Atención inicial al trauma grave. Utilidad de la videograbación en la valoración de la calidad asistencial / Trauma initial management. Usefulness of the video recording in the evaluation of the quality of care

Objetivo: Determinar la utilidad de la videograbación en la monitorización de la calidad asistencial. Pacientes y método: Estudio descriptivo prospectivo observacional durante un periodo de seis meses. Se incluyeron todos los pacientes adultos con lesión traumática admitidos en la UCI procedentes del medio extrahospitalario. Se realizó grabación continua en vídeo de la resucitación inicial, con posterior revisión por un grupo multidisciplinar. Se analizaron las características epidemiológicas, adhesión al protocolo establecido, tiempos de actuación y la incidencia de errores y/o fallos del sistema. Resultados: 117 pacientes, edad media 43 años, varones 71%, índice de gravedad (ISS) 19.8 ± 15.6. El promedio de cumplimentación del protocolo en el reconocimiento primario y secundario fue del 79.9% y el 70% respectivamente. En la valoración del trabajo en equipo se mantuvieron: liderazgo 87%, organización del equipo 88%, organización de la asistencia 75% y seguimiento de roles 76%. La asistencia se realizó en 43 minutos. Conclusiones: La utilización de la videograbación durante la atención inicial al paciente traumatizado permite analizar la presencia de errores o retrasos que influyen en la calidad de la asistencia prestada (AU)

Objective: To study usefulness of the video recording in the evaluation of the quality of care in hospital initial care of patients with severe trauma. Patients and methods: Prospective observational study over a period of 6 months. We included all adult patients with traumatic injury admitted to the ICU from the pre-hospital means. Continuous recording took place in video of the initial resuscitation, with subsequent review by a multidisciplinary group. Epidemiological characteristics, adherence to the established protocol, time management and the incidence of errors or system failures were analyzed. Results: 117 patients admitted were included. Of these, 71% were male, with an average age of 43 years and Injury Severity Score (ISS) 19.8 ± 15.6. Overall protocol compliance in the primary and secondary survey was 79.9% and 70% respectively. The evaluation of trauma team performance were: leadership 87%, team organization 88%, care organization 75% and roles follow-up 76%. Resuscitation took 43 minutes. Conclusion: The video-recording of trauma resuscitation allows to analyze the presence of errors and/or delays affecting the quality of the assistance provided (AU)

Contralateral extraaxial hematomas after urgent neurosurgery of a mass lesion in patients with traumatic brain injury.

PURPOSE: The development of a contralateral extraaxial hematoma has repeatedly been described in small series and descriptive studies. However, the evidence available to date is limited. OBJECTIVES: To evaluate the incidence and risk factors leading to the development of a contralateral extraaxial hematoma and to describe the characteristics of cases. METHODS: A retrospective cohort study with prospective data collection was undertaken. All patients admitted to an intensive care unit (ICU) from 2006 to 2010 were studied. The inclusion criteria were as follows: severe trauma [Injury Severity Score (ISS ≥ 16)], neurosurgery (NeuroSx) in the first 24 h. The following were excluded: subacute/chronic subdural hematomas, first bilateral NeuroSx. Cases were those who required immediate contralateral NeuroSx after the first NeuroSx due to the occurrence of a new extraaxial injury or significant growth of a previous one. Controls were those patients those who did not require second NeuroSx or who required reoperation due to ipsilateral lesions. The variables considered were: demographics, neurological assessment, traumatic injuries and severity, image and surgical findings, clinical course, and outcome. Statistics analysis comprised descriptive, inferential, and multivariate analysis by logistic regression. RESULTS: A total of 120 patients were included, among which there were 11 cases (incidence 9.2 %). The cases showed a significantly higher frequency of coma or severe traumatic brain injury (TBI) at admission, contralateral injury and contralateral skull fracture in the preoperative computed tomography (CT) scan, as well as decompressive craniectomy. There were no significant differences in the severity scores, clinical course, or outcomes. The presence of contralateral fracture was identified as an independent risk factor [relative risk (RR) 47.9, 95 % confidence interval (CI) 5.2-443]. CONCLUSIONS: Contralateral extraaxial hematoma is a rare entity, although it has a high mortality rate. Therefore, it requires a high index of suspicion, especially in patients with severe TBI, with minimal contralateral injury and mainly with contralateral skull fracture on the initial CT scan.

