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.

Predictors for prognosis of adult patients with acute traumatic shock / 中华创伤杂志

Objective:To analyze the predictive factors for prognosis of adult patients with acute traumatic shock.Methods:A retrospective cohort study was used to analyze the clinical data of 122 adult patients with acute traumatic shock treated in ICU of Second People′s Hospital of Liaocheng from July 2013 to September 2021. There were 90 males and 32 females with the age range of 18-83 years [(49.8±16.9)years]. Injury severity score (ISS) was 14-50 points [(28.6±6.3)points]. According to the prognosis, the patients were divided into good prognosis group ( n=48) and poor prognosis group ( n=74). The gender, age, and leukocyte count, neutrophil count, lymphocyte count, platelet count, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), D-dimer, lactic acid, ISS and shock index (SI) on emergency admission were compared between the two groups. Univariate stepwise regression analysis and multivariate Logistic regression analysis were used to screen the indicators affecting the prognosis of patients with acute traumatic shock. Predictive value of the indicators affecting patients′ prognosis were analyzed by receiver operating characteristic (ROC) curve, and the area under the curve (AUC), sensitivity, specificity and optimal cut-off value were calculated. The indicators affecting the prognosis were analyzed by stratification analysis. Results:There was no significant difference between the two groups in gender, platelet count, D-dimer, ISS and SI (all P>0.05). The age, lymphocyte count and lactate level in poor prognosis group were higher than those in good prognosis group, while the leukocyte count, neutrophil count, NLR and PLR in poor prognosis group were lower than those in good prognosis group (all P<0.01). Univariate stepwise regression analysis showed that age and NLR were related to the prognosis of patients with acute traumatic shock (all P<0.01). While the gender, leukocyte count, neutrophil count, platelet count, PLR, D-dimer, lactic acid, ISS and SI had no correlation with the prognosis (all P>0.05). Multivariate Logistic regression analysis showed that age ( OR=0.96, 95% CI 0.93-0.98) and NLR ( OR=1.19, 95% CI 1.10-1.29) were the affecting factors for prognosis of patients with acute traumatic shock. ROC analysis showed the AUC of age for 0.32 (95% CI 0.22-0.41) together with the optimal cut-off value predicting prognosis for 48.5 years (sensitivity 68.9%, specificity 64.6%), the AUC of NLR for 0.79 (95% CI 0.71-0.90) together with the optimal cut-off value predicting prognosis for 6.51 (sensitivity 77.1%, specificity 71.6%). Stratified analysis showed that the proportion of patients in poor prognosis group was increased gradually with the increase of age ( P<0.01), while that was decreased significantly with the increase of NLR level ( P<0.01). Conclusions:Age and level of NLR on emergency admission can predict the prognosis of adult patients with acute traumatic shock, with the best cut-off value of 48.5 years and 0.79. Moreover, advanced age and lower level of NLR indicate much poorer prognosis.

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.

Resuscitation aortic balloon occlusion and resuscitation thoracotomy in the treatment of non- compressible torso hemorrhage: a Meta-analysis / 中华创伤杂志

Objective:To systematically compare the prognosis in non-compressible torso hemorrhage（NCTH）treated by resuscitative endovascular balloon occlusion of the aorta（REBOA）and resuscitation thoracotomy（RT）.Methods:Data were searched form MEDLINE, EMBASE, PubMed, WanFang, CNKI and VIP databases to collect studies on the prognosis of patients with NCTH undergone REBOA and RT from inception to December 2020. Two reviewers independently screened studies according to the inclusion and exclusion criteria, extracted data and evaluated the quality of the included studies. The Meta-analysis was performed using Revman 5.3. The patients were divided into REBOA group and RT group according to the different surgical treatment methods on admission, and the prognosis of each group was evaluated. The difference of mortality rate, reoperation rate of laparotomy after operation, reoperation rate of embolization after operation and mortality rate in different operating room area were compared between the two groups. Publication bias was assessed using the Egger test.Results:A total of 2 prospective studies and 4 retrospective studies involving 2, 588 subjects were included. There were 1, 591 patients in REBOA group and 997 patients in RT group. Significant differences were observed in the mortality rate（ I2=68%, OR=0.33, 95% CI 0.26-0.42, P<0.01）, reoperation rate of laparotomy after operation（ I2=76%, OR=1.41, 95% CI 1.11-1.77, P<0.01）and reoperation rate of embolization after operation（ I2=84%, OR=0.76, 95% CI 0.59-0.99, P<0.05）between REBOA group and RT group. Subgroup analysis showed that the mortality rate in the ICU were not statistically different between the two groups（ I2=83%, OR=0.69, 95% CI 0.45-1.05, P>0.05）, but the mortality rate in the emergency room was lower in REBOA group than that in RT group（ I2=94%, OR=0.52, 95% CI 0.38-0.70, P<0.01）. Egger test showed that publication bias had little effect on the results. Conclusions:For patients with NCTH, REBOA can reduce the mortality rate and reoperation rate of embolization after operation, but increase the reoperation rate of laparotomy after operation when compared with RT. In addition, the emergency room may be a more suitable operationg room area for REBOA.

