Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries / 中华创伤杂志(英文版)

PURPOSE@#To develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees' performance for emergent and urgent thoracic surgeries.@*METHODS@#With a homemade machine, animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage, urgent sternotomy, and emergent thoracotomy. Coefficient of variation of abbreviated injury scale and blood loss was calculated to judge the reproducibility of animal models. Five operation teams from basic-level hospitals (group A) and five operation teams from level III hospitals (group B) were included to be trained and tested. Testing standards for the operations were established after thorough literature review, and expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards. Tests were carried out after the training. Pre- and post-training performances were compared. Post-training survey using 7-point Likert scale was taken to evaluate the feelings of the trainees to these training approaches.@*RESULTS@#Animal models of the three kinds of penetrating chest injuries were successfully established and the coefficient of variation of abbreviated injury scale and blood loss were all less than 25%. After literature review, testing standards were established, and expert questionnaire results showed that the scientific score was 7.30 ± 1.49, and the feasibility score was 7.50 ± 0.89. Post-training performance was significantly higher in both group A and group B than pre-training performance. Post-training survey showed that all the trainees felt confident in applying the operations and were generally agreed that the training procedure were very helpful in improving operation skills for thoracic penetrating injury.@*CONCLUSIONS@#Animal model-based simulation training established in the current study could improve the trainees' performance for emergent and urgent thoracic surgeries, especially of the surgical teams from basic-level hospitals.

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.

Hallazgos tomográficos posoperatorios en pacientes con traumatismos torácicos / Tomographic postoperative findings in patients with thoracic trauma

Introducción: El trauma torácico se encuentra entre las primeras causas de muerte, fundamentalmente en personas jóvenes. Objetivos: Caracterizar a una población operada por traumatismos torácicos según variables clinicoepidemiológicas y describir los hallazgos tomográficos posquirúrgicos. Métodos: Se llevó a cabo un estudio observacional y descriptivo de 48 pacientes atendidos en el Servicio de Radiología del Provincial Clínico-Quirúrgico Docente Saturnino Lora de Santiago de Cuba, de enero del 2016 a diciembre del 2018, a los cuales se les realizó tomografía computarizada multidetector. Resultados: Los traumas torácicos predominaron en personas jóvenes del sexo masculino, asociadas fundamentalmente a acciones violentas que provocaron traumas abiertos. La contusión pulmonar resultó ser el hallazgo tomográfico inicial más frecuente, en tanto, el neumotórax persistente y el hemotórax coagulado constituyeron los hallazgos tomográficos más influyentes en la decisión de una reintervención quirúrgica. Conclusiones: La tomografía es un medio diagnóstico que permite una descripción detallada del estado posoperatorio de los órganos afectados, con un alto valor orientativo para decidir procedimientos quirúrgicos posteriores.

Introduction: The thoracic trauma is among the first causes of death, fundamentally in young people. Objectives: To characterize a population operated due to thoracic trauma according to clinical epidemiological variables and describe the postsurgical tomographic findings. Methods: An observational and descriptive study of 48 patients assisted in the Radiology Service of Saturnino Lora Teaching Clinical Surgical Provincial Hospital was carried out in Santiago de Cuba, from January, 2016 to December, 2018, to whom a multidetector computed tomography was carried out. Results: The thoracic traumas prevailed in young male people, fundamentally associated with violent actions that caused open traumas. The lung contusion was the most frequent initial tomographic finding, as long as, the persistent pneumothorax and the coagulated hemothorax constituted the most influential tomographic findings in the decision of a surgical reintervention. Conclusions: Tomography is a diagnostic means that allows a detailed description of the postoperative state in the affected organs, with a high orientative value to decide later surgical procedures.

Manejo actualizado de las fracturas costales / Current management of rib fractures

RESUMEN Las fracturas costales son la lesión más frecuente en los traumatismos torácicos. La fijación de las fracturas ha estado dirigida clásicamente al volet costal. En los últimos años se han extendido las indi caciones a las fracturas múltiples desplazadas aun sin volet. Se consideran asimismo otras indicaciones de osteosíntesis menos frecuentes. La neumonía y contusión pulmonar graves que requieren asisten cia respiratoria mecánica son consideradas contraindicaciones para la fijación quirúrgica. La primera semana es el momento óptimo para su realización. Diversos dispositivos de fijación se han ideado; las placas de titanio son las más utilizadas. La osteosíntesis costal ofrece a los pacientes una recuperación más rápida con menor estadía hospitalaria y en cuidados críticos, así como mejor funcionalidad respi ratoria y menor dolor en el corto y largo plazo.

