Trombectomía mecánica en el ictus isquémico agudo, conociendo nuestros resultados / Mechanical thrombectomy in acute ischemic stroke, knowing our results

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Empleo de ECMO en UCI. Recomendaciones de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias / The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units

El empleo de sistemas de oxigenación con membrana extracorpórea se ha incrementado significativamente en los últimos años; ante esta realidad, la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC) ha decidido elaborar una serie de recomendaciones que sirvan de marco para el empleo de esta técnica en las Unidades de Cuidados intensivos. Los tres ámbitos de empleo de oxigenación con membrana extracorpórea más frecuentes en nuestro medio son: como soporte cardiocirculatorio, como soporte respiratorio y para el mantenimiento de los órganos abdominales en donantes. La SEMICYUC nombró una serie de expertos pertenecientes a los tres grupos de trabajo implicados (Cuidados Intensivos Cardiológicos y RCP, Insuficiencia Respiratoria Aguda y Grupo de trabajo de Trasplantes de SEMICYUC) que tras la revisión de la literatura existente hasta marzo de 2018, elaboraron una serie de recomendaciones. Estas recomendaciones fueron expuestas en la web de la SEMICYUC para recibir las sugerencias de los intensivistas y finalmente fueron aprobadas por el Comité Científico de la Sociedad. Las recomendaciones, en base al conocimiento actual, versan sobre qué pacientes pueden ser candidatos a la técnica, cuándo iniciarla y las condiciones de infraestructura necesarias de los centros hospitalarios o en su caso, las condiciones para el traslado a centros con experiencia. Aunque desde un punto de vista fisiopatólogico, existen claros argumentos para el empleo de oxigenación con membrana extracorpórea, la evidencia científica actual es débil por lo que es necesario estudios que definen con más precisión qué pacientes se benefician más de la técnica y en qué momento deben iniciarse

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start

The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units. / Empleo de ECMO en UCI. Recomendaciones de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias.

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.

Paciente traumatizado recuperado: buena suerte y... hasta la próxima / Recovered trauma patient: Good luck and... until next time

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Consideraciones sobre la baja adherencia a las guías de práctica clínica / Considerations on the low adherence to clinical practice guidelines

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Ingreso en cuidados intensivos por un traumatismo relacionado con el consumo de alcohol o drogas, un «momento propicio de enseñanza» para el inicio del cambio / Admission to Intensive Care for a trauma related to alcohol or drugs, a 'teachable moment' for the beginning of a change

Objetivos: Estimar cuántos de los pacientes ingresados en la UCI por un traumatismo serían candidatos a un programa de prevención secundaria por traumatismos relacionados con el consumo de alcohol y drogas mediante intervención motivacional breve y establecer qué factores impiden la realización de esta intervención. Métodos: Se incluyeron en el estudio todos los pacientes de entre 16 a 70 años (n = 242) ingresados en la UCI por lesiones traumáticas en 32 meses no consecutivos (de noviembre de 2011 a marzo de 2015), coincidiendo con la implantación de un programa de cribado e intervención motivacional breve para traumatizados relacionados con el consumo de sustancias. El programa incluye el cribado de exposición a sustancias en el ingreso. Se recogieron prospectivamente variables sociodemográficas y clínicas. Resultados: Del total de pacientes ingresados, a 38 (15,7%) no se les realizó la determinación a sustancias. Dieron resultado negativo 101 (49,5%) de los pacientes analizados. Las variables que en mayor proporción impedían la intervención entre los positivos fueron las secuelas neurológicas debidas al traumatismo (23 pacientes; 37,1%) y el trastorno psiquiátrico previo (18 pacientes; 29%). Ambas variables aparecieron asociadas al consumo: 9,9% negativos vs 22,3% positivos (p = 0,001) y 3% negativos vs 17,5% positivos (p = 0,016), respectivamente. El número de pacientes candidatos a intervención motivacional fue de 41, el 16,9% del total de ingresados. Conclusiones: Casi 2 de cada 10 pacientes fueron potenciales candidatos a la intervención. Los factores que en mayor proporción la impedían entre los positivos fueron los que aparecieron asociados al consumo. La mortalidad en la UCI se asoció con el incumplimiento del protocolo de cribado

