Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 1.665
Filtrar
1.
J Med Case Rep ; 15(1): 269, 2021 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-34001279

RESUMO

BACKGROUND: In cases of hypertrophic obstructive cardiomyopathy (HOCM), the systolic anterior motion of the mitral valve apparatus results in an obstruction of the left ventricular outflow tract (LVOT), which is known as the SAM [systolic anterior motion] phenomenon. Hypothetically, a pathological obstruction of the LVOT of a different etiology would result in a comparable hemodynamic instability, which would be refractory to inotrope therapy, and may be detectable through echocardiography. CASE PRESENTATION: We observed a severely impaired left ventricular function due to a combination of a thrombotic LVOT obstruction and distinctive mitral regurgitation in a 56-year-old Caucasian, female patient after massive transfusion with aggressive procoagulant therapy. Initially, the patient had to be resuscitated due to cardiac arrest after a long-distance flight. The resuscitation attempts in combination with lysis therapy due to suspected pulmonary artery embolism were initially successful but resulted in traumatic liver injury, hemorrhagic shock and subsequent acute respiratory distress syndrome (ARDS). Oxygenation was stabilized with veno-venous extracorporeal membrane oxygenation (ECMO), but the hemodynamic situation deteriorated further. Transesophageal echocardiography (TEE) showed a massive, dynamic LVOT obstruction. Two thrombi were attached to the anterior leaflet of the mitral valve, resulting in a predominantly systolic obstruction. Unfortunately, the patient died of multiple-organ failure despite another round of lysis therapy and escalation of the ECMO circuit to a veno-venoarterial cannulation for hemodynamic support. CONCLUSION: Massive transfusion with aggressive procoagulant therapy resulted in mitral valve leaflet thrombosis with dynamic, predominantly systolic LVOT obstruction, comparable to the SAM phenomenon. The pathology was only detectable with a TEE investigation.


Assuntos
Cardiomiopatia Hipertrófica , Insuficiência da Valva Mitral , Choque Hemorrágico , Obstrução do Fluxo Ventricular Externo , Feminino , Humanos , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/diagnóstico por imagem , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/etiologia , Obstrução do Fluxo Ventricular Externo/terapia
2.
Ann R Coll Surg Engl ; 103(3): e101-e105, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33645269

RESUMO

Suprarenal or adrenal gland haemorrhage is an uncommon but potentially lethal condition if unrecognised. Adrenal masses rarely present with haemorrhage, but they remain an important differential aetiology for adrenal bleeding. We present a novel case of primary adrenal lymphoma with adrenal haemorrhage in a middle-aged woman who presented with right-sided abdominal pain and class 1 haemorrhagic shock. She was found to have spontaneous unilateral adrenal gland haemorrhage in the absence of any underlying previous pathology. Presenting features, diagnosis and subsequent oncological management are reported.


Assuntos
Neoplasias das Glândulas Suprarrenais/diagnóstico por imagem , Linfadenopatia/diagnóstico por imagem , Linfoma Difuso de Grandes Células B/diagnóstico por imagem , Choque Hemorrágico/diagnóstico , Dor Abdominal/etiologia , Doenças das Glândulas Suprarrenais/diagnóstico por imagem , Doenças das Glândulas Suprarrenais/etiologia , Neoplasias das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/tratamento farmacológico , Neoplasias das Glândulas Suprarrenais/patologia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Ciclofosfamida/uso terapêutico , Doxorrubicina/uso terapêutico , Feminino , Hemorragia/diagnóstico por imagem , Hemorragia/etiologia , Humanos , Linfoma Difuso de Grandes Células B/complicações , Linfoma Difuso de Grandes Células B/tratamento farmacológico , Linfoma Difuso de Grandes Células B/patologia , Pessoa de Meia-Idade , Prednisona/uso terapêutico , Rituximab/uso terapêutico , Choque Hemorrágico/etiologia , Tomografia Computadorizada por Raios X , Ultrassonografia , Vincristina/uso terapêutico
4.
BMJ Case Rep ; 13(12)2020 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-33370938

RESUMO

A 31-year-old woman with hepatocellular carcinoma suffered from recurrent oesophageal variceal bleeding due to portal hypertension, which was caused by severe compression of the portal vein by metastatic lymph nodes. Endoscopic band ligation and pharmacological treatment did not suffice to prevent recurrence of variceal bleeding. Eventually, after the fifth variceal bleeding within 6 months, the patient was admitted to the intensive care unit in a haemodynamic shock. A Sengstaken-Blakemore tube was inserted and all treatment options were discussed, but only percutaneous transhepatic recanalisation of the portal vein with stent placement to reduce portal vein pressure was thought to be feasible with any chance to relieve portal vein pressure. After successful portal vein stenting, our patient did not have any recurrent bleeding in the remaining year of her life. We suggest that percutaneous transhepatic portal vein stenting may be a feasible and adequate last line treatment for complications of portal hypertension.


Assuntos
Carcinoma Hepatocelular/complicações , Varizes Esofágicas e Gástricas/cirurgia , Hemorragia Gastrointestinal/cirurgia , Neoplasias Hepáticas/complicações , Prevenção Secundária/métodos , Choque Hemorrágico/cirurgia , Adulto , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/etiologia , Esofagoscopia , Esôfago/irrigação sanguínea , Esôfago/diagnóstico por imagem , Estudos de Viabilidade , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Humanos , Veia Porta/cirurgia , Recidiva , Prevenção Secundária/instrumentação , Choque Hemorrágico/etiologia , Stents , Tomografia Computadorizada por Raios X , Resultado do Tratamento
5.
Rev Med Liege ; 75(10): 649-652, 2020 Oct.
Artigo em Francês | MEDLINE | ID: mdl-33030840

RESUMO

Transfusion plays a major role in the management of hemorrhagic shock where every minute counts. A pre-hospital transfusion protocol is established in the medical vehicle within the emergency department of CHR hospital Liège. It is based on predefined clinical and biological severity criteria which allow us to start a massive transfusion protocol as early as possible and thus to optimize its effect during traumatic hemorrhagic shock.


Assuntos
Transfusão de Sangue , Choque Hemorrágico , Serviço Hospitalar de Emergência , Hemorragia , Humanos , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia
6.
Leg Med (Tokyo) ; 47: 101785, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32977197

RESUMO

Splenic angiosarcoma (SA) is a rare disease that can cause spontaneous splenic rupture leading to unexpected death. The rare incidence and non-specific clinical presentations made the early correct diagnosis of SA impossible in clinical practice. Even with medical intervention, 80% of patients died within 6 months after diagnosis. Here, we report a man who had complained of abdominal distension for 2 weeks and succumbed to the disease nine hours after admission. Diagnosis of hepatic and splenic angiosarcomas was based on post-mortem histopathological examination and immunohistochemistry, and the cause of death was hemorrhagic shock caused by spontaneous splenic rupture secondary to SA. This present case was the first forensic autopsy of spontaneous splenic rupture secondary to SA, which can highlight the diagnosis of rare diseases in forensic practice, and forensic pathologists should bear in mind these rare diseases even in routine practice.


Assuntos
Autopsia , Morte Súbita/etiologia , Morte Súbita/patologia , Patologia Legal , Hemangiossarcoma/complicações , Hemangiossarcoma/diagnóstico , Neoplasias Esplênicas/complicações , Neoplasias Esplênicas/diagnóstico , Ruptura Esplênica/etiologia , Adulto , Evolução Fatal , Hemangiossarcoma/patologia , Humanos , Masculino , Doenças Raras , Ruptura Espontânea , Choque Hemorrágico/etiologia , Neoplasias Esplênicas/patologia
7.
J Spec Oper Med ; 20(3): 97-102, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32969011

RESUMO

Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.


