The role of autopsy on the diagnosis of missed injuries and on the trauma quality program goal definitions: study of 192 cases.

OBJECTIVE: to assess the role of autopsy in the diagnosis of missed injuries (MI) and definition of trauma quality program goals. METHOD: Retrospective analysis of autopsy reports and patient's charts. Injuries present in the autopsy, but not in the chart, were defined as "missed". MI were characterized using Goldman's criteria: Class I, if the diagnosis would have modified the management and outcome; Class II, if it would have modified the management, but not the outcome; Class III, if it would not have modified neither the management nor the outcome. We used Mann-Whitney's U and Pearson's chi square for statistical analysis, considering p<0.05 as significant. RESULTS: We included 192 patients, with mean age of 56.8 years. Blunt trauma accounted for 181 cases, and 28.6% were due to falls from the same level. MI were diagnosed in 39 patients (20.3%). Using Goldman's criteria, MI were categorized as Class I in 3 (1.6%) and Class II in 11 (5.6%). MI were more often diagnosed in the thoracic segment (25 patients, 64.1% of the MI). The variables significantly associated (p<0.05) to MI were: time of hospitalization < 48 h, severe trauma mechanism, and not undergoing surgery or computed tomography. At autopsy, the values of ISS and NISS were higher in patients with MI. CONCLUSION: the review of the autopsy report allowed diagnosis of MIs, which did not influence outcome in their majority. Many opportunities of improvement in quality of care were identified.

Clinical assessment of head injuries in motorcyclists involved in traffic accidents: A prospective, observational study.

OBJECTIVE: to review the clinical assessment of head injuries in motorcyclists involved in traffic accidents. METHOD: prospective observational study, including adult motorcyclists involved in traffic accidents in a period of 12 months. Patients sustaining signs of intoxication were excluded. A modification of the Canadian Head CT Rules was used to indicate computed tomography (CT). Patients not undergoing CT were followed by phone calls for three months. Collected variables were compared between the group sustaining head injuries and the others. We used chi-square, Fisher, and Student's t for statistical analysis, considering p<0.05 as significant. RESULTS: we included 208 patients, 99.0% were wearing helmets. Seventeen sustained signs of intoxication and were excluded. Ninety (47.1%) underwent CT and 12 (6.3%) sustained head injuries. Head injuries were significantly associated with Glasgow Coma Scale<15 (52.3% vs. 2.8% - p<0,001) and a positive physical exam (17.1% vs. zero - p<0,05). Four (2.1%) patients with intracranial mass lesions needed surgical interventions. None helmet-wearing patients admitted with GCS=15 and normal physical examination sustained head injuries. CONCLUSION: Head CT is not necessary for helmet-wearing motorcyclists admitted with GCS=15 and normal physical examination.

The role of autopsy on the diagnosis of missed injuries and on the trauma quality program goal definitions: study of 192 cases / Valor da autópsia no diagnóstico de lesões despercebidas e na definição de metas para programa de qualidade em trauma: estudo de 192 casos

ABSTRACT Objective: to assess the role of autopsy in the diagnosis of missed injuries (MI) and definition of trauma quality program goals. Method: Retrospective analysis of autopsy reports and patient's charts. Injuries present in the autopsy, but not in the chart, were defined as "missed". MI were characterized using Goldman's criteria: Class I, if the diagnosis would have modified the management and outcome; Class II, if it would have modified the management, but not the outcome; Class III, if it would not have modified neither the management nor the outcome. We used Mann-Whitney's U and Pearson's chi square for statistical analysis, considering p<0.05 as significant. Results: We included 192 patients, with mean age of 56.8 years. Blunt trauma accounted for 181 cases, and 28.6% were due to falls from the same level. MI were diagnosed in 39 patients (20.3%). Using Goldman's criteria, MI were categorized as Class I in 3 (1.6%) and Class II in 11 (5.6%). MI were more often diagnosed in the thoracic segment (25 patients, 64.1% of the MI). The variables significantly associated (p<0.05) to MI were: time of hospitalization < 48 h, severe trauma mechanism, and not undergoing surgery or computed tomography. At autopsy, the values of ISS and NISS were higher in patients with MI. Conclusion: the review of the autopsy report allowed diagnosis of MIs, which did not influence outcome in their majority. Many opportunities of improvement in quality of care were identified.

