Patients with severe polytrauma: management and imaging protocols.

Traumatic injuries can be severe and complex, requiring the coordinated efforts of a multidisciplinary team. Imaging tests play a fundamental role in rapid and accurate diagnosis. In particular, whole-body computed tomography (CT) has become a key tool. There are different CT protocols depending on the patient's condition; whereas dose-optimized protocols can be used in stable patients, time/precision protocols prioritizing speed at the cost of delivering higher doses of radiation should be used in more severe patients. In unstable patients who cannot be examined by CT, X-rays of the chest and pelvis and FAST or e-FAST ultrasound studies, although less sensitive than CT, enable the detection of situations that require immediate treatment. This article reviews the imaging techniques and CT protocols for the initial hospital workup for patients with multiple trauma.

Manejo con control de temperatura en los cuidados posparada cardiaca: documento de expertos / Management of temperature control in post-cardiac arrest care: an expert report

Actualmente, el control estricto de temperatura mediante hipotermia inducida (entre 32 y 36 oC) se considera un tratamiento de primera línea en el manejo de pacientes con parada cardiaca recuperada que ingresan en Unidades de Cuidados Intensivos. Su objetivo es disminuir el daño neurológico secundario a anoxia cerebral. Aunque existen múltiples evidencias sobre sus beneficios, el empleo de esta técnica en nuestro país es pobre y todavía existen temas controvertidos como temperatura óptima, velocidad de instauración, duración y proceso de calentamiento. El objetivo de este trabajo es desarrollar la evidencia científica actual y las recomendaciones de las principales guías internacionales. El enfoque de este documento se centra también en aplicación práctica del control estricto de la temperatura en la parada cardiaca recuperada en nuestras Unidades de Cuidados Intensivos Generales o Cardiológicas, principalmente en los métodos de aplicación, protocolos, manejo de las complicaciones y elaboración del pronóstico neurológico. (AU)

Targeted temperature management (TTM) through induced hypothermia (between 32-36 oC) is currently regarded as a first-line treatment during the management of post-cardiac arrest patients admitted to the Intensive Care Unit (ICU). The aim of TTM is to afford neuroprotection and reduce secondary neurological damage caused by anoxia. Despite the large body of evidence on its benefits, the TTM is still little used in Spain. There are controversial issues referred to its implementation, such as the optimal target body temperature, timing, duration and the rewarming process. The present study reviews the best available scientific evidence and the current recommendations contained in the international guidelines. In addition, the study focuses on the practical implementation of TTM in post-cardiac arrest patients in general and cardiological ICUs, with a discussion of the implementation strategies, protocols, management of complications and assessment of the neurological prognosis. (AU)

Management of temperature control in post-cardiac arrest care: an expert report. / Manejo con control de temperatura en los cuidados posparada cardiaca: documento de expertos.

Targeted temperature management (TTM) through induced hypothermia (between 32-36 oC) is currently regarded as a first-line treatment during the management of post-cardiac arrest patients admitted to the Intensive Care Unit (ICU). The aim of TTM is to afford neuroprotection and reduce secondary neurological damage caused by anoxia. Despite the large body of evidence on its benefits, the TTM is still little used in Spain. There are controversial issues referred to its implementation, such as the optimal target body temperature, timing, duration and the rewarming process. The present study reviews the best available scientific evidence and the current recommendations contained in the international guidelines. In addition, the study focuses on the practical implementation of TTM in post-cardiac arrest patients in general and cardiological ICUs, with a discussion of the implementation strategies, protocols, management of complications and assessment of the neurological prognosis.

