Safety and Metabolic Tolerance of Citrate Anticoagulation in Critically Ill Polytrauma Patients with Acute Kidney Injury Requiring an Early Continuous Kidney Replacement Therapy.

For severe polytrauma patients with an early AKI requiring renal replacement therapy, anticoagulation remains a great challenge. Due to a high bleeding risk, hemodynamic instability, and increased lactate levels, continuous modality (CKRT) and citrate anticoagulation seem to be the most appropriate. However, their safety with regard to the potential risk of impaired citrate metabolism is not documented. A retrospective study of 60 severe polytrauma patients admitted to the emergency department between January 2000 and December 2021 was conducted; the patients requiring CKRT during the first 72 h were treated with citrate (n. 46, group Citrate) or with heparin (n. 14, group Heparin). Out of 60 patients, 31 survived (51.7%). According to logistic regression analysis, age and SOFA score were significant predictors of mortality. The incidence of rhabdomyolysis was more common in the survivors (77.4 vs. 51.7%), and Kaplan-Meyer analysis showed a better trend towards survival at 90 days for the group Citrate than the group Heparin (p 0.0956). In the group Citrate, hemorrhagic episodes were significantly less common (0.045 vs. 0.273 episodes/day, p < 0.001); the effective duration (h/day) of CKRT was longer; and the effective net ultrafiltration rate (mL/kg/h) and blood flow rate were lower. For severe polytrauma patients, early, soft CKRT with citrate anticoagulation at a low blood flow rate and circuit citratemia showed a better safety and hemodynamic stability, suggesting that citrate should be the first choice anticoagulant in this subset of patients.

Delayed Surgical Treatment of Displaced Intra-Articular Calcaneal Fractures in Major Trauma Is Safe and Effective.

BACKGROUND: To assess whether delaying operative fixation through the sinus tarsi approach resulted in a decreased wound complications rate or could hinder the quality of reduction in subjects with Sanders type II and III displaced intra-articular calcaneus fractures. METHODS: From January 2015 to December 2019, all polytrauma patients were screened for eligibility. We divided patients into two groups: Group A, treated within 21 days after injury; Group B, treated more than 21 days after injury. Wound infections were recorded. Radiographic assessment consisted of serial radiographs and CT scans: postoperatively (T0) and at 12 weeks (T1) and at 12 months after surgery (T2). The quality of reduction of the posterior subtalar joint facet and calcaneal cuboid joint (CCJ) was classified as anatomical and non-anatomical. A post hoc power calculation was performed. RESULTS: A total of 54 subjects were enrolled. Four wound complications (three superficial, one deep) were identified in Group A; two wound complications (one superficial one deep) were identified in Group B. According to "mean interval between trauma and surgery" and "duration of intervention", there was a significant difference between the groups (p < 0.001). There were no significant differences between Groups A and B in terms of wound complications or quality of reduction. CONCLUSIONS: The sinus tarsi approach is a valuable approach for the surgical treatment of closed displaced intra-articular calcaneus fractures in major trauma patients who need delayed surgery. The timing of surgery did not negatively influence the quality of the reduction and the wound complication rate. LEVEL OF EVIDENCE: level II, prospective comparative study.

The role of internal jugular vein Doppler ultrasonography in predicting hypovolemic shock in polytrauma patients.

PURPOSE: The aim of this study was to evaluate the accuracy of internal jugular vein (IJV) Doppler ultrasonography in predicting hypovolemic shock in polytrauma patients. METHODS: This prospective observational study was conducted on 75 multiple trauma patients (injury severity score >15) with a mean age of 33.00±9.57 years. IJV Doppler ultrasonography was performed in all patients with stable vital signs and a negative extended focused assessment with sonography for trauma. Jugular pulsatility index (JPI) values were calculated using the equation (Vmax-Vmin)/Vmax. Clinical and laboratory indices of hypovolemic shock were recorded at the time of admission. Patients were subsequently divided into those with hemorrhagic shock (n=36) and those without (n=39) based on the occurrence of hemorrhagic shock within 6 hours after admission. The results were compared between these groups. RESULTS: IJV Doppler ultrasound parameters (JPI, Vmin, and Vmax-Vmin) showed significant differences between the two groups. The JPI values of patients with hemorrhagic shock were significantly lower than those in the control group (0.43±0.21 vs. 0.78±0.24, P<0.001). The sensitivity, specificity, and discriminant ability (area under the curve) of JPI with a cutoff of 0.58 in detecting hemorrhagic shock were 86.11%, 82.05%, and 0.853 (P<0.001), respectively. CONCLUSION: IJV Doppler ultrasonography can reliably predict hemorrhagic shock in polytrauma patients with stable vital signs. Ultrasonography can be used in combination with clinical signs and laboratory findings to diagnose patients at risk of hypovolemic shock.