Objectives: To estimate how many of the trauma patients admitted to ICU would be candidates for a secondary prevention programme for trauma related to alcohol or drug use by brief motivational intervention and to define what factors prevent that intervention being performed. Methods: All 16-70 year old trauma patients (n = 242) admitted to ICU in 32 non-consecutive months (November 2011 to March 2015) were included in the study, coinciding with the implementation of a screening and brief motivational intervention programme for trauma patients related to substance consumption. The programme includes screening for exposure to substances at admission. Sociodemographic and clinical variables were collected prospectively. Results: The screening for substances was not performed in 38 (15.7%) of all admitted patients. Of the patients screened, 101 (49.5%) were negative. The variables that in greater proportion impeded intervention between screening positive patients were neurological damage due to the trauma with 23 patients (37.1%) and prior psychiatric disorder with 18 (29%). Both variables were associated with substance consumption: negatives 9.9% vs positive 22.3% (P = .001) and negatives 3% vs positive 17.5% (P = .016) respectively. The number of candidates for motivational intervention was 41, 16.9% of all admitted patients. Conclusions: Almost 2 out of 10 patients were potential candidates. The factors that in a greater proportion precluded the intervention were the same as those associated with consumption. Mortality in ICU was associated with non-compliance with the screening protocol

Admission to Intensive Care for a trauma related to alcohol or drugs, a 'teachable moment' for the beginning of a change. / Ingreso en cuidados intensivos por un traumatismo relacionado con el consumo de alcohol o drogas, un «momento propicio de enseñanza¼ para el inicio del cambio.

OBJECTIVES: To estimate how many of the trauma patients admitted to ICU would be candidates for a secondary prevention programme for trauma related to alcohol or drug use by brief motivational intervention and to define what factors prevent that intervention being performed. METHODS: All 16-70year old trauma patients (n=242) admitted to ICU in 32 non-consecutive months (November 2011 to March 2015) were included in the study, coinciding with the implementation of a screening and brief motivational intervention programme for trauma patients related to substance consumption. The programme includes screening for exposure to substances at admission. Sociodemographic and clinical variables were collected prospectively. RESULTS: The screening for substances was not performed in 38 (15.7%) of all admitted patients. Of the patients screened, 101 (49.5%) were negative. The variables that in greater proportion impeded intervention between screening positive patients were neurological damage due to the trauma with 23 patients (37.1%) and prior psychiatric disorder with 18 (29%). Both variables were associated with substance consumption: negatives 9.9% vs positive 22.3% (P=.001) and negatives 3% vs positive 17.5% (P=.016) respectively. The number of candidates for motivational intervention was 41, 16.9% of all admitted patients. CONCLUSIONS: Almost 2 out of 10 patients were potential candidates. The factors that in a greater proportion precluded the intervention were the same as those associated with consumption. Mortality in ICU was associated with non-compliance with the screening protocol.

Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS) / Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)

La hemorragia masiva es una entidad frecuente que se asocia a una elevada morbimortalidad. Ante la necesidad de la implementación y estandarización de su manejo, se realizó una revisión sistemática de la literatura, con extracción de recomendaciones en base a las evidencias existentes. A partir de las mismas se redactó un documento de consenso multidisciplinar. Desde las definiciones de hemorragia masiva y transfusión masiva, se establecen recomendaciones de actuación estructuradas en las medidas generales de manejo de las mismas (valoración clínica de la hemorragia, manejo de la hipotermia, reposición de la volemia, reanimación hipotensiva y cirugía de contención de daños), monitorización de la volemia, administración de hemocomponentes (concentrado de hematíes, plasma fresco, plaquetas, y óptima relación de administración entre ellos), y de hemostáticos (complejo protrombínico, fibrinógeno, factor VIIa, antifibrinolíticos) (AU)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents) (AU)

[Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. / Documento multidisciplinar de consenso sobre elmanejo de la hemorragia masiva (document HEMOMAS)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS) / Multidisciplinary consensus document on the management of massive hemorrhage (HEMOMAS document)

La hemorragia masiva es una entidad frecuente que se asocia a una elevada morbimortalidad. Ante la necesidad de la implementación y estandarización de su manejo, se realizó una revisión sistemática de la literatura, con extracción de recomendaciones en base a las evidencias existentes. A partir de las mismas se redactó un documento de consenso multidisciplinar. Desde las definiciones de hemorragia masiva y transfusión masiva, se establecen recomendaciones de actuación estructuradas en las medidas generales de manejo de las mismas (valoración clínica de la hemorragia, manejo de la hipotermia, reposición de la volemia, reanimación hipotensiva y cirugía de contención de daños), monitorización de la volemia, administración de hemocomponentes (concentrado de hematíes, plasma fresco, plaquetas, y óptima relación de administración entre ellos), y de hemostáticos (complejo protrombínico, fibrinógeno, factor VIIa, antifibrinolíticos) (AU)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents) (AU)

