Manejo cirúrgico de ferimento auto-infligido por arma de fogo em região maxilofacial / Surgical management of self-inflicted injury by gun in the maxillofacial region

INTRODUÇÃO: O manejo dos pacientes vítimas de PAF possui vertentes divergentes a respeito do tratamento cirúrgico, que pode ser realizado de forma imedata ou tardia. Em lesões auto-infligidas, a distância entre a arma e a região acometida é menor, causando consequências estéticas e funcionais mais devastadoras. Aliado ao fato desse tipo de trauma criar uma ferida suja devido à comunicação com a cavidade oral e seios paranasais, o manejo das lesões representam um desafio mesmo à cirurgiões experientes. OBJETIVO: Estre trabalho relata o manejo cirúrgico de uma ferida auto-infligida por arma de fogo que resultou em avulsão dos tecidos moles na região maxilofacial. DESCRIÇÃO DO CASO: Paciente do sexo masculino, 35 anos, vítima de projétil de arma de fogo auto-infligido em região maxilofacial, cursando com extenso ferimento em região de língua e mento. Clinicamente, o paciente não apresentava sinais de fratura em ossos da face. Ambos os ferimentos apresentavam secreção purulenta e o paciente manifestava disfonia devido a grande destruição tecidual. CONSIDERAÇÕES FINAIS: O tratamento de ferimentos por arma de fogo não só é um grande desafio para o cirurgião, como para toda a equipe multidisciplinar requerida para tais casos, visto que não há protocolos bem definidos para o tratamento dessas lesões(AU)

INTRODUCTION: The management of patients who are victims of FAP has divergent aspects regarding surgical treatment, which can be performed immediately or late. In self-inflicted injuries, the distance between the weapon and the affected region is smaller, causing more devastating aesthetic and functional consequences. Allied to the fact that this type of trauma creates a dirty wound due to the communication with the oral cavity and paranasal sinuses, the management of injuries represents a challenge even for experienced surgeons. OBJECTIVE: This paper reports the surgical management of a self-inflicted gunshot wound that resulted in soft tissue avulsion in the maxillofacial region. CASE DESCRIPTION: Male patient, 35 years old, victim of a self-inflicted firearm projectile in the maxillofacial region, coursing with extensive injury in the region of the tongue and chin. Clinically, the patient did not show signs of facial bone fractures. Both wounds had purulent secretion and the patient had dysphonia due to extensive tissue destruction. FINAL CONSIDERATIONS: The treatment of gunshot wounds is not only a great challenge for the surgeon, but also for the entire multidisciplinary team required for such cases, since there are no well-defined protocols for the treatment of these injuries(AU)

[Prehospital Care Times and Interventions for Victims of Major Trauma in the Central Region of Portugal: A Retrospective Study]. / Tempos de Resposta e Intervenções Extra-Hospitalar à Vítima de Trauma Major na Região Centro de Portugal: Um Estudo Retrospetivo.

INTRODUCTION: The quality and promptness of prehospital care for major trauma patients are vital in order to lower their high mortality rate. However, the effectiveness of this response in Portugal is unknown. The objective of this study was to analyze response times and interventions for major trauma patients in the central region of Portugal. METHODS: This was a retrospective, descriptive study, using the 2022 clinical records of the National Institute of Medical Emergency's differentiated resources. Cases of death prior to arrival at the hospital and other non-transport situations were excluded. Five-time intervals were determined, among which are the response time (T1, between activation and arrival at the scene), on-scene time (T2), and transportation time (T5; between the decision to transport and arrival at the emergency service). For each ambulance type, averages and dispersion times were calculated, as well as the proportion of cases in which the nationally and internationally recommended times were met. The frequency of recording six key interventions was also assessed. RESULTS: Of the 3366 records, 602 were eliminated (384 due to death), resulting in 2764 cases: nurse-technician ambulance (SIV) = 36.0%, physician- nurse ambulance (VMER) = 62.2% and physician-nurse helicopter = 1.8%. In a very large number of records, it was not possible to determine prehospital care times: for example, transport time (T5) could be determined in only 29%, 13% and 8% of cases, respectively for SIV, VMER and helicopter. The recommended time for stabilization (T2 ≤ 20 min) was met in 19.8% (SIV), 36.5% (VMER) and 18.2% (helicopter). Time to hospital (T5 ≤ 45 min) was achieved in 80.0% (SIV), 93.1% (VMER) and 75.0% (helicopter) of the records. The administration of analgesia (42% in SIV) and measures to prevent hypothermia (23.5% in SIV) were the most recorded interventions. CONCLUSION: There was substantial missing data on statuses and a lack of information in the records, especially in the VMER and helicopter. According to the records, the time taken to stabilize the victim on-scene often exceeded the recommendations, while the time taken to transport them to the hospital tended to be within the recommendations.

Introdução: A qualidade e rapidez do socorro pré-hospitalar à pessoa vítima de trauma major é vital para diminuir a sua elevada mortalidade. Contudo, desconhece-se a efetividade desta resposta em Portugal. O objetivo deste estudo foi analisar os tempos de resposta e as intervenções realizadas às vítimas de trauma major na região centro de Portugal. Métodos: Estudo retrospetivo, descritivo, utilizando os registos clínicos de 2022 dos meios diferenciados do Instituto Nacional de Emergência Médica. Casos de óbito pré-chegada ao hospital e outras situações de não transporte foram excluídos. Determinaram-se cinco tempos, entre os quais o tempo de resposta (T1, decorrente entre acionamento e chegada ao local), o tempo no local (T2) e o tempo de transporte (T5, intervalo entre a decisão de transporte e a chegada ao serviço de urgência). Foram calculadas médias e medidas de dispersão para cada meio, bem como a proporção de casos em que foram cumpridos os tempos recomendados nacional e internacionalmente. Avaliou-se também a frequência de registo de seis intervenções chave. Resultados: Dos 3366 registos, eliminaram-se 602 (384 por óbito), resultando em 2764 casos [suporte imediato de vida (SIV) = 36,0%, viaturas médicas de emergência e reanimação (VMER) = 62,2%, helicóptero de emergência médica (HEM) = 1,8%]. Num elevado número de registos não foi possível determinar tempos de socorro: por exemplo, o tempo de transporte (T5) foi determinável em apenas 29%, 13%, e 8% dos casos, respetivamente para SIV, VMER e HEM. O tempo recomendado para a estabilização (T2 ≤ 20 min), foi cumprido em 19,8% (SIV), 36,5% (VMER), e 18,2% (HEM) dos regis- tos. Já o tempo de transporte (T5 ≤ 45 min) foi cumprido em 80,0% (SIV), 93,1% (VMER) e 75,0% (HEM) dos registos (avaliáveis). A administração de analgesia (42% na SIV) e as medidas de prevenção de hipotermia (23,5% na SIV) foram as intervenções mais registadas. Conclusão: Observaram-se muitos status omissos e falta de informação nos registos, sobretudo na VMER e HEM. De acordo com os registos, o tempo no local superou frequentemente as recomendações, enquanto o tempo de transporte tende a estar dentro das normas.

Assessing the quality of emergency department data for injury surveillance in Victoria, Australia: a comparative analysis of two Victorian hospital data sources.

OBJECTIVE: The emergency department (ED) is pivotal in treating serious injuries, making it a valuable source for population-based injury surveillance. In Victoria, information that is relevant to injury surveillance is collected in the Victorian Emergency Minimum Dataset (VEMD). This study aims to assess the data quality of the VEMD as an injury data source by comparing it with the Victorian Admitted Episodes Dataset (VAED). DESIGN: A retrospective observational study of administrative healthcare data. SETTING AND PARTICIPANTS: VEMD and VAED data from July 2014 to June 2019 were compared. Including only hospitals contributing to both datasets, cases that (1) arrived at the ED and (2) were subsequently admitted, were selected. RESULTS: While the overall number of cases was similar, VAED outnumbered VEMD cases (414 630 vs 404 608), suggesting potential under-reporting of injuries in the ED. Age-related differences indicated a relative under-representation of older individuals in the VEMD. Injuries caused by falls or transport, and intentional injuries were relatively under-reported in the VEMD. CONCLUSIONS: Injury cases were more numerous in the VAED than in the VEMD even though the number is expected to be equal based on case selection. Older patients were under-represented in the VEMD; this could partly be attributed to patients being admitted for an injury after they presented to the ED with a non-injury ailment. The patterns of under-representation described in this study should be taken into account in ED-based injury incidence reporting.