Prehospital time and mortality in polytrauma patients: a retrospective analysis.

BACKGROUND: The time from injury to treatment is considered as one of the major determinants for patient outcome after trauma. Previous studies already attempted to investigate the correlation between prehospital time and trauma patient outcome. However, the outcome for severely injured patients is not clear yet, as little data is available from prehospital systems with both Emergency Medical Services (EMS) and physician staffed Helicopter Emergency Medical Services (HEMS). Therefore, the aim was to investigate the association between prehospital time and mortality in polytrauma patients in a Dutch level I trauma center. METHODS: A retrospective study was performed using data derived from the Dutch trauma registry of the National Network for Acute Care from Amsterdam UMC location VUmc over a 2-year period. Severely injured polytrauma patients (Injury Severity Score (ISS) ≥ 16), who were treated on-scene by EMS or both EMS and HEMS and transported to our level I trauma center, were included. Patient characteristics, prehospital time, comorbidity, mechanism of injury, type of injury, HEMS assistance, prehospital Glasgow Coma Score and ISS were analyzed using logistic regression analysis. The outcome measure was in-hospital mortality. RESULTS: In total, 342 polytrauma patients were included in the analysis. The total mortality rate was 25.7% (n = 88). Similar mean prehospital times were found between the surviving and non-surviving patient groups, 45.3 min (SD 14.4) and 44.9 min (SD 13.2) respectively (p = 0.819). The confounder-adjusted analysis revealed no significant association between prehospital time and mortality (p = 0.156). CONCLUSION: This analysis found no association between prehospital time and mortality in polytrauma patients. Future research is recommended to explore factors of influence on prehospital time and mortality.

Process related decisions and in-hospital transport times in polytrauma patients benefit from 24/7 in-house presence of trauma surgeons.

BACKGROUND: Time and cause of death in polytrauma has shifted due to improvements in trauma and critical care. These include logistical improvements with dedicated trauma teams and in-house trauma surgeons. This study investigated in-hospital transport times and influence of process related decisions on mortality in polytrauma patients. STUDY DESIGN: A 6.5-year prospective study included consecutive polytrauma patients ≥15 years admitted to a Level-1 Trauma Center ICU with 24/7 in-house trauma surgeons. Demographics, physiologic parameters, pre- and in-hospital transport times were prospectively collected. Data are presented as median(IQR). RESULTS: 391 patients were included with median ISS of 29(22-36). 82 patients(21%) had a SBP≤90 mmHg on arrival in ED. 44 patients went from ED directly to OR for urgent surgery, all others had CT prior to OR and/or ICU. Patients who went directly to OR from ED had median transport time of 28(23-37) min. Patients who had CT after ED had median transport time of 31(25-42) min. 74(19%) patients died, majority caused by TBI(70%). Ten patients died <24 h after trauma (4 hemorrhage,3 TBI,2 ischemia,1 cardiac injury), 9 of them went straight to OR from ED. Death could possibly have been prevented in 1 patient (1%) who later died of hemorrhage but went to CT before urgent surgery. CONCLUSION: In-hospital transport times from ED were half an hour regardless of the following destination (OR/CT). Decisions for transport order based on clinical signs in primary survey were rapid and accurate. This could be attributed to dedicated trauma teams and 24/7 physical presence of trauma surgeons.

Global changes in mortality rates in polytrauma patients admitted to the ICU-a systematic review.

