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2.
Crit Care ; 24(1): 541, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32873326

RESUMO

BACKGROUND: The effectiveness and indications of open-chest cardiopulmonary resuscitation (OCCPR) have been still debatable. Although current guidelines state that the presence of signs of life (SOL) is an indication for OCCPR, scientific evidence corroborating this recommendation has been scarce. This study aimed to compare the effectiveness of OCCPR to closed-chest cardiopulmonary resuscitation (CCCPR) in severe trauma patients with SOL upon arrival at the emergency department (ED). METHODS: A retrospective cohort study analyzing data from the Trauma Quality Improvement Program (TQIP) database, a nationwide trauma registry in the USA, between 2010 and 2016 was conducted. Severe trauma patients who had SOL upon arrival at the hospital and received cardiopulmonary resuscitation within the first 6 h of ED admission were identified. Survival to hospital discharge was evaluated using logistic regression analysis, instrumental variable analysis, and propensity score matching analysis adjusting for potential confounders. RESULTS: A total of 2682 patients (OCCPR 1032; CCCPR 1650) were evaluated; of those 157 patients (15.2%) in the OCCPR group and 193 patients (11.7%) in the CCCPR group survived. OCCPR was significantly associated with higher survival to hospital discharge in both the logistic regression analysis (adjusted odds ratio [95% confidence interval] = 1.99 [1.42-2.79], p <  0.001) and the instrumental variable analysis (adjusted odds ratio [95% confidence interval] = 1.16 [1.02-1.31], p = 0.021). In the propensity score matching analysis, 531 matched pairs were generated, and the OCCPR group still showed significantly higher survival at hospital discharge (89 patients [16.8%] in the OCCPR group vs 58 patients [10.9%] in the CCCPR group; odds ratio [95% confidence interval] = 1.66 [1.13-2.42], p = 0.009). CONCLUSIONS: Compared to CCCPR, OCCPR was associated with significantly higher survival at hospital discharge in severe trauma patients with SOL upon ED arrival. Further studies to confirm these results and to assess long-term neurologic outcomes are needed.


Assuntos
Reanimação Cardiopulmonar/métodos , Ferimentos e Lesões/terapia , Adulto , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Sinais Vitais , Adulto Jovem
3.
Emerg Med Clin North Am ; 38(4): 795-805, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981618

RESUMO

Successful emergency transfusions require early recognition and activation of resources to minimize treatment delays. The initial goals should focus on replacement of blood in a balanced fashion. There is an ongoing debate regarding the best approach to transfusions, with some advocating for resuscitation with a fixed ratio of blood products and others preferring to use viscoelastic assays to guide transfusions. Whole-blood transfusion also is a debated strategy. Despite these different approaches, it generally is accepted that transfusions should be started early and crystalloid infusions limited. As hemodynamic stability is restored, endpoints of resuscitation should be used to guide the resuscitation.


Assuntos
Transfusão de Sangue , Choque Hemorrágico/terapia , Antifibrinolíticos/uso terapêutico , Tipagem e Reações Cruzadas Sanguíneas , Cateterismo Venoso Central , Tomada de Decisão Clínica , Protocolos Clínicos , Estado Terminal , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Humanos , Hipotensão , Infusões Intraósseas , Infusões Intravenosas , Ressuscitação , Tromboelastografia , Ácido Tranexâmico/uso terapêutico , Ferimentos e Lesões/terapia
4.
Emerg Med Clin North Am ; 38(4): 819-839, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981620

RESUMO

Pediatric cardiac arrest is a relatively rare but devastating presentation in infants and children. In contrast to adult patients, in whom a primary cardiac dysrhythmia is the most likely cause of cardiac arrest, pediatric patients experience cardiovascular collapse most frequently after an initial respiratory arrest. Aggressive treatment in the precardiac arrest state should be initiated to prevent deterioration and should focus on support of oxygenation, ventilation, and hemodynamics, regardless of the presumed cause. Unfortunately, outcomes for pediatric cardiac arrest, whether in hospital or out of hospital, continue to be poor.