Assuntos
Choque Hemorrágico , Humanos , Consumo de Oxigênio , Respiração com Pressão Positiva/efeitos adversos , Indução e Intubação de Sequência Rápida , Ressuscitação , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia
8.
J Trauma Acute Care Surg ; 89(2): 329-335, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32744830

RESUMO

INTRODUCTION: Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients. METHODS: We analyzed the (2015-2016) Trauma Quality Improvement Program. We included adult (age, ≥18 years) trauma patients presenting with hemorrhagic shock and requiring at least 1 U of packed red blood cells (pRBCs) within 4 hours. Patients were stratified into WB-CT versus CT only. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were hospital length of stay and major complications. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 8,494 patients were identified, of which 280 received WB-CT (WB, 1 [1-1]; pRBC, 16 [10-23]; FFP, 9 [6-16]; platelets, 3 [2-5]) and 8,214 received CT only (pRBC, 15 [10-24]; FFP, 10 [6-16]; platelets, 2 [1-4]). Mean ± SD age was 34 ± 16 years, 79% were male, Injury Severity Score was 33 (24-43), and 63% had penetrating injuries. Patients who received WB-CT had a lower 24-hour mortality (17% vs. 25%; p = 0.002), in-hospital mortality (29% vs. 40%; p < 0.001), major complications (29% vs. 41%; p < 0.001), and a shorter length of stay (9 [7-12] vs. 15 [10-21]; p = 0.011). On regression analysis, WB was independently associated with reduced 24-hour mortality (odds ratio [OR], 0.78 [0.59-0.89]; p = 0.006), in-hospital mortality (OR, 0.88 [0.81-0.90]; p = 0.011), and major complications (OR, 0.92 [0.87-0.96]; p = 0.013). CONCLUSION: The use of WB as an adjunct to CT is associated with improved outcomes in resuscitation of severely injured civilian trauma patients. Further studies are required to evaluate the role of adding WB to massive transfusion protocols. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Transfusão de Componentes Sanguíneos , Transfusão de Sangue , Técnicas Hemostáticas , Choque Hemorrágico/terapia , Ferimentos e Lesões/complicações , Adulto , Terapia Combinada , Serviço Hospitalar de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Choque Hemorrágico/etiologia , Resultado do Tratamento , Estados Unidos
9.
Medicine (Baltimore) ; 99(28): e20829, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664077

RESUMO

INTRODUCTION: Anabolic steroids are widely administered to patients with aplastic anemia (AA) and are associated with numerous medical complications. To assist with future diagnoses, we report about a young boy with multiple hepatocellular adenomas (HAs) induced by long-term use of anabolic androgenic steroids (AAS) for AA and present a related literature review. PATIENT CONCERN: A 15-year-old boy who was diagnosed with AA in 2011 had been treated with stanozolol (6 mg per day) and ciclosporin A (120-150 mg per day) for almost 4 years. He presented with epigastric pain and fever, and abdominal computed tomography showed a lesion of heterogenous density measuring 13.5 × 13.0 × 8.0 cm in the left hepatic lobe, which was initially misdiagnosed as a liver abscess. DIAGNOSIS: The patient went into hemorrhagic shock twice after invasive manipulation that aimed at diagnosis and was finally diagnosed with HA using fine needle aspiration. INTERVENTIONS: The patient discontinued AAS and only reserved ciclosporin A for AA treatment. OUTCOMES: Follow-up abdominal computed tomography performed 4 years after AAS discontinuation showed obvious regression of the hepatic lesions. CONCLUSION: It is of great importance for hematologists to completely understand that the long-term use of AAS may cause HA, which carries a great risk of hemorrhage and malignant transformation.


Assuntos
Adenoma de Células Hepáticas/induzido quimicamente , Anemia Aplástica/complicações , Neoplasias Hepáticas/patologia , Estanozolol/efeitos adversos , Congêneres da Testosterona/efeitos adversos , Dor Abdominal/etiologia , Adenoma de Células Hepáticas/patologia , Adolescente , Adulto , Assistência ao Convalescente , Idoso , Anemia Aplástica/tratamento farmacológico , Biópsia por Agulha Fina/métodos , Ciclosporina/uso terapêutico , Erros de Diagnóstico , Feminino , Febre/etiologia , Humanos , Imunossupressores/uso terapêutico , Abscesso Hepático/diagnóstico por imagem , Neoplasias Hepáticas/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/etiologia , Estanozolol/uso terapêutico , Congêneres da Testosterona/uso terapêutico , Tomografia Computadorizada por Raios X/métodos
10.
J Trauma Acute Care Surg ; 89(4): 792-800, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32590558