ABSTRACT Rib fractures are the most common injuries in chest trauma. Fracture fixation has been traditionally performed in flail chest patients. Over the past years, the indication has been extended to multiple, severely displaced non-flail pattern fractures. Other less common indications for osteosynthesis have also been considered. Severe pneumonia and lung contusion requiring mechanical ventilation are considered contraindication for surgical fixation. The optimal timing for the intervention is the first week. Several devices have been developed for fracture fixation; titanium plates are the most commonly used. Rib fixation offers patients a more rapid recovery with shorter length of hospital stay and of intensive care unit stay with improved respiratory function and pain management in the short and long term.

Traumatismo torácico por arma de fuego / Thoracic trauma by firearms

Resumen Introducción: Los traumatismos torácicos por armas de fuego (TTAF) son cada vez más frecuentes. Objetivos: Describir características clínicas, morbilidad, mortalidad y la evolución a través del tiempo de hospitalizados por TTAF. Materiales y Método: Estudio analítico longitudinal. Período enero de 1981-diciembre de 2018. Revisión base de datos, protocolos prospectivos y fichas clínicas. Se utilizó planilla Microsoft Excel® y programa SPSS24® con chi cuadrado y de Mann-Whitney. Descripción de características de TTAF en pacientes hospitalizados y comparación por períodos. Se calcularon índices de gravedad del traumatismo (IGT): Injury Severity Score (ISS), Revised Trauma Score (RTS-T), Trauma Injury Severity Score (TRISS). Resultados: Total 4.306 pacientes hospitalizados por traumatismo torácico (TT), 205 (4,8%) hospitalizados por TTAF. Hombres: 188 (91,7%), edad promedio 28,8 ± 11,2 años, TTAF aislado 115 (56,1%), asociado a lesiones extratorácicas 90 (43,9%), de estos 55 (26,8%) se consideraron politraumatismos. Mecanismo: Agresión 193 (94,1%), autoagresión 11 (5,4%) y accidental 1 (0,5%). Lesiones y/o hallazgos torácicos más frecuentes: Hemotórax 127 (62,0%), neumotórax 96 (46,8%) y contusión pulmonar 51 (24,9%). Tratamiento definitivo: Pleurotomía 88 (42,9%), cirugía 71 (34,6%) y tratamiento médico 46 (22,4%). Mediana de hospitalización 7 días. Según IGT: ISS promedio 16,7 ± 11,7, RTS-T promedio 11,1 ± 2,1, TRISS promedio 9,6. Morbilidad: 44 (21,5%). Mortalidad: 14 (6,8%). En los diferentes períodos, se observó aumento de politraumatismos y TRISS, sin cambios en mortalidad. Discusión: La mayoría de los TTAF fueron aislados. Aproximadamente un tercio de los pacientes requirió cirugía. La mortalidad observada es menor a la esperada. Se observan cambios en los TTAF a través del tiempo.

