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2.
Fa Yi Xue Za Zhi ; 36(4): 525-530, 2020 Aug.
Artigo em Inglês, Chinês | MEDLINE | ID: mdl-33047538

RESUMO

Abstract: Objective To investigate the epidemiological and forensic characteristics of multiple organ dysfunction syndrome (MODS) after severe trauma and explore the reference indexes for determining traumatic MODS. Methods In terms of the number of organs or systems involved in MODS, the number of failures of each organ or system, the first failing organ and the survival time after organ failure, 72 cases of MODS death caused by traffic accidents were retrospectively analyzed. The cases were divided into two groups according to the mean injury severity score (ISS). The t test was used to analyze the differences in the number of organs or systems involved in MODS in the two groups. Chi-square test was used to analyze the differences in the types of first failing organs and the differences between the two groups in the number of cases of organ or system failure involved in MODS. Wilcoxon signed-rank test was used to analyze the differences between the two groups in survival time of MODS after trauma. Kaplan-Meier survival curve was drawn and Log-Rank test was performed. Results The number of MODS involved organs or systems after trauma in ISS≤35 group was 3-5, and 2-4 in the ISS>35 group (P<0.05). The cases of MODS organ or system failure after trauma occurred more in brain and lung in the two groups. The first failing organ after trauma was mainly the lung or kidney. The median time of first organ failure after trauma was 2.00 d, the median survival time of MODS after trauma in ISS≤35 group was 6.00 d, and 2.33 d in ISS>35 group (P<0.05). The survival curve of ISS≤35 group was relatively high and declined gradually, while the survival curve of ISS>35 group was relatively low and the decline was steep (P<0.05). Conclusion The epidemiological and forensic characteristics of MODS caused by traffic accidents have certain specificity. The ISS and the forensic characteristics of MODS at ISS>35 can be used as reliable reference indexes for evaluation of the causal relationship among trauma, MODS and death.


Assuntos
Insuficiência de Múltiplos Órgãos , Ferimentos e Lesões , Acidentes de Trânsito , Humanos , Escala de Gravidade do Ferimento , Insuficiência de Múltiplos Órgãos/epidemiologia , Insuficiência de Múltiplos Órgãos/etiologia , Estudos Retrospectivos , Sensibilidade e Especificidade , Ferimentos e Lesões/complicações
3.
Orv Hetil ; 161(37): 1599-1605, 2020 09.
Artigo em Húngaro | MEDLINE | ID: mdl-32894740

RESUMO

Major trauma is a frequent cause of death, and is the leading cause of death in the younger agegroups. Severe bleeding is often responsible for early mortality. The background of the latter is the trauma-induced coagulopathy (TIC), which - often very early - develops after the onset of bleeding. The high amount of blood products, i.e., massive transfusion administered during the management of traumatic bleeding can result in severe, even fatal complications. Modern, aggressive management of masssive traumatic bleeding is effective in reducing exsanguination and mortality or late complications. This method also fits into the concept of Patient Blood Management. This review deals with the up-to-date, goal-directed, preventive management of traumatic bleeding and coagulopathy, with emphasis on theoretical grounds. The aim is to present the essence of this management method also to those who are not directly involved in this activity. Orv Hetil. 2020; 161(37): 1599-1605.


Assuntos
Transtornos da Coagulação Sanguínea , Hemorragia , Ferimentos e Lesões , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/terapia , Transfusão de Sangue , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Ferimentos e Lesões/complicações
4.
Emerg Med Clin North Am ; 38(4): 857-869, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981622

RESUMO

The obesity pandemic now affects hundreds of millions of people worldwide. As obesity rates continue to increase, emergency physicians are called on with increasing frequency to resuscitate obese patients. This article discusses important anatomic, physiologic, and practical challenges imposed by obesity on resuscitative care. Impacts on hemodynamic monitoring, airway and ventilator management, and pharmacologic therapy are discussed. Finally, several important clinical scenarios (trauma, cardiac arrest, and sepsis), in which alterations to standard treatments may benefit obese patients, are highlighted.