RESUMO

BACKGROUND: Whole blood is optimal for resuscitation of traumatic hemorrhage. Walking Blood Banks provide fresh whole blood (FWB) where conventional blood components or stored, tested whole blood are not readily available. There is an increasing interest in this as an emergency resilience measure for isolated communities and during crises including the coronavirus disease 2019 pandemic. We conducted a systematic review and meta-analysis of the available evidence to inform practice. METHODS: Standard systematic review methodology was used to obtain studies that reported the delivery of FWB (PROSPERO registry CRD42019153849). Studies that only reported whole blood from conventional blood banking were excluded. For outcomes, odds ratios (ORs) and 95% confidence interval (CI) were calculated using random-effects modeling because of high risk of heterogeneity. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. RESULTS: Twenty-seven studies published from 2006 to 2020 reported >10,000 U of FWB for >3,000 patients (precise values not available for all studies). Evidence for studies was "low" or "very low" except for one study, which was "moderate" in quality. Fresh whole blood patients were more severely injured than non-FWB patients. Overall, survival was equivalent between FWB and non-FWB groups for eight studies that compared these (OR, 1.00 [95% CI, 0.65-1.55]; p = 0.61). However, the highest quality study (matched groups for physiological and injury characteristics) reported an adjusted OR of 0.27 (95% CI, 0.13-0.58) for mortality for the FWB group (p < 0.01). CONCLUSION: Thousands of units of FWB from Walking Blood Banks have been transfused in patients following life-threatening hemorrhage. Survival is equivalent for FWB resuscitation when compared with non-FWB, even when patients were more severely injured. Evidence is scarce and of relative low quality and may underestimate potential adverse events. Whereas Walking Blood Banks may be an attractive resilience measure, caution is still advised. Walking Blood Banks should be subject to prospective evaluation to optimize care and inform policy. LEVEL OF EVIDENCE: Systematic/therapeutic, level 3.


Assuntos
Bancos de Sangue , Transfusão de Sangue/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Choque Traumático/terapia , Humanos , Índice de Gravidade de Doença , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Choque Traumático/complicações , Choque Traumático/diagnóstico , Choque Traumático/mortalidade , Análise de Sobrevida , Resultado do Tratamento
11.
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
12.
J Surg Res ; 253: 127-138, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32353638

RESUMO

BACKGROUND: Noncompressible hemorrhage is the leading cause of preventable death in military and civilian trauma. Our aim was to examine the effect of adenosine, lidocaine, and magnesium (Mg2+; ALM) on cardiovascular and cerebral function in a porcine hepatic hemorrhage model. MATERIALS AND METHODS: Pigs (59.1 ± 0.34 kg) were anesthetized, instrumented, and randomly assigned into sham (n = 6), saline controls (n = 10) or ALM (n = 10) groups before laparoscopic liver resection. After 30 min, groups received 4 mL/kg 3% NaCl ± ALM bolus (Phase 1) followed 60 min later with 3 mL/kg/h 0.9% NaCl ± ALM drip (4 h; Phase 2), then transfusion. Hemodynamics, carotid artery flow, and intracranial pressure were measured continuously. Microdialysis samples were analyzed for metabolites. RESULTS: Saline controls had 20% mortality (mean survival time: 307 ± 38 min) with no ALM deaths over 6 h. Bolus administration increased mean arterial pressure (MAP) in both groups, and drip led to further increases to 62 ± 10 mmHg in controls compared with a steady fall to 47 ± 8 mmHg in ALM group at 240 min. The lower MAP was associated with a dramatic fall in systemic vascular resistance and improved oxygen delivery. ALM drip significantly increased cardiac output and stroke volume with lower dP/dtMin, indicating a less stiff heart. ALM drip also significantly decreased cerebral perfusion pressure, reduced cerebral oxygen consumption (28%), and reduced brain glycerol (60%), lactate (47%), and relative expression of hypoxia-inducible factor (38%) compared with saline controls. CONCLUSIONS: ALM therapy improved cardiac function and oxygen delivery by lowering systemic vascular resistance after noncompressible hemorrhage. ALM also appeared to protect the brain at hypotensive MAPs with significantly lower cerebral perfusion pressure, lower O2 consumption, and significantly lower cortical lactate and glycerol levels compared to saline controls.


Assuntos
Hidratação/métodos , Hipotensão/terapia , Hipóxia Encefálica/prevenção & controle , Ressuscitação/métodos , Choque Hemorrágico/terapia , Adenosina/administração & dosagem , Animais , Encéfalo/efeitos dos fármacos , Encéfalo/metabolismo , Química Encefálica/efeitos dos fármacos , Modelos Animais de Doenças , Esquema de Medicação , Quimioterapia Combinada/métodos , Feminino , Glicerol/análise , Humanos , Hipotensão/etiologia , Hipóxia Encefálica/etiologia , Subunidade alfa do Fator 1 Induzível por Hipóxia/análise , Infusões Intravenosas/métodos , Injeções Intravenosas/métodos , Ácido Láctico/análise , Lidocaína/administração & dosagem , Fígado/irrigação sanguínea , Fígado/lesões , Magnésio/administração & dosagem , Oxigênio/metabolismo , Choque Hemorrágico/etiologia , Volume Sistólico/efeitos dos fármacos , Sus scrofa , Resistência Vascular/efeitos dos fármacos , Vasodilatação/efeitos dos fármacos
13.
Ann Vasc Surg ; 69: 448.e9-448.e13, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32473305

RESUMO

A spontaneous fistula between a ruptured common iliac artery aneurysm and the ileal pouch neobladder is quite rare. We present the case of a 74-year-old man presenting with intense abdominal pain and massive hematuria. Computed tomography angiography revealed a ruptured common iliac artery aneurysm-ileal pouch neobladder fistula. His hemodynamics was unstable; emergent endovascular aortic repair was performed successfully. Infection and dysfunction of the neobladder were avoided owing to appropriate management.


Assuntos
Aneurisma Roto/cirurgia , Implante de Prótese Vascular , Bolsas Cólicas/efeitos adversos , Procedimentos Endovasculares , Aneurisma Ilíaco/cirurgia , Fístula Intestinal/etiologia , Estruturas Criadas Cirurgicamente/efeitos adversos , Fístula da Bexiga Urinária/etiologia , Bexiga Urinária/cirurgia , Idoso , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/etiologia , Embolização Terapêutica , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Aneurisma Ilíaco/etiologia , Fístula Intestinal/diagnóstico por imagem , Fístula Intestinal/terapia , Masculino , Choque Hemorrágico/etiologia , Resultado do Tratamento , Fístula da Bexiga Urinária/diagnóstico por imagem , Fístula da Bexiga Urinária/terapia
14.
J Trauma Acute Care Surg ; 88(5): 597-606, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32317576

RESUMO

BACKGROUND: Hemodynamically unstable pelvic fractures often require a multi-modal approach including both operative and endovascular management. While an important adjunct in hemorrhage control, time to angioembolization even at the most advanced trauma centers may take hours. Extraperitoneal packing (EPP) is a fast and effective procedure that can immediately address pelvic hemorrhage from the retroperitoneal space in severe pelvic injuries. The aim of this study was to evaluate the efficacy of early EPP, looking at 24 hours and overall mortality, and the hemodynamic impact of EPP in unstable blunt pelvic trauma. METHODS: All trauma patients admitted to an urban Level I trauma center were evaluated from 2002 to 2018 in a retrospective single-center comparative study. Inclusion criteria were patients 14 years or older who sustained blunt trauma with pelvic fractures and hemodynamic instability. Exclusion criteria were a concomitant head injury (Abbreviated Injury Scale >3) and patients who underwent resuscitative thoracotomy. The patient population was divided into two groups: an EPP group and a no-EPP group. Propensity score matching was used to adjust for differences in baseline characteristics in the two groups: a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each patient. RESULTS: Two hundred forty-four patients presented hemodynamically unstable, with a pelvic fracture (180 no-EPP, 64 EPP). With propensity score matching, 37 patients in each group were analyzed. Survival within the first 24 hours was significantly improved in the EPP group (81.1% vs. 59.5%, p = 0.042) and we registered similar results in overall survival rate (78.4% EPP group vs. 56.8% no-EPP group, p = 0.047). Those patients who underwent early EPP (n = 64) were associated with a significant improvement in hemodynamic stability, with a pre-EPP mean arterial pressure of 49.9 mm Hg and post-EPP mean arterial pressure of 70.1 mm Hg (p < 0.01). CONCLUSION: Extraperitoneal pelvic packing is an effective procedure that can be performed immediately, even within the trauma bay, to improve hemodynamic stability and overall survival in patients who sustain severe blunt pelvic trauma. The early use of EPP can be lifesaving. LEVEL OF EVIDENCE: Therapeutic, Level III.