Effects of fluid resuscitation under pulse-indicated continuous cardiac output monitoring on endothelial function, inflammatory indexes and hemodynamics in patients with traumatic shock / 中国基层医药

Objective:To investigate the effects of fluid resuscitation under pulse-indicated continuous cardiac output monitoring on endothelial function, inflammatory indexes and hemodynamics in patients with traumatic shock.Methods:The clinical data of 62 patients with traumatic shock who received treatment in the First Affiliated Hospital of Zhejiang Chinese Medical University, China between July 2019 and July 2020 were retrospectively analyzed. These patients were divided into observation and control groups ( n = 31/group) according to different fluid resuscitation methods. The control group was given conventional fluid resuscitation and the observation group was subjected to guided fluid resuscitation under pulse-indicated continuous cardiac output monitoring. General treatment and nitric oxide, endothelin-1, C-reactive protein, interleukin-6, interleukin-1β, tumor necrosis factor-α, central venous pressure, mean arterial pressure, and central venous oxygen saturation before and 24 hours after treatment as well as complications were compared between the two groups. Results:Time to early resuscitation, duration of mechanical ventilation, intensive care unit length of stay and the length of hospital stay in the observation group were (5.33 ± 0.51) hours, (37.45 ± 4.84) hours, (8.75 ± 1.20) days, (16.85 ± 2.03) days, respectively, which were significantly shorter than those in the control group [(8.14 ± 1.20) hours, (46.06 ± 4.71) hours, (11.46 ± 1.63) days, (20.01 ± 2.41) days, t = 11.999, 7.098, 7.455, 5.584, all P < 0.01). At 24 hours after treatment, serum level of nitric oxide in the observation group was significantly higher than that in the control group [(52.04 ± 3.91) μmol/L vs. (40.25 ± 4.25) μmol/L, t = 11.367, P < 0.01]. Serum level of endothelin-1 in the observation group was significantly lower than that in the control group [(66.95 ± 4.75) ng/L vs. (78.04 ± 7.92) ng/L, t = 6.686, P < 0.01)]. Serum levels of C-reactive protein, interleukin-6, interleukin-1β, tumor necrosis factor-α in the observation group were (8.32 ± 1.56) mg/L, (113.03 ± 15.74) ng/L, (69.82 ± 6.50) ng/L, (42.80 ± 4.32) ng/L, respectively, which were significantly lower than those in the control group [(11.61 ± 1.74) mg/L, (130.42 ± 20.68) ng/L, (81.33 ± 7.30) ng/L, (56.11 ± 6.36) ng/L, t = 7.838, 3.726, 6.556, 9.639, all P < 0.01)]. Mean arterial pressure, central venous pressure and central venous oxygen saturation in the observation group were (76.64 ± 5.05) mmHg, (10.79 ± 0.53) mmHg, (79.93 ± 5.04) %, respectively, which were significantly higher than those in the control group [(70.32 ± 4.31) mmHg, (9.50 ± 0.62) mmHg, (73.40 ± 4.76) %, t = 5.300, 8.806, 5.245, all P < 0.01]. The incidence of complications in the observation group was significantly lower than that in the control group [9.68% (10/31) vs. 32.26% (8/31), χ2 = 4.769, P < 0.05]. Conclusion:Fluid resuscitation under pulse-indicated continuous cardiac output monitoring has an obvious effect traumatic shock, which can improve vascular endothelial function, inflammatory index and hemodynamic index, and is worthy of popularization and application.