RESUMO Objetivo: Avaliar a utilidade da autópsia no diagnóstico de lesões despercebidas (LD) e no estabelecimento de metas para programa de qualidade em trauma. Método: análise retrospectiva dos laudos de autópsia por trauma entre outubro/2017 e março/2019 provenientes do mesmo hospital. Lesões descritas na autópsia, mas não no prontuário médico, foram consideradas como despercebidas (LD) e classificadas pelos critérios de Goldman: Classe I: mudariam a conduta e alterariam o desfecho; Classe II: mudariam a conduta, mas não o desfecho; Classe III: não mudariam nem a conduta nem o desfecho. As variáveis coletadas foram comparadas entre o grupo com LD e os demais, através de método estatístico orientado por profissional na área. Consideramos p<0,05 como significativo. Resultados: analisamos 192 casos, com média etária de 56,8 anos. O trauma fechado foi o mecanismo em 181 casos, sendo 28,6% por quedas da própria altura. LD foram observadas em 39 casos (20,3%), sendo 3 (1,6%) classe I e 11 (5,6%) classe II. O tórax foi o segmento com maior número de LD (25 casos - 64,1% das LD). Foram associados à presença de LD (p<0,05): tempo de internação menor que 48 horas, mecanismo de trauma grave e a não realização de procedimento cirúrgico ou tomografia. Nos óbitos até 48h, valores de ISS e NISS nas autópsias foram maiores que os da internação. Conclusão: a revisão das autópsias permitiu identificação de LD, na sua maioria sem influência sobre conduta e prognóstico. Mesmo assim, várias oportunidades foram criadas para o programa de qualidade.

Clinical assessment of head injuries in motorcyclists involved in traffic accidents: A prospective, observational study / Investigação da presença de lesões traumáticas em segmento cefálico em motociclistas vítimas de acidentes de tráfego: Estudo observacional prospectivo

ABSTRACT Objective: to review the clinical assessment of head injuries in motorcyclists involved in traffic accidents. Method: prospective observational study, including adult motorcyclists involved in traffic accidents in a period of 12 months. Patients sustaining signs of intoxication were excluded. A modification of the Canadian Head CT Rules was used to indicate computed tomography (CT). Patients not undergoing CT were followed by phone calls for three months. Collected variables were compared between the group sustaining head injuries and the others. We used chi-square, Fisher, and Student's t for statistical analysis, considering p<0.05 as significant. Results: we included 208 patients, 99.0% were wearing helmets. Seventeen sustained signs of intoxication and were excluded. Ninety (47.1%) underwent CT and 12 (6.3%) sustained head injuries. Head injuries were significantly associated with Glasgow Coma Scale<15 (52.3% vs. 2.8% - p<0,001) and a positive physical exam (17.1% vs. zero - p<0,05). Four (2.1%) patients with intracranial mass lesions needed surgical interventions. None helmet-wearing patients admitted with GCS=15 and normal physical examination sustained head injuries. Conclusion: Head CT is not necessary for helmet-wearing motorcyclists admitted with GCS=15 and normal physical examination.

