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1.
Artigo em Inglês | MEDLINE | ID: mdl-32044870

RESUMO

BACKGROUND: Trauma is the leading cause of non-obstetric death during pregnancy and is associated with an increased risk of maternal and fetal mortality. In an effort to improve the delivery of care to pregnant trauma patients, we developed an institutional multidisciplinary quality initiative designed to improve response times of non-trauma specialists and ensure immediate availability of resources. We hypothesized that implementation of a Perinatal Emergency Response Team (PERT) would improve time to patient and fetal evaluation and monitoring by the Obstetrics (OB) team, and improve both maternal and fetal outcomes. METHODS: We performed a 6-year (2012-2018) retrospective cohort analysis of consecutive pregnant trauma patients presenting to our University-affiliated, Level I Trauma Center. Patients in the pre-PERT cohort (prior to April 2015) were compared to a post-PERT cohort. Variables analyzed included patient demographics, mechanism of injury, injury severity score (ISS), and level of trauma activation. The main outcome measure was time to OB evaluation. Secondary outcomes included time to cardiotocometry, and mortality. RESULTS: Of 92 pregnant trauma patients, there were 50 patients (54.3%) in the pre-PERT cohort and 42 (45.7%) in the post-PERT group. Blunt injuries predominated (98.9%), with the most common mechanism being motor vehicle collisions (76.1%), followed by assaults (13%), and falls (6.5%). The mean time to obstetrical evaluation was 44 minutes in the pre-PERT cohort compared to 14 minutes in the post-PERT cohort (p = 0.001). There was a significant decrease in Level I (highest acuity) trauma activations pre- and post-PERT (46% vs. 21%, p=0.01), and the time to cardiotocography was significantly decreased post-PERT implementation (72 vs. CONCLUSION: Implementation of a multidisciplinary perinatal emergency response team (PERT) improves time to evaluation by the obstetrics team and time to cardiotocometry in the pregnant trauma patient. LEVEL OF EVIDENCE: IV STUDY TYPE: Retrospective review.

2.
Am Surg ; 85(10): 1139-1141, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657310

RESUMO

Decisions regarding whether to close the skin in trauma patients with hollow viscus injuries (HVIs) are based on surgeon discretion and the perceived risk for an SSI. We hypothesized that leaving the skin open would result in fewer wound complications in patients with HVIs. We performed a retrospective analysis of all adult patients who underwent operative repair of an HVI. The main outcome measure was superficial or deep SSIs. Of 141 patients, 38 (27%) had HVIs. Twenty-six patients developed SSIs, of which 13 (50%) were superficial or deep SSIs. On adjusted analysis, only female gender (P = 0.03) and base deficit were associated (P = 0.001) with wound infections Open wound management was not associated with a decreased incidence of SSIs (P = 0.19) in patients with HVIs. Further research is required to determine optimal strategies for reducing wound complications in patients sustaining HVIs.


Assuntos
Traumatismos Abdominais/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/efeitos adversos , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Ferida Cirúrgica/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/estatística & dados numéricos , Adulto , Antibioticoprofilaxia/estatística & dados numéricos , Procedimentos Cirúrgicos Dermatológicos/métodos , Duodeno/lesões , Feminino , Humanos , Intestino Delgado/lesões , Jejuno/lesões , Masculino , Estudos Retrospectivos , Pele , Estatísticas não Paramétricas , Estômago/lesões , Infecção da Ferida Cirúrgica/classificação , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
3.
Am Surg ; 85(10): 1146-1149, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657312

RESUMO

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic (P < 0.001), had a higher incidence of preadmission antithrombotic therapy use (P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups (P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.


Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Tratamento de Emergência/efeitos adversos , Cálculos Biliares/cirurgia , Complicações Intraoperatórias/epidemiologia , Cirrose Hepática/complicações , Doença Aguda , Adulto , Fatores Etários , Ductos Biliares/lesões , Conversão para Cirurgia Aberta/estatística & dados numéricos , Tratamento de Emergência/métodos , Feminino , Fibrinolíticos/uso terapêutico , Cálculos Biliares/etiologia , Hemorragia/epidemiologia , Humanos , Incidência , Intestinos/lesões , Complicações Intraoperatórias/etiologia , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Segurança , Fatores Sexuais , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos
4.
Am J Surg ; 218(6): 1185-1188, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31551145

RESUMO

INTRODUCTION: The early identification of hemorrhagic shock may be challenging. The objective of this study was to examine the utility of a narrowed pulse pressure in identifying the need for emergent interventions following penetrating trauma. METHODS: In this 2.5-year retrospective study of adult patients with a penetrating mechanism, patients with a narrowed pulse pressure (<30 mmHg) were compared to those without. Main outcomes measures were the need for a massive transfusion or emergent operation. RESULTS: There were 957 patients, of which the majority were male (86%) and 55% presented with gunshot wounds. On multivariate analysis, a narrowed pulse pressure was associated with the need for massive transfusion (OR 3.74, 95% C.I. 1.8-7.7, p = 0.0003) and emergent surgery (OR 1.68, 95% C.I. 1.14-2.48, p = 0.009). CONCLUSIONS: A narrowed pulse pressure is associated with the presence of hemorrhagic shock and need for emergent interventions among patients with penetrating torso trauma.

5.
Prehosp Emerg Care ; 23(6): 828-837, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30893573

RESUMO

Objective: We evaluated the performance of individual trauma triage criteria using data from a regional trauma registry. Methods: Los Angeles County (LAC) paramedics use triage criteria adapted from the 2011 Center for Disease Control (CDC) guidelines to triage injured patients to Trauma Centers (TCs). TCs report outcomes to a LAC EMS registry. We abstracted data for patients 15 years or older from 2013 to 2015 and identified all trauma triage criteria that were met for each encounter. Study outcomes were: (1) "clear need" for a TC, defined as receiving a non-orthopedic operative intervention within 6 hours of arrival, injury severity score (ISS) > 15, or surgical ICU admission; or (2) "no need" for a TC, defined as discharge home from the emergency department (ED). We also defined "possible need" as those patients not discharged home from the ED, inclusive of "clear need" and all other admitted patients. For each individual triage criteria, we calculated the positive likelihood ratios and positive predictive values for TC need. Results: There were 71,536 adult patients in the registry transported by EMS to a LAC TC during the study. Median age was 38 years (IQR 25-55) with 73% male. There were 23,628 (33%) who met "no need" criteria for a TC, leaving 47,908 (67%) patients with "possible need" for a TC, of whom 13,343 patients (19% of total) met "clear need" for a TC. No individual trauma criterion met the a priori likelihood ratio threshold of 10 for predicting "clear need" for a TC. Cardiopulmonary arrest with penetrating torso trauma and flail chest met this threshold for "possible need." Conclusion: In this retrospective analysis, no individual triage criterion definitively identified patients who benefit from transport to a TC. Yet, the majority of patients demonstrated potential benefit for nearly all criteria, supporting CDC recommendations that trauma triage criteria be considered in their entirety, not as individual criterion.

6.
Trauma Surg Acute Care Open ; 4(1): e000264, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30899795

RESUMO

Background: Necrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process. Methods: We conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2 test, Fisher's exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant. Results: Of 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve. Conclusions: Clinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress. Level of evidence: Retrospective cohort study, level III.