Exploring the effect of wound related pain on psychological stress, inflammatory response, and wound healing.

AIMS AND OBJECTIVES: The relationship between pain and poor healing is intricate, potentially mediated by psychological stress and aberrations in inflammatory response. The purpose of this study was to examine the biopsychosocial model of pain by assessing the relationships between pain, stress, inflammation and healing in people with chronic wounds. DESIGN: This was a 4-week prospective observational study to explore the relationship of pain, stress, inflammation and wound healing in a convenience sample of patients with chronic wounds in a chronic care hospital in Canada. METHODS: Only subjects over 18 with chronic wounds were recruited into the study. Chronic wounds were defined by the duration of wounds for more than 4 weeks of various aetiologies including wounds caused by pressure injuries, venous disease, arterial insufficiency, surgery or trauma and diabetic neuropathy. Participants were evaluated for pain by responding to the Brief Pain Inventory-Short Form, the McGill Pain Questionnaire-Short Form and the Leeds Assessment of Neuropathic Symptoms and Signs scale. Stress was measured by the Perceived Stress Scale (PSS). All wounds were assessed with the Pressure Ulcer Scale for Healing tool. The levels of matrix metalloproteinases were analysis by obtaining wound fluid from all participants. RESULTS: A total of 32 individuals with chronic wounds participated in the study. Correlation analysis indicated pain severity was positively and significantly related to pain interference, McGill Pain Questionnaire scores, neuropathic pain and matrix metalloproteinase levels. Logistic regression was used to determine the predictors for high or low perceived stress. The only significant variable that contributed to the stress levels was BPI-I. Results suggested that participants who experienced higher levels of pain interference also had an increased odds to report high level of stress by 1.6 times controlling for all other factor in the model. CONCLUSION: Pain is a complex biopsychosocial phenomenon affecting quality of life in people with chronic wounds. Results of this study identified a significant relationship between pain, stress and wound healing.

Nanomaterial strategies in wound healing: A comprehensive review of nanoparticles, nanofibres and nanosheets.

Wound healing is a complex process that orchestrates the coordinated action of various cells, cytokines and growth factors. Nanotechnology offers exciting new possibilities for enhancing the healing process by providing novel materials and approaches to deliver bioactive molecules to the wound site. This article elucidates recent advancements in utilizing nanoparticles, nanofibres and nanosheets for wound healing. It comprehensively discusses the advantages and limitations of each of these materials, as well as their potential applications in various types of wounds. Each of these materials, despite sharing common properties, can exhibit distinct practical characteristics that render them particularly valuable for healing various types of wounds. In this review, our primary focus is to provide a comprehensive overview of the current state-of-the-art in applying nanoparticles, nanofibres, nanosheets and their combinations to wound healing, serving as a valuable resource to guide researchers in their appropriate utilization of these nanomaterials in wound-healing research. Further studies are necessary to gain insight into the application of this type of nanomaterials in clinical settings.

Applying a Trauma-Informed Lens to Challenging Adolescent Encounters: A Faculty Development Session for Pediatricians.

Introduction: Patient encounters perceived to be challenging are common and contribute to both suboptimal patient health outcomes and provider burnout. A trauma-informed care (TIC) approach to these encounters is critical, as many of the characteristics associated with challenging patient encounters can be linked to a history of trauma exposure. Methods: Our team created and delivered a 1-hour synchronous virtual session intended to bolster provider knowledge of TIC principles and their application to challenging adolescent encounters. Participants were all faculty and staff engaged in pediatric primary care at an urban academic center, including physicians, nurse practitioners, psychologists, and social workers. The content was rooted in adult learning principles and included didactic components anchored to case-based learning with facilitated group discussions and opportunities for reflection. We used paired pre- and postsession self-assessments of provider knowledge, confidence, and practice related to TIC using Likert-scale and free-text questions. Descriptive statistics and a paired t test were used to determine the impact of the session on these metrics. Results: In 24 paired surveys, there were statistically significant increases (p ≤ .001) in participant perceived knowledge, confidence, and practice, with 100% of participants having a statistically significant improvement in one or more of these domains. There were also strongly positive Likert-scale and free-text responses regarding content relevance and delivery. Discussion: We demonstrate that a brief session can create improvement in pediatric providers' perceived knowledge about the application of TIC principles to challenging adolescent encounters as well as confidence in their ability to put these into practice.

