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1.
J Surg Res ; 257: 227-231, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32861100

RESUMO

BACKGROUND: Angioembolization (AE) is an adjunct to nonoperative management (NOM) of splenic injuries. We hypothesize that failure of AE is associated with blood transfusion, grade of injury, and technique of AE. METHODS: We performed a retrospective (2010-2017) multicenter study (nine Level I trauma centers) of adult trauma patients with splenic injuries who underwent splenic AE. Variables included patient physiology, injury grade, transfusion requirement, and embolization technique. The primary outcome was NOM failure requiring splenectomy. Secondary outcomes were mortality, complications, and length of stay. RESULTS: A total of 409 patients met inclusion criteria; only 33 patients (8%) required delayed splenectomy. Patients who failed received more blood in the first 24 h (P = 0.009) and more often received massive transfusion (P = 0.01). There was no difference in failure rates for grade of injury, contrast blush on computed tomography, and branch embolized. After logistic regression, transfusion in the first 24 h was independently associated with failure of NOM (P = 0.02). Patients who failed NOM had more complications (P = 0.002) and spent more days in the intensive care unit (P < 0.0001), on the ventilator (P = 0.0001), and in the hospital (P < 0.0001). Patients who failed NOM had a higher mortality (15% versus 3%, P = 0.007), and delayed splenectomy was independently associated with mortality (odds ratio, 4.2; 95% confidence interval, 1.2-14.7; P = 0.03). CONCLUSIONS: AE for splenic injury leads to effective NOM in 92% of patients. Transfusion in the first 24 h is independently associated with failure of NOM. Patients who required a delayed splenectomy suffered more complications and had higher hospital length of stay. Failure of NOM is independently associated with a fourfold increase in mortality.


Assuntos
Traumatismos Abdominais/terapia , Transfusão de Sangue/estatística & dados numéricos , Embolização Terapêutica/estatística & dados numéricos , Baço/lesões , Esplenectomia/estatística & dados numéricos , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Baço/irrigação sanguínea , Baço/cirurgia , Artéria Esplênica/diagnóstico por imagem , Tempo para o Tratamento , Centros de Traumatologia/estatística & dados numéricos , Falha de Tratamento , Adulto Jovem
2.
S Afr Med J ; 0(0): 13183, 2020 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-33334392

RESUMO

BACKGROUND: In response to the coronavirus pandemic, lockdown restrictions and a ban on alcohol sales were introduced in South Africa. Objectives. To investigate the impact of lockdown measures on the number of patients who visited a tertiary urban trauma centre. Methods. The period of investigation was from 1 February to 30 June 2020 and was segmented into three intervals: pre-lockdown (February and March 2020), hard lockdown (April and May 2020) and immediately post lockdown (June 2020). The electronic HECTIS health record registry was interrogated for the total number of patients that were seen per month. These were further categorised according to mechanism of injury (stab, gunshot, blunt assault and road traffic injuries). Penetrating (stab and gunshot) and blunt assault victims were collectively grouped as violent trauma. Results. The mean total number of patients seen decreased by 53% during the hard lockdown period. There was a moderate reduction (15%) in patients with gunshot injuries seen during the hard lockdown phase, but there was an 80% increase in the post-lockdown period. The proportion of patients injured in road traffic collisions pre lockdown, hard lockdown and immediate post lockdown was 16.4%, 8.9% and 11.1%, respectively. Patients injured in road traffic collisions decreased by 74% during the hard lockdown period and maintained a reduction of 32% during the immediate post-lockdown period. The mean total number of patients who visited the trauma unit returned to pre-lockdown levels in June. Conclusions. There was an overall trend of reduced number of patients who visited the trauma unit during the hard lockdown period; however, these numbers returned to pre-lockdown levels during the immediate post-lockdown period. The number of road traffic injury admissions remained reduced during all three phases of lockdown, while the number of gunshot victims increased substantially during the post-lockdown period.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Controle de Doenças Transmissíveis , Violência/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Ferimentos por Arma de Fogo/epidemiologia , Adulto , Consumo de Bebidas Alcoólicas/epidemiologia , /prevenção & controle , Controle de Doenças Transmissíveis/métodos , Controle de Doenças Transmissíveis/organização & administração , Feminino , Humanos , Masculino , África do Sul/epidemiologia , Centros de Traumatologia/estatística & dados numéricos
3.
Injury ; 51(12): 2834-2839, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33162012