7.
J Am Coll Surg ; 229(2): 141-149, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30878583

RESUMO

BACKGROUND: Gunshot wound (GSW) injuries present a unique surgical challenge. This study explored the financial and clinical burdens of GSW patients across 2 Los Angeles County Level I trauma centers over the last 12 years, and compared them with other forms of interpersonal injury (OIPI). STUDY DESIGN: This was a retrospective study of patients presenting as those with GSW and OIPI (defined as combined stab wound or blunt assault), between January 1, 2006 and March 30, 2018, at LAC+USC Medical Center (LAC+USC) and Harbor UCLA Medical Center (HUCLA). Demographic and clinical variables were assessed for GSW patients and compared with victims of OIPI. RESULTS: There were 17,871 patients who met inclusion criteria. There was a significant difference in mortality for patients with GSW vs OIPI (11% vs 2%, p < 0.001). The odds ratio for GSW patients requiring operation was twice as high as those suffering OIPI (odds ratio [OR] 2.0, 95% CI 1.8 to 2.2). The odds ratio for GSW patients requiring ICU admission was 20% higher than that for OIPI patients (OR 1.23, 95% CI 1.11 to 1.36). Gunshot wound patients experienced a longer median length of stay vs OIPI patients (3 days vs 2 days, p < 0.001). The median hospital charge per admission for GSW was twice that of OIPI (GSW $12,612 vs OIPI $6,195; p < 0.001). CONCLUSIONS: When compared with OIPI, GSW patients arrived more severely injured and required more operations, more ICU admissions, and longer hospital stays. Patients with GSW incurred significantly higher hospital charges and had a significantly higher mortality rate. Gunshot wound injury is a unique public health concern requiring comprehensive, nation-wide, contemporary study.

8.
Am Surg ; 84(10): 1626-1629, 2018 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30747683

RESUMO

Presently, there are no standardized guidelines regarding the necessity or timing of repeat head imaging in patients on antithrombotics (antiplatelet agents, warfarin, or novel oral anticoagulants) with suspected traumatic brain injury. This is a two-year single institutional retrospective analysis of patients with suspected traumatic brain injury on antithrombotic medications. Patients with a stable or negative repeat head CT were compared with patients who developed a new bleed or demonstrated progression of intracranial hemorrhage (ICH). Of 110 patients, 55 patients (50%) had a positive initial CT, two patients (1.8%) developed a new bleed after initially normal head CT, and 21 patients (19.1%) demonstrated worsening ICH. Patients with worsening or delayed ICH had a higher median Injury Severity Score (14 vs 5, P < 0.001), higher head/neck and face Abbreviated Injury Severity scores (both P < 0.05), and were more likely to be receiving combination therapy with warfarin and clopidogrel (4.3% vs 0%, P = 0.05). On multivariate analysis, lower face and head/neck Abbreviated Injury Severity scores were associated with a decreased risk for delayed or worsening hemorrhage (odds ratio = 0.21 and 0.46, respectively, P < 0.05). Repeat head CT in patients on a preinjury antithrombotic has a low yield. The use of combination therapy may result in an increased risk for delayed hemorrhage or hemorrhage progression.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico por imagem , Fibrinolíticos/efeitos adversos , Idoso , Anticoagulantes/efeitos adversos , Hemorragia Cerebral/induzido quimicamente , Progressão da Doença , Quimioterapia Combinada , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Los Angeles , Masculino , Inibidores da Agregação de Plaquetas/efeitos adversos , Retratamento/estatística & dados numéricos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Varfarina/efeitos adversos
9.
Ann Emerg Med ; 70(2): 161-168, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28258762

RESUMO

STUDY OBJECTIVE: Regionalized systems of trauma care and level verification are promulgated by the American College of Surgeons. Whether patient outcomes differ between the 2 highest verifications, Levels I and II, is unknown. In contrast to Level II centers, Level I centers are required to care for a minimum number of severely injured patients, have immediate availability of subspecialty services and equipment, and demonstrate research, substance abuse screening, and injury prevention. We compare risk-adjusted mortality outcomes at Levels I and II centers. METHODS: This was an analysis of data from the 2012 to 2014 Los Angeles County Trauma and Emergency Medical Information System. The system includes 14 trauma centers: 5 Level I and 9 Level II centers. Patients meeting criteria for transport to a trauma center are routed to the closest center, regardless of verification level. All adult patients (≥15 years) treated at any of the trauma centers were included. Outcomes of patients treated at Level I versus Level II centers were compared with 2 validated risk-adjusted models: Trauma Score-Injury Severity Score (TRISS) and the Haider model. RESULTS: Adult subjects (33,890) were treated at a Level I center; 29,724, at a Level II center. We found lower overall mortality at Level II centers compared with Level I, using TRISS (odds ratio 0.68; 95% confidence interval 0.59 to 0.78) and Haider (odds ratio 0.84; 95% confidence interval 0.73 to 0.97). CONCLUSION: In this cohort of patients treated at urban and suburban trauma centers, treatment at a Level II trauma center was associated with overall risk-adjusted reduced mortality relative to that at a Level I center. In the subset of penetrating trauma, no differences in mortality were found. Further study is warranted to determine optimal trauma system configuration and allocation of resources.