Assuntos
Fraturas Ósseas/complicações , Hemostasia Cirúrgica/métodos , Ossos Pélvicos/lesões , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos não Penetrantes/complicações , Adulto , Feminino , Fraturas Ósseas/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pelve/cirurgia , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Taxa de Sobrevida , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
15.
J Surg Res ; 252: 139-146, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32278968

RESUMO

BACKGROUND: Age and massive transfusion are predictors of mortality after trauma. We hypothesized that increasing age and high-volume transfusion would result in progressively elevated mortality rates and that a transfusion "ceiling" would define futility. METHODS: The Trauma Quality Improvement Program (TQIP) database was queried for 2013-2016 records and our level I trauma registry was reviewed from 2013 to 2018. Demographic, mortality, and blood transfusion data were collected. Patients were grouped by decade of life and by packed red blood cell (pRBC) transfusion requirement (zero units, 1-3 units, or ≥4 units) within 4 h of admission. RESULTS: TQIP analysis demonstrated an in-hospital mortality risk that increased linearly with age, to an odds ratio of 10.1 in ≥80 y old (P < 0.01). Mortality rates were significantly higher in older adults (P < 0.01) and those with more pRBCs transfused. In massively transfused patients, the transfusion "ceiling" was dependent on age. Owing to the lack granularity in the TQIP database, 230 patients from our institution who received ≥4 units of pRBCs within 4 h of admission were reviewed. On arrival, younger patients had significantly higher heart rates and more severe derangements in lactate levels, base deficits, and pH compared with older patients. There were no differences among age groups in injury severity score, systolic blood pressure, or mortality. CONCLUSIONS: In massively transfused patients, mortality increased with age. However, a significant proportion of older adults were successfully resuscitated. Therefore, age alone should not be considered a contraindication to high-volume transfusion. Traditional physiologic and laboratory criteria indicative of hemorrhagic shock may have reduced reliability with increasing age, and thus providers must have a heightened suspicion for hemorrhage in the elderly. Early transfusion requirements can be combined with age to establish prognosis to define futility to help counsel families regarding mortality after traumatic injury.


Assuntos
Transfusão de Eritrócitos/normas , Futilidade Médica , Ressuscitação/normas , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Adulto , Fatores Etários , Idoso , Tomada de Decisão Clínica/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Sistema de Registros/estatística & dados numéricos , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade
16.
Am J Emerg Med ; 38(7): 1541.e1-1541.e2, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32224041

RESUMO

Meckel's diverticulum classically follows the rule of two's; presenting before the age of two years, found 2 ft. from the ileocecal valve, approximately 2 in. in length, and present in roughly 2% of the population. To our knowledge, there are few cases detailing emergent medicine management of hemorrhagic shock in patients with acute blood loss from a Meckel's diverticulum. We report the case of a 13-year-old male presenting in hemorrhagic shock secondary to an undifferentiated gastrointestinal bleed who was effectively resuscitated in a children's emergency department. Meckel's scan revealed abnormal tracer uptake consistent with Meckel's diverticulum and the patient underwent surgical resection of the diverticulum. This case report details the importance of prompt recognition and appropriate volume resuscitation in a pediatric patient suffering from hemorrhagic shock. Emergency medicine physicians should maintain an index of suspicion for Meckel's diverticulum in any pediatric patient presenting with undifferentiated gastrointestinal hemorrhage.


Assuntos
Hemorragia Gastrointestinal/etiologia , Divertículo Ileal/diagnóstico , Choque Hemorrágico/etiologia , Adolescente , Hemorragia Gastrointestinal/cirurgia , Humanos , Masculino , Divertículo Ileal/cirurgia , Choque Hemorrágico/cirurgia
17.
Updates Surg ; 72(2): 527-536, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32130669

RESUMO

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.


Assuntos
Aorta , Arteriopatias Oclusivas/terapia , Oclusão com Balão/métodos , Pelve/lesões , Sistema de Registros , Choque Hemorrágico/terapia , Adolescente , Adulto , Arteriopatias Oclusivas/etiologia , Oclusão com Balão/efeitos adversos , Feminino , Humanos , Concentração de Íons de Hidrogênio , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Sístole , Índices de Gravidade do Trauma , Adulto Jovem
18.
Transfusion ; 60(5): 1104-1107, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32154589

RESUMO

BACKGROUND: Prehospital hemorrhagic shock accounts for approximately 25,000 civilian deaths annually in the United States. A balanced, blood-based resuscitation strategy is hypothesized to be the optimal treatment for these patients. Due to logistical constraints, delivering a balanced, blood-based resuscitation is difficult in the prehospital setting. A low titer O+ whole blood (LTO+ WB) ground ambulance initiative, may help alleviate this capability gap. CASE REPORT: A 37-year-old female was involved in a motor vehicle collision at approximately 16:30. While she was trapped inside the vehicle, her mental status deteriorated. The patient was successfully extricated at 17:04 and found to be in cardiac arrest. The paramedics and firefighters quickly secured her airway and applied a mechanical CPR device. The first responder team obtained return of spontaneous circulation, but the patient's blood pressure was 43/27 mmHg. The paramedics transfused one unit of LTO+ WB. Twenty-one minutes after the initial LTO+ WB transfusion, the air ambulance team transfused a second unit of LTO+ WB. Upon hospital arrival, the transfusion was completed, and the patient's shock index improved to 1.0. The trauma team identified a grade 5 splenic injury with active extravasation. Interventional radiology performed an angiogram and successfully embolized the tertiary branches of the inferior splenic pole. She was extubated on postinjury Day one and discharged to her home neurologically intact on postinjury Day 12. CONCLUSION: The prehospital availability of LTO+ WB may enhance the resuscitation of critically ill trauma patients.


Assuntos
Transfusão de Sangue , Serviços Médicos de Emergência/métodos , Parada Cardíaca Extra-Hospitalar/terapia , Ressuscitação/métodos , Ferimentos não Penetrantes/terapia , Acidentes de Trânsito , Adulto , Feminino , Humanos , Parada Cardíaca Extra-Hospitalar/etiologia , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia , Baço/lesões , Ferimentos não Penetrantes/etiologia
19.
West J Emerg Med ; 21(2): 217-225, 2020 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-32191179

