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1.
Vasc Endovascular Surg ; 54(5): 449-454, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32372719

RESUMO

BACKGROUND: Renal artery-inferior vena cava (IVC) fistula is usually caused by penetrating injury to the back. However, it is a very rarely reported entity with only 20 cases reported in the literature. They may present acutely with hemodynamic instability or chronically as congestive heart failure. A thorough examination and adequate imaging are required to avoid missing such injuries. CASE PRESENTATION: A 28-year-old gentleman presented after sustaining stab injury to the back. The stab had penetrated the renal artery and IVC, leading to arteriovenous fistula. He was managed surgically, as he went into hemorrhagic shock, with a successful outcome. The case is also unique as an accessory renal artery was also involved in the fistula. CONCLUSION: Early identification and management of renal artery-IVC fistula is important to ensure a successful outcome. Such fistulas can be managed by either endovascular approach or surgical approach. The decision of approach depends on the level of expertise available and hemodynamic status of the patient.


Assuntos
Fístula Arteriovenosa/cirurgia , Artéria Renal/cirurgia , Lesões do Sistema Vascular/cirurgia , Veia Cava Inferior/cirurgia , Ferimentos Perfurantes/complicações , Adulto , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/etiologia , Fístula Arteriovenosa/fisiopatologia , Hemodinâmica , Humanos , Masculino , Artéria Renal/diagnóstico por imagem , Artéria Renal/lesões , Artéria Renal/fisiopatologia , Choque Hemorrágico/etiologia , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/fisiopatologia , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/lesões , Veia Cava Inferior/fisiopatologia
2.
J Trauma Acute Care Surg ; 88(2): 298-304, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31996655

RESUMO

BACKGROUND: Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) and intermittent REBOA (iREBOA) are techniques to extend the therapeutic duration of REBOA by balloon titration for distal flow or cyclical balloon inflation/deflation to allow transient distal flow, respectively. We hypothesized that manually titrated pREBOA would reduce blood losses and ischemic burden when compared with iREBOA. METHODS: Following 20% blood volume controlled hemorrhage, 10 anesthetized pigs underwent uncontrolled hemorrhage from the right iliac artery and vein. Once in hemorrhagic shock, animals underwent 15 minutes of complete zone 1 REBOA followed by 75 minutes of either pREBOA or iREBOA (n = 5/group). After 90 minutes, definitive hemorrhage control was obtained, animals were resuscitated with the remaining collected blood, and then received 2 hours of critical care. RESULTS: There were no differences in mortality. Animals randomized to iREBOA spent a larger portion of the time at full occlusion when compared with pREBOA (median, 70 minutes; interquartile range [IQR], 70-80 vs. median, 20 minutes; IQR, 20-40, respectively; p = 0.008). While the average blood pressure during the intervention period was equivalent between groups, this was offset by large fluctuations in blood pressure and significantly more rescue occlusions for hypotension with iREBOA. Despite lower maximum aortic flow rates, the pREBOA group tolerated a greater total amount of distal aortic flow during the intervention period (median, 20.9 L; IQR, 20.1-23.0 vs. median, 9.8 L; IQR, 6.8-10.3; p = 0.03) with equivalent abdominal blood losses. Final plasma lactate and creatinine concentrations were equivalent, although iREBOA animals had increased duodenal edema on histology. CONCLUSION: Compared with iREBOA, pREBOA reduced the time spent at full occlusion and the number of precipitous drops in proximal mean arterial pressure while delivering more distal aortic flow but not increasing total blood loss in this highly lethal injury model. Neither technique demonstrated a survival benefit. Further refinement of these techniques is necessary before clinical guidelines are issued.


Assuntos
Oclusão com Balão/métodos , Procedimentos Endovasculares/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Animais , Aorta/cirurgia , Oclusão com Balão/efeitos adversos , Oclusão com Balão/instrumentação , Modelos Animais de Doenças , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Ressuscitação/efeitos adversos , Ressuscitação/instrumentação , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Análise de Sobrevida , Sus scrofa , Fatores de Tempo , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico
3.
Am J Surg ; 219(4): 707-710, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31109633

RESUMO

BACKGROUND: Retroperitoneal and rectus sheath hematomas can occur spontaneously. There is a lack of research about the disease progression, optimal treatment strategies and the need for surgical intervention. Our study investigated their outcomes and management. STUDY DESIGN: Adult patients admitted during a one-year period with non-traumatic retroperitoneal or rectus sheath hematomas were retrospectively identified. Biographical, hospital-course, and outcome data were extracted. RESULTS: 99 patients were included; median age was 73-years (IQR 61-80). 88 patients were on an anticoagulant or antiplatelet agent. Warfarin and intravenous heparin being the most commonly utilized agents (42% and 36.4%, respectively). All 99 patients were diagnosed by CT scan. 79 patients received some sort of blood product (79.8% PRBC, 43.4% FFP, 17% platelets), and 26 patients were in hemorrhagic shock. 17 patients underwent angiography and/or angioembolization. Neither anticoagulation in general nor any specific agent was associated with the need for blood product transfusion or angiography. 13 patients died but none were attributable to the hematoma. CONCLUSION: Both hematomas are usually self-limiting and rarely require surgical intervention. A subset may require angioembolization.


Assuntos
Hematoma/terapia , Doenças Retais/terapia , Espaço Retroperitoneal , Idoso , Idoso de 80 Anos ou mais , Angiografia/estatística & dados numéricos , Anticoagulantes/uso terapêutico , Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Embolização Terapêutica , Feminino , Hematoma/diagnóstico por imagem , Humanos , Coeficiente Internacional Normatizado , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Tempo de Protrombina , Doenças Retais/diagnóstico por imagem , Espaço Retroperitoneal/diagnóstico por imagem , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia , Tomografia Computadorizada por Raios X
4.
J Trauma Acute Care Surg ; 88(2): 207-218, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31804413

RESUMO

BACKGROUND: Administration of human mesenchymal stem cell (MSC)-derived exosomes can enhance neurorestoration in models of traumatic brain injury (TBI) and hemorrhagic shock (HS). The impact of early treatment with MSC-derived exosomes on brain injury in a large animal model remains unknown. We sought to evaluate the impact of early single-dose exosome treatment on brain swelling and lesion size, blood-based cerebral biomarkers, and blood-brain barrier (BBB) integrity. METHODS: Female Yorkshire swine were subjected to a severe TBI (12-mm cortical impact) and HS (40% estimated total blood volume). One hour into shock, animals were randomized (n = 5/cohort) to receive either lactated Ringer's (LR; 5 mL) or LR + exosomes (1 × 10 exosome particles in 5 mL LR). Animals then underwent additional shock (1 hour) followed by normal saline resuscitation. After 6 hours of observation, brain swelling (% increase compared with the uninjured side) and lesion size (mm) were assessed. Cerebral hemodynamics and blood-based biomarkers of brain injury were compared. Immunofluorescence and RNA sequencing with differential gene expression and pathway analysis were used to assess the integrity of the perilesion BBB. RESULTS: Exosome-treated animals had significantly less (p < 0.05) brain swelling and smaller lesion size. They also had significantly decreased (p < 0.05) intracranial pressures and increased cerebral perfusion pressures. Exosome-treated animals had significantly decreased (p < 0.05) albumin extravasation and significantly higher (p < 0.05) laminin, claudin-5, and zonula occludens 1 levels. Differential gene expression and pathway analysis confirmed these findings. Serum glial fibrillary acidic protein levels were also significantly lower (p < 0.05) in the exosome-treated cohort at the end of the experiment. CONCLUSION: In a large animal model of TBI and HS, early treatment with a single dose of MSC-derived exosomes significantly attenuates brain swelling and lesion size, decreases levels of blood-based cerebral biomarkers, and improves BBB integrity.


Assuntos
Barreira Hematoencefálica/patologia , Lesões Encefálicas Traumáticas/terapia , Exossomos/transplante , Células-Tronco Mesenquimais/citologia , Choque Hemorrágico/terapia , Animais , Lesões Encefálicas Traumáticas/etiologia , Lesões Encefálicas Traumáticas/patologia , Modelos Animais de Doenças , Feminino , Humanos , Ressuscitação/métodos , Choque Hemorrágico/etiologia , Choque Hemorrágico/patologia , Sus scrofa , Fatores de Tempo , Resultado do Tratamento
5.
J Trauma Acute Care Surg ; 88(2): 305-309, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31804421

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a viable resuscitation approach for a subdiaphragmatic injury that can regulate arterial blood flow. On the other hand, the evaluation of venous or portal venous blood flow during REBOA remains insufficient because invasive cannulation or exposure of the vessel may affect the blood flow, and Doppler echography is highly operator-dependent. However, phase contrast magnetic resonance imaging has enabled accurate evaluation and noninvasive measurement. This study aimed to investigate the change of venous and portal venous blood flow during REBOA in a porcine model. METHODS: Seven pigs were anesthetized, and a REBOA catheter was placed. The blood flows of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV), and superior vena cava (SVC) were measured using phase contrast magnetic resonance imaging, in both the balloon deflated (no-REBOA) and fully balloon inflated (REBOA) states. Mean arterial pressure (MAP), central venous pressure, cardiac index, and systemic vascular resistance index were measured. RESULTS: The blood flows of the suprahepatic, infrahepatic, and distal IVC, HV, and PV in the no-REBOA state were 1.40 ± 0.36 L·min, 0.94 ± 0.16 L·min, 0.50 ± 0.19 L·min, 0.060 ± 0.018 L·min, and 0.32 ± 0.091 L·min, respectively. The blood flow of each section in the REBOA condition was significantly decreased at 0.41 ± 0.078 (33% of baseline), 0.15 ± 0.13 (15%), 0.043 ± 0.034 (9%), 0.029 ± 0.017 (37%), and 0.070 ± 0.034 L·min (21%), respectively. The blood flow of the SVC increased significantly in the REBOA condition (1.4 ± 0.63 L·min vs. 0.53 ± 0.14 L·min [257%]). Mean arterial pressure, central venous pressure, cardiac index, and systemic vascular resistance index were significantly increased after REBOA inflation. CONCLUSION: Resuscitative endovascular balloon occlusion of the aorta decreased blood flows of the IVC, HV, and PV and increased blood flow of the SVC. This result could be explained by the collateral flow from the lower body to the SVC. A better understanding of the effect of REBOA on the venous and portal venous systems may help control liver injury.


Assuntos
Oclusão com Balão/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Sistema Porta/fisiologia , Fluxo Sanguíneo Regional/fisiologia , Ressuscitação/efeitos adversos , Animais , Aorta/cirurgia , Oclusão com Balão/métodos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Fígado/irrigação sanguínea , Fígado/diagnóstico por imagem , Fígado/lesões , Imagem por Ressonância Magnética , Masculino , Modelos Animais , Sistema Porta/diagnóstico por imagem , Ressuscitação/métodos , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia , Suínos , Porco Miniatura
6.
Platelets ; 31(1): 94-102, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-30810451

RESUMO

The aim of this study was to investigate the association between nadir platelet count and acute kidney injury (AKI) or 28-day all-cause mortality induced by hemorrhagic shock (HS), and to determine the cutoff value of nadir platelet count in HS clinical practice. This retrospective study included hospitalized patients enrolled in a tertiary-care teaching hospital from January 1, 2010 to December 31, 2015. Clinical data from HS admitted to the intensive care unit (ICU) were evaluated. Nadir platelet count was defined as the lowest values in the first 48 h. Multivariate logistic regression and Cox proportional hazards regression were used to assess the correlation between nadir platelet count and AKI or 28-day all-cause mortality induced by HS, respectively; the area under receiver operating characteristic (AU-ROC) and Youde's index were used to determine the optimal cutoff value of nadir platelet count. Kaplan-Meier's method and log-rank test were assessed for the 28-day all-cause mortality in AKI and non-AKI groups. Of 1589 patients screened, 84 patients (mean age,37.1 years; 58 males) were included in the primary analysis in which 30 patients with AKI. Multiple logistic results indicated that nadir platelet count was a risk factor of AKI (OR = 0.71,95% confidence interval [CI] 0.54-0.93, P < 0.05). Cox regression analysis revealed that nadir platelet count was independent risk factors for 28-day all-cause mortality (Hazard ratios [HR]0.89,95%CI 0.76-0.99, P < 0.05). Kaplan-Meier curve showed that 28-day all-cause mortality was significantly higher in patients with AKI than non-AKI (P < 0.001).These results suggest that nadir platelet count in the first 48 h is a new biomarker for AKI and 28-day all-cause mortality induced by HS. Moreover, the risk for AKI and 28-day all-cause mortality in HS patients decreased by 29% and 11%, respectively, for every 10 × 109/L increase in platelet count. Additional studies are needed to investigate whether elevation of nadir platelet count reduces the risk in different genders.


Assuntos
Lesão Renal Aguda/sangue , Lesão Renal Aguda/etiologia , Biomarcadores , Contagem de Plaquetas , Choque Hemorrágico/complicações , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue , Causas de Morte , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Adulto Jovem
8.
BMJ Case Rep ; 12(10)2019 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-31676504

RESUMO

Spontaneous hepatic rupture is an uncommon cause of haemorrhagic shock and very rarely happens due to amyloidosis. This report describes one such case in which a middle-aged man presented in extremis. He was managed initially with massive transfusion, interventional radiology embolisation and decompressive laparotomy for abdominal compartment syndrome. Subsequent coagulopathy was treated with activated factor VII due to deficient native activity. Serum protein electrophoresis and liver biopsy during his hospital course yielded a diagnosis of amyloidosis, which was treated palliatively with steroids and bortezomib. Despite supportive care, he died 10 days after presentation. This case illustrates the importance of considering an uncommon pathology when a patient presents with a condition in an uncommon way.


Assuntos
Amiloidose/complicações , Hepatopatias/patologia , Ruptura Espontânea/etiologia , Choque Hemorrágico/diagnóstico , Amiloidose/tratamento farmacológico , Amiloidose/patologia , Antineoplásicos/uso terapêutico , Biópsia , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Eletroforese das Proteínas Sanguíneas/métodos , Bortezomib/uso terapêutico , Embolização Terapêutica/métodos , Fator VII/uso terapêutico , Evolução Fatal , Humanos , Hipertensão Intra-Abdominal/cirurgia , Laparotomia/métodos , Fígado/patologia , Hepatopatias/terapia , Masculino , Pessoa de Meia-Idade , Choque Hemorrágico/etiologia , Esteroides/uso terapêutico
9.
Ann Emerg Med ; 74(5): 706-710, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31668242

RESUMO

In cases of severe subdiaphragmatic vascular trauma, only in extremis interventions such as emergency thoracotomy with aortic cross clamping or resuscitative endovascular balloon occlusion of the aorta are available for temporization until definitive care. This case report proposes a noninvasive approach consisting of localizing the proximal aorta with ultrasonographic guidance and applying a compressive force to occlude the aorta and limit distal flow. Using point-of-care ultrasonography allows precise compression, continuous monitoring of its efficacy, and early detection of return of spontaneous circulation in arrest patients. We present the case of a patient who sustained a gunshot wound causing a left iliac artery injury and subsequent cardiac arrest while he was on route to the hospital. Point-of-care ultrasonographically guided proximal external aortic compression was attempted and return of spontaneous circulation was achieved and maintained, allowing transfer of the patient to the operating room. This single-case report suggests that point-of-care ultrasonographically guided proximal external aortic compression could be used as a bridge to definitive care or to more advanced techniques such as resuscitative endovascular balloon occlusion of the aorta and emergency department thoracotomy with aortic cross clamping.


Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Técnicas Hemostáticas/instrumentação , Sistemas Automatizados de Assistência Junto ao Leito , Choque Hemorrágico/prevenção & controle , Ultrassonografia , Ferimentos por Arma de Fogo/diagnóstico por imagem , Traumatismos Abdominais/fisiopatologia , Traumatismos Abdominais/cirurgia , Adulto , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/lesões , Serviço Hospitalar de Emergência , Procedimentos Endovasculares , Humanos , Escala de Gravidade do Ferimento , Masculino , Choque Hemorrágico/etiologia , Ferimentos por Arma de Fogo/fisiopatologia , Ferimentos por Arma de Fogo/cirurgia
10.
A A Pract ; 13(10): 392-395, 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31567270

RESUMO

Systemic mastocytosis (SM) is a rare clinical condition resulting from a clonal proliferation of abnormal mast cells. The clinical presentation may vary from mild cutaneous manifestations to aggressive systemic symptoms including intermittent episodes of anaphylaxis. We present a case of a 69-year-old male with abrupt and recurrent episodes of anaphylaxis with refractory distributive shock following cardiac surgery with cardiopulmonary bypass. Following a complex postoperative course, a bone marrow biopsy ultimately confirmed the diagnosis. Although rare, SM should be considered in the differential diagnosis of postoperative patients with unexplained and recurrent episodes of distributive shock.


Assuntos
Anafilaxia/etiologia , Ponte Cardiopulmonar/efeitos adversos , Mastocitose Sistêmica/diagnóstico , Choque Hemorrágico/etiologia , Idoso , Substituição de Aminoácidos , Biópsia , Gerenciamento Clínico , Humanos , Masculino , Mastocitose Sistêmica/sangue , Mastocitose Sistêmica/genética , Ponte Miocárdica/cirurgia , Proteínas Proto-Oncogênicas c-kit/genética
11.
J Med Case Rep ; 13(1): 317, 2019 Oct 25.
Artigo em Inglês | MEDLINE | ID: mdl-31651338

RESUMO

BACKGROUND: Pneumocephalus and pneumorachis, presence of air inside the skull and spinal canal, are mostly seen after neurosurgical procedures and neuraxial anesthesia. They have also been described after penetrating trauma, but never after blunt trauma without adjacent bone fractures. CASE DESCRIPTION: We present the case of an 85-year-old white male patient admitted to our intensive care unit after a high velocity car accident. On site clinical evaluation showed normal consciousness with 15/15 Glasgow Coma Scale after a short initial loss of consciousness. The patient was first sent to a nearby hospital where a whole-body computed tomography scan revealed pneumocephalus and pneumorachis and an important left hemopneumothorax with pneumomediastinum with extensive subcutaneous emphysema. The state of the patient quickly worsened with hemorrhagic shock. The patient was sent to our intensive care unit; upon neurosurgical evaluation, no surgical indication was retained due to the absence of skull and spine fracture. A computed tomography scan performed on day 6 showed total regression of the pneumocephalus and pneumorachis. A follow-up computed tomography scan performed on day 30 revealed no intracranial bleeding or stroke, but a left pleural hernia between ribs 5 and 6. Due to respiratory complications, our patient could not be weaned from ventilator support for a proper neurological examination. Our patient's state finally worsened with septic shock due to ventilator-acquired pneumonia leading to multiple organ failure and our patient died on day 37. CONCLUSIONS: This is the first case report to describe pneumorachis and pneumocephalus following blunt trauma with pneumothorax, but no spinal or skull fractures. The mechanism that is probably involved here is a migration of air with subcutaneous emphysema and a pleural hernia into the spinal canal. However, in cases of pneumorachis or pneumocephalus, skull fractures need to be investigated as these require surgery and appropriate vaccination to prevent meningitis.


Assuntos
Acidentes de Trânsito , Pneumocefalia/diagnóstico por imagem , Pneumorraque/diagnóstico por imagem , Traumatismos Torácicos/complicações , Ferimentos não Penetrantes/complicações , Idoso de 80 Anos ou mais , Evolução Fatal , Hemopneumotórax/diagnóstico por imagem , Hemopneumotórax/etiologia , Humanos , Masculino , Enfisema Mediastínico/diagnóstico por imagem , Enfisema Mediastínico/etiologia , Insuficiência de Múltiplos Órgãos/etiologia , Pneumocefalia/etiologia , Pneumonia Associada à Ventilação Mecânica/complicações , Pneumorraque/etiologia , Choque Hemorrágico/etiologia , Enfisema Subcutâneo/diagnóstico por imagem , Enfisema Subcutâneo/etiologia , Tomografia Computadorizada por Raios X , Imagem Corporal Total
12.
BMJ Case Rep ; 12(9)2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31537592

RESUMO

We present the case of a 22-year-old man transferred to the regional major trauma centre following a fall of ~15 m. He remained consistently haemodynamically stable for over 10 hours of observation until he deteriorated suddenly with major haemorrhagic shock requiring immediate trauma laparotomy. At laparotomy, 2 L of blood was drained from the abdomen but no source of active bleeding identified. 30 minutes after closure of the abdomen, 500 mL of fresh blood was noted in the drain so he was returned to the theatre where the bleeding source was found to be-after manual compression of a mildly bruised hepatoduodenal ligament-the proper hepatic artery (PHA). This case describes an unusual finding at relaparotomy and shows that even when there is no active bleeding from abdominal organs or classified vessels, it is possible to have isolated injury to PHA.


Assuntos
Duodeno/lesões , Artéria Hepática/lesões , Fígado/lesões , Choque Hemorrágico/etiologia , Contusões , Diagnóstico Diferencial , Duodeno/anatomia & histologia , Humanos , Laparotomia/métodos , Ligamentos/lesões , Fígado/anatomia & histologia , Fígado/diagnóstico por imagem , Fígado/patologia , Masculino , Reoperação , Choque Hemorrágico/cirurgia , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Adulto Jovem
13.
Am J Surg ; 218(6): 1169-1174, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31540684

RESUMO

INTRODUCTION: The aim of our study was to evaluate if pre-hospital shock index (SI) can predict transfusion requirements, resource utilization and mortality in trauma patients. METHODS: We performed a 2-year analysis of all adult trauma patients in the TQIP database. Shock index was calculated by dividing heart-rate over systolic blood pressure. Patients were divided into two groups pre-hospital SI ≤ 1 and prehospital SI > 1. Regression and ROC curve analyses were performed. RESULTS: 144951 patients were included in the study. Mean age was 45 ±â€¯34 years, 61% were male, 84.7% had blunt injuries and median ISS was 13 [9-17]. Overall 9.1% of the patients had a pre-hospital SI > 1. Patients with pre-hospital SI > 1 had higher likelihood of requiring massive transfusion (25% vs. 0.012%, p < 0.02), interventional-radiology intervention (6.2% vs. 1%,p < 0.001) or operative intervention (14.7% vs. 2%,p < 0.001) compared to SI ≤ 1. Similarly, patients with SI > 1 had higher mortality (12.3% vs. 5.2%, p < 0.001) and were more likely to be discharged to Rehab/SNF (34.6% vs. 21.4%, p < 0.001). CONCLUSIONS: Pre-hospital SI predicts trauma-center resource utilization and can guide patient triage and trauma resource recruitment.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Ferimentos e Lesões/complicações , Adulto , Serviços Médicos de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Triagem , Sinais Vitais
15.
J Trauma Acute Care Surg ; 87(1): 117-124, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31260426

RESUMO

BACKGROUND: Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS: This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS: A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION: Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE: Therapeutic study, level IV.


Assuntos
Fraturas Ósseas/complicações , Ossos Pélvicos/lesões , Choque Hemorrágico/terapia , Adulto , Feminino , Fraturas Ósseas/terapia , Técnicas Hemostáticas/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento
16.
Vasc Endovascular Surg ; 53(7): 599-601, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31262229

RESUMO

INTRODUCTION: A 90-year-old patient was admitted with a hemorrhagic shock from a huge ruptured abdominal aortic aneurysm with an unfavourable infrarenal aortic neck and a horseshoe kidney (HSK). REPORT: We decided on an open surgical approach: the HSK isthmus was sectioned with an Endo GIA 45 mm, and we performed a suprarenal aortic cross-clamping and an aortic graft reconstruction. Postoperatively, no urinary leakage was detected, and renal function showed no impairment. The patient died on the 10th postoperative day from pneumonia. CONCLUSION: We believe that the sectioning of the HSK isthmus with Endo GIA is a fast and simple maneouvre.


Assuntos
Aneurisma Roto/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Rim Fundido/complicações , Grampeamento Cirúrgico/métodos , Idoso de 80 Anos ou mais , Aneurisma Roto/complicações , Aneurisma Roto/diagnóstico por imagem , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada , Evolução Fatal , Feminino , Rim Fundido/diagnóstico por imagem , Humanos , Pneumonia/etiologia , Choque Hemorrágico/etiologia , Grampeadores Cirúrgicos , Grampeamento Cirúrgico/efeitos adversos , Grampeamento Cirúrgico/instrumentação , Resultado do Tratamento
17.
Transfus Clin Biol ; 26(3): 174-179, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31262629

RESUMO

Whole blood, that is blood that is not manufactured into its component red blood cells (RBC) plasma, and platelets (PLT) units, was the mainstay of transfusion for many years until it was discovered that the component parts of a blood donation could be stored under different conditions thereby optimizing the storage length of each product. The use of low anti-A and -B titer group O whole blood (LTOWB) has recently been rediscovered for use in massively bleeding trauma patients. Whole blood has several advantages over conventional component therapy for these patients, including simplifying the logistics of the resuscitation, being more concentrated than whole blood that is reconstituted from conventional components, and providing cold-stored PLTs, amongst other benefits. While randomized controlled trials to determine the efficacy of using LTOWB in the resuscitation of massively bleeding trauma patients are currently underway, retrospective data has shown that massively bleeding recipients of LTOWB with traumatic injury do not have worse outcomes compared to patients who received conventional components and, in some cases, recipients of LTOWB have more favourable outcomes. This paper will describe some of the advantages of using LTOWB and will discuss the emerging evidence for its use in massively bleeding patients.


Assuntos
Transfusão de Sangue/métodos , Hemorragia/terapia , Doença Aguda , Anticoagulantes/efeitos adversos , Tipagem e Reações Cruzadas Sanguíneas/métodos , Preservação de Sangue/métodos , Substitutos Sanguíneos/efeitos adversos , Substitutos Sanguíneos/uso terapêutico , Citratos/efeitos adversos , Soluções Cristaloides/efeitos adversos , Soluções Cristaloides/uso terapêutico , Serviços Médicos de Emergência , Glucose/efeitos adversos , Hemorragia/etiologia , Humanos , Procedimentos de Redução de Leucócitos , Ressuscitação , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Reação Transfusional/prevenção & controle , Resultado do Tratamento , Ferimentos e Lesões/complicações
18.
J Surg Res ; 244: 63-68, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31279265

RESUMO

BACKGROUND: Several serum biomarkers have been studied to diagnose incidence and severity of traumatic brain injury (TBI), but a reliable biomarker in TBI has yet to be identified. Ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) has been proposed as a biomarker in clinical and preclinical studies, largely in the setting of isolated TBI or concussion. The aim of this study was to evaluate the performance of UCH-L1 as a serum biomarker in the setting of polytrauma and TBI. METHODS: Multiple variations of murine TBI and polytrauma models were used to evaluate serum biomarkers. The different models included TBI with and without hemorrhagic shock and resuscitation, isolated extremity vascular ligation, extremity ischemia/reperfusion, and blunt tail injury. Blood was drawn at intervals after injury, and serum levels of neuron-specific enolase, UCH-L1, creatine kinase, and syndecan-1 were evaluated by enzyme-linked immunosorbent assay. RESULTS: UCH-L1 levels were not significantly different between TBI, tail injury, and sham TBI. By contrast, neuron-specific enolase levels were increased in TBI mice compared with tail injury and sham TBI mice. UCH-L1 levels increased regardless of TBI status at 30 min and 4 h after hemorrhagic shock and resuscitation. In mice that underwent femoral artery cannulation followed by hemorrhagic shock/resuscitation, UCH-L1 levels were significantly elevated compared with shock sham mice at 4 h (3158 ± 2168 pg/mL, 4 h shock versus 0 ± 0 pg/mL, 4 h shock sham; P < 0.01) and at 24 h (3253 ± 2954 pg/mL, 24 h shock versus 324 ± 482 pg/mL, 24 h shock sham; P = 0.03). No differences were observed in UCH-L1 levels between the sham shock and the arterial ligation, vein ligation, or extremity ischemia/reperfusion groups at any time point. Similar to UCH-L1, creatine kinase was elevated only after shock compared with sham mice at 4, 24, and 72 h after injury. CONCLUSIONS: Our study demonstrates that UCH-L1 is not a specific marker for TBI but is elevated in models that induce central and peripheral nerve ischemia. Given the increase in UCH-L1 levels observed after hemorrhagic shock, we propose that UCH-L1 may be a useful adjunct in quantifying severity of shock or global ischemia rather than as a specific marker of TBI.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico , Traumatismo Múltiplo/complicações , Choque Hemorrágico/diagnóstico , Ubiquitina Tiolesterase/sangue , Animais , Biomarcadores/sangue , Lesões Encefálicas Traumáticas/sangue , Lesões Encefálicas Traumáticas/etiologia , Modelos Animais de Doenças , Escala de Coma de Glasgow , Humanos , Masculino , Camundongos , Traumatismo Múltiplo/sangue , Índice de Gravidade de Doença , Choque Hemorrágico/sangue , Choque Hemorrágico/etiologia
19.
Am J Forensic Med Pathol ; 40(4): 386-390, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31305278

RESUMO

The injection of drugs of abuse causes many millions of deaths each year; deaths are mostly due to fatal overdose and the trauma and infection caused by repeated injections. The scientific literature widely reports cases of infected pseudoaneurysm in injecting drug abusers; however, most of these autopsy cases deal with the rupture of pseudoaneurysm of the femoral artery. We present fatal hemorrhagic shock in a heroin-cocaine abuser subsequent to rupture of pseudoaneurysm of the brachial artery; the man collapsed just before injecting himself with a dose of heroin-cocaine (speedball).


Assuntos
Falso Aneurisma/patologia , Aneurisma Roto/patologia , Artéria Braquial/patologia , Choque Hemorrágico/etiologia , Abuso de Substâncias por Via Intravenosa/complicações , Adulto , Usuários de Drogas , Evolução Fatal , Humanos , Masculino
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