Assuntos
Parada Cardíaca/terapia , Ressuscitação/métodos , Manuseio das Vias Aéreas , Glicemia/análise , Criança , Maus-Tratos Infantis/terapia , Cardioversão Elétrica , Eletroencefalografia , Serviço Hospitalar de Emergência , Epinefrina/uso terapêutico , Oxigenação por Membrana Extracorpórea , Parada Cardíaca/etiologia , Cardiopatias Congênitas/terapia , Frequência Cardíaca , Humanos , Hipotermia/complicações , Hipotermia/terapia , Hipotermia Induzida , Pneumopatias/terapia , Pais , Exame Físico , Envenenamento/terapia , Avaliação de Processos em Cuidados de Saúde , Valores de Referência , Insuficiência Respiratória/terapia , Taxa Respiratória , Ordens quanto à Conduta (Ética Médica) , Sepse/terapia , Choque/etiologia , Choque/terapia , Vasoconstritores/uso terapêutico , Ferimentos e Lesões/terapia
5.
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
6.
Soins ; 65(845): 20-22, 2020 May.
Artigo em Francês | MEDLINE | ID: mdl-32862958

RESUMO

Over 40 patients benefited from remote iconographic follow-up of wounds in an oncology centre. This system is piloted by three expert nurses. They carry out an initial analysis of the photographs received, seek medical expertise if necessary and liaise with the city's professionals. This system makes it possible to expertly accompany professionals and patients while avoiding unnecessary travel. The satisfaction survey conducted in 2018 established full satisfaction of patients and professionals (> 95%) and a guarantee in terms of the safety and quality of care of the wounds.


Assuntos
Assistência ao Convalescente/métodos , Institutos de Câncer , Satisfação do Paciente/estatística & dados numéricos , Consulta Remota/métodos , Ferimentos e Lesões/terapia , Pesquisas sobre Serviços de Saúde , Humanos , Enfermagem Oncológica , Fotografação , Projetos Piloto
7.
Medicine (Baltimore) ; 99(37): e22144, 2020 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-32925769

RESUMO

The aim of this study was to determine the effectiveness of a skin stretching technique with adjustable external fixators in treating skin defects.Eighteen patients treated with a skin-stretching technique with adjustable external fixators for skin defects from April 2017 to October 2019 were included. Visual Analogue Scale (VAS) scores were collected during therapy. The skin defects gradually became smaller until they were completely resolved according to the blood flow of the affected limb and wound skin (the color, temperature, elasticity, and capillary response). The defect sizes ranged from 4 cm × 2 cm to 20 cm × 6 cm.The 18 adjustable external fixators were dismantled in 2 to 9 days (mean, 4.05 days) after the operation, and the defects were completely closed and the sutures were removed after 2 to 3 weeks. The average VAS score was 5.97. The follow-up period was 4 to 12 months (mean, 6.3 months); 17 patients healed well with linear small scar, and no infections or patients of necrosis were observed. Sensory recovery was assessed using the Medical Research Council scale, and all the sensation scores were S3+. Eight patients were healed after the first stage. Nine patients were closed totally while small sinus or skin defect were observed after sutures were removed; 3 patients were healed after the second debridement, and 6 patients finally healed after the dressings were changed. Patellar osteomyelitis recurred in 1 patient who was transferred to the Orthopedic Department for further treatment, and a flap graft procedure was performed.The operation was simple and obviously reduced the course of the disease, the costs, and the damage to the donor site, and it is also significantly superior to skin graft or flap transplantation procedures in terms of the resulting skin sensation, color, texture, elasticity, and appearance.


Assuntos
Fixadores Externos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Cicatrização/fisiologia , Ferimentos e Lesões/terapia , Adulto , Idoso , Elasticidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Satisfação do Paciente , Pigmentação da Pele , Temperatura Cutânea , Fatores de Tempo
8.
Int Heart J ; 61(5): 993-998, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32921671

RESUMO

Venous thromboembolism (VTE) is a life-threatening complication after trauma. Several studies have reported VTE prophylaxis using low-molecular-weight heparin; however, there is no consensus for prophylaxis after trauma. This study aimed to assess the efficacy and safety of our new anticoagulation therapy protocol using unfractionated heparin (UFH) plus intermittent pneumatic compression (IPC) to prevent post-traumatic VTE in high-risk trauma patients.This study enrolled 70 trauma patients who were admitted to the emergency medical center of Nagasaki University Hospital and had Risk Assessment Profile (RAP) scores ≥ 5. After stopping bleeding at the trauma site, all patients received intravenous UFH (10,000 U/day) plus IPC, which was continued for 14 days or until the patients could walk. On days 7 and 14, all patients underwent lower extremity sonography for deep-vein thrombosis screening. VTE incidences between patients with the above intervention and historical controls with IPC alone were compared.No significant differences in age, sex, and the RAP score were observed between the 105 controls and intervention patients. VTE occurrence was fewer in patients with the intervention (14.3%) than in the controls (28.6%; P = 0.029). No hemorrhagic complications occurred after UFH administration. Multivariable logistic analysis revealed a significant association between the intervention and low incidence of VTE (odds ratio: 0.390; 95% confidence interval: 0.163-0.913; P = 0.030).Routine UFH administration with IPC may prevent post-traumatic VTE without adverse events.