RESUMO

INTRODUCTION: By May 2020, Peru was the country with the third most COVID-19 cases in the Americas. The current study's overall aim was to examine the impact of the current COVID-19 outbreak on the number of non-COVID-related patient presentations to a major national emergency traumatology/orthopedics referral center in Latin America. METHODS: An observational study was performed at one of Peru's main tertiary trauma referral centers, during the current COVID-19 pandemic. Numbers of non-follow-up patients presenting to the traumatology/ orthopedics service were counted and compared between January through April 2019 and January through April 2020; and between the month immediately prior to the Peruvian government's implementation of national lock-down measures (Feb 16-Mar 15; Period 1) and the month immediately following (Mar 16-Apr 15; Period 2). The number of surgery service hospitalizations also was compared pre- versus post lockdown initiation (Period 1 vs. 2), as were patient characteristics and outcomes, like age, sex, discharge disposition, mortality, indications for hospital admission, and COVID-19 status. RESULT: Comparing 2019 and 2020, no appreciable differences were detected in the number of patients seen in either January or February. However, relative to March and April 2019, the numbers of patients seen in March and April 2020 (the two months after the first Peruvian case of COVID-19 was detected) were reduced by 55.8 and 88.6%, respectively. Comparing the months immediately pre and post lockdown, the number of service patients declined by 79.9% in April, while the number of hospitalizations declined by 30.9%. The number of admissions for various surgical indications either remained stable or declined in parallel with the overall decline in admissions for all indications except for osteoporotic hip fractures and diabetic foot ulcers (both of which increased proportional to the overall number of admissions) and for hand and foot fractures, both of which decreased. CONCLUSION: At our hospital, not all indications for traumatology/orthopedics service utilization declined despite the national government's directive to reduce non-COVID-related consultations and admissions. Some disorders presented with even greater frequency, which must be considered when developing contingencies for the reallocation of healthcare resources during a pandemic.


Assuntos
/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Idoso , Idoso de 80 Anos ou mais , /prevenção & controle , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pandemias/prevenção & controle , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Peru/epidemiologia , Encaminhamento e Consulta/estatística & dados numéricos , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia
4.
Am J Emerg Med ; 38(10): 2041-2044, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33142171

RESUMO

BACKGROUND: Injury results in more deaths in children than all other causes combined, but there is little data regarding the association of early coagulopathy on outcomes in pediatric patients with traumatic injuries. The aim of this study was to determine the optimal cut-off value for the Prothrombin Time ratio (PTr) and to show the diagnostic characteristics of the PTr to predict mortality. METHODS: We retrospectively included during 4 years all patients less than 16 years old referred to our trauma center for traumatic injury with ISS ≥9. RESULTS: A total of 272 children were included. Mean age was 9.4 ± 4.8 years and median ISS was 17 [interquartile range, 12 to 26]. Day 28 mortality was 6.7%. The optimal cut-off value in our population for predicting day 28 mortality was 1.24. Using this value, the sensitivity of PTr was 84%, specificity was 82%, positive likelihood ratio was 4.7, and negative likelihood ratio was 0.19. Early mortality (i.e., mortality at 24 h) was also well-predicted (1.0% versus 16.4%, p < .0001), as the need for massive transfuion. Similarly, patients with PTr ≥1.24 at admission presented with a higher rate of severe thoracic and abdominal trauma, higher ISS, higher likelihood of admission to an intensive care unit, longer hospitalization, and higher rate of significant procedure (e.g., surgery or embolization). CONCLUSIONS: Trauma-induced coagulopathy defined only by a PTr ≥1.24 could be used as a severity predictive marker and as a sensitive, specific, quick, and easy to use tool for admission triage of pediatric patients.


