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1.
Medicine (Baltimore) ; 100(10): e24981, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725868

RESUMO

RATIONALE: Necrotizing fasciitis (NF) is a rapidly progressing bacterial soft tissue infection with a high mortality rate. It is characterized by significant soft tissue destruction with associated sepsis. The mainstay of treatment is coverage with appropriate broad-spectrum antibiotic therapy and emergent surgical debridement. PATIENT CONCERNS: A previously healthy 66-year-old female presented with a deep laceration to her right, posterior calf with subsequent contamination with lake water. After the wound was irrigated and closed, the patient developed NF. DIAGNOSIS: Laceration of the right lower extremity complicated by NF secondary to Aeromonas sobria. INTERVENTIONS: The patient underwent emergent surgical debridements with intravenous broad-spectrum antibiotics and negative pressure wound therapy. The lower extremity was reconstructed with split-thickness skin grafts. OUTCOMES: The patient's initial penetrating trauma was closed in the emergency room, and the patient was discharged home with antibiotics. She returned the next day with unstable vitals and was admitted to the intensive care unit. Her condition continued to deteriorate, and she underwent serial surgical debridements. Her condition improved and was discharged home after 13 days in the hospital. LESSONS LEARNED: Close monitoring for NF is important for tissue infections sustained in aquatic environments. Timely identification and surgical management of NF increases overall survival.


Assuntos
Aeromonas/isolamento & purificação , Antibacterianos/administração & dosagem , Desbridamento , Fasciite Necrosante/microbiologia , Infecções por Bactérias Gram-Negativas/microbiologia , Ferimentos Penetrantes/complicações , Idoso , Fasciite Necrosante/diagnóstico , Fasciite Necrosante/terapia , Feminino , Infecções por Bactérias Gram-Negativas/diagnóstico , Infecções por Bactérias Gram-Negativas/terapia , Humanos , Lagos/microbiologia , Perna (Membro) , Transplante de Pele , Resultado do Tratamento , Ferimentos Penetrantes/microbiologia , Ferimentos Penetrantes/cirurgia
2.
Medicine (Baltimore) ; 100(4): e24043, 2021 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-33530199

RESUMO

RATIONALE: Respiratory dysfunction resulting from unilateral diaphragmatic paralysis during neck trauma is very rare in adults. We describe the symptoms, diagnosis and treatment of 1 patient with chronic respiratory insufficiency, in whom the diaphragmatic paralysis was associated with phrenic nerve injury due to penetrating neck trauma. PATIENT CONCERNS: A 50-year-old worker was admitted because of left penetrating neck trauma. Imaging investigations demonstrated elevation of the left hemidiaphragm and the C5 and C6 roots avulsion. He complained of gradually worsening dyspnea on exertion 2 months later. DIAGNOSES: The patient was diagnosed with chronic respiratory dysfunction secondary to diaphragmatic paralysis, which caused by phrenic nerve injury. INTERVENTIONS: A conventional video-assisted thoracoscopic diaphragm plication was performed after failed conservative management. OUTCOMES: The respiratory status improved markedly, and he did well without recurrence until 2 years' follow-up. LESSONS: The possibilities of phrenic nerve palsy and diaphragmatic paralysis should not be overlooked during the evaluation of neck trauma.


Assuntos
Lesões do Pescoço/complicações , Insuficiência Respiratória/etiologia , Paralisia Respiratória/etiologia , Ferimentos Penetrantes/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Nervo Frênico/lesões , Paralisia Respiratória/cirurgia , Toracoscopia/métodos
3.
J Surg Res ; 257: 69-78, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32818786

RESUMO

BACKGROUND: Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS: The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS: MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE: Level III Prognostic.


Assuntos
Abdome/cirurgia , Traumatismos Abdominais/cirurgia , Laparotomia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Ferimentos Penetrantes/cirurgia , Abscesso Abdominal/epidemiologia , Traumatismos Abdominais/complicações , Traumatismos Abdominais/mortalidade , Adolescente , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Laparotomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/cirurgia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/mortalidade , Ferimentos Perfurantes/complicações , Ferimentos Perfurantes/cirurgia , Adulto Jovem
4.
Am J Surg ; 221(1): 233-239, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32690211

RESUMO

BACKGROUND: Violent trauma has lasting psychological impacts. Our institution's Community Violence Response Team (CVRT) offers mental health services to trauma victims. We characterized implementation and determined factors associated with utilization by pediatric survivors of interpersonal violence-related penetrating trauma. METHODS: Analysis included survivors (0-21 years) of violent penetrating injury at our institution (2011-2017). Injury and demographic data were collected. Nonparametric regression models determined factors associated with utilization. RESULTS: There was initial rapid uptake of CVRT (2011-2013) after which it plateaued, serving >80% of eligible patients (2017). White race and higher injury severity were associated with receipt and duration of services. In post-hoc analysis, race was found to be associated with continued treatment but not with initial consultation. CONCLUSION: Successful implementation required three years, aiding >80% of patients. CVRT is a blueprint to strengthen existing violence intervention programs. Efforts should be made to ensure that barriers to providing care, including those related to race, are overcome.


Assuntos
Utilização de Instalações e Serviços/estatística & dados numéricos , Transtornos Mentais/psicologia , Transtornos Mentais/terapia , Serviços de Saúde Mental/estatística & dados numéricos , Violência , Ferimentos Penetrantes/psicologia , Adolescente , Criança , Feminino , Humanos , Masculino , Transtornos Mentais/etiologia , Estudos Retrospectivos , Ferimentos Penetrantes/complicações , Adulto Jovem
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.
Chirurgia (Bucur) ; 115(4): 530-536, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32876028

RESUMO

The enlarged number of powerful vehicles in our country led to an increased speed of travel and hence the high number of traffic accidents with severe consequences, even death. Along with polytrauma caused by occupational accidents, these types of traumas require complex and often multidisciplinary surgical therapy against the clock, which places the surgeon in front of situations that are not found in the everyday practice. Injuries involving damage to the thoracic-phreno-abdominal region fall into this specific category that we have chosen to discuss in the present work. We will further present three clinical cases of patients with thoraco-phreno-abdominal injuries produced by different mechanisms. A work-accident wound produced by an angle grinder, causing left thoracoabdominal injuries; a polytrauma caused by a road accident, with a thoraco-phreno abdominal wound produced by a piece of wood that penetrated obliquely through the right thorax, in the 5th and 6th intercostal spaces, crossed the right lower lung lobe, the diaphragm, the 7th liver segment, and stopped in the right posterior costal grid, and a polytrauma following a fall from a height, with a torn diaphragm and mesentery.


Assuntos
Traumatismos Abdominais/cirurgia , Traumatismo Múltiplo/cirurgia , Traumatismos Torácicos/cirurgia , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/complicações , Acidentes por Quedas , Acidentes de Trânsito , Humanos , Traumatismo Múltiplo/complicações , Traumatismos Ocupacionais/complicações , Traumatismos Ocupacionais/cirurgia , Traumatismos Torácicos/complicações , Resultado do Tratamento , Ferimentos Penetrantes/complicações
7.
Cochrane Database Syst Rev ; 7: CD013031, 2020 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-32702777

RESUMO

BACKGROUND: Chest X-ray (CXR) is a longstanding method for the diagnosis of pneumothorax but chest ultrasonography (CUS) may be a safer, more rapid, and more accurate modality in trauma patients at the bedside that does not expose the patient to ionizing radiation. This may lead to improved and expedited management of traumatic pneumothorax and improved patient safety and clinical outcomes. OBJECTIVES: To compare the diagnostic accuracy of chest ultrasonography (CUS) by frontline non-radiologist physicians versus chest X-ray (CXR) for diagnosis of pneumothorax in trauma patients in the emergency department (ED). To investigate the effects of potential sources of heterogeneity such as type of CUS operator (frontline non-radiologist physicians), type of trauma (blunt vs penetrating), and type of US probe on test accuracy. SEARCH METHODS: We conducted a comprehensive search of the following electronic databases from database inception to 10 April 2020: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection and Clinicaltrials.gov. We handsearched reference lists of included articles and reviews retrieved via electronic searching; and we carried out forward citation searching of relevant articles in Google Scholar and looked at the "Related articles" on PubMed. SELECTION CRITERIA: We included prospective, paired comparative accuracy studies comparing CUS performed by frontline non-radiologist physicians to supine CXR in trauma patients in the emergency department (ED) suspected of having pneumothorax, and with computed tomography (CT) of the chest or tube thoracostomy as the reference standard. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from each included study using a data extraction form. We included studies using patients as the unit of analysis in the main analysis and we included those using lung fields in the secondary analysis. We performed meta-analyses by using a bivariate model to estimate and compare summary sensitivities and specificities. MAIN RESULTS: We included 13 studies of which nine (410 traumatic pneumothorax patients out of 1271 patients) used patients as the unit of analysis; we thus included them in the primary analysis. The remaining four studies used lung field as the unit of analysis and we included them in the secondary analysis. We judged all studies to be at high or unclear risk of bias in one or more domains, with most studies (11/13, 85%) being judged at high or unclear risk of bias in the patient selection domain. There was substantial heterogeneity in the sensitivity of supine CXR amongst the included studies. In the primary analysis, the summary sensitivity and specificity of CUS were 0.91 (95% confidence interval (CI) 0.85 to 0.94) and 0.99 (95% CI 0.97 to 1.00); and the summary sensitivity and specificity of supine CXR were 0.47 (95% CI 0.31 to 0.63) and 1.00 (95% CI 0.97 to 1.00). There was a significant difference in the sensitivity of CUS compared to CXR with an absolute difference in sensitivity of 0.44 (95% CI 0.27 to 0.61; P < 0.001). In contrast, CUS and CXR had similar specificities: comparing CUS to CXR, the absolute difference in specificity was -0.007 (95% CI -0.018 to 0.005, P = 0.35). The findings imply that in a hypothetical cohort of 100 patients if 30 patients have traumatic pneumothorax (i.e. prevalence of 30%), CUS would miss 3 (95% CI 2 to 4) cases (false negatives) and overdiagnose 1 (95% CI 0 to 2) of those without pneumothorax (false positives); while CXR would miss 16 (95% CI 11 to 21) cases with 0 (95% CI 0 to 2) overdiagnosis of those who do not have pneumothorax. AUTHORS' CONCLUSIONS: The diagnostic accuracy of CUS performed by frontline non-radiologist physicians for the diagnosis of pneumothorax in ED trauma patients is superior to supine CXR, independent of the type of trauma, type of CUS operator, or type of CUS probe used. These findings suggest that CUS for the diagnosis of traumatic pneumothorax should be incorporated into trauma protocols and algorithms in future medical training programmes; and that CUS may beneficially change routine management of trauma.


Assuntos
Pneumotórax/diagnóstico por imagem , Radiografia Torácica/métodos , Decúbito Dorsal , Traumatismos Torácicos/complicações , Ultrassonografia/métodos , Viés , Intervalos de Confiança , Serviço Hospitalar de Emergência , Humanos , Pneumotórax/etiologia , Estudos Prospectivos , Sensibilidade e Especificidade , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/complicações
8.
World Neurosurg ; 141: 402-405, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32561491

RESUMO

BACKGROUND: Nonmissile penetrating injuries to the craniocervical junction caused by a glass fragment are rare, and a standard management strategy has not been established. CASE DESCRIPTION: A 75-year-old Japanese man was brought into our emergency department after receiving a left retroauricular stab wound by broken glass fragments. After spinal immobilization, a computed tomography (CT) scan revealed glass fragments penetrating at the right craniocervical junction to the interatlantooccipital subarachnoid space. CT angiography showed that both vertebral arteries were not injured. Magnetic resonance imaging demonstrated that the glass fragments did not penetrate the cervical cord or medulla oblongata. These glass fragments were removed via a midline incision from the external occipital protuberance to the C7 and with laminectomy without suboccipital craniectomy. Five of the glass fragments were found and removed in total. The dural defect was patched with a free fascia autograft. His postoperative course was uneventful. Postoperative CT angiography showed that both vertebral arteries were intact and the glass fragments had been removed completely. CONCLUSIONS: CT graphical diagnosis is useful for the management of penetrating craniocervical junction trauma, and it should be considered in the evaluation of patients who have suffered craniocervical penetrating injury even in the absence of major wounds or bleeding. Spinal immobilization of patients with craniocervical penetrating injuries is crucial to avoid not only secondary neurologic damage but also secondary critical vascular damage. Incomplete or inadequate assessment of craniocervical stab wounds results in unexpected hazards that are preventable.


Assuntos
Articulação Atlantoccipital/lesões , Infecções por Coronavirus , Vidro , Pandemias , Pneumonia Viral , Espaço Subaracnóideo/lesões , Traumatismos do Sistema Nervoso/complicações , Traumatismos do Sistema Nervoso/cirurgia , Idoso , Articulação Atlantoccipital/diagnóstico por imagem , Humanos , Imagem por Ressonância Magnética , Masculino , Espaço Subaracnóideo/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Traumatismos do Sistema Nervoso/diagnóstico por imagem , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/cirurgia , Ferimentos Perfurantes/terapia
9.
Rev. cir. (Impr.) ; 72(3): 224-230, jun. 2020. tab
Artigo em Espanhol | LILACS | ID: biblio-1115546

RESUMO

Resumen Introducción: Los traumatismos constituyen la quinta causa de muerte en el adulto mayor (60 años o más), siendo los traumatismos contusos los más frecuentes. Objetivo: Describir características, índices de gravedad de traumatismo (IGT), morbilidad y mortalidad en adultos mayores (AM) hospitalizados con traumatismo torácico (TT). Materiales y Método: Estudio descriptivo transversal. Período desde enero de 1981 a diciembre de 2017. Revisión de base de datos, protocolos quirúrgicos y fichas clínicas. Descripción de características de TT en AM hospitalizados. Se calculó IGT: Injury Severity Score (ISS), Revised Trauma Score (RTS-T), Trauma Injury Severity Score (TRISS). Resultados: Total 4.163 TT, AM 513 (12,3%). Hombres: 350 (68,2%), edad promedio 71,2 ± 8,4 años, mediana 70 (rango: 60-103), TT aislado 350 (68,2%), asociado a lesiones extratorácicas 163 (31,8%) y de estos 96 (18,7%) se consideraron politraumatismos. Traumatismo contuso 456 (88,9%) y penetrante 57 (11,1%). La causa más frecuente fueron las caídas en 252 (49,1%). Lesiones y/o hallazgos torácicos más frecuentes: fracturas costales 409 (79,7%), hemotórax 186 (36,3%) y neumotórax 185 (36,1%). Tratamiento definitivo: médico 287 (55,9%), pleurotomía 193 (37,6%) y cirugía 40 (7,8%). Cirugía extratorácica 33 (6,4%). Hospitalización promedio 9,0 ± 8,8 días. Según IGT: ISS promedio 12,1 ± 9,6, RTS-T promedio 11,6 ± 1,3, TRISS promedio 8,1. Morbilidad 76 (14,8%) y mortalidad 26 (5,1%). Discusión: La mayoría de los TT en AM son contusos, causados por accidentes domésticos. Las lesiones y hallazgos más frecuentes fueron fracturas costales y hemotórax. La mortalidad fue menor a la esperada según IGT.


Introduction: Trauma is the fifth leading cause of death in the elderly (60 or older), with blunt trauma being the most frequent. Objective: To describe characteristics, Trauma Severity Indices (TSI) and morbidity and mortality in hospitalized elderly for Thoracic Trauma (TT). Materials and Method: Crosssectional descriptive study was carried out. Term: from January 1981 to December 2017. Database review, surgical protocols and medical records were performed. TT description of characteristics was conducted in hospitalized elderly. TSI was calculated: Injury Severity Score (ISS), Revised Trauma Score (RTS-T), Trauma Injury Severity Score (TRISS). Results: Total 4.163 TT, 513 elderly (12.3%). Men: 350 (68.2%), average age 71.2 ± 8.4 years, 70 median (range 60-103). Isolated TT: 350 (68.2%), 163 associated with extrathoracic trauma (31.8%) and of these 96 (18.7%) were considered polytraumatism. Blunt trauma 456 (88.9%) and penetrating 57 (11.1%). Most frequent domestic accident mechanism was 196 (38.2%) and 158 traffic accidents (30.8%). Frequently thoracic injuries or findings: 409 rib fractures (79.7%), 186 hemothorax (36.3%), and 185 pneumothorax (36.1%). Final treatment: 287 Medical treatment (55.9%), 193 pleurotomy (37.6%), and 40 thoracic surgery (7.8%). Extrathoracic surgery 33 (6.4%). Average hospitalization: 9.0 ± 8.8 days. According IGT: ISS 12.1 ± 9.6, RTS-T 11.6 ± 1.3, TRISS 8.1. Morbidity: 76 (14.8%) and mortality: 26 (5.1%). Discussion: Most TT in elderly are blunt, caused by domestic accidents. Injuries and most frequent findings were rib fractures and hemothorax. Mortality was lower than expected according to TSI.


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Traumatismos Torácicos/etiologia , Traumatismos Torácicos/mortalidade , Traumatismos Torácicos/epidemiologia , Traumatismos Torácicos/fisiopatologia , Ferimentos Penetrantes/complicações , Acidentes de Trânsito , Índices de Gravidade do Trauma , Epidemiologia Descritiva
10.
Medicine (Baltimore) ; 99(16): e19853, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32312008

RESUMO

RATIONALE: Kidney is the most frequently injured organ of the genitourinary system during trauma. Bilateral penetrating renal trauma (BPRT) is extremely rare and sporadically reported in the previous literature. Here, we reported a unique case of BPRT. PATIENT CONCERNS: A 43-year-old man, with no medical history, was accidentally penetrated by a wooden stick and presented with sharp pain in the left flank. DIAGNOSIS: Laboratory tests revealed microscopic hematuria, mildly elevated leucocyte and amylase, normal hemoglobin (145 g/L) and creatinine (1.05 mg/dl). Computed tomography demonstrated bilateral penetrating renal injuries with perinephric/subcapsular hematoma, fracture of the second lumbar vertebra and 10th rib. INTERVENTIONS: An emergency exploratory laparotomy was executed immediately. According to the American Association for the Surgery of Trauma Organ Injury Scale grading system, grade V and III injuries were considered for the left and right kidney, respectively. Nephrectomy and renorrhaphy were performed on the left and right kidney, respectively. OUTCOMES: The postoperative course was uneventful. Eleven days after the surgery, the patient discharged with no complications. LESSONS: We present a rare and challenging case which was handled successfully, and it may provide useful information for the management of BPRT.


Assuntos
Dor no Flanco/etiologia , Rim/lesões , Ferimentos Penetrantes/complicações , Adulto , Dor no Flanco/diagnóstico , Hematoma , Hematúria/diagnóstico , Humanos , Rim/diagnóstico por imagem , Rim/patologia , Laparotomia/métodos , Masculino , Nefrectomia/métodos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Ferimentos e Lesões/complicações , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/patologia
11.
J Trauma Acute Care Surg ; 89(2): 311-319, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32345890

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging option for hemorrhage control, but its use is limited in scenarios such as penetrating chest trauma. The aim of this study was to describe the use of REBOA as a resuscitative adjunct in these cases with major hemorrhage and to propose a new clinical management algorithm. METHODS: This was a prospective, observational study conducted at a single Level I trauma center in Colombia. We included all patients older than 14 years with severe trauma who underwent REBOA from January 2015 to December 2019. Patients received REBOA if they were in hemorrhagic shock and were unresponsive to resuscitation. RESULTS: A total of 56 patients underwent REBOA placement of which 37 had penetrating trauma and 23 had chest trauma. All patients were hemodynamically unstable upon arrival to the emergency department, with a median systolic blood pressure of 69 mm Hg (interquartile range [IQR], 57-90 mm Hg) and median Injury Severity Score was 25 (IQR, 25-41). All REBOAs were deployed and inflated in zone 1, median inflation time was 40 minutes (IQR, 26-55 minutes), and no adverse neurologic outcomes were observed. Fifteen patients had REBOA and a median sternotomy. Eleven patients had concomitant abdominal wounds. Overall mortality was 28.6%, and there was no significant difference between penetrating versus blunt trauma patients (21.6% vs. 42.1%, p = 0.11). The survival rate of thoracic injured patients was similar to the predicted survival (65.2% vs. 63.3%). CONCLUSION: Resuscitative endovascular balloon occlusion of the aorta can be used safely in penetrating chest trauma, and the implementation of a REBOA management algorithm is feasible with a well-trained multidisciplinary team. LEVEL OF EVIDENCE: Therapeutic, level V.


Assuntos
Aorta/lesões , Oclusão com Balão , Protocolos Clínicos , Procedimentos Endovasculares/métodos , Choque Hemorrágico/terapia , Traumatismos Torácicos/complicações , Ferimentos Penetrantes/complicações , Traumatismos Abdominais/complicações , Adulto , Algoritmos , Colômbia , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Índices de Gravidade do Trauma , Ferimentos não Penetrantes/complicações , Adulto Jovem
14.
J Trauma Acute Care Surg ; 88(6): 725-733, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32102042

RESUMO

BACKGROUND: While there is little debate that pediatric trauma centers (PTC) are uniquely equipped to manage pediatric trauma patients, the extent to which adolescents benefit from treatment there remains controversial. We sought to elucidate differences in management approach and outcome between PTC and adult trauma centers (ATC) for the adolescent penetrating trauma population. We hypothesized that improved mortality would be observed at ATC for this subset of patients. METHODS: Adolescent patients (age, 15-18 years), presenting to Pennsylvania-accredited trauma centers between 2003 and 2017 with penetrating injury, were queried from the Pennsylvania Trauma Outcome Study database. Dead on arrival, transfer patients, and those admitted to a Level III or Level IV trauma center were excluded from analysis. Patient length of stay, number of complications, surgical intervention, and mortality were compared between ATC and PTC. Multilevel mixed effects logistic regression models with trauma center as the clustering variable were used to assess the impact of center type (ATC/PTC) on management approach and mortality adjusted for appropriate covariates. RESULTS: A total of 2,630 adolescent patients met inclusion criteria (PTC: n = 428 [16.3%]; ATC: n = 2,202 [83.7%]). Pediatric trauma centers had a lower adjusted odds of mortality (adjusted odds ratio [AOR], 0.35; 95% confidence interval [CI], 0.17-0.74; p = 0.006) and a lower adjusted odds of surgery (AOR, 0.67; 95% CI, 0.0.48-0.93; p = 0.016) than their ATC counterparts. There were no differences in complication rates (AOR, 0.94; 95% CI, 0.57-1.55; p = 0.793) or length of stay longer than 4 days (AOR, 0.95; 95% CI, 0.61-1.48; p = 0.812) between the PTCs and ATCs. There were also differences in penetrating injury type between PTC and ATC. CONCLUSION: The adolescent penetrating trauma patient population treated at PTC had less surgery performed with improved mortality compared with ATC. LEVEL OF EVIDENCE: Therapeutic, Level IV.