Background: Thoracic trauma by firearms (TTF) are increasingly frequent. Aim: To describe clinical characteristics, morbidity and mortality and the evolution over time of patients hospitalized due TTF. Materials and Method: Longitudinal analytical study. Period January 1981 - December 2018. Database review, prospective protocols and clinical files. Microsoft Excel® spreadsheet and SPSS24® program with chi square and Mann-Whitney tests were used. Description of characteristics of TTF in hospitalized patients and comparison of TTF by periods. Trauma severity indexes (TSI) were calculated: Injury Severity Score (ISS), Revised Trauma Score (RTS-T), Trauma Injury Severity Score (TRISS). Results: Total: 4306 hospitalized patients due thoracic trauma (TT), 205 (4.8%) hospitalized due TTF. Men: 188 (91.7%), average age 28.8 ± 11.2 years, isolated TTF 115 (56.1%), associated with extrathoracic lesions 90 (43.9%), and of these 55 (26.8%) were considered polytraumatism. Mechanisms: aggression 193 (94.1%), self-harm 11 (5.4%) and accidental 1 (0.5%). Frequent thoracic injuries and/or findings: hemothorax 127 (62.0%), pneumothorax 96 (46.8%) and pulmonary contusion 51 (24.9%). Definitive treatment: Pleurotomy 88 (42.9%), surgery 71 (34.6%) and medical treatment 46 (22.4%). Median hospitalization 7 days. According TSI: Average ISS 16.7 ± 11.7, average RTS-T 11.1 ± 2.1, average TRISS 9.6. Morbidity: 44 (21.5%). Mortality: 14 (6.8%). There is an increase in polytraumatism and average TRISS, without changes in mortality. Discussion: The majority of TTF were isolated TT. Approximately one third of patients required surgery. The observed mortality is lower than expected. Changes in TTF were observed over time.

Traumatismo torácico por arma blanca / Thoracic trauma by a bladed weapon

Resumen Objetivos Describir las características, índices de gravedad de traumatismo (IGT), morbilidad, mortalidad y factores asociados a mortalidad en pacientes hospitalizados por traumatismo torácico por arma blanca (TTAB). Materiales y Método Estudio analítico transversal. Período enero de 1981 a diciembre de 2017. Revisión base de datos prospectiva, protocolos quirúrgicos, fichas clínicas. Se describe y compara las características de los TTAB. Se calculó IGT: Injury Severity Score (ISS), Revised Trauma Score ( RTS-T) y Trauma Injury Severity Score (TRISS). Resultados Total 4.163 pacientes hospitalizados por TT, 2.286 hospitalizados por TTAB. Hombres: 2.131 (93,2%), edad promedio 27,8 ± 10,7 años, TTAB aislado 2.035 (89,0%), asociado a lesiones extratorácicas 251 (11,0%) y de éstos 124 (5,5%) se consideraron politraumatismos. Mecanismos principales del traumatismo: agresión 2.246 (98,3%) y autoagresión 22 (1,0%). Lesiones y hallazgos torácicos más frecuentes: neumotórax 1.473 (64,4%), hemotórax 1.408 (61,6%), enfisema subcutáneo 485 (21,2%). Tratamiento definitivo: pleurotomía 1.378 (60,3%), cirugía torácica 537 (23,5%) y tratamiento médico 370 (16,2%). Hospitalización promedio 6,2 ± 6,5 días, IGT: ISS promedio 10,9 ± 7,2, RTS-T promedio 11,6 ± 1,4 y TRISS promedio 3,6. Morbilidad: 318 (13,9%). Mortalidad: 32 (1,4%). Conclusión Los TTAB ocurren frecuentemente en hombres jóvenes por agresión. La mayoría se puede tratar con pleurotomía exclusiva.

Aim Our objectives are to describe and correlate the clinical characteristics, trauma severity indexes (TSI) and morbidity and mortality in patients hospitalized for thoracic trauma by a bladed weapon (TTBW). Materials and Method Transversal analytic study. Period January-1981 to December-2017. Prospective database review, surgical protocols, clinical files. The characteristics of the TTBW are described and compared. Injury Severity Score (ISS), Revised Trauma Score (RTS-T) and Trauma Injury Severity Score (TRISS) were calculated. Results Total of 4,163 patients hospitalized for TT, 2,286 hospitalized for TTBW. Men: 2,131 (93.2%), average age 27.8 ± 10.7 years, isolated TTBW 2,035 (89.0%), associated with extra thoracic injuries 251 (11.0%) and of these 124 (5.5%) were considered polytrauma. Main mechanisms of trauma: Aggression 2,246 (98.3%) and self-aggression 22 (1.0%). Most frequent injuries and thoracic findings: pneumothorax 1,473 (64.4%), hemothorax 1,408 (61.6%), subcutaneous emphysema 485 (21.2%). Definitive treatment: Pleurotomy 1,378 (60.3%), thoracic surgery 537 (23.5%) and medical treatment 370 (16.2%). Average hospital stay: 6.2 ± 6.5 days. ISS average 10.9 ± 7.2, RTS-T average 11.6 ± 1.4 and TRISS average 3.6. Morbidity: 318 (13.9%). Mortality: 32 (1.4%). Discussion TTBW are frequent in our environment, unlike on an international level. Conclusions TTBW frequently occur in young male patients due to aggression. The majority can be treated with exclusive pleurotomy.