Efficacy of an extravascular lung water-driven negative fluid balance protocol

OBJECTIVE: To analyze the efficacy of negative fluid balance in hypoxemic patients with an elevated extravascular lung water index (EVLWI). DESIGN: A retrospective observational study was made. SETTING: Intensive Care Unit of Virgen de las Nieves Hospital (Spain). PARTICIPANTS: Forty-four patients participated in the study. INTERVENTIONS: We analyzed our database of hypoxemic patients covering a period of 11 consecutive months. We included all hemodynamically stable and hypoxemic patients with EVLWI > 9 ml/kg. The protocol dictates a negative fluid balance between 500 and 1500 ml/day. We analyzed the impact of this negative fluid balance strategy upon pulmonary, hemodynamic, and renal function. MAIN VARIABLES OF INTEREST: Demographic data, severity scores, clinical, hemodynamic, pulmonary, metabolic and renal function data. RESULTS: Thirty-three patients achieved negative fluid balance (NFB group) and 11 had a positive fluid balance (PFB group). In the former group, PaO2/FiO2 improved from 145 (IQR 106, 200) to 210 mmHg (IQR 164, 248) (p < 0.001), and EVLWI decreased from 14 (11, 18) to 10 ml/kg (8, 14) (p < 0.001). In the PFB group, EVLWI also decreased from 11 (10, 14) to 10 ml/kg (8, 14) at the end of the protocol (p = 0.004). For these patients there were no changes in oxygenation, with a PaO2/FiO2 of 216 mmHg (IQR 137, 260) at the beginning versus 205 mmHg (IQR 99,257) at the end of the study (p = 0.08). CONCLUSION: Three out of four hypoxic patients with elevated EVLWI tolerated the NFB protocol. In these subjects, the improvement of various analyzed physiological parameters was greater and faster than in those unable to complete the protocol. Patients who did not tolerate the protocol were usually in more severe condition, though a larger sample would be needed to detect specific characteristics of this group

OBJETIVO: Analizar la eficacia del balance hídrico negativo en pacientes hipoxémicos y con Agua Pulmonar Extravascular Indexada (EVLWI) elevada. Diseño: Estudio retrospectivo y observacional. ÁMBITO: Unidad de Cuidados Intensivos del Hospital Virgen de las Nieves. Participantes: 44 pacientes. Intervenciones: Se analizó la base de datos de pacientes hipoxémicos durante 11 meses consecutivos. Se incluyeron los pacientes hipoxémicos, hemodinámicamente estables y con EVLWI > 9 ml/kg. El protocolo dicta un balance hídrico negativo entre 500 y 1500 ml/día. Se analizó el impacto de esta estrategia de balance negativo en la función respiratoria, hemodinámica y renal. Variables de interés principales: Datos demográficos, escalas de gravedad y datos clínicos hemodinámicos, respiratorios, metabólicos y de función renal. RESULTADOS: 33 pacientes lograron balance hídrico negativo (Grupo BHN) y 11 tuvieron balance hídrico positivo (Grupo BHP). En el grupo BHN la PaO2/FiO2 pasó de 145 (IQR 106,200) a 210 (IQR 164, 248) mmHg (p < 0.001), el EVLWI descendió de 14 (11, 18) a 10 (8, 14) ml/kg (p < 0.001). En el grupo BHP, el EVLWI también descendió de 11(10, 14) a 10 (8, 14) ml/kg al final del protocolo (p = 0.004); en este último grupo no hubo cambios estadísticamente significativos en la oxigenación y la PaO2/FiO2 pasó de 216 (IQR 137, 260) a 205 (IQR 99, 257) mmHg (p = 0.08). CONCLUSIÓN: Tres de cada cuatro pacientes hipoxémicos y con EVLWI elevados toleraron el protocolo; en ellos, la mejora de diversos parámetros analizados fue mayor y más rápida que en los pacientes que no hicieron balance negativo. Los pacientes que no toleraron el protocolo fueron los más graves aunque se necesitaría una muestra mayor para determinar las características específicas en estos

Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document).