Assuntos
Hospitais Pediátricos/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos Penetrantes/cirurgia , Adolescente , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pennsylvania/epidemiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/métodos , Análise de Sobrevida , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade
16.
Wilderness Environ Med ; 31(1): 78-81, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31983600

RESUMO

Stingrays are found in open waters and are also kept in exhibits in many aquariums throughout the world. They are generally nonaggressive creatures by nature, but they can inflict injuries with their spines if provoked. We present a case of a 62-y-old diver who was pierced in the chest by the barb of a stingray while transferring the animal to another tank as part of his work in a public aquarium. He was rescued immediately from the tank but was found to be in cardiac arrest. Bystander cardiopulmonary resuscitation was promptly initiated by his colleagues. He was rapidly evacuated to the nearest emergency department, where he was noted to be in pulseless electrical activity. A single puncture wound was noted over the right second intercostal space, with the spine of the stingray still impaled in the chest. Trauma surgeons were activated promptly, and resuscitation was continued based on advanced cardiac and trauma life support guidelines, which included ongoing cardiopulmonary resuscitation, securing the airway, and emergency blood transfusion. An emergency department thoracotomy was performed, but despite aggressive resuscitation the thoracic injury was fatal. An autopsy revealed transection of the aorta by an impaled barb. We present a review of stingray injuries and suggest a general approach to management.


Assuntos
Aorta/lesões , Mordeduras e Picadas/complicações , Elasmobrânquios , Traumatismos Ocupacionais/complicações , Traumatismos Torácicos/complicações , Ferimentos Penetrantes/complicações , Animais , Animais de Zoológico , Mordeduras e Picadas/etiologia , Evolução Fatal , Humanos , Masculino , Pessoa de Meia-Idade , Traumatismos Ocupacionais/etiologia , Traumatismos Torácicos/etiologia , Ferimentos Penetrantes/etiologia
17.
J Pak Med Assoc ; 70(Suppl 1)(2): S27-S32, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31981332

RESUMO

OBJECTIVE: To review the managing strategies of adult patients with liver trauma in a tertiary care hospital during a six years period. METHODS: The medical records of all patients admitted with a diagnosis of liver trauma from January 2012 to December 2017 in the Aga Khan University Hospital were retrospectively reviewed. The details of demographic, clinical, and outcome variables including morbidity and mortality rates were noted. RESULTS: A total of 182 patients were admitted at AKUH with liver trauma between January 2012 and December 2017. Twenty-two patients were excluded according to our study criteria. Of 160 patients, 139 were male and 21 were female. One hundred twenty seven (79.4%) patients were less than 45 years of age. Most patients (89.4%) had no comorbids and 48 (44%) arrived at the hospital within 4 hours of injury. Majority, 101 (63.1%) of the patients had blunt trauma and 142 (89%) met with road accidents. A total of 109 (68.1%) patients were stable at arrival and 77 (48.1%) had abdominal signs present on examination. FAST ultrasound was done on 75 (46.9%) patients and CT scan abdomen on 145 (90.6 %) patients. Liver injuries were associated with other abdominal or systemic injuries in 139 (86.6%) patients. Low grade (Grade I & II) liver injuries were found in only 41 (25.6%) patients, with the remainder being high grade (Grade III- 41 patients, Grade IV-42 patients and Grade V-2 patients). Conservative treatment was offered to 68 (41.9%) patients, of which 57 (85.1%) remained stable and were eventually discharged. Of these, 2 expired and 3 required intervention. There were a total of 92 (57.2%) interventions done of which 60 patients were cured, 14 expired and 18 readmitted. Interventions included perihepatic packing (n=18), hepatorraphy (n=3), angioembolization (n=12) and hepatectomy (n=1). There were 16(10%) deaths in which liver haemorrhage and sepsis were the most common cause of mortality. Mean hospital stay in our study population was 8.9 days. Second admission was observed in 28 (17.5%) patients (n=28). Morbidity rate in our patients was 17.5% (n=28). The most common complication noted was that of a liver abscess, developing in 2 (1.3%) patients. Other significant problems were intra-abdominal collections (n=2) and biliary complications (n=3). Unstable haemodynamic status at arrival and prolonged stay in high dependency unit were noted to be independent risk factors for mortality. CONCLUSIONS: Conservative treatment was found successful in most of our patients with an intervention rate of 57.5% and overall mortality rate of 10%. So, NOMLI can be safely offered to liver trauma patients, even in high grade injuries.