Tórax inestable en paciente pediátrico: reporte de un caso / Flail chest in pediatric patient: case report

El tórax inestable se define por fractura de 3 o más costillas adyacentes, en 2 o más sitios, con movimiento paradojal del tórax afectado. Se presenta en el 2-4 % de los traumas de tórax contusos, con una mortalidad del 10-15 %.El tratamiento se realiza de forma conservadora, mediante analgesia y el uso de ventilación con presión positiva o, quirúrgicamente, mediante osteosíntesis de las fracturas costales.Se presenta el caso de una niña de 9 años con diagnóstico de traumatismo cerrado de tórax y tórax inestable. En la tomografía computada, se evidenciaron fracturas costales de 2da a 7maizquierdas, arcos medios y anteriores. Por inadecuado manejo del dolor, se colocó asistencia ventilatoria mecánica. A las 72 horas, se decidió la resolución quirúrgica mediante osteosíntesis de las costillas 3a-7a. La paciente evolucionó favorablemente. El manejo quirúrgico permitió reducir los días de ventilación mecánica y de internación.

Flail chest is defined by fracture of 3 or more adjacent ribs, at 2 or more sites, with paradoxical movement of the affected chest. It occurs in 2 to 4 % of blunt chest trauma, with a mortality of 10 to 15 %.Treatment is conservative, using analgesia and positive pressure ventilation, or surgical osteosynthesis of rib fractures.We present the case of a 9-year-old girl with blunt chest trauma and flail chest. Computed tomography showed rib fractures from 2nd to 7th left ribs, in middle and anterior arches. Due to inadequate pain management, it was placed in mechanical ventilation. After 72 hours the surgical resolution was decided, osteosynthesis of the 3rd to 7th ribs was performed. The patient evolved favorably. The surgical management allowed reducing days of mechanical ventilation and days of hospitalization.

Controle de danos para lesão de artéria subclávia / Damage control for subclavian artery injury

Resumo Os traumas penetrantes de vasos subclávios atingem mortalidade de até 60% em um cenário pré-hospitalar. A mortalidade no intraoperatório varia de 5-30%. Apresenta-se um caso de estratégia de controle de danos para um paciente com lesão na origem da artéria subclávia esquerda, através de ligadura, sem necessidade de outra intervenção, mantendo a viabilidade do membro superior esquerdo por meio de circulação colateral. Os autores fazem uma revisão sobre vias de acesso e estratégias de tratamento com ênfase em controle de danos para lesões de vasos subclávios.

Abstract Mortality from penetrating traumas involving the subclavian vessels can be as high as 60% in pre-hospital settings. Operating room mortality is in the range of 5-30%. This paper presents a case in which a strategy for damage control was employed for a patient with an injury to the origin of the left subclavian artery, using subclavian ligation, with no need for any other intervention, and maintaining viability of the left upper limb via collateral circulation. The authors also review surgical approaches and treatment strategies with a focus on damage control in subclavian vessel injuries.

Fraturas de esterno em uma unidade de tratamento intensivo especializada em trauma / Sternal fractures in a level III trauma intensive care unit

RESUMO Objetivo: avaliar epidemiologia, características anatômicas, manejo e prognóstico de pacientes críticos com fraturas de esterno. Métodos: análise retrospectiva de pacientes internados em unidade de terapia intensiva (UTI) de emergências cirúrgicas e trauma de um centro de trauma Tipo III em São Paulo, Brasil. Resultados: foram admitidos 1552 pacientes traumatizados no período de janeiro de 2012 a abril de 2016. Desses, 439 apresentavam trauma torácico e 13 apresentavam fratura de esterno, configurando 0,9% das admissões de trauma e 3% dos traumas torácicos. Desses pacientes, três apresentavam tórax instável e dois foram submetidos à conduta cirúrgica para fixação da fratura. A mortalidade de pacientes com fratura de esterno foi de 29% (três pacientes). Em um dos óbitos pôde-se atribuir a fratura do esterno como contribuinte principal para o desfecho. Conclusão: a fratura de esterno foi diagnosticada em 0,9% dos pacientes críticos vítimas de trauma em UTI especializada. Somente 15% dos pacientes necessitaram de conduta cirúrgica específica na fase aguda e a mortalidade foi decorrente das outras lesões na maior parte dos casos.

