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1.
Am Surg ; 87(2): 183-187, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33522267

RESUMO

This article is an update of a paper which Dave Richardson and I published in 1982, and serves as both an update of management of esophageal injuries and as a lasting tribute to my mentor and hero J. David Richardson.


Assuntos
Esôfago/lesões , Esôfago/cirurgia , História do Século XX , Humanos , Kentucky , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/história , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/história , Ferimentos Penetrantes/cirurgia
2.
Rev. chil. obstet. ginecol. (En línea) ; 85(4): 371-375, ago. 2020. graf
Artigo em Espanhol | LILACS | ID: biblio-1138634

RESUMO

RESUMEN Las lesiones del tracto genital femenino tras relaciones sexuales son un problema frecuente en las urgencias de ginecología, pero poco estudiado salvo su aspecto médico-legal. Su incidencia es desconocida ya que muchas mujeres no llegan a consultar por miedo o pudor. El reconocimiento precoz de estas lesiones y su correcto tratamiento puede evitar la parición de secuelas que acompañarán a nuestra paciente durante el resto de su vida. Presentamos el caso de una paciente de 18 años con un desgarro perineal con mucosa vaginal íntegra tras su primera relación sexual.


ABSTRACT Injuries to the female genital tract after sexual intercourse are a frequent problem in gynecological emergencies, but little studied except for their medico-legal aspect. Its incidence is unknown since many women do not go to their specialist out of fear or embarrassment. Early recognition of these injuries and their correct treatment may prevent the appearance of sequelae that will accompany our patient for the rest of her life. We present the case of an 18-year-old patient with a perineal tear with intact vaginal mucosa after her first sexual intercourse.


Assuntos
Humanos , Feminino , Adolescente , Vagina/lesões , Ferimentos Penetrantes/etiologia , Coito , Vagina/cirurgia , Doenças Vaginais/cirurgia , Doenças Vaginais/etiologia , Ferimentos Penetrantes/cirurgia , Ferimentos Penetrantes/diagnóstico , Fatores de Risco , Lacerações , Membrana Mucosa/cirurgia , Membrana Mucosa/lesões
3.
Ulus Travma Acil Cerrahi Derg ; 26(3): 469-474, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32436965

RESUMO

BACKGROUND: Diaphragmatic injuries, which can be seen after penetrating thoracic traumas, have some difficulties in diagnosis. Undiagnosed small diaphragmatic lacerations may lead to serious health problems. This study aims to evaluate the role of VATS (Video Assisted Thoracoscopic Surgery) in the diagnosis and treatment of diaphragmatic injuries after penetrating thoracic traumas. METHODS: Among 268 penetrating thoracic trauma patients, we retrospectively evaluated a total of 22 patients performed VATS due to suspected diaphragmatic injury in our department between June 2008 and June 2018. RESULTS: Twenty (91%) patients were male, and two (9%) patients were female with a mean age of 28.01±6.4 (18-42) years. In 11 (50%) patients, VATS was performed on the right side and the others on the left side according to the penetrating area of trauma. In 10 (45%) patients, diaphragmatic laceration was detected and was repaired. In six cases (27%) in which diaphragmatic laceration detected with VATS, preoperative traumatic pathologies were detected radiologically. The missed injury rate was 18%. VATS had a specificity, sensitivity, positive predictive value and negative predictive value of 75%, 71.5%, 60% and 83.3%, respectively. There was no significant statistical difference between types of penetrating trauma, ages and gender of cases (p>0.05). No complication was detected during the mean follow up period of 36.2±9.3 (range 9-62) months. CONCLUSION: Our opinion is that VATS is important and feasible in hemodynamically stable patients with suspected isolated diaphragmatic laceration after penetrating thoracic trauma that cannot be determined by radiologically.


Assuntos
Traumatismos Abdominais , Diafragma , Traumatismos Torácicos , Cirurgia Torácica Vídeoassistida , Ferimentos Penetrantes , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/cirurgia , Adolescente , Adulto , Diafragma/diagnóstico por imagem , Diafragma/lesões , Diafragma/cirurgia , Feminino , Humanos , Masculino , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/cirurgia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/cirurgia , Adulto Jovem
4.
J Trauma Acute Care Surg ; 88(5): 579-587, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32039976

RESUMO

BACKGROUND: Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients. METHODS: We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and ß-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses. RESULTS: Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission ß-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). ß-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05). CONCLUSION: Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.


