Tracheobronchial injuries in chest trauma: a 17-year experience / Lesões traqueobrônquicas no trauma torácico: experiência de 17 anos

ABSTRACT Objective: to discuss the clinical and therapeutic aspects of tracheobronchial lesions in victims of thoracic trauma. Methods: we analyzed the medical records of patients with tracheobronchial lesions treated at the São Paulo Holy Home from April 1991 to June 2008. We established patients' severity through physiological (RTS) and anatomical trauma indices (ISS, PTTI). We used TRISS (Trauma Revised Injury Severity Score) to evaluate the probability of survival. Results: nine patients had tracheobronchial lesions, all males, aged between 17 and 38 years. The mean values ​​of the trauma indices were: RTS - 6.8; ISS - 38; PTTI - 20.0; and TRISS - 0.78. Regarding the clinical picture, six patients displayed only emphysema of the thoracic wall or the mediastinum and three presented with hemodynamic or respiratory instability. The time interval from patient admission to diagnosis ranged from one hour to three days. Cervicotomy was performed in two patients and thoracotomy, in seven (77.7%), being bilateral in one case. Length of hospitalization ranged from nine to 60 days, mean of 21. Complications appeared in four patients (44%) and mortality was nil. Conclusion: tracheobronchial tree trauma is rare, it can evolve with few symptoms, which makes immediate diagnosis difficult, and presents a high rate of complications, although with low mortality.

RESUMO Objetivo: discutir os aspectos clínicos e terapêuticos de lesões traqueobrônquicas em vítimas de trauma torácico. Métodos: análise de dados dos prontuários de pacientes com lesões traqueobrônquicas atendidas na Santa Casa de São Paulo no período de abril de 1991 a junho de 2008. A caracterização da gravidade dos doentes foi feita por meio de índices de trauma fisiológico (RTS) e anatômicos (ISS, PTTI). O TRISS (Trauma Revised Injury Severity Score) foi utilizado para avaliar a probabilidade de sobrevida. Resultados: nove doentes tinham lesões traqueobrônquicas, todos do sexo masculino, com idades entre 17 e 38 anos. Os valores médios dos índices de trauma foram: RTS- 6,8; ISS- 38; PTTI-20,0; TRISS-0,78. Com relação ao quadro clínico, seis apresentaram apenas enfisema de parede torácica ou do mediastino e três doentes se apresentaram com instabilidade hemodinâmica ou respiratória. O intervalo de tempo necessário para se firmar o diagnóstico, desde a admissão do doente, variou de uma hora a três dias. Cervicotomia foi realizada em dois pacientes e toracotomia foi realizada em sete (77,7%), sendo bilateral em um caso. O tempo de internação variou de nove a 60 dias, média de 21 dias. Complicações apareceram em quatro pacientes (44%) e a mortalidade foi nula. Conclusão: o trauma da árvore traqueobrônquica é raro, pode evoluir com poucos sintomas, o que dificulta o diagnóstico imediato, e apresenta alto índice de complicações embora com baixa mortalidade.

Escore de alerta precoce modificado: avaliação de pacientes traumáticos / Puntuación de alerta temprana modificada: evaluación de los pacientes traumáticos / Modified early warning score: evaluation of trauma patients

RESUMO Objetivo: identificar a gravidade de pacientes admitidos em uma emergência de trauma. Método: estudo transversal e retrospectivo realizado com 115 pacientes com trauma, classificados como laranja (Sistema de Manchester), no período de junho de 2013 a julho de 2014. Os dados foram apresentados por média e desvio padrão, além dos testes Qui-quadrado de Pearson, One-Way ANOVA e Tukey. Resultados: da amostra, 81,7% eram do sexo masculino, com idade média de 39,46±19,71 anos. Maior ocorrência por trauma maior (48,7%) e traumatismo cranioencefálico (37,4%). No desfecho final e MEWS, a maioria dos casos que obtiveram escore de 1 a 3 foi encaminhada ao centro cirúrgico e à CTI. Conclusão: o MEWS inicial foi de 2 a 3 pontos, havendo evolução significativa do quadro de gravidade dos pacientes atendidos após 6 horas, sendo que aproximadamente metade dos indivíduos avaliados sofreu intervenção cirúrgica, indicando que a escala é um bom preditivo de gravidade.