RESUMO

INTRODUCTION: Patients with trauma-induced coagulopathies may benefit from the use of antifibrinolytic agents, such as tranexamic acid (TXA). This study evaluated the safety and efficacy of TXA in civilian adults hospitalized with traumatic hemorrhagic shock. METHODS: Patients who sustained blunt or penetrating trauma with signs of hemorrhagic shock from June 2014 through July 2018 were considered for TXA treatment. A retrospective control group was formed from patients seen in the same past five years who were not administered TXA and matched based on age, gender, Injury Severity Score (ISS), and mechanism of injury (blunt vs penetrating trauma). The primary outcome of this study was mortality measured at 24 hours, 48 hours, and 28 days. Secondary outcomes included total blood products transfused, hospital length of stay (LOS), intensive care unit LOS, and adverse events. We conducted three pre-specified subgroup analyses to assess outcomes of patients, including (1) those who were severely injured (ISS >15), (2) those who sustained significant blood loss (≥10 units of total blood products transfused), and (3) those who sustained blunt vs penetrating trauma. RESULTS: Propensity matching yielded two cohorts: the hospital TXA group (n = 280) and a control group (n = 280). The hospital TXA group had statistically lower mortality at 28 days (1.1% vs 5%, odds ratio [OR] [0.21], (95% confidence interval [CI], 0.06, 0.72)) and used fewer units of blood products (median = 4 units, interquartile range (IQR) = [1, 10] vs median=7 units, IQR = [2, 12.5] for the hospital TXA and control groups, respectively, (95% CI for the difference in median, -3 to -1). There were no statistically significant differences between groups with regard to 24-hour mortality (1.1% vs 1.1%, OR = 1, 95% CI, 0.20, 5.00), 48-hour mortality (1.1% vs 1.4%, OR [0.74], 95% CI, 0.17, 3.37), hospital LOS (median= 9 days, IQR = (5, 16) vs median =12 days IQR = (6, 22.5) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-5 to 0)), and incidence of thromboembolic events (eg, deep vein thrombosis, pulmonary embolism) during hospital stay (0.7% vs 0.7% for the hospital TXA and control group, respectively, OR [1], 95% CI, 0.14 to 7.15). We conducted subgroup analyses on patients with ISS>15, patients transfused with ≥10 units of blood products, and blunt vs penetrating trauma. The results indicated lower 28-day mortality for ISS>15 (1.8% vs 7.1%, OR [0.23], 95% CI, 0.06 to 0.81) and blunt trauma (0.6% vs 6.3%, OR [0.09], 95% CI, 0.01 to 0.75); fewer units of blood products for penetrating trauma (median = 2 units, IQR = (1, 8) vs median = 8 units, IQR = (5, 15) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-6 to -3)), and ISS>15 (median = 7 units, IQR = (2, 14) vs median = 8.5 units, IQR = (4, 16) for the hospital TXA and control groups, respectively, 95% CI for the difference in median, -3 to 0). CONCLUSION: The current study demonstrates a statistically significant reduction in mortality after TXA administration at 28 days, but not at 24 and 48 hours, in patients with traumatic hemorrhagic shock.


Assuntos
Ressuscitação/métodos , Choque Hemorrágico , Ácido Tranexâmico/uso terapêutico , Ferimentos e Lesões , Adulto , Antifibrinolíticos/uso terapêutico , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/fisiopatologia , Ferimentos e Lesões/terapia
20.
J Trauma Acute Care Surg ; 88(5): 661-670, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32068718

RESUMO

BACKGROUND: Fibrinogen concentrate is widely used in traumatic hemorrhagic shock despite weak evidence in the literature. The aim of the study was to evaluate the effect of fibrinogen concentrate administration within the first 6 hours on 24-hour all-cause mortality in traumatic hemorrhagic shock using a causal inference approach. METHODS: Observational study from a French multicenter prospective trauma registry was performed. Hemorrhagic shock was defined as transfusion of four or more red blood cell units within the first 6 hours after admission. The confounding variables for the outcome (24-hour all-cause mortality) and treatment allocation (fibrinogen concentrate administration within the first 6 hours) were chosen by a Delphi method. The propensity score was specified with a data-adaptive algorithm and a doubly-robust approach with inverse proportionality of treatment weighting allowed to compute the average treatment effect. Sensitivity analyses were performed. RESULTS: Of 14,336 patients in the registry during the study period, 1,027 in hemorrhagic shock were analyzed (758 receiving fibrinogen concentrate within 6 hours and 269 not receiving fibrinogen concentrate). The average treatment effect, expressed as a risk difference, was -0.031 (95% confidence interval, -0.084 to 0.021). All sensitivity analysis confirmed the results. CONCLUSIONS: Fibrinogen concentrate administration within the first 6 hours of a traumatic hemorrhagic shock did not decrease 24-hour all-cause mortality. LEVEL OF EVIDENCE: Prognostic, level III.


Assuntos
Transfusão de Eritrócitos/estatística & dados numéricos , Fibrinogênio/administração & dosagem , Hemostáticos/administração & dosagem , Choque Hemorrágico/terapia , Choque Traumático/terapia , Adulto , Técnica Delfos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Choque Traumático/etiologia , Choque Traumático/mortalidade , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Resultado do Tratamento , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...