Traumatismo de grandes vasos del tórax: tratamiento quirúrgico con soporte de circulación extracorpórea / Injury of the great vessels of the chest: surgical treatment with cardiopulmonary bypass support: clinical cases

Resumen Objetivo: Presentar dos casos en que se empleó como soporte la circulación extracorpórea (CEC) durante cirugía por traumatismo torácico con lesión de grandes vasos del tórax (TTLGV). Materiales y Método: Se presentan dos casos con TTLGV en que se empleó cirugía con CEC. Resultados: Caso 1; hombre de 31 años con TTLGV por cuerpo extraño (tubo pleural) intracavitario del tronco de la arteria pulmonar izquierda, con entrada a través de parénquima pulmonar, en que se realizó cirugía abierta para retiro de cuerpo extraño más toractotomía pulmonar utilizando CEC como soporte. Caso 2; hombre de 21 años con TTLGV contuso y lesión de aorta en unión sino tubular, en que se realizó cirugía abierta y reemplazo de aorta ascendente con prótesis y uso CEC como soporte. Discusión: El uso de CEC como soporte es una alternativa para sustituir la función cardíaca y/o pulmonar durante cirugías excepcionales de reparación de TTLGV. Conclusión: El uso de técnicas de asistencia circulatoria como soporte durante la cirugía de reparación de TTLGV ocurre en casos muy seleccionados, siendo una alternativa ante lesiones particularmente complejas.

Aim: To present two cases of thoracic trauma with great vessel injury (TTGVI) surgeries where extracorporeal circulation (ECC) was employed. Materials and Method: Two TTGVI cases are presented and ECC during surgery was used in both. Results: Case 1; 31-year-old man with TTGVI due to an intracavitary foreign body (pleural tube) in the left pulmonary artery trunk, which entered through lung parenchyma. An open surgery was performed to remove the foreign body with pulmonary tractotomy using ECC as support. Case 2; 21-year-old man with blunt TTGVI and aortic injury at sinotubular junction. An open surgery with ascending aorta prosthesis replacement was performed, using ECC as support. Discussion: The use of ECC as support is an alternative to replace cardiac and/or pulmonary function during exceptional TTGVI reparation surgeries. Conclusión: The use of circulation assist techniques as support during TTGVI repair surgery occurs in highly selected cases, being an alternative to face very complex injuries.

Terapia endovascular en trauma periférico: una alternativa a la cirugía abierta tradicional / Endovascular therapy in peripheral trauma: our experience

Resumen Introducción: La terapia endovascular ha demostrado ser una buena alternativa de tratamiento en las enfermedades arteriales y venosas. Asimismo, en trauma vascular periférico constituye una excelente opción, especialmente en sitios anatómicos difíciles de acceder y con lesiones complejas como seudoaneurismas, fístulas arteriovenosas (FAV) o la combinación de ambos, con numerosas ventajas. Objetivo: Evaluar los resultados del tratamiento endovascular en trauma vascular penetrante por agresiones y iatrogenias. Materiales y Método: Revisión retrospectiva de todos los pacientes con trauma vascular periférico sometidos a terapia endovascular. Resultados: Entre abril de 2011 y mayo de 2020 se trataron 30 pacientes, 28 hombres y 2 mujeres. Con edades fluctuantes entre 17 y 84 años. La causa del trauma fue 20 penetrantes y 10 iatrogenias. Los vasos afectados fueron arteria femoral superficial 6, femoral profunda 2, subclavia 9, axilar 1, poplítea 4, ilíacas 1, peronea 1, tibial anterior 5, tronco venoso braquiocefálico 1. Diecisiete pacientes fueron tratados con endoprótesis, 9 con embolización y 4 con cierre percutáneo en relación con catéteres arteriales en subclavia. No hubo mortalidad, pero dos pacientes requirieron reparación abierta: un seudoaneurisma poplíteo gigante y un seudoaneurisma de tibial anterior, en ambos se constató sección completa de ambas arterias. El seguimiento clínico ha sido entre 30 días y 3 años. Conclusiones: En esta serie de casos, la terapia endovascular en lesiones de trauma vascular periférico ofrece excelentes resultados con baja morbimortalidad y permeabilidad aceptable a corto y mediano plazo.

Introduction: Endovascular therapy has proven to be a good treatment alternative in arterial and venous diseases. Likewise, in peripheral vascular trauma it is an excellent option, especially in anatomical sites that are difficult to access and with complex lesions such as pseudoaneurysms, arteriovenous fistulas (AVFs) or the combination of both, with numerous advantages. Aim: To evaluate the results of endovascular treatment in trauma Penetrating vascular injury and iatrogenesis. Materials and Method: Retrospective review of all patients with peripheral vascular trauma undergoing endovascular therapy. Results: Between April 2011 and May 2020, 30 patients were treated, 28 men and 2 women. With fluctuating ages between 17 and 84 years. The cause of the trauma was 20 penetrating and 10 iatrogenic. The affected vessels were superficial femoral artery 6, deep femoral 2, subclavian 9, axillary 1, popliteal 4, iliac 1, peroneal 1, anterior tibial 5, brachiocephalic venous trunk 1. Seventeen patients were treated with endoprosthesis, 9 with embolization and 4 with percutaneous closure in relation to arterial catheters in the subclavian. There was no mortality but two patients required open repair: a giant popliteal pseudoaneurysm and an anterior tibial pseudoaneurysm in which both sections of both arteries were found to be complete. Clinical follow-up was between 30 days and 3 years. Conclusión: In this serie, endovascular therapy in peripheral vascular trauma lesions offers excellent results with low morbidity and mortality and acceptable patency in the short and medium term.

Non-operative management of blunt splenic trauma: evolution, results and controversies / Tratamento não operatório do trauma esplênico: evolução, resultados e controvérsias

ABSTRACT The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.

RESUMO O baço é um dos órgãos mais frequentemente afetados no trauma abdominal contuso. Desde os trabalhos de Upadhyaya, o tratamento do trauma esplênico vem sofrendo importantes modificações. Atualmente, é consenso que todo trauma esplênico que se apresenta com estabilidade hemodinâmica pode ser tratado inicialmente de forma não operatória, desde que o serviço possua estrutura adequada e o paciente não apresente outras condições que indiquem exploração da cavidade abdominal. Entretanto, vários tópicos permanecem controversos no que diz respeito ao tratamento não operatório (TNO) do trauma esplênico. A angioembolização esplênica é uma ferramenta de grande auxílio no TNO, porém não há consenso sobre suas indicações precisas. Não há uma definição na literatura a respeito da forma como o TNO deve ser conduzido, tampouco a respeito da periodicidade do controle hematimétrico, do limiar de transfusão que define falha do TNO, de quando iniciar a profilaxia contra tromboembolismo venoso, da necessidade de exames de imagem de controle, do período de repouso no leito, e de quando é seguro indicar alta hospitalar. O objetivo desta revisão é analisar de forma crítica a literatura a respeito desse tema, expondo o estado da arte no TNO do trauma esplênico.

Trauma abdominal contuso por golpe con manubrio de bicicleta: evaluación y tratamiento / Blunt abdominal trauma due to handlebar injury

INTRODUCCIÓN: Los accidentes en bicicleta son una causa frecuente de trauma abdominal contuso en pediatría. En Chile no existen publicaciones científicas que traten sobre las lesiones abdominales por manubrio de bicicleta, su presentación y manejo. OBJETIVO: Describir tres casos clínicos de trauma abdominal contuso provocados por manubrio de bicicleta en niños, ilustrar las distintas lesiones observadas, sus formas de presentación y manejo. CASOS CLÍNICOS: 1) Paciente masculino, 11 años, consulta tras golpe con manubrio de bicicleta en epigastrio; en la Tomografía Computada (TC) de abdomen y pelvis se describió neumoretroperitoneo. Se realizó laparotomía exploradora, reparándose una perforación duodenal. 2) Paciente masculino, 14 años, consulta tras golpe en el hipocondrio izquierdo con el manubrio de la bicicleta; en la TC se evidenció fractura esplénica con múltiples laceraciones. Por la presencia de sangrado activo se trató con angioembolización, lográndose resolución de la lesión y viabilidad del órgano luego de 6 semanas de seguimiento. 3) Paciente masculino, 9 años, ingresó tras sufrir golpe con manubrio de bicicleta en el hipocondrio derecho. En TC se observó una laceración hepática, que fue manejada de forma expectante, con resolución de la lesión luego de 8 semanas de seguimiento. Todos los pacientes tuvieron una evolución favorable. CONCLUSIÓN: El trauma abdominal contuso por golpe con manubrio de bicicleta puede ser potencialmente grave en pacientes pediátricos, pudiendo afectar órganos sólidos y vísceras huecas. El manejo no quirúrgico cada vez es más utilizado, logrando altas tasas de éxito en pacientes estables. Los pacientes inestables o en los que se sospeche perforación de víscera hueca, requerirán cirugía como primera aproximación.

INTRODUCTION: Bicycle accidents are a frequent cause of blunt abdominal trauma in children. In Chile, there are no scientific articles about such accidents, their presentation and management. OBJECTIVE: The aim of this study is to describe three cases of blunt abdominal trauma due to handlebar injury in children, in order to illustrate the different kinds of lesions, their presentation, and management. CLINICAL CASES: 1) 11-year-old boy presented to Emergency Department (ED) after falling on a bi cycle handlebar, hitting his epigastric region. A CT scan showed signs of duodenal perforation. A la parotomy was performed and the duodenal perforation repaired. 2) 14-year-old boy seen at ED after a bicycle accident in which the handlebar hit him in the abdomen area. A CT scan showed a splenic injury with multiple lacerations and active bleeding that was treated with angioembolization. After 6 weeks of follow-up, he presented resolution of the lesion and viability of the spleen. 3) 9-year-old boy admitted due to a hit with the bicycle handlebar on the abdomen area. A CT scan showed a he patic injury that was managed with non-surgical procedures, achieving resolution of the lesion after 8 weeks of follow-up. CONCLUSION: Blunt abdominal trauma caused by handlebar can be potentially serious in pediatric patients, since it may affect solid and hollow abdominal viscera. Non-surgical ma nagement is becoming more used for stable patients, achieving high success rates. Unstable patients or those with suspicion of hollow viscera perforation will require surgery as first approach.

Implementation of a new Single-Pass Whole-Body Computed Tomography Protocol: Is it safe, effective and efficient in patients with severe trauma? / Implementación de un nuevo protocolo de Tomografía Computarizada Corporal Total de un solo pase: ¿Es seguro, efectivo y eficiente en pacientes con trauma severo?

Abstract Purpose: The objective of this study was to evaluate the implementation of a new single-pass whole-body computed tomography Protocol in the management of patients with severe trauma. Methods: This was a descriptive evaluation of polytrauma patients who underwent whole-body computed tomography. Patients were divided into three groups: 1. Blunt trauma hemodynamically stable 2. Blunt trauma hemodynamically unstable and 3. Penetrating trauma. Demographics, whole-body computed tomography parameters and outcome variables were evaluated. Results: Were included 263 patients. Median injury severity score was 22 (IQR: 16-22). Time between arrival to the emergency department and completing the whole-body computed tomography was under 30 minutes in most patients [Group 1: 28 minutes (IQR: 14-55), Group 2: 29 minutes (IQR: 16-57), and Group 3: 31 minutes (IQR: 13-50; p= 0.96)]. 172 patients (65.4%) underwent non-operative management. The calculated and the real survival rates did not vary among the groups either [Group 1: TRISS 86.4% vs. real survival rate 85% (p= 0.69); Group 2: TRISS 69% vs. real survival rate 74% (p= 0.25); Group 3: TRISS 93% vs. real survival rate 87% (p= 0.07)]. Conclusion: This new single-pass whole-body computed tomography protocol was safe, effective and efficient to decide whether the patient with severe trauma requires a surgical intervention independently of the mechanism of injury or the hemodynamic stability of the patient. Its use could also potentially reduce the rate of unnecessary surgical interventions of patients with severe trauma including those with penetrating trauma.

Resumen Introducción: El objetivo de este estudio fue evaluar la implementación de un nuevo protocolo de tomografía computarizada corporal total para el manejo de pacientes con trauma severo. Métodos: Este estudio es una evaluación descriptiva de pacientes que recibieron tomografía computarizada corporal total. Los pacientes fueron divididos en 3 grupos: 1. Trauma cerrado hemodinámicamente estables, 2. Trauma cerrado hemodinámicamente inestables y 3. Trauma penetrante. Se evaluaron las características demográficas, parámetros relacionados con la técnica y los desenlaces de los pacientes. Resultados: Se incluyeron 263 pacientes. La mediana del puntaje de severidad de la lesión fue 22 (RIQ: 16-22). El tiempo entre el ingreso a urgencias y completar la tomografía corporal total fue menor a 30 minutos en la mayoría de pacientes [Grupo 1: 28 minutos (RIQ: 14-55), Grupo 2: 29 minutos (RIQ: 16-57), y Grupo 3: 31 minutos (RIQ: 13-50; p= 0.96). 172 pacientes (65.4%) recibieron manejo no operatorio. Las tasas de supervivencia calculadas y reales no difirieron entre ninguno de los grupos [Grupo 1: TRISS 86.4% vs. Tasa real de supervivencia 85% (p= 0.69); Grupo 2: TRISS 69% vs. Tasa real de supervivencia 74% (p= 0.25); Grupo 3: TRISS 93% vs. Tasa real de supervivencia 87% (p= 0.07)]. Conclusión: Este nuevo protocolo de tomografía corporal total de un solo pase fue seguro, efectivo y eficiente para definir si los pacientes con trauma severo requieren o no una intervención quirúrgica. Su uso podría reducir la tasa de intervenciones quirúrgicas innecesarias en estos pacientes incluyendo los que se presentan con trauma penetrante.

High grade renal trauma due to blunt injury in children: do all require intervention? / Trauma renal de alto grau devido a lesão contusa em crianças: será que todas necessitam intervenção?

ABSTRACT Introduction: The aim of this study was to analyze the presentation and management of major grade renal trauma in children. Method: A retrospective study was performed including data collected from the patients who were admitted in Pediatric surgery with major grade renal injury (grade 3 and more) from January 2015 to August 2018. Demography, clinical parameters, management, duration of hospital stay and final outcome were noted. Results: Out of 13 children (9 males and 4 females), with age range 2-12 years (mean of 8 years), reported self-fall was the commonest mode of injury followed by road traffic accident. The majority (10/13, 75%) had a right renal injury. Eight children had a grade IV injury, one had a grade V injury, and four children had grade III injury. Duration of hospital stay varied from 3 to 28 (mean of 11.7) days. Three children required blood transfusion. One child required image guided aspiration twice and two required pigtail insertion for perinephric collection. All the 13 children improved without readmission or need for any other surgical intervention. Conclusion: Children with major grade renal trauma due to blunt injury can be successfully managed without surgical intervention and minimal intervention may only be needed in select situations.

RESUMO Introdução: O objetivo deste estudo foi analisar a apresentação e tratamento de grande trauma renal em crianças. Método: Foi realizado um estudo retrospectivo incluindo dados coletados dos pacientes que foram internados na cirurgia pediátrica com lesão renal de grau importante (grau 3 ou mais) de janeiro de 2015 a agosto de 2018. Coletamos dados a respeito de demografia, parâmetros clínicos, manejo, tempo de internação e resultado final. Resultados: Das 13 crianças (9 homens e 4 mulheres) com faixa etária de 2-12 anos (média de 8 anos), a queda auto-relatada foi o modo de lesão mais comum seguido de acidente de trânsito. A maioria (10/13, 75%) apresentou lesão renal direita. Oito crianças tiveram uma lesão grau IV, uma apresentou uma lesão grau V e quatro crianças apresentaram lesão grau III. A duração da internação hospitalar variou de 3 a 28 (média de 11,7) dias. Três crianças necessitaram de transfusão de sangue. Uma criança necessitou de aspiração guiada por imagem duas vezes e duas inserções de dreno pigtail exigidas para coleções perinefréticas. Todas as 13 crianças melhoraram sem re-internação ou necessidade de qualquer outra intervenção cirúrgica. Conclusão: Crianças com trauma renal de alto grau devido a lesão contusa podem ser manejadas com sucesso sem intervenção cirúrgica, e intervenção mínima pode ser necessária apenas em situações selecionadas.

Traumatismo torácico contuso / Blunt Thoracic Trauma

INTRODUCCIÓN: El traumatismo torácico (TT) es una causa importante de morbilidad y mortalidad, presente en el 25-50% de la mortalidad por traumatismo. El TT contuso (TTC) es el tipo más frecuente de TT según las diferentes publicaciones internacionales. OBJETIVO: Nuestros objetivos son describir las características, tratamientos, morbilidad y mortalidad en pacientes hospitalizados por TTC en nuestra institución. MATERIAL Y MÉTODOS: Estudio descriptivo transversal desde enero-1981 a diciembre-2017. Revisión de una base de datos prospectiva, protocolos quirúrgicos y fichas clínicas. Se describen y comparan las características de los TTC. Se calcularon índices de gravedad de traumatismo (IGT): Injury Severity Score (ISS), Revised Trauma Score (RTS-T), Trauma Injury Severity Score (TRISS). RESULTADOS: Total 4.163 pacientes hospitalizados por TT, 1.719 (41,3%) TTC. Hombres 1.327 (77,2%), edad promedio 46,7±18,8 años. Se consideró TT aislado 966 (56,2%), asociado a lesiones extratorácicas 753 (43,8%) y de estos 508 (29,6%) eran politraumatizados. Mecanismo: Accidente de tránsito 838 (48,7%), caída de altura 279 (16,2%). Lesiones y hallazgos torácicos: fractura costal 1.294 (75,3%), neumotórax 752 (43,1%). Tratamiento: médico 874 (50,8%), pleurotomía 704 (41%) y cirugía torácica 141 (8,2%). Período de hospitalización 9,2 ± 9,5 días. Según IGT: ISS promedio 14,1 ± 11,1, RTS-Tpromedio 11,5 ± 1,5, TRISS promedio 6,6. Morbilidad en 297 (17,3%), mortalidad en 68 (4%). DISCUSIÓN: La causa principal de los TTC fue el accidente de tránsito. La fractura costal correspondió a la lesión torácica más frecuente. La mayoría requirió solo tratamiento médico. La mortalidad fue menor a la esperada según IGT.

BACKGROUND: Thoracic trauma (TT) is a major cause of morbimortality, involved in 25-50% of trauma deaths. Internationally, blunt thoracic trauma (BTT) is the most frequent type of TT. OBJECTIVE: Our objectives are to describe the clinical characteristics, treatments, morbidity and mortality in patients hospitalized by blunt thoracic trauma (BTT) in our institution. MATERIAL AND METHODS: Cross-sectional descriptive study from january-1981 to december-2017. Prospective database review, surgical protocols and clinical files. The characteristics of the BTT are described and compared. The following trauma severity indices (TSI) were calculated: Injury Severity Score (ISS), Revised Trauma Score (RTS-T) and Trauma Injury Severity Score (TRISS). RESULTS: 4,163 patients were hospitalized because of TT, 1.719 (41.3%) of them with BTT. 1,327 (77.2%)patients were men, average age 46.7 ± 18.8 years-old. We considered isolated TT 966 (56.2%), associated with extrathoracic lesions 753 (43,8%) and 508 (29.6%)with polytraumatism. Mechanism: Traffic accident 838 (48.7%), fall down from a height 279 (16.2%). Lesions and intrathoracic findings: rib fracture 1.294 (75.3%), pneumothorax 752 (43.7%). Treatment: Medical 876 (50.8%), pleurotomy 704 (41%) and thoracic surgery 141 (8.2%). Average hospitalized period 9.2 ± 9.5 days. According to TSI: ISS average 14.1 ± 11.1, RTS-T average 11.5 ± 1.5, TRISS average 6.6. Morbidity in 297 (17.3%), mortality in 68 (4%). DISCUSSION: The TTC was mainly attributed to the traffic accident. Rib fracture was the most common chest injury. The majority of patients required only medical treatment. Mortality was lower than expected according to TSI.

Tratamiento mínimamente invasivo de una lesión de la vía biliar secundaria a un traumatismo abdominal cerrado: Caso clínico / Minimally invasive treatment of biliary tract injury secondary to closed abdominal trauma: Clinical case

Las lesiones hepáticas y de las vías biliares por causa traumática son poco usuales en la edad pediátrica. Del total de pacientes con trauma abdominal cerrado, menos del 9 % presentan lesión hepática, y la frecuencia varía entre el 2 % y el 3 % de la lesión de las vías biliares. Actualmente, el tratamiento recomendado para el trauma abdominal cerrado con lesión hepática sin repercusión hemodinámica es conservador; en caso de presentar lesión de la vía biliar intra- o extrahepática, los abordajes de preferencia son mínimamente invasivos, como la cirugía percutánea o endoscópica, y se utiliza la laparotomía en casos seleccionados. Se presenta el caso de un paciente con trauma abdominal cerrado y trauma hepático, inicialmente laparotomizado en 2 ocasiones por inestabilidad hemodinámica y hemoperitoneo; presentó un bilioma subdiafragmático y coleperitoneo, en el que se realizó un manejo mínimamente invasivo por drenaje percutáneo bajo control tomográfico.

Hepatic and biliary tract injuries due to traumatic causes are rare in pediatric patients. Of the total number of patients with closed abdominal trauma, less than 9 % have liver injury, and the frequency varies between 2 and 3 % of biliary tract lesions. Currently, the recommended treatment for closed abdominal trauma with liver injury without hemodynamic repercussion is conservative. In case of presenting intra or extrahepatic biliary tract lesion, the preferred approaches are minimally invasive, such as percutaneous or endoscopic surgery, using laparotomy in selected cases. We present the case of a patient with closed abdominal trauma and liver trauma, initially laparotomized on 2 occasions due to hemodynamic instability and hemoperitoneum; presented a subdiaphragmatic and coleperitoneal bilioma; it was performed minimally invasive percutaneous drainage under tomographic control.

Factores asociados a falla en el manejo no operatorio de lesiones hepáticas o esplénicas secundarias a trauma abdominal cerrado en niños / Associated factors to non-operative management failure of hepatic and splenic lesions secondary to blunt abdominal trauma in children

Introducción: El manejo no operatorio (MNO) es el manejo estándar del trauma cerrado esplénico y hepático en el paciente pediátrico. Se han identificado como fallas a este manejo inestabilidad hemodinámica y transfusiones masivas. Pocos trabajos evalúan si existen factores que permitan una anticipación a estos eventos. El objetivo fue determinar la existencia de factores asociados a la falla en MNO de las lesiones esplénicas y/o hepáticas secundarias al trauma abdominal cerrado. Pacientes y Método: Análisis retrospectivo 2007 a 2015 de los pacientes que ingresaron al servicio de Cirugía infantil del Hospital Universitario San Vicente Fundación con trauma hepático y/o esplénico cerrado. Resultados: Ingresaron 70 pacientes con trauma cerrado de abdomen, 3 fueron excluidos por cirugía inmediata (2 inestabilidad hemodinámica y 1 irritación peritoneal). De 67 pacientes que recibieron MNO, 58 tuvieron éxito y 9 presentaron falla (8 inestabilidad hemodinámica y 1 lesión de víscera hueca). Encontramos 3 factores asociados a la falla MNO: presión arterial (PAS) < 90 mmHg al ingreso (p=0,0126; RR =5,19), caída de la Hemoglobina (Hb) > 2 g/dl en las primeras 24 h (p=0,0009; RR= 15,3), y transfusión de 3 o más unidades de glóbulos rojos (UGR) (0,00001; RR= 17,1). Mecanismo del trauma, severidad e Índice de Trauma Pediátrico no se asociaron con fallo MNO. Conclusiones: Los niños con trauma cerrado hepático o esplénico responden al MNO. Los factores como PA menor de 90 al ingreso, caída de la Hb >2 g/dl en las primeras 24 h y la transfusión de 3 o más UGR pueden asociarse con la falla en el MNO.

Introduction: The non operative management (NOM) is the standard management of splenic and liver blunt trauma in pediatric patients.Hemodynamic instability and massive transfusions have been identified as management failures. Few studies evaluate whether there exist factors allowing anticipation of these events. The objective was to identify factors associated with the failure of NOM in splenic and liver injuries for blunt abdominal trauma. Patients and Method: Retrospective analysis between 2007-2015 of patients admitted to the pediatric surgery at University Hospital Saint Vincent Foundation with liver trauma and/or closed Spleen. Results: 70 patients were admitted with blunt abdominal trauma, 3 were excluded for immediate surgery (2 hemodynamic instability, 1 peritoneal irritation). Of 67 patients who received NOM, 58 were successful and 9 showed failure (8 hemodynamic instability, 1 hollow viscera injury). We found 3 factors associated with failure NOM: blood pressure (BP) < 90 mmHg at admission (p = 0.0126; RR = 5.19), drop in hemoglobin (Hb) > 2 g/dl in the first 24 hours (p = 0.0009; RR = 15.3), and transfusion of 3 or more units of red blood cells (RBC) (0.00001; RR = 17.1). Mechanism and severity of trauma and Pediatric Trauma Index were not associated with failure NOM. Conclusions: Children with blunted hepatic or splenic trauma respond to NOM. Factors such as BP < 90 mmHg at admission, an Hb fall > 2 g/dl in the first 24 hours and transfusion of 3 or more units of RBC were associated with the failure in NOM.

Main controversies in the nonoperative management of blunt splenic injuries / Principais controvérsias do tratamento não operatório das lesões contusas do baço

Introduction: The nonoperative management of traumatic spleen injuries is the modality of choice in patients with blunt abdominal trauma and hemodynamic stability. However, there are still questions about the treatment indication in some groups of patients, as well as its follow-up. Aim : Update knowledge about the spleen injury. Method: Was performed review of the literature on the nonoperative management of blunt injuries of the spleen in databases: Cochrane Library, Medline and SciELO. Were evaluated articles in English and Portuguese, between 1955 and 2014, using the headings "splenic injury, nonoperative management and blunt abdominal trauma". Results: Were selected 35 articles. Most of them were recommendation grade B and C. Conclusion: The spleen traumatic injuries are frequent and its nonoperative management is a worldwide trend. The available literature does not explain all aspects on treatment. The authors developed a systematization of care based on the best available scientific evidence to better treat this condition.

Introdução: O tratamento não operatório das lesões traumáticas do baço é a modalidade de escolha nos pacientes com trauma abdominal contuso e estabilidade hemodinâmica. No entanto, ainda existem dúvidas sobre a indicação do tratamento em determinado grupo de pacientes, assim como o seu seguimento. Objetivo : Atualizar o conhecimento sobre as lesões do baço. Método: Realizou-se revisão da literatura sobre o tratamento não operatório das lesões contusas do baço nas bases de dados: Cochrane, Medline e SciELO. Foram incluídos os artigos em línguas portuguesa e inglesa entre 1955 e 2014, utilizando os descritores "splenic injury, nonoperative management e blunt abdominal trauma". Resultado: Foram selecionados 35 artigos. A maioria dos trabalhos eran em grau de recomendação B e C. Conclusão: As lesões traumáticas do baço são frequentes e o seu tratamento não operatório apresenta tendência mundial. A literatura disponível não esclarece todos os aspectos deste tratamento. Elaborou-se sistematização de atendimento baseada nas melhores evidências científicas disponíveis para facilitar seu manejo.

Traumatic wound dehiscence after corneal keratoplasty / Deiscência de sutura pós-trauma ocular em olhos submetidos a transplante de córnea

ABSTRACTPurpose:To assess patient characteristics, risk factors, outcomes, and the treatment of wound dehiscence (WD) in patients after corneal keratoplasty.Methods:Retrospective chart review of 11 eyes of 11 patients with corneal grafts who underwent repair of WD from January 1, 2004 to December 31, 2012 at Hospital Oftalmologico de Brasilia.Results:Eight (72.7%) patients were men and three were women. Six (54.5%) patients had deep anterior lamellar keratoplasty (DALK) and 5 had penetrating keratoplasty. The mean age at trauma was 31.1 years. The mean time from corneal keratoplasty to WD was 12.82 months (range, 3-33 months). The mean best-corrected visual acuity of patients before trauma was 20/60 (0.48 logMAR) and after final treatment was 20/160 (0.90 logMAR) (P=0.15). In one case, visual acuity decreased to no light perception because of retinal detachment and phthisis bulbi. Accidental blunt trauma and fall were the most common causes of WD.Conclusion:Patients who undergo corneal keratoplasty have a life-long risk of WD. The full-thickness rupture at the graft-host junction in our study suggests that the junction remains vulnerable, even following DALK, and can rupture with trauma. In our series, depending upon the severity of the trauma, postkeratoplastic WD can be associated with a good visual prognosis.

RESUMOObjetivo:Avaliar as características, os fatores de risco, resultados, e tratamento de pacientes que apresentaram deiscência traumática de sutura após transplante de córnea.Métodos:Estudo retrospectivo em que foram avaliados 11 olhos de 11 pacientes submetidos a transplante de córnea e que desenvolveram deiscência de sutura entre janeiro de 2004 e dezembro de 2012 no Hospital Oftalmológico de Brasília.Resultados:Oito (72,7%) pacientes eram homens e três mulheres. Seis (54,5%) pacientes foram submetidos a ceratoplastia lamelar anterior profunda (DALK) e 5 pacientes a ceratoplastia penetrante (PK). A média de idade dos pacientes no momento do trauma era de 31,1 anos. O tempo médio entre o transplante de córnea e a deiscência de sutura foi de 12,82 meses (variando de 3 a 33 meses). A melhor acuidade visual corrigida (AVCC) doa pacientes antes do trauma era de 20/60 (0,48 logMAR), e após o trauma era de 20/160 (0,90 logMAR) (P=0,15). Em um caso, a acuidade visual reduziu para sem percepção luminosa devido a descolamento de retina e posterior atrofia bulbar. O trauma ocular acidental e a queda da própria altura foram as principais causas de deiscência de sutura nos olhos transplantados.Conclusão:Pacientes previamente submetidos a transplante de córnea apresentam um risco prolongado de deiscência de sutura. A ruptura completa na junção doador-receptor no nosso estudo sugere que mesmo após um DALK a junção permanece vulnerável e pode romper com o trauma. Na nossa série, dependendo da severidade do trauma, a deiscência pós-ceratoplastia pode estar associada a um bom prognóstico visual.

Tratamento não operatório de lesão esplênica grau IV é seguro usando-se rígido protocolo / Nonoperative management of splenic injury grade IV is safe using rigid protocol

OBJETIVO: demonstrar o protocolo e a experiência do serviço no TNO de lesões esplênicas contusas grau IV (classificação da Associação Americana de Cirurgia do Trauma). MÉTODOS: estudo retrospectivo baseado em registro de trauma de hospital universitário no período de 1990 a 2010. Prontuários de todos os pacientes com lesão esplênica foram revisados e os doentes tratados de modo não operatório com lesão grau IV foram incluídos no estudo. RESULTADOS: noventa e quatro pacientes com lesão esplênica contusa grau IV foram admitidos neste período. Vinte e seis (27,6%) apresentaram os critérios para o TNO. A média de pressão arterial sistólica na admissão foi de 113,07 ± 22,22mmHg, RTS = 7,66 ± 0,49 e ISS = 18,34 ± 3,90. Dez pacientes (38,5%) necessitaram de transfusão sanguínea, com uma média de 1,92 ± 1,77 concentrado de hemácias por paciente. Lesões abdominais associadas estavam presentes em dois pacientes (7,7%). O TNO falhou em dois pacientes (7,7%), operados devido à piora da dor abdominal e choque hipovolêmico. Nenhum paciente desenvolveu complicações relativas ao baço e não houve óbito na presente casuística. A média de dias de internação foi 7,12 ± 1,98 dias. CONCLUSÃO: o tratamento não operatório de lesões esplênicas grau IV no trauma abdominal contuso é seguro seguindo-se rígido protocolo.

OBJECTIVE: To demonstrate the protocol and experience of our service in the nonoperative management (NOM) of grade IV blunt splenic injuries. METHODS: This is a retrospective study based on trauma registry of a university hospital between 1990-2010. Charts of all patients with splenic injury were reviewed and patients with grade IV lesions treated nonoperatively were included in the study. RESULTS: ninety-four patients with grade IV blunt splenic injury were admitted during this period. Twenty-six (27.6%) met the inclusion criteria for NOM. The average systolic blood pressure on admission was 113.07 ± 22.22 mmHg, RTS 7.66 ± 0.49 and ISS 18.34 ± 3.90. Ten patients (38.5%) required blood transfusion, with a mean of 1.92 ± 1.77 packed red cells per patient. Associated abdominal injuries were present in two patients (7.7%). NOM failed in two patients (7.7%), operated on due to worsening of abdominal pain and hypovolemic shock. No patient developed complications related to the spleen and there were no deaths in this series. Average length of hospital stay was 7.12 ± 1.98 days. CONCLUSION: Nonoperative treatment of grade IV splenic injuries in blunt abdominal trauma is safe when a rigid protocol is followed.

Atualização da classificação e tratamento das lesões renais complexas / Update in the classification and treatment of complex renal injuries

A reunião de revista "Telemedicina Baseada em Evidência - Cirurgia do Trauma e Emergência" (TBE-CiTE) realizou uma revisão crítica da literatura e selecionou três artigos atuais sobre o tratamento do trauma renaldefinido como graus III a V pela classificação da Associação Americana de Cirurgia do Trauma (AAST). O primeiro trabalho propõe subestratificação da lesão renal AAST grau IV em 4a (baixo risco) e 4b (alto risco). O segundo trabalho revisa o atual sistema de classificação de lesão renal AASTpara incluir lesões vasculares segmentares e estabelecer uma definição mais detalhada dos graus IV e V. O último artigo analisa a angiografia diagnóstica e angioembolização na fase aguda do trauma renal utilizando dados americanos. A reunião de revista TBE-CiTE elaborou as conclusões e recomendações para o tratamento do trauma renal de alto grau.

The "Evidence-Based Telemedicine - Trauma and Acute Care Surgery" (EBT-TACS) Journal Club performed a critical review of the literature and selected three up-to-date articles on the management of renal trauma defined as American Association for the Surgery of Trauma (AAST) injury grade III-V. The first paper was the proposal for the AAST grade 4renal injury substratification into grades 4a (Low Risk) and 4b (High Risk). The second paper was a revision of the current AAST renal injury grading system, expanding to include segmental vascular injuries and to establish a more rigorous definition of severe grade IV and V renal injuries.The last article analyses the diagnostic angiography and angioembolization in the acute management of renal trauma using a nationaldata set in the USA. The EBT-TACS Journal Club elaborated conclusions and recommendations for the management of high-grade renal trauma.

Renal artery pseudoaneurysm after blunt renal trauma: report on three cases and review of the literature / Pseudoaneurisma de arteria renal apos trauma renal fechado: relato de tres casos e revisao da literatura

CONTEXT: Renal artery pseudoaneurysm is a rare complication after renal injury but should be suspected whenever there is recurrent hematuria after renal trauma. CASE REPORTS: We present three cases of pseudoaneurysm after blunt renal trauma and a review of the literature. All patients underwent renal angiography. Two cases were diagnosed during the initial hospital stay due to hematuria, or in the follow-up period during recovery. One patient was hemodynamically unstable. Two patients successfully underwent coil embolization in a single session. In the other case, selective embolization was attempted, but was unsuccessful because artery catheterization was impossible. Procedural and medical success and complications were retrospectively assessed from the patients' records. The clinical presentation, treatment options and clinical decisions are discussed. CONCLUSIONS: Renal artery pseudoaneurysm may develop acutely or even years after the initial injury. Signs and symptoms may have a wide spectrum of presentation. Selective angiographic embolization is an effective treatment that reduces the extent of parenchymal infarction. .

CONTEXTO: Pseudoaneurisma de artéria renal é uma complicação rara após lesão renal, mas deve ser suspeitada quando houver hematúria recorrente após trauma renal. RELATO DE CASOS: Três casos de pseudoaneurisma após trauma renal fechado são apresentados, além de revisão da literatura. Todos os pacientes foram submetidos a angiografia renal. Dois dos casos foram diagnosticados durante a estadia hospitalar inicial, por hematúria ou no período de acompanhamento durante a recuperação. Um paciente estava hemodinamicamente instável. Dois pacientes foram submetidos a embolização com coil com sucesso em uma única sessão. No outro caso, a embolização seletiva foi tentada sem sucesso, devido à impossibilidade de cateterização da artéria. O sucesso médico e do procedimento e as complicações foram retrospectivamente avaliados a partir dos registros dos pacientes. A apresentação clínica, opções de tratamento e decisões clínicas são discutidas. CONCLUSÕES: Pseudoaneurisma de artéria renal pode se desenvolver agudamente ou até mesmo anos após o trauma inicial. Sinais e sintomas podem ter um amplo espectro de apresentação. Embolização angiográfica seletiva é um tratamento efetivo, reduzindo a extensão de infarto parenquimatoso. .

Trauma hepático contuso: comparação entre o tratamento cirúrgico e o não operatório / Blunt hepatic trauma: comparison between surgical and nonoperative treatment

OBJETIVO: Analisar a evolução do trauma hepático fechado e comparar o tratamento operatório e não operatório em pacientes admitidos com estabilidade hemodinâmica e nenhuma indicação óbvia de laparotomia. MÉTODOS: Estudo retrospectivo de casos admitidos em um hospital universitário entre 2000 e 2010. Os pacientes submetidos ao tratamento operatório foram distribuídos em dois grupos: a) todos os pacientes submetidos ao tratamento cirúrgico e b) pacientes sem indicações óbvias de laparotomia. RESULTADOS: Neste período, 120 pacientes foram admitidos com trauma hepático fechado. Sessenta e cinco pacientes (54,1%) foram submetidos ao tratamento não operatório e 55 pacientes foram operados. Pacientes submetidos ao tratamento não operatório tiveram melhores parâmetros fisiológicos na admissão, menor gravidade de lesões (exceto pelo grau de lesão hepática), menor necessidade de transfusão sanguínea e menor morbidade e mortalidade quando comparados aos pacientes operados. Os pacientes operados sem indicação óbvia de cirurgia tiveram maiores taxas de complicações e mortalidade do que os pacientes submetidos ao tratamento não operatório. CONCLUSÃO: O tratamento não operatório resultou em menor taxa de complicações, menor necessidade de transfusão sanguínea e menor mortalidade.

OBJECTIVE: To examine the outcomes of blunt hepatic trauma, and compare surgical and non-surgical treatment in patients admitted with hemodynamic stability and with no obvious indications of laparotomy. METHODS: This is a retrospective study of cases admitted to a university teaching hospital between the years 2000 and 2010. Patients undergoing surgical treatment were divided into two groups: (a) all patients undergoing surgical treatment, and (b) patients with obvious need for surgery. RESULTS: In this period, 120 patients were admitted with blunt hepatic trauma. Sixty five patients (54.1%) were treated non-operatively and fifty five patients were operated upon. Patients treated non-operatively had better physiologic conditions on admission, demonstrated less severe injuries (except the grade of hepatic injury), received less blood components and had lower morbidity and mortality than the patients operated upon. Patients who underwent non-operative treatment had a lower need for blood transfusion but higher rates of complications and mortality than the patients operated upon. Patients who were operated upon, with no obvious indications for surgery, had higher rates of complication and mortality than patients not operated upon. CONCLUSION: A non-operative approach resulted in lower complications, a lower need for blood transfusions and lower mortality.

Blunt cerebrovascular injuries: a review of the literature

Blunt cerebrovascular injuries [BCVI] have been a topic of interest to many researchers worldwide as evidenced by the vast amount of available literature. The interest in these rare injuries is probably due to the significant possibility of mortality and morbidity amongst patients who sustain them, when the employment of radiological screening methods could prevent such an outcome. Recognition of these injuries is the most important step towards prevention of adverse outcomes. We present a comprehensive review of the literature regarding the mechanism of injury, imaging, management, and complications of BCVI. Articles were identified through a search of MEDLINE and the Cochrane Central Register of Controlled Trials using the keywords Blunt; Vascular; Carotid; Vertebral; Trauma; Stroke; Management, and Endovascular. The search was limited to humans and articles in English

[Management of blunt hepatic trauma in patients referred to Isfahan Alzahra hospital during 1998-2008]

Liver is the most commonly injured organ in blunt abdominal trauma. Early diagnosis and appropriate treatment of blunt hepatic trauma would decrease morbidity and mortality rates. To achieve this goal, physicians should be aware of the prevalence, etiologies, signs and symptoms, diagnostic procedures and up-to-date management of blunt hepatic trauma. A descriptive retrospective study was conducted on all 130 patients admitted to the emergency department of Isfahan Alzahra Hospital during 1998- 2008. Data were collected from patients' medical records and analyzed using descriptive statistical methods. Out of 130 patients, 103 cases [79.2%] were male. Mean age of cases was 29.7 +/- 13.46. The most common traumatic mechanism was vehicle accidents in 100 cases [76.9%]. Sonography in association with CT scan as the most commonly used diagnostic method was obtained in 68 cases [52.3%]. Eighty-eight cases [67.7%] underwent surgery while conservative treatment was selected for the other 42 cases [32.3%]. Admission to ICU was more frequently needed in conservative treatment group [P=0.001]. The mean length of hospitalization was shorter for patients underwent surgery. Better clinical results and fewer complications in the group managed conservatively presents it as a safer and more efficient treatment method

Accidentalidad por fluidos biológicos en profesionales de laboratorios clínicos de Maracaibo, Venezuela / Biological fluid-related accidents amongst professionals working in clinical laboratories in Maracaibo, Venezuela

Objetivo Determinar la exposición laboral accidental a fluidos biológicos por contacto percutáneo en el personal Bioanalista de Laboratorios Clínicos públicos, sus factores asociados y el cumplimiento de medidas post exposición biológica. Métodos Se realizó un estudio descriptivo transversal, la muestra fue de 156 bioanalistas adscritos a laboratorios clínicos del área metropolitana del estado Zulia. Para la recolección de datos se aplicó un instrumento de escalas que exploró la exposición percutánea, los factores vinculados y el cumplimiento de medidas post exposición biológica. Resultados Se evidenció exposición por accidentes percutáneos, representados principalmente por pinchazos y cortaduras, detectados en razón de su ocurrencia en un nivel moderado (media entre 2-3,99). Como factores vinculados a la accidentabilidad percutánea, se registra la ocurrencia en nivel moderado con diversas agujas huecas, con sangre y hemoderivados, en manos y dedos, con una severidad superficial, en áreas de toma y procesamiento de muestras durante el re-encapuchado de objetos punzo cortantes. Un nivel de mediano cumplimiento se obtuvo para el manejo post exposición. Existe relación entre la exposición percutánea con el nivel de cumplimiento detectado para el manejo post exposición p <0,001. Conclusión La magnitud y características de la exposición a fluidos biológicos detectada en este colectivo laboral reviste una problemática que puede impactar en la salud del personal y debe ser abordada institucionalmente para una efectiva gestión de prevención y control de riesgo.

Objective Determining the occupational exposure to biological fluids of medical technicians working in public clinical laboratories caused by accidental percutaneous contact, associated factors and compliance with post-exposure biological measures. Methods This was a descriptive cross-sectional study. The sample consisted of 156 medical technicians assigned to clinical laboratories in the metropolitan area of Zulia state in Venezuela. Data was collected by applying an instrument for exploring exposure and related factors, as well as compliance with established post-biological exposure measures. Results There was evidence of exposure caused by percutaneous accidents, mainly represented by a moderate level of needle-pricks and cuts (2-3.99 mean). There was a moderate level of factors regarding percutaneous injury in the hands and fingers associated with hollow needles, blood and blood products and superficial severity in sample taking and processing areas when recapping needles or handling sharp or cutting objects. A medium level (2-3.99 mean) of compliance was obtained for post-exposure handling. A significant correlation was found (p<001) between percutaneous exposure and level of compliance with post-exposure management. Conclusion The magnitude and characteristics of exposure to biological fluids detected in this work represents a problematic situation which can affect staff health and must be approached by institutions to ensure effective prevention management and risk control.