ABSTRACT Objective: to evaluate epidemiology, anatomical characteristics, management, and prognosis of critical patients with sternum fractures. Methods: retrospective analysis of patients admitted to intensive care unit (ICU) of a Level III trauma center in Sao Paulo, Brazil. Results: 1552 trauma patients were admitted from January 2012 to April 2016. A total of 439 patients had thoracic trauma and among these, 13 patients had sternum fracture, making up 0.9% of all trauma admissions and 3% of all thoracic trauma cases. Three of these 13 patients had unstable chest, two underwent surgical management for fracture fixation, and three died (mortality was of 29%). In one of the deaths, sternum fracture was assessed as the main contributor to the outcome. Conclusion: sternum fracture was diagnosed in 0.9% of critical trauma patients in a specialized ICU. Only 15% of patients required specific surgical management in the acute phase. In most cases, mortality was due to other injuries.

Outcome Evaluation of Patients with Burst Thoracolumbar Fractures: A Case Series

Objective The aim of the present study was to evaluate the outcome of short segment instrumentation in patients affected by burst thoracolumbar fractures. Methods A total of 19 patients with unstable burst fractures of the thoracolumbar spine were eligible for short segment instrumentation. Their functional outcome (by using the Oswestry and Denis scales) and back pain (using the visual analog scale) were evaluated after 12 months. Results Themean age of the patients was 30.7 years old, andmost of them weremale (n » 15). The mean hospital stay was 4.6 days. The mean standard deviation (SD) of the pain score according to the visual analog scale was 1.63 1.25 after 12 months of surgery, and there were no patients classified with grades 4 or 5 on the Denis work scale. The average Oswestry disability index (ODI) was 17% during the follow-ups. Conclusions The outcome of the studied patients, including the clinical pain and the functional outcome of postsurgical patients, suggested that the short-segment instrumentation could be an appropriate method for patients with unstable thoracolumbar junction fractures. However, a long-term follow-up is recommended.

Reconstrucción temprana en el tórax inestable con sistema de osteosíntesis torácico: Reporte de caso / Early unstable chest reconstruction with thoracic osteosynthesis: A case report

Se presenta el caso de un paciente varón con tórax inestable. Esta lesión es una entidad poco común que puede ser originada por múltiples traumatismos de alto impacto. El diagnóstico se estableció por signos clínicos y estudios de imágenes. El paciente recibió tratamiento quirúrgico con un sistema de osteosíntesis costal (StraCos®); se discuten los resultados obtenidos y sugerencias para casos de este tipo. (AU)

We present the case of a male patient with unstable chest, which is a rare entity that may be caused by high impact trauma. The diagnosis was stablished by clinical manifestations and image results. The patient received surgical treatment with a rib osteosynthesis. We discussed the results obtained and propose suggestions to manage this kind of patients. (AU)

Cirugía videoasistida en traumatismo de tórax / Video assisted thoracic surgery in thoracic trauma

El objetivo es discutir el manejo del hemotórax traumático con cirugía videoasistida (VATS) y una revisión de sus principales indicaciones. Se presenta el caso de un paciente con hemotórax por traumatismo penetrante. Inicialmente manejado con pleurostomía, evoluciona con persistencia del sangrado, por lo que se explora. Como hallazgo se encuentra una lesión de arteria torácica interna que se controla con clips de VATS. El paciente evoluciona estable, sin dolor, por lo que se da de alta al tercer día. El manejo quirúrgico preferido del traumatismo de tórax clásicamente ha sido la toracotomía, pero los abordajes mínimamente invasivos han ganado espacio gracias a su menor morbilidad asociada. Algunos de sus beneficios son el menor dolor en el posoperatorio, menor sangrado y menor tiempo operatorio. Algunas indicaciones validadas son el hemotórax retenido y la persistencia del sangrado, siempre que el paciente se encuentre hemodinámicamente estable y no haya sospecha de lesión cardíaca o de grandes vasos. Se concluye que la VATS es una técnica apropiada en casos seleccionados de hemotórax traumático, pero el abordaje de elección sigue siendo la toracotomía tradicional.