RESUMO Objetivo: análise crítica da investigação diagnóstica de lesões em segmento cefálico de motociclistas vítimas de acidentes de tráfego. Método: estudo observacional prospectivo incluindo motociclistas adultos vítimas de trauma, sem intoxicação exógena, em um período de 12 meses. A tomografia de crânio (TC) foi indicada de acordo com uma modificação dos "critérios canadenses". Os pacientes que não foram submetidos a TC de crânio tiveram acompanhamento telefônico por três meses. A presença de lesões foi correlacionada com as varáveis coletadas através dos testes Qui-quadrado, t de Student ou Fisher, considerando p<0,05 como significativo. Resultados: dos 208 inicialmente incluídos, 206 (99,0%) estavam usando capacete. Dezessete estavam com sinais de intoxicação exógena e foram excluídos, restando 191 para análise. Noventa pacientes (47,1%) realizaram TC e 12 (6,3%) apresentaram lesões craniencefálicas, que se associaram significativamente a Escala de Coma de Glasgow (ECG) <15 (52,3% vs. 2,8% - p<0,001) e alterações ao exame físico da região cefálica/neurológico (17,1% vs. zero - p<0,05). Quatro pacientes (2,1%) precisaram tratamento cirúrgico de lesões intracranianas. Nenhum dos pacientes admitidos com ECG 15, em uso de capacete e sem alterações no exame físico apresentou TC alterada. Conclusões: para pacientes admitidos com ECG 15, que utilizavam o capacete no acidente e não apresentavam quaisquer alterações no exame físico, a realização da TC de crânio não trouxe mudanças no atendimento ao paciente. .

Management of acute appendicitis during the COVID-19 pandemic: Views of two Brazilian surgical societies.

Acute appendicitis (AA) is a frequent cause of abdominal pain requiring surgical treatment. During the COVID-19 pandemic, surgical societies considered other therapeutic options due to uncertainties in the evolution of the disease. The purpose of this study is to assess the treatment of AA by members of two Brazilian surgical societies in this period. A common questionnaire was sent in 2020. There were 382 responses. Most surgeons had more than 15 years of profession (68.3%) and treated more than five cases per month (44.8%). About 72.5% would indicate chest CT to investigate COVID-19 in patients with AA. For those patients sustaining uncomplicated AA, without COVID-19, 60.2% would indicate laparoscopic appendectomy (VLA), followed by open appendectomy (OA) (31.7%) and non-operative management (NOM) (1.3%). For those with mild COVID-19, OA was suggested by 51.0%, followed by VLA (29.6%) and NOM (6.0%). For those with severe COVID-19, OA was proposed by 35.3%, followed by NOM (19.9%) and VLA (18.6%). For patients with periappendiceal abscesses, without COVID-19, VLA was suggested by 54.2%, followed by OA (33.2%) and NOM (4.4%). For those with mild COVID-19, OA was proposed in 49.5%, followed by VLA (29.3%) and NOM (8.9%). In those with severe COVID-19, OA was proposed in 36.6%, followed by NOM (25.1%) and VLA (17.3%). This information, based on two recognized Brazilian surgical societies, can help the surgeon to select the best approach individually.

Management of acute appendicitis during the COVID-19 pandemic: Views of two Brazilian surgical societies / Análise descritiva do tratamento dos doentes com apendicite aguda durante a pandemia de COVID-19: A visão dos cirurgiões de duas sociedades nacionais

ABSTRACT Acute appendicitis (AA) is a frequent cause of abdominal pain requiring surgical treatment. During the COVID-19 pandemic, surgical societies considered other therapeutic options due to uncertainties in the evolution of the disease. The purpose of this study is to assess the treatment of AA by members of two Brazilian surgical societies in this period. A common questionnaire was sent in 2020. There were 382 responses. Most surgeons had more than 15 years of profession (68.3%) and treated more than five cases per month (44.8%). About 72.5% would indicate chest CT to investigate COVID-19 in patients with AA. For those patients sustaining uncomplicated AA, without COVID-19, 60.2% would indicate laparoscopic appendectomy (VLA), followed by open appendectomy (OA) (31.7%) and non-operative management (NOM) (1.3%). For those with mild COVID-19, OA was suggested by 51.0%, followed by VLA (29.6%) and NOM (6.0%). For those with severe COVID-19, OA was proposed by 35.3%, followed by NOM (19.9%) and VLA (18.6%). For patients with periappendiceal abscesses, without COVID-19, VLA was suggested by 54.2%, followed by OA (33.2%) and NOM (4.4%). For those with mild COVID-19, OA was proposed in 49.5%, followed by VLA (29.3%) and NOM (8.9%). In those with severe COVID-19, OA was proposed in 36.6%, followed by NOM (25.1%) and VLA (17.3%). This information, based on two recognized Brazilian surgical societies, can help the surgeon to select the best approach individually.

RESUMO A apendicite aguda (AA) é causa frequente de abdome agudo cirúrgico. Durante a pandemia de COVID-19, devido às incertezas na evolução da doença, sociedades consideraram outras opções terapêuticas. Nosso objetivo é descrever o tratamento da AA por membros do CBC e SBAIT neste período. O questionário foi enviado em 2020. Houve 382 respostas. A maioria dos profissionais tinha mais de 15 anos de profissão (68,3%) e atendia mais de cinco casos por mês (44,8%). Cerca de 72,5% realizariam TC de tórax para investigação de COVID-19 em pacientes com AA. Nos com AA não complicada, sem COVID-19, 60,2% optariam pela apendicectomia videolaparoscópica (AVL), seguido de apendicectomia aberta (AAB) (31,7%) e tratamento não operatório (TNO) (1,3%). Nos com COVID-19 leve, AAB foi proposta por 51,0%, seguido da AVL (29,6%) e TNO (6,0%). Nos com COVID-19 grave, a AAB foi proposta por 35,3%, seguido de TNO (19,9%) e AVL (18,6%). Nos com AA complicadas com abscesso, sem COVID-19, AVL foi sugerida por 54,2%, seguida da AAB (33,2%) e TNO (4,4%). Nos com COVID-19 leve, a AAB foi proposta em 49,5%, seguidos da AVL (29,3%) e TNO (8,9%). Nos com COVID-19 grave, a AAB foi proposta em 36,6%, seguido de TNO (25,1%) e AVL (17,3%). Estas são opções de cirurgiões de duas sociedades cirúrgicas reconhecidas e podem auxiliar o colega que está na linha de frente a definir a melhor conduta individualmente.

Optimizing Pelvic X-Ray indication in blunt trauma patients using clinical criteria.

OBJECTIVE: to identify a subgroup of blunt trauma patients with very low chance of sustaining pelvic fractures based on clinical criteria. METHODS: retrospective analysis of the trauma registry data, collected in a period of 24 months. We selected adult blunt trauma patients who had a PXR on admission. The frequency of pelvic fractures was calculated for the following groups: Normal neurological examination at admission (NNE), hemodynamical stability (HS), normal pelvic examination at admission (NPE), less than 60 years old (ID<60) and absence of distracting injuries (ADI). Logistic regression analysis was carried out in order to create a probability model of negative PXR. RESULTS: an abnormal PXR was identified in 101 (3.3%) out of the 3,055 patients who had undergone a PXR at admission. Out of these, 1,863 sustained a NNE, with 38 positive CXRs (2.0%) in this group. Considering only the 1,535 patients with NNE and HS, we found 28 positive PXRs (1.8%). Out of these, 1,506 have NPE, with 21 abnormal PXRs (1.4%). Of these, 1,202 were younger than 60 y, with 11 positive PXRs (0.9%). By adding all these criteria to the ADI, we found 2 abnormal PXRs in 502 (0.4%) cases. The probability model including all these variables had a 0,89 area under the ROC curve. CONCLUSIONS: by adding clinical criteria, it is possible to identify a group of trauma patients with very low chance of sustaining pelvic fractures. The necessity of PXR in these patients needs to be reassessed.

Trauma quality indicators: a way to identify attention points in the treatment of elderly trauma patients.