BACKGROUND: Many factors of trauma care have changed in the last decades. This review investigated the effect of these changes on global all-cause and cause-specific mortality in polytrauma patients admitted to the intensive care unit (ICU). Moreover, changes in trauma mechanism over time and differences between continents were analyzed. MAIN BODY: A systematic review of literature on all-cause mortality in polytrauma patients admitted to ICU was conducted. All-cause and cause-specific mortality rates were extracted as well as trauma mechanism of each patient. Poisson regression analysis was used to model time trends in all-cause and cause-specific mortality. Thirty studies, which reported mortality rates for 82,272 patients, were included and showed a decrease of 1.8% (95% CI 1.6-2.0%) in all-cause mortality per year since 1966. The relative contribution of brain injury-related death has increased over the years, whereas the relative contribution of death due to multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome, and sepsis decreased. MODS was the most common cause of death in North America, and brain-related death was the most common in Asia, South America, and Europe. Penetrating trauma was most often reported in North America and Asia. CONCLUSIONS: All-cause mortality in polytrauma patients admitted to the ICU has decreased over the last decades. A shift from MODS to brain-related death was observed. Geographical differences in cause-specific mortality were present, which may provide region-specific learning possibilities resulting in improvement of global trauma care.

Hemoterapia en el paciente gravemente enfermo / Hemotherapy in the seriously ill patients

Introducción: Para mejorar la estabilidad hemodinámica, trastornos de la coagulación, perfusión hística, capacidad de transporte de oxígeno, entre otros, en el paciente crítico se hace necesario la transfusión de sangre y derivados. Objetivo: Caracterizar la población de pacientes graves que recibieron tratamiento con sangre y hemoderivados. Métodos: Se realizó un estudio descriptivo y transversal en 199 pacientes ingresados en la unidad de cuidados intensivos del Hospital General Orlando Pantoja Tamayo del municipio Contramaestre, provincia Santiago de Cuba, desde enero de 2016 hasta abril de 2019. Las variables analizadas fueron: edad, sexo, causas de hemoterapia, tipo de componente sanguíneo empleado, frecuencia de administración, reacciones adversas y estado al egreso. Se utilizó el porcentaje para resumir la información, así como el test chi cuadrado para identificar asociación estadística. Resultados: Predominaron el sexo femenino (56,7 por ciento) y la edad comprendida entre 65 años y más, con el diagnóstico de politraumatizados, sangrado digestivo alto y sepsis. El concentrado de hematíes fue el más empleado y la frecuencia de administración, en una ocasión, fue en la categoría que más reacciones adversas se encontró (56,6 por ciento); el empleo en cuatro o más ocasiones incrementó la mortalidad. Conclusiones: El concentrado de hematíes fue el hemoderivado más administrado, la administración en una ocasión fue la que más reacciones adversas provocó y la mayoría fueron del tipo inmediatas inmunológicas(AU)

Introduction: To improve hemodynamic stability, coagulation disorders, tissue perfusion, oxygen transport capacity, among others, the transfusion of blood and plasma derivatives is necessary in the critically-ill patient. Objective: To characterize the population of seriously-ill patients who received treatment with blood and hemoderivatives. Methods: A descriptive and cross-sectional study was carried out with 199 patients admitted to the intensive care unit of Orlando Pantoja Tamayo General Hospital in Contramaestre Municipality, Santiago de Cuba Province, from January 2016 to April 2019. The variables analyzed were age, sex, causes for hemotherapy, type of blood component used, frequency of administration, adverse reactions, and discharge status. Percentage was used to summarize the information. Also, the chi-square test was used to identify statistical association. Results: There was a predominance of the female sex (56.7%) and of the age 65 years and older, with diagnosis of polytrauma, high digestive bleeding, and sepsis. The red blood cell concentrate was the most used and the frequency of administration, on one occasion, occurred in the category with the highest amount of adverse reactions (56.6%). Administration on four or more occasions increased mortality. Conclusions: The red blood cell concentrate was the most administered hemoderivative. Administration on one occasion that caused the most adverse reactions and most were immediate immunological ones(AU)

Indication of whole body computed tomography in pediatric polytrauma patients-Diagnostic potential of the Glasgow Coma Scale, the mechanism of injury and clinical examination.

OBJECTIVE: To evaluate the diagnostic potential of the Glasgow Coma Scale (GCS), the mechanism of injury (MOI) and clinical examination (CE) for the indication of whole body computed tomography (WBCT) in pediatric polytrauma patients. MATERIALS & METHODS: 100 pediatric polytrauma patients with WBCT were analysed in terms of age, gender, (MOI), GCS, detected injury, FAST, CE and Injury Severity Score (ISS). Correlations between all clinical variables and patient groups with (p+) and without (p-) injury were assessed. RESULTS: Mean age was 9.13 ±â€¯4.4 years (28% female patients). Injury was detected in 71% of the patients, most commonly of the head (43%). There was no significant correlation between type or severity of MOI and ISS (p > 0.1). None of the clinical variables had a significant predictive effect on p+. The optimum discrimination threshold of GCS was at 12.5 relating to craniocerebral injuries. Severity of MOI and FAST showed best predictive effects on thoracic and abdominal pathologies, respectively, but with only low sensitivities (<20%). CONCLUSION: There is no clinical variable, which can be used as sole indication for WBCT in pediatric polytrauma patients. GCS had a significant predictive value for craniocerbral injuries and CCT is recommended at GCS ≤ 13.

Orthopedic Injuries in Pediatric Trauma.

BACKGROUND: Trauma remains the leading cause of death in children, of which the majority of patients have orthopedic injuries. The range of injured bones is various, each requiring knowledge and expertise to appropriately manage in a timely fashion. OBJECTIVES: The importance of a systematic approach to the pediatric polytrauma patient is paramount. This chapter will highlight orthopedic issues important to the pediatric polytrauma patient including the unique anatomy and properties of pediatric bone. A systematic approach to the pediatric polytrauma patient will also be discussed. METHODS: A review of the literature was undertaken to identify current practices in pediatric orthopedic trauma care. RESULT AND CONCLUSION: Orthopedic injuries in polytrauma are a common and important entity in children. Special attention to the unique anatomy and injury patterns in children should be undertaken as they are important for their management.

The Expression of Nuclear Transcription Factor Kappa B (NF-κB) in the Case of Critically Ill Polytrauma Patients with Sepsis and Its Interactions with microRNAs.

Critical polytrauma patients present a series of pathophysiological disturbances, biochemical and molecular dysfunction, which comprise to be the major cause of intensive care unit admission. In regard to molecular damage, there exists a series of factors, which all together contribute to the aggravation of the clinical status leading to increased mortality rate in these patients. One of the most important biochemical factors involved is the nuclear transcription factor B (NF-κB). Impaired NF-κB functioning is reflected on the clinical status of the patient through increased production of pro-inflammatory molecule, leading to multiple organ dysfunction syndrome. In addition to this, through microRNAs interactions, various pathophysiological as well as biochemical disturbances are produced, which altogether further reduce the patient's survival rate. In this paper, we would like to present the modifications seen in the expression of NF-κB in critically polytraumatized patients with sepsis. In additions to this, we would like to discuss the correlation between the microRNAs and its further implications in clinical status of these patients.

Development of a scoring system based on conventional parameters to assess polytrauma patients: PolyTrauma Grading Score (PTGS).

BACKGROUND: The impact of conventional laboratory data to identify polytrauma patients at risk of complications is established. However, it has not been assessed in terms of prognostic accuracy for systemic complications (ARDS, organ failure). We therefore assessed the most predictive parameters for systemic complications and developed a scoring system for early grading of polytrauma patients. METHODS: A population based trauma registry was used. INCLUSION CRITERIA: age >16 years, Abbreviated Injury Score (AIS) of the abdomen or chest ≥ 3 points and treatment in an intensive care unit, or Injury Severity Score (ISS) ≥ 16 points. The primary endpoint was hospital mortality. Patients were graded according their risk of death: low risk of death (5-14% mortality), intermediate risk patients (15-39% mortality) and high risk (>40%). Routine clinical and laboratory parameters on admission were assessed to determine their specific relevance to describe the risk profile of the patient. Based on these data, a scoring system for the description of the clinical status was developed. Statistical analysis included uniand multivariate analysis. RESULTS: 11.436 patients were included, the mean ISS was 22.7 ± 11.2 points, 73% were male, and 95.6% had blunt injuries. The most sensitive parameters were found to be the following ones: systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered. The multivariate analysis revealed the following threshold levels: BP 76-90 mmHg: r = 0.249, OR 1.283: Base deficit 8-10 r = 0.474, OR 1.606; INR 1.4-2 r = 0.160, OR 1.174; NISS 35-39 r = 0.9, OR 2.46; pBRC 3-14: r = 0.671, OR 1.957. The following ranges of score values were found to be associated with different patient status: <6 points: stable patients; 6-11 points: borderline condition; >11 points: unstable patients. When using this score, 80.6% were stable, 14.6% in a borderline condition and 4.8% unstable. CONCLUSION: We developed a scoring system to discriminate polytrauma patients on admission that are at risk of systemic complications. Systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered are able to provide a prognosis of patients at risk of posttraumatic complications. Further prospective studies should be performed to verify this new scoring system.

Atención inicial al politraumatizado maxilofacial: evaluación de la vía aérea y la circulación / Initial care of maxillofacial polytrauma patients: evaluation of the airway and circulation

Introducción: la traumatología facial es una vertiente de la Cirugía Maxilofacial, donde son necesarios conocimientos profundos de disciplinas tales como anatomía, fisiología, patología, y la estrecha relación con otras especialidades (quirúrgicas o no). Objetivo: realizar una revisión bibliográfica sobre la atención al politraumatizado maxilofacial, enfatizando en aspectos relacionados con el Soporte Vital Avanzado en Trauma y dentro de él, el manejo de la vía aérea con la estabilización de la columna cervical, de la ventilación y la circulación. Métodos: se realizó una revisión bibliográfica en el periodo comprendido entre diciembre de 2014 y enero de 2015. Se evaluaron revistas de impacto de Web of Sciencies (41 revistas) y 6 libros. Se consultaron las bases de datos de sistemas referativos MEDLINE, PubMed y SciELO. Se utilizaron como descriptores maxilofacial trauma, maxilofacial emergency, emergency management, critical care y sus equivalentes en español. Se incluyeron artículos en idioma inglés y español, publicados preferentemente en los últimos 5 años. Se obtuvieron 147 artículos. El estudio se circunscribió a 50 que enfocaban estas temáticas de manera más integral. Análisis e integración de la información: al analizar el comportamiento de los artículos referidos al tema, en relación con su representatividad en las revistas científicas, se halló que 6 por ciento correspondió a la Journal of Oral and Maxillofacial Surgery. Conclusiones: la atención eficaz del politraumatizado maxilofacial asegura resultados satisfactorios, tanto en la conservación de la vida, como desde el punto de vista estético y funcional. En esta temática es imprescindible manejar las directrices del Soporte Vital Avanzado del trauma y dentro de él, el manejo de la vía aérea con la estabilización de la columna cervical, ventilación y circulación(AU)

Introduction: facial traumatology is a branch of maxillofacial surgery requiring deep knowledge about disciplines such as anatomy, physiology and pathology, as well as their close relationship to other specialties, either surgical or not. Objective: carry out a bibliographic review about the care of maxillofacial polytrauma patients, highlighting aspects related to advanced trauma life support, particularly management of the airway with cervical spine stabilization, ventilation and circulation. Methods: a bibliographic review was performed which covered the period from December 2014 to January 2015. The evaluation included high impact journals from theWeb of Sciences (41 journals) and 6 books. The databases MEDLINE, PubMed and SciELO were consulted, using the search terms maxillofacial trauma, maxillofacial emergency, emergency management and critical care, and their Spanish counterparts. The review included papers in English and Spanish, preferably published the last five years. Of the 147 papers obtained, the reviewers selected the 50 which approached the study topics in a more comprehensive manner. Data analysis and integration: Analysis of the representativeness of papers in scientific journals revealed that 6 percent corresponded to the Journal of Oral and Maxillofacial Surgery. Conclusions: effective care of maxillofacial polytrauma patients ensures satisfactory results, both in the preservation of life as from an esthetic and functional point of view. It is indispensable to have a good command of advanced trauma life support guidelines, particularly the management of the airway with stabilization of the cervical spine, ventilation and circulation(AU)

Atención inicial al politraumatizado maxilofacial: evaluación, conducta terapéutica y prevención / Initial care of maxillofacial polytrauma patients: evaluation, therapeutic management and prevention

Introducción: las fracturas maxilofaciales requieren tratamiento de urgencia y de un personal altamente calificado. Pueden aparecer complicaciones que ocasionen la pérdida de la vida del paciente. Objetivo: realizar una revisión bibliográfica sobre la atención al politraumatizado maxilofacial, enfatizando aspectos del soporte vital avanzado de trauma como el manejo del déficit neurológico, de la exposición del paciente y del control de la temperatura, anexos a la valoración primaria, valoración secundaria, tratamiento definitivo, lesiones asociadas, equipo multidisciplinario del trauma, traumatismos maxilofaciales con características distintivas, condiciones que influyen en el manejo del trauma y prevención. Métodos: se realizó una revisión bibliográfica entre diciembre de 2014 y enero de 2015. Se evaluaron revistas de impacto de Web of Sciencies (39), 1 cubana y 5 libros. Se consultaron las bases de datos de los sistemas MEDLINE, PubMed y SciELO. Se utilizaron como descriptores: maxilofacial trauma, advanced trauma life support, secondary survey, associated injuries, multidisciplinary team of trauma, prevention y sus equivalentes en español. Se incluyeron artículos en inglés y español, publicados preferentemente en los últimos 5 años. Se obtuvieron 141 artículos. El estudio estuvo circunscrito solo a 51, que enfocaban estas temáticas de forma más integral. Análisis e integración de la información: al analizar el comportamiento de los artículos atendiendo a su representatividad en las revistas científicas, encontramos que 5,9 por ciento correspondían a la Journal of Craniomaxillofacial Surgery. Conclusiones: es imprescindible que los cirujanos maxilofaciales que se desempeñan en la atención de emergencia puedan reconocer, diagnosticar y establecer el manejo básico de un traumatismo maxilofacial. La falta de diagnóstico y de correcto manejo puede conducir a la pérdida de funciones y al desarrollo de deformidades secundarias difíciles de corregir luego. Esta corrección también podría inducir resultados decepcionantes, que podrían comprometer la vida del paciente(AU)

Introduction: maxillofacial fractures require emergency treatment by highly qualified personnel. Complications may occur which may cause the death of the patient. Objective: carry out a bibliographic review about the care of maxillofacial polytrauma patients, highlighting the following aspects of advanced trauma life support: management of neurological deficit, exposure and temperature control, annexes to primary assessment, secondary assessment, definitive treatment, associated injuries, multidisciplinary trauma team, maxillofacial traumas with distinctive characteristics, conditions influencing trauma management and prevention. Methods: a bibliographic review was conducted from December 2014 to January 2015. The evaluation included high impact journals from the Web of Sciences (39 journals), as well as one Cuban journal and five books. The databases MEDLINE, PubMed and SciELO were consulted, using the search terms maxillofacial trauma, advanced trauma life support, secondary survey, associated injuries, multidisciplinary trauma team, prevention, and their Spanish counterparts. The review included papers in English and Spanish, preferably published the last five years. Of the 141 papers obtained, the reviewers selected the 51 which approached the study topics in a more comprehensive manner. Data analysis and integration: analysis of the representativeness of papers in scientific journals revealed that 5.9 percent corresponded to the Journal of Craniomaxillofacial Surgery. Conclusions: it is indispensable for emergency maxillofacial surgeons to be able to recognize, diagnose and determine the basic management of maxillofacial trauma. Lack of a diagnosis or inappropriate management may lead to the loss of functions and the development of secondary deformities difficult to correct in the future. Such correction could also lead to disappointing results which may risk the patient's life(AU)

Early, reliable, utilitarian predictive factors for fat embolism syndrome in polytrauma patients.

BACKGROUND: Fat embolism is one of the apocalyptic pulmonary complications following high energy trauma situations. Since delay in diagnosis may have devastating consequences, early, easily accessible and relatively inexpensive investigations for risk stratification may prove useful, especially in developing nations. MATERIALS AND METHODS: This prospective trial included a total of 67 young polytrauma patients, in whom the role of nine easily available, rapidly performable clinical or laboratory investigations (or observations noted at admission) in predicting the later occurrence of fat embolism syndrome were assessed. All the patients also underwent continuous monitoring of oxygen saturation with pulsoximetry. RESULTS: The correlation between initial serum lactate (within 12 hours of injury) and hypoxia was statistically significant. There was a trend towards correlation with FES(by Gurd's criteria) (P=0.07), Sensitivity of 24-hour monitoring of oxygen saturation in predicting later pulmonary deterioration approached 100%. CONCLUSIONS: The combination of three factors including polytrauma (with NISS >17), serum lactate >22 mmol/l at admission (within 12 hours of injury) fall in oxygen saturation (SaO2 below 90% in the initial 24 hours) predict the development of post-traumatic pulmonary complications, especially the fat embolism syndrome.

Diagnóstico e manejo das lesões ortopédicas em pacientes politraumatizados / Diagnosis and management of orthopedic lesions in polytrauma patients

Concluído o atendimento inicial com a realização das manobras básicas preconizadas pelo ATLS® (Advanced Trauma Life Support), o manejo das fraturas expostas figura entre as prioridades no atendimento inicial ortopédico em politraumatizados. Lavagem abundante, desbridamento adequado, profilaxia antitetânica e antibioticoterapia intravenosa precoce e de amplo espectro são fundamentais para o adequado manejo das mesmas. Fraturas da pelve e do quadril, francamente relacionadas a traumas de alta energia, são as únicas que, por estarem ligadas a grandes sangramentos retroperitoniais, podem levar ao óbito logo após o trauma, configurando emergências traumatológicas. As fraturas em membro inferior apresentam alta morbidade, sendo as de tíbia as consideradas mais frequentes dentre as expostas e em ossos longos. Embora as de fêmur se apresentem com menor frequência, acabam por deixar sequelas mais importantes. Diferentemente destas, as fraturas de escápula, clavícula, rádio e ulna podem receber um manejo simples de redução e contenção, requerendo apenas em casos particulares de intervenções cirúrgicas. A avaliação radiológica no politraumatizado jamais deve interromper as manobras de reanimação. Duas incidências radiográficas ortogonais costumam ser suficientes para a visualização de lesões ortopédicas. Outros exames normalmente ficam reservados para um segundo tempo do atendimento na avaliação de estruturas e lesões de maior complexidade.

Following performance of basic procedures recommended by ATLS® (Advanced Trauma Life Support), the management of open fractures is a priority in the early orthopedic management of polytrauma patients. Thorough washing, adequate debridement, tetanus prophylaxis and early, broad-spectrum intravenous antibiotic therapy are key elements for the adequate management of these lesions. Pelvic and hip fractures usually result from high-energy trauma and are the only ones that may lead to death soon after the traumatic event, because of the possibility of major retroperitoneal bleeding; these cases should therefore be considered as orthopedic emergencies. Lower limb fractures present high morbidity, and tibial fractures are the most frequent ones among open fractures affecting long bones. Femoral fractures, although less frequent, usually have important sequelae. On the other hand, scapular, clavicle, radial and ulnar fractures can be easily managed by reduction and immobilization, rarely requiring surgical intervention. The radiological assessment of polytrauma patients should never interrupt ressuscitation procedures. Two orthogonal radiographic projections are usually enough for the analysis of orthopedic lesions. Additional exams are usually reserved for a second stage, during the assessment of structures and lesions of higher complexity.