Traumatismo craneoencefálico en el nuevo milenio. El paciente anciano / Head trauma in the new millennium: elderly patients

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Factores de riesgo y protección del estrés traumático secundario en los cuidados intensivos: un estudio exploratorio en un hospital terciario de Madrid / Risk and protective factors of secondary traumatic stress in Intensive Care Units: An exploratory study in a hospital in Madrid (Spain)

OBJETIVO: Proponer un modelo de predictores del estrés traumático secundario. DISEÑO: Se trata de un diseño transversal descriptivo. Ámbito: El estudio se llevó a cabo en las unidades de cuidados intensivos de un hospital terciario de Madrid. PARTICIPANTES: La muestra estuvo formada por 103 profesionales sanitarios. INTERVENCIONES: Se creó una batería de cuestionarios que fue rellenada por los profesionales. Respecto al análisis de datos, se utilizó una metodología de redes y análisis de regresión jerárquica. Variables de interés: Se evaluaron variables sociodemográficas tales como género, años de experiencia y puesto, el estrés traumático secundario, la pasión por el trabajo, los estresores laborales, el esfuerzo emocional, la empatía, la autocompasión. RESULTADOS: Se establece: a) para la fatiga por compasión, los años de experiencia como factor de riesgo (β = 0,224 y p = 0,029) y la pasión armoniosa como protector (β = −0,363 y p = 0,001); b) para la sacudida de creencias, el esfuerzo emocional y la empatía como factores de riesgo (β = 0,304 y p = 0,004; β = 0,394 y p = 0,000, respectivamente) y c) para la sintomatología, los estresores laborales y la empatía como factores de riesgo (β = 0,189 y p = 0,039; β = 0,395 y p = 0,000, respectivamente) y los años de experiencia como protector (β = −0,266 y p = 0,002). CONCLUSIONES: Este modelo predictivo del estrés traumático secundario asienta factores protectores que podrían aumentarse, como la pasión armoniosa, y factores de riesgo que sería conveniente reducir, como la empatía y el esfuerzo emocional, con el fin de mejorar la calidad asistencial y de vida de los profesionales

AIM: To propose a predictive model of secondary traumatic stress. DESIGN: A descriptive cross-sectional study was carried out. Context: The study was conducted in the Intensive Care Units of a hospital in Madrid (Spain). PARTICIPANTS: The sample comprised 103 health professionals. INTERVENTIONS: A series of questionnaires were created and completed by the participants. Network analysis and multiple regression were used for data analysis. Variables of interest: Sociodemographic variables such as gender, years of experience and position, secondary traumatic stress, passion for work, work stressors, emotional effort, empathy and self-compassion were evaluated. RESULTS: The result identified the following: a) years of experience as a risk factor for compassion fatigue (β=0.224 and P=0.029), and harmonious passion as a protector (β=−0.363 and P=0.001); b) emotional effort and empathy as risk factors for shattered assumptions (β=0.304 and P=0.004; β=0.394 and P=0.000, respectively); and c), work stressors and empathy as risk factors for symptomatology (β=0.189 and P=0.039; β=0.395 and P=0.000, respectively), and years of experience as a protector (β=−0.266 and P=0.002). CONCLUSIONS: This predictive model of secondary traumatic stress identifies protective factors which could be reinforced, such as harmonious passion, and risk factors which should be reduced, such as empathy and emotional effort, with a view to promoting quality of care and quality of life among these professionals

Valoración de la calidad asistencial al traumatismo grave mediante comparación con estándares internacionales / Evaluation of quality of care in trauma patients using international scoring systems

OBJETIVO: Evaluar la capacidad de los modelos TRISS y PS14 para predecir la probabilidad de supervivencia en nuestro sistema de salud y población. DISEÑO: Desarrollamos un estudio observacional retrospectivo durante un periodo de 66 meses. ÁMBITO: El estudio se llevó a cabo en una UCI especializada en traumatología en un hospital urbano de alta complejidad. PACIENTES: Se incluyeron en el estudio los pacientes mayores de 14 años con traumatismo grave (definido como ISS ≥ 16 y/o RTS < 12). VARIABLES DE INTERÉS: Se calculó el estadístico W (diferencia entre la mortalidad -hospitalaria o a los 30 días para los modelos TRISS o PS14 respectivamente- calculada y observada por cada 100 pacientes) y su nivel de significación para cada modelo. Se realizó un análisis por subgrupos. La calibración y discriminación se evaluaron por medio del test de Hosmer-Lemeshoy y cinturón GiViTI y curvas ROC respectivamente. RESULTADOS: Se incluyeron 1.240 pacientes. La supervivencia global al alta fue de 81,9%. El estadístico W para los modelos TRISS, TRISS2010 y PS14 fue respectivamente +6,72 (p < 0,01), +1,48 (p = 0,08) y +2,74 (p < 0,01). El AUROC para los citados modelos fue respectivamente 0,915, 0,919 y 0,914, sin que se encontraran diferencias significativas entre ellos. Tanto el test de Hosmer-Lemeshow como el cinturón de calibración GiViTI mostraron escasa calibración en los 3 modelos. CONCLUSIONES: Estos modelos son una herramienta adecuada para la evaluación de la calidad asistencial en una UCI de traumatismo. En nuestro centro las tasas de supervivencia fueron mayores de lo predicho por los modelos

OBJECTIVE: To evaluate the ability of the TRISS and PS14 models to predict mortality rates in our medical system and population. DESIGN: A retrospective observational study was carried out over a 66-month period. BACKGROUND: The study was conducted in the Trauma Intensive Care Unit (ICU) of a third level hospital. PATIENTS: All severe trauma patients (Injury Severity Score ≥ 16 and/or Revised Trauma Score < 12) aged > 14 years were included. Variables of interest: Medical care data were prospectively recorded. The "W" statistic (difference between expected and observed mortality for every 100 patients) and its significance were calculated for each model. Discrimination and calibration were evaluated by means of receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow test and GiViTI calibration belt, respectively. RESULTS: A total of 1240 patients were included. Survival at hospital discharge was 81.9%. The "W" scores for the TRISS, TRISS 2010 and PS14 models were +6.72 (P < .01), +1.48 (P = .08) and +2.74 (P < .01) respectively. Subgroup analysis revealed significant favorable results for some populations. The areas under the ROC curve for the TRISS, TRISS 2010 and PS14 models were 0.915, 0.919 and 0.914, respectively. There were no significant differences among them (P > .05). Both the Hosmer-Lemeshow test and GiViTI calibration belt demonstrated poor calibration for the three models. CONCLUSIONS: These models are suitable tools for assessing quality of care in a Trauma ICU, affording excellent discrimination but poor calibration. In our institution, survival rates higher than expected were observed

Outcomes of very elderly trauma ICU PATIENTS: Results from the Spanish trauma ICU registry / Desenlace de los pacientes traumáticos muy ancianos en la unidad de cuidados intensivos. Resultados del Registro Español de Trauma en las UCI

OBJECTIVE: To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry. DESIGN: A multicenter nationwide registry. Retrospective analysis. November 2012-May 2017. SETTING: Participating ICUs. PATIENTS: Trauma patients aged ≥ 80 years. INTERVENTIONS: None. Main variables of interest: The outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed.comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value < 0.05 was considered statistically significant. RESULTS: The mean patient age was 83.4 ± 3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5 ± 11.1, with a mean ICU stay of 7.45 ± 9.9 days. The probability of survival based on the TRISS methodology was 69.8 ± 29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury. CONCLUSIONS: Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury

OBJETIVO: Analizar el desenlace y los factores relacionados con la mortalidad de los pacientes traumáticos muy ancianos ingresados en las Unidades de Cuidados Intensivos (UCI) participantes en el Registro Español de Trauma en las UCI (RETRAUCI). DISEÑO: Registro multicéntrico nacional. Análisis retrospectivo. Noviembre de 2012-mayo de 2017. Ámbito: Las UCI participantes. Pacientes o PARTICIPANTES: Pacientes traumáticos con edad ≥ 80 años. INTERVENCIONES: Ninguna. Variables de interés principales: Analizamos el desenlace y la influencia de la limitación de los tratamientos de soporte vital (LLST). Las comparaciones entre grupos se realizaron mediante la prueba de Wilcoxon, la prueba de Chi-cuadrado y la prueba exacta de Fisher según estuviera indicado. Se realizó un análisis multivariante mediante regresión logística para analizar las variables asociadas a la mortalidad. Un valor de p < 0,05 se consideró el límite de la significación estadística. RESULTADOS: La edad media fue de 83,4 ± 3,3 años. Varones 281 (60,4%). La causa principal del traumatismo fueron las caídas de baja energía en 256 pacientes (55,1%). El Injury Severity Score (ISS) medio fue de 20,5 ± 11,1. La estancia media en las UCI fue de 7,45 ± 9,9 días. La probabilidad de supervivencia, de acuerdo con la metodología TRISS fue de 69,8 ± 29,7%. La mortalidad en las UCI fue del 15,5%. La mortalidad hospitalaria fue del 19,2%. La causa principal fue la hipertensión intracraneal (42,7%). El ISS, la necesidad de medidas de primer o segundo nivel para controlar la presión intracraneal y el ingreso en las UCI orientado a la donación de órganos fueron predictores independientes de mortalidad. Se documentó la LLST en 128 pacientes (27,9%). Los pacientes con LLST fueron mayores, con una mayor gravedad lesional y un traumatismo craneoencefálico más grave. CONCLUSIONES: Los pacientes traumáticos muy ancianos en las UCI presentaron menor mortalidad de la predicha por la gravedad del traumatismo

Risk and protective factors of secondary traumatic stress in Intensive Care Units: An exploratory study in a hospital in Madrid (Spain). / Factores de riesgo y protección del estrés traumático secundario en los cuidados intensivos: un estudio exploratorio en un hospital terciario de Madrid.

AIM: To propose a predictive model of secondary traumatic stress. DESIGN: A descriptive cross-sectional study was carried out. CONTEXT: The study was conducted in the Intensive Care Units of a hospital in Madrid (Spain). PARTICIPANTS: The sample comprised 103 health professionals. INTERVENTIONS: A series of questionnaires were created and completed by the participants. Network analysis and multiple regression were used for data analysis. VARIABLES OF INTEREST: Sociodemographic variables such as gender, years of experience and position, secondary traumatic stress, passion for work, work stressors, emotional effort, empathy and self-compassion were evaluated. RESULTS: The result identified the following: a) years of experience as a risk factor for compassion fatigue (ß=0.224 and P=0.029), and harmonious passion as a protector (ß=-0.363 and P=0.001); b) emotional effort and empathy as risk factors for shattered assumptions (ß=0.304 and P=0.004; ß=0.394 and P=0.000, respectively); and c), work stressors and empathy as risk factors for symptomatology (ß=0.189 and P=0.039; ß=0.395 and P=0.000, respectively), and years of experience as a protector (ß=-0.266 and P=0.002). CONCLUSIONS: This predictive model of secondary traumatic stress identifies protective factors which could be reinforced, such as harmonious passion, and risk factors which should be reduced, such as empathy and emotional effort, with a view to promoting quality of care and quality of life among these professionals.

Outcomes of very elderly trauma ICU patients. Results from the Spanish trauma ICU registry.

OBJECTIVE: To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry. DESIGN: A multicenter nationwide registry. Retrospective analysis. November 2012-May 2017. SETTING: Participating ICUs. PATIENTS: Trauma patients aged ≥80 years. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: The outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed. Comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value <0.05 was considered statistically significant. RESULTS: The mean patient age was 83.4±3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5±11.1, with a mean ICU stay of 7.45±9.9 days. The probability of survival based on the TRISS methodology was 69.8±29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury. CONCLUSIONS: Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury.