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

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

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

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

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

Ruling out intra-abdominal injuries in blunt trauma patients using clinical criteria and abdominal ultrasound.

OBJECTIVE: to identify victims of blunt abdominal trauma in which intra-abdominal injuries can be excluded by clinical criteria and by complete abdominal ultrasonography. METHODS: retrospective analysis of victims of blunt trauma in which the following clinical variables were analyzed: hemodynamic stability, normal neurologic exam at admission, normal physical exam of the chest at admission, normal abdomen and pelvis physical exam at admission and absence of distracting lesions (Abbreviated Injury Scale >2 at skull, thorax and/or extremities). The ultrasound results were then studied in the group of patients with all clinical variables evaluated. RESULTS: we studied 5536 victims of blunt trauma. Intra-abdominal lesions with AIS>1 were identified in 144 (2.6%); in patients with hemodynamic stability they were present in 86 (2%); in those with hemodynamic stability and normal neurological exam at admission in 50 (1.8%); in patients with hemodynamic stability and normal neurological and chest physical exam at admission, in 39 (1.5%); in those with hemodynamic stability, normal neurological, chest, abdominal and pelvic physical exam at admission, in 12 (0.5%); in patients with hemodynamic stability, normal neurological, chest, abdominal and pelvic physical exam at admission, and absence of distracting lesions, only two (0.1%) had intra-abdominal lesions. Among those with all clinical variables, 693 had normal total abdominal ultrasound, and, within this group, there were no identified intra-abdominal lesions. CONCLUSION: when all clinical criteria and total abdominal ultrasound are associated, it is possible to identify a group of victims of blunt trauma with low chance of significant intra-abdominal lesions.

Ruling out intra-abdominal injuries in blunt trauma patients using clinical criteria and abdominal ultrasound / Exclusão de lesões intra-abdominais em vítimas de trauma fechado através de variáveis clínicas e ultrassom abdominal completo

ABSTRACT Objective: to identify victims of blunt abdominal trauma in which intra-abdominal injuries can be excluded by clinical criteria and by complete abdominal ultrasonography. Methods: retrospective analysis of victims of blunt trauma in which the following clinical variables were analyzed: hemodynamic stability, normal neurologic exam at admission, normal physical exam of the chest at admission, normal abdomen and pelvis physical exam at admission and absence of distracting lesions (Abbreviated Injury Scale >2 at skull, thorax and/or extremities). The ultrasound results were then studied in the group of patients with all clinical variables evaluated. Results: we studied 5536 victims of blunt trauma. Intra-abdominal lesions with AIS>1 were identified in 144 (2.6%); in patients with hemodynamic stability they were present in 86 (2%); in those with hemodynamic stability and normal neurological exam at admission in 50 (1.8%); in patients with hemodynamic stability and normal neurological and chest physical exam at admission, in 39 (1.5%); in those with hemodynamic stability, normal neurological, chest, abdominal and pelvic physical exam at admission, in 12 (0.5%); in patients with hemodynamic stability, normal neurological, chest, abdominal and pelvic physical exam at admission, and absence of distracting lesions, only two (0.1%) had intra-abdominal lesions. Among those with all clinical variables, 693 had normal total abdominal ultrasound, and, within this group, there were no identified intra-abdominal lesions. Conclusion: when all clinical criteria and total abdominal ultrasound are associated, it is possible to identify a group of victims of blunt trauma with low chance of significant intra-abdominal lesions.

RESUMO Objetivo: identificar vítimas de trauma fechado de abdome nas quais as lesões intra-abdominais possam ser excluídas por critérios clínicos e por ultrassonografia abdominal completa. Métodos: análise retrospectiva de vítimas de trauma fechado em que se analisou as seguintes variáveis clínicas: estabilidade hemodinâmica, exame neurológico normal à admissão, exame físico do tórax, do abdome e da pelve normais à admissão e ausência de lesões distrativas (Abbreviated Injury Scale >2 em crânio, tórax e/ou extremidades). Em seguida estudou-se o resultado da ultrassonografia no grupo de pacientes com todas as variáveis clínicas avaliadas. Resultados: estudamos 5536 vítimas de trauma fechado. Lesões intra-abdominais com AIS>1 foram identificadas em 144 (2,6%) casos; em pacientes com estabilidade hemodinâmica, estavam presentes em 86 (2%); naqueles com estabilidade hemodinâmica e exame neurológico normal à admissão em 50 (1,8%); nos casos com estabilidade hemodinâmica, exame neurológico e do tórax normais à admissão em 39 (1,5%); em pacientes com estabilidade hemodinâmica e com exame neurológico, do tórax, do abdome e da pelve normais em 12 (0,5%); naqueles com estabilidade hemodinâmica e com exame neurológico, do tórax, do abdome e da pelve normais e ausência de lesões distrativas, em apenas dois (0,1%) pacientes. Nos pacientes com todas as variáveis clínicas, 693 apresentavam ultrassonografia abdominal completa normal e, neste grupo, não foram identificadas lesões intra-abdominais posteriormente. Conclusão: pela somatória de critérios clínicos e ultrassonografia abdominal completa, é possível identificar um grupo de vítimas de trauma fechado com baixa chance de apresentar lesões intra-abdominais significativas.

Trauma mechanism predicts the frequency and the severity of injuries in blunt trauma patients. / Relação entre o mecanismo de trauma e lesões diagnosticadas em vítimas de trauma fechado.

OBJECTIVE: to study the correlation of trauma mechanism with frequency and severity of injuries in blunt trauma patients. METHODS: retrospective analysis of trauma registry in a 15-month period was carried out. Trauma mechanism was classified into six types: occupants of four-wheeled vehicles involved in road traffic accidents (AUTO), pedestrians struck by road vehicles (PED), motorcyclists involved in road traffic accidents (MOTO), falls from height (FALL), physical assault with blunt instruments (ASSA) and falls on same level (FSL). Injuries with AIS>2 were considered severe. One-way ANOVA, Students t and Chi-square tests were used for statistical analysis, considering p<0.05 significant. RESULTS: trauma mechanism was classified by group for 3639 cases, comprising 337 (9.3%) AUTO, 855 (23.5%) PED, 924 (25.4%) MOTO, 455 (12.5%) FALL, 424 (11.7%) ASSA and 644 (17.7%) FSL. There was significant difference among groups when comparing the Revised Trauma Score (RTS), the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) of the head, thorax, abdomen and extremities (p<0.001). Severe injuries in the head and in the extremities were more frequent in PED patients (p<0.001). Severe injuries to the chest were more frequent in AUTO (p<0.001). Abdominal injuries were less frequent in FSL (p=0.004). Complex fractures of the pelvis and spine were more frequent in FALL (p<0.001). Lethality was greater in PED, followed by FALL and AUTO (p<0.001). CONCLUSION: trauma mechanism analysis predicted frequency and severity of injuries in blunt trauma patients.

OBJETIVO: analisar a correlação do mecanismo de trauma com a frequência e a gravidade das lesões. MÉTODOS: análise retrospectiva das informações do registro de trauma em período de 15 meses. O mecanismo de trauma foi classificado em seis tipos: ocupantes de veículo de quadro rodas envolvidos em acidente de tráfego (AUTO), pedestres vítimas de atropelamento (ATRO), motociclistas vítimas de acidentes de tráfego (MOTO), vítimas de quedas de altura (QUED), vítimas de agressão física com instrumentos contundentes (AGRE) e vítimas de queda do mesmo nível (QMN). RESULTADOS: o mecanismo de trauma foi classificado em 3639 casos, sendo 337 (9,3%) AUTO, 855 (23,5%) ATRO, 924 (25,4%) MOTO, 455 (12,5%) QUED, 424 (11,7%) AGRE e 644 (17,7%) QMN. Houve diferença significativa na comparação entre os grupos das médias dos índices do Revised Trauma Score (RTS), do Injury Severity Score (ISS) e da Abbreviated Injury Scale (AIS) do segmento cefálico, torácico, abdominal e extremidades (p<0,05). Lesões graves em segmento cefálico foram mais frequentes nas vítimas de ATRO, seguidos de AGRE e QUED (p<0,001). Lesões graves em tórax foram mais frequentes em AUTO, seguidos de QUED e ATRO (p<0,001). As lesões abdominais foram menos frequentes nas vítimas de QMN (p=0,004). Lesões graves em extremidades foram mais frequentes em ATRO, seguidos de MOTO e QUED (p<0,001). CONCLUSÃO: com a análise do mecanismo de trauma é possível prever a frequência e a gravidade das lesões em vítimas de trauma fechado.