The objective is to discuss the use of video assisted thoracic surgery (VATS) in thoracic trauma and to review the most common indications. A young male with a hemothorax due to penetrating trauma is seen at the emergency department. Initial management with a pleural tube revealed persistence of bleeding so surgical exploration was performed. A lesion of the internal thoracic artery was found and controlled with VATS using laparoscopic clips. The patient had an uneventful postoperative course and was discharged home on the third day posterior to surgery. Usually, surgical management of thoracic trauma has been thoracotomy, but minimally invasive procedures have gained terrain in this area thanks to their lower morbility. Some benefits of these are less postoperative pain, less bleeding, and shorter surgical time. Its validated indications include retained hemothorax and persistent bleeding, but only if the patient is hemodinamically stable and cardiac or large vessel lesions are not suspected. As a conclussion, VATS is an appropriate technique for selected cases of traumatic hemothorax, but thoracotomy still remains as the prefered surgical approach.

Osteosíntesis de múltiples fracturas costales desplazadas en un paciente con tórax batiente / Osteosynthesis of multiple displaced costal fractures in a patient with flail chest

El tratamiento de las fracturas costales debe ser individualizado de acuerdo con la severidad de las lesiones y a la magnitud del trauma. El objetivo de esta investigación es presentar un caso donde se utilizaron láminas de titanio, en un paciente con fracturas múltiples de las costillas. Se reporta el caso de un paciente con múltiples fracturas costales de forma lineal y paralelas de los arcos costales con un tórax batiente, que llega al cuerpo de guardia con dolor torácico moderado y disnea. Aunque aún no existe suficiente evidencia científica a favor de los métodos de fijación costal, se realizó la fijación con láminas de titanio logrando la estabilidad de la pared, aliviando el dolor, mejorando la mecánica ventilatoria y logrando su rápida reincorporación a la sociedad(AU)

The treatment of costal fractures should be individualized according to the severity of the injuries and the magnitude of trauma. The objective of this investigation is to present a case where titanium plates were used in a patient with multiple rib fractures. We report the case of a patient with multiple rib fractures of a linear and parallel shape of the costal arches with a swinging thorax, who arrives the emergency room with moderate chest pain and dyspnea. Although there is still not enough scientific evidence that favors the costal fixation methods, the fixation with titanium plates was performed, achieving the stability of the wall, relieving pain, improving the ventilatory mechanics, and achieving the patient's quick reincorporation to the society(AU)

Predictors of chest drainage complications in trauma patients / Fatores preditores de complicações da drenagem de tórax em pacientes vítimas de trauma

ABSTRACT Objective: to identify predictors of chest drainage complications in trauma patients attended at a University Hospital. Methods: we conducted a retrospective study of 68 patients submitted to thoracic drainage after trauma, in a one-year period. We analyzed gender, age, trauma mechanism, trauma indices, thoracic and associated lesions, environment in which the procedure was performed, drainage time, experience of the performer, complications and evolution. Results: the mean age of the patients was 35 years and the male gender was the most prevalent (89%). Blunt trauma was the most frequent, with 67% of cases, and of these, 50% were due to traffic accidents. The mean TRISS (Trauma and Injury Severity Score) was 98, with a mortality rate of 1.4%. The most frequent thoracic and associated lesions were, respectively, rib fractures (51%) and abdominal trauma (32%). The mean drainage time was 6.93 days, being higher in patients under mechanical ventilation (p=0.0163). The complication rate was 26.5%, mainly poor drain positioning (11.77%). Hospital drainage was performed in 89% of cases by doctors in the first year of specialization. Thoracic drainage performed in prehospital care presented nine times more chances of complications (p=0.0015). Conclusion: the predictors of post-trauma complications for chest drainage were a procedure performed in an adverse site and mechanical ventilation. The high rate of complications demonstrates the importance of protocols of care with the thoracic drainage.