Desarrollo de una herramienta de comunicación para la seguridad del paciente (Briefing). Experiencia en una unidad de cuidados intensivos de trauma y emergencias / Development of communication tool for patient safety (

Objetivo: Validar una herramienta de seguridad utilizada en sectores de alto riesgo (briefing de seguridad) en la medicina intensiva. Diseño: Estudio prospectivo, observacional y analítico. Ámbito: UCI de Trauma y Emergencias de un hospital terciario. Pacientes: Pacientes con trauma grave (Injury Severity Score-ISS>16). Intervención: Recogida de incidentes, relacionados con la seguridad del paciente (SP). Variables: Características de la población, estado de la unidad, incidentes de SP, aspectos de la herramienta e impacto sobre la cultura de seguridad. Resultados: Se incluyeron 441 pacientes (edad media 39,9±17,5 años), 75,15% hombres, 89% con trauma cerrado y un 10,5% de mortalidad. La herramienta se aplicó en 586 turnos de 798 posibles (73,4%) y se recogieron 942 incidentes (2,20 incidentes por paciente). Los incidentes más frecuentes se relacionaron con la medicación (20,7%), los dispositivos (colocación 4,03% y mantenimiento 17,8%) y la vía aérea y la ventilación mecánica (VM) (17,09%). Se estableció una correlación entre la presencia de incidentes y las características del enfermo (mayor Injury Severity Score, presencia de VM y terapias de reemplazo renal continuo) y con el estado de la unidad (más de 6 pacientes por turno sobre 8 posibles y el periodo vacacional). La herramienta influyó en diferentes aspectos de la cultura de seguridad de la unidad de manera significativa (frecuencia de comunicación, número de eventos, pérdida de carácter punitivo y trabajo de manera activa en SP). Conclusiones: El briefing es una herramienta para la recogida de los incidentes, simple, fácil de usar, útil para implantar mejoras e influir en la cultura de seguridad (AU)

Objective: To validate a safety tool used in high-risk sectors (safety briefing) in intensive care medicine. Design: A prospective, observational and analytical study was carried out. Setting: Trauma and emergency intensive care unit in a tertiary hospital. Patients: Patients with severe trauma (Injury Severity Score ISS>16). Intervention: Documentation of incidents related to patient safety (PS). Variables: Patients characteristics, state of the Unit, patient safety incidents, aspects of the tool (SP) and safety culture impact. Results: We included 441 patients (75.15% males, mean age 39.9±17.5 years), with blunt trauma in 89% and a 10.5% mortality rate. The tool was applied in 586 out of 798 possible shifts (73.4%), and documented 942 events (2.20 incidents per patient). The incidents were more frequently associated with medication (20.7%), devices (placement 4.03%, and maintenance 17.8%) and airway and mechanical ventilation (MV) (17.09%). A correlation was established between the occurrence of incidents and the characteristics of the patient (higher Injury Severity Score, presence of MV, and continuous renal replacement therapies) and the status of the Unit (more than 6 patients per shift out of 8 possible, and holiday period). The tool significantly influenced different aspects of the safety culture of the unit (communication frequency, number of events, punitive loss and active work in PS). Conclusions: Safety briefing is a tool for the documentation of incidents that is simple and easy to use, and is useful for implementing improvements and in influencing safety culture (AU)

[Development of communication tool for patient safety ("Briefing"). Experience in a trauma and emergency intensive care unit]. / Desarrollo de una herramienta de comunicación para la seguridad del paciente (Briefing). Experiencia en una unidad de cuidados intensivos de trauma y emergencias.

OBJECTIVE: To validate a safety tool used in high-risk sectors (safety briefing) in intensive care medicine. DESIGN: A prospective, observational and analytical study was carried out. SETTING: Trauma and emergency intensive care unit in a tertiary hospital. PATIENTS: Patients with severe trauma (Injury Severity Score ISS≥16). INTERVENTION: Documentation of incidents related to patient safety (PS). VARIABLES: Patients characteristics, state of the Unit, patient safety incidents, aspects of the tool (SP) and safety culture impact. RESULTS: We included 441 patients (75.15% males, mean age 39.9±17.5 years), with blunt trauma in 89% and a 10.5% mortality rate. The tool was applied in 586 out of 798 possible shifts (73.4%), and documented 942 events (2.20 incidents per patient). The incidents were more frequently associated with medication (20.7%), devices (placement 4.03%, and maintenance 17.8%) and airway and mechanical ventilation (MV) (17.09%). A correlation was established between the occurrence of incidents and the characteristics of the patient (higher Injury Severity Score, presence of MV, and continuous renal replacement therapies) and the status of the Unit (more than 6 patients per shift out of 8 possible, and holiday period). The tool significantly influenced different aspects of the safety culture of the unit (communication frequency, number of events, punitive loss and active work in PS). CONCLUSIONS: Safety briefing is a tool for the documentation of incidents that is simple and easy to use, and is useful for implementing improvements and in influencing safety culture.

Escalas predictivas de transfusión masiva en trauma. Experiencia de un registro de transfusiones / Massive transfusion predictive scores in trauma. Experience of a transfusion registry

Objetivo: Valorar la utilidad de diferentes escalas previamente descritas, en la predicción de transfusión masiva (TM) con un registro de transfusiones en trauma grave. Diseño: Estudio retrospectivo de cohortes. Ámbito: Unidad de Cuidados Intensivos de Trauma de un hospital terciario. Pacientes: Se incluyeron pacientes adultos con trauma grave (Injury Severity Score >15), admitidos desde octubre de 2006 hasta julio de 2009.Intervención: Ninguna. Variables: Se evaluaron las siguientes escalas y puntos de corte (PC): Trauma Associated Severe Haemorrhage (TASH) PC: ≥ 16 y ≥ 18; Assessment Blood Consumption (ABC) PC: ≥ 2 y Emergency Transfusion Score (ETS) PC: ≥ 3, ≥ 4 y ≥ 6. TM fue definida como la transfusión de 10 o más unidades de concentrados de hematíes (CH) en las primeras 24 horas del ingreso. Estudiamosla sensibilidad (S), especificidad (E), valor predictivo positivo y negativo (VPP y VPN), razones de verosimilitud positiva y negativa (RVP y RVN) y las curvas receiver-operating characteristics (ROC) y el área bajo las mismas (AUROC).Resultados: Se estudiaron 568 pacientes, el 77,6% hombres, con una edad media de 41,16 ± 18 años e ISS de 30 ± 13. El 93,8% con trauma cerrado. La frecuencia global de TM fue del 18,8%. La mejor S se obtuvo para el ETS ≥ 3 y la mejor especificidad con el TASH ≥ 18. El AUROC para los diferentes escalas fue: ABC: 0,779, ETS: 0,784 y el TASH: 0,889.Conclusiones: Estas escalas pueden ser útiles para caracterizar la población con TM, la exclusión de población de bajo riesgo, intentar ser objetivos en la resucitación con control de daños y apoyar las decisiones clínicas, con pocos datos y fáciles de obtener. (AU)

Objectives: Our purpose is to validate previously described massive transfusion (MT) scoring in our Transfusion Trauma Registry. Design: A retrospective cohort of adult trauma patients. Setting: Trauma and Emergency Intensive Care Unit of a tertiary hospital. Patients: Patients with severe trauma (injury severity score > 15) admitted from October 2006to July 2009.Interventions: None. Variables: The following MT scoring and cutoff points (CP) were evaluated: Trauma-Associated Severe Hemorrhage (TASH) CP: ≥ 16 and ≥ 18; Assessment Blood Consumption (ABC) CP: ≥ 2and Emergency Transfusion Score (ETS) CP: ≥ 3, ≥ 4, ≥ 6. MT was defined as the transfusion of10 units or more of packed red blood cells in the first 24 hours. We studied the sensivity (S),specifity (SP), and positive and negative predictive values (PPV, NPV), the positive and negative likehood ratios (LHR +, LHR-) and area under the receiver operating characteristic curve (ROC).Results: A total of 568 patients were available for analysis; 77.6% were men, with a mean age of 41.16 ± 18 years and an ISS of 30 ± 13. 93.8% with blunt trauma. The overall MT rate was18.8%. The best S was obtained with ETS ≥3 and best SP was obtained with TASH ≥18. ROC for different scores was: ABC: 0.779, ETS: 0. 784, TASH: 0.889.Conclusion: These scales can be useful for characterizing the TM population, for excluding low risk populations, and for attempting to be objective in hematological damage control and in supporting clinical decisions, based on fe1w and easily obtainable data (AU)

[Massive transfusion predictive scores in trauma. Experience of a transfusion registry]. / Escalas predictivas de transfusión masiva en trauma. Experiencia de un registro de transfusiones.