PURPOSE: to trauma quality indicators as a tool to identify opportunities of improvement in elderly trauma patient's' treatment. METHODS: prospective analysis of data collected between 2014-2015, and stored in the iTreg software (by Ecossistemas). Trauma victims, aged older than 60 years and trauma quality indicators were assessed, based on those supported by SBAIT in 2013: (F1) Acute subdural hematoma drainage after 4 hours from admission, in patients with GCS<9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours from extubation; (F4) Admission-laparotomy time greater than 60 min. in hemodynamically uinstable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours from admission; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time greater than 6 hours; (F10) Surgery after 24 from admission. The indicators, treatments, adverse effects and deaths were analyzed, using the SPSS software, and the chi-squared and Fisher tests were used to calculate the statistical relevance. RESULTS: from the 92 cases, 36 (39,1%) had complications and 15 (16,3%) died. The adequate use of quality indicator's were substantially different among those who survived (was of 12%) compared to those who died (55,6%). The incidence of complications was of 77,8% (7/9) in patients with compromised indicators and 34,9% (28/83) in those without (p=0.017). CONCLUSIONS: trauma quality indicators are directly related with the occurrence of complications and deaths, in elderly trauma patients.

Optimizing Pelvic X-Ray indication in blunt trauma patients using clinical criteria / Uso de critérios clínicos para a otimização da indicação de radiografia simples de pelve das vítimas de trauma fechado

ABSTRACT Objective: to identify a subgroup of blunt trauma patients with very low chance of sustaining pelvic fractures based on clinical criteria. Methods: retrospective analysis of the trauma registry data, collected in a period of 24 months. We selected adult blunt trauma patients who had a PXR on admission. The frequency of pelvic fractures was calculated for the following groups: Normal neurological examination at admission (NNE), hemodynamical stability (HS), normal pelvic examination at admission (NPE), less than 60 years old (ID<60) and absence of distracting injuries (ADI). Logistic regression analysis was carried out in order to create a probability model of negative PXR. Results: an abnormal PXR was identified in 101 (3.3%) out of the 3,055 patients who had undergone a PXR at admission. Out of these, 1,863 sustained a NNE, with 38 positive CXRs (2.0%) in this group. Considering only the 1,535 patients with NNE and HS, we found 28 positive PXRs (1.8%). Out of these, 1,506 have NPE, with 21 abnormal PXRs (1.4%). Of these, 1,202 were younger than 60 y, with 11 positive PXRs (0.9%). By adding all these criteria to the ADI, we found 2 abnormal PXRs in 502 (0.4%) cases. The probability model including all these variables had a 0,89 area under the ROC curve. Conclusions: by adding clinical criteria, it is possible to identify a group of trauma patients with very low chance of sustaining pelvic fractures. The necessity of PXR in these patients needs to be reassessed.

RESUMO Objetivo: identificar, baseados em critérios clínicos, grupo de vítimas de trauma fechado com baixa probabilidade de apresentar fraturas na radiografia simples de pelve à admissão (RXP). Método: análise retrospectiva dos dados de registro de trauma em um período de 24 meses. Foram selecionados adultos vítimas de trauma fechado que realizaram RXP à admissão. A frequência de fraturas de pelve foi calculada nos seguintes grupos: exame neurológico normal à admissão (ExNN), estabilidade hemodinâmica (EH), exame da pelve normal à admissão (ExPN), idade inferior a 60 anos (ID<60) e ausência de lesões distrativas (ALD). Estas variáveis foram sobrepostas, na tentativa de identificar um grupo com a menor frequência de fraturas de pelve. Por meio de regressão logística, foi criado modelo preditivo de "ausência" de fraturas de pelve. Resultados: foram identificados 101 (3,3%) RXP positivos dentre os 3.055 realizados. Nos 1.863 pacientes com ExNN, identificamos 39 RXP alteradas (2,1%). Nos 1.535 com ExNN e EH, observaram-se 28 RXP alteradas (1,8%). Nos 1.506 com ExNN, EH e ExPN, identificamos 21 com RXP positiva (1,4%). Dos 1.202 com ExNN, EH, ExPN e ID<60, 11 tinham RXP alteradas (0,9%). Dos 502 com ExNN, EH, ExPN, ID<60 e ALD, houve apenas 2 RXP anormais (0,4%). O modelo preditivo derivado da regressão logística, apresentou área sob a curva ROC (AUC) de 0,89. Conclusões: é possível identificar grupo vítimas de trauma fechado com probabilidade muito baixa de apresentar fraturas pélvicas com base em critérios clínicos. A necessidade de RXP neste grupo deve ser revista.