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Cristaloides y coloides en la reanimación del paciente crítico / Crystalloids and colloids in critical patient resuscitation

La reanimación con fluidos es esencial para la supervivencia del paciente crítico en shock, independientemente de la causa que lo origine. Hoy en día disponemos de diversos cristaloides y coloides (sintéticos y naturales), existiendo una viva controversia sobre qué tipo de fluidos debemos emplear y los posibles efectos adversos asociados a su uso, especialmente el desarrollo de fracaso renal con necesidad de técnicas de reemplazo renal. Recientemente se han publicado varios ensayos clínicos y metaanálisis que evidencian que el empleo de hidroxietilalmidón (130/0,4) se asocia a un mayor riesgo de muerte e insuficiencia renal, así como datos que muestran un beneficio clínico con el empleo de cristaloides que contienen menor concentración de sodio y cloro que el suero salino. Ello ha contribuido a aumentar la incertidumbre de los clínicos sobre qué tipo de fluido emplear. Por ello, hemos realizado una revisión narrativa de la literatura con el fin de elaborar unas recomendaciones prácticas sobre el empleo de fluidos en la fase de reanimación del paciente crítico adulto y que se presentan en este documento

Fluid resuscitation is essential for the survival of critically ill patients in shock, regardless of the origin of shock. A number of crystalloids and colloids (synthetic and natural) are currently available, and there is strong controversy regarding which type of fluid should be administered and the potential adverse effects associated with the use of these products, especially the development of renal failure requiring renal replacement therapy. Recently, several clinical trials and metaanalyses have suggested the use of hydroxyethyl starch (130/0.4) to be associated with an increased risk of death and kidney failure, and data have been obtained showing clinical benefit with the use of crystalloids that contain a lesser concentration of sodium and chlorine than normal saline. This new information has increased uncertainty among clinicians regarding which type of fluid should be used. We therefore have conducted a review of the literature with a view to developing practical recommendations on the use of fluids in the resuscitation phase in critically ill adults

Crystalloids and colloids in critical patient resuscitation.

Fluid resuscitation is essential for the survival of critically ill patients in shock, regardless of the origin of shock. A number of crystalloids and colloids (synthetic and natural) are currently available, and there is strong controversy regarding which type of fluid should be administered and the potential adverse effects associated with the use of these products, especially the development of renal failure requiring renal replacement therapy. Recently, several clinical trials and metaanalyses have suggested the use of hydroxyethyl starch (130/0.4) to be associated with an increased risk of death and kidney failure, and data have been obtained showing clinical benefit with the use of crystalloids that contain a lesser concentration of sodium and chlorine than normal saline. This new information has increased uncertainty among clinicians regarding which type of fluid should be used. We therefore have conducted a review of the literature with a view to developing practical recommendations on the use of fluids in the resuscitation phase in critically ill adults.

Efficacy of an extravascular lung water-driven negative fluid balance protocol.

OBJECTIVE: To analyze the efficacy of negative fluid balance in hypoxemic patients with an elevated extravascular lung water index (EVLWI). DESIGN: A retrospective observational study was made. SETTING: Intensive Care Unit of Virgen de las Nieves Hospital (Spain). PARTICIPANTS: Forty-four patients participated in the study. INTERVENTIONS: We analyzed our database of hypoxemic patients covering a period of 11 consecutive months. We included all hemodynamically stable and hypoxemic patients with EVLWI>9ml/kg. The protocol dictates a negative fluid balance between 500 and 1500ml/day. We analyzed the impact of this negative fluid balance strategy upon pulmonary, hemodynamic, and renal function. MAIN VARIABLES OF INTEREST: Demographic data, severity scores, clinical, hemodynamic, pulmonary, metabolic and renal function data. RESULTS: Thirty-three patients achieved negative fluid balance (NFB group) and 11 had a positive fluid balance (PFB group). In the former group, PaO2/FiO2 improved from 145 (IQR 106, 200) to 210mmHg (IQR 164, 248) (p<0.001), and EVLWI decreased from 14 (11, 18) to 10ml/kg (8, 14) (p<0.001). In the PFB group, EVLWI also decreased from 11 (10, 14) to 10ml/kg (8, 14) at the end of the protocol (p=0.004). For these patients there were no changes in oxygenation, with a PaO2/FiO2 of 216mmHg (IQR 137, 260) at the beginning versus 205mmHg (IQR 99,257) at the end of the study (p=0.08). CONCLUSION: Three out of four hypoxic patients with elevated EVLWI tolerated the NFB protocol. In these subjects, the improvement of various analyzed physiological parameters was greater and faster than in those unable to complete the protocol. Patients who did not tolerate the protocol were usually in more severe condition, though a larger sample would be needed to detect specific characteristics of this group.

