Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing.

INTRODUCTION: in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality. METHODS: a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing. RESULTS: data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05). CONCLUSION: age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

Use of alcohol and illicit drugs by trauma patients in Sao Paulo, Brazil.

INTRODUCTION: Alcohol and illicit drugs impair cognitive and psychomotor skills and may thereby increase the risk of involvement in a road traffic crash and other types of injuries. However, the knowledge on the use of psychoactive substances among injured patients presenting to emergency departments in low and middle-income countries remains limited. AIMS: To estimate the prevalence of alcohol and illicit drug use among patients with traumatic injuries admitted to an emergency department in Sao Paulo, Brazil. METHODS: Blood samples from injured patients requiring hospitalization for more than 24 h due to road traffic crashes, falls, or violence, were collected from July 2018 to June 2019. The samples were analyzed for alcohol and illicit drugs. RESULTS: A total of 376 patients were included in this study; the median age was 36 years and 80% of patients were male. The majority (56%) of injuries resulted from road traffic crashes, with approximately half of them being motorcyclists. Alcohol, drugs, or both were detected in 32% of samples. The proportion that tested positive was highest for males (35%), for the age group 18-39 years (41%), for singles (43%), and for patients injured at nighttime (44%). Patients injured due to violence had the highest prevalence of alcohol or drugs in their blood samples (44%). Alcohol was most prevalent (23%), followed by cocaine (12%) and cannabis (5%). CONCLUSION: The use of alcohol and illicit drugs was common among injured patients in Sao Paulo; it was likely a contributing factor in a third of the injurious accidents. Alcohol was the most prevalent substance followed by cocaine and cannabis.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing / Fatores preditivos de mortalidade em pacientes com fratura de pelve e instabilidade hemodinâmica submetidos ao tamponamento extraperitoneal de pelve

ABSTRACT Introduction: in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality. Methods: a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing. Results: data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05). Conclusion: age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

RESUMO Introdução: nas últimas décadas, tem sido difundida a técnica de tamponamento pélvico extraperitoneal, porém ainda existem poucos estudos. Decidiu-se analisar os resultados do tamponamento extraperitoneal de pelve, em pacientes com fratura pélvica e choque, com objetivo de identificar fatores preditivos de mortalidade. Métodos: foi realizada revisão do prontuário dos pacientes submetidos ao tamponamento extraperitoneal de pelve. Foram analisadas as características dos pacientes, dados do atendimento pré-hospitalar e na sala de emergência, classificação da fratura, presença de lesões associadas, exames laboratoriais e de imagem, dados relativos ao tamponamento, e outros procedimentos realizados, complicações, parâmetros hemodinâmicos e quantidade de hemoderivados transfudidos. Resultados: foram analisados os dados de 51 pacientes, com sinais de choque desde o atendimento pré-hospitalar, presença de acidose, elevado déficit de bases e lactato arterial. Houve alta prevalência de lesões graves associadas, requerendo múltiplos procedimentos cirúrgicos. A incidência de coagulopatia foi 70,58% e mortalidade 56,86%. O grupo de pacientes não sobreviventes apresentou idade e intubação orotraqueal pré-hospitalar maiores, e escores na escala de coma de Glasgow menores (p<0,05). O mesmo grupo apresentou, antes e após o tamponamento extraperitoneal de pelve, parâmetros hemodinâmicos menores de pressão arterial média, pH, déficit de bases e hemoglobina, e maior de lactato arterial (p<0,05). O grupo de pacientes não sobreviventes recebeu mais concentrados de hemácias, plasma fresco congelado e concentrado de plaquetas nas 24h seguintes ao tamponamento extraperitoneal de pelve (p<0,05). Conclusão: idade e o excesso de bases são fatores preditivos independentes de mortalidade em pacientes submetidos ao tamponamento extraperitoneal de pelve.

Outcomes of Elderly Patients Undergoing Emergency Surgery for Complicated Colorectal Cancer: A Retrospective Cohort Study.