OBJECTIVES: Our purpose is to validate previously described massive transfusion (MT) scoring in our Transfusion Trauma Registry. DESIGN: A retrospective cohort of adult trauma patients. SETTING: Trauma and Emergency Intensive Care Unit of a tertiary hospital. PATIENTS: Patients with severe trauma (injury severity score>15) admitted from October 2006 to July 2009. INTERVENTIONS: None. VARIABLES: The following MT scoring and cutoff points (CP) were evaluated: Trauma-Associated Severe Hemorrhage (TASH) CP: ≥16 and ≥18; Assessment Blood Consumption (ABC) CP: ≥2 and Emergency Transfusion Score (ETS) CP: ≥3, ≥4, ≥6. MT was defined as the transfusion of 10 units or more of packed red blood cells in the first 24 hours. We studied the sensivity (S), specifity (SP), and positive and negative predictive values (PPV, NPV), the positive and negative likehood ratios (LHR +, LHR-) and area under the receiver operating characteristic curve (ROC). RESULTS: A total of 568 patients were available for analysis; 77.6% were men, with a mean age of 41.16 ± 18 years and an ISS of 30 ± 13. 93.8% with blunt trauma. The overall MT rate was 18.8%. The best S was obtained with ETS ≥3 and best SP was obtained with TASH ≥18. ROC for different scores was: ABC: 0.779, ETS: 0. 784, TASH: 0.889. CONCLUSION: These scales can be useful for characterizing the TM population, for excluding low-risk populations, and for attempting to be objective in hematological damage control and in supporting clinical decisions, based on fe1w and easily obtainable data.

[Differences in injury mechanism and pattern, severity and outcome of multiple trauma patients depending on gender]. / Diferencias en el mecanismo y patrón lesional,gravedad y evolución de los pacientes politraumatizados en función del género.

OBJECTIVE: To study de prognostic value and the difference between genders in the injury mechanism and pattern of multiple trauma patients. DESIGN: Prospective descriptive observational study. SETTING: Trauma Intensive Care Unit (ICU) of a tertiary hospital equipped with an heliport. Patients. 953 patients consecutively admitted to ICU between 2003 and 2005. MAIN VARIABLES OF INTEREST: We describe the injury pattern with MAIS of each anatomical region and use Injury Severity Score (ISS) to estimate severity and Trauma Injury Severity Score (TRISS) methodology to calculate survival probability at admission. RESULTS: Ratio male:female was 4:1, with a mean age of 38 +/- 16 years. More than 50% of patients were injured in a traffic accident. MAIS1 had a value of more than 4 in 21.3% of males and in 28.3% of females (p < 0.05); MAIS6 was more than 2 in 9.9% of males and in 16.7% of females (p < 0.01); MAIS8 was greater than 2 in 23,8% of males and in 31.8% of females (p < 0.05). Survival at discharge from ICU was 85.5% for males and 76.8% for females (p < 0.01). Mean ISS was 23.9 (23.2 for males and 26.5 for females, p < 0.01). CONCLUSION: Gender does not play a role in mortality adjusted to severity at admission. Wo - men are one fifth of all admissions but are more severe and suffer more craniocerebral injuries and these are more severe. There are few differences in injury mechanism and pattern between men and women.

Diferencias en el mecanismo y patrón lesional, gravedad y evolución de los pacientes politraumatizados en función del género / Differences in injury mechanism and pattern, severity and outcome of multiple trauma patients depending on gender