Relação entre o mecanismo de trauma e lesões diagnosticadas em vítimas de trauma fechado / Trauma mechanism predicts the frequency and the severity of injuries in blunt trauma patients

RESUMO Objetivo: analisar a correlação do mecanismo de trauma com a frequência e a gravidade das lesões. Métodos: análise retrospectiva das informações do registro de trauma em período de 15 meses. O mecanismo de trauma foi classificado em seis tipos: ocupantes de veículo de quadro rodas envolvidos em acidente de tráfego (AUTO), pedestres vítimas de atropelamento (ATRO), motociclistas vítimas de acidentes de tráfego (MOTO), vítimas de quedas de altura (QUED), vítimas de agressão física com instrumentos contundentes (AGRE) e vítimas de queda do mesmo nível (QMN). Resultados: o mecanismo de trauma foi classificado em 3639 casos, sendo 337 (9,3%) AUTO, 855 (23,5%) ATRO, 924 (25,4%) MOTO, 455 (12,5%) QUED, 424 (11,7%) AGRE e 644 (17,7%) QMN. Houve diferença significativa na comparação entre os grupos das médias dos índices do Revised Trauma Score (RTS), do Injury Severity Score (ISS) e da Abbreviated Injury Scale (AIS) do segmento cefálico, torácico, abdominal e extremidades (p<0,05). Lesões graves em segmento cefálico foram mais frequentes nas vítimas de ATRO, seguidos de AGRE e QUED (p<0,001). Lesões graves em tórax foram mais frequentes em AUTO, seguidos de QUED e ATRO (p<0,001). As lesões abdominais foram menos frequentes nas vítimas de QMN (p=0,004). Lesões graves em extremidades foram mais frequentes em ATRO, seguidos de MOTO e QUED (p<0,001). Conclusão: com a análise do mecanismo de trauma é possível prever a frequência e a gravidade das lesões em vítimas de trauma fechado.

ABSTRACT Objective: to study the correlation of trauma mechanism with frequency and severity of injuries in blunt trauma patients. Methods: retrospective analysis of trauma registry in a 15-month period was carried out. Trauma mechanism was classified into six types: occupants of four-wheeled vehicles involved in road traffic accidents (AUTO), pedestrians struck by road vehicles (PED), motorcyclists involved in road traffic accidents (MOTO), falls from height (FALL), physical assault with blunt instruments (ASSA) and falls on same level (FSL). Injuries with AIS>2 were considered severe. One-way ANOVA, Students t and Chi-square tests were used for statistical analysis, considering p<0.05 significant. Results: trauma mechanism was classified by group for 3639 cases, comprising 337 (9.3%) AUTO, 855 (23.5%) PED, 924 (25.4%) MOTO, 455 (12.5%) FALL, 424 (11.7%) ASSA and 644 (17.7%) FSL. There was significant difference among groups when comparing the Revised Trauma Score (RTS), the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) of the head, thorax, abdomen and extremities (p<0.001). Severe injuries in the head and in the extremities were more frequent in PED patients (p<0.001). Severe injuries to the chest were more frequent in AUTO (p<0.001). Abdominal injuries were less frequent in FSL (p=0.004). Complex fractures of the pelvis and spine were more frequent in FALL (p<0.001). Lethality was greater in PED, followed by FALL and AUTO (p<0.001). Conclusion: trauma mechanism analysis predicted frequency and severity of injuries in blunt trauma patients.

Implementation of the trauma registry as a tool for quality improvement in trauma care in a brazilian hospital: the first 12 months.

OBJECTIVE: to analyze the implementation of a trauma registry in a university teaching hospital delivering care under the unified health system (SUS), and its ability to identify points for improvement in the quality of care provided. METHODS: the data collection group comprised students from medicine and nursing courses who were holders of FAPESP scholarships (technical training 1) or otherwise, overseen by the coordinators of the project. The itreg (ECO Sistemas-RJ/SBAIT) software was used as the database tool. Several quality "filters" were proposed to select those cases for review in the quality control process. RESULTS: data for 1344 trauma patients were input to the itreg database between March and November 2014. Around 87.0% of cases were blunt trauma patients, 59.6% had RTS>7.0 and 67% ISS<9. Full records were available for 292 cases, which were selected for review in the quality program. The auditing filters most frequently registered were laparotomy four hours after admission and drainage of acute subdural hematomas four hours after admission. Several points for improvement were flagged, such as control of overtriage of patients, the need to reduce the number of negative imaging exams, the development of protocols for achieving central venous access, and management of major TBI. CONCLUSION: the trauma registry provides a clear picture of the points to be improved in trauma patient care, however, there are specific peculiarities for implementing this tool in the Brazilian milieu.

Implementation of the trauma registry as a tool for quality improvement in trauma care in a brazilian hospital: the first 12 months / Implantação de registro de trauma como ferramenta para melhorar a qualidade do atendimento a traumatizados: os primeiros 12 meses

ABSTRACTObjective:to analyze the implementation of a trauma registry in a university teaching hospital delivering care under the unified health system (SUS), and its ability to identify points for improvement in the quality of care provided.Methods:the data collection group comprised students from medicine and nursing courses who were holders of FAPESP scholarships (technical training 1) or otherwise, overseen by the coordinators of the project. The itreg (ECO Sistemas-RJ/SBAIT) software was used as the database tool. Several quality "filters" were proposed to select those cases for review in the quality control process.Results:data for 1344 trauma patients were input to the itreg database between March and November 2014. Around 87.0% of cases were blunt trauma patients, 59.6% had RTS>7.0 and 67% ISS<9. Full records were available for 292 cases, which were selected for review in the quality program. The auditing filters most frequently registered were laparotomy four hours after admission and drainage of acute subdural hematomas four hours after admission. Several points for improvement were flagged, such as control of overtriage of patients, the need to reduce the number of negative imaging exams, the development of protocols for achieving central venous access, and management of major TBI.Conclusion: the trauma registry provides a clear picture of the points to be improved in trauma patient care, however, there are specific peculiarities for implementing this tool in the Brazilian milieu.

RESUMOObjetivo:analisar a implantação de registro de trauma em hospital universitário com atendimento ao SUS, bem como, sua capacidade em identificar pontos para melhorada qualidade no atendimento.Métodos:o grupo de coleta de dados foi composto por alunos dos cursos de medicina e enfermagem, orientados pelos coordenadores do projeto. Utilizamos o software itreg (ECO Sistemas-RJ/SBAIT) como ferramenta de banco de dados. Vários "filtros" de qualidade foram propostos no intuito de selecionar os casos a serem revistos no processo de controle de qualidade.Resultados:entre março e novembro de 2014, foram inseridos no itreg dados de 1344 vítimas de trauma. Cerca de 87% foram vítimas de trauma fechado, 59,6% apresentaram RTS>7,0 e, 67%, ISS<9. Os registros foram completos em 292 casos, que foram selecionados para a revisãono programa de qualidade. Os filtros de auditoria mais frequentemente anotadosforam a laparotomia após quatro horas da admissão e a drenagem dos hematomas subdurais agudos após quatro horas da admissão. Identificamos vários pontos a serem desenvolvidos, como o controle da "supertriagem" de doentes, a necessidade de diminuição do número de exames de imagem negativos, o desenvolvimento de protocolos para passagem de acessos venosos centrais e tratamento de trauma craniencefálico grave.Conclusão:o Registro de Trauma traz uma visão clara dos pontos a serem melhorados no atendimento ao traumatizado, contudo, há características específicas na implantação desta ferramenta.