Assuntos
Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Dispositivos de Compressão Pneumática Intermitente , Embolia Pulmonar/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/prevenção & controle , Ferimentos e Lesões/terapia , Idoso , Estudos de Coortes , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Hospitalização , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Tempo de Tromboplastina Parcial , Medição de Risco , Trombofilia/sangue , Ferimentos e Lesões/sangue
11.
Nat Commun ; 11(1): 4167, 2020 08 20.
Artigo em Inglês | MEDLINE | ID: mdl-32820177

RESUMO

Muscle regeneration depends on a robust albeit transient inflammatory response. Persistent inflammation is a feature of age-related regenerative deficits, yet the underlying mechanisms are poorly understood. Here, we find inflammatory-related CC-chemokine-receptor 2 (Ccr2) expression in non-hematopoietic myogenic progenitors (MPs) during regeneration. After injury, the expression of Ccr2 in MPs corresponds to the levels of its ligands, the chemokines Ccl2, 7, and 8. We find stimulation of Ccr2-activity inhibits MP fusion and contribution to myofibers. This occurs in association with increases in MAPKp38δ/γ signaling, MyoD phosphorylation, and repression of the terminal myogenic commitment factor Myogenin. High levels of Ccr2-chemokines are a feature of regenerating aged muscle. Correspondingly, deletion of Ccr2 in MPs is necessary for proper fusion into regenerating aged muscle. Finally, opportune Ccr2 inhibition after injury enhances aged regeneration and functional recovery. These results demonstrate that inflammatory-induced activation of Ccr2 signaling in myogenic cells contributes to aged muscle regenerative decline.


Assuntos
Mediadores da Inflamação/metabolismo , Músculo Esquelético/fisiopatologia , Receptores CCR2/metabolismo , Regeneração/fisiologia , Transdução de Sinais/fisiologia , Fatores Etários , Animais , Transplante de Células/métodos , Quimiocina CCL2/metabolismo , Quimiocina CCL7/metabolismo , Quimiocina CCL8/metabolismo , Camundongos Endogâmicos C57BL , Camundongos Knockout , Desenvolvimento Muscular/genética , Músculo Esquelético/lesões , Músculo Esquelético/metabolismo , Miogenina/genética , Miogenina/metabolismo , Receptores CCR2/genética , Regeneração/genética , Células Satélites de Músculo Esquelético/citologia , Células Satélites de Músculo Esquelético/metabolismo , Células Satélites de Músculo Esquelético/transplante , Transdução de Sinais/genética , Ferimentos e Lesões/genética , Ferimentos e Lesões/fisiopatologia , Ferimentos e Lesões/terapia
12.
J Rehabil Med ; 52(8): jrm00092, 2020 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-32778903

RESUMO

BACKGROUND: Ambulant biofeedback devices can be used to provide real-time feedback for trauma patients on weight-bearing regimes. The devices also enable prescribing clinicians to monitor and train patients' level of weight-bearing. However, there is limited evidence regarding the feasibility of use of such devices in controlling weight-bearing, and their full potential remains to be elucidated. OBJECTIVE: To investigate the feasibility of using ambulant biofeedback training devices to improve compliance with weight-bearing regimes in trauma patients with lower extremity fractures. METHODS: A literature review of the feasibility and clinical validity of ambulant biofeedback devices. RESULTS: Three clinically validated biofeedback devices were found feasible for use in monitoring the compliance of patients who have lower extremity fractures with different weight-bearing regimes. CONCLUSION: Further information about the feasibility and clinical validity of biofeedback training devices is nee-ded in order to optimize weight-bearing instructions for patients.


Assuntos
Biorretroalimentação Psicológica/métodos , Fraturas Ósseas/terapia , Extremidade Inferior/lesões , Suporte de Carga/fisiologia , Ferimentos e Lesões/terapia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Cooperação do Paciente , Reprodutibilidade dos Testes
13.
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
14.
Am Surg ; 86(8): 933-936, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32856933

RESUMO

BACKGROUND: Several studies have described the population of adult trauma patients who undergo withdrawal of life-sustaining treatments (WLST); however, no study has looked specifically at trauma patients who undergo WLST following surgery. METHODS: This was a retrospective chart review of all trauma patients who underwent surgery at our trauma center between January 1 and December 31, 2017. Demographics were collected along with injury patterns and advance directives. Charts of all patients who died or who were discharged to hospice were analyzed to determine whether WLST occurred. Statistics included Fisher's exact test and Mann-Whitney U test. RESULTS: Three thousand and twenty-five adult trauma patients received care and 1495 (49.4%) had operations. Thirty (2.0%) patients underwent WLST, 15 (50.0%) of whom died in the hospital and 15 (50.0%) of whom were discharged to hospice. Twenty-six (86.7%) patients had a palliative care consult and 12 (40.0%) had prior advance directives. The most common injuries were femur fractures and subdural hematomas. Adjusting for age, white race, and age-adjusted CCI, femur fracture patients had, on average, 8.8 more hours between presentation and surgery (95% CI 2.1-15.4, P = .01) and 39 fewer hours between surgery and WLST (95% CI -107-29, P = .26) than traumatic brain injury patients. DISCUSSION: The short time between surgery and WLST in this cohort of patients may demonstrate that surgery was not aligned with patients' goals of care. A patient-centered approach that includes surgeon-driven palliative care discussions may help avoid nonbeneficial surgery in the last few days of life.


Assuntos
Cuidados Paliativos/estatística & dados numéricos , Conforto do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios , Suspensão de Tratamento/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adulto , Diretivas Antecipadas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Humanos , Masculino , Futilidade Médica , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente , Estudos Retrospectivos , Ferimentos e Lesões/mortalidade
15.
Rev Bras Epidemiol ; 23 Suppl 1: e200004.SUPL.1, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32638987

RESUMO

INTRODUCTION: Violence experienced in adolescence results in serious damage and suffering to society. This study aims to characterize the profile of violence victims and likely perpetrators of violence against adolescents, as well as to describe the percentage of notifying municipalities according to the federation unit. METHODS: Cross-sectional study conducted with data on notification of violence against adolescents from the Information System for Notifiable Diseases, from 2011 to 2017. The chi-square test was used to assess the statistical significance of the differences between the proportions in the comparison between genders. Proportion ratios for the most frequent types of violence were estimated according to selected variables. RESULTS: The notifications came from 75.4% of all the Brazilian municipalities. Physical violence predominated among males, aged 15-19 years. Psychological violence was predominant among females, between 10 and 14 years old, when perpetrated repeatedly at home by family aggressors. Sexual violence prevailed among females, aged 10 to 14 years old, in the indigenous, black and yellow races/colors, when perpetrated repeatedly at home. Negligence was more common among males, between 10 and 14 years old, when perpetrated repeatedly by family aggressors. CONCLUSIONS: Sexual violence occurred predominantly against females and generated significant negative impacts on mental, physical, sexual and reproductive health. Community violence, perpetrated with sharp objects and firearms, were prominent among males and are important risk factors for male over-mortality. Because the problems are complex, addressing them requires intersectoral actions.


Assuntos
Violência/estatística & dados numéricos , Adolescente , Brasil/epidemiologia , Criança , Estudos Transversais , Notificação de Doenças/estatística & dados numéricos , Feminino , Setor de Assistência à Saúde , Humanos , Masculino , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia , Adulto Jovem
16.
17.
Medicine (Baltimore) ; 99(28): e21148, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664147

RESUMO

Negative pressure wound therapy (NPWT) is an important therapy for the management of refractory wounds. The aim of this retrospective preliminary study was to introduce a modified NPWT (m-NPWT) and compared the efficacy of it with conventional NPWT (c-NPWT) in the management of refractory wounds.A total of 127 patients with refractory wounds receiving the NPWT from January 2010 to October 2017 in our hospital were retrospectively reviewed. The demographics and clinical data were collected from medical records and compared between m-NPWT group and c-NPWT group.There were 65 patients in c-NPWT group and 62 patients in m-NPWT group. No significant difference was observed between 2 groups in antimicrobial use (P = .51), hospitalization time (P = .24), wound-healing rate (P = .44) or complication rate (P = .59). However, patients in m-NPWT group had shorter wound-healing time (24.82 vs 27.66 days, P < .01), less debridement times (1.23 vs 2.08, P < .01), less total cost (3743.93 vs 6344.33 yuan, P < .01) and higher satisfaction rate (56/62 vs 44/65, P = .02) compared to those in c-NPWT group.The m-NPWT technique was an efficient and safe alternative therapy for refractory wounds.