Assuntos
Valor Preditivo dos Testes , Tempo de Protrombina/estatística & dados numéricos , Ferimentos e Lesões/mortalidade , Adolescente , Criança , Pré-Escolar , Feminino , França/epidemiologia , Humanos , Lactente , Masculino , Mortalidade/tendências , Pediatria/instrumentação , Pediatria/métodos , Pediatria/tendências , Tempo de Protrombina/métodos , Estudos Retrospectivos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/sangue , Ferimentos e Lesões/complicações
5.
Can J Surg ; 63(5): E422-E430, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33009903

RESUMO

BACKGROUND: Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS: We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS: We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION: A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.


Assuntos
Hemorragia/diagnóstico , Modelos Biológicos , Triagem/métodos , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/complicações , Adulto , Transfusão de Sangue/estatística & dados numéricos , Canadá/epidemiologia , Tomada de Decisão Clínica , Embolização Terapêutica/estatística & dados numéricos , Feminino , Hemorragia/epidemiologia , Hemorragia/etiologia , Hemorragia/terapia , Hemostasia Cirúrgica/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco/métodos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia
6.
BMJ Open ; 10(10): e041772, 2020 10 20.
Artigo em Inglês | MEDLINE | ID: mdl-33082198

RESUMO

OBJECTIVES: Assess the impacts of the COVID-19 pandemic on service delivery by frontline healthcare providers in acute care medical and emergency department settings and identify strategies used to cope with pandemic-related physical and mental health demands. DESIGN: Rapid clinical ethnography of patient-provider encounters during an initial pandemic 'surge' conducted by a team of clinician-researchers using a structured protocol for qualitative data collection and analysis. SETTING: Level 1 trauma centre at Harborview Hospital in Seattle Washington in April 2020. PARTICIPANTS: Frontline clinical providers serving as participant observers during performance of their clinical duties recorded observations and summaries of conversations with other providers and patients. RESULTS: We identified four different kinds of impacts: procedural, provider, patient and overall. Each impact highlighted two or more levels of a socioecological model of services delivery: (1) the epidemiology of COVID-19, (2) outer setting, (3) inner or organisational setting and (4) individual patient and provider. Despite significant changes in procedures that included COVID-19 screening of all admitted patients, social distancing and use of personal protective equipment, as well as changes in patient and provider behaviour, the overall impact of the pandemic on the emergency department and acute care service delivery was minimal. This is attributed to having a smaller surge than expected, a quick response by the healthcare system to anticipated demands for service delivery and protection of patients and providers, adequate supplies and high provider morale. CONCLUSIONS: Although limited to one setting in one healthcare system in one community, the findings offer some important lessons for healthcare systems that have yet to be impacted as well as systems that have been more severely impacted. Each of the socioecological framework levels was found to impact service delivery to patients, and variations at each of these levels account for variations in that quality of care globally.


Assuntos
Atitude do Pessoal de Saúde , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pandemias , Pneumonia Viral/epidemiologia , Pesquisa Qualitativa , Centros de Traumatologia/estatística & dados numéricos , Humanos , Washington/epidemiologia
7.
Medicine (Baltimore) ; 99(39): e22279, 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32991428

RESUMO

PURPOSE: The aim of this study was to have a comprehensive evaluation of the effect of trauma care systems on the mortality of injured adult patients. MATERIALS AND METHODS: This protocol established in this study has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Web of Science, PubMed, EMBASE, Scopus, and the Cochrane Library were searched for all clinical trials evaluating the effect of trauma care systems on the mortality of injured adult patients until July 31, 2020. We will use a combination of Medical Subject Heading and free-text terms with various synonyms to search based on the eligibility criteria. Two investigators independently reviewed the included studies and extracted relevant data. The odds ratio (OR) and 95% confidence intervals (CIs) were used as effect estimate. I-square (I) test, substantial heterogeneity, sensitivity analysis, and publication bias assessment will be performed accordingly. Stata 15.0 and Review Manger 5.3 are used for meta-analysis and systematic review. RESULTS: The results will be published in a peer-reviewed journal. CONCLUSION: The results of this review will be widely disseminated through peer-reviewed publications and conference presentations. This evidence may also provide a comprehensive evaluation of the effect of trauma care systems on the mortality of injured adult patients. REGISTRATION NUMBER: INPLASY202080058.


Assuntos
Revisão da Pesquisa por Pares/métodos , Centros de Traumatologia/organização & administração , Ferimentos e Lesões/mortalidade , Adulto , Ensaios Clínicos como Assunto , Humanos , Viés de Publicação , Sensibilidade e Especificidade , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia
8.
Unfallchirurg ; 123(11): 862-869, 2020 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-32986217

RESUMO

BACKGROUND: As part of the COVID-19 pandemic, political decisions were made to reduce social interaction and to reduce the number of infections. The aim was to create capacities for the in-hospital care of the patients. OBJECTIVE: The aim of the study was to check whether a reduction in the number of trauma patients compared to the mean of the previous 3 years could be observed. MATERIAL AND METHODS: We retrospectively analyzed all patients who presented in the emergency admission from 1 March to 15 April 2020 with the mean of the patients from the previous 3 years 2017-2019. The age of the patients, time of presentation, diagnoses, whereabouts of the patients, inpatient or outpatient, number and duration of the operative care and required capacity on the normal ward and intensive care units (ICU) were recorded. The injury mechanism was also examined. RESULTS: A total of 4967 patients between 1 March and 15 April were included. On average over the 3 previous years, a total of 1348 patients, i.e. 29.3 patients per day were counted in our emergency room. In 2020 a total of 923, i.e. 20 patients per day (p < 0.01) were counted. On average 227 (24.6%) were admitted to hospital compared to 311.5 (23.1%) in 2020. On average 143 operations were performed compared to 136 in 2020. The days on the ward were reduced from 2442 on average for the previous years, in 2020 to 1172 days by 52.1% (p < 0.01). The number of days on the ICU was 450 days on average in previous years and 303 days in 2020 (-32.7%, p < 0.01). CONCLUSION: The number of patients in the emergency admission was significantly reduced in the observation period in 2020 compared to the mean of the previous 3 years. This directly made resources available for the care of COVID-19 patients.


Assuntos
Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Centros de Traumatologia/estatística & dados numéricos , Betacoronavirus , Humanos , Pandemias , Estudos Retrospectivos
9.
Injury ; 51(12): 2811-2815, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32958345

RESUMO

INTRODUCTION: In Iran, like most other countries, COVID-19 has had a deep impact on children's lives. Our hypothesis was that, a significant change in the number of pediatric injuries has happened in trauma centers. In the current study, we intend to identify the possible epidemiological shift in pediatric fracture patterns, by comparing the data from 'COVID-19 era' and the mean data from the past 2 years. To the best of our knowledge there are only few reports on epidemiology of pediatric fractures during the COVID-19 outbreak. METHODS: Data are reported in two sections. In the descriptive section, epidemiological data regarding pediatric fractures referred to Taleghani tertiary trauma center, including demographics, distribution curves, etiologies and fracture types are presented during the 'COVID era', from 1 March 2020 to 15 April 2020. In the comparative section, the aforementioned data are compared with mean data from the past 2 years, the 'non-COVID era'. RESULTS: Altogether 117 of the 288 trauma children (40.62%) had a fractured bone (145 fractures). Patients were mostly boys, with a mean age of 9.87 years (SD=5.27). The three most common fracture types in children included distal radius, mid-forearm and humeral supracondylar fractures. Compared to non-COVID era, the number of pediatric trauma admissions dropped from 589 to 288. No significant change happened in the mean age, male/female ratio and percentage of motor vehicle accidents. Proportion of proximal humeral, proximal forearm, carpal, and hand fractures declined. The number of open fractures significantly dropped (from 12 to 2). CONCLUSIONS: In Iran, overall trend of pediatric trauma has been decreasing during the outbreak; but the lack of reduction in proportion of accidents may pose an alarm that an effective lock-down has not been imposed. This study has implications as to preparing appropriate resources particular to common "COVID era fractures".


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Controle de Doenças Transmissíveis/normas , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Acidentes de Trânsito/tendências , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Irã (Geográfico)/epidemiologia , Masculino , Pandemias/prevenção & controle , Admissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Centros de Traumatologia/normas , Centros de Traumatologia/tendências , Ferimentos e Lesões/etiologia
12.
Plast Reconstr Surg ; 146(2): 332-338, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32740583

RESUMO

BACKGROUND: Local health care facilities are often unequipped to treat complex upper extremity injuries, and patients are therefore transferred to designated trauma centers. This study describes the characteristics of patients transferred to a Level I trauma center for hand and upper extremity injuries and to investigate the accuracy of the provided diagnosis at the time of referral. METHODS: Adult patients transferred from outside facilities to the authors' Level I trauma center by means of direct contract with the on-call fellow for the care of hand and upper extremity injuries were identified. Patient- and injury-related information was prospectively collected at the time of referral before patient transfer, and again following diagnostic evaluation by a hand surgeon at the authors' institution. RESULTS: Sixty-three patients were transferred to the authors' hand surgery service from outside facilities after direct contact with the on-call fellow. Most patients were referred by emergency medicine physicians [n = 47 (76 percent)], followed by midlevel emergency department providers (physician assistant or nurse practitioner) [n = 12 (19 percent)] or hand surgeons [n = 3 (5 percent)]. Six patients were transferred directly from a Level I trauma center. Twenty-one transferred patients (33 percent) had an inaccurate diagnosis at the time of referral. Factors associated with an inaccurate diagnosis included trauma level of the referring hospital and diagnoses of infection or dysvascularity. CONCLUSIONS: The diagnostic accuracy for hand injuries transferred from outside facilities by means of provider-to-provider communication is imperfect, and some injuries are misdiagnosed. Hand surgeons should continue to improve the triage and transfer process for patients with acute hand surgery injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.


Assuntos
Traumatismos do Braço/diagnóstico , Traumatismos da Mão/diagnóstico , Sobremedicalização/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Triagem/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Encaminhamento e Consulta/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Adulto Jovem
13.
Can J Surg ; 63(5): E383-E390, 2020 08 28.
Artigo em Inglês | MEDLINE | ID: mdl-32856887

RESUMO

Background: The care of rural trauma patients in northern Alberta can be extremely challenging because of the vast geographic area, the limited access to health care facilities and the lack of adequate resources to manage severe injuries. Identifying gaps in equipment and personnel in rural centres can provide opportunities for improving the care of injured patients in these environments. We conducted a survey based on Canadian Accreditation Council quality indicators to evaluate trauma infrastructure and human resources in rural centres across northern Alberta. Methods: A standardized survey was developed to assess the availability of trauma-specific equipment and personnel across the prehospital and emergency department (ED) settings. The survey was distributed to 50 peripheral hospitals biannually from January 2017 to September 2018. Two-tailed paired t tests were used to evaluate changes in survey responses; a p value of less than 0.05 was considered statistically significant. Results: The survey response rate was 100%. By the end of the study period, there were significant improvements in the number of providers (p = 0.04), nurses (p = 0.01) and dedicated trauma resuscitation bays (p = 0.04) in the ED for managing injured patients. There were also significant increases in the availability of equipment, including advanced airway management tools (p = 0.02), rapid infusion devices (p = 0.02) and warmers (p = 0.04). Access to x-ray equipment (p = 0.03) and computed tomography (CT) scanners (p = 0.04) as well as equipment to support telehealth and teleconferencing (p = 0.04) increased during the study period. Access to, and supply of, blood products also increased significantly (p = 0.02) during the study period. Conclusion: Our study demonstrates that the trauma resources of rural health care centres may be evaluated in a standardized fashion centres, and the results point to opportunities to remedy gaps in equipment and personnel. Our methods may be applied to any trauma network that serves geographically large areas with a sparse distribution of health care facilities, to provide critical information for the optimization of resources in rural trauma.


Assuntos
Equipamentos e Provisões Hospitalares/provisão & distribução , Recursos em Saúde/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Alberta , Pesquisas sobre Serviços de Saúde , Humanos , Estudos Prospectivos
14.
Am Surg ; 86(9): 1135-1143, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32809869

RESUMO

BACKGROUND: Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL. METHODS: A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed. RESULTS: A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001). CONCLUSIONS: Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.


Assuntos
Traumatismos Abdominais/diagnóstico , Avaliação Geriátrica/métodos , Laparotomia/métodos , Centros de Traumatologia/estatística & dados numéricos , Traumatismos Abdominais/cirurgia , Fatores Etários , Idoso , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
15.
Malawi Med J ; 32(1): 24-30, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32733656

RESUMO

Introduction: Globally, the burden of interpersonal violence and its significant impact on mortality, morbidity and disability makes it a major public health problem which necessitates intervention. This article examines characteristics of victims of interpersonal violence and violent events in Malawi. The focus is on a population that has been traditionally neglected in literature. Methods: Queen Elizabeth Central Hospital (QECH) maintains a trauma registry with data that is prospectively collected. Patients offered trauma care after interpersonal violence from May 2013 to May 2015 were evaluated. Results: There were 1431 patients with violent events recorded at the Adult Emergency Trauma Centre (AETC) with a male predominance of 79.5%. The dominant age group was young adults between 25-29 years old (22%). Most attacks occurred during cold and dry season (46.9%) and most common location was on the road (37.2%). Alcohol use by victims was recorded in 10.5% of cases. Soft tissue injuries were the most common injuries sustained (74.1%). Most patients were treated as outpatients (80.9%). There were two deaths. At multivariate analysis, women had a lower risk of interpersonal violence as compared to men, (OR 0.82 [0.69-0.98]). Victims' use of alcohol was associated with increased risk of assault (OR 1.63 [1.27-2.10]). As compared to other places, odds of being assaulted were higher at home (OR 1.62 [1.27-2.06]) but lower at work (OR 0.68 [0.52-0.89) and on the road (OR 0.82 [0.65-1.03]). Odds of being assaulted were higher in the cold and dry season as compared to hot and dry season, (OR 1.26 [1.08-1.47]). Conclusion: Young males were most involved in interpersonal violence. Location of injury and seasonal variation were significant factors associated with interpersonal violence and most commonly sustained injuries were soft tissue injuries. These findings will help in identifying targeted interventions for interpersonal violence in Malawi and other low-and-middle-income countries (LMICs).


Assuntos
Violência Doméstica/estatística & dados numéricos , Relações Interpessoais , Centros de Traumatologia/estatística & dados numéricos , Violência/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Adolescente , Adulto , Distribuição por Idade , Fatores Etários , Intoxicação Alcoólica/epidemiologia , Feminino , Humanos , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Distribuição por Sexo , Fatores Sexuais , Violência/classificação , Adulto Jovem
16.
Geriatr Gerontol Int ; 20(9): 817-821, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32697435

RESUMO

AIM: The number of geriatric trauma patients is rising; yet, there is no established best team to care for them. This study analyzed a geriatric trauma service (GTS) that is integrated into the trauma surgery workflow rather than a separate consultation service. We hypothesize this team will lead to decreased mortality, shorter length of stay and increased favorable discharges for geriatric trauma patients. METHODS: In July 2017, we established a GTS consisting of geriatric nurse practitioners who were part of the hospital's geriatrics service, trauma surgeons and surgery residents on the acute care surgery service. The geriatric nurse practitioners were integrated into the trauma surgery workflow and functioned as independent members. The GTS responded to traumas and consultations for patients aged ≥65 years. Trauma surgeons carried out intensive care and operative management, while the geriatric nurse practitioners managed medical issues, family communication and end-of-life planning. We carried out a 2 year retrospective analysis of trauma patients aged ≥65 years seen at Dell Seton Medical Center at the University of Texas, Austin, Texas, USA, comparing patient outcomes before and after the GTS. The primary outcome was mortality, whereas secondary outcomes included hospital days, intensive care unit days, and discharge disposition. RESULTS: We found no difference in mortality, intensive care unit days or hospital days with the GTS. However, post-GTS patients were more often discharged to home, rehabilitation, or hospice, and less often to nursing homes. CONCLUSION: An integrated geriatric and trauma team is feasible, and significant changes in disposition can be made by utilizing geriatric nurse practitioners. Geriatr Gerontol Int 2020; 20: 817-821.


Assuntos
Centros de Traumatologia/estatística & dados numéricos , Centros Médicos Acadêmicos , Idoso , Idoso de 80 Anos ou mais , Feminino , Enfermagem Geriátrica , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Profissionais de Enfermagem , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Texas
17.
J Surg Res ; 255: 556-564, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32640407

RESUMO

BACKGROUND: Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes. METHODS: We performed a 2013-2014 retrospective analysis of all adult trauma patients diagnosed with rib fractures from the American College of Surgeons-Trauma Quality Improvement Program database. We excluded patients who were acutely intoxicated with alcohol. Patients were stratified into two groups: AUD + and AUD -. A 1:1 ratio propensity score matching for demographics, admission vitals, injury severity, smoking status, operative intervention, and number of rib fractures was performed. Outcome measures were in-hospital complications, mortality, hospital and intensive care unit length of stay, and ventilator days. RESULTS: We matched 19,638 patients (AUD +:9,819, AUD -:9819). Mean age was 53 ± 22y, and median injury severity score was 15[10-20]. Matched groups were similar in age (P = 0.18), smoking status (P = 0.82), injury severity score (P = 0.28), chest Abbreviated Injury Scale (P = 0.24), and number of rib fractures (2[1-4] versus 2[1-4], P = 0.86). Alcoholic patients had higher rates of pneumonia (18.1% versus 9.2%, P < 0.01), unplanned intubation (18.5% versus 9.7, P < 0.001), sepsis (10.8% versus 6.3%, P < 0.001), acute respiratory distress syndrome (12.2% versus 7.4%, P < 0.001), and mortality (8.0 versus 5.7%, P < 0.001). Patients with AUD spent more days in the hospital and intensive care unit . There was no difference in ventilator days between the two groups. CONCLUSIONS: Patients with AUD and rib fractures had higher rates of adverse events than patients without AUD. Early identification of patients with rib fractures with AUD may allow better resource allocation and help improve outcomes. LEVEL OF EVIDENCE: Level III prognostic.


Assuntos
Alcoolismo/epidemiologia , Pneumonia/epidemiologia , Fraturas das Costelas/terapia , Sepse/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alcoolismo/complicações , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Intubação/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pneumonia/etiologia , Pneumonia/terapia , /terapia , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico , Fraturas das Costelas/mortalidade , Fatores de Risco , Sepse/etiologia , Sepse/terapia , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto Jovem
18.
J Surg Res ; 255: 442-448, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32619859

RESUMO

BACKGROUND: We investigated the potential link between trauma center American College of Surgeons verification level and institutional volume of penetrating thoracic trauma with outcomes for patients with penetrating thoracic trauma. METHODS: Penetrating thoracic injuries were identified in the National Trauma Data Bank from 2013 to 2016. Primary exposures were trauma center American College of Surgeons verification level and annual penetrating trauma caseload by center. Cox models were used to evaluate the association between primary exposures and mortality. Poisson regression was used to evaluate admission and outcome rate differences by trauma center status. RESULTS: Of 68,727 patients identified, 38% were treated at level I centers, 18% at level II centers, and 44% at other centers. Only 3.1% required major surgery for thoracic injury (3.1% at level I, 2.6% at level II, and 3.2% at other). Overall, annual volume of penetrating thoracic trauma was not associated with mortality. For specific injuries, level I centers had superior outcomes for injuries to the thoracic aorta and vena cava compared with other centers. Level I centers also showed improved outcomes for lung/bronchus injuries compared with level II centers. Level I centers had less sepsis/acute respiratory distress syndrome, but more surgical site infection, venous thromboembolism, and unplanned operation compared with non-level I centers. CONCLUSIONS: There was no identified impact of penetrating thoracic trauma volume or trauma center verification level on overall mortality. However, level I verification did correlate with improved outcomes for some specific injuries. Further study to identify factors that improve outcomes in patients with high-risk penetrating thoracic mechanisms is warranted.


Assuntos
Traumatismos Torácicos/terapia , Centros de Traumatologia/estatística & dados numéricos , Ferimentos Penetrantes/terapia , Adulto , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos Torácicos/mortalidade , Estados Unidos/epidemiologia , Ferimentos Penetrantes/mortalidade , Adulto Jovem
19.
Am Surg ; 86(9): 1194-1199, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32723178

RESUMO

BACKGROUND: Most triage guidelines for blunt chest wall trauma focus on advanced age and multiple fractured ribs to indicate a high-risk patient population that should be admitted to an intensive care unit (ICU). Overly sensitive ICU admission criteria, however, may result in overutilization of resources. We revised our rib fracture triage guideline to de-emphasize age and number of rib fractures, hypothesizing that we could lower ICU admission rates without compromising outcomes. METHODS: Patients admitted to our level 1 trauma center over 9 months after the institution of the revised guideline (N = 248) were compared with those admitted over 6 months following the original guideline (N = 207) using Fisher's exact and Wilcoxon-Mann-Whitney tests, as appropriate. Univariate followed by multivariate analyses were performed to determine risk factors for complications. RESULTS: The ICU admission rate significantly decreased from 73% to 63% (P = .02) after the institution of the revised guideline, despite an increase in the patient's age and injury acuity of the cohort. There was no significant difference in respiratory complications, unplanned ICU admission rates, and overall mortality. Poor incentive spirometer effort (750 mL or less) and dyspnea in the trauma bay were the strongest predictors of an adverse composite outcome and prolonged hospital length of stay. DISCUSSION: A revised rib fracture triage guideline with less emphasis on the patient's age and the number of fractured ribs safely lowered ICU admission rates. Poor functional status rather than age and anatomy was the strongest predictor of complications and prolonged hospital stay.


Assuntos
Fraturas Múltiplas/diagnóstico , Fraturas das Costelas/diagnóstico , Traumatismos Torácicos/complicações , Centros de Traumatologia/estatística & dados numéricos , Triagem/métodos , Ferimentos não Penetrantes/complicações , Feminino , Fraturas Múltiplas/complicações , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Traumatismos Torácicos/diagnóstico , Ferimentos não Penetrantes/diagnóstico
20.
Am Surg ; 86(9): 1185-1193, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32723180

RESUMO

BACKGROUND: Venous thromboembolism (VTE) remains a serious complication for trauma patients. While early VTE prophylaxis has gained traction, the timing of prophylaxis remains uncertain. We hypothesized that VTE prophylaxis within 24 hours of admission would have lower VTE rates and similar rates of adverse events in seriously injured patients. METHODS: Trauma patients were included from 32 American College of Surgeons verified Level 1 and 2 trauma centers over a 10-year period. Patients with injury severity score (ISS) <15, death or discharge within 48 hours of arrival, or who received no prophylaxis were excluded. RESULTS: 14 096 patients received VTE prophylaxis with an ISS of ≥15. Patients given prophylaxis at <24 hours had fewer VTE events and trended toward fewer serious in-hospital complications. Mortality and return to the operating room were similar across groups. Hospital and intensive care unit length of stay in the <24 hours prophylaxis group was significantly shorter when VTE prophylaxis was initiated earlier. CONCLUSIONS: In severely injured trauma patients with ISS >15, early VTE prophylaxis within 24 hours significantly reduced the risk of VTE as compared with delayed prophylaxis. Early chemoprophylaxis was found to be efficacious in reducing the incidence of VTE; however, the safety of this practice should be evaluated by future prospective studies.


Assuntos
Anticoagulantes/uso terapêutico , Quimioprevenção/métodos , Unidades de Terapia Intensiva/estatística & dados numéricos , Medição de Risco/métodos , Centros de Traumatologia/estatística & dados numéricos , Tromboembolia Venosa/prevenção & controle , Ferimentos e Lesões/complicações , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Ferimentos e Lesões/diagnóstico
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