Uso de la tomografía corporal total en pacientes con heridas de arma de fuego y hemodinámicamente inestables: ¿Rompiendo paradigmas de atención inicial? / Whole-body computed tomography in hemodynamically unstable patients with gunshot wounds: A paradigm shift in trauma management?

Introducción. El objetivo del estudio fue analizar el impacto del uso de la tomografía corporal total en la evaluación de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables atendidos en un centro de referencia de trauma. Métodos. Se realizó un estudio analítico, retrospectivo, con base en un subanálisis del registro de la Sociedad Panamericana de Trauma ­ Fundación Valle del Lili. Se incluyeron los pacientes con trauma penetrante por proyectil de arma de fuego atendidos entre 2018 y 2021. Se excluyeron los pacientes con trauma craneoencefálico severo, trauma leve y en condición in extremis. Resultados. Doscientos pacientes cumplieron los criterios de elegibilidad, 115 fueron estudiados con tomografía corporal total y se compararon con 85 controles. La mortalidad intrahospitalaria en el grupo de tomografía fue de 4/115 (3,5 %) vs 10/85 (12 %) en el grupo control. En el análisis multivariado se identificó que la tomografía no tenía asociación significativa con la mortalidad (aOR=0,46; IC95% 0,10-1,94). El grupo de tomografía tuvo una reducción relativa del 39 % en la frecuencia de cirugías mayores, con un efecto asociado en la disminución de la necesidad de cirugía (aOR=0,47; IC95% 0,22-0,98). Conclusiones. La tomografía corporal total fue empleada en el abordaje inicial de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables. Su uso no se asoció con una mayor mortalidad, pero sí con una menor frecuencia de cirugías mayores.

Introduction. This study aims to assess the impact of whole-body computed tomography (WBCT) in the evaluation of patients with penetrating gunshot wounds (GSW) who are hemodynamically unstable and treated at a trauma referral center. Methods. An analytical, retrospective study was conducted based on a subanalysis of the Panamerican Trauma Society-FVL registry. Patients with GSW treated between 2018 and 2021 were included. Patients with severe cranioencephalic trauma, minor trauma, and those in extremis were excluded. Patients with and without WBCT were compared. The primary outcome was in-hospital mortality, and the secondary outcome was the frequency of major surgeries (thoracotomy, sternotomy, cervicotomy, and/or laparotomy) during initial care. Results. Two hundred eligible patients were included, with 115 undergoing WBCT and compared to 85 controls. In-hospital mortality in the WBCT group was 4/115 (3.5%) compared to 10/85 (12%) in the control group. Multivariate analysis showed that WBCT was not significantly associated to mortality (aOR: 0.46; 95% CI 0.10-1.94). The WBCT group had a relative reduction of 39% in the frequency of major surgeries, with an associated effect on reducing the need for surgery (aOR: 0.47; 95% CI 0.22-0.98). Conclusions. Whole-body computed tomography was employed in the initial management of patients with penetrating firearm projectile injuries and hemodynamic instability. The use of WBCT was not associated with mortality but rather with a reduction in the frequency of major surgery.

Predictores de mortalidad precoz en pacientes con trauma complejo hemorrágico / Early mortality predictors in patients with complex hemorrhagic trauma

RESUMEN Fundamento: El trauma complejo es un problema de salud a nivel mundial y cuando es de tipo hemorrágico la mortalidad es superior a los otros tipos de traumas complejos. Objetivo: Determinar las variables predictoras de mortalidad precoz en pacientes hospitalizados con trauma complejo hemorrágico en una institución hospitalaria del segundo nivel de atención en Cuba. Metodología: Se realizó un estudio transversal en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, durante 6 años. Se incluyeron 207 pacientes. Las variables se agruparon en sociodemográficas, enfermedades crónicas asociadas, mecanismo lesional, tipo de trauma, localización topográfica, tiempo entre admisión hospitalaria, diagnóstico y tratamiento, complicaciones precoces, tratamiento médico y quirúrgico, y mortalidad precoz. Se elaboró un árbol de decisión mediante el método Chaid exhaustivo, la variable dependiente fue la mortalidad por trauma complejo hemorrágico. Resultados: Predominaron los pacientes del sexo masculino (85 %), con 60 años y menos (83 %), con trauma contuso (57.5 %) y politraumatizados (42.5 %). Predominaron también los que presentaron acidosis metabólica (66.7 %), coagulopatía aguda (44.4 %), hipotermia (41.5 %). El 30 % de los pacientes falleció precozmente. El árbol de decisión tuvo una sensibilidad de 82.3 %, una especificidad de 97.2 % y un porcentaje global de pronóstico correcto del 92.8 %. Se identificaron 4 variables predictores de mortalidad: hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante. Conclusiones: La probabilidad más alta de fallecer precozmente durante un trauma complejo hemorrágico se da entre pacientes con hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante.

ABSTRACT Background: Complex trauma is a worldwide health problem and when hemorrhagic, mortality is higher than other types of complex trauma. Objective: To determine predictive variables of early mortality in hospitalized patients with complex hemorrhagic trauma in a second care level hospital in Cuba. Methodology: A cross-sectional study was conducted at Camilo Cienfuegos Provincial General Hospital in Sancti Spíritus, for 6 years. 207 patients were included. The variables were grouped into sociodemographic, associated chronic diseases, injury mechanism, type of trauma, topographic location, time between hospital admission, diagnosis and treatment, early complications, medical and surgical treatment, and early mortality. A decision tree was developed using the exhaustive Chaid method, the dependent variable was mortality due to complex hemorrhagic trauma. Results: Male patients (85 %), 60 years and younger (83 %), with blunt trauma (57.5 %) and polytraumatized patients (42.5 %) predominated. Those who presented metabolic acidosis (66.7 %), acute coagulopathy (44.4 %), and hypothermia (41.5 %) also predominated. 30 % of patients died early. The decision tree had a sensitivity of 82.3 %, a specificity of 97.2 % and an overall percentage of correct forecast of 92.8 %. Four variables that predicted mortality were identified: hypothermia, metabolic acidosis, acute coagulopathy, and penetrating trauma. Conclusions: The highest probability of early dying during a complex hemorrhagic trauma occurs among patients with hypothermia, metabolic acidosis, acute coagulopathy and penetrating trauma.

Distal femoral fractures from high-energy trauma: a retrospective review of complication rate and risk factors / Fraturas distais do fêmur por trauma de alta energia: uma revisão retrospectiva da taxa de complicações e fatores de risco

ABSTRACT Objective Determine complications' incidence and risk factors in high-energy distal femur fractures fixed with a lateral locked plate. Methods Forty-seven patients were included; 87.2% were male, and the average age was 38.9. The main radiographic parameters collected were distal lateral femoral angle (DFA), distal posterior femoral angle (DPLF), comminution length, plate length, screw working length, bone loss, and medial contact after reduction and plate-bone contact, location of callus formation, and implant failure. The complications recorded were nonunion, implant failure, and infection. Results Complex C2 and C3 fractures accounted for 85.1% of cases. Open fractures accounted for 63.8% of cases. The mean AFDL and AFDP were 79.8 4.0 and 79.3 6.0, respectively. The average total proximal and distal working lengths were 133.3 42.7, 60.4 33.4, and 29.5 21.8 mm, respectively. The infection rate was 29.8%, and the only risk factor was open fracture (p = 0.005). The nonunion rate was 19.1%, with longer working length (p = 0.035) and higher PDFA (p = 0.001) as risk factors. The site of callus formation also influenced pseudoarthrosis (p = 0.034). Conclusion High-energy distal femoral fractures have a higher incidence of pseudoarthrosis and infection. Nonunion has greater working length, greater AFDL, and absence of callus formation on the medial and posterior sides as risk factors. The risk factor for infection was an open fracture. Level of Evidence III; Retrospective Cohort Study.