OBJECTIVE: Colorectal cancer is one of the most frequent types of malignant neoplasms. Age is a risk factor for this disease, with 75% of cases diagnosed in patients older than 65 years. Complications such as obstruction, hemorrhage, and perforation are present in more than one-third of cases and require emergency treatment. We aim to analyze the profile of elderly patients undergoing surgery for complicated colorectal cancer, and to evaluate factors related to worse short-term prognosis. METHODS: A retrospective analysis of patients who underwent emergency surgical treatment for complicated colorectal cancer was performed. Demographics, clinical, radiological and histological data were collected. RESULTS: Sixty-seven patients were analyzed. The median age was 72 years, and almost half (46%) of the patients were female. Obstruction was the most prevalent complication at initial presentation (72%). The most common sites of neoplasia were the left and sigmoid colon in 22 patients (32.8%), and the right colon in 17 patients (25.4%). Resection was performed in 88% of cases, followed by primary anastomosis in almost half. The most frequent clinical stages were II (48%) and III (22%). Forty-three patients (65.7%) had some form of postoperative complication. Clavien-Dindo grades 1, 2, and 4, were the most frequent. Complete oncologic resection was observed in 80% of the cases. The thirty-day mortality rate was 10.4%. Advanced age was associated with worse morbidity and mortality. CONCLUSION: Elderly patients with complicated colorectal cancer undergoing emergency surgery have high morbidity and mortality rates. Advanced age is significantly associated with worse outcomes.

Outcomes of elderly patients undergoing emergency surgery for complicated colorectal cancer: a retrospective cohort study

OBJECTIVE: Colorectal cancer is one of the most frequent types of malignant neoplasms. Age is a risk factor for this disease, with 75% of cases diagnosed in patients older than 65 years. Complications such as obstruction, hemorrhage, and perforation are present in more than one-third of cases and require emergency treatment. We aim to analyze the profile of elderly patients undergoing surgery for complicated colorectal cancer, and to evaluate factors related to worse short-term prognosis. METHODS: A retrospective analysis of patients who underwent emergency surgical treatment for complicated colorectal cancer was performed. Demographics, clinical, radiological and histological data were collected. RESULTS: Sixty-seven patients were analyzed. The median age was 72 years, and almost half (46%) of the patients were female. Obstruction was the most prevalent complication at initial presentation (72%). The most common sites of neoplasia were the left and sigmoid colon in 22 patients (32.8%), and the right colon in 17 patients (25.4%). Resection was performed in 88% of cases, followed by primary anastomosis in almost half. The most frequent clinical stages were II (48%) and III (22%). Forty-three patients (65.7%) had some form of postoperative complication. Clavien-Dindo grades 1, 2, and 4, were the most frequent. Complete oncologic resection was observed in 80% of the cases. The thirty-day mortality rate was 10.4%. Advanced age was associated with worse morbidity and mortality. CONCLUSION: Elderly patients with complicated colorectal cancer undergoing emergency surgery have high morbidity and mortality rates. Advanced age is significantly associated with worse outcomes.

Factors related to motorcycle accidents with victims: an epidemiological survey / Fatores relacionados com os acidentes de motocicleta: estudo epidemiológico

OBJECTIVE: To evaluate the factors associated with traffic motorcycles accidents. METHODS: The sample consisted of 285 motorcycle accident victims in São Paulo. Data were collected from 24-hour emergency service shifts regarding: conditions of the victims, security equipment, road and vehicle conditions. RESULTS: Victims were mostly young men (92%); 23% used the motorcycle for work (average: 8 hours per day); 45% had owned a motorcycle for less than two years; 77% were licensed motorcycle drivers; 33% had less than four years of qualification; 31% had attended a course of defensive driving. Severe lesions were identified in 67% of the unlicensed drivers. Polytrauma occurred in 9% head trauma in 5% of the entire population. Lower limb fractures occurred more frequently than upper limb (17% vs. 12%). Most wore helmets (90%) but only 18% wore helmet, boots and jacket. Positive readings for alcohol (7%) and drugs (14%) occurred in 21% of victims. Most accidents occurred as a consequence of imprudence (88%), during the day (67%), in dry weather conditions (94%). A side impact was registered in 48% of cases; 80% of motorcycles had an engine capacity up to 250 cc. In 51% of the accidents the person responsible for the accident was the driver of the other vehicle in the accident. CONCLUSION: Most accidents involve motorcyclists who are young male adults, use the motorcycle as a means of transport and do not consider safety, defensive driving and the use of alcohol and drugs as important factors.

OBJETIVOS: Avaliar fatores associados com acidentes de trânsito com motocicletas. MÉTODOS: Foram avaliadas 285 vítimas de acidente de motocicleta em São Paulo. Os dados foram coletados em plantões nas unidades de emergência. Foram coletadas informações sobre: condições das vítimas, uso de equipamentos de segurança, condições de estrada e veículo. RESULTADOS: As vítimas eram principalmente homens jovens (92%); 23% usavam a motocicleta para o trabalho (média: 8 horas por dia); 45% possuíam a motocicleta por menos de dois anos; 77% tinham habilitação para dirigir; 33% tinham menos de quatro anos de habilitação; 31% tinham feito curso de direção defensiva. Lesões graves foram identificadas em 67% dos motoristas não habilitados. Houve politraumatismo em 9% das vítimas e traumatismo craniano em 5% da população avaliada. Fraturas de membros inferiores ocorreram mais frequentemente do em membros superiores (17% contra 12%). A maioria usava capacetes (90%), mas apenas 18% usava capacete, botas e jaqueta. Dosagens positivas de álcool (7%) e drogas (14%) foram vistas e totalizaram 21% de todas as vítimas. A maioria dos acidentes ocorreu como consequência de imprudência (88%), durante o dia (67%) e sem chuva (94%). CONCLUSÃO: A maioria dos acidentes envolve vítimas do sexo masculino, adultos, que usam a motocicleta como meio de transporte e não consideram equipamentos de segurança, condução defensiva e o consumo de álcool e drogas fatores importantes para prevenção dos acidentes.

Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone.

OBJECTIVE:: To present our experience in the management of patients with infected pancreatic necrosis without drainage. METHODS:: The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed. RESULTS:: We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died. CONCLUSIONS:: In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.

Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone

OBJECTIVE: To present our experience in the management of patients with infected pancreatic necrosis without drainage. METHODS: The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed. RESULTS: We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died. CONCLUSIONS: In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.

Safety in selective surgical exploration in penetrating neck trauma.

BACKGROUND: Selective management of penetrating neck injuries has been considered the standard of care with minimal risks to patient safety. In a previous non-randomized prospective study conducted at our center, selective management proved to be safe and reduced unnecessary exploratory cervicotomies. In the present study, the role of clinical examination and selective diagnostic tests were assessed by reviewing demographic and clinical data. A comparison of results between two groups (mandatory surgical exploration versus selective surgical exploration) was made to check the safety of selective management in terms of the rates of morbidity and mortality. METHODS: A retrospective analysis at the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo was performed by a chart review of our trauma registry, identifying 161 penetrating neck trauma victims. RESULTS: Of the 161 patients, 81.6 % were stabbed and 18.4 % had gunshot injuries. Stratifying the wound entry points by neck zones, we observed that zone I was penetrated in 32.8 %, zone II in 44.1 % and zone III in 23.1 % of all the cases. Thirty one patients (19.2 %) had immediate surgical exploration, which had a mean length of stay of 6 days, a complication rate of 12.9 % and a mortality rate of 9.4 %. Of the 130 who underwent selective surgical exploration 34 (26.1 %) required operative procedures after careful physical examination and diagnostic testing based on clinical indications. The mean length of stay for the selective surgical exploration group was 2 days with a complication rate of 17.6 % with no mortality, and virtually all of them were related to associated injuries in distant body segment. No statistical significance was found comparing mortality and complication rates between the two groups. Selective approach avoided 59 % of unnecessary exploratory cervicotomies. CONCLUSION: Careful evaluation of asymptomatic and stable patients with minor signs of injury can safely avoid unnecessary neck explorations with low rates of morbidity. This should be the standard management of such patients.

Alcohol and drug involvement in motorcycle driver injuries in the city of Sao Paulo, Brazil: Analysis of crash culpability and other associated factors.

BACKGROUND: Earlier studies have already identified that a greater proportion of injured drivers are under the effects of illicit drugs than alcohol in Brazil, but the crash risk attributable to each substance is still unknown. METHODS: Injured motorcycle drivers who were involved in traffic accidents in the West Zone of the city of Sao Paulo were recruited for a cross-sectional study based on crash culpability analysis. Alcohol and drug positivity among drivers was evaluated according to their responsibility for the crash. Culpability ratios were generated based on the proportion of drivers who were deemed culpable in relation to those considered not culpable according to the use of drugs and alcohol. RESULTS: Of the 273 drivers recruited, 10.6% tested positive for alcohol. Among those who were also tested for drugs (n=232), 20.3% had consumed either alcohol and/or other drugs, 15.5% of whom were positive only for drugs other than alcohol, specifically cannabis and cocaine. Drivers who tested positive for alcohol were significantly less likely to possess a valid driver's license and to report driving professionally, whereas those who had consumed only drugs were more likely to drive professionally. The culpability ratio estimated for alcohol-positive drivers was three times higher than that for alcohol-free drivers, showing a superior ratio than drivers who had consumed only drugs other than alcohol, who presented a 1.7 times higher culpability ratio than drug-free drivers. CONCLUSION: Substance use was overrepresented among culpable motorcycle drivers, with alcohol showing a greater contribution to crash culpability than other drugs.

Can we respect the principles of oncologic resection in an emergency surgery to treat colon cancer?

Patients with colorectal cancer admitted to the emergency room are generally at more advanced stage of the disease and are usually submitted to a resection with curative intent in a smaller scale. In such scenario, one of the aspects to be considered is whether the principles of oncologic resection are observed when those patients diagnosed with colon cancer are treated with surgery. We selected 87 patients with adenocarcinoma of colon and/or upper rectum submitted to an emergency surgical resection. The major variables reviewed retrospectively were: the extent of resection performed, the number of dissected regional lymph nodes and the overall survival rate. Intestinal obstruction was observed in 67 patients (77%) while perforation was found in 20 patients (23%). Seven (8%) specimens had circumferential compromised margins, all found in patients with T4 tumors combine with poor clinical status. The number of dissected regional lymph nodes was greater than, or equal to, 12 in 71% of patients. While the average days of stay in the ICU was 5.7 days, the median was 3 days. The morbidity and peri-operative mortality stood at 33.6% and 20%, respectively. The outcome of an emergency surgery of colorectal cancer observed in this study was similar to those found in the literature. The principles of oncologic resection were respected when considering and analyzing the extent of the resection, the surgical margins and the number of dissected lymph nodes.

Diagnostic value of tomography of the cervical spine in victims of blunt trauma.

OBJECTIVE: to assess the value of computed tomography in the diagnosis of cervical spine and spinal cord injuries in victims of blunt trauma. METHODS: we reviewed the charts of blunt trauma victims from January 2006 to December 2008. We analyzed the following data: epidemiology, mechanism of trauma, transportation of victims to the hospital, intra-hospital care, indication criteria for CT, diagnosis, treatment and evolution of the victims. The victims were divided into two groups: Group I - without cervical spine injury, Group II - with cervical spine injury. RESULTS: we gathered medical records from 3,101 victims. Computed tomography was performed in 1572 (51%) patients, with male predominance (79%) and mean age of 38.53 years in Group I and 37.60 years in Group II. The distribution of trauma mechanisms was similar in both groups. Lesions found included: 53 fractures, eight vertebral listeses and eight spinal cord injuries. Sequelae included: paraplegia in three cases, quadriplegia in eight and brain injury in five. There were seven deaths in Group II and 240 in Group I. The average length of hospital stay was 11 days for Group I and 26.2 days for Group II. CONCLUSION. A CT scan of the cervical spine in victims of blunt trauma was effective in identifying lesions of the cervical spine and spinal cord injuries. Thus, despite the cost of neck CT and the low incidence of lesions identified by it, its indication based on the usual criteria seems justified.

Valor diagnóstico da tomografia de coluna cervical em vítimas de trauma contuso / Diagnostic value of tomography of the cervical spine in victims of blunt trauma

OBJETIVO. Avaliar o valor da tomografia computadorizada no diagnóstico de lesões da coluna e medula cervicais em vítimas de trauma contuso. MÉTODOS. Revisão dos prontuários de vítimas de trauma contuso atendidas de janeiro de 2006 a dezembro de 2008. Foram analisados os seguintes dados: epidemiológicos, mecanismo de trauma, transporte das vítimas para o hospital, atendimento intra-hospitalar, critérios de indicação da TC, diagnóstico, tratamento, e evolução das vítimas em estudo. As vítimas foram distribuídas em dois grupos: Grupo I - sem lesão na coluna cervical; Grupo II - com lesão na coluna cervical . RESULTADOS. Foram analisados os prontuários de 3.101 vítimas. A tomografia computadorizada foi indicada em 1.572 (51 por cento) pacientes, Foi observado predomínio masculino entre as vítimas (79 por cento), com média etária de 38,53 anos no Grupo I e 37,60 anos no Grupo II. A distribuição dos mecanismos de trauma foi semelhante nos dois grupos. Lesões encontradas: 53 fraturas, oito listeses vertebrais e oito lesões medulares. As sequelas incluíram: três paraplegias, cinco tetraplegias e oito sequelas de lesão cerebral. No Grupo II ocorreram sete óbitos ,no Grupo I 240. A duração média de internação hospitalar foi de 11 dias para o Grupo I e 26,2 dias para o Grupo II. CONCLUSÃO. A TC de coluna cervical em vítimas de trauma contuso foi eficaz na identificação de lesões da coluna e medula cervicais. Assim, apesar do custo da TC cervical, e da baixa incidência de lesões por ela identificáveis, a sua indicação baseada nos critérios usuais parece justificável.

OBJECTIVE: to assess the value of computed tomography in the diagnosis of cervical spine and spinal cord injuries in victims of blunt trauma. METHODS: we reviewed the charts of blunt trauma victims from January 2006 to December 2008. We analyzed the following data: epidemiology, mechanism of trauma, transportation of victims to the hospital, intra-hospital care, indication criteria for CT, diagnosis, treatment and evolution of the victims. The victims were divided into two groups: Group I - without cervical spine injury, Group II - with cervical spine injury. RESULTS: we gathered medical records from 3,101 victims. Computed tomography was performed in 1572 (51 percent) patients, with male predominance (79 percent) and mean age of 38.53 years in Group I and 37.60 years in Group II. The distribution of trauma mechanisms was similar in both groups. Lesions found included: 53 fractures, eight vertebral listeses and eight spinal cord injuries. Sequelae included: paraplegia in three cases, quadriplegia in eight and brain injury in five. There were seven deaths in Group II and 240 in Group I. The average length of hospital stay was 11 days for Group I and 26.2 days for Group II. CONCLUSION. A CT scan of the cervical spine in victims of blunt trauma was effective in identifying lesions of the cervical spine and spinal cord injuries. Thus, despite the cost of neck CT and the low incidence of lesions identified by it, its indication based on the usual criteria seems justified.

Ruptura traumatica de diverticulo duodenal: relato de um caso e revisao da literatura / Traumatic rupture of duodenal diverticulum: report of a case and review of literature

O diverticulo duodenal e uma anormalidade anatomica comum. Sua perfuracao decorrente de processo inflamatorio e bastante rara, com menos de 100 relatos na literatura consultada. Mais rara ainda e a perfuracao traumatica, representada apenas por tres casos relatados. Os autores relatam um caso de ruptura traumatica de diverticulo duodenal, e fazem uma revisao da literatura, focalizando a patogenia, o diagnostico e a terapeutica desta grave patologia

Ferimentos laringotraqueais / Laryngotracheal injury

Realizado um estudo retrospectivo de 54 pacientes vítimas de ferimentos laringotraqueais, com o objetivo de se reverem os princípios básicos do diagnóstico e tratamento. As lesöes foram devidas a ferimento penetrante em 88,8 por cento e trauma fechado em 11,2 por cento dos casos. Em 14 casos, a lesäo foi a nível supraglótico, um a nível glótico, 18 infraglótico e, em 21 casos, a lesäo foi traqueal. Em 14 casos houve necessidade de canulaçäo da via aérea na admissäo. Em sete casos, com ferimentos leves supraglóticos, a lesäo foi tratada de maneira conservadora. Os demais casos foram operados , e as lesöes foram suturadas em todos os pacientes. Associamos a traqueostomia nos ferimentos a nível glótico e nas lesöes extensas. Ocorreram complicaçöes em 12 pacientes (22,2 por cento), e seis faleceram (11,1 por cento). A mortalidade esteve intimamente associada à presença de traumatismo raquimedular e à lesäo de esôfago. Analisando nossos dados, concluímos que os princípios do diagnóstico e tratamento säo: 1) Nos casos com desconforto respiratório, a entubaçäo orotraqueal ou canulaçäo das lesöes é prioritária; 2) O diagnóstico é habitualmente feito pela história do trauma, exame físico, RX e laringoscopia; 3) É de suma importância a avaliaçäo do esôfago; 4) As lesöes leves a nível supraglótico podem ser tratadas de maneira conservadora; 5) As demais lesöes devem ser tratadas cirurgicamente, com sutura, reduçäo das fraturas de cartilagem associadas à traqueostomia nos ferimentos glóticos, nos ferimentos laringotraqueais extensos e quando houver trauma raquimedular concomitante

Baläo de tamponamento em ferimentos transfixantes de fígado: resultados imediatos / Balloon tamponade in transfixing wounds of the liver: immediates results

O tratamento cirúrgico das lesöes traumáticas transfixantes do fígado e acompanhadas de grandes hemorragias costuma ser tecnicamente difícil. Näo raramente ocorre óbito de pacientes por exsanguinaçäo intra-operatória. A adoçäo das técnicas convencionais de tamponamento ou ressecçäo costuma levar a índices de elevados de complicaçöes pós-operatórias. Motivados por estes fatos os autores desenvolveram dispositivo de tamponamento de fácil confecçäo e aplicaçäo. Esta comunicaçäo relata a experiência nos primeiros nove casos em que foi utilizado. O dispositivo mostrou-se eficiente em todos os casos, ocorreu um óbito, por lesöes associadas, uma complicaçäo que exigiu reintervençäo e seis fístulas biliares que se resolveram espontaneamente. Tais resultados confirmam a utilidade do método proposto e permitem recomendar sua utilizaçäo

Complicaçöes raras em hérnias: relato de um caso de apendicite aguda em hérnia incisional / Rare complications in hernias: report of a case of acute appendicitis in incisional hernia

Descreve-se um caso de apendicite aguda ocorrido em uma hérnia incisional de longa duraçäo. Faz-se uma revisäo da literatura, encontrando-se apenas um caso semelhante. Comenta-se a dificuldade do diagnóstico diferencial com estrangulamento de hérnia

Ferimentos de veia cava inferior: análise de 75 casos / Injuries of the inferior vena cava: analysis of 75 cases

Apesar da diminuiçäo dos índices de mortalidade observados nas duas últimas décadas, os ferimentos de veia cava inferior (VCI) revestem-se ainda de muita gravidade. A análise de 75 casos com lesöes traumáticas de VCI, que constituem o motivo desta apresentaçäo, revelou índice de mortalidade de 32%, ocasionada principalmente por abundantes hemorragias e lesöes viscerais associadas. Embora tais resultados sejam aceitáveis e comparáveis aos da literatura, cumpre frisar que as lesöes de VCI retro-hepática continuam representando grande desafio terapêutico, comprovado pelo índice de mortalidade que, nesses casos, foi de 66%. O conhecimento da anatomia da VCI e de suas tributárias é importante para o tratamento cirúrgico dessas lesöes. Deve-se sempre dar preferência à sutura da veia e evitar, assim, a ligadura, pois esta predispöe à trombose venosa profunda e suas seqüelas