First report of hepatic hematoma after presumed Bothrops envenomation

ABSTRACTIn Latin America, Bothrops envenomation is responsible for the majority of accidents caused by venomous snakes. Patients usually present local edema, bleeding and coagulopathy. Visceral hemorrhage is extremely rare and considered a challenge for diagnosis and management. We report the first case of hepatic hematoma owing to the bothropic envenomation in a 66-year-old man who was bitten in the left leg. He presented local edema, coagulopathy, and acute kidney injury. Radiological findings suggested hepatic hematoma, with a volume of almost 3 liters. The hepatic hematoma was gradually absorbed without the need for surgical intervention with complete resolution in 8 months.

Avaliação das decisões médicas durante o processo do morrer / Evaluation of medical decisions at the end-of-life process

OBJETIVOS: Avaliar as condutas médicas adotadas durante o morrer de pacientes que foram a óbito no HU/UFSC. Comparar essas condutas e o perfil epidemiológico dos que morreram na unidade de terapia intensiva (UTI) com o dos que morreram nas enfermarias de clínica médica (ECM) ou cirúrgicas (ECC). MÉTODOS: Estudo retrospectivo e observacional, onde foram anotados os dados demográficos, clínicos e terapêuticos dos pacientes adultos que morreram nas enfermarias e na unidade de terapia intensiva do HU/UFSC, no período de julho/2004 a dezembro/2008. Para análise estatística foram utilizados os testes: t Student, χ2 e ANOVA (significante p<0.05). RESULTADOS: Foram analisadas 1124 mortes: 404 ocorreram na UTI, 607 na ECM e 113 na ECC. A taxa de mortalidade hospitalar foi 5,9 por cento (UTI=24,5 por cento, ECM=7,2 por cento, ECC=1,69 por cento). A idade média dos doentes foi: UTI=56,7, ECM=69,3 e ECC=70,4 anos (p<0,01). A recusa/suspensão de terapêutica precedeu 30,7 por cento dos óbitos na unidade de terapia intensiva e 10,0 por cento nas enfermarias (p<0,01). Não houve reanimação cardiorrespiratória em 65 por cento dos casos na UTI, 79 por cento na ECM e 62 por cento na ECC. Excluindo-se reanimação cardiorrespiratória, a recusa/suspensão de terapêutica mais freqüente na unidade de terapia intensiva foi droga vasoativa; já nas enfermarias foi a não internação na unidade de terapia intensiva. Ordem de não reanimar foi documentada em 2,4 por cento dos casos na UTI e em 2,6 por cento na ECM. Condutas paliativas e de conforto foram prestados a 2,0 por cento dos pacientes na UTI, 11,5 por cento na ECM e 8,0 por cento na ECC. A terminalidade da doença foi reconhecida em 40,0 por cento dos casos na UTI, 34,6 por cento na ECM e 16,8 por cento na ECC. CONCLUSÕES: O perfil dos pacientes que morreram e as condutas médicas adotadas durante o processo de morrer foram diferentes nas enfermarias clínicas, cirúrgicas e na unidade de terapia intensiva.

OBJECTIVES: To evaluate the medical decisions at end-of-life of patients admitted at HU/UFSC and to compare these decisions and the profile of patients who died in the intensive care unit (ICU) to those who died in medical (MW) and surgical wards (SW). METHODS: This is a retrospective and observational study. Demographic data, clinical features, treatment and the end-of-life care decisions of adult patients who died in wards and the intensive care unit of HU/UFSC from July/2004 to December/2008 were analyzed . For statistical analysis the Student's t, χ2 and ANOVA tests were used: (significance p <0.05). RESULTS: An analysis was made of 1124 deaths: 404 occurred in ICU, 607 in MW and 113 in SW. The overall hospital mortality rate was 5.9 percent (ICU=24.49 percent, MW=7.2 percent, SW=1.69 percent). Mean ages of patients were: ICU=56.7, MW=69.3 and SW=70.4 years (p <0.01). Withholding/withdrawing life support was performed prior to 30.7 percent of deaths in the intensive care unit and 10 percent in the wards (p <0.01). Cardiopulmonary resuscitation was not carried out in 65 percent of cases in ICU, 79 percent in MW and 62 percent in SW. Besides cardiopulmonary resuscitation, the more frequent withholding/withdrawing life support in the intensive care unit were vasoactive drugs and in the wards refusal of admission to intensive care unit . Do-not-resuscitate order was documented in 2.4 percent of cases in ICU and 2.6 percent in MW. Palliative and comfort care were provided to 2 percent of patients in ICU, 11.5 percent in MW and 8 percent in SW. Terminality of the disease was recognized in 40 percent of cases in ICU, 34.6 percent in MW and 16.8 percent in SW. CONCLUSIONS: The profile of patients who died and medical decisions during the end-of-life process were different in the intensive care unit, clinical and surgical wards.