Trauma craneoencefálico penetrante por una herida de arpón. Presentación de un caso / Penetrating cranioencephalic trauma due to harpoon wound. Presentation of a case

RESUMEN Las heridas craneocerebrales penetrantes más frecuentes son las provocadas por armas de fuego; las restantes resultan de rara frecuencia. Se presentó un caso que recibió agresión craneoencefálica por arpón, de forma accidental, fuera del agua. Se describieron los detalles del suceso, los exámenes complementarios, la conducta adoptada, el manejo neuroquirúrgico, y la sorprendente evolución postoperatoria del paciente (AU).

ABSTRACT The most frequent penetrating craniocerebral wounds are those caused by firearms; the remaining ones are rare. We presented a case that received accidental cranioencephalic aggression by harpoon, an event that occurred out of the water. Details of the event, complementary examinations, adopted behavior and neurosurgical management that were decided, as well as the surprising post-operative evolution of the patient were described (AU).

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.

O uso da tomografia computadorizada na triagem da lesão cardíaca penetrante / The use of computed tomography for penetrating heart injury screening

RESUMO Objetivo: determinar se a tomografia computadorizada representa uma opção segura para triagem de lesões cardíacas penetrantes. Métodos: estudo transversal retrospectivo, que confrontou os achados tomográficos com os detectados na exploração cirúrgica em pacientes operados por suspeita de trauma cardíaco no período de janeiro de 2016 a janeiro de 2018. Resultados: setenta e dois casos foram analisados; 97,2% eram do sexo masculino e a faixa etária mais prevalente foi de 20 a 29 anos; 56,9% apresentaram ferimentos por projéteis de arma de fogo e 43,1% por arma branca. Em 20 casos, a tomografia computadorizada foi sugestiva de lesão cardíaca, confirmada em 13 casos durante a cirurgia. A sensibilidade da tomografia computadorizada foi de 56,5% e a especificidade de 85,7%. Conclusão: a tomografia computadorizada não deve ser adotada rotineiramente para triagem de ferimentos cardíacos penetrantes.

ABSTRACT Objective: to determine if computed tomography represents a safe option for penetrating heart injury screening. Methods: retrospective transversal study which confronted tomographic findings with the ones detected in surgical exploration in patients that had undergone surgery because of suspected cardiac trauma from January, 2016 to January, 2018. Results: seventy-two cases were analysed; 97.2% of them were males, and the most prevalent age range was 20 to 29 years; 56.9% of them presented injuries caused by firearm shots and 43.1% by cutting weapons. In 20 cases, computed tomography suggested heart injury, confirmed in 13 cases during surgery. Sensitivity of computed tomography was 56.5%, reaching a specificity of 85.7%. Conclusion: computed tomography must not be adopted as a routine for the screening of penetrating heart injuries.

The role of computerized tomography in penetrating abdominal trauma / O papel da tomografia no trauma abdominal penetrante

ABSTRACT Objective: to evaluate the role of abdominal computed tomography in the management of penetrating abdominal trauma. Methods: we conducted a historical cohort study of patients treated for penetrating trauma in the anterior abdomen, dorsum or thoracoabdominal transition, that were submitted to a computed tomography carried out on admission. We evaluated the location of the wound and the presence of tomographic findings, and the management of these patients as for nonoperative treatment or laparotomy. We calculated the sensitivity and specificity of computed tomography according to the evolution of the nonoperative treatment or the surgical findings. Results: we selected 61 patients, 31 with trauma to the anterior abdomen and 30 to the dorsum or thoracoabdominal transition. The mortality rate was 6.5% (n=4), all in the late postoperative period. Eleven patients with trauma to the anterior abdomen were submitted to nonoperative treatment, and 20, to laparotomy. Of the 30 patients with trauma to the dorsum or thoracoabdominal transition, 23 underwent nonoperative treatment and seven, laparotomy. There were three nonoperative treatment failures. In penetrating trauma of the anterior abdomen, the sensitivity of computed tomography was 94.1% and the negative predictive value was 93.3%. In dorsal or thoracoabdominal transition lesions, the sensitivity was 90% and the negative predictive value was 95.5%. In both groups, the specificity and the positive predictive value were 100%. Conclusion: the accuracy of computed tomography was adequate to guide the management of stable patients who could be treated conservatively, avoiding mandatory surgery in 34 patients and reducing the morbidity and mortality of non-therapeutic laparotomies.

RESUMO Objetivo: avaliar o papel da tomografia computadorizada de abdome no manejo do trauma abdominal penetrante. Métodos: estudo de coorte histórico de pacientes tratados por trauma penetrante em abdome anterior, dorso ou transição tóraco-abdominal que realizaram tomografia computadorizada à admissão. Avaliou-se a localização do ferimento e a presença de achados tomográficos, e o manejo desses pacientes quanto ao tratamento não operatório ou laparotomia. A sensibilidade e especificidade da tomografia computadorizada foram calculadas de acordo com a evolução do tratamento não operatório ou com os achados cirúrgicos. Resultados: foram selecionados 61 pacientes, 31 com trauma em abdome anterior e 30 em dorso ou transição tóraco-abdominal. A taxa de mortalidade foi de 6,5% (n=4), todos no pós-operatório tardio. Onze pacientes com trauma em abdome anterior foram submetidos a tratamento não operatório e 20 à laparotomia. Dos 30 pacientes com trauma em dorso ou transição tóraco-abdominal, 23 realizaram tratamento não operatório e sete foram submetidos à laparotomia. Houve três falhas do tratamento não operatório. Em traumas penetrantes do abdome anterior, a sensibilidade da TC foi de 94,1% e o valor preditivo negativo, 93,3%. Em lesões de dorso ou transição tóraco-abdominal, a sensibilidade foi de 90%, e o valor preditivo negativo foi de 95,5%. Em ambos os grupos, a especificidade e o valor preditivo positivo foram de 100%. Conclusão: a acurácia da tomografia computadorizada foi adequada para direcionar o manejo de pacientes estáveis que puderam ser tratados de forma conservadora, evitando cirurgia mandatória em 34 pacientes e reduzindo a morbimortalidade de laparotomias não terapêuticas.

Evaluation of the use of tomography in penetrating neck trauma / Avaliação da utilização da tomografia computadorizada no trauma cervical penetrante

ABSTRACTObjective:the study has the intention of evaluate the accuracy of computed tomography for the diagnosis of cervical lesions on penetrating neck trauma and also identify the most frequent mechanisms of trauma. Most injured structures, determine the age range and the most prevalent sex.Methods: observational descriptive retrospective study executed by the systematic retrospective review of medical records of all patients victims of penetrating neck trauma that went through surgery and CT scans, admitted into Hospital do Trabalhador, between January 2009 and December 2013.Results:the final sample was of 30 patients, 96.7% of the male sex, the median age was of 28 years old. Most patients suffered injuries by gun (56.7%) and 33,3% suffered stab wounds. The most stricken area of the neck was Zone II (77.8%) and the left side (55.2%). Regarding the structures injured, the CT showed 6.7% lesions on airways but the surgery showed 40% of damaged, with a value of p=0.002. As to damages of the esophagus and pharynx the CT detected 10% of lesions, while surgery found 30% of lesions, therefore with a significant value of p=0.013. As for the analysis the CT showed reliable. As for the analysis of vascular damage, the CT showed to be, in most cases, reliable to the findings during the surgical act.Conclusion:besides the great use of CT for the diagnosis of penetrating neck injuries we can say that this is an exam with low accuracy for the diagnosis of lesions of aerodigestive tract, therefore it is important a clinical correlation for a good diagnosis.as for the vascular lesions and of other structures, the CT had high sensibility and specificity, thus a good exam to be used in overall.