Assuntos
Mortalidade Hospitalar/tendências , Centros de Traumatologia/classificação , Ferimentos e Lesões/mortalidade , Adulto , Causas de Morte , Terapia Combinada , Feminino , Humanos , Escala de Gravidade do Ferimento , Los Angeles/epidemiologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Medição de Risco , População Urbana , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia , Adulto Jovem
10.
Am Surg ; 83(10): 1117-1121, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-29391107

RESUMO

Necrotizing soft tissue infections (NSTIs) are aggressive infections requiring prompt diagnosis and extensive surgical debridement. Traditionally, patients undergo mandatory re-exploration to ensure adequacy of source control. The purpose of this study is to determine if re-exploration in the operating room is mandatory for all patients with NSTIs. An eight-year retrospective analysis of adult patients with NSTIs was performed comparing two groups: mandatory operative re-exploration versus operative re-exploration based on clinical examination findings. Outcomes measured included mortality, number of debridements, and length of stay (LOS). Twenty-two per cent of patients underwent a mandatory re-exploration. These patients were older, had a higher incidence of diabetes, and a longer duration of symptoms. There were no significant differences between groups with regard to the physical examination, severity of sepsis, time to repeat debridements, or in-hospital mortality, whereas LOS and the total number of debridements were increased in mandatory re-exploration. Bacteremia and septic shock were predictive of the need for further debridement in patients in the operative re-exploration based on clinical examination findings group. Mandatory re-exploration after initial debridement may not be necessary in all patients with NSTIs. Instead, bedside wound checks may be a safe strategy to determine the need for further operative debridement.


Assuntos
Desbridamento , Reoperação , Infecções dos Tecidos Moles/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Necrose/diagnóstico , Necrose/mortalidade , Necrose/cirurgia , Estudos Retrospectivos , Infecções dos Tecidos Moles/diagnóstico , Infecções dos Tecidos Moles/mortalidade
11.
Am Surg ; 82(10): 898-902, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27779969

RESUMO

Consensus is lacking for ideal management of mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH). Patients are often monitored in the intensive care unit (ICU) without additional interventions. We sought to identify admission variables associated with a favorable outcome (ICU admission for 24 hours, no neurosurgical interventions, no complications or mortality) to divert these patients to a non-ICU setting in the future. We reviewed all patients with mTBI [Glasgow Coma Scale (GCS) = 13-15] and concomitant ICH between July 1, 2012, and June 30, 2015. Variables collected included demographics, vital signs, neurologic examination, imaging results, ICU course, mortality, and disposition. Of 201 patients, 78 (39%) had a favorable outcome. On univariate analysis, these patients were younger, more often had an isolated subarachnoid hemorrhage, and were more likely to have a GCS of 15 at admission. On multivariate regression analysis, after controlling for admission blood pressure, time to CT scan, and Marshall Score, age <55, GCS of 15 on arrival to the ICU, and isolated subarachnoid hemorrhage remained independent predictors of a favorable outcome. Patients meeting these criteria after mTBI with ICH likely do not require ICU-level care.


Assuntos
Concussão Encefálica/mortalidade , Concussão Encefálica/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Concussão Encefálica/diagnóstico , California , Cuidados Críticos/métodos , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Resultado do Tratamento
12.
Am Surg ; 82(10): 926-929, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27779975

RESUMO

The population of the United States is predicted to age dramatically over the next few decades; as such older patients will comprise an increasing proportion of the injured populations. Due to multiple comorbidities and frailty, the old and very old are at greater risk for mortality than younger patients. To identify predictors of inhospital mortality in these patients, we performed a retrospective cohort study at our Level 1 trauma center. Between April 2009 and October 2014, we identified 193 trauma patients aged 80 years and older admitted to the intensive care unit. The mean age was 86 years old (4.9) and a majority of patients were white (57%) and male (54%). Univariate analysis found Injury Severity Score (P < 0.01), initial Glasgow Coma Scale (P < 0.01), admission pH (P = <0.01), admission lactate (P < 0.01), the need for mechanical ventilation (P < 0.01), and Geriatric Trauma Outcome Score (P < 0.01) to be predictors of mortality. Multivariate analysis identified length of mechanical ventilation [odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.60-0.90, P < 0.01], admission lactate (OR = 1.74, 95% CI = 1.21-2.51, P < 0.01), and the need for mechanical ventilation (OR = 18.2, 95% CI = 3.33-99.8, P < 0.01) as independent predictors of mortality. These predictors can help guide clinical decisions and should prompt early discussion of goals of care. The association between mechanical ventilation and mortality is confounded by withdrawal of care.


Assuntos
Avaliação Geriátrica , Mortalidade Hospitalar , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade , Fatores Etários , Idoso de 80 Anos ou mais , Análise de Variância , Estudos de Coortes , Comorbidade , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Análise de Sobrevida , Centros de Traumatologia , Estados Unidos , Ferimentos e Lesões/terapia
13.
Am J Surg ; 212(6): 1096-1100, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27780558

RESUMO

BACKGROUND: The objectives of this study were to examine the incidence and severity of early acute respiratory distress syndrome (ARDS) according to the Berlin Definition and to identify risk factors associated with the development of early post-traumatic ARDS. METHODS: A 2.5-year retrospective database of adult trauma patients who required mechanical ventilation for greater than 48 hours at a level 1 trauma center was analyzed for variables predictive of early (<48 hours after injury), mild, moderate, and severe ARDS and in-hospital mortality. RESULTS: Of 305 patients, 59 (19.3%) developed early ARDS: mild, 27 (45.8%); moderate, 26 (44.1%); and severe, 6 (10.1%). Performance of an emergent thoracotomy, blunt mechanism, and fresh frozen plasma administration were independently associated with the development of early ARDS. ARDS was not predictive of mortality. CONCLUSIONS: Trauma patients with blunt mechanism, who receive fresh frozen plasma, or undergo thoracotomy, are at risk of developing early ARDS.


Assuntos
Síndrome do Desconforto Respiratório do Adulto/epidemiologia , Ferimentos e Lesões/complicações , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Centros de Traumatologia , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia
14.
Ann Vasc Surg ; 33: 88-93, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26965801

RESUMO

BACKGROUND: Vascular injuries occurring at the junction of the trunk and lower extremity are uncommon yet challenging because of their location and potential for associated truncal injuries. The purpose of this study was to examine and compare outcomes among patients sustaining external iliac and femoral vascular injuries. METHODS: We performed a 13-year retrospective analysis of our level 1 trauma center database to identify and compare patients with external iliac and femoral vessel injuries. Multiple logistic regression analysis was performed to identify independent predictors for mortality. RESULTS: During the study period, 135 patients with a median (interquartile range [IQR]) age of 25 (20-35) years were identified with external iliac (n = 29) and femoral vascular injuries (n = 106). The majority were male (85.9%) with a penetrating mechanism (84.5%), and the median (IQR) Injury Severity Score (ISS) was 16 (11-26). The overall mortality rate was 14.1%. In comparison with patients with femoral vascular injuries, patients with external iliac injuries presented with higher ISS (25 vs. 16, P < 0.001), lower Glasgow Coma Scale (14 vs. 15, P = 0.001) and had a higher incidence of mortality (41.4% vs. 6.6%, P < 0.001) and disability (13.8% vs. 1%, P = 0.007). Shunts were used in only 7 patients (5.2%). Stepwise logistic regression consistently identified external iliac injury (odds ratio, 15.6; 95% confidence interval, 1.72-141, P = 0.014 in best-fitted model) as independently associated with mortality. CONCLUSIONS: In comparison with femoral vascular injuries, external iliac vascular injuries are associated with higher blood loss, more intense resuscitation, higher disability and mortality in patients sustaining junctional groin injuries. Early recognition and application of damage control techniques and resuscitative practices may result in improved outcomes.