Assuntos
Obesidade/complicações , Ressuscitação/métodos , Manuseio das Vias Aéreas/métodos , Analgésicos/administração & dosagem , Antibacterianos/administração & dosagem , Composição Corporal , Fármacos Cardiovasculares/administração & dosagem , Doenças Cardiovasculares/complicações , Relação Dose-Resposta a Droga , Serviço Hospitalar de Emergência , Parada Cardíaca/terapia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Medidas de Volume Pulmonar , Consumo de Oxigênio , Farmacocinética , Respiração com Pressão Positiva , Sepse/complicações , Sepse/terapia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia
5.
Emerg Med Clin North Am ; 38(4): 891-901, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981624

RESUMO

Evaluating and treating traumatic cardiac arrest remains a challenge to the emergency medicine provider. Guidelines have established criteria for patients who can benefit from treatment and resuscitation versus those who will likely not survive. Patient factors that predict survival are penetrating injury, signs of life with emergency medical services or on arrival to the Emergency Department, short length of prehospital cardiopulmonary resuscitation, cardiac motion on ultrasound, pediatric patients, and those with reversible causes including pericardial tamponade and tension pneumothorax. Newer technologies such as resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, and extracorporeal membrane oxygenation may improve outcomes, but remain primarily investigational.


Assuntos
Parada Cardíaca/terapia , Ferimentos e Lesões/complicações , Abdome/diagnóstico por imagem , Aorta , Oclusão com Balão , Serviço Hospitalar de Emergência , Oxigenação por Membrana Extracorpórea , Coração/diagnóstico por imagem , Parada Cardíaca/etiologia , Humanos , Guias de Prática Clínica como Assunto , Ressuscitação , Ordens quanto à Conduta (Ética Médica) , Toracotomia , Ultrassonografia
6.
J Orthop Trauma ; 34(10): e377-e381, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32947588

RESUMO

BACKGROUND: Hospitals worldwide have postponed all nonessential surgery during the COVID-19 pandemic, but non-COVID-19 patients are still in urgent need of care. Uncertainty about a patient's COVID-19 status risks infecting health care workers and non-COVID-19 inpatients. We evaluated the use of quantitative reverse transcription polymerase chain reaction (RT-qPCR) screening for COVID-19 on admission for all patients with fractures. METHODS: We conducted a retrospective cohort study of patients older than 18 years admitted with low-energy fractures who were tested by RT-qPCR for SARS-CoV-2 at any time during hospitalization. Two periods based on the applied testing protocol were defined. During the first period, patients were only tested because of epidemiological criteria or clinical suspicion based on fever, respiratory symptoms, or radiological findings. In the second period, all patients admitted for fracture treatment were screened by RT-qPCR. RESULTS: We identified 15 patients in the first period and 42 in the second. In total, 9 (15.8%) patients without clinical or radiological findings tested positive at any moment. Five (33.3%) patients tested positive postoperatively in the first period and 3 (7.1%) in the second period (P = 0.02). For clinically unsuspected patients, postoperative positive detection went from 3 of 15 (20%) during the first period to 2 of 42 (4.8%) in the second (P = 0.11). Clinical symptoms demonstrated high specificity (92.1%) but poor sensitivity (52.6%) for infection detection. CONCLUSIONS: Symptom-based screening for COVID-19 has shown to be specific but not sensitive. Negative clinical symptoms do not rule out infection. Protocols and separated areas are necessary to treat infected patients. RT-qPCR testing on admission helps minimize the risk of nosocomial and occupational infection. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Betacoronavirus/genética , Infecções por Coronavirus/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , RNA Viral/análise , Triagem/métodos , Ferimentos e Lesões/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Técnicas de Laboratório Clínico , Infecções por Coronavirus/diagnóstico , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/diagnóstico , Reação em Cadeia da Polimerase , Estudos Retrospectivos , Espanha/epidemiologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/epidemiologia
7.
PLoS One ; 15(9): e0238182, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32915808