Objetivo. Estudiar el valor pronóstico y la diferencia entre géneros de los mecanismos y patrones lesionales de los pacientes politraumatizados. Diseño.Estudio observacional descriptivo pros - pectivo. Ámbito. Unidad de Cuidados Intensivos (UCI) de Politrauma de un hospital terciario con helisuperficie. Pacientes. Novecientos cincuenta y tres pacientes ingresados consecutivamente en la UCI de Politrauma entre 2003 y 2005. Variables de interés principales.Describimos el patrón lesional según el MAIS de cada región anatómica y empleamos el Injury Severity Score (ISS) para estimar la gravedad y la metodología Trauma Injury Severity Score para calcular la probabilidad de supervivencia al ingreso. Resultados. La relación hombres:mujeres fue de 4:1 con una edad media de 38 ± 16 años. Más del 50% de los ingresos fueron por accidente de tráfico. Las regiones anatómicas de la Ab br e via - ted Injury Scale en las que hubo diferencias estadísticamente significativas entre géneros fueron la 1, la 6 y la 8. El valor MAIS1 fue mayor de 4 en el 21,3% de los hombres y en el 28,3% de las mujeres (p < 0,05); el MAIS6 fue mayor de 2 en el 9,9% de los hombres y en el 16,7% de las mujeres (p < 0,01); el MAIS8 fue mayor de 2 en el 23,8% de los hombres y en el 31,8% de las mujeres (p < 0,05). La supervivencia al alta de la UCI fue del 85,5% para los hombres y del 76,8% para las mujeres (p < 0,01). El ISS medio fue de 23,9 (23,2 para los hombres y 26,5 para las mujeres [p < 0,01]). Conclusión. La mortalidad ajustada a gravedad al ingreso no está influida por el género. Las mujeres suponen sólo el 20% de los ingresos pero presentan mayor gravedad y más lesiones craneo - encefálicas, y éstas son más graves. Las diferencias en el mecanismo y el patrón lesional entre hombres y mujeres son escasas

Objective.To study de prognostic value and the difference between genders in the injury mechanism and pattern of multiple trauma patients. Design. Prospective descriptive observational study. Setting. Trauma Intensive Care Unit (ICU) of a tertiary hospital equipped with an heliport. Patients. 953 patients consecutively admitted to ICU between 2003 and 2005. Main variables of interest.We describe the injury pattern with MAIS of each anatomical region and use Injury Severity Score (ISS) to estimate severity and Trauma Injury Severity Score (TRISS) methodology to calculate survival probability at admission. Results.Ratio male:female was 4:1, with a mean age of 38 ± 16 years. More than 50% of patients were injured in a traffic accident. MAIS1 had a value of more than 4 in 21.3% of males and in 28.3% of females (p < 0.05); MAIS6 was more than 2 in 9.9% of males and in 16.7% of females (p < 0.01); MAIS8 was greater than 2 in 23,8% of males and in 31.8% of females (p < 0.05). Survival at discharge from ICU was 85.5% for males and 76.8% for females (p < 0.01). Mean ISS was 23.9 (23.2 for males and 26.5 for females, p < 0.01). Conclussion. Gender does not play a role in mortality adjusted to severity at admission. Wo - men are one fifth of all admissions but are more severe and suffer more craniocerebral injuries and these are more severe. There are few differences in injury mechanism and pattern between men and women

Resucitación en pacientes con shock. Reposición de volumen en el shock / Resuscitation in shock. Volume replacement in shock

El shock representa un síndrome multifactorial (secundario a una patología evidente) que compromete la vida del paciente por inadecuado aporte de O2 a nivel tisular, celular y subcelular, así como por la respuesta que genera en el huésped. Se caracteriza por un conjunto de signos y síntomas propios del inadecuado transporte deO2 y de la hipoxia tisular generada. Las causas del shock se pueden clasificar en vasodilatadoras, hipovolémias y cardiogénicas. La reposición de volumen durante el estado de shock va a depender de la causa responsable del mismo, motivo por el que es necesario una adecuada aproximación diagnóstica. Los líquidos a infundir se pueden resumir en los siguientes grupos: Soluciones cristaloides isotónicas, soluciones hipertónicas, soluciones coloides, fundamentalmente gelatinas, dextranos y almidones, como coloides sintéticos, y albúmina como coloide natural, hemoderivados y soluciones alternativas de hemoglobinassintéticas. La reposición de volumen en el shock es, salvo en el shock cardiogénico con presiones de llenado elevadas, la primeramedida y más eficaz para mejorar la micro circulación y el transporte de oxígeno. En el shock séptico y anafiláctico con importante componente de vasodilatación debe ser generoso en su utilización, valorándola expansión del espacio intravascular e intersticial con coloides/cristaloides. En el shock hemorrágico y antes de controlar el sangrado se debe limitar el volumen y estratificar el paciente. En el medio prehospitalario y en fases iniciales puede ser una buena alternativa el salino hipertónico. El líquido óptimo no está determinado, pero en un futuro inmediato los sustitutos de la hemoglobina tendrán un papel fundamental (AU)