Assuntos
Microbioma Gastrointestinal/fisiologia , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Adulto , Idoso , Serviço Hospitalar de Emergência/estatística & dados numéricos , Fezes/microbiologia , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/microbiologia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/microbiologia
5.
J Surg Res ; 250: 59-69, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32018144

RESUMO

BACKGROUND: Previous studies have shown that a notable portion of patients who are readmitted for reinjury after penetrating trauma present to a different hospital. The purpose of this study was to identify the risk factors for reinjury after penetrating trauma including reinjury admissions to different hospitals. METHODS: The 2010-2014 Nationwide Readmissions Database was queried for patients surviving penetrating trauma. E-codes identified patients subsequently admitted with a new diagnosis of blunt or penetrating trauma. Univariable analysis was performed using 44 injury, patient, and hospital characteristics. Multivariable logistic regression using significant variables identified risk factors for the outcomes of reinjury, different hospital readmission, and in-hospital mortality after reinjury. RESULTS: There were 443,113 patients identified. The reinjury rate was 3.5%. Patients presented to a different hospital in 30.0% of reinjuries. Self-inflicted injuries had a higher risk of reinjury (odds ratio [OR]: 2.66, P < 0.05). Readmission to a different hospital increased risk of mortality (OR: 1.62, P < 0.05). Firearm injury on index admission increased risk of mortality after reinjury (OR: 1.94, P < 0.05). CONCLUSIONS: This study represents the first national finding that one in three patients present to a different hospital for reinjury after penetrating trauma and have a higher risk of mortality due to this fragmentation of care. These findings have implications for quality and cost improvements by identifying areas to improve continuity of care and the implementation of penetrating injury prevention programs.


Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Necessidades e Demandas de Serviços de Saúde , Readmissão do Paciente/estatística & dados numéricos , Ferimentos Penetrantes/epidemiologia , Adolescente , Adulto , Idoso , Continuidade da Assistência ao Paciente/economia , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/economia , Ferimentos Penetrantes/cirurgia , Adulto Jovem
6.
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
7.
Urologe A ; 59(2): 169-175, 2020 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-31745577

RESUMO

INTRODUCTION: The objective was to analyze patterns of injury, management, imaging, and follow-up care of renal trauma at a Swiss level 1 trauma center. METHODS: We examined 138 patients (>16 years) with renal organ injuries who presented to our institution between January 2008 and March 2018. Data on demographics, patterns of injury, clinical presentation, management, and follow-up were recorded. RESULTS: The injury grade of the 142 injured kidneys was grade 1 in 25% (n = 36), grade 2 in 16% (n = 23), grade 3 in 32% (n = 46), grade 4 in 24% (n = 34), and grade 5 in 2% (n = 3). The predominant injury mechanism was winter sports (45%). Conservative management was successful in all grade 1 renal injuries, and 91%, 86%, 35%, and 33% of grade 2, 3, 4, and 5 injuries, respectively. Early follow-up with CT or MRI scan was performed in 23% of grade 1-3 injuries and 57% of grade 4-5 injuries with clinical signs of complications as the most frequent indication for grade 1-3 injuries and routine follow-up imaging for grade 4-5 injuries, respectively. In follow-up care (1-9 months after injury) imaging showed persistent pathologies in 39% of grade 1-3 renal injuries and 62% of grade 4-5 injuries. CONCLUSIONS: Most minor renal injuries (grade 1-3) can be successfully managed conservatively. Early follow-up imaging is indicated for patients showing clinical signs of complications. Routine repeat imaging may not be justified for high-grade renal injuries without clinical symptoms. Re-imaging in follow-up care still lacks evidence-based recommendations.


Assuntos
Assistência ao Convalescente/métodos , Rim/lesões , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Rim/diagnóstico por imagem , Estudos Retrospectivos , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/patologia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/patologia
8.
J Surg Res ; 247: 227-233, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31759620

RESUMO

BACKGROUND: Little is known about the injuries, mechanisms, and outcomes in trauma patients undergoing sternotomy for hemorrhage control (SHC). The purpose of this study was to identify predictors of mortality for SHC and provide a descriptive analysis of the use of SHC in trauma. We hypothesize blunt trauma is associated with higher mortality compared with penetrating trauma among trauma patients requiring SHC. METHODS: The Trauma Quality Improvement Program (2013-2016) database was queried for adult patients undergoing SHC within 24 h of admission. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U-test. A multivariable logistic regression model was used to determine the risk of mortality. RESULTS: Of 584 patients undergoing SHC, 322 (55.1%) were involved in penetrating trauma, and 69 (11.8%) were involved in blunt. The blunt trauma group had a higher median injury severity score (31.5 versus 25.0; P < 0.001) compared with the penetrating group. The median time to hemorrhage control was longer in those with blunt compared with penetrating trauma (84.6 versus 49.8 min; P < 0.001). The mortality rate was higher in patients with blunt compared with penetrating trauma (29.0% versus 12.7%; P < 0.001). However, after adjusting for covariates, there was no difference in risk of mortality between blunt and penetrating trauma (P = 0.06). CONCLUSIONS: Trauma patients requiring SHC after blunt trauma had a higher mortality rate than those in penetrating trauma. After adjusting for predictors of mortality, there was no difference in risk of mortality despite nearly double the time to hemorrhage control in patients presenting after blunt trauma.


Assuntos
Hemorragia/cirurgia , Hemostasia Cirúrgica/métodos , Esternotomia/métodos , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgia , Adulto , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Hemostasia Cirúrgica/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Esternotomia/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade , Adulto Jovem
9.
J Surg Res ; 246: 153-159, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31586889

RESUMO

BACKGROUND: Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS). MATERIALS AND METHODS: We performed a retrospective cohort study at two level I pediatric trauma centers. INCLUSION CRITERIA: <15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics. RESULTS: We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82). CONCLUSIONS: Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.


Assuntos
Transporte de Pacientes/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Triagem/organização & administração , Ferimentos não Penetrantes/diagnóstico , Ferimentos Penetrantes/diagnóstico , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços/organização & administração , Utilização de Instalações e Serviços/normas , Utilização de Instalações e Serviços/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Admissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos , Triagem/normas , Triagem/estatística & dados numéricos , Estados Unidos , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia
10.
J Surg Res ; 245: 593-599, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31499365

RESUMO

BACKGROUND: After traumatic arrest, resuscitative thoracotomy is lifesaving in appropriately selected patients, yet data are limited regarding hospital course after intensive care unit (ICU) admission. The objective of this study was to describe the natural history of resuscitative thoracotomy survivors admitted to the ICU. MATERIALS AND METHODS: We conducted a retrospective review (January 1, 2012-June 30, 2017) of all adult trauma patients who underwent resuscitative thoracotomy after traumatic arrest at two adult level 1 trauma centers. Data evaluated include demographics, injury characteristics, hospital course, and outcome. RESULTS: Over 66 mo, there were 52,624 trauma activations. Two hundred ninety-eight patients underwent resuscitative thoracotomy and 96 (32%) survived to ICU admission. At ICU admission, mean age was 35.8 ± 14.5 y, 79 (82%) were male, 36 (38%) sustained blunt trauma, and the mean injury severity score was 32.3 ± 13.7. Eight blunt and 20 penetrating patients (22% and 34% of ICU admissions, respectively) survived to discharge. 67% of deaths in the ICU occurred within the first 24 h, whereas 90% of those alive at day 21 survived to discharge. For the 28 survivors, mean ICU length of stay was 24.1 ± 17.9 d and mean hospital length of stay was 43.9 ± 32.1 d. Survivors averaged 1.9 ± 1.5 complications. Twenty-four patients (86% of hospital survivors) went home or to a rehabilitation center. CONCLUSIONS: After resuscitative thoracotomy and subsequent ICU admission, 29% of patients survived to hospital discharge. Complications and a long hospital stay should be expected, but the functional outcome for survivors is not as bleak as previously reported.


Assuntos
Parada Cardíaca/cirurgia , Complicações Pós-Operatórias/epidemiologia , Ressuscitação/efeitos adversos , Toracotomia/efeitos adversos , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/complicações , Adulto , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Centros de Reabilitação/estatística & dados numéricos , Ressuscitação/métodos , Estudos Retrospectivos , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/cirurgia , Adulto Jovem
11.
Injury ; 51(1): 32-38, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31540800

RESUMO

INTRODUCTION: Indications for nonoperative management (NOM) after penetrating renal injury remain ill-defined. Using a national database, we sought to describe the experience of operative and nonoperative management in the United States and retrospectively examine risk factors for failure of NOM. MATERIALS AND METHODS: The TQIP database 2010-2016 was used to identify patients with penetrating renal trauma. Outcomes of patients treated with an immediate operation (IO) and NOM are described. Failure of NOM was defined as the need for a renal operation after 4 h from arrival. Univariate then multivariable regression analyses were performed to identify predictors of NOM failure. RESULTS: Out of 8139 patients with kidney trauma, 1,842 had a penetrating mechanism of injury and were included. Of those, 89% were male, median age was 28 years, and 330 (18%) were offered NOM. Compared to IO, NOM patients were less likely to have gunshot wound (59% vs 89% p < 0.001) or high-grade renal injuries [AAST 4-5] (48% vs 76%, p < 0.001). Lower rates of in-hospital complications and shorter ICU and hospital stays were observed in the NOM group. NOM failed in 26 patients (8%). Independent predictors of NOM failure included a concomitant abdominal injury (OR = 3.99, 95% CI 1.03-23.23, p = 0.044), and every point increase in AAST grade (OR = 2.43, 95% CI 1.27-5.21, p = 0.005). CONCLUSIONS: NOM is highly successful in selected patients. Concomitant abdominal injuries and higher grade AAST injuries predict NOM failure and should be considered when selecting patients for IO or NOM.


Assuntos
Traumatismos Abdominais/terapia , Tratamento Conservador/métodos , Gerenciamento Clínico , Rim/lesões , Ferimentos Penetrantes/terapia , Traumatismos Abdominais/diagnóstico , Adulto , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Rim/diagnóstico por imagem , Masculino , Seleção de Pacientes , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos Penetrantes/diagnóstico , Adulto Jovem
12.
J Trauma Acute Care Surg ; 88(1): 33-41, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31524836

RESUMO

INTRODUCTION: Recent evidence demonstrated that prehospital plasma in patients at risk of hemorrhagic shock was safe for ground transport and resulted in a 28-day survival benefit for air medical transport patients. Whether any beneficial effect of prehospital plasma varies across injury mechanism remains unknown. METHODS: We performed a secondary analysis using a harmonized data set derived from two recent prehospital plasma randomized trials. Identical inclusion/exclusion criteria and primary/secondary outcomes were used for the trials. Prehospital time, arrival shock parameters, and 24-hour transfusion requirements were compared across plasma and control groups stratified by mechanism of injury. Stratified survival analysis and Cox hazard regression were performed to determine the independent survival benefits of plasma across blunt and penetrating injury. RESULTS: Blunt patients had higher injury severity, were older, and had a lower Glasgow Coma Scale. Arrival indices of shock and coagulation parameters were similar across blunt and penetrating injury. The percentage of patients with a prehospital time less than 20 minutes was significantly higher for penetrating patients relative to blunt injured patients (28.0% vs. 11.6%, p < 0.01). Stratified Kaplan-Meier curves demonstrated a significant separation for blunt injured patients (n = 465, p = 0.01) with no separation demonstrated for penetrating injured patients (n = 161, p = 0.60) Stratified Cox hazard regression verified, after controlling for all important confounders, that prehospital plasma was associated with a 32% lower independent hazard for 28-day mortality in blunt injured patients (hazard ratio, 0.68; 95% confidence interval, 0.47-0.96; p = 0.03) with no independent survival benefit found in penetrating patients (hazard ratio, 1.16; 95% confidence interval, 0.4-3.1; p = 0.78). CONCLUSION: A survival benefit associated with prehospital plasma at 24 hours and 28 days exists primarily in blunt injured patients with no benefit shown in penetrating trauma patients. No detrimental effects attributable to plasma are demonstrated in penetrating injury. These results have important relevance to military and civilian trauma systems. LEVEL OF EVIDENCE: Therapeutic, I.


Assuntos
Transfusão de Componentes Sanguíneos/métodos , Primeiros Socorros/métodos , Plasma , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Adulto , Fatores Etários , Estudos de Coortes , Soluções Cristaloides/administração & dosagem , Conjuntos de Dados como Assunto , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade
13.
Surg Endosc ; 34(1): 261-267, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30963262

RESUMO

BACKGROUND: Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries. METHODS: Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy. RESULTS: Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively. CONCLUSION: Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.


Assuntos
Diafragma , Laparoscopia , Laparotomia , Sobremedicalização/prevenção & controle , Complicações Pós-Operatórias , Traumatismos Torácicos , Tomografia Computadorizada por Raios X/métodos , Ferimentos Perfurantes , Traumatismos Abdominais/cirurgia , Adulto , Brasil , Conversão para Cirurgia Aberta/estatística & dados numéricos , Diafragma/diagnóstico por imagem , Diafragma/lesões , Feminino , Hemodinâmica , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Laparotomia/efeitos adversos , Laparotomia/métodos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Traumatismos Torácicos/etiologia , Traumatismos Torácicos/fisiopatologia , Traumatismos Torácicos/cirurgia , Procedimentos Desnecessários , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/cirurgia , Ferimentos Perfurantes/complicações , Ferimentos Perfurantes/diagnóstico , Ferimentos Perfurantes/cirurgia
14.
Am J Surg ; 220(1): 240-244, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31761299

RESUMO

BACKGROUND: Prompt surgical control of hemorrhage is crucial in penetrating trauma patients. We aimed to study the impact of prehospital response time (PreRespT) and scene time (SceneT) on hospital mortality. METHODS: Using the Trauma Quality Improvement Program (TQIP) 2010-2016 database, we identified all adults with penetrating injury. We defined PreRespT as time from EMS dispatch to scene arrival, and SceneT as time spent on scene. Univariate then multivariable logistic regression analyses were performed to study the independent correlation between PreRespT and SceneT on hospital mortality, adjusting for several covariates. RESULTS: Out of a total of 1,403,470 patients, 43,467 patients were included. Multivariable analyses suggested that: 1) every minute increase in PreRespT independently correlates with a 2% increase in mortality (OR 1.02, p < 0.0001), and 2) every minute increase in SceneT independently correlates with a 1% increase in mortality (OR 1.01, p = 0.001). CONCLUSION: In the penetrating injury trauma patient, PreRespT and SceneT independently correlate with hospital mortality. This data suggests that a faster PreRespT and a "scoop and run" strategy may be more beneficial in this population.


Assuntos
Centros de Traumatologia/estatística & dados numéricos , Ferimentos Penetrantes/mortalidade , Adulto , Bases de Dados Factuais , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia , Adulto Jovem
15.
BMJ Case Rep ; 12(11)2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31772131

RESUMO

Penetrating ocular injuries from writing instruments that are thrown, especially by children, in the community can result in significant ocular morbidity. Often these cases present to the accident and emergency department. Accurate and prompt assessment is key in saving sight. We present a case of one such injury and how it was surgically managed.


Assuntos
Corpos Estranhos no Olho/cirurgia , Ferimentos Oculares Penetrantes/diagnóstico por imagem , Vitrectomia/métodos , Ferimentos Penetrantes/etiologia , Adolescente , Ferimentos Oculares Penetrantes/patologia , Ferimentos Oculares Penetrantes/cirurgia , Humanos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Acuidade Visual/fisiologia , Ferimentos Penetrantes/diagnóstico
16.
S Afr J Surg ; 57(4): 29-32, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31773929

RESUMO

BACKGROUND: For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. This study in a dedicated Trauma Intensive Care Unit (TICU) population aimed to assess the outcomes of renal injuries and identify factors that predict the need for nephrectomy. METHODS: Patients, older than 18 years, admitted to TICU from January 2007 to December 2014 who sustained renal injuries had data extracted from the prospectively collected Class Approved Trauma Registry (BCA207-09). Patients who underwent surgical intervention for the renal injury or received non-operative management were compared. The key variables analysed were: patient demographics, mechanism of injury, grade of renal injury, presenting haemoglobin, initial systolic blood pressure, Injury Severity Score and Renal Injury AAST Grade on CT scan in patients who did not necessarily require immediate surgery, or at surgery in those patients who needed emergency laparotomy. RESULTS: There were 74 confirmed renal injuries. There were 42 low grade injuries (grade I-III) and 32 high grade injuries (5 grade IV and 27 grade V). Twenty-six (35%) had a nephrectomy: 24 with grade V injuries and 2 with grade IV injuries required nephrectomy. Six patients in the high injury grade arm had non-operative management. A low haemoglobin, low systolic blood pressure, higher injury severity score, and a high-grade renal injury, as well as increasing age were positive predictors for nephrectomy in trauma patients with renal injury. CONCLUSION: Non-operative management is a viable option with favourable survival rates in lower grade injury; however, complications should be anticipated and managed accordingly. High grade injuries predict the need for surgery.


Assuntos
Lesão Renal Aguda/terapia , Tratamento Conservador/métodos , Cuidados Críticos/métodos , Nefrectomia/métodos , Sistema de Registros , Ferimentos não Penetrantes/terapia , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Adolescente , Adulto , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , África do Sul , Análise de Sobrevida , Centros de Traumatologia , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Adulto Jovem
18.
Cir. Esp. (Ed. impr.) ; 97(9): 489-500, nov. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-187625

RESUMO

Las lesiones cervicales traumáticas suponen un 5-10% del total de las lesiones traumáticas y acarrean una alta tasa de morbimortalidad, debido a que varias estructuras vitales pueden resultar dañadas. En la actualidad existen varias corrientes de tratamiento, basadas en el manejo inicial por zonas, manejo inicial no basado en zonas y el manejo conservador de pacientes seleccionados. El objetivo de esta revisión sistemática es describir el tratamiento de las lesiones cervicales traumáticas


Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Lesões do Pescoço/diagnóstico , Administração dos Cuidados ao Paciente/métodos , Ferimentos Penetrantes/classificação , Ferimentos Penetrantes/diagnóstico , Algoritmos , Incidência , Mortalidade , Pescoço/anatomia & histologia , Lesões do Pescoço/epidemiologia , Lesões do Pescoço/mortalidade , Lesões do Pescoço/terapia , Administração dos Cuidados ao Paciente/normas , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/mortalidade , Ferimentos Penetrantes/complicações
19.
Scand J Urol ; 53(6): 398-402, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31578115

RESUMO

Background: Management of renal trauma injuries is shifting towards more conservative approaches in hemodynamically stable adult patients, even for high grade and/or penetrating trauma. The objective of this study was to analyze the patterns of injury, management and complications in renal trauma patients at a Danish university hospital with a level 1 trauma center.Method: Patients diagnosed with renal trauma at Rigshospitalet, Copenhagen, Denmark, between January 2010 and December 2015 were identified retrospectively by the ICD-10 code. Data were collected from electronic patient records. Imaging was classified by radiologists.Results: Out of 107 patients identified, blunt injuries comprised 93%. Median age was 28. The distribution of injury grade according to AAST was 20% grade I, 4% grade II, 33% grade III, 33% grade IV and 10% grade V. All patients with grade I-III were managed conservatively. Two patients were treated with angioembolization (1 with grade IV and 1 with grade V). Five patients with grade IV were treated with an internal ureteral stent and one patient with grade IV blunt trauma had an emergency nephrectomy performed. Overall complication rate was 7%. No patient died due to their renal injury. Renal function was normal in all patients at discharge, assessed by eGFR measurement. Of the 50% of patients who were followed up with a renography, none developed obstruction due to the renal trauma.Conclusion: The vast majority of renal injuries were due to blunt trauma. Hemodynamically stable patients, even with penetrating and/or high-grade blunt trauma, were managed non-operatively and there was a low rate of complications.


Assuntos
Rim/lesões , Centros de Traumatologia , Ferimentos não Penetrantes , Ferimentos Penetrantes , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Dinamarca , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia , Adulto Jovem
20.
Artigo em Inglês | MEDLINE | ID: mdl-31632707

RESUMO

Introduction: Cultural and socioeconomic factors influence the risk of sustaining a Traumatic Spinal Cord Injury (TSCI). The standard of management and rehabilitation available to TSCI patients differs greatly between high-income and low-income countries. Case presentation: We report a 17-year-old male bird hunter, with no prior medical history, presenting with paraplegia and sensory loss from the xiphoid process down after being struck by an arrow in the left lateral side of the neck. Discussion: Penetrating neck injuries are potentially life threatening because of the complex arrangement of vital structures in the neck. Management of spinal cord trauma resulting from such injuries in low-resource settings is challenging.


Assuntos
Lesões do Pescoço , Paraplegia , Traumatismos da Medula Espinal , Ferimentos Penetrantes , Adolescente , Humanos , Masculino , Lesões do Pescoço/complicações , Lesões do Pescoço/diagnóstico , Lesões do Pescoço/terapia , Paraplegia/diagnóstico , Paraplegia/etiologia , Paraplegia/terapia , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/terapia , Tanzânia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia
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