RESUMO Objetivo: identificar fatores preditores de complicações da drenagem torácica em pacientes vítimas de trauma, atendidos em um Hospital Universitário. Métodos: estudo retrospectivo de 68 pacientes submetidos à drenagem torácica pós-trauma, no período de um ano. Foram analisadas as seguintes variáveis: sexo, idade, mecanismo de trauma, índices de trauma, lesões torácicas e associadas, ambiente em que foi realizado o procedimento, tempo de permanência do dreno, grau de experiência do executor do procedimento, complicações e evolução. Resultados: a média de idade dos pacientes foi de 35 anos e o sexo masculino foi o mais prevalente (89%). O trauma contuso foi o mais frequente, com 67% dos casos, e destes, 50% por acidentes de trânsito. A média do TRISS (Trauma and Injury Severity Score) foi 98, com taxa de mortalidade de 1,4%. As lesões torácicas e associadas mais frequentes foram, respectivamente, fraturas de costelas (51%) e trauma abdominal (32%). A média de permanência do dreno foi de 6,93 dias, sendo maior nos pacientes sob ventilação mecânica (p=0,0163). A taxa de complicações foi de 26,5%, com destaque para o mau posicionamento do dreno (11,77%). A drenagem hospitalar foi realizada, em 89% dos casos, por médicos do primeiro ano de especialização. A drenagem torácica realizada no atendimento pré-hospitalar apresentou nove vezes mais chances de complicações (p=0,0015). Conclusão: os fatores preditores de complicações para drenagem torácica pós-trauma foram: procedimento realizado em local adverso e ventilação mecânica. A alta taxa de complicações demonstra a importância dos protocolos de cuidados com a drenagem torácica.

Factores pronósticos de complicaciones y mortalidad posoperatorias en la cirugía torácica en ancianos / Thoracic surgery in elderlies. Prognostic factor for postoperative complications and mortality

Introducción: el aumento de la población de ancianos incrementará el número de operaciones torácicas en pacientes con índices de mortalidad y complicaciones posoperatorias significativas. Objetivo: definir la relación de la edad con las complicaciones y la mortalidad en ancianos sometidos a intervenciones torácicas. Métodos: estudio observacional, longitudinal y de cohorte de 77 pacientes operados por lesiones torácicas entre enero de 2012 y enero de 2015, clasificados en 2 grupos. A: pacientes entre 60 y 69 años (control) y B: pacientes de 70 años o mayores (estudio). Las variables sexo, enfermedades asociadas y los resultados de las clasificaciones ASA, ECOG e IMC se usaron para caracterizar los grupos de edad. Las variables de respuesta fueron complicaciones y mortalidad. Resultados: al grupo A pertenecían 44 pacientes (57,1 por ciento) y al B, 33 (42,9 por ciento). No hubo diferencias significativas entre los grupos de edad según sexo (p= 0,891), enfermedades asociadas (p= 0,7), clasificaciones ASA (p= 0,364), ECOG (p= 0,57) e índice de masa corporal (p= 0,924); 20,5 por ciento y 23,3 por ciento en los grupos A y B, respectivamente, presentaron complicaciones. La mortalidad fue del 6,8 por ciento (grupo A) y 9,1 por cietno (grupo B). No obstante, las complicaciones (p= 0,368) y la mortalidad (Fi, p= 0,516) no mostraron asociación significativa con la edad. El sangrado perioperatorio se asoció con la mortalidad (Fisher, p= 0,029 RR:9,13). Conclusiones: las complicaciones y la mortalidad fueron más frecuentes en el grupo B. No obstante, no se demostró relación estadística con la edad, hecho probablemente explicado por los resultados similares de las variables para caracterizar ambos grupos(AU)