Effect of trauma control concept on severe multiple injuries / 中国基层医药

Objective To explore the effect of trauma control concept on severe multiple injuries.Methods From March 2016 to March 2018,74 emergency patients with severe multiple injuries were selected in Yiwu Central Hospital.The patients were divided into the observation group and the control group according to the digital table method,with 37 cases in each group.The control group was treated with one-time surgical treatment,and the observation group was given treatment measures for severe multiple trauma in emergency department under the concept of trauma control.The recovery time of body temperature,the recovery time of prothrombin (PT),the time of shock correction,the occurrence of complications,and the therapeutic effect were compared between the two groups.Results The body temperature recovery time,PT recovery time and shock correction time in the observation group were (6.73 ± 3.29) h,(5.18 ± 1.89) h and (5.84 ± 3.14) h,respectively,which were shorter than those in the control group [(9.85 ± 1.62) h,(9.86 ± 2.41) h,(8.45 ± 0.87) h],and the differences were statistically significant (t =5.175,9.295,4.873,all P ＜0.05).The incidence rate of complications in the observation group was 8.11％ (3/37),which was lower than that in the control group [32.43％ (12/37)],the difference was statistically significant(x2 =6.773,P ＜ 0.05).The cure rate of the observation group was 97.30％ (36/37),which was higher than that of the control group [91.89％ (34/37)],but there was no statistically significant difference (P ＞ 0.05).Conclusion The treatment effect of severe multiple injuries under the concept of trauma control is obvious.It is an effective and feasible method,which can effectively reduce the complications and fatality rate.

The safety and efficacy of fluid resuscitation with hypertonic saline in traumatic hypovolemic shock:a meta-analysis / 中国医师杂志

Objective To assess the safety and efficacy of hypertonic saline in traumatic hypovolemic shock with Meta-analysis.Methods Comprehensive electronic search strategies were developed using the following electronic databases:PubMed,EMBASE,Medline,Ovid、Clinical Trials,CNKI,Wan Fang,CBM and FMJS.The Literature published before August of 2017 was searched.The randomized controlled trials (RCTs) about hypertonic saline in traumatic hypovolemic shock were included.A data-extraction sheet was developed based on the preset standards.The data from eligible studies were pooled through Meta-analysis.Results 9 trials with a total of 1600 patients (741cases in observation group,859 cases in control group) met the inclusion criteria.The meta-analysis showed that the hypertonic saline group displayed remarkable increase in the systolic blood pressure and decrease in hemoglobin level,compared with the isotonic saline group [MD =6.43,95％ CI(1.16,11.70),P ＜0.05],[MD =-5.99,95％ CI (-9.04,-2.95),P ＜0.05].The level of serum sodium [MD =7.94,95％ CI(7.39,8.50),P ＜0.05],serum chloride [MD =9.67,95 ％ CI(8.77,10.57),P ＜ 0.05] and osmolality [MD =18.11,95％ CI (10.73,25.49),P ＜ 0.05] in the hypertonic saline group was increased significantly but acceptable.No significant difference in mortality was found between the hypertonic saline group and the isotonic saline group [OR =0.88,95％ CI(0.69,1.11),P ＞ 0.05].Conclusions Available evidence shows that small volume hypertonic Sodium Chloride saline is safe and effective for resuscitation in patients with traumatic hemorrhagic shock.Since the quality of the inclued studes were not high,more high-quality,multicenter randomized controlled clinical studies need to provide better evidence for the above conclusion.

