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1.
Am Surg ; 86(7): 826-829, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32916072

RESUMO

BACKGROUND: The need to reverse the coagulation impairment caused by chronic antiplatelet agents in traumatic brain injury (TBI) patients with acute traumatic intracerebral hemorrhage (TICH) remains controversial. We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy. METHODS: All adult blunt TICH patients (age ≥16 years) over a 4-year period were retrospectively reviewed. Patients with penetrating TBI, blunt TBI without TICH on admission computed tomography (CT), receiving warfarin, not on antiplatelet agents, or requiring immediate operative intervention were excluded. Patients were divided into 2 groups depending on whether they received a platelet transfusion: reversal group (RV) versus no reversal group (NR). Patient outcomes were analyzed using Mann-Whitney U and Fisher's exact tests. RESULTS: 169 blunt TBI patients on chronic antiplatelet therapy were studied (102 RV group, 67 NR group). The groups were well matched with regard to age, Injury Severity Score, Abbreviated Injury Scale-head, Glasgow Coma Score, mechanism of injury, need for intubation, time to initial CT scan, and hospital length of stay. Immediate platelet transfusion did not alter the occurrence of TICH extension on follow-up CT (26% vs 21%, P = .71), TBI-specific mortality (9% vs 13%, P = .45), need for ICP monitor (2% vs 3%, P = 1.0), burr hole (1% vs 3%, P = .56), or craniotomy (1% vs 3%, P = .56). DISCUSSION: Immediate platelet transfusion is unnecessary in blunt TBI patients on chronic antiplatelet therapy who do not require immediate craniotomy.


Assuntos
Lesões Encefálicas Traumáticas/terapia , Hemorragia Cerebral Traumática/prevenção & controle , Inibidores da Agregação de Plaquetas/administração & dosagem , Transfusão de Plaquetas , Ferimentos não Penetrantes/terapia , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/mortalidade , Hemorragia Cerebral Traumática/epidemiologia , Craniotomia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
2.
Am Surg ; 86(6): 690-694, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32683975

RESUMO

OBJECTIVES: The purpose of this study is to examine the outcomes of splenic angioembolization (SAE) as the first modality for nonoperative management (NOM) in hypotensive patients with high-grade splenic injuries. METHODS: Data were collected from the 2007-2010 National Trauma Data Bank data sets of the United States. The data included patients with massive blunt splenic injuries with an Abbreviated Injury Scale (AIS) of 4 or 5, initial systolic blood pressure ≤90, and who underwent either a total splenectomy or SAE (Group 1 and Group 2, respectively) within 4 hours of hospital arrival. The outcomes of interest are in-hospital mortality and complications. RESULTS: Of the 1052 patients analyzed, 996 (94.7%) underwent total splenectomy while 56 (5.3%) underwent SAE. There were significant differences regarding injury mechanism (P = .01) and the proportion of patients with an AIS of 5 (57.6% vs 39.3% respectively, P = .01). A significantly higher number of patients, however, developed organ space infections (3.9% vs 11.6%, P = .02) in Group 2. The multivariate logistic regression model for mortality, which accounted for demography, Glasgow Coma Scale Motor (GCSM) score, Injury Severity Score (ISS), AIS, time to procedure, and procedure type showed the procedure type was not a contributing factor to patient mortality, but higher age, ISS, and lower GCSM score were strong predictors of mortality. CONCLUSION: The treatment of approximately 95% of hypotensive patients with massive splenic injury was total splenectomy. However, if the interventional radiology resources are immediately available, SAE can be used as a first intervention without an increased risk of mortality.


Assuntos
Traumatismos Abdominais/cirurgia , Embolização Terapêutica , Hipotensão/terapia , Baço/lesões , Esplenectomia , Ferimentos não Penetrantes/cirurgia , Escala Resumida de Ferimentos , Traumatismos Abdominais/complicações , Traumatismos Abdominais/mortalidade , Adulto , Embolização Terapêutica/métodos , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Esplenectomia/métodos , Estados Unidos , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade
3.
Am Surg ; 86(4): 354-361, 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32391760

RESUMO

In recent years, the incidence of blunt cardiac injury (BCI) has increased rapidly and is an important cause of death in trauma patients. This study aimed to explore early diagnosis and therapy to increase survival. All patients with BCI during the past 15 years were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. The patients were divided into two groups according to the needs of their condition-nonoperative (Group A) and operative (Group B). Comparisons of the groups were performed. A total of 348 patients with BCI accounted for 18.3 per cent of 1903 patients with blunt thoracic injury. The main cause of injury was traffic accidents, with an incidence of 48.3 per cent. In Group A (n = 305), most patients sustained myocardial contusion, and the mortality was 6.9 per cent. In Group B (n = 43), including those with cardiac rupture and pericardial hernia, the mortality was 32.6 per cent. Comparisons of the groups regarding the shock rate and mortality were significant (P < 0.01). Deaths directly resulting from BCI in Group B were greater than those in Group A (P < 0.05). In all 348 patients, the mortality rate was 10.1 per cent. When facing a patient with blunt thoracic injury, a high index of suspicion for BCI must be maintained. To manage myocardial contusion, it is necessary to protect the heart, alleviate edema of the myocardium, and control arrhythmia with drugs. To deal with those requiring operation, early recognition and expeditious thoracotomy are essential.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Traumatismos Cardíacos , Ferimentos não Penetrantes , Acidentes de Trânsito , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/tratamento farmacológico , Arritmias Cardíacas/etiologia , Ecocardiografia , Eletrocardiografia , Feminino , Coração/diagnóstico por imagem , Traumatismos Cardíacos/diagnóstico , Traumatismos Cardíacos/mortalidade , Traumatismos Cardíacos/terapia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Adulto Jovem
4.
J Vasc Surg ; 72(1): 189-197, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32247701

RESUMO

OBJECTIVE: Traumatic popliteal artery injury is associated with an increased propensity for limb loss, morbidity, and mortality above an already elevated baseline risk to life and limb. Previous studies of outcomes in this patient group have been limited by selection bias. This study analyzed outcomes after blunt popliteal artery injury using propensity matching to reduce confounding variables associated with multiple mechanisms of traumatic vascular injury and to identify factors associated with amputation. METHODS: A retrospective review was conducted of prospectively collected data from the National Trauma Data Bank. Patients were identified using International Classification of Diseases, Ninth Revision codes related to patterns of blunt injury associated with popliteal arterial injury or intervention. Using Trauma Quality Improvement Program variables as a reference, specific characteristics were collected. Variables found significant on univariate analysis were used to generate propensity-matched amputation and nonamputation cohorts. Multivariate logistic regression was used to assess for risk factors associated with amputation and inpatient mortality. RESULTS: In total, 3029 patients with blunt popliteal artery injury were identified; 628 (20.7%) underwent amputation. Patients who underwent amputation presented with more frequent hypotension (systolic blood pressure of 0-99 mm Hg, 22.7% vs 12.8%; P < .001) and tachycardia (heart rate >120 beats/min, 28.5% vs 14.5%; P < .001). Limb loss was also associated with concurrent popliteal vein injury (18.3% vs 8.7%; P < .001) and tibial nerve injury (5.3% vs 1.3%; P < .001) as well as with elevated Injury Severity Score (median, 13 vs 9; P < .001) and lower extremity Abbreviated Injury Scale score (3 vs 2; P < .001). Subsequently, 794 patients were divided into equal number propensity-matched amputation and nonamputation cohorts. Regression analysis revealed that patients with diabetes mellitus (odds ratio [OR], 1.763; P = .049), popliteal vein injury (OR, 1.657; P = .012), or tibial nerve injury (OR, 3.537; P = .007) were more likely to undergo amputation. Further regression analysis with patients matched for Injury Severity Score revealed that age ≥86 years (OR, 38.092; P = .009), patellar fracture (OR, 3.445; P = .036), and elevated Abbreviated Injury Scale score (OR, 1.101; P < .001) were associated with higher risk of inpatient death. CONCLUSIONS: Trauma patients who sustain blunt popliteal artery injury are at an increased risk of amputation. Propensity-matched analysis revealed that concurrent popliteal vein and tibial nerve injury but not severity of tissue injury predicted limb loss.


Assuntos
Amputação , Artéria Poplítea/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Amputação/efeitos adversos , Amputação/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/lesões , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
5.
J Trauma Acute Care Surg ; 88(5): 597-606, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32317576

RESUMO

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


Assuntos
Fraturas Ósseas/complicações , Hemostasia Cirúrgica/métodos , Ossos Pélvicos/lesões , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos não Penetrantes/complicações , Adulto , Feminino , Fraturas Ósseas/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pelve/cirurgia , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Taxa de Sobrevida , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
6.
Scand J Trauma Resusc Emerg Med ; 28(1): 21, 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164757

RESUMO

BACKGROUND: Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of patients with TBI. METHODS: We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TR-DGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3-5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AISThorax= 2-5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ2-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value < 0.05. RESULTS: A total of 5414 matched pairs (10,828 patients) were included. The presence of additional thoracic injuries in patients with TBI was associated with a longer duration of mechanical ventilation and a prolonged ICU and hospital length of stay. Additional thoracic trauma was also associated with higher mortality rates. These effects were most pronounced in thoracic AIS subgroups 4 and 5. Additional thoracic trauma, regardless of its severity (AISThorax ≥2) was associated with significantly decreased rates of good neurologic recovery (GOS = 5) after TBI. CONCLUSIONS: Chest trauma in general, regardless of its initial severity (AISThorax= 2-5), is associated with decreased chance of good neurologic recovery after TBI. Affected patients should be considered "at risk" and vigilance for the maintenance of optimal neuro-protective measures should be high.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/mortalidade , Traumatismos Torácicos/complicações , Traumatismos Torácicos/mortalidade , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade , Escala Resumida de Ferimentos , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/terapia , Bases de Dados Factuais , Feminino , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Respiração Artificial , Estatísticas não Paramétricas , Taxa de Sobrevida , Traumatismos Torácicos/terapia , Ferimentos não Penetrantes/terapia , Adulto Jovem
7.
J Vasc Surg ; 71(6): 1851-1857, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32014287

RESUMO

OBJECTIVE: The purpose of this study was to report the updated results of a prospective, multicenter, nonrandomized, single-arm investigational device exemption study conducted at 17 sites in the United States to assess safety and effectiveness of the Zenith Alpha thoracic endovascular graft (Cook Medical, Bloomington, Ind) for treatment of blunt thoracic aortic injury (BTAI). METHODS: The primary safety end point was 30-day all-cause mortality and aortic injury-related mortality. The primary effectiveness end point was 30-day device success. Additional outcomes evaluated included major adverse events and imaging findings including aortic injury healing, graft patency, and device integrity as analyzed by the core laboratory on follow-up computed tomography imaging through 5 years. RESULTS: A total of 50 patients with BTAI were enrolled in the TRANSFIX study between January 2013 and May 2014. Mean follow-up was 21 months (range, 0.6-35 months). The 30-day mortality was 2% (n = 1), and it was unrelated to the aortic repair or study device. Five deaths occurred after 30 days, and one was considered procedure related. Freedom from all-cause and BTAI-related mortality was 89.3% and 97.6%, respectively, at 2 years. Aortic injury healing was noted in 96% at 2 years. An incidental finding of thrombus formation within the stent graft, most commonly at the distal aspect of the study device, occurred in 15 patients (30%; 12 by core laboratory, 3 by site) and was confirmed in 13 patients (26%). None of these patients were noted to have clinical sequelae on most recent follow-up. CONCLUSIONS: The updated results from the TRANSFIX study continue to show low rates of aortic injury-related mortality and major adverse events during follow-up. However, findings of in-graft thrombus have resulted in the manufacturer's voluntary removal of the BTAI indication for this device. Caution should be exercised in appropriate and accurate device sizing and planning (eg, limiting graft oversizing) as well as in regular, lifelong follow-up evaluation.


Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade
8.
Am J Surg ; 220(3): 778-782, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32061397

RESUMO

BACKGROUND: While the incidence of geriatric trauma continues to increase, the management of high-grade blunt splenic injury (BSI) in the elderly remains controversial. Among this population, data evaluating survival rates following non-operative and operative management are inconsistent. We analyzed mortality risk in geriatric patients with high-grade BSI based on operative vs. non-operative management. METHODS: A retrospective analysis of the National Trauma Database identified patients with isolated, high-grade (AIS ≥ 3) BSI from 2014 to 2015. Patients were stratified into three groups: non-elderly (<65 years), elderly (65-79 years), and advanced age (80 years and older). Each age group was stratified into three management groups: non-operative (including embolization), initial operative management (OR within 24 h), and failed non-operative management. Patient characteristics and outcomes were compared. Multivariable logistic regression estimated association with mortality. RESULTS: 5560 patients with isolated, high-grade BSI were identified. In the group that failed NOM, mortality was 2% in non-elderly patients, versus 22.2% in elderly patients and 50% in patients of advanced age (p < .01). In this group, patients over 80 years old spent an average of 6.5 days longer in the ICU vs. non-elderly patients (median 10.5 days, IQR [6.75, 19.5] vs. 4 days, IQR [3,6], p = 0.02). In patients with isolated, high grade BSI, age was independently associated with mortality (AOR 1.02; p < 0.01). Elderly patients who required surgery were over three times more likely to die (AOR 3.39; p < 0.01). Advanced age patients who required surgery were over eight times more likely to die (AOR 8.1; p < 0.01). CONCLUSIONS: For patients with BSI, age is independently associated with death in both operative and non-operative cases.


Assuntos
Baço/lesões , Ferimentos não Penetrantes/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco
9.
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
10.
Ann Thorac Surg ; 110(3): 815-820, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-31991136

RESUMO

BACKGROUND: The Clinical PeRformancE of the Valiant Thoracic Stent Graft with Capitvia Delivery System for the EndovaSCUlar treatment of Blunt Thoracic Aortic Injuries (RESCUE) study evaluating thoracic endovascular repair using the Valiant Captivia endograft for blunt thoracic aortic injury reported promising 30-day outcomes. We now describe 5 years of follow-up of this cohort. METHODS: Fifty patients (mean age 40.7 ± 17.4 years, 76% male, mean injury severity score 38 ± 14.4) were treated for blunt thoracic aortic injury (2010 to 2012) with this endograft. Seventy percent (n = 35) of blunt thoracic aortic injury extent was grade III or higher. Extent of arch repair required full (40%) or partial (18%) left subclavian artery coverage. At 5 years, clinical and imaging compliance was 90.3% (28 of 31) and 67.7% (21 of 31), respectively. RESULTS: Thirty-day mortality was 8%. Three additional patients died of non-device-related causes (respiratory failure, infection, metastatic cancer) through 5-year follow-up, yielding a Kaplan-Meier survival of 85.2% through 5 years. Neither stroke nor spinal cord ischemia was observed at 5 years. Two type II endoleaks seen at 30 days resolved spontaneously, and no additional endoleaks were described in the study cohort through 5 years. No secondary endovascular procedures or conversion to open surgery were reported through 5 years. Four subjects underwent left subclavian revascularization for symptomatic indications. Finally, complete exclusion of the traumatic injury was maintained with no incidences of stent graft kinking, fracture, loss of patency, or migration through 5 years in all patients. CONCLUSIONS: This multicenter clinical trial describes excellent 5-year outcomes and durable exclusion of blunt thoracic aortic injury using a novel stent graft system. Thoracic endovascular repair with this endograft appears to be a safe and effective treatment option for patients with blunt thoracic aortic injury.


Assuntos
Aorta Torácica/lesões , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Stents , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Idoso , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade
11.
J Pak Med Assoc ; 70(Suppl 1)(2): S99-S101, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31981344

RESUMO

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


Assuntos
Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Veia Cava Inferior/lesões , Ferimentos por Arma de Fogo/cirurgia , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/complicações , Acidentes de Trânsito/mortalidade , Adolescente , Adulto , Colo Ascendente/lesões , Gangrena , Hospitais Universitários , Humanos , Intestinos/patologia , Rim/lesões , Ligadura , Fígado/lesões , Masculino , Mortalidade , Traumatismo Múltiplo , Estudos Retrospectivos , Lesões do Sistema Vascular/mortalidade , Trombose Venosa , Ferimentos por Arma de Fogo/mortalidade , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/mortalidade , Adulto Jovem
12.
Forensic Sci Int ; 307: 110141, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31945737

RESUMO

AIMS: We aimed at analyzing homicide trends and patterns in Italy over the period 1980-2014. METHODS: We collected data from the Italian Mortality Database (Italian National Institute of Statistics), for the study period. Temporal trends were analyzed using joinpoint regression analysis, with estimated annual percentage change computed for each detected trend. The possible effect of the mafia subculture was examined using an indicator of mafia social penetration. Differences between age classes, genders, geographical regions, and homicide methods were also analyzed. RESULTS: The analyses showed an overall reduction in homicides during the study period, including a reduction in homicides by firearm. Further, we found significant differences between homicides involving male and female victims. A peak in male homicides, observed in the early 1990s, was significantly associated with mafia penetration. CONCLUSIONS: The overall reduction in homicides can be interpreted as an expression of a "civilizing process."


Assuntos
Homicídio/tendências , Adolescente , Adulto , Distribuição por Idade , Idoso , Asfixia/mortalidade , Criança , Pré-Escolar , Vítimas de Crime/estatística & dados numéricos , Feminino , Armas de Fogo , Medicina Legal , Homicídio/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Lesões do Pescoço/mortalidade , Distribuição por Sexo , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Adulto Jovem
13.
Ann Thorac Surg ; 110(2): 524-530, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31962115

RESUMO

BACKGROUND: Blunt thoracic aortic injury treatment has evolved over the past decade particularly with respect to endovascular intervention options. We investigated the trends in blunt thoracic aortic injury management and outcomes over an 11-year span at the sole tertiary referral center in our state. METHODS: We retrospectively reviewed all patients who presented to our institution with blunt traumatic aortic injury between 2007 and 2017. Baseline demographics including aortic injury grade, injury severity score, and abbreviated injury scale were collected. Outcomes were compared by type and timing of treatment, which included either nonoperative management, endovascular repair, or open surgical repair. Bivariate and multivariable analyses were performed to examine treatment group differences and factors associated with 30-day mortality. RESULTS: In total, 229 patients were reviewed. The distribution of injury severity was grade 1 (30%), grade 2 (8%), grade 3 (30%), and grade 4 (31%). Overall, 27% of patients underwent endovascular repair, 29% open surgery, and 44% definitive nonoperative management. Over the study period, there was a dramatic decline in open surgery and a corresponding rise in endovascular treatment. Thirty-day mortality for the entire cohort was 22%. Mortality by treatment subgroup was 30% for nonoperative management, 8.2% for endovascular treatment, and 21% for open surgery. Delaying endovascular or open surgical treatment by at least 24 hours after admission was associated with significantly improved 30-day survival. CONCLUSIONS: Procedural intervention, whether endovascular or surgical, is associated with improved mortality compared with nonoperative treatment. Delayed intervention, particularly in the case of high-grade injuries, may allow for initial patient stabilization and improved outcomes.


Assuntos
Previsões , Centros de Atenção Terciária , Traumatismos Torácicos/cirurgia , Procedimentos Cirúrgicos Torácicos/métodos , Ferimentos não Penetrantes/cirurgia , Adulto , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Indiana/epidemiologia , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/mortalidade , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade
14.
Ann Vasc Surg ; 66: 242-249, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31978483

RESUMO

BACKGROUND: Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. METHODS: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. RESULTS: From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001). CONCLUSIONS: A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.


Assuntos
Procedimentos Endovasculares , Fratura-Luxação/terapia , Traumatismos da Perna/terapia , Artéria Poplítea/cirurgia , Veia Poplítea/cirurgia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/terapia , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Adolescente , Fatores Etários , Amputação , Criança , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fratura-Luxação/diagnóstico por imagem , Fratura-Luxação/mortalidade , Humanos , Traumatismos da Perna/diagnóstico por imagem , Traumatismos da Perna/mortalidade , Salvamento de Membro , Masculino , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/lesões , Veia Poplítea/diagnóstico por imagem , Veia Poplítea/lesões , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/mortalidade
15.
Ann Vasc Surg ; 66: 250-262, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31923601

RESUMO

BACKGROUND: Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes. METHODS: Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com. RESULTS: Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid. CONCLUSIONS: Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications. LEVEL OF EVIDENCE: III (Retrospective therapeutic study and systematic literature review).


Assuntos
Aneurisma Dissecante/epidemiologia , Artéria Celíaca/lesões , Lesões do Sistema Vascular/epidemiologia , Ferimentos não Penetrantes/epidemiologia , Adolescente , Adulto , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/cirurgia , Artéria Celíaca/diagnóstico por imagem , Tratamento Conservador , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgia
17.
J Vasc Surg ; 71(6): 1858-1866, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31699513

RESUMO

OBJECTIVE: Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI. RESULTS: From 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001). CONCLUSIONS: In the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.


Assuntos
Traumatismos Abdominais/mortalidade , Aorta Abdominal/lesões , Traumatismo Múltiplo/mortalidade , Ferimentos não Penetrantes/mortalidade , Traumatismos Abdominais/diagnóstico por imagem , Acidentes de Trânsito , Adulto , Idoso , Aorta Abdominal/diagnóstico por imagem , Bases de Dados Factuais , Feminino , Hemopneumotórax/mortalidade , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/diagnóstico por imagem , Pedestres , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia , Veia Cava Inferior/lesões , Ferimentos não Penetrantes/diagnóstico por imagem , Adulto Jovem
18.
Ann Vasc Surg ; 65: 113-123, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31678544

RESUMO

BACKGROUND: The aim of this study is to evaluate recent national trends in the clinical characteristics, management, and outcomes of patients with isolated axillary artery injuries. METHODS: The National Trauma Data Bank was queried to identify records submitted from 2011 to 2015 that contained an ICD-9-CM diagnosis code for an injury to axillary artery (903.01) and an external cause of injury code indicating blunt or penetrating trauma. Records that contained a diagnosis code for an injury to an additional blood vessel (900.00-903.00, 903.2-904.9), an injury to a nonupper extremity or unclassifiable body region, or whose operative management could not be discerned were excluded. The final study sample included 221 patients with isolated axillary artery injury. The patient's clinical management was the primary outcome of interest. The study sample was stratified by trauma type, and descriptive statistics were performed on all variables. RESULTS: Seventy-one percent of patients received operative management. Patients with penetrating injury were 24% more likely to be managed operatively than bluntly injured patients (76.9% vs. 62.1%, P = 0.0178). In operatively managed patients, the open repair rate was 82.8% and endovascular repair rate was 10.2%. Graft repair was performed most often (28.0%), followed by placement of a temporary intravenous shunt (17.8%) and surgical occlusion (10.2%). Surgical vessel occlusion was significantly more likely to be performed on patients with penetrating injury than with blunt injury (14.6% vs. 1.9%, P = 0.0124). Patients with penetrating injury had significantly shorter median emergency department length of stay (87.0 min vs. 152.0 min, P < 0.0001), intensive care unit length of stay (2.0 days vs. 3.0 days, P < 0.0388), hospital length of stay (4.0 days vs. 5.0 days, P = 0.0026), and time-to-operative management (1.6 hr vs. 3.9 hr, P < 0.001) compared to bluntly injured patients. Patients with blunt injury had a higher reportable in-hospital complication rate (13.8% vs. 6.0%, P = 0.0477). The overall mortality rate was 3.1% for isolated axillary artery injuries and did not significantly differ by trauma type. CONCLUSIONS: Axillary artery injury is more often caused by penetrating trauma. Despite introduction of novel endovascular techniques, the majority of patients with isolated axillary artery injury are managed using open repair. Penetrating axillary artery injury is significantly more likely to be managed using open repair and by surgical occlusion. Patients with blunt injury have higher complication rates and longer hospital length of stays. The mortality rate is lower than previously published.


Assuntos
Artéria Axilar/cirurgia , Implante de Prótese Vascular/tendências , Procedimentos Endovasculares/tendências , Técnicas Hemostáticas/tendências , Tempo para o Tratamento/tendências , Lesões do Sistema Vascular/terapia , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Adolescente , Adulto , Idoso , Artéria Axilar/diagnóstico por imagem , Artéria Axilar/lesões , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Técnicas Hemostáticas/efeitos adversos , Técnicas Hemostáticas/instrumentação , Técnicas Hemostáticas/mortalidade , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/mortalidade , Adulto Jovem
20.
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
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