Introduction: The increased number of elderly people will increase the number of thoracic surgical interventions in this group of patients. Objective: To define the relationship between age, complications and mortality in elderly people surgically treated by thoracic interventions. Methods: Observational, longitudinal and cohort study of 77 patients operated for thoracic lesions, between January 2012 and January 2015, and classified in two groups. Group A: patients aged 60-69 years (control group), and group B: patients aged 70 years and over (study group). The variables sex, comorbidity and outcome of the classifications according to ASA, ECOG and BMI were used to characterize both groups. The answer variables were complications and mortality. Results: There were 44 (57.1 percent) patients in group A and 33 (42.9 percent) in group B. There were no significant differences between age groups and sex (P=0.891), comorbidity (P=,0,7), neither on classifications according to ASA (P=0.364), ECOG (P=0.57), IMC (P=0.924). The complication incidence was 205 percent (group A) and 23.3 percent (group B). Mortality was 6.8 percent (group A) and 9.1 percent (group B). Nevertheless, complications (p=0.368) and mortality (p=0.516) were not associated with age. Perioperative bleeding was associated with mortality (Fisher, p=0.029; RR: 913). Conclusions: Complications and mortality were more frequent in group B. However, no statistic relation was shown with age, probably due to similar results of the variables for characterizing both groups(AU)

Fractura de esternón: presentación de un caso / Sternal fracture: case report

Resumen Introducción: En Cuba los reportes de series de fracturas de esternón son prácticamente nulos. Resulta de opinión unánime en la bibliografía consultada que esta es una entidad poco frecuente. Objetivo: Presentar un caso tratado pues a pesar de ser conocido, su incidencia es muy baja, y el escaso número de series estudiadas unido a la diversidad de las técnicas quirúrgicas propuestas dificultan la selección de una que ofrezca los mejores resultados. Método: Paciente femenina de 26 años de edad con antecedentes de esquizofrenia paranoide que saltó desde un puente de 10 m en un intento suicida. Por los antecedentes y la clínica se diagnosticó una fractura esternal simple desplazada y fracturas expuestas de ambos miembros inferiores. Decidimos intervenir quirúrgicamente de urgencia la fractura esternal. Realizamos reducción de la fractura y osteosíntesis con alambre quirúrgico n.o 5. La evolución fue satisfactoria hasta el egreso hospitalario. Conclusiones: Realizamos tratamiento quirúrgico como indicación de la deformidad torácica y la paciente evolucionó de forma favorable sin complicaciones a corto y a largo plazos.

Abstract Introduction: In Cuba the reports of sternal fractures series are practically null. It is the unanimous opinion in the consulted bibliography that this it is a not very frequent entity. Objective: To present a treated case that in spite of being known, their incidence is very low, and the scarce number of studied series together to the diversity of the techniques surgical proposals hinders the selection of one that offers the best results. Method: Female patient of 26 years of age with antecedents of paranoid schizophrenia that jumped from a bridge of 10 m in a suicidal intent. For the antecedents and the clinical was diagnosed a sternal fracture displaced simple and exposed fractures of both inferior members. We decided to intervene surgically of urgency the sternal fracture. We carried out reduction of the fracture and osteosynthesis with surgical wire No. 5. The progression was satisfactory till the hospital discharge. Conclusions: We carry out surgical treatment as indication of the thoracic deformity and the patient evolved in a favourable way without complications to short and long term.

Repair of penetrating pericardial and diaphragmatic injury with cormatrix® patch in a case of suicide attempt

Abstract The authors report the case of a suicide attempt. A 59-year-old man with self-inflicted penetrating chest trauma underwent emergency cardiothoracic surgery. Pre-operative computed tomography scan showed critical proximity between the blade and the right ventricle. Intraoperative findings showed a pericardial laceration and a huge diaphragmatic lesion with heart and abdominal organs integrity. The diaphragm muscle was repaired with a CorMatrix® patch, an acceptable alternative to the traditional synthetic mesh avoiding infection and repeated herniation.

Thoracic damage control surgery / Cirurgia de controle de danos torácico

ABSTRACT The damage control surgery came up with the philosophy of applying essential maneuvers to control bleeding and abdominal contamination in trauma patients who are within the limits of their physiological reserves. This concept was extended to thoracic injuries, where relatively simple maneuvers can shorten operative time of in extremis patients. This article aims to revise the various damage control techniques in thoracic organs that must be known to the surgeon engaged in emergency care.

RESUMO A cirurgia de controle de danos surgiu com a filosofia de se aplicar manobras essenciais para controle de sangramento e contaminação abdominal, em doentