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1.
Dimens Crit Care Nurs ; 40(3): 192-201, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33792279

RESUMEN

BACKGROUND: Massive transfusion (MT) in trauma is initiated on the basis of factors of different natures and depending on protocols and scales used both in prehospital and in-hospital care areas. OBJECTIVE: The main goal was to analyze and relate factors and predictive variables for MT requirements considering both health care areas. METHOD: This was a retrospective cohort study that included patients who were treated either at the emergency department of a large hospital or through prehospital care before arrival at the hospital. The patients included were adults who received MT, defined as a blood bank request of 10 or more units of red cells in the first 24 hours or 5 or more within 4 hours of trauma, from January 1, 2009, to January 1, 2017. The variables included were individual characteristics and those associated with the trauma, clinical-analytical assessment, resuscitation, timing, and survival. RESULTS: A total of 52 patients who received MT were included. The average age of the patients was 41.23 ± 16.06 years, a mean of 19.56 ± 12.77 units was administered, and the mortality rate was 21.2%. DISCUSSION: Injury mechanism, clinical-analytical variables, and resuscitation strategies have a significant influence on the need for MT; therefore, early identification is fundamental for performing quality management and addressing avoidable factors during MT processes.


Asunto(s)
Urgencias Médicas , Heridas y Traumatismos , Adulto , Transfusión Sanguínea , Hospitales , Humanos , Puntaje de Gravedad del Traumatismo , Persona de Mediana Edad , Estudios Retrospectivos , Centros Traumatológicos , Heridas y Traumatismos/terapia
2.
Bone Joint J ; 103-B(4): 769-774, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33789468

RESUMEN

AIMS: Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). METHODS: Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. RESULTS: In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. CONCLUSION: A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769-774.


Asunto(s)
Fracturas del Fémur/cirugía , Puntaje de Gravedad del Traumatismo , Traumatismos de la Pierna/cirugía , Fracturas de la Tibia/cirugía , Amputación , Femenino , Humanos , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Calidad de Vida , Sistema de Registros , Victoria
3.
Bone Joint J ; 103-B(4): 746-754, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33789481

RESUMEN

AIMS: Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. METHODS: A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). RESULTS: The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (ppreop = 0.05; pdischarge < 0.001) and need for narcotics (ppreop = 0.064; ppostop = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. CONCLUSION: Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746-754.


Asunto(s)
Fracturas de Tobillo/complicaciones , Edema/etiología , Edema/prevención & control , Aparatos de Compresión Neumática Intermitente , Femenino , Alemania , Humanos , Puntaje de Gravedad del Traumatismo , Extremidad Inferior/irrigación sanguínea , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Estudios Prospectivos
5.
BMC Surg ; 21(1): 142, 2021 Mar 19.
Artículo en Inglés | MEDLINE | ID: mdl-33740945

RESUMEN

BACKGROUND: We present here our experience with surgical management of traumatic diaphragmatic hernia, trying to find out the era impact of different periods on the outcome and risk factors of mortality. METHODS: A series of 63 patients with traumatic diaphragmatic hernia were referred to us and operated on during March, 1990-August, 2017. The patient records were reviewed and statistically analyzed to demonstrate injury characteristics and to find out optimal treatment strategy, risk factors of death as well as the difference between two periods (1990-2005, 2005-2017) divided by introduction of computed tomography at our institution. RESULTS: The overall mean age was 31.2 ± 16.3 years old with a female to male ratio of 11/52. The mechanism was penetrating trauma in 19 cases (30.2%), and blunt trauma in 44 cases (69.9%). Two thirds of the patients in the second group (2005-2017) yet none in the first group (1990-2005) underwent computed tomography. Ten patients (15.9%), of which 8 in the first and the other 2 in the second group (p = .042), had late diagnoses. The most commonly used incision was a thoracotomy (n = 43, 89.6%). There was no statistical difference in etiology or mortality between the two periods. Univariate analysis showed survivors were younger, and had lesser injury severity scores (ISS) and lower American Association for the Surgery of Trauma (AAST) grade than non-survivors. By multivariate logistic regression analysis, increased age (odds ratio, 1.275; p = .013) and greater ISS (OR, 1.174; p = .028) were risk factors of death in all patients. CONCLUSIONS: High-definition computed tomography has significantly improved the preoperative diagnosis rate. The transthoracic approach could be used in selected cases with traumatic diaphragmatic hernia with good outcomes. Patients with greater ISS and advanced ages are at a higher risk of death.


Asunto(s)
Hernia Diafragmática Traumática , Heridas no Penetrantes , Heridas Penetrantes , Adolescente , Adulto , Femenino , Hernia Diafragmática Traumática/mortalidad , Hernia Diafragmática Traumática/cirugía , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Factores de Riesgo , Resultado del Tratamiento , Heridas no Penetrantes/mortalidad , Heridas no Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Heridas Penetrantes/cirugía , Adulto Joven
6.
Isr Med Assoc J ; 23(3): 180-185, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-33734632

RESUMEN

BACKGROUND: Pancreatic trauma is uncommon in pediatric patients and presents diagnostic and therapeutic challenges. While non-operative management (NOM) of minor pancreatic injuries is well accepted, the management of major pancreatic injuries remains controversial. OBJECTIVES: To evaluate management strategies for major blunt pancreatic injury in children. METHODS: Data were retrospectively collected for all children treated for grade III or higher pancreatic injury due to blunt abdominal trauma from 1992 to 2015 at two medical centers. Data included demographics, mechanism of injury, laboratory and imaging studies, management strategy, clinical course, operative findings, and outcome. RESULTS: The cohort included seven boys and four girls aged 4-15 years old (median 9). Six patients had associated abdominal (mainly liver, n=3) injuries. The main mechanism of injury was bicycle (handlebar) trauma (n=6). Five patients had grade III injury and six had grade IV. The highest mean amylase level was recorded at 48 hours after injury (1418 U/L). Management strategies included conservative (n=5) and operative treatment (n=6): distal (n=3) and central (n=1) pancreatectomy, drainage only (n=2) based on the computed tomography findings and patient hemodynamic stability. Pseudocyst developed in all NOM patients (n=5) and two OM cases, and one patient developed a pancreatic fistula. There were no differences in average length of hospital stay. CONCLUSIONS: NOM of high-grade blunt pancreatic injury in children may pose a higher risk of pseudocyst formation than OM, with a similar hospitalization time. However, pseudocyst is a relatively benign complication with a high rate of spontaneous resolution with no need for surgical intervention.


Asunto(s)
Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/epidemiología , Páncreas/lesiones , Heridas no Penetrantes/diagnóstico , Heridas no Penetrantes/epidemiología , Traumatismos Abdominales/terapia , Adolescente , Factores de Edad , Niño , Preescolar , Drenaje , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Masculino , Pancreatectomía , Estudios Retrospectivos , Heridas no Penetrantes/terapia
7.
Medicine (Baltimore) ; 100(10): e25056, 2021 Mar 12.
Artículo en Inglés | MEDLINE | ID: mdl-33725892

RESUMEN

ABSTRACT: Sacral fracture is the most frequent posterior injury among unstable pelvic ring fractures and is prone to massive hemorrhage and hemodynamic instability. Contrast extravasation (CE) on computed tomography (CT) is widely used as an indicator of significant arterial bleeding. However, while CE is effective to detect significant arterial bleeding but negative result cannot completely rule out massive bleeding. Therefore, additional factors help to compensate CE for the prediction of early hemodynamically unstable condition.We evaluated the risk factors that predict CE on enhanced computed CT in patients with sacral fractures. Patients were classified into 2 groups: CE positive on enhanced CT of the pelvis [CE(+)] and CE negative [CE(-)]. We compared age, sex, injury severity score (ISS), systolic blood pressure (sBP), type of sacral fracture based on Denis classification, platelet (PLT), base excess, lactate, prothrombin time-international normalized ratio, hemoglobin (Hb), activated partial thromboplastin time, D-dimer, and fibrinogen between the 2 groups.A total of 82 patients were treated for sacral fracture, of whom 69 patients were enrolled. There were 17 patients (10 men and 7 women) in CE(+) and 52 patients (28 men and 24 women) in CE(-). Age, ISS, and blood transfusion within 24 hours were significantly higher in the CE(+) group than in the CE(-) group (P = .023, P < .001, P < .001). sBP, Hb, PLT, fibrinogen were significantly lower in the CE(+) group than in the CE(-) group (P < .001, P < .001, P < .001, P < .001). D-dimer and lactate were higher in the CE(+) group than in the CE(-) group (P = .036, P < .001) with significant differences. On multivariate analysis, the level of fibrinogen was an independent predictor of CE(+). The area under the curve value for fibrinogen was 0.88, and the optimal cut-off value for prediction was 199 mg/dL.The fibrinogen levels on admission can predict contrast extravasation on enhanced CT in patients with sacral fractures. The optimal cut-off value of fibrinogen for CE(+) prediction in sacral fracture was 199 mg/dL. The use of fibrinogen to predict CE(+) could lead to prompt and effective treatment of active arterial hemorrhage in sacral fracture.


Asunto(s)
Extravasación de Materiales Terapéuticos y Diagnósticos/etiología , Fibrinógeno/análisis , Hemorragia/diagnóstico , Sacro/lesiones , Fracturas de la Columna Vertebral/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Medios de Contraste/administración & dosificación , Estudios de Factibilidad , Femenino , Hemorragia/sangre , Hemorragia/etiología , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Observacionales como Asunto , Admisión del Paciente , Pronóstico , Curva ROC , Valores de Referencia , Estudios Retrospectivos , Sacro/irrigación sanguínea , Sacro/diagnóstico por imagen , Fracturas de la Columna Vertebral/sangre , Fracturas de la Columna Vertebral/diagnóstico , Tomografía Computarizada por Rayos X
8.
Rev Col Bras Cir ; 48: e20202784, 2021.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-33787764

RESUMEN

OBJECTIVE: the aim of this study was to identify associated factors with the increased length of hospital stay for patients undergoing surgical treatment for liver trauma, and predictors of mortality as well as the epidemiology of this trauma. METHODS: retrospective study of 191 patients admitted to the Cajuru University Hospital, a reference in the treatment of multiple trauma patients, between 2010 and 2017, with epidemiological, clinicopathological and therapeutic variables analyzed using the STATA version 15.0 program. RESULTS: most of the included patients were men with a mean age of 29 years. Firearm injury represents the most common trauma mechanism. The right hepatic lobe was injured in 51.2% of the cases, and hepatorraphy was the most commonly used surgical correction. The length of hospital stay was an average of 11 (0-78) days and the length of stay in the intensive care unit was 5 (0-52) days. Predictors for longer hospital stay were the mechanisms of trauma, hemodynamic instability at admission, number of associated injuries, degree of liver damage and affected lobe, used surgical technique, presence of complications, need for reoperation and other surgical procedures. Mortality rate was 22.7%. CONCLUSIONS: the study corroborated the epidemiology reported by the literature. Greater severity of liver trauma and associated injuries characterize patients undergoing surgical treatment, who have increased hospital stay due to the penetrating trauma, hemodynamic instability, hepatic packaging, complications and reoperations.


Asunto(s)
Armas de Fuego , Heridas por Arma de Fuego , Adulto , Hospitalización , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Hígado/lesiones , Hígado/cirugía , Masculino , Estudios Retrospectivos , Centros Traumatológicos
9.
ANZ J Surg ; 91(4): 633-638, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33656252

RESUMEN

BACKGROUND: The New Zealand government implemented restrictive public health interventions to eradicate Covid-19. Early reports suggest that one downstream ramification is a change in trauma presentations. The aim of this study is to evaluate the effect these public health measures had on major trauma admissions in the Northern Region, New Zealand. METHODS: A retrospective comparative cohort study was performed. Two cohorts were identified: 16 March to 8 June 2020 and the same period in 2019. Data was extracted from the New Zealand Major Trauma Registry which prospectively collects data on all major trauma in New Zealand. All patients who presented to a hospital in the Northern Region with major trauma and met the Registry inclusion criteria were included. RESULTS: There were 163 major trauma admissions in 2019 and 123 in 2020, a reduction of 25% (rate ratio 0.75, 95% confidence interval 0.6-0.95; P = 0.018). There was no significant difference in mechanism of injury (P = 0.442), type of injury (P = 0.062) or intent of injury (P = 0.971). There was a significant difference in place of injury (P = 0.004) with 20% of injuries happening at home in 2019 compared with 35% in 2020. CONCLUSION: This study has shown that public health interventions to prevent the spread of COVID-19 reduced major trauma admissions in the Northern Region of New Zealand. There was a variation in effect a between institutions within the region and a change in pattern of injury.


Asunto(s)
Hospitalización/estadística & datos numéricos , Salud Pública , Heridas y Traumatismos/epidemiología , Estudios de Cohortes , Humanos , Puntaje de Gravedad del Traumatismo , Nueva Zelanda/epidemiología , Estudios Retrospectivos , Centros Traumatológicos/estadística & datos numéricos
10.
Rev Col Bras Cir ; 48: e20202769, 2021.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-33656134

RESUMEN

PURPOSE: to analyze the relation between Trauma Quality Indicators (QI) and death, as well as clinical adverse events in severe trauma patients. METHODS: analysis of data collected in the Trauma Register between 2014-2015, including patients with Injury Severity Score (ISS) > 16, reviewing the QI: (F1) Acute subdural hematoma drainage > 4 hours with Glasgow Coma Scale (GCS) <9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours; (F4) Admission-laparotomy time greater than 60 min in hemodynamically instable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time > 6 hours; (F10) Surgery > 24 hours. T the chi-squared and Fisher tests were used to calculate statistical relevance, considering p<0.05 as relevant. RESULTS: 127 patients were included, whose ISS ranged from 17 to 75 (28.8 + 11.5). There were adverse events in 80 cases (63%) and 29 died (22.8%). Twenty-six patients had some QI compromised (20.6%). From the 101 patients with no QI, 22% died, and 7 of 26 patients with compromised QI (26.9%) (p=0.595). From the patients with no compromised QI, 62% presented some adverse event. From the patients with any compromised QI, 18 (65.4%) had some adverse event on clinical evolution (p=0.751). CONCLUSION: the QI should not be used as death or adverse events predictors in severe trauma patients.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Hemorragia , Indicadores de Calidad de la Atención de Salud , Adolescente , Adulto , Anciano , Escala de Coma de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Persona de Mediana Edad , Estudios Retrospectivos , Índices de Gravedad del Trauma , Adulto Joven
11.
Int J Qual Health Care ; 33(1)2021 Mar 11.
Artículo en Inglés | MEDLINE | ID: mdl-33693687

RESUMEN

OBJECTIVE: Injury coding is well known for lack of completeness and accuracy. The objective of this study was to perform a nationwide assessment of accuracy and reliability on Abbreviated Injury Scale (AIS) coding by Dutch Trauma Registry (DTR) coders and to determine the effect on Injury Severity Score (ISS). Additionally, the coders' characteristics were surveyed. METHODS: Three fictional trauma cases were presented to all Dutch trauma coders in a nationwide survey (response rate 69%). The coders were asked to extract and code the cases' injuries according to the AIS manual (version 2005, update 2008). Reference standard was set by three highly experienced coders. Summary statistics were used to describe the registered AIS codes and ISS distribution. The primary outcome measures were accuracy of injury coding and inter-rater agreement on AIS codes. Secondary outcome measures were characteristics of coders: profession, work setting, experience in injury coding and training level in injury coding. RESULTS: The total number of different AIS codes used to describe 14 separate injuries in the three cases was 89. Mean accuracy per AIS code was 42.2% (range 2.4-92.7%). Mean accuracy on number of AIS codes was 23%. Overall inter-rater agreement per AIS code was 49.1% (range 2.4-92.7%). The number of assigned AIS codes varied between 0 and 18 per injury. Twenty-seven percentage of injuries were overlooked. ISS was correctly scored in 42.4%. In 31.7%, the AIS coding of the two more complex cases led to incorrect classification of the patient as ISS < 16 or ISS ≥ 16. Half (47%) of the coders had no (para)medical degree, 26% were working in level I trauma centers, 37% had less than 2 years of experience and 40% had no training in AIS coding. CONCLUSIONS: Accuracy of and inter-rater agreement on AIS injury scoring by DTR coders is limited. This may in part be due to the heterogeneous backgrounds and training levels of the coders. As a result of the inconsistent coding, the number of major trauma patients in the DTR may be over- or underestimated. Conclusions based on DTR data should therefore be drawn with caution.


Asunto(s)
Codificación Clínica/normas , Sistema de Registros/normas , Centros Traumatológicos/normas , Heridas y Traumatismos/clasificación , Humanos , Puntaje de Gravedad del Traumatismo , Países Bajos , Reproducibilidad de los Resultados
12.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 33(2): 223-228, 2021 Feb.
Artículo en Chino | MEDLINE | ID: mdl-33729144

RESUMEN

OBJECTIVE: To study the dynamic changes of cellular immune function in peripheral blood of trauma patients and its role in the evaluation of traumatic complications. METHODS: A prospective cohort study design was conducted. Patients with blunt trauma admitted to Chongqing Emergency Medical Center from November 2019 to January 2020 were consecutively enrolled. The peripheral blood samples were collected at 1, 3, 5, 7, and 14 days after injury. The expressions of CD64, CD274, and CD279 on the surface of neutrophils, lymphocytes, and monocytes as well as CD3+, CD4+ and CD8+ T lymphocyte subsets were measured by flow cytometry. The trauma patients were divided into different groups according to the injury severity score (ISS) and sepsis within 28 days after injury, respectively. The dynamic changes of cellular immune function in different time points after injury and differences between different groups were compared. Furthermore, the correlation with acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), and ISS were evaluated by Pearson correlation analysis. RESULTS: A total of 42 patients with trauma were finally enrolled, containing 8 severe trauma patients with ISS greater than 25 scores, 17 patients with ISS between 16 and 25 scores, and 17 patients with ISS less than 16 scores. The sepsis morbidity rates were 14.3% (n = 6) within 28 days after injury. CD64 index and CD4+ T lymphocyte subsets were significantly increased at different time points after trauma (H = 15.464, P = 0.004; F = 2.491, P = 0.035). The CD64 index and positive rates of CD279 in neutrophils, lymphocytes, and monocytes were increased with the severity of injury at day 1 and day 3 after injury, respectively. At the first day after injury, CD64 index were 2.81±1.79, 1.77±0.92, 3.49±1.09; positive rate of CD279 in neutrophils were 1.40% (0.32%, 2.04%), 0.95% (0.44%, 2.70%), 12.73% (3.00%, 25.20%); positive rate of CD279 in lymphocytes were 3.77% (3.04%, 5.15%), 4.71% (4.08%, 6.32%), 8.01% (4.59%, 11.59%); positive rate of CD279 in monocytes were 0.57% (0.24%, 1.09%), 0.85% (0.22%, 1.25%), 6.74% (2.61%, 18.94%) from mild to severe injury groups, respectively. The CD64 index in severe injury group was significantly higher than that in moderate group, and the positive rates of CD279 in neutrophils, lymphocytes and monocytes of severe injury patients were higher than those in other two groups (all P < 0.05). At 3rd day after injury, compared to moderate group, severe injury patients had significantly higher CD64 index and positive rate of CD279 in lymphocytes [4.58±2.41 vs. 2.43±1.68, 7.35% (5.90%, 12.28%) vs. 4.63% (3.26%, 6.06%), both P < 0.05]. Compared with the non-sepsis patients, the sepsis patients had significantly higher CD64 index and positive rate of CD279 in monocytes at day 1 after injury [4.06±1.72 vs. 2.36±1.31, 3.29% (1.14%, 12.84%) vs. 0.67% (0.25%, 1.48%), both P < 0.05], and positive rate of CD279 in lymphocytes significantly higher at 3rd day after injury [8.73% (7.52%, 15.82%) vs. 4.67% (3.82%, 6.21%), P < 0.05]. In addition, correlation analysis showed that positive rate of CD279 in lymphocytes was positively correlated with SOFA and ISS, respectively (r values were 0.533 and 0.394, both P < 0.05), positive rate of CD279 in monocytes was positively correlated with APACHE II, SOFA and ISS scores, respectively (r values were 0.579, 0.452 and 0.490, all P < 0.01), positive rate of CD279 in neutrophils was positively correlated with APACHE II and ISS, respectively (r values were 0.358 and 0.388, both P < 0.05). CONCLUSIONS: CD64 index and CD279 expression in neutrophils, lymphocytes, and monocytes are significantly related to the severity and prognosis of trauma. Dynamic monitoring the cellular immune function may be helpful for assessing the prognosis of trauma patients.


Asunto(s)
Sepsis , APACHE , Humanos , Inmunidad , Puntaje de Gravedad del Traumatismo , Pronóstico , Estudios Prospectivos , Curva ROC , Estudios Retrospectivos
13.
Eur J Radiol ; 137: 109578, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33561627

RESUMEN

PURPOSE: To address the disagreement about the need for splenic artery embolization (SAE) in medium grade blunt splenic trauma this retrospective study evaluates the clinical outcome of non-operative management (NOM) and the possible impact of a more liberal indication for primary SAE. METHOD: From 01/2010 to 12/2019 186 patients presented with splenic injury on computed tomography (CT) after blunt abdominal trauma. The extent of splenic injuries according to Marmery, vascular pathologies, active bleeding as well as clinical and laboratory parameters were recorded and analyzed with regard to the success rates of NOM and SAE. Procedural complications and clinical outcome were noted. The number needed to treat (NNT) was determined for a possible extension of the indication for SAE to grade 3 injuries. RESULTS: Of 186 patients 126 were managed non-operatively, 47 underwent primary SAE and twelve splenectomy. NOM was successful in 119/126 (94 %) patients. Conversion rate was significantly higher in patients with active bleeding or vascular pathology. Patients with failed NOM had a significantly greater decrease in haemoglobin and haematocrit levels. Primary SAE was successful in 45/47 (96 %) cases. Major complications occurred in four cases (9%), all managed without sequela. The NNT in grade 3 splenic injuries equals 13. CONCLUSIONS: NOM of low to medium-grade blunt splenic trauma has a low failure rate. Presence of active haemorrhage is the most important predictor for failure of NOM. SAE should be reserved for high-grade injuries and visible vascular pathology or active bleeding to avoid a disproportionate increase in the NNT.


Asunto(s)
Traumatismos Abdominales , Embolización Terapéutica , Heridas no Penetrantes , Humanos , Puntaje de Gravedad del Traumatismo , Estudios Retrospectivos , Arteria Esplénica/diagnóstico por imagen , Resultado del Tratamiento , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/terapia
14.
Medicine (Baltimore) ; 100(6): e24438, 2021 Feb 12.
Artículo en Inglés | MEDLINE | ID: mdl-33578536

RESUMEN

ABSTRACT: Despite its public health significance, TBI management across US healthcare institutions and patient characteristics with an emphasis on utilization and outcomes of TBI-specific procedures have not been evaluated at the national level.We aimed to characterize top 10 procedure codes among hospitalized adults with TBI as primary diagnosis by injury severity.A Cross-sectional study was conducted using 546, 548 hospitalization records from the 2004 to 2014 Nationwide Inpatient Sample were analyzed.Data elements of interest included injury, patient, hospital characteristics, procedures, in-hospital death and length of stay.Ten top procedure codes were "Closure of skin and subcutaneous tissue of other sites", "Insertion of endotracheal tube", "Continuous invasive mechanical ventilation for less than 96 consecutive hours", "Venous catheterization (not elsewhere classified)", "Continuous invasive mechanical ventilation for 96 consecutive hours or more", "Transfusion of packed cells", "Incision of cerebral meninges", "Serum transfusion (not elsewhere classified)", "Temporary tracheostomy", and "Arterial catherization". Prevalence rates ranged between 3.1% and 15.5%, with variations according to injury severity and over time. Whereas "Closure of skin and subcutaneous tissue of other sites" was associated with fewer in-hospital deaths and shorter hospitalizations, "Temporary tracheostomy" was associated with fewer in-hospital deaths among moderate-to-severe TBI patients, and "Continuous invasive mechanical ventilation for less than 96 consecutive hours" was associated with shorter hospitalizations among severe TBI patients. Other procedures were associated with worse outcomes.Nationwide, the most frequently reported hospitalization procedure codes among TBI patients aimed at homeostatic stabilization and differed in prevalence, trends, and outcomes according to injury severity.


Asunto(s)
Lesiones Traumáticas del Encéfalo/terapia , Adolescente , Adulto , Anciano , Lesiones Traumáticas del Encéfalo/mortalidad , Lesiones Traumáticas del Encéfalo/patología , Estudios Transversales , Femenino , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Puntaje de Gravedad del Traumatismo , Clasificación Internacional de Enfermedades , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estados Unidos , Adulto Joven
15.
JAMA Netw Open ; 4(2): e211320, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33616667

RESUMEN

Importance: Describing the changes in trauma volume and injury patterns during the course of the coronavirus disease 2019 (COVID-19) pandemic could help to inform policy development and hospital resource planning. Objective: To examine trends in trauma admissions throughout Los Angeles County (LAC) during the pandemic. Design, Setting, and Participants: In this cohort study, all trauma admissions to the 15 verified level 1 and level 2 trauma centers in LAC from January 1 to June 7, 2020 were reviewed. All trauma admissions from the same period in 2019 were used as historical control. For overall admissions, the study period was divided into 3 intervals based on daily admission trend analysis (January 1 through February 28, March 1 through April 9, April 10 through June 7). For the blunt trauma subgroup analysis, the study period was divided into 3 similar intervals (January 1 through February 27, February 28 through April 5, April 6 through June 7). Exposures: COVID-19 pandemic. Main Outcomes and Measures: Trends in trauma admission volume and injury patterns. Results: A total of 6777 patients in 2020 and 6937 in 2019 met inclusion criteria. Of those admitted in 2020, the median (interquartile range) age was 42 (28-61) years and 5100 (75.3%) were men. Mechanisms of injury were significantly different between the 2 years, with a higher incidence of penetrating trauma and fewer blunt injuries in 2020 compared with 2019 (penetrating: 1065 [15.7%] vs 1065 [15.4%]; blunt: 5309 [78.3%] vs 5528 [79.7%]). Overall admissions by interval in 2020 were 2681, 1684, and 2412, whereas in 2019 they were 2462, 1862, and 2613, respectively. There was a significant increase in overall admissions per week during the first interval (incidence rate ratio [IRR], 1.02; 95% CI, 1.002-1.04; P = .03) followed by a decrease in the second interval (IRR, 0.92; 95% CI, 0.90-0.94; P < .001) and, finally, an increase in the third interval (IRR, 1.05; CI, 1.03-1.07; P < .001). On subgroup analysis, blunt admissions followed a similar pattern to overall admissions, while penetrating admissions increased throughout the study period. Conclusions and Relevance: In this study, trauma centers throughout LAC experienced a significant change in injury patterns and admission trends during the COVID-19 pandemic. A transient decrease in volume was followed by a quick return to baseline levels. Trauma centers should prioritize maintaining access, capacity, and functionality during pandemics and other national emergencies.


Asunto(s)
/epidemiología , Hospitalización/tendencias , Centros Traumatológicos , Heridas y Traumatismos/epidemiología , Escala Resumida de Traumatismos , Accidentes por Caídas/estadística & datos numéricos , Accidentes de Tránsito/estadística & datos numéricos , Adulto , Mordeduras y Picaduras/epidemiología , California/epidemiología , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Los Angeles/epidemiología , Masculino , Persona de Mediana Edad , Violencia/estadística & datos numéricos , Heridas por Arma de Fuego/epidemiología , Heridas Punzantes/epidemiología
16.
J Trauma Acute Care Surg ; 90(2): 376-383, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33502149

RESUMEN

BACKGROUND: As the prevalence of obesity has increased, trauma centers are faced with managing this expanding demographics' unique care requirements. Research on the effects of body mass index (BMI) in trauma patients remains conflicting. This study aims to evaluate the impact of BMI on patterns of injury and patient outcomes following trauma. METHODS: Patients from 87 hospitals' trauma registries were selected. Those missing height, weight, disposition, or who died in the emergency department were excluded. The BMI categories were calculated from admission height and weight and verified against the electronic medical records. Patients were grouped by the National Institutes of Health-defined obesity class and compared by rate of mortality and in-hospital complications. Logistic regression was used to estimate associations, adjusting for age, gender, race, Injury Severity Score, and number of comorbidities. RESULTS: There were 191,274 patients, 53% male; mean age was 60.4 years, mean Glasgow Coma Scale score 14.4, mean Injury Severity Score of 8.8, and 40.4% normal weight. Increased BMI was associated with an injury pattern of increased rates of extremity fractures (humerus, femur, tibia/fibula) and decreased rates of hip fractures and head injuries. Compared with the normal weight group, patients were more likely to die if they were Underweight (adjusted odds ratio [AOR], 1.18; 95% confidence interval [CI], 1.01-1.38), obese class II (AOR, 1.24; 95% CI, 1.07-1.45), or obese class III (AOR, 1.55; 95% CI, 1.29-1.87). Obese class III was associated with higher odds of a National Trauma Data Standard complication (AOR, 1.20; 95% CI, 1.11-1.30). CONCLUSION: In this large multicenter study, increasing BMI and lower than normal BMI were strongly associated with higher mortality. Increasing BMI was also associated with longer length of stay, increased complications, and unique injury patterns. These untoward outcomes, coupled with a distinct injury pattern, warrant care guidelines specific to trauma patients with higher BMI, as well as those with BMI lower than normal. LEVEL OF EVIDENCE: Epidemiological, Level III.


Asunto(s)
Traumatismos Craneocerebrales , Fracturas Óseas , Mortalidad , Obesidad , Delgadez , Heridas y Traumatismos , Índice de Masa Corporal , Comorbilidad , Traumatismos Craneocerebrales/epidemiología , Traumatismos Craneocerebrales/etiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Fracturas Óseas/epidemiología , Fracturas Óseas/etiología , Hospitalización/estadística & datos numéricos , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Obesidad/diagnóstico , Obesidad/epidemiología , Evaluación de Resultado en la Atención de Salud , Pronóstico , Sistema de Registros/estadística & datos numéricos , Delgadez/diagnóstico , Delgadez/epidemiología , Centros Traumatológicos/estadística & datos numéricos , Estados Unidos/epidemiología , Heridas y Traumatismos/clasificación , Heridas y Traumatismos/complicaciones , Heridas y Traumatismos/diagnóstico , Heridas y Traumatismos/mortalidad
17.
J Trauma Acute Care Surg ; 90(2): 403-412, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33502151

RESUMEN

BACKGROUND: Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care. METHODS: Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings. RESULTS: Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting. CONCLUSION: Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds. LEVEL OF EVIDENCE: Systematic review, level III.


Asunto(s)
Servicios Médicos de Urgencia/métodos , Evaluación Geriátrica/métodos , Triaje , Heridas y Traumatismos/diagnóstico , Anciano , Errores Diagnósticos/prevención & control , Humanos , Puntaje de Gravedad del Traumatismo , Triaje/métodos , Triaje/normas
18.
Mil Med ; 186(Suppl 1): 316-323, 2021 01 25.
Artículo en Inglés | MEDLINE | ID: mdl-33499492

RESUMEN

INTRODUCTION: Rapid sequence intubation of patients experiencing traumatic hemorrhage represents a precarious phase of care, which can be marked by hemodynamic instability and pulseless arrest. Military combat trauma guidelines recommend reduced induction dose and early blood product resuscitation. Few studies have evaluated the role of induction dose and preintubation transfusion on hemodynamic outcomes. We compared rates of postintubation systolic blood pressure (SBP) of < 70 mm Hg, > 30% drop in SBP, pulseless arrest, and mortality at 24 hours and 30 days among patients who did and did not receive blood products before intubation and then examined if induction agent and dose influenced the same outcomes. MATERIALS AND METHODS: A retrospective analysis was performed of battle-injured personnel presenting to surgical care facilities in Iraq and Afghanistan between 2004 and 2018. Those who received blood transfusions, underwent intubation, and had an Injury Severity Score of ≥15 were included. Intubation for primary head, facial, or neck injury, burns, operative room intubations, or those with cardiopulmonary resuscitation in progress were excluded. Multivariable logistic regression was performed with unadjusted and adjusted odds ratios for the five study outcomes among patients who did and did not receive preintubation blood products. The same analysis was performed for patients who received full or excessive versus partial induction agent dose. RESULTS: A total of 153 patients had a mean age of 24.9 (SD 4.5), Injury Severity Score 29.7 (SD 11.2), heart rate 122.8 (SD 24), SBP 108.2 (SD 26.6). Eighty-one (53%) patients received preintubation blood products and had similar characteristics to those who did not receive transfusions. Adjusted multivariate analysis found odds ratios as follows: 30% SBP decrease 9.4 (95% CI 2.3-38.0), SBP < 70 13.0 (95% CI 3.3-51.6), pulseless arrest 18.5 (95% CI 1.2-279.3), 24-hour mortality 3.8 (95% CI 0.7-21.5), and 30-day mortality 1.3 (0.4-4.7). In analysis of induction agent choice and comparison of induction agent dose, no statistically significant benefit was seen. CONCLUSION: Within the context of this historical cohort, the early use of blood products conferred a statistically significant benefit in reducing postintubation hypotension and pulseless arrest among combat trauma victims exposed to traumatic hemorrhage. Induction agent choice and dose did not significantly influence the hemodynamic or mortality outcomes.


Asunto(s)
Personal Militar , Afganistán , Humanos , Puntaje de Gravedad del Traumatismo , Irak , Intubación e Inducción de Secuencia Rápida , Estudios Retrospectivos , Heridas y Traumatismos/complicaciones , Heridas y Traumatismos/terapia
19.
Am J Surg ; 221(3): 606-608, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33485622

RESUMEN

BACKGROUND: Many institutions obtain a delayed head CT in patients presenting after a ground level fall while on anticoagulation. This study evaluates their risk of delayed ICH. METHODS: Retrospective chart review of 635 patients on anticoagulation who sustained a ground level fall with a negative initial head CT and a GCS above eight. Patients underwent a repeat head CT within 48 h. The ISS was calculated for all patients. RESULTS: Five patients had a delayed ICH. All survived and none required neurosurgical intervention. Patient variables did not have any correlation with development of ICH. Patients with a delayed ICH had a significantly higher ISS. CONCLUSION: Patients on anticoagulation presenting to the hospital after a ground level fall, with a GCS above eight and an initial negative head CT, do not need to undergo repeat imaging. ISS could be used to stratify patients who are at higher risk of delayed ICH.


Asunto(s)
Accidentes por Caídas , Anticoagulantes/uso terapéutico , Traumatismos Craneocerebrales/diagnóstico por imagen , Hemorragias Intracraneales/diagnóstico por imagen , Hemorragias Intracraneales/epidemiología , Anciano , Traumatismos Craneocerebrales/complicaciones , Femenino , Escala de Coma de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Estudios Retrospectivos , Factores de Tiempo , Tomografía Computarizada por Rayos X
20.
Health Qual Life Outcomes ; 19(1): 18, 2021 Jan 08.
Artículo en Inglés | MEDLINE | ID: mdl-33419450

RESUMEN

BACKGROUND: The long-term fate of severely injured patients in terms of their quality of life is not well known. Our aim was to assess the quality of life of patients who have suffered moderate to severe trauma and to identify primary factors of long-term quality of life impairment. METHODS: A prospective monocentric study conducted on a number of patients who were victims of moderate to severe injuries during the year 2012. Patients were selected based on an Injury Severity Score (ISS) more than or equal to 9. Quality of life was assessed by the MOS SF-36 and NHP scores as a primary evaluation criterion. The secondary evaluation criteria were the determination of the socio-economic impact on quality of life and the identification of factors associated with disability. RESULTS: Two hundred and eight patients were contacted by e-mail or telephone. Fifty-five patients participated in this study (with a participation level of 26.4%), including 78.2% men, with a median age of 46. Significant alterations in quality of life were observed with the NHP and MOS SF-36 scale, including physical and psychological components. This resulted in a major socio-economic impact as 26% of the patients could not resume their professional activities (n = 10), 20% required retraining in other lines of work, and 36.4% had a disability status. The study showed that scores ≤ 85 on the physical functioning variable of the MOS SF 36 scale was associated with disability. CONCLUSION: More than five years after a moderate to severe injury, patients' quality of life was significantly impacted, resulting in significant socio-economic consequences. Disability secondary to major trauma seems to be associated with a score ≤ 85 on the physical functioning dimension of the MOS SF-36 scale. This study raises the question of whether or not early rehabilitation programs should be implemented in order to limit the long-term impact of major trauma.


Asunto(s)
Personas con Discapacidad/psicología , Personas con Discapacidad/estadística & datos numéricos , Calidad de Vida/psicología , Heridas y Traumatismos/psicología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Francia , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto Joven
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