My Magical Day in the Trauma ICU.

Healing is a difficult concept to describe, quantify, or replicate. It is a complex mixture of personal contributions from the professional providing care, including competence, compassion, and empathy, that conjoins with the needs, sensitivities, and receptivity of the one who is receiving the care. Although it may be difficult to predict all the elements that come together to initiate sustained healing, as well as the long-term impact, it is important to observe the moments that make a difference. For those who study the nature of healing, a patient's reflections can surface the kinds of elements that are present when healing is sustained. [J Contin Educ Nurs. 2024;55(7):326-327.].

Concentrated surfactant gel dressing for effective wound healing in pediatric patients: a case series.

BACKGROUND: CSG dressing is water-soluble and helps to hydrate the wound, control exudate, and provide gentle debridement by virtue of a high concentration of surfactant micelles. The primary objective of this retrospective case series is to report on the feasibility of CSG use in pediatric wounds and its mechanism of action. The secondary aim was to measure pain during application and removal of CSG. METHODS: Eight pediatric patients ranging in age from newborn to a few months old with wounds requiring medical intervention were treated with CSG. The CSG dressing was applied twice daily at initiation of treatment in some patients, but mostly once daily. NIPS was utilized for pain measurements. RESULTS: Near-complete healing of wounds was observed by the end of treatment duration, which was only a few days. The calm temperament of these patients during dressing changes and objective NIPS suggested minimal to no pain. None of the patients experienced any adverse events related to the use of this dressing. CONCLUSION: The CSG dressing could be the dressing of choice in this population to enhance debridement and maintain moist healing and support granulation, either proactively or if other treatments fail.

Granulation-embedded autologous skin grafting improves healing chronic wounds at high altitudes: a pilot study.

BACKGROUND: The management of chronic wounds presents a challenge for surgeons. In this pilot study, the authors established a novel auto-grafting approach for chronic wounds and evaluated its efficacy. PURPOSE: The objective of this pilot study was to observe the clinical efficacy of granulation-embedded skin grafting for the treatment of chronic wounds at high altitudes. METHODS: The data of 45 patients with chronic wounds were obtained from the medical records of the Yushu People's Hospital. Patients were divided into stamp skin-grafting and granulation-embedded skin-grafting groups. Skin graft survival rate, wound coverage rate, and wound-healing time were observed and recorded. The length of hospital stay and 1% total body surface area (TBSA) treatment cost were compared. RESULTS: Significant differences were noted in skin graft survival rate (94% ± 3% vs 86% ± 3%, P < .01), wound coverage rate on postoperative day 7 (61% ± 16% vs 54% ± 18%, P < .01), and wound-healing times (23 ± 2.52 days vs 31 ± 3.61 days, P < .05). The length of hospital stay and 1% TBSA treatment cost were significantly reduced in the granulation-embedded skin grafting group (P < .05). CONCLUSIONS: Granulation-embedded skin grafting can improve the healing of chronic wounds at high altitudes. These findings provide a new approach to the clinical treatment of chronic wounds.

Extracorporeal shockwave therapy (ESWT) in an outpatient wound care clinic: case series analysis of a non-invasive technology in the management of chronic wounds for wound bed preparation.

BACKGROUND: Extracorporeal shockwave therapy (ESWT) has been shown to reduce wound dimensions and healing time in chronic wounds and should be considered a valuable tool in the healing of chronic complex lower extremity wounds. PURPOSE: The aim of this small case series was to evaluate the effect of ESWT on complex chronic wounds in patients with multiple comorbidities in a medically underserved outpatient wound care clinic setting. METHODS: All patients had baseline wound measurements taken. Pictures of the wounds were also taken at the time of the initial visit. Patients selected for ESWT received weekly treatments for a maximum recorded duration of 12 weeks in the form of focused electro-hydraulic acoustic pulses. Wound beds were cleansed according to standard of care. RESULTS: Thirteen patients were followed with a total of 18 wounds treated. After retrospectively analyzing the data, 3 subjects and a total of 5 wounds were excluded, leaving 10 total subjects and 13 wounds. Out of these wounds, 12 healed completely by or before week 12 of ESWT. All wounds demonstrated significant wound dimension reduction during the first 12 weeks of treatment. CONCLUSION: ESWT could offer accessible, fast, safe, and cost-effective management of some complex chronic wounds. Further research is needed to validate these findings.

The Challenge of Chronic Wounds in Older Adults.

Care for the older patient living with a chronic wound comes with challenges not seen in younger patients. The aging skin, impacted by the environment and intrinsic physiologic changes, makes it susceptible to injury and poor healing. Likewise, older adults' goals with regards to wound healing may vary depending on their functional abilities and quality of life. The clinician must pay attention to these nuances and collaborate with the older patient in developing a treatment plan. Careful systematic description, documentation, and communication with the patient/caregiver aids the clinician in tracking the treatment goals and potentially reducing medical liability risk.

Surgical Aspects of Wound Care in Older Adults.

The physical, emotional, and financial toll of acute and chronic nonhealing wounds on older adults and their caregivers is immense. Surgical treatment of wounds in older adults can facilitate healing but must consider the medical complexity of the patient, the patient's desires for treatment and the likelihood of healing. Innovative approaches and devices can promote rapid healing. By using a team approach, from preoperative planning to postoperative care, with a focus on the needs and desires of the patient, successful outcomes with improved patient satisfaction are possible even in medically complex patients.

Wound Bed Preparation and Treatment Modalities.

Wound healing is a highly complex natural process, and its failure results in chronic wounds. The causes of delayed wound healing include patient-related and local wound factors. The main local impediments to delayed healing are the presence of nonviable tissue, excessive inflammation, infection, and moisture imbalance. For wounds that can be healed with adequate blood supply, a stepwise approach to identify and treat these barriers is termed wound bed preparation. Currently, a combination of patient-related and local factors, including wound debridement, specialty dressings, and advanced technologies, is available and successfully used to facilitate the healing process.

The Chronic Wound-Related Pain Model: Holistic Assessment and Person-Centered Treatment.

Chronic wound-related pain is a complex biopsychosocial experience that is experienced spontaneously at rest and exacerbated during activities. Tissue debridement, trauma at dressing change, increased bioburden or infection, exposure of periwound skin to moisture, and related treatment can modulate chronic wound-related pain. Clinicians should consider multimodal and multidisciplinary management approach that take into account the biology, emotions, cognitive thinking, social environment, and other personal determinants of pain. Unresolved pain can have a significant impact on wound healing, patients' adherence to treatment, and individual's quality of life.

Nutritional Aspects of Wound Care.

Malnutrition is a collective term that includes both undernutrition and malnutrition. Malnutrition presents with and without inflammation, is reported in underweight, normal weight, and overweight individuals, and is associated with undesirable alterations in body composition, and diminished functional status. Older adults commonly experience dwindling nutritional status as evidenced by insidious weight loss, insufficient dietary intake, loss of muscle mass, quality, and strength, declining functional status, and other physical and emotional decline indicators. Sustained pressure, acute trauma, malnutrition, and inflammatory-driven chronic conditions increase the risk for skin integrity issues.

Other Wounds Encountered in Clinical Practice.

This chapter delves into uncommon wounds including pyoderma gangrenosum, sickle cell disease ulcers, vasculitic wounds, Martorell hypertensive ischemic leg ulcers, and malignant ulcers. Emphasizing a multidisciplinary approach, it covers diagnostics, treatments, and challenges, with case studies illustrating complexities in managing these conditions. The discussion extends to radiation-related wounds, underscoring the need for patient-centered care, interdisciplinary collaboration, and realistic goal setting. Overall, the chapter navigates the intricacies of uncommon wounds, emphasizing the importance of tailored approaches for improved outcomes in patients with diverse underlying conditions.