RESUMO

BACKGROUND: Hospital-admitted patients are at risk of experiencing certain adverse outcomes during their hospital-stay. Patients may need to be admitted to the intensive care unit or be placed on the ventilator while there is also a possibility for complications to develop. Pre-existing comorbidity could increase the risk of these outcomes. The Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Measure (ECM), originally derived for mortality outcomes among general medical populations, are widely used for assessing these in-hospital complications even among specific injury populations. This study derived indices to specifically capture the effect of comorbidity on intensive care unit and ventilator use as well as hospital-acquired complications for injury patients. METHODS: Retrospective data on injury hospital-admissions from July 2012 to June 2014 (161,334 patients) for the state of Victoria, Australia was analysed. Results from multivariable regression analysis were used to derive the Australian Injury Comorbidity Indices (AICIs) for intensive care unit and ventilator hours and hospital-acquired complications. The AICIs, CCI and ECM were validated on data from Victoria and two other Australian states. RESULTS: Five comorbidities were significantly associated with intensive care unit hours, two with ventilator hours and fifteen with hospital-acquired complications for hospitalised injury patients. Not all diseases listed in the CCI or ECM were found to be associated with these outcomes. The AICIs performed equally well in terms of predictive ability to the long-listed ECM and in most instances outperformed the CCI. CONCLUSIONS: Associations between outcomes and comorbidities vary based on the type of outcome measure. The new comorbidity indices developed in this study provide a relevant, parsimonious and up-to-date method to capture the effect of comorbidity on in-hospital complications among admitted injury patients and is better suited for use in that context compared to the CCI and ECM.


Assuntos
Comorbidade , Bases de Dados Factuais , Adolescente , Adulto , Idoso , Austrália , Criança , Pré-Escolar , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ventiladores Mecânicos/efeitos adversos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/patologia , Adulto Jovem
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.
J Trauma Acute Care Surg ; 89(2): 351-357, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32744831

RESUMO

BACKGROUND: Increased clinical experience and the decreased need for systemic anticoagulation have renewed interest in the use of extracorporeal membrane oxygenation (ECMO) for posttraumatic respiratory and cardiopulmonary failure. The objectives of this study were to describe the incidence and temporal trends of ECMO use at trauma centers, the outcomes of trauma patients undergoing ECMO, and the characteristics of trauma centers providing ECMO. METHODS: Data were derived from the American College of Surgeons Trauma Quality Improvement Program data set. We included adults with at least one severe injury admitted to a level I or II trauma center between 2012 and 2016 who received at least 1 day of mechanical ventilation. Patients were categorized based on whether or not they received ECMO during their admission. The primary outcome was change in the incidence of ECMO across study years. We also evaluated patient outcomes and variation in ECMO volumes across centers. RESULTS: Of 194,314 severely injured patients undergoing mechanical ventilation across 450 centers, 269 (0.14%) received ECMO. Extracorporeal membrane oxygenation patients had significantly higher mortality than non-ECMO patients (32% vs. 19%). The standardized rate of ECMO from 2012 to 2016 increased significantly from 75.2 to 179.0 cases per 100,000 severely injured patients undergoing mechanical ventilation. The average annual growth rate was 24%. Of the 82 centers(18%) reporting at least 1 ECMO trauma case, 34 (41%) reported only a single case. CONCLUSION: The use of ECMO for trauma, although rare, is rapidly increasing. Two thirds of patients who receive ECMO following traumatic injury survive their hospitalization. These data suggest that ECMO represents a potential treatment strategy for trauma patients with respiratory or cardiopulmonary failure. However, given the rarity of the procedure, there exists an opportunity to develop practice guidelines regarding the indications for, and approach to, ECMO in the setting of trauma. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.


Assuntos
Serviço Hospitalar de Emergência/normas , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/tendências , Insuficiência Cardíaca/terapia , Melhoria de Qualidade , Insuficiência Respiratória/terapia , Centros de Traumatologia/normas , Adulto , Idoso , Serviço Hospitalar de Emergência/tendências , Feminino , Previsões , Insuficiência Cardíaca/complicações , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Utilização de Procedimentos e Técnicas , Respiração Artificial , Insuficiência Respiratória/complicações , Estudos Retrospectivos , Centros de Traumatologia/tendências , Resultado do Tratamento , Estados Unidos , Ferimentos e Lesões/complicações
10.
Am Surg ; 86(8): 937-943, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32762468

RESUMO

INTRODUCTION: There is disagreement in the trauma community concerning the extent to which emergency medical services (EMS) should perform on-scene interventions. Additionally, in recent years the "ABC" algorithm has been questioned in hypotensive patients. The objective of this study was to quantify the delay introduced by different on-scene interventions. METHODS: A retrospective analysis of hypotensive trauma patients brought to an urban level 1 trauma center by EMS from 2007 to 2018 was performed, and patients were stratified by mechanism of injury and new injury severity score (NISS). Independent samples median tests were used to compare median on-scene times. RESULTS: Among 982 trauma patients, median on-scene time was 5 minutes (interquartile range 3-8). In penetrating trauma patients (n = 488) with NISS of 16-25, intubation significantly increased scene time from 4 to 6 minutes (P < .05). In penetrating trauma patients with NISS of 10-15, wound care significantly increased scene time from 3 to 6 minutes (P < .05). Tourniquet use, interosseous (IO) access, intravenous (IV) access, and needle decompression did not significantly increase scene time. CONCLUSION: Understanding that intubation increases scene time in penetrating trauma, while IV and IO access do not, alterations to the traditional "ABC" algorithm may be warranted. Further investigation of prehospital interventions is needed to determine which are appropriate on-scene.


Assuntos
Algoritmos , Tomada de Decisão Clínica/métodos , Serviços Médicos de Emergência/métodos , Hipotensão/terapia , Tempo para o Tratamento/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Feminino , Mortalidade Hospitalar , Humanos , Hipotensão/etiologia , Hipotensão/mortalidade , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Transporte de Pacientes , Centros de Traumatologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade
11.
Am J Emerg Med ; 38(9): 1875-1878, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32739859

RESUMO

INTRODUCTION: Previous studies have identified obesity as a risk factor for difficult IV access, but this has not been studied in the acute trauma setting. The primary objective was to determine if obesity is associated with increased difficulty placing peripheral IVs in trauma patients. Secondary analysis evaluated IV difficulty and associations with nursing self-competence ratings, trauma experience, and patient demographics. METHODS: Prospective, observational study at academic level I trauma center with 58,000 annual visits. Trauma activation patients between January and October of 2016 were included. Each nurse who attempted IV placement, completed anonymous 7 question survey, including trauma experience (years), self-competence and IV difficulty (Likert scales 1-5), and attempts. Demographic and clinical information was retrospectively collected from the EMR and nursing surveys. Descriptive statistics, chi-square tests, and spearman correlations were used. RESULTS: 200 patients included in the study with 185 BMI calculations. 110 overweight (BMI > 25) and 48 obese (BMI > 30). 70 (35%) female, 149 (75%) white, average age 48. Increased BMI and IV difficulty displayed spearman correlation (ρ) of 0.026 (P = 0.72) suggesting against significant association. Increased trauma experience and self-competence ratings significantly correlated with decreased IV difficulty, ρ = -0.173 and -0.162 (P = 0.010 and 0.014). There was no statistically significant association with IV difficulty in regards to patient race, age, sex, or location of IV placement. CONCLUSION: Obesity was not associated with increased difficulty in placing peripheral IVs in trauma activation patients. Nurses with greater trauma experience and higher self-competence ratings, had less difficulty inserting IVs.


Assuntos
Cateterismo Periférico , Obesidade/complicações , Ferimentos e Lesões/terapia , Cateterismo Periférico/efeitos adversos , Competência Clínica , Enfermagem em Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Inquéritos e Questionários , Ferimentos e Lesões/complicações
12.
Leg Med (Tokyo) ; 47: 101742, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32653857

RESUMO

The fatal rupture of a saccular aneurysm at the junction between the left anterior cerebral artery and anterior communicating artery affected by fibromuscular dysplasia (FMD) is a rare condition. Here is reported the case of a subject involved in a road traffic accident a few minutes before the death, which opened the debate on the real cause of death in a forensic setting. By autopsy, the examination of the brain revealed subarachnoid haemorrhage with flooding of the ventricles due to the breached saccular aneurysm of the junction between the left anterior cerebral artery and anterior communicating artery, in FMD mainly affecting the circle of Willis arteries. A spontaneous aneurysmal rupture was excluded on the basis of probabilistic analysis, in the presence of alternative hypotheses that could explain the facts. The passenger's delayed loss of consciousness may be explained as much by a hypertension-linked rupture of the aneurysm triggered by the emotional stress experienced, as by the traumatic shaking/impact of the aneurysm against the bony skull structures, in a subject predisposed to aneurysm frailty due to FMD. Overall, the concausal role of both the road traffic accident, typified by high kinetic energy, and the presence of a pre-existing aneurysmatic weakness due to FMD is fully recognized. The identification of anatomical variants, jointly with uncommon diseases at the examination of the brain base arteries in any case of isolated basal subarachnoid haemorrhage, may avoid wrong legal consequences even when the cause of death seems to be obviously of simple traumatic origin.