Assuntos
Artéria Femoral/lesões , Artéria Ilíaca/lesões , Lesões do Sistema Vascular , Ferimentos Penetrantes , Adulto , California , Bases de Dados Factuais , Diagnóstico Precoce , Procedimentos Endovasculares , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Artéria Ilíaca/diagnóstico por imagem , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Centros de Traumatologia , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/terapia , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Adulto Jovem
15.
Ann Vasc Surg ; 33: 83-7, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-26996406

RESUMO

BACKGROUND: Popliteal artery trauma has the highest rate of limb loss of all peripheral vascular injuries. The objectives of this study were to evaluate outcomes after popliteal vascular injury and to identify predictors of amputation. METHODS: Retrospective data over a 14-year period were collected for patients with popliteal artery with or without vein injuries. Patient demographics, mechanism of injury, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), and physiologic parameters were extracted. Time to operative intervention, operative time, type of vascular repair, need for concomitant orthopedic procedures, and outcomes including amputation rate, and in-hospital mortality were recorded. RESULTS: Fifty-one patients were found to have popliteal artery injuries, with a median age of 25 (range 10-70 years). The median ISS was 9, and the mean extremity Abbreviated Injury Severity score was 3. The mechanism of injury was blunt for 43% and penetrating for 57%. Fasciotomies were performed in 74% of patients and 64% of patients underwent combined orthopedic and vascular procedures. Overall, 66% of these patients had their vascular procedure performed first. Ten patients required amputation: 1 immediate and 9 after attempted limb salvage (20%). We found that those patients requiring amputation had a higher incidence of blunt trauma (80% vs. 35%, P = 0.014) and higher MESS score (7.1 vs. 4.7, P = 0.02). There was no difference in the incidence of amputation for those who underwent orthopedic fixation before vascular repair (P = 0.68). CONCLUSIONS: Popliteal vascular injuries continue to be associated with a high risk of amputation. Those patients undergoing attempted limb salvage should be revascularized expediently, but selected patients may undergo orthopedic stabilization before vascular repair without increased risk of limb loss.


Assuntos
Amputação , Artéria Poplítea/cirurgia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgia , Adolescente , Adulto , Idoso , Amputação/efeitos adversos , Amputação/mortalidade , Criança , Fasciotomia , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Procedimentos Ortopédicos , Artéria Poplítea/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/mortalidade , Adulto Jovem
16.
Am J Surg ; 210(6): 1082-6; discussion 1086-7, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26482513

RESUMO

BACKGROUND: The effect of intracranial pressure (ICP) monitoring on mortality after severe traumatic brain injury (sTBI) remains unclear. We hypothesized that ICP monitoring would not be associated with improved survival in patients with sTBI. METHODS: A retrospective analysis was performed on sTBI patients, defined as admission Glasgow Coma Scale score of 8 or less with intracranial hemorrhage. Patients who underwent ICP monitoring were compared with patients who did not. The primary outcome measure was inhospital mortality. RESULTS: Of 123 sTBI patients meeting inclusion criteria, 40 (32.5%) underwent ICP monitoring. On bivariate and multivariate regression analyses, ICP monitoring was associated with decreased mortality (odds ratio = .32, 95% confidence interval = .10 to .99, P = .049). This finding persisted on propensity-adjusted analysis. CONCLUSIONS: ICP monitoring is associated with improved survival in adult patients with sTBI. In addition, significant variability exists in the use of ICP monitoring among patients with sTBI.


Assuntos
Lesões Encefálicas/mortalidade , Lesões Encefálicas/fisiopatologia , Pressão Intracraniana/fisiologia , Adulto , Lesões Encefálicas/complicações , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Estudos Retrospectivos , Taxa de Sobrevida
17.
Am Surg ; 81(10): 922-6, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26463281

RESUMO

Unsalvageable foot infections require a two-staged amputation: an initial guillotine below-knee amputation (BKA) followed by formalization. No literature exists regarding the optimal timing to formalization, and the role of nutrition on outcomes remains unclear. This study was conducted to evaluate whether timing to formalization or nutritional markers correlate with stump complications. A retrospective review of all guillotine BKAs done at our county-funded, academic medical center between 2008 and 2013 was performed. Comorbidities, albumin, prealbumin, glycated hemoglobin, days to formalization, and postoperative complications were recorded. Primary outcome was surgical site infection or need for reoperation of the formalized stump within 30 days. One hundred and twenty-eight guillotine BKAs and subsequent formalizations were performed. Twenty-two (17.2%) patients developed surgical site infections and six (4.9%) required reoperation. Patients formalized within 14 days were as likely to develop stump complications as those formalized later (odds ratio 0.7, 0.3-1.8, P = 0.5). When comparing patients who developed stump complications to those who did not, there was no difference in preoperative albumin (2.6 ± 0.7 vs 2.4 ± 0.7, P = 0.3), prealbumin, (14.4 ± 6.2 vs 15.2 ± 5.5, P = 0.5), or glycated hemoglobin (8.8 ± 2.9 vs 9.0 ± 2.5, P = 0.7). Neither timing of formalization nor nutritional parameters predicted wound complications.


Assuntos
Cotos de Amputação , Amputação/efeitos adversos , Perna (Membro)/cirurgia , Estado Nutricional , Medição de Risco , Cicatrização , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
18.
Am Surg ; 81(10): 965-8, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26463290

RESUMO

Chest computed tomography (CCT) is used to screen for injuries in hemodynamically stable patients with penetrating injury. We aim to determine the incidence of missed injuries detected on CCT after a negative chest radiograph (CXR) in patients with thoracic stab wounds. A 10-year retrospective review of a Level I trauma center registry was performed on patients with thoracic stab wounds. Patients who were hemodynamically unstable or did not undergo both CXR and CCT were excluded. Patients with a negative CXR were evaluated to determine if additional findings were diagnosed on CCT. Of 386 patients with stab wounds to the chest, 154 (40%) underwent both CXR and CCT. One hundred and fifteen (75%) had a negative screening CXR. CCT identified injuries in 42 patients (37%) that were not seen on CXR. Pneumothorax and/or hemothorax occurred in 40 patients (35%), of which 14 patients underwent tube thoracostomy. Two patients had hemopericardium on CCT and both required operative intervention. Greater than one-third of patients with a normal screening CXR were found to have abnormalities on CCT. Future studies comparing repeat CXR to CCT are required to further define the optimal diagnostic strategy in patients with stab wounds to chest after normal screening CXR.


Assuntos
Erros de Diagnóstico/estatística & dados numéricos , Hemotórax/diagnóstico por imagem , Pneumotórax/diagnóstico por imagem , Radiografia Torácica/estatística & dados numéricos , Traumatismos Torácicos/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Ferimentos Perfurantes/diagnóstico por imagem , Adulto , Feminino , Seguimentos , Hemotórax/etiologia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pneumotórax/etiologia , Radiografia Torácica/métodos , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Índices de Gravidade do Trauma , Ferimentos Perfurantes/complicações
19.
Am Surg ; 81(10): 1000-4, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26463297