RESUMO Objetivos Determinar a incidência e os fatores de risco de complicações nas fraturas de alta energia das fraturas distais do fêmur fixadas com placa bloqueada lateral. Métodos Foram incluídos 47 pacientes, sendo 87,2% homens e idade média de 38,9 anos. Os principais parâmetros radiográficos coletados foram o ângulo femoral distal lateral (AFDL), ângulo femoral distal posterior (AFDP), comprimento da cominuição, comprimento da placa, comprimento de trabalho dos parafusos, perda óssea, contato medial após a redução e contato placa-osso, localização da formação do calo e falha do implante. As complicações registradas foram não união, falha do implante e infecção. Resultados Fraturas complexas C2 e C3 representaram 85,1% dos casos. As fraturas expostas corresponderam a 63,8% dos casos. O AFDL e AFDP médios foram 79,8° ± 4,0° e 79,3°± 6,0°, respectivamente. Os comprimentos de trabalho total, proximal e distal médios foram 133,3 ± 42,7, 60,4 ± 33,4 e 29,5 ± 21,8 mm, respectivamente. A taxa de infecção foi de 29,8% e o único fator de risco foi a fratura exposta (p = 0,005). A taxa de não união foi de 19,1%, com maior comprimento de trabalho (p = 0,035) e maior PDFA (p = 0,001) como fatores de risco. O local de formação do calo também influenciou na pseudoartrose (p = 0,034). Conclusões Fraturas distais do fêmur de alta energia apresentam maior incidência de pseudoartrose e infecção. A não união tem como fatores de risco maior comprimento de trabalho, maior AFDL e ausência de formação de calo nos lados medial e posterior. O fator de risco para infecção foi a fratura exposta. Nível de evidência III; Estudo de Coorte Retrospectivo.

El impacto de la inclusión de médicos en la atención prehospitalaria en el cuarto de shock del Hospital Vicente Corral Moscoso, Cuenca 2011-2012 / The impact of the inclusion of doctors in the pre-hospital care in the shock room of Hospital Vicente Corral Moscoso, Cuenca 2011-2012

Objetivo: Conocer el impacto de la inclu-sión de médicos en la atención pre hospitalaria en el cuarto de shock del Hospital Vicente Corral Moscoso (HVCM).Materiales y método: Se realizó un estudio descriptivo, la muestra fue de 288 pacien-tes atendidos en el cuarto de shock del HVCM durante seis meses en el 2011 (atención por personal de la Cruz Roja, Bomberos, etc.) y seis meses del 2012 (atención por parte de médicos del ECU911). El criterio de inclusión fue todo paciente con patología quirúrgica. Se analizaron las variables utilizando las frecuencias, porcentajes y chi cuadrado. Se empleó el programa SPSS versión 18 y Epidat 3.1.Resultados: La mortalidad del centro de trauma fue de 17%; el 14,6% falleció dentro de las primeras 24 horas. El mecanismo de trauma más frecuente fue accidentes de tránsito con el 42%. Las causas de atención fueron: TEC (trauma encéfalo craneal) con el 45,14%; trauma abdominal (8,33%); trauma de tórax (7,29%); otros con el 39,24% (politraumatizado, policontusión, abdomen agudo oclusivo, fracturas óseas, etc.). El 43,1% de los pacientes fueron atendidos en el año 2011 y el 56,9% en el 2012, observándose un incremento del 13,8% en relación al año 2012, tiempo en el que se implanto la atención pre hospitalaria medicalizada. La atención pre hospitalaria medicalizada no influyó de forma significativa en la mortalidad del centro de trauma con una p=0,5, aunque existió una disminución del 3%; no obstante, existe correlación con disminución en el tiempo de estancia hospitalaria en el cuarto de shock y su tratamiento resolutivo que se llevó a cabo con una p< 0,05.Conclusión: Ha disminuido el tiempo de estancia de los pacientes en el cuarto de shock y su tratamiento resolutivo al implementarse la atención pre hospitalaria por parte de médicos; no obstante, no se observó una disminución significativa de la mortalidad del cuarto de shock aunque ha existido una disminución del 3%.