Assuntos
Tratamento de Ferimentos com Pressão Negativa/métodos , Cicatrização , Ferimentos e Lesões/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
18.
Am Surg ; 86(5): 400-406, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32684018

RESUMO

INTRODUCTION: This study sought to compare the outcomes of trauma patients taken directly from the field to a level I trauma center (direct) versus patients that were first brought to a level III trauma center prior to being transferred to a level I (transfer) within our inclusive Delaware trauma system. METHODS: A retrospective review of the level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single level I trauma center from two surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. RESULTS: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared to direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (OR 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001). DISCUSSION: Delays in presentation to our level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.


Assuntos
Seleção de Pacientes , Transferência de Pacientes/normas , Centros de Traumatologia , Triagem/normas , Ferimentos e Lesões/terapia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tempo para o Tratamento , Centros de Traumatologia/classificação , Resultado do Tratamento
19.
Am Surg ; 86(5): 486-492, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32684040

RESUMO

BACKGROUND: Extended hospital length of stay (LOS) is widely associated with significant healthcare costs. Since LOS is a known surrogate for cost, we sought to evaluate outliers. We hypothesized that particular characteristics are likely predictive of trauma high resource consumers (THRC) and can be used to more effectively manage care of this population. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2017 for all adult (age ≥15) trauma patients admitted to accredited trauma centers in Pennsylvania. THRC were defined as patients with hospital LOS two standard deviations above the population mean or ≥22 days (p<0.05). Patient demographics, comorbid conditions and clinical variables were compared between THRC and non-THRC to identify potential predictor variables. A multilevel mixed-effects logistic regression model controlling for age, gender, injury severity, admission Glasgow coma score, systolic blood pressure, and injury year assessed the adjusted impact of clinical factors in predicting THRC status. The National Trauma Data Bank (NTDB) was retrospectively queried from 2014-2016 for all adult (age ≥15) trauma patients admitted to state-accredited trauma centers and likewise were assessed for factors associated with THRC. RESULTS: A total of 465,601 patients met inclusion criteria [THRC: 16,818 (3.6%); non-THRC 448,783 (96.4%)]. Compared to non-THRC counterparts, THRC patients were significantly more severely injured (median ISS: 9 vs. 22, p<0.001). In adjusted analysis, gunshot wound (GSW) to the abdomen, undergoing major surgery and reintubation along with injury to the spine, upper or lower extremities were significantly associated with THRC. From the NTDB, 2 323 945 patients met inclusion criteria. In adjusted analysis, GSW to the abdomen was significantly associated with THRC. Penetrating injury overall was associated with decreased risk of being a THRC in the NTDB dataset. Those who had either GSW to abdomen, surgery, or reintubation required significantly longer LOS (p<0.001). CONCLUSIONS: Reintubation, major surgery, gunshot wound to abdomen, along with injury to the spine, upper or lower extremities are all strongly predictive of THRC. Understanding the profile of the THRC will allow clinicians and case management to proactively put processes in place to streamline care and potentially reduce costs and LOS.


Assuntos
Tempo de Internação/estatística & dados numéricos , Ferimentos e Lesões , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Previsões , Recursos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/terapia , Adulto Jovem
20.
Surg Clin North Am ; 100(4): 741-756, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32681874

RESUMO

Cellular and/or tissue-based products (CTPs) have advanced greatly in the past several decades and improve the ability to heal wounds more efficiently. Products can be characterized as nonviable cells, tissue based, animal; nonviable cells, tissue based, human; viable human cells, cultured in vitro, animal substrate; viable human cells, cultured in vitro, synthetic substrate; viable human cells, noncultured, intact tissue. There are approximately 77 different CTPs at the time of this writing, with many more being investigated. Cellular and/or tissue-based product selection, application, postapplication course, and patient selection depend on patient attributes, CTP specifications, and surgeon preference.


Assuntos
Bandagens , Cicatrização/fisiologia , Ferimentos e Lesões/terapia , Bioengenharia , Curativos Biológicos , Queimaduras/fisiopatologia , Queimaduras/terapia , Humanos , Pele Artificial , Infecção dos Ferimentos/fisiopatologia , Infecção dos Ferimentos/prevenção & controle , Ferimentos e Lesões/fisiopatologia
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