RESUMO

Inferior vena cava (IVC) injuries are associated with significant morbidity and mortality. To identify clinical factors associated with mortality in patients undergoing operative intervention for penetrating IVC injuries, a retrospective review of 98 patients was performed, excluding blunt injuries (n = 20) and deaths before surgery (n = 16). The overall mortality was 58 per cent. Nonsurvivors more commonly presented with hypotension (50% vs 23%, P = 0.03) and underwent resuscitative thoracotomy more frequently (42% vs 4%, P = 0.01). Retrohepatic injuries were more common among nonsurvivors (P = 0.04). There was no difference in the use of ligation (7% vs 17%, P = 0.29) or the massive transfusion protocol (35% vs 25%, P = 0.41). On multivariate analysis, after controlling for mechanism of injury, admission hypotension, Glasgow Coma Scale score , preoperative cumulative fluids, resuscitative thoracotomy , absence of spontaneous tamponade, and location of IVC injury, the only independent predictor of mortality was the absence of spontaneous tamponade at the time of laparotomy (odds ratio = 5.4, 95% confidence interval: 1.11-25.95; P = 0.04). Penetrating IVC injuries continue to be associated with a high mortality, particularly among patients with free intraabdominal hemorrhage at laparotomy. Large multicenter studies are required to define the optimal resuscitative and operative management techniques in these severely injured patients.


Assuntos
Traumatismos Abdominais/cirurgia , Laparotomia , Salas Cirúrgicas , Sobreviventes , Veia Cava Inferior/lesões , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/mortalidade , Adulto , California/epidemiologia , Feminino , Seguimentos , Escala de Coma de Glasgow , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taxa de Sobrevida/tendências , Ferimentos Penetrantes/mortalidade
20.
Ann Vasc Surg ; 29(4): 764-9, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25725276

RESUMO

BACKGROUND: Injuries of the abdominal aorta are uncommon and associated with a high mortality. The purpose of this study was to examine the impact of an institutional massive transfusion protocol (MTP) on outcomes in patients with injuries of the abdominal aorta. METHODS: A 12.5-year retrospective analysis of a Level 1 trauma center database to identify patients with abdominal aortic injuries was conducted. Demographics, associated injuries and severity, operative procedures, resuscitation requirements, and outcomes were compared among patients before and after implementation of an MTP. RESULTS: Of the 46 patients with abdominal aortic injuries, 29 (63%) were in the pre-MTP group and 17 (37%) were in the post-MTP group. The mean age of the entire cohort was 32 ± 17 years and the two most common mechanisms of injury were gunshot wounds (63%) followed by motor vehicle collisions (24%). Thirteen patients (28%) underwent an emergency department thoracotomy and 11 patients (24%) sustained concomitant inferior vena cava injuries. There was a significant reduction in the volume of pre- and intraoperative crystalloids administered between the pre- and post-MTP groups. Intraoperatively, the use of tranexamic acid was increased in the post-MTP group (P < 0.001). A statistically significant difference in achievement of a low packed red blood cells to fresh frozen plasma ratio was observed for the post- versus the pre-MTP group (88% vs. 30%, P = 0.015). Overall survival was improved among post- versus pre-MTP patients (47% vs. 14%, P = 0.03). CONCLUSIONS: Abdominal aortic injuries continue to represent a challenge and remain associated with a high mortality. Modern improvements in damage control resuscitation techniques including implementation of an institutional MTP may improve outcomes in patients with these injuries.


Assuntos
Traumatismos Abdominais/terapia , Aorta Abdominal/cirurgia , Transfusão de Sangue/métodos , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/terapia , Ferimentos por Arma de Fogo/terapia , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Acidentes de Trânsito , Adolescente , Adulto , Antifibrinolíticos/administração & dosagem , Aorta Abdominal/lesões , Transfusão de Sangue/mortalidade , California , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Ácido Tranexâmico/administração & dosagem , Reação Transfusional , Centros de Traumatologia , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos por Arma de Fogo/mortalidade , Adulto Jovem
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