Effects of application of pulse contour cardiac output monitoring technology in early treatment of patients with large area burns / 中华烧伤杂志

Objective@#To analyze the changes and relationship of early hemodynamic indexes of patients with large area burns monitored by pulse contour cardiac output (PiCCO) monitoring technology, so as to assess the guiding value of this technology in the treatment of patients with large area burns during shock period.@*Methods@#Eighteen patients with large area burns, confirming to the study criteria, were admitted to our unit from May 2016 to May 2017. Pulse contour cardiac output index (PCCI), systemic vascular resistance index (SVRI), global end-diastolic volume index (GEDVI), and extravascular lung water index (EVLWI) of patients were monitored by PiCCO instrument from admission to post injury day (PID) 7, and they were calibrated and recorded once every four hours. The fluid infusion coefficients of patients at the first and second 24 hours post injury were calculated. The blood lactic acid values of patients from PID 1 to 7 were also recorded. The correlations among PCCI, SVRI, and GEDVI as well as the correlation between SVRI and blood lactic acid of these 18 patients were analyzed. Prognosis of patients were recorded. Data were processed with one-way analysis of variance, single sample ttest and Bonferroni correction, Pearson correlation analysis, and Spearman rank correlation analysis.@*Results@#(1) There was statistically significant difference in PCCI value of patients from post injury hour (PIH) 4 to 168 (F=7.428, P<0.01). The PCCI values of patients at PIH 4, 8, 12, 16, 20, and 24 were (2.4±0.9), (2.6±1.2), (2.2±0.6), (2.6±0.7), (2.8±0.6), and (2.7±0.7) L·min-1·m-2, respectively, and they were significantly lower than the normal value 4 L·min-1·m-2(t=-3.143, -3.251, -11.511, -8.889, -6.735, -6.976, P<0.05 or P<0.01). At PIH 76, 80, 84, 88, 92, and 96, the PCCI values of patients were (4.9±1.5), (5.7±2.0), (5.9±1.7), (5.5±1.3), (5.3±1.1), and (4.9±1.4) L·min-1·m-2, respectively, and they were significantly higher than the normal value (t=2.277, 3.142, 4.050, 4.111, 4.128, 2.423, P<0.05 or P<0.01). The PCCI values of patients at other time points were close to normal value (P>0.05). (2) There was statistically significant difference in SVRI value of patients from PIH 4 to 168 (F=7.863, P<0.01). The SVRI values of patients at PIH 12, 16, 20, 24, and 28 were (2 298±747), (2 581±498), (2 705±780), (2 773±669), and (3 109±1 215) dyn·s·cm-5·m2, respectively, and they were significantly higher than the normal value 2 050 dyn·s·cm-5·m2(t=0.878, 3.370, 2.519, 3.747, 3.144, P<0.05 or P<0.01). At PIH 4, 8, 72, 76, 80, 84, 88, 92, and 96, the SVRI values of patients were (1 632±129), (2 012±896), (1 381±503), (1 180±378), (1 259±400), (1 376±483), (1 329±385), (1 410±370), and (1 346±346) dyn·s·cm-5·m2, respectively, and they were significantly lower than the normal value (t=-4.593, -0.112, -5.157, -8.905, -7.914, -5.226, -6.756, -6.233, -7.038, P<0.01). The SVRI values of patients at other time points were close to normal value (P>0.05). (3) There was no statistically significant difference in the GEDVI values of patients from PIH 4 to 168 (F=0.704, P>0.05). The GEDVI values of patients at PIH 8, 12, 16, 20, and 24 were significantly lower than normal value (t=-3.112, -3.554, -2.969, -2.450, -2.476, P<0.05). The GEDVI values of patients at other time points were close to normal value (P>0.05). (4) There was statistically significant difference in EVLWI value of patients from PIH 4 to 168 (F=1.859, P<0.01). The EVLWI values of patients at PIH 16, 20, 24, 28, 32, 36, and 40 were significantly higher than normal value (t=4.386, 3.335, 6.363, 4.391, 7.513, 5.392, 5.642, P<0.01). The EVLWI values of patients at other time points were close to normal value (P>0.05). (5) The fluid infusion coefficients of patients at the first and second 24 hours post injury were 1.90 and 1.39, respectively. The blood lactic acid values of patients from PID 1 to 7 were 7.99, 5.21, 4.57, 4.26, 2.54, 3.13, and 3.20 mmol/L, respectively, showing a declined tendency. (6) There was obvious negative correlation between PCCI and SVRI (r=-0.528, P<0.01). There was obvious positive correlation between GEDVI and PCCI (r=0.577, P<0.01). There was no obvious correlation between GEDVI and SVRI (r=0.081, P>0.05). There was obvious positive correlation between blood lactic acid and SVRI (r=0.878, P<0.01). (7) All patients were cured except the one who abandoned treatment.@*Conclusions@#PiCCO monitoring technology can monitor the changes of early hemodynamic indexes and volume of burn patients dynamically, continuously, and conveniently, and provide valuable reference for early-stage comprehensive treatment like anti-shock of patients with large area burns.

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.

A massive transfusion protocol for the abdominal surgical patients with traumatic shock / 中华普通外科杂志

Objective To investigate the clinical value of the massive transfusion protocols (MTP) in abdominal surgical patients with traumatic shock.Methods An analysis was made on the clinical data of patients before and after the use of MTP,including the general condition,amount of blood transfusion,transfusion components and ratio,blood and coagulation function test,and blood transfusion related complications and mortality.Results Before implement of MTP,the average RBC transfusion in the first 24 hours was 19.5U,FFBwas 12.6U,and the ratio ofRBC ∶ FFB was 1.55 ∶ 1.After implement of MTP,the average RBC transfusion in the first 24 hours was 17.3 U,and the ratio of RBC:FFB was 1 ∶ 1.There were no significant statistical differences between the two groups about PT,APTT,Hb and PLT on admission.After 24 hours of admission,there was no significant difference in Hb between the two groups,there were significant differences of PT,APTT and PLT.Blood transfusion related complications were 11 (14.9％) in control group and 7 (11.9％) in MTP,group,and the mortality was 9.46％ and 6.78％ respectively.Conclusions MTP improves blood coagulation function,reduces blood transfusion and enhances survival rate of abdominal surgical patients with traumatic shock.

Effect of baicalin on inflammatory factors and oxygen free radical metabolism in patients with traumatic shock / 中国基层医药

Objective To investigate the effect of baicalin on inflammatory factors and oxygen free radical metabolism in patients with traumatic shock.Methods 38 patients with traumatic shock were treated with baicalin 200mg intravenous injection when admitted to hospital.Before and 1 h after treatment,TNF-α,IL-6,IL-8,MDA and SOD were measured in blood.Results Compared with before treatment,TNF-,IL-6,IL-8,and MDA levels were decreased after treatment (t =7.32,6.12,20.21,16.10,all P ＜ 0.05),while SOD activity was significantly increased (t =1.69,P ＜ 0.01).Conclusion Baicalin could inhibit the production and release of inflammatory factors TNF-α,IL-6,IL-8 in patients with traumatic shock,reduce the damage of oxygen free radicals to the cells.Early treatment with baicalin had protective effect on patients with traumatic shock.

The clinical comparative analysis of traditional rehydration and sub-shock therapy for pre-hospital emergency treatment of traumatic shock / 中国医师进修杂志

Objective To investigate the clinical effects of the traditional rehydration and sub-shock therapy for pre-hospital treatment of traumatic shock.Methods Two hundred and sixteen patients with traumatic shock,were divided into two groups by random digits table:group A (103 cases) and group B (113cases).Group A was treated by traditional rehydration method,group B was treated by sub-shock therapy.The mortality,incidence of serious complications,and laboratory parameters between two groups were compared.Results The total mortality in group A was significantly higher than that in group B [38.8％ (40/103) vs.25.7％ (29/113),P ＜ 0.01].There was no statistically significant difference in ＜ 1 h,＞ 2 h mortality between two groups (P＞ 0.05).The 1-2 h mortality in group A was significantly higher than that in group B [18.4％(19/103) vs.8.0％(9/113),P ＜ 0.05].The incidence of serious complications in group A was significantly higher than that in group B [41.7％ (43/103) vs.21.2％ (24/113),P ＜ 0.01].Treatment of 1 h various laboratory parameters in group B were significantly better than those in group A (P ＜ 0.01 or ＜0.05).The average amount of fluid in group A was significantly more than that in group B [(2352.6 ± 763.1)ml vs.(592.4 ±236.3) ml,P ＜0.01].There was no statistically significant difference in systolic blood pressure between two groups (P ＞ 0.05).Conclusions Sub-shock therapy in pre-hospital emergency treatment of traumatic shock has some advantages compared with traditional rehydration method,which is conductive to the maintenance of the patient' s vital signs,to reduce bleeding and improve patient treatment rate.

Features and prevention of complications after severe traumatic hemorrhagic shock in plateau / 中华创伤杂志

Objective To investigate the features and prevention measures of complications secondary to severe traumatic hemorrhagic shock (THS) of different crowds in plateau (3 658 meters above the sea level).Methods A retrospective study was conducted on 591 severe THS patients undergone traditional resuscitation (traditional resuscitation group,n =103) from October 1976 to October 1990 and integrated treatment (integrated treatment group,n =488) from October 1991 to October 2012.The patients included native Tibetans,Han immigrants in plateau (≥ 3 months) and Han people who entered plateau rapidly (＜ 7 days).Outcome of the two treatments was compared.Results With regard to the traditional resuscitation group,native Tibetans sustained the main complications including stress ulcer (n =2),pulmonary edema (n =1),MODS (n =3) and death (n =3) ； Han immigrants in plateau sustained the main complications including stress ulcer (n =9),pulmonary edema (n =8),ARDS (n =3),cerebral edema (n =1),acute renal failure (n =3),disseminated intravascular coagulation (DIC) (n =2),MODS (n =13) and death (n =11)； Han people who entered plateau rapidly sustained the main complications including stress ulcer (n =5),pulmonary edema (n =4),ARDS (n =4),cerebral edema (n =2),acute renal failure (n =3),DIC (n =2),MODS (n =6) and death (n =4).Whereas in contrast to the relevant patient crowds in the traditional resuscitation group,the native Tibetans,Han immigrants in plateau and Han people who entered plateau rapidly presented significant reduction of complication rate and mortality rate in the integrated treatment group.Conclusions (1) Traditional resuscitation for severe THS patients in plateau results in much more complications with quick occurrence,high incidence,rapid progression,high severity and high mortality.Moreover,the complications are more severe in Han people who entered plateau rapidly than in the Han immigrants in plateau and native Tibetans.(2) The incidence of complications and death rate are significantly reduced after integrated treatment.(3) Han people who entered plateau rapidly present larger dependence on integrated treatment than the Han immigrants in plateau and native Tibetans.

Change of Th17/Treg ratio in peripheral blood and its clinical significance in patients with traumatic sepsis / 中华创伤杂志

ObjectiveTo investigate changes of Th17/Treg ratio in peripheral blood of patients with traumatic sepsis and discuss the underlying clinical significance.MethodsThrity-five multi-trauma patients enrolled in the study were divided into trauma group (n =22) and sepsis group (n =13 ).Another nine healthy volunteers were designed as the control group.Peripheral blood was collected from all the groups so as to determine the ratios of Th17 and Treg by flow cytometry,detect the mRNA expressions of RORγt and FoxP3 by real time fluorescence quantitative PCR and measure serum levels of IL-4,IL-6,IL-10,IL-17A,IL-23,transforming growth factor-β (TGF-β),interferon-γ (IFN-γ) and C-reaction protein (CRP) by ELISA.Further,the change of Th17/Treg ratio and its clinical significance were analyzed.ResultsThe proportion of Th17 in the trauma group showed no significant difference with that in the control group, whereas the ratio of Th17/Treg was lower than that in the control group (P ＜ 0.05).The proportion of Th17 and ratio of Th17/Treg in the sepsis group were higher than those in the trauma group and control group (P ＜ 0.01 ).Serum concentrations of TGF-β,IL-6 and IL-23 in the sepsis group were all significantly higher than those in the control group ( P ＜ 0.01 ).Serum levels of TGF-β had no significant difference between the sepsis group and the trauma group,while serum concentrations of IL-6 and IL-23 in the sepsis group were higher than those in the trauma group ( P ＜ 0.01 ).Serum level of IL-17A and mRNA expression of RORγt in the sepsis group were higher than those in the trauma and control groups ( both P ＜ 0.01 ).ConclusionTh17/Treg imbalance is closely correlated with the development of sepsis in patients with severe trauma.

Protective effect of penehyclidine hydrochloride on secondary lung injury after traumatic shock in rats / 中华创伤杂志

Objective To observe the interfering effect of different doses of penehyclidine hydrochloride (PHC) on the mRNA expressions of nuclear factor kappa B (NF-κB) and inducible nitric oxide synthase (iNOS) in the lung tissue of rats with traumatic shock so as to investigate the protective role of PHC in secondary long injury following traumatic shock and the underlying mechanism.Methods The traumatic shock model was established.A total of 104 Wistar rats were randomly divided into four groups:control group,shock group,low dose PHC group ( P1 group) and high dose PHC group ( P2 group).At the beginning of resuscitation,the rats in P1 and P2 groups were given transjugular intravenous injection of 2 ml/kg isotonic saline containing 0.15 mg/kg and 0- 45 mg/kg PHC respectively,while the rats in shock and control groups were injected only isometric isotonic saline.The rats in the four groups were killed at 2 h,6 h,12 h and 24 h after resuscitation respectively to detect the mRNA expressions of NF-κB and iNOS by using RT-PCR and determine the lung wet/dry weight (W/D) ratio,lung permeability index (LPI) and lung injury score (LIS).Results The mRNA expressions of NF-κB and iNOS,lung W/D ratio,LPI and LIS at all the time intervals in the shock,P1 and P2 groups were all significantly increased as compared with those in the control group (P＜0.05).Howerver,the P2 group showed significant reduction in aspects of the mRNA expressions of NF- κB and iNOS,lung W/D ratio,LPI and LIS at all time points and P1 group also had significant decrease regarding the mRNA expressions of NF-κB and iNOS,lung W/D ratio at2 h,6 h,and LPI and LIS at 2 h,6 h,12 h,as compared with the shock group.Meanwhile,P2 group showed evident decrease at 6 h concerning the mRNA expressions of NF-κB and iNOS,lung W/D ratio,LPI and LIS as compared with P1 group (P ＜ 0.05 ).Conclusions PHC,especially at a large dosage,can significantly mitigate the long injury secondary to traumatic shock,and the mechanism may be associated with the inhibition of mRNA expressions of NF-κB and iNOS.

Establishment of rat model of traumatic brain injury combined with hemorrhagic shock / 中华创伤杂志

ObjectiveTo establish rat model of traumatic brain injury combined with hemorrhagic shock.Methods Rat models of traumatic brain injury (produced by free fall impact method) combined with hemorrhagic shock (produced by venous injury method) were established and the related physiological parameters were recorded.The neurological impairment score,cerebral edema degree and blood brain barrier (BBB) were determined by using neurofunction scales,dry-wet method and Evans blue (EB) respectively.HE staining and immunohistochemical staining were applied to evaluate the pathological changes in brain sections.ResultsBlood pressure dropped from 95 mm Hg to 25 mm Hg within three minutes after modeling and maintained around 60 mm Hg one hour later.Neurological impairment score was increased dramatically.The ratio of water content in the brain tissue was elevated nearly from 77％ to 81％.The concentration of EB residual in the brain tissue was increased more than one fold.Neuronal pathological abnormalities,including neuron shrinking,dark eosinophilic staining,perineuronal vacuole in HE staining,and positive staining of β-amyloid precursor protein (β-APP) in immunohistochemical staining were also observed. ConclusionsRat models of traumatic brain injury combined with hemorrhagic shock are successfully established.In addition,the main pathological changes,such as cerebral edema,disruption of BBB,neuron damage,and expression of β-APP are replicated.

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.

Effects of ω-3 polyunsaturated fotty acid preconditioning on liver injury in a rat model of traumatic shock / 中华麻醉学杂志

ObjectiveTo investigate the effects of ω-3 polyunsaturated fatty acid (PUFA) preconditioning on liver injury in a rat model of traumatic shock.MethodsForty-eight male Wistar rats aged 3 months weighing 240-260 g were randomly divided into 4 groups ( n =12 each): sham operation group (group S) ; group S + ω-3 PUFA; traumatic shock group (group TS) and group TS + ω-3 PUFA.In groups S + ω-3 PUFA and group TS + ω-3 PUFA,ω-3 PUFA 2 ml/kg was injected via the caudal vein at 12 and 2 h before induction of traumatic shock.In groups S and TS,normal saline was given instead of ω-3 PUFA.Traumatic shock was induced by fracture of femur and hemorrhage in groups TS and TS + ω-3 PUFA.The arterial blood samples were taken at 2 h after induction of traumatic shock for determination of serum activities of ALT,AST and concentrations of 8-iso-prostagiandin F2,(8-iso-PGF2α) and TNF-α.The liver was removed for determination of levels of SOD and MDA,glutathione (GSH)and microscopic examination.ResultsCompared with group S,the serum ALT,AST,8-iso-PGF2α and TNF-α levels and MDA content in the liver tissues and score of liver injury were significantly increased,but the liver tissues levels of SOD,GSH were decreased in groups TS and TS + ω-3 PUFA( P ＜ 0.01 ).Compared with group TS,the serum ALT,AST,8-iso-PGF2α and TNF-α levels and MDA content in the liver tissues and score of liver injury were significantly decreased,but SOD activity and GSH content in the liver tissues were increased in group TS + ω-3 PUFA( P ＜ 0.05 or 0.01 ).Conclusionω-3 PUFA preconditioning can reduced liver injury in a rat model of traumatic shock through inhibiting lipid peroxidation and inflammatory reaction.

Protective mechanisms of glycine against the secondary liver injury of rats after taumatic shock / 中华创伤杂志

Objective To investigate the effects of glycine on the expression of HSP70 and TNF-α mRNA in the liver tissue of rats with traumatic shock and explore the protective mechanism of glycine a-gainst secondary liver injury after traumatic shock. Methods The traumatic shock model was established and 120 Wistar rats were divided randomly into three groups: treatment group, shock group and control group. At the beginning of resuscitation, the rats in the treatment were injected with 0.5 ml isotonic saline containing 100 mg/kg glycine, those rats in the shock group were injected only with 0.5 ml isotonic saline. The rats in three groups were killed at 3, 6, 12, 24 and 48 hours after resuscitation respectively. The ex-pression of HSP70 and TNF-α mRNA in the liver tissue were detected by RT-PCR, pathological changes were observed and serum ALT and AST were measured. Results The expressions of HSP70 and TNF-α mRNA in the liver tissue of rats in the shock group began to increase at 3 hours and both reached the peak value at 6 hours after resuscitation, but the expression of HSP70 mRNA in the treatment group reached the peak value at 12 hours after resuscitation. Compared with the control group, the expression of HSP70 mR-NA in the treatment group increased significantly and that of TNF-α mRNA decreased siganicantly, serum ALT and AST decreased and pathological damage was relieved significantly (all P < 0.05). Conclusion By enhancing the expression of HSP70 mRNA and decreasing the expression of TNF-α mRNA, glycine may play a protective role against the secondary damage of liver after traumatic shock.

Rotura de válvula tricúspide con insuficiencia masiva secundaria a traumatismo torácico cerrado: caso clínico / Massive tricuspid valve insufficiency after blunt chest trauma: report of one case

Cardiac valve lesions after a blunt chest trauma are rare and less than 1 percent of cardiac lesions because of chest trauma affect the tricuspid valve. We report a 70 year-old female that suffered a severe chest trauma in a car accident. Duríng the repair of the múltiple skeletal lesions, the patient had a severe hemodynamic decompensation. A myocardial trauma with pericardial effusion and massive tricuspid insufficiency, due to anterior leaflet prolapse, was diagnosed on echocardiography. After discharge the patient remained in functional class II, with hepatomegaly, jugular ingurgitation and lower limb edema. A control echocardiogram, perfomed six months after the accident, showed dilatation of right heart chambers and massive tricuspid insufficiency. The patient was operated, and a tricuspid valve repair was performed suturing the ruptured papillary muscle to the ventricular wall and performing a triscuspid annuloplasty with a prosthetic ring. After 15 months of follow up, the patient remains asymptomatic.