Assuntos
Traumatismos Abdominais/terapia , Tratamento Conservador , Hemorragia/terapia , Fígado/lesões , Ferimentos não Penetrantes/terapia , Traumatismos Abdominais/complicações , Traumatismos Abdominais/mortalidade , Acidentes de Trânsito , Adolescente , Adulto , Causas de Morte , Embolização Terapêutica , Feminino , Avaliação Sonográfica Focada no Trauma , Hemorragia/etiologia , Hemorragia/mortalidade , Hepatectomia , Humanos , Tempo de Internação , Abscesso Hepático/etiologia , Abscesso Hepático/terapia , Hepatopatias/etiologia , Hepatopatias/mortalidade , Hepatopatias/terapia , Masculino , Traumatismo Múltiplo , Readmissão do Paciente , Modelos de Riscos Proporcionais , Sepse/mortalidade , Centros de Atenção Terciária , Tomografia Computadorizada por Raios X , Índices de Gravidade do Trauma , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/terapia , Adulto Jovem
18.
J Pak Med Assoc ; 70(Suppl 1)(2): S99-S101, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31981344

RESUMO

Inferior vena caval (IVC) injuries are uncommon and challenging. The objective of the study is to evaluate outcomes of patients operated for inferior vena caval injuries at a university hospital. This is a retrospective case series of all adult patients aged >18 years who had been operated for traumatic IVC injuries at a university hospital between Jan 1998 to December 2018. During the study period, 9 patients with IVC injuries were operated with mean age of 26±10.3 years and all were males. Five (55.5%) patients had penetrating injuries while 4 (44.4%) had blunt trauma. Four (44.4%) patients had infra-renal while 5(66.7%) had suprarenal segment injuries with 4 (44.4%) patients undergoing primary repair of the injury. The most injured associated organ was liver 5 (55.6%). Thirty-days operative mortality was 66.7%.


Assuntos
Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Veia Cava Inferior/lesões , Ferimentos por Arma de Fogo/cirurgia , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/complicações , Acidentes de Trânsito/mortalidade , Adolescente , Adulto , Colo Ascendente/lesões , Gangrena , Hospitais Universitários , Humanos , Intestinos/patologia , Rim/lesões , Ligadura , Fígado/lesões , Masculino , Mortalidade , Traumatismo Múltiplo , Estudos Retrospectivos , Lesões do Sistema Vascular/mortalidade , Trombose Venosa , Ferimentos por Arma de Fogo/mortalidade , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/mortalidade , Adulto Jovem
19.
J Pak Med Assoc ; 70(Suppl 1)(2): S110-S112, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31981348

RESUMO

Tracheal stenosis is rare but a recognized complication after traumatic injury or prolonged intubation. We assessed the time lag between onset of indication for tracheal reconstruction surgery following trauma and actual surgical intervention. We reviewed our operative records for all patients undergoing tracheal reconstruction over the past 10 years. Files were reviewed retrospectively to collect all the relevant data. Surgically all patients were operated via cervical approach. Series 12 cases were identified with an equal split between external trauma and iatrogenic tracheal trauma from prolonged intubation. On, an average patients presented 185 days after initial indication of surgery however there was a wide range of time lag which leads to the importance of early diagnosis of such injuries to reduce delay of definitive management.


Assuntos
Procedimentos Cirúrgicos Reconstrutivos/métodos , Tempo para o Tratamento/estatística & dados numéricos , Traqueia/lesões , Estenose Traqueal/cirurgia , Adulto , Idoso , Feminino , Humanos , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Estenose Traqueal/etiologia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/cirurgia , Adulto Jovem
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