Trauma quality indicators: a way to identify attention points in the treatment of elderly trauma patients / Filtros de qualidade: uma maneira de identificar pontos de atenção no atendimento ao idoso traumatizado

ABSTRACT Purpose: to trauma quality indicators as a tool to identify opportunities of improvement in elderly trauma patient's' treatment. Methods: prospective analysis of data collected between 2014-2015, and stored in the iTreg software (by Ecossistemas). Trauma victims, aged older than 60 years and trauma quality indicators were assessed, based on those supported by SBAIT in 2013: (F1) Acute subdural hematoma drainage after 4 hours from admission, in patients with GCS<9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours from extubation; (F4) Admission-laparotomy time greater than 60 min. in hemodynamically uinstable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours from admission; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time greater than 6 hours; (F10) Surgery after 24 from admission. The indicators, treatments, adverse effects and deaths were analyzed, using the SPSS software, and the chi-squared and Fisher tests were used to calculate the statistical relevance. Results: from the 92 cases, 36 (39,1%) had complications and 15 (16,3%) died. The adequate use of quality indicator's were substantially different among those who survived (was of 12%) compared to those who died (55,6%). The incidence of complications was of 77,8% (7/9) in patients with compromised indicators and 34,9% (28/83) in those without (p=0.017). Conclusions: trauma quality indicators are directly related with the occurrence of complications and deaths, in elderly trauma patients.

RESUMO Objetivo: analisar a utilidade de "filtros de qualidade" pré-estabelecidos para a identificação de oportunidades de melhora no atendimento ao idoso traumatizado. Método: análise prospectiva dos dados coletados entre 2014-2015 e armazenados em software iTreg (Ecossistemas). Foram revisados vítimas de trauma maiores de 60 anos e filtros de qualidade propostos, baseados naqueles idealizados pela SBAIT em 2013: (F1) Drenagem de hematoma subdural agudo após 4 horas da admissão em pacientes com ECG<9; (F2) transferência da sala de emergência sem via aérea definitiva e ECG<9; (F3) Reintubação em até 48 horas da extubação; (F4) Tempo admissão-laparotomia exploradora maior que 60 min. em pacientes instáveis com foco abdominal; (F5) Reoperação não programada; (F6) Laparotomia após 4 horas da admissão; (F7) Fratura de diáfise de fémur não fixada; (F8) Tratamento não operatório de ferimento abdominal por PAF; (F9) Tempo admissão-tratamento de fraturas expostas de tíbia superior a 6 horas; (F10) Operação após 24 horas da admissão. Foi analisada relação dos filtros com tratamentos, complicações e óbitos, pelo software SPSS, utilizando-se o teste qui-quadrado e Fisher para calcular a relevância estatística. Resultados: dos 92 casos, 36 (39,1%) tiveram complicações e 15 (16,3%) morreram. A frequência da quebra dos filtros foi de 12% em pacientes que sobreviveram e 55,6% nos entre os que faleceram (p=0,005). A incidência de complicações foi de 77,8% (7/9) nos doentes com FQ comprometido, contra 34,9% (28/83) nos não comprometidos (p=0,017). Conclusões: o comprometimento dos filtros de qualidade se relaciona diretamente com a ocorrência de complicações e óbitos em idosos traumatizados.