Objective: To determine the impact of the physicians inclusion in the pre hospital care in the shock room in the Vicente Corral Moscoso Hospital (VCMH).Materials and Methods: A descriptive study was made, the sample consisted of 288 pa-tients treated at the shock of VCMH room for six months in 2011 (emergency medi-cal services, Fire department, etc.) and six months of 2012 (attention from ECU911doc-tors). The inclusion criterion was any patient with surgical pathology. The variables were analyzed using frequencies, percentages and chi square. SPSS version 18 and Epidat 3.1were used.Results: The mortality of trauma center was 17%; 14.6% died within the first 24 hours. The most common mechanism of trauma was traffic accidents with 42%. The cau-ses of attention were: CBT (cranial brain trauma) with 45.14%; abdominal trauma (8.33%); chest trauma (7.29%); others with the 39.24% (polytrauma, polycontusion, occlusive acute abdomen, bone fractures, etc.).The 43.1% of patients were treated in 2011 and 56.9% in 2012, with an increase of 13.8% compared to 2012, in that time the pre hos-pital care was inserted. The pre hospital care did not influence signi-ficantly in the mortality trauma center with a p = 0.5, although there was a decrease of 3%; however, there is correlation with a decrease in the length of hospital stay in the shock room and its operative treatment which was conducted with p <0.05.Conclusion: Decreased length of stay of patients in the shock room and operative treatment when the pre hospital care was implemented by physicians; however, a significant decrease in the mortality of the shock room was observed although there has been a decrease of 3%.

Choque neurogênico e posicionamento após trauma raquimedular / Neurogenic shock and positioning after spinal cord injury

A lesão raquimedular constitui consequência importante no cenário do trauma no Brasil. Sua incidência é desconhecida, porém estima-se que ocorram a cada ano no país mais de 10.000 novos casos.1 É importante que o anestesiologista esteja atento a essa enfermidade, incluindo não só o manejo anestésico como também suas inúmeras complicações. Trata--se de paciente de 31 anos, sexo feminino, vítima de trauma raquimedular (TRM) após acidente automobilístico (fratura de T2-T4 e fratura-luxação de T6-T7), além de fratura de arcos costais e de esterno e hemotórax bilateral drenado no atendimento inicial, sem evidências de contusão pulmonar. Admitida no centro cirúrgico para realização de artrodese de coluna torácica via posterior no quarto dia pós-trauma. Após monitorização e indução anestésica, a paciente foi posicionada em decúbito ventral e apresentou queda brusca e acentuada da pressão arterial média (PAM), não responsiva a doses crescentes de vasopressornoradrenalina. Optou-se pelo retorno da paciente para decúbito dorsal, com normalizacão do quadro hipotensivo após poucos minutos. O procedimento foi então suspenso, a paciente encaminhada à UTI e posteriormente realizado sem intercorrências após três semanas. Conclui-se que o conhecimento da história natural e evolução do TRM é muito importante para o manejo perioperatório, devendo ser escolhido o melhor momento para a intervenção cirúrgica. O diagnóstico diferencial entre as várias possíveis etiologias de choque que podem se apresentar nesses casos é fundamental para a boa evolução.

The rachis injury constitutes an important consequence in the scenario of trauma in Brazil. Its incidence is unknown, however, it is estimated that more than 10,000 new cases occur in the country each year.1 It is important that the anesthesiologist is aware of this disease not only forthe anesthetic management but to prevent its numerous complications too. This was a 31-year-old patient, female, victim of spinal cord injury (SCI) after a car accident (T2-T4 fracture and fracturedislocation of T6-T7), with ribs and sternum fracture, bilateral hemothorax drained in the initial attendance, and no evidence of pulmonary contusion. The patient was admitted to the surgical center for thoracic spine arthrodesis via posterior on the fourth day following the trauma. After monitoring and anesthetic induction, the patient was placed in ventral decubitus and presented sudden and sharp drop in the mean arterial pressure (MAP) becoming non-responsive to increasing doses of vasopressor noradrenaline. We opted for the return of the patient to the supine position, which normalized the hypotensive condition after a few minutes. The procedure was thensuspended; the patient was transferred to the ICU, and the procedure was subsequently performed without complications after three weeks. It is concluded that the knowledge on the natural history and evolution of the TRM is very important for the perioperative management; the best time forthe surgical intervention must be chosen. The differential diagnosis between the several possible etiologies of shock that can be presented in these cases is essential for a good case progression.

Fratura de pelve: um marcador de gravidade em trauma / Pelvic fractures as a marker of injury severity in trauma patients

OBJETIVO: avaliar se a presença de fratura de pelve é associada à maior gravidade e pior prognóstico em vítimas de trauma fechado. MÉTODOS: análise retrospectiva dos protocolos e prontuários das vítimas de trauma fechado admitidas de 10/06/2008 a 10/03/2009, separadas em dois grupos: com fratura de pelve (Grupo I) e os demais (Grupo II). Foram avaliados dados do pré-hospitalar e admissão, índices de trauma, exames complementares, lesões diagnosticadas, tratamento e evolução. Utilizamos os testes t de Student, Fisher e qui-quadrado na análise estatística, considerando p<0,05 como significativo. RESULTADOS: No período de estudo, 2019 politraumatizados tiveram protocolos preenchidos, sendo que 43 (2,1 por cento) apresentaram fratura de pelve. Os doentes do grupo I apresentaram, significativamente, menor média de pressão arterial sistêmica à admissão, maior média de frequência cardíaca à admissão, menor média da escala de coma de Glasgow, maior média nos AIS em segmentos cefálico, torácico, abdominal e extremidades, bem como, maior média do ISS e menor média de RTS e TRISS. O grupo I apresentou, com maior frequência, hemorragia subaracnoidea traumática (7 por cento vs. 1,6 por cento), trauma raquimedular (9 por cento vs. 1 por cento), lesões torácicas e abdominais, bem como necessidade de laparotomias (21 por cento vs. 1 por cento), drenagem de tórax (32 por cento vs. 2 por cento) e controle de danos (9 por cento vs. 0 por cento). As complicações foram mais frequentes no grupo I: SARA (9 por cento vs. 0 por cento), choque persistente (30 por cento vs. 1 por cento), coagulopatia (23 por cento vs. 1 por cento), insuficiência renal aguda (21 por cento vs. 0 por cento) e óbito (28 por cento vs. 2 por cento). CONCLUSÃO: a presença de fratura de pelve é um marcador de maior gravidade e pior prognóstico em vítimas de trauma fechado.

OBJECTIVE: To assess whether the presence of a pelvic fracture is associated with greater severity and worse prognosis in victims of blunt trauma. METHODS: A retrospective analysis of protocols and records of victims of blunt trauma admitted from June 2008 to March 2009 was separated into two groups: those with pelvic fracture (Group I) and those without it (Group II). Data were collected from pre-hospital admission rates of trauma, laboratory tests, diagnosed lesions, treatment and outcome. We used the Student t test, Fisher's exact test and chi-square test for statistical analysis, considering p <0.05 as significant. RESULTS: During the study period, 2019 individuals had multiple trauma protocols completed, of which 43 (2.1 percent) had pelvic fractures. Patients in Group I had significantly lower average blood pressure, higher mean heart rate, lower mean Glasgow Coma Scale, the highest average AIS in the segments head, chest, abdomen and extremities, as well as higher mean ISS and lower mean TRISS and RTS on admission. Group I more frequently presented with traumatic subarachnoid hemorrhage (7 percent vs. 1.6 percent), spinal cord injury (9 percent vs. 1 percent), thoracic and abdominal injuries, as well as need for laparotomy (21 percent vs. 1 percent), chest drainage (32 percent vs. 2 percent) and damage control (9 percent vs. 0 percent). Complications were more frequent in group I: ARDS (9 percent vs. 0 percent), persistent shock (30 percent vs. 1 percent), coagulopathy (23 percent vs. 1 percent), acute renal failure (21 percent vs. 0 percent) and death (28 percent vs. 2 percent). CONCLUSION: The presence of a pelvic fracture is a marker of greater severity and worse prognosis in victims of blunt trauma.