Retos asistenciales en la atención al paciente traumatizado en España. La necesidad de implementación de la evidencia científica incluyendo la prevención secundaria / Challenges in care of trauma patient in Spain. The need for implementation of scientific evidence including secondary prevention

La mortalidad de los pacientes traumatizados ha descendido significativamente en las últimas décadas como consecuencia de una combinación de factores tanto asistenciales como estructurales y educacionales. La generalización de los servicios de emergencias extrahospitalarios y la asistencia hospitalaria en centros específicos para traumatizados ha contribuido sin duda a este descenso, pero otros factores como las campañas periódicas de prevención de accidentes de tráfico y laborales, así como las mejoras en la red viaria han jugado un papel fundamental. El reto actual consiste en seguir disminuyendo la mortalidad, para lo cual es fundamental un análisis de la situación que detecte las potenciales áreas de mejora. La aplicación de actuaciones diagnósticas o terapéuticas con evidencia científica se asocia con una menor mortalidad pero, como en otras parcelas de la medicina, en los pacientes traumatizados la aplicación de la evidencia científica apenas llega al 50%. Por otra parte, casi el90% de los pacientes que fallecen por traumatismos lo hacen en el lugar del accidente o en las primeras 72 h de hospitalización, la inmensa mayoría de las veces como consecuencia de lesiones incompatibles con la vida. En estas circunstancias parece evidente que la prevención es la actuación más eficiente. Como médicos asistenciales, nuestro papel en la prevención se centra fundamentalmente en la prevención secundaria para evitar la reincidencia, para los cuales necesaria la identificación de los factores de riesgo (generalmente alcohol, drogas ilegales, psicofármacos) y realizar una intervención motivacional breve que puede reducir la reincidencia casi un 50%. En España, la actividad en este campo es prácticamente nula, por lo que deben implementarse medidas para su implantación

The mortality of trauma patients has improved significantly in recent decades due to a combination of factors: medical care, educational campaigns and structural changes. Generalization of out-of hospital emergence medical services and the hospital care in specific centers for traumatized has undoubtedly contributed to this decline, but other factors such as periodic campaigns to prevent workplace and traffic accidents, as well as improvements in the roadnet work have played a key role. The challenge now is to continue to decrease mortality, for which is essential an analysis of the situation to detect potential areas of improvement. The application of diagnostic or therapeutic actions with scientific evidence is associated with lower mortality, but as in other areas of medicine, the application of scientific evidence in trauma patients is barely 50%. Moreover, nearly 90% of trauma deaths occur in the crash site or in the first 72 h of hospitalization, the vast majority as a result of injuries incompatible with life. In these circumstances it is clear that prevention is the most cost-effective activity. As medical practitioners, our role in prevention is mainly focused on the secondary prevention to avoid recidivism, for which it is necessary to identify risk factor (frequently alcohol, illegal drugs, psychotropic medication etc.) and implement a brief motivational intervention. This activity can reduce recidivism by nearly 50%. In Spain, the activity in this field is negligible therefore measures should be implemented for dissemination of secondary prevention in trauma

[Challenges in care of trauma patient in Spain. The need for implementation of scientific evidence including secondary prevention]. / Retos asistenciales en la atención al paciente traumatizado en España. La necesidad de implementación de la evidencia científica incluyendo la prevención secundaria.

The mortality of trauma patients has improved significantly in recent decades due to a combination of factors: medical care, educational campaigns and structural changes. Generalization of out-of hospital emergence medical services and the hospital care in specific centers for traumatized has undoubtedly contributed to this decline, but other factors such as periodic campaigns to prevent workplace and traffic accidents, as well as improvements in the road network have played a key role. The challenge now is to continue to decrease mortality, for which is essential an analysis of the situation to detect potential areas of improvement. The application of diagnostic or therapeutic actions with scientific evidence is associated with lower mortality, but as in other areas of medicine, the application of scientific evidence in trauma patients is barely 50%. Moreover, nearly 90% of trauma deaths occur in the crash site or in the first 72h of hospitalization, the vast majority as a result of injuries incompatible with life. In these circumstances it is clear that prevention is the most cost-effective activity. As medical practitioners, our role in prevention is mainly focused on the secondary prevention to avoid recidivism, for which it is necessary to identify risk factor (frequently alcohol, illegal drugs, psychotropic medication etc.) and implement a brief motivational intervention. This activity can reduce recidivism by nearly 50%. In Spain, the activity in this field is negligible therefore measures should be implemented for dissemination of secondary prevention in trauma.