RESUMOObjetivo:avaliar a acurácia da tomografia computadorizada no diagnóstico de lesões do trauma cervical penetrante.Métodos:estudo retrospectivo descritivo observacional realizado através da revisão de prontuários de todos os pacientes vítimas de trauma cervical penetrante que foram operados e submetidos à tomografia computadorizada no pré-operatório.Resultados:a amostra final compreendeu 30 pacientes, sendo 96,7% do sexo masculino e a mediana de idade foi 28 anos. A maioria dos pacientes sofreu ferimento por arma de fogo (FAF) em 56,7% dos casos e 33,3% foram ferimentos por arma branca (FAB). A zona do pescoço mais acometido foi a zona II (77,8%) e no lado esquerdo (55,2%). Em relação às estruturas lesadas, a tomografia computadorizada (TC) mostrou 6,7% de lesões em vias aéreas e durante a operação encontrou-se 40% de alterações (p=0,002). A tomografia computadorizada detectou 10% de leões do esôfago e faringe, durante a operação encontrou-se 30% de lesões (p=0,013). Já, para análise de danos vasculares, a TC se mostrou, na maioria dos casos, fidedigna aos achados durante o procedimento operatório.Conclusão:apesar do grande uso da tomografia computadorizada no diagnóstico de lesões cervicais penetrantes, pode-se afirmar que este é um exame com baixa acurácia no diagnóstico de lesões de trato aerodigestivo, sendo importante uma correlação clínica para um bom diagnóstico. Já para lesões vasculares e de outras estruturas, a TC apresentou alto grau de sensibilidade e especificidade, sendo assim um bom exame a ser utilizado nesses casos.

Herida penetrante del cráneo / Skull penetrating wound

El traumatismo craneoencefálico es común en los servicios de urgencia de instituciones que atienden a pacientes politraumatizados y se ha convertido en un problema de salud para muchos países. El traumatismo penetrante del cráneo ocupa un lugar especial por su baja frecuencia. En este trabajo se presenta el caso de un paciente varón, de 52 años de edad, que sufrió una herida penetrante del cráneo producida por un arma blanca que quedó retenida en la región frontotemporal izquierda. Tras un estudio imaginológico se procedió al tratamiento quirúrgico de urgencia, y el paciente evoluciona satisfactoriamente después de 25 días de hospitalización. En la actualidad se encuentra en tratamiento de rehabilitación por una hemiparesia derecha residual(AU)

The cranioencephalic trauma is common in the emergence centers to care for patients with multiple traumata and it becames in a health problem in many countries. Skull penetrating trauma is located in a special place due to its low frequency. In present paper a case of male patient aged 52 severely skull-injured with penetrating wound caused by a cold steel that remained introduced into the left frontotemporal region. After an imaging study the emergence surgical treatment was applied and patient evolves adequately after 25 days of hospitalization. Nowadays, she is under rehabilitation treatment due to a residual right hemiparesis(AU)

Accurate determination of wound depth with ultrasound and its forensic significance / 法医学杂志

Accurate determination of the wound depth has long been a difficult task in forensic medicine due to lack of technology. Nowadays, the depth of the wound can be accurately determined by using high frequency 2-D ultrasound and Color Doppler Flow Imaging (CDFI). Two typical cases with ultrasonic images were reported to show the importance of ultrasound technology in forensic medicine. The new technology provides scientific evidence of the injury assessment.

Unusual self-inflicted penetrating craniocerebral injury by a nail.

Penetrating injuries of the brain caused by a nail are rare. An interesting case of a patient with schizophrenia who attempted suicide by a self-inflicted penetrating intracranial injury using a nail is reported here. The literature related to this unusual case is reviewed.

Injury to anterior optic pathways.

Fourteen patients with injury to the anterior optic pathways have been presented and analysed. Their clinical profile, radiological data and problems involved therein have been discussed. Since an expectant policy has been the rule so far, an attempt has been made to define the role of surgery in such cases.

Emergency femoral arteriography in lower limb vascular trauma.

There are difficulties in obtaining emergency arteriographic evaluation in lower limb vascular trauma even in the best centres in the world. Ten emergency room arteriograms were performed at the new Accident Service of the General Hospital, Colombo from February to October 1992 by the vascular team, using a venous cannula and improvised tubing systems. The indications were, absence of distal pulses with closed injury to the limb, previous attempts at repair, injury to the limb at more than one site and multiple shrapnel injury. A traumatic arteriovenous communication was shown in one of the arteriograms. Unnecessary exploration of the artery was prevented by the demonstration of a patent femoropopliteal segment in two cases. The average delay caused by this procedure was less than one hour, which compares well with centres in the West. Provision of an arteriogram kit at the Accident Service will help to overcome practical problems.