow-up or new surgery. In 77.27% of the cases, the emergency transfusion protocol was activated, and the median time between admission and the first dispensing of blood components was 19 minutes. Shock Index (with a cutoff point of 0.9) and the Assessment of Blood Consumption score (with a cutoff point of 2.0) had moderate agreement (42.77%/p<0.001), by the Kappa test, to predict the need for massive transfusion. The incidence density of deaths for this group of patients was 13.57 (10.13-18.17 95%CI) per thousand person-day. The probability of death was higher among patients who did not use platelets and tranexamic acid, with no statistically significant difference compared to those who did not use these substances. It was identified that the probability of death among patients who used volumes equal to or greater than 10 units of packed red blood cells was higher than for those patients who used smaller volumes of this blood component (p < 0.05). The analysis showed that trauma victims submitted to massive transfusiosns are young men, with severe condition and who are more likely to progress to deth when they receive volume of red blood cells greater than 3000ml. The results provide information that contributes to the assessment and follow-up of these patients, as signs of severity and factors to be observed in its evolution, as well as whic can determine a greater probability of death. They reinforce the importance of caring in pre-hospital environment, during hospital care and after discharge.

Shen-fu injection alleviates acute renal injury by reducing cytokine levels and modulating apoptosis in a porcine hemorrhagic shock model

ABSTRACT Purpose Shen-fu injection (SFI) was used to intervene in the resuscitation of porcine hemorrhagic shock (HS) model to study its protective effects on acute kidney injury. Methods After 60 min of HS, 28 animals were randomly assigned into four groups. The groups were as follows: hemorrhagic shock group (HS); HS resuscitation with shed-blood group (HSR); HS resuscitation with shed-blood and SFI (1 mL·kg-1) group (HSR-SFI); and the sham operation group (Sham). The bloods were analyzed for serum creatinine (sCr), cystatin C (CysC) and neutrophil gelatinase-associated lipocalin (NGAL). BAX, Bcl-2, and caspase-3 protein expressions by Western blot analysis and immunohistochemical staining. The renal tissues were removed and pathologic changes were observed. Results Mean aortic pressure (MAP) in HSR-SFI groups were higher than that in HSR groups after shock. At the 6th hour after shock, the urine volume per hour in the HSR-SFI groups was more than that in the HSR groups. The sCr, NGAL, CysC and cytokine levels of HSR-SFI groups were lower. The Bcl-2 expression was increased in the HSR-SFI groups. The BAX and caspase-3 expressions were reduced. The histopathologic score in the HSR-SFI was lower. Conclusions SFI may reduce the risk of acute kidney injury (AKI) following hemorrhagic shock by attenuating systemic inflammatory responses, and regulating the expression of apoptosis-related proteins.

Fatores solúveis de células-tronco mesenquimais (FS-CTM) como uma ferramenta potencial para reduzir a inflamação nos pulmões de doadores após choque hipovolêmico / Soluble factors of mesenchimal stem cells (FS-MSC) as a potential tool to reduce inflammation in donor's lungs after hypovolemic shock

RESUMO Objetivo A escassez de pulmões viáveis ainda é um grande obstáculo para o transplante. As vítimas de trauma, que constituem potenciais doadores de pulmão, comumente apresentam choque hipovolêmico que acarreta inflamação e deterioração pulmonar e rejeição após o transplante. Buscando melhorar o enxerto pulmonar, testaram-se novas abordagens ao tratamento do doador. Este estudo foca o tratamento com células-tronco mesenquimais (CTMs) ou fatores solúveis produzidos pelas CTMs (FS-CTMs), usando um modelo com ratos para doadores de pulmão após choque hemorrágico. Métodos Quarenta e oito ratos foram divididos em quatro grupos: Controle (n=12), animais sem indução de choque hipovolêmico; Choque (n=12), animais submetidos a choque hipovolêmico (pressão arterial média de 40 mmHg); CTM (n=12), animais submetidos a choque hipovolêmico e tratados com CTMs; e FS (n=12), animais submetidos a choque hipovolêmico e tratados com FS-CTMs. Os animais foram submetidos a um procedimento de choque hipovolêmico (40 mmHg) com 50 minutos de duração. Os animais tratados foram monitorados por 115 minutos. Realizamos análise histopatológica do tecido pulmonar e quantificação dos marcadores inflamatórios (TNF-α, IL-1β, IL-6, IL-10, iCAM e vCAM) no tecido pulmonar e leucócitos no sangue periférico (LSPs). Resultados O choque hemorrágico resultou em taxas mais altas de LSPs e infiltrado de neutrófilos nos pulmões. Os animais do grupo FS apresentaram menor densidade de neutrófilos em comparação com os animais dos grupos Choque e CTM (p<0,001). Não foram observadas diferenças entre os grupos quanto aos níveis de citocinas no tecido pulmonar. Conclusão Os pulmões dos ratos submetidos a choque hemorrágico e tratados com FS-CTM apresentaram inflamação reduzida indicada por uma diminuição do infiltrado de neutrófilos nos pulmões.

ABSTRACT Objective The shortage of viable lungs is still a major obstacle for transplantation. Trauma victims who represent potential lung donors commonly present hypovolemic shock leading to pulmonary inflammation and deterioration and rejection after transplantation. Seeking to improve lung graft, new approaches to donor treatment have been tested. This study focuses on treatment with mesenchymal stem cells (MSCs) or soluble factors produced by MSCs (FS-MSC) using a rat model for lung donors after hemorrhagic shock. Methods Forty-eight rats were divided into four groups: Sham (n=12), animals without induction of hypovolemic shock; Shock (n=12), animals submitted to hypovolemic shock (mean arterial pressure 40 mmHg); MSC (n=12), animals submitted to hypovolemic shock and treated with MSCs, and FS (n=12), animals submitted to hypovolemic shock and treated with FS-MSC. The animals were subjected to a 50-minute hypovolemic shock (40 mmHg) procedure. The treated animals were monitored for 115 minutes. We performed histopathology of lung tissue and quantification of inflammatory markers (TNF-α, IL-1β, IL-6, IL-10, iCAM and vCAM) in lung tissue and peripheral blood leukocytes (PBLs). Results Hemorrhagic shock resulted in higher PBLs and neutrophil infiltrate in the lungs. FS animals had lower neutrophil density comparing with Shock and MSC animals (p<0.001). No differences in the cytokine levels in lung tissue were observed between the groups. Conclusions The lungs of rats submitted to hemorrhagic shock and treated with FS-MSC showed reduced inflammation indicated in a decrease in lung neutrophil infiltrate.

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.