RESUMEN Objetivo: identificar la gravedad de los pacientes ingresados en un trauma de emergencia. Método: estudio transversal y retrospectivo realizado en 115 pacientes con traumatismos clasificados como naranja (sistema de triage Manchester) a partir de junio de 2013 hasta julio de 2014. Los datos se presentaron como media y desviación estándar, y prueba de chi-cuadrado Pearson, ANOVA de una vía y Tukey. Resultados: 81,7% de hombres, edad media 39,46±19,71 años. Mayor incidencia de traumatismos graves (48,7%) y lesión cerebral traumática (37,4%). En el resultado final y MEWS (modified early warning score - puntuación de alerta temprana modificada), la mayoría de los casos tenían una puntuación de 1-3 y se remitieron a la sala de operaciones y UCI (unidad de cuidados intensivos). Conclusión: la puntuación inicial MEWS fue de 2 a 3 puntos, con un aumento importante en la gravedad de la situación de los pacientes atendidos después de 6 horas, y aproximadamente la mitad de los individuos se sometieron a la cirugía, lo que indica que la escala es un buen predictor de la gravedad.

ABSTRACT Objective: to identify the severity of patients admitted to an emergency trauma. Method: A cross-sectional and retrospective study with 115 trauma patients classified as orange (Manchester System), from June 2013 to July 2014. The data were presented as mean and standard deviation, in addition to the Pearson Chi-square test, One-Way ANOVA and Tukey tests. Results: from the sample, 81.7% were male with mean age of 39.46±19.71 years. Higher incidence of major trauma (48.7%) and traumatic brain injury (37.4%). At the end of the outcome and MEWS, most cases that had score 1 to 3 were referred to the operating room and the ICU. Conclusion: the start point of MEWS was 2 to 3 points, with significant increase in the severity of the situation of patients seen after 6 hours, and approximately half of the individuals underwent surgery, indicating that the scale is a good predictor of severity.

Atención del dolor en el paciente politraumatizado en el Hospital Militar Central "Dr. Carlos J. Finlay" / Pain management in the multi-trauma patient in ¨Dr Carlos J. Finlay¨ central military hospital

INTRODUCCIÓN: los traumatismos se han relacionado siempre con el dolor como síntoma acompañante que influye negativamente en la evolución del paciente. OBJETIVO: valorar la atención a los pacientes politraumatizados en lo referente a la evaluación y tratamiento del dolor. MÉTODO: se realizó un estudio observacional, retrospectivo, de corte transversal, de enero a diciembre de 2013, en una muestra de 60 pacientes que ingresaron con diagnóstico de politrauma, en el Hospital Militar Central "Dr. Carlos J. Finlay". Se emplearon como descriptores estadísticos medidas de resumen de los datos cualitativos (razones y proporciones). RESULTADOS: el 83,3 % de los pacientes refirió dolor al menos una vez durante el ingreso; en 51,7 % se le evaluó el síntoma, utilizando la escala verbal simple en el 26,7 %; en el resto no se usó ninguna escala. Los antinflamatorios no esteroideos se indicaron en todos los casos, con gran variabilidad en relación a las dosificaciones e intervalos de administración. Fue escasa el uso de opioides (6,7 %), ketamina (3,4 %), anestésicos locales (3,4 %) y coadyuvantes (1,7 %). Prevaleció la indicación a demanda, administrándose la analgesia en este grupo en el 46,7 %. No se evaluó la reducción del dolor en el 50 % de los casos en que se administró la analgesia, constatándose su reducción solo en el 42,9 %. En el 91,7 % de la muestra se valoró el tratamiento como inadecuado. CONCLUSIONES: la evaluación y el tratamiento analgésico son inadecuados, confirmando la necesidad de implementar estrategias para mejorar el control del dolor en el trauma.

INTRODUCTION: trauma has been related always with pain as an accompanist symptom that affects negatively the evolution of the patient. This work aspire to value the attention to polytrauma patient refers to evaluation and treatment of the pain. METHODS: an observational, retrospective, transversal study was made, since January until December of 2013. The sample was 60 patients received in "Dr. Carlos J. Finlay" Military Central Hospital with polytrauma. Stadistics measures descriptors were employed (reasons and proportions). RESULTS: the 83.3 % of the patients reports pain, at least one time during the intern; only 56.0 % of these were evaluated; in 51.7 % of the sample were evaluated the symptom; in 26.7 % of the sample was used a verbal scale; the rest of the patients were no evaluated. In all of cases were used non-steroids anti-inflammatory drugs, with doses and administration intervals vary. The use of opioids (6.7 %), ketamina (3.4 %), local anesthesics (3.4 %) and support drugs (1.7 %) were poor. Prevail the demand indication (88.3 %), using indicate analgesia in 46.7 % of the sample. The reduction of pain was evaluated in 50.0 % of cases that received analgesia; verify it only in 42.9 % of patients. In 91.7 % of the sample was valued the treatment as inadecuated. CONCLUTIONS: the evaluation and treatment of pain is deficient, confirm the necessity of implement strategies of properties actuations.

Manejo inicial del politraumatizado / Initial management of politraumatized patient

Trauma is today the first cause of death in young population; Motor vehicle crashes (MVC’s) are the main specific cause. The initial approach of the trauma patient takes place in the prehospital and hospital environment, following a systematic evaluation and priorizing some systems above others. Primary evaluation (with the classic sequence: ABCDE), sets intervention priorities that ultimately target a reduction in trauma early mortality. The in-corporation of ultrasonography in the evaluation of the trauma patient, has been fundamental in searching for injuries that may have been overlooked in the primary evaluation. Injuries that compromise ventilation may cause hypoxemia and hemodynamic instability. Early bleed control is the main therapeutic target in the trauma patient with active hemorrhage, which leads to reduction of early mortality and also prevents future complications. Fluid resuscitation is the main intervention to restore tissue perfusion. Also, the use of transfusional therapy, permissive hypotension and tranexamic acid must also be considered. Emergency Ultrasound is today a fundamental instrument in the initial trauma patient evaluation, because it greatly contributes to the evaluation of ventilatory derangement and hemodynamic instability causes. Finally, one must remember that trauma is a dynamic process, and therefore reevaluating is imperative, especially because findings of neurological deficit or deterioration in time, will ultimately conduct to the diagnose of injuries that cause brain hypoperfusion...

Diagnósticos reais e proposta de intervenções de enfermagem para os pacientes vítimas de múltiplos traumas / Real diagnoses and nursing intervention proposals for multiple trauma victims / Diagnósticos reales y propuesta de intervenciones de enfermería para pacientes víctimas de múltiples traumas

Estudo quantitativo descritivo realizado em uma emergência hospitalar de referência em traumatologia cujo objetivo foi identificar os diagnósticos de enfermagem apresentados por pacientes vítimas de múltiplos traumas atendidos no período de fevereiro a abril de 2012 e, posteriormente, propor intervenções de enfermagem. Foram avaliados 41 pacientes encaminhados por serviços de atendimento pré-hospitalar, maiores de 18 anos, de ambos os sexos e não gestantes utilizando como referencial teórico a Taxonomia II da NANDA Internacional e a Nursing Interventions Classification. Foram identificados 25 diagnósticos. Os mais prevalentes foram: dor aguda; mobilidade física prejudicada; deambulação prejudicada; déficit no autocuidado para banho; déficit no autocuidado para vestir-se; déficit no autocuidado para higiene íntima; mobilidade no leito prejudicada; capacidade de transferência prejudicada; integridade da pele prejudicada; integridade tissular prejudicada; déficit no autocuidado para alimentação; padrão respiratório ineficaz. Após, foram propostas 82 intervenções de enfermagem que pudessem propiciar uma redução de danos a esses pacientes.

This descriptive quantitative study was performed at a reference trauma hospital emergency room with the objective to identify the nursing diagnoses presented by multiple trauma victims treated between February and April of 2012 and, next, propose nursing interventions. Evaluations were conducted with 41 patients referred by pre-hospital care services. All patients were 18 years of age or older, male and female, not pregnant and using the NANDA International Taxonomy II and Nursing Interventions Classification. Among the 25 identified diagnoses, the most prevalent were: acute pain; impaired physical mobility; impaired walking; bathing self-care deficit; dressing self-care deficit; intimate hygiene self-care deficit; impaired bed mobility; impaired transfer ability; impaired skin integrity; impaired tissue integrity; feeding self-care deficit; and ineffective respiratory pattern. Nest, 82 nursing interventions were proposed aiming to reduce patient harm.

Estudio cuantitativo, descriptivo, realizado en servicio de urgencias de hospital de referencia en traumatología, objetivando identificar diagnósticos de enfermería presentados por pacientes víctima de múltiples traumas atendidos entre febrero y abril 2012 y, posteriormente, proponer intervenciones de enfermería. Fueron evaluados 41 pacientes, derivados por servicios prehospitalarios, mayores de 18 años, ambos sexos, no gestantes. Se utilizaron como referenciales teóricos: Taxonomía II de NANDA Internacional y Nursing Interventions Classification. Identificados 25 diagnósticos, los más prevalentes: dolor agudo; deterioro de la movilidad física; deterioro de la ambulación; déficit de autocuidado: baño; déficit de autocuidado: vestido; déficit de autocuidado: uso del inodoro; deterioro de movilidad en la cama; deterioro de habilidad para la traslación; deterioro de integridad de la piel; deterioro de habilidad para traslación; perfusión tisular periférica ineficaz; déficit de autocuidado: alimentación; deterioro de ventilación espontánea. Fueron propuestas luego 82 intervenciones de enfermería que posibilitaran reducción del padecimiento de los pacientes.

Fratura de pênis com trauma uretra / Penile fracture with urethral trauma

We reported a case of a twenty-nine-year-old male who presented a penile fracture associated with urethral injury caused by a sexual intercourse. An ideal anamnesis and a special physical examination were determinant to correct diagnostics. Ultrasonography and uretrocistography must be performed for confirmation. The treatment is based on the presence of associated urethral injury. The surgical repair of cavernous body and urethra can produce good results, with a favorable prognosis and minimal rate of complications.

Ressuscitação no trauma / Trauma resuscitation

Este texto aborda a avaliação inicial e o manejo sistematizado da criança vítima de trauma, assim comoas particularidades da ressuscitação no trauma crânio-encefálico.

This paper discusses the initial assessment and systematic management of the pediatric trauma victim,as well as the peculiarities of resuscitation of head injured children.

Missed Injuries in Multiple Trauma Patients: a Tertiary Care Experience in Tanzania

Background: Missed injuries remain a worldwide problem in all trauma centers and contribute significantly to high morbidity and mortality among trauma patients. There is paucity of information regarding missed injuries in Tanzania. The aim of this study was to establish the incidence; contributing factors; and short-term outcome of missed injuries among polytraumatized patients in our setting. Methods: This was a one-year duration (from January to December 2009) prospective cohort study involving all multiple trauma patients (ISS 16) admitted to Bugando Medical Centre. After informed consent to participate in the study; all patients were consecutively enrolled in the study. Data was collected using a pre-tested; coded questionnaire and analyzed using SPSS computer software version 11.5. Results: Ninety six of 462 patients (incidence; 20.1) had 112 missed injuries. Head and the neck (46.4) was the most common body region affected. Clinical error (57.1) was the most common factor contributed to the occurrence of missed injuries. Of the factors contributing to missed injuries; 57.4were potentially avoidable and 42.6were unavoidable. There was statistically significant difference in the mean ISS; mean GCS; orotracheal intubation; patient's arrival time and seniority of the attending doctor between patients with missed injuries and those without missed injuries (p-value 0.001). Mortality in patients with missed injuries was 19.8compared with 8.7in patients without missed injuries (p-value 0.001). Among the deaths in patients with missed injuries; 57.9were directly attributable to missed injuries (O.R. = 14.8; p-value =0.001; 95CI = 6.1- 32.46). Patients with missed injuries had longer stays in the hospital compared with patients without missed injuries (p-value 0.001). Conclusion: The incidence of missed injuries at BMC is high in patients with high ISS; low GCS; orotracheal intubation and those who reported during night hours. A high index of suspicious is needed when dealing with such a group of patients. The majority of missed injuries are potentially avoidable by repeated assessments both clinically and radiologically and by staff redistribution to address the increase of missed injuries during night hours. Implementation of a tertiary trauma survey should be routine in the Accident et Emergency department to minimize the occurrence of missed injuries.) had 112 missed injuries. Head and the neck (46.4) was the most common body region affected. Clinical error (57.1) was the most common factor contributed to the occurrence of missed injuries. Of the factors contributing to missed injuries; 57.4were potentially avoidable and 42.6were unavoidable. There was statistically significant difference in the mean ISS; mean GCS; orotracheal intubation; patient's arrival time and seniority of the attending doctor between patients with missed injuries and those without missed injuries (p-value 0.001). Mortality in patients with missed injuries was 19.8compared with 8.7in patients without missed injuries (p-value 0.001). Among the deaths in patients with missed injuries; 57.9were directly attributable to missed injuries (O.R. = 14.8; p-value =0.001; 95CI = 6.1- 32.46). Patients with missed injuries had longer stays in the hospital compared with patients without missed injuries (p-value 0.001). Conclusion: The incidence of missed injuries at BMC is high in patients with high ISS; low GCS; orotracheal intubation and those who reported during night hours. A high index of suspicious is needed when dealing with such a group of patients. The majority of missed injuries are potentially avoidable by repeated assessments both clinically and radiologically and by staff redistribution to address the increase of missed injuries during night hours. Implementation of a tertiary trauma survey should be routine in the Accident et Emergency department to minimize the occurrence of missed injuries

Neumonía y ventilación mecánica: estudio de un año(2006-2007) en la UCIE / Pneumonia and mechanic ventilation- one-year study (2006-2007) at the Specialized Intensive Care Unit

La estabilidad funcional del pulmón tiene una estrecha relación con los mecanismos defensores propios de su estructura. Cuando estos mecanismos se deterioran provocan las infecciones que conllevan a neumonías y entre ellas las asociadas a la ventilación mecánica. El objetivo de este trabajo fue valorar el comportamiento de las neumonías asociadas a la ventilación como un indicador de calidad asistencial. Se realizó un estudio descriptivo-transversal, se tomó una muestra de 130 pacientes por el método EPIDAT, de un universo de 1930, que fueron atendidos en la Unidad de Cuidados Intensivos y Emergencia del hospital Clínico Quirúrgico de Matanzas entre enero de 2006 y diciembre de 2007. Para obtener el dato primario se revisaron la totalidad de las historias clínicas, y se confeccionó un formulario con las siguientes variables: grupo de edad, sexo, afecciones que propiciaron la ventilación, movilización del paciente según enfermedad, tiempo de aparición de los síntomas y evolución de las neumonías. Se encontró que 23 pacientes entre 60-65 años (25,5 por ciento) fueron los más vulnerables a presentar neumonía asociada a ventilación mecánica, el sexo masculino predominó con 22 pacientes lo que representó el (24.4 por ciento) de las entidades por la cual se indicó ventilación mecánica, el politrauma y los traumatismos craneoencefálicos fueron lo más representativos (83.3 por ciento) Estos pacientes se derivaron a Unidades de Cuidados Intensivos Polivalentes. Los síntomas de esta afección aparecieron en un período de 24 a 48 horas en 11 pacientes (8.4 por ciento) y 40 pacientes la desarrollaron en el plazo de 4 a 6 días cuando la estadía de estos casos aumento en el servicio por la no disponibilidad de camas en las unidades del grave.

The functional stability of the lung presents a tight relation with the proper defense mechanisms of its structure. When these mechanisms get deteriorated they cause the infections leading to pneumonias, including those associated to the mechanical ventilation. The objective of this work was valuing the behavior of those pneumonias associated to ventilation as an indicator of health care quality. We carried out a descriptive-transversal study, using the EPIDAT method, with a sample of 130 patients from a universe of 1930 patients attended at the Specialized Intensive Care Unit of the Surgical Clinical Hospital of Matanzas in the period from January 2006 to December 2007. To obtain the primary data all the clinical histories were reviewed and a and a form was designed collecting the following data: age, sex, affections leading to the ventilation, mobilization of the patient according to the disease, time of the symptoms beginning and evolution of the pneumonias. We found that 23 patients between 60 and 65 years old (25.5 percent) were the most vulnerable for presenting pneumonia associated to mechanical ventilation. The male sex was predominant with 22 patients representing 24.4 percent of the entities in which the mechanical ventilation was indicated. The polytrauma and the crania-encephalic traumas were the most representative ones (83.3 percent). These patients were sent to Polyvalent Intensive Care Units. The symptoms of this disease appeared in a period of 24 to 48 hours in 11 patients (8.4 percent) and 40 patients developed the disease in a term of 4 to 6 days when the staying.

Endoscopic cystogastrostomy.

Endoscopic cystoenterostomy for drainage of pancreatic pseudocyst is a new emerging modality which has rarely been reported in pediatric patients. Only ten successfully performed cases of pediatric endoscopic cystoenterostomy have been reported previously. We report a case of 9 year old male child with post traumatic pseudocyst of pancreas, successfully managed by endoscopic cystogastrostomy. To best of our knowledge, this is the first pediatric case report in Indian literature.

Reconstruction of body injuries leads to unraveling mystery behind unidentified mutilated skeletonised human remains.

Medico legists are frequently requisitioned by investigating agencies to examine and opine regarding identity, cause, manner & time since death of unidentified mutilated decomposed/ skeletonised human remains. Such an opinion in some of these cases can be very intriguing or even impossible to make. However, availability and examination of relevant facts/ information/ documents with regards to circumstantial evidences and their corroboration with autopsy findings including reconstruction of body injuries and examination of articles pertinent to the case can do wonders in this regard. The case relates to unidentified mutilated human remains in advanced stage of decomposition, partial adipocere formation, near skeletonisation & partial mutilation, recovered from a ground well not in use for drinking water purpose, tied to a heavy stone slab. The pelvis and left Femur bones showed sharp cut injuries in unique and patterned fashion. The paper discusses important issues of reconstructive Forensic Medicine in the light of the given case.

Atendimento oftalmológico ao paciente politraumatizado: classificação e fatores prognósticos / Ophthalmic approach to tje politraumatized patient: classification and prognostic factors

Os traumatismos oculares são encontrados frequentemente nos pacientes politraumatizados. Para diminuir o risco de morte, de sequelas físicas e visuais, devemos identificar, classificar e prognosticar adequadamente as diversas lesões envolvidas. Este trabalho tem por objetivo analisar as classificações e os índices do trauma geral e oftalmológico, permitindo uma melhor abordagem de cada caso, pelos oftalmologistas da emergência, num contexto multidisciplinar.

Epidemiología de Campo: FETP II Guatemala

Contiene: Investigación de campo (Brotes de Malaria, Enfermedad Diarreica, Intoxicación por Alimentos, Leptospirosis), Análisis de Vigilancia (Malaria, Virus respiratorio e Influenza, deshidratacion), Estudios Epidemiológicos (Vacunación, Infecciones respiratorias, lesiones, hipertensión arterial), Presentaciones en conferencias científicas internacionales.

Mortality and injury from motorcycle collisions in Phetchaburi Province.

A retrospective analysis was done in 3,225 injured motorcyclists treated at Phra Chom Klao Hospital between April 1, 1999 and March 31, 2000. The peak of all motorcycle crashes was found between 6 p.m. and 9 p.m. Male motorcycle riders accounted for 69 per cent of the accident population, and most riders were under 21 years of age. Approximately 21 per cent of the accident-involved riders had been drinking alcohol and about half of the riders were unlicensed. Only 4 per cent of the riders were wearing helmets at the time of the accident. Helmet usage was much lower among passengers, only about 1 per cent. The upper and lower extremities were injured most frequently, although these injuries were not life threatening. The most fatal injuries to the motorcyclists were to the head, abdomen, and chest in decreasing frequency.

Tratamiento Medico del Traumatismo Encefalocraneano Grave: Experiencia de la U.T.I. del Hospital "Santa Barbara" con 50 pascientes que evolucionaron favorablemente / Health Treatment of the traumatic Encephalocraneal injuries burden: experience of the UTI of hospital Santa Barbara with 50 patients who evolved favorably

Se revisa la casustica, complicaciones y mortalidad del traumatismo encefalo craneano grave, en la Unidad de Terapia Intensiva del Hospital de Clinicas Santa Barbara desde febrero del 2001 hasta agosto del 2003. ademas analizar, el protocolo de tratamiento medico.