Shock represents a multifactorial syndrome (secondary to an evident condition), which is life threatening both through inadequateO2 supply at tissular, cellular and subcellular level and through the response it induces in the patient. It is characterised by a constellation of symptoms and signs derived from inadequate O2 transport and from the generated tissue ischaemia. The causes of shock may be classed into vasodilatory, hypovolaemic and cardiogenic ones. Volume replacement during shock will depend on the cause responsible for the situation, and thus an adequate diagnostic approach is required. The liquids to be infused may be divided into the following groups: isotonic crystalloid solutions, hypertonic solutions, colloid solutions (mainly gelatins, dextranes and starches, as synthetic colloids, and albumin as a naturalone), haemoderivates, and alternative synthetic haemoglobin solutions. Volume replacement in shock is, with the exception of cardiogenic shock with increased filling pressures, the first and most effective measure for improving microcirculation and oxygen transport. In septic and anaphylactic shock with a marked vasodilation component volume replacement should be generous, with assessment of the extravascular and interstitial compartment expansion with colloids/crystalloids. In haemorrhagicshock, before the bleeding is brought under control, volume replacement should be limited and the patient should be stratified. In the pre-hospital environment and in the early phases, hypertonic saline solution might be a good alternative. The optimum fluid to be used has not been determined yet, but in the near/immediate future haemoglobin substitutes will doubtlessly play a fundamental role (AU)

Midazolam and 2% propofol in long-term sedation of traumatized critically ill patients: efficacy and safety comparison.

OBJECTIVE: We proposed to compare the efficacy and safety of midazolam and propofol in its new preparation (2% propofol) when used for prolonged, deep sedation in traumatized, critically ill patients. We also retrospectively compared 2% propofol with its original preparation, 1% propofol, used in a previous study in a similar and contemporary set of patients. DESIGN: A prospective, randomized, unblinded trial (midazolam and 2% propofol) and a retrospective, contemporary trial (2% propofol and 1% propofol). SETTINGS: A trauma intensive care unit in a tertiary university hospital. PATIENTS: A total of 63 consecutive trauma patients, admitted within a period of 5 months and requiring mechanical ventilatory support for >48 hrs, 43 of whom (73%) suffered severe head trauma. We also retrospectively compared the 2% propofol group with a series of patients in whom 1% propofol was used. INTERVENTIONS: For the prospective trial, we randomized two groups--a midazolam group with continuous administration of midazolam at dosages 0.1-0.35 mg/kg/hr, and a 2% propofol group with continuous infusion at dosages 1.5-6 mg/kg/hr. Equal dosages of analgesics were administered. Similar management protocols were applied in the 1% propofol group, used in the retrospective analysis with 2% propofol. MEASUREMENTS AND MAIN RESULTS: Epidemiologic and efficacy variables were recorded. Hemodynamic and biochemical variables were also monitored on a regular basis. Neuromonitoring was also performed on those patients with head trauma. Sedation adequacy was similar and patient behavior after drug discontinuation was not different in either prospective group (midazolam and 2% propofol). Hemodynamic or neuromonitoring variables were also similar for both groups. Triglyceride levels were significantly higher in the 2% propofol group compared with the midazolam group. A higher number of therapeutic failures because of sedative inefficacy was seen in the 2% propofol group compared with the midazolam group, especially during the first sedation days. When comparing 2% propofol and 1% propofol, a significantly higher number of therapeutic failures because of hypertriglyceridemia were found in the 1% propofol group, as opposed to a major number of therapeutic failures because of inefficacy, found in the 2% propofol group. CONCLUSIONS: Propofol's new preparation is safe when used in severely traumatized patients. Its more concentrated formula improves the lipid overload problem seen with the prolonged use of the previous preparation. Nevertheless, a major number of therapeutic failures were detected with 2% propofol because of the need for dosage increase. This fact could be caused by a different disposition and tissue distribution pattern of both propofol preparations. New studies will be needed to confirm these results.