Assuntos
Acidentes de Trânsito , Aneurisma Roto/etiologia , Círculo Arterial do Cérebro , Displasia Fibromuscular/complicações , Displasia Fibromuscular/diagnóstico , Medicina Legal , Aneurisma Intracraniano/etiologia , Ferimentos e Lesões/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/patologia , Autopsia , Feminino , Displasia Fibromuscular/patologia , Humanos , Hipertensão/complicações , Aneurisma Intracraniano/patologia , Masculino , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/etiologia , Hemorragia Subaracnóidea/patologia , Adulto Jovem
13.
Surg Clin North Am ; 100(4): 695-705, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32681870

RESUMO

Wound healing is affected by several factors. Preexisting diagnoses may significantly alter, delay, or inhibit normal wound healing. This is most commonly seen with chronic disorders, such as diabetes and renal failure, but also occurs secondary to aging and substance abuse. Less commonly, genetic or inflammatory disorders are the cause of delayed wound healing. In some cases, it is not the illness, but the treatment that can inhibit wound healing. This is seen in patients getting chemotherapy, radiation, steroids, methotrexate, and a host of other medications. Understanding these processes may help treat or avoid wound healing problems.


Assuntos
Falência Renal Crônica/fisiopatologia , Cicatrização/fisiologia , Ferimentos e Lesões/fisiopatologia , Fatores Etários , Antineoplásicos/efeitos adversos , Doenças Autoimunes/complicações , Doenças Autoimunes/fisiopatologia , Doença Crônica , Doenças Genéticas Inatas/complicações , Doenças Genéticas Inatas/fisiopatologia , Humanos , Infecções/complicações , Infecções/fisiopatologia , Falência Renal Crônica/complicações , Transtornos Nutricionais/complicações , Transtornos Nutricionais/fisiopatologia , Lesões por Radiação/complicações , Lesões por Radiação/fisiopatologia , Pele/efeitos da radiação , Dermatopatias/complicações , Dermatopatias/fisiopatologia , Fumar/efeitos adversos , Fumar/fisiopatologia , Ferimentos e Lesões/complicações
14.
PLoS One ; 15(7): e0236094, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32701972

RESUMO

OBJECTIVE: To test the following hypothesis: the ratio of shock index to pulse oxygen saturation can better predict the mortality of emergency trauma patients than shock index. METHODS: 1723 Patients of trauma admitted to the Emergency Department of the First Affiliated Hospital of Soochow University from 1 November 2016 to 30 November 2019 were retrospectively evaluated. We defined SS as the ratio of SI to SPO2, and the mortality of trauma patients in the emergency department as end-point of outcome. We calculated the crude HR of SS and adjusted HR with the adjustment for risk factors including sex, age, revised trauma score (RTS) by Cox regression model. ROC curve analyses were performed to compare the area under the curve (AUC) of SS and SI. RESULTS: The crude HR of SS was: 4.31, 95%CI (2.89-6.42) and adjusted HR: 3.01, 95%CI(1.86-4.88); ROC curve analyses showed that AUC of SS was higher than that of shock index (SI), and the difference was statistically significant: 0.69, 95%CI(0.55-0.83) vs 0.65, 95%CI (0.51-0.79), P = 0.001. CONCLUSION: The ratio of shock index to pulse oxygen saturation is good predictor for emergency trauma patients, which has a better prognostic value than shock index.


Assuntos
Serviço Hospitalar de Emergência , Oxigênio/metabolismo , Choque/complicações , Choque/metabolismo , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos
15.
Am Surg ; 86(9): 1185-1193, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32723180

RESUMO

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


Assuntos
Anticoagulantes/uso terapêutico , Quimioprevenção/métodos , Unidades de Terapia Intensiva/estatística & dados numéricos , Medição de Risco/métodos , Centros de Traumatologia/estatística & dados numéricos , Tromboembolia Venosa/prevenção & controle , Ferimentos e Lesões/complicações , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Ferimentos e Lesões/diagnóstico
16.
Nat Med ; 26(7): 1084-1088, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32632194

RESUMO

Annually, approximately 30 million patients are discharged from the emergency department (ED) after a traumatic event1. These patients are at substantial psychiatric risk, with approximately 10-20% developing one or more disorders, including anxiety, depression or post-traumatic stress disorder (PTSD)2-4. At present, no accurate method exists to predict the development of PTSD symptoms upon ED admission after trauma5. Accurate risk identification at the point of treatment by ED services is necessary to inform the targeted deployment of existing treatment6-9 to mitigate subsequent psychopathology in high-risk populations10,11. This work reports the development and validation of an algorithm for prediction of post-traumatic stress course over 12 months using two independently collected prospective cohorts of trauma survivors from two level 1 emergency trauma centers, which uses routinely collectible data from electronic medical records, along with brief clinical assessments of the patient's immediate stress reaction. Results demonstrate externally validated accuracy to discriminate PTSD risk with high precision. While the predictive algorithm yields useful reproducible results on two independent prospective cohorts of ED patients, future research should extend the generalizability to the broad, clinically heterogeneous ED population under conditions of routine medical care.


Assuntos
Medição de Risco , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Ferimentos e Lesões/diagnóstico , Adolescente , Adulto , Idoso , Algoritmos , Ansiedade , Serviço Hospitalar de Emergência/normas , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco , Transtornos de Estresse Pós-Traumáticos/etiologia , Transtornos de Estresse Pós-Traumáticos/patologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/fisiopatologia , Ferimentos e Lesões/psicologia , Adulto Jovem
18.
Pediatr Surg Int ; 36(7): 809-815, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32488401

RESUMO

BACKGROUND/PURPOSE: The purpose of this study was to characterize current practices to prevent venous thromboembolism (VTE) in children and measure adherence to recent joint consensus guidelines from the Pediatric Trauma Society and Eastern Association for the Surgery of Trauma (PTS/EAST). METHODS: An 18-question survey was sent to the membership of PTS and the Trauma Center Association of American. Responses were compared with Chi-square test. RESULTS: One hundred twenty-nine members completed the survey. Most respondents were from academic (84.5%), Level 1 pediatric (62.0%) trauma centers. Criteria for VTE prophylaxis varied between hospitals with freestanding pediatric trauma centers significantly more likely to stratify children by risk factors than adult trauma centers (p = 0.020). While awareness of PTS/EAST guidelines (58.7% overall) was not statistically different between hospital types (44% freestanding adult, 52% freestanding pediatric, 71% combined adult pediatric, p = 0.131), self-reported adherence to these guidelines was uniformly low at 37.2% for all respondents. Lastly, in three clinical scenarios, respondents chose VTE screening and prophylaxis plans in accordance with a prospective application of PTS/EAST guidelines 55.0% correctly. CONCLUSION: Currently no consensus regarding the prevention of VTE in pediatric trauma exists. Prospective application of PTS/EAST guidelines has been limited, likely due to poor quality of evidence and a reliance on post-injury metrics. Results of this survey suggest that further investigation is needed to more clearly define the risk of VTE in children, evaluate, and prospectively validate alternative scoring systems for VTE prevention in injured children. LEVEL OF EVIDENCE: N/A-Survey.


Assuntos
Pesquisas sobre Serviços de Saúde/métodos , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Tromboembolia Venosa/prevenção & controle , Ferimentos e Lesões/complicações , Adulto , Criança , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Masculino , Pediatras/estatística & dados numéricos , Fatores de Risco , Sociedades Médicas , Estados Unidos , Tromboembolia Venosa/etiologia
19.
PLoS One ; 15(6): e0234203, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32541999

RESUMO

BACKGROUND: Nepal, like many other low-income countries, has a great burden of mental health issues but few resources to meet them. In addition, Nepal has endured several traumatic events in recent decades but the impact on mental health has not been studied in clinical settings. This study explores trauma-related psychiatric disorders and their correlates. METHODS: 100 patients with a history of trauma who visited the outpatient psychiatry clinic at a University hospital in Kathmandu were assessed. The Composite International Diagnostic Interview 2.1 (CIDI) was used to evaluate lifetime and current depressive disorder, generalized anxiety disorder (GAD) and lifetime post-traumatic stress disorder (PTSD). Current PTSD was evaluated using PSTD Checklist-Civilian Version (PCL-C). RESULTS: The median number of lifetime traumatic events was two. Natural disaster was the most common trauma type (84%) compared to other types of trauma. Rape was reported as the most traumatizing. Current PTSD was found in 15%, depression in 33% and GAD in 38% of the patients. The lifetime rates were PTSD 83%, depression 45% and GAD 40%. There was high comorbidity between the disorders. The 31 to 45 years age group, above high school education level and trauma types other than earthquake were independently associated with current PTSD. Marital status and upper socioeconomic status (SES) compared to upper-middle SES were independently associated with lifetime PTSD. Both lifetime and current depression rates were independently associated with the upper SES compared to upper-middle SES. Place of living, education above high school and lower-middle SES were significantly associated with lifetime and current GAD. CONCLUSION: PTSD, depression and GAD were prevalent in a trauma exposed patient population visiting a psychiatric clinic in Nepal. High rates of comorbidities and several risk factors were identified. Our findings highlight the need for addressing trauma related disorders in clinical settings in developing countries.


Assuntos
Transtornos de Ansiedade/epidemiologia , Depressão/epidemiologia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/psicologia , Adolescente , Adulto , Transtornos de Ansiedade/etiologia , Comorbidade , Estudos Transversais , Depressão/etiologia , Depressão/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nepal/epidemiologia , Fatores Socioeconômicos , Transtornos de Estresse Pós-Traumáticos/psicologia , Ferimentos e Lesões/complicações , Adulto Jovem
20.
Medicine (Baltimore) ; 99(26): e20929, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32590805

RESUMO

Retrospective reviewThe degree of spinal cord compression and bony spinal canal stenosis are risk factors for the occurrence of spinal cord injury (SCI) without major fracture or dislocation, but they do not affect the severity of neurological symptoms. However, whether a relatively large spinal cord for the dural sac influences the severity of symptoms in SCI cases is unknown.The purpose of this study was to verify the influence of spinal cord size relative to dural sac on the severity of paralysis in elderly patients with cervical SCI caused by minor trauma.Subjects were 50 elderly patients with SCI caused by falls on flat ground. At 72 hours after injury, neurological assessment was performed using the Japanese Orthopaedic Association (JOA) scoring system. Bony canal anteroposterior diameters (APD) at mid C5 vertebral body were measured with computed tomography. We measured dural sac and spinal cord APD at the injured level and mid C5 with magnetic resonance imaging. Spinal cord compression ratio was calculated by dividing spinal cord at the injured level by spinal cord at mid C5. As the evaluation of spinal cord size relative to the dural sac, spinal cord/dural sac ratio was calculated at the injured level and mid C5. To clarify the factors influencing the severity of paralysis, the relationships between JOA score and those parameters were examined statistically.A significant negative correlation was observed between JOA score and spinal cord/dural sac ratio at mid C5. No clear relationship was observed between JOA score and bony canal APD or spinal cord compression ratio.In elderly patients with SCI caused by minor trauma, a relatively large spinal cord for the dural sac was shown to be a factor that influences the severity of paralysis. This result can be useful for the treatment and prevention of SCI in the elderly.


Assuntos
Vértebras Cervicais/lesões , Paralisia/etiologia , Canal Vertebral/anatomia & histologia , Traumatismos da Medula Espinal/etiologia , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais/anatomia & histologia , Feminino , Geriatria/métodos , Humanos , Japão/epidemiologia , Imagem por Ressonância Magnética/métodos , Masculino , Paralisia/epidemiologia , Índice de Gravidade de Doença , Canal Vertebral/patologia , Medula Espinal/anormalidades , Medula Espinal/fisiologia , Traumatismos da Medula Espinal/classificação , Traumatismos da Medula Espinal/epidemiologia , Tomografia Computadorizada por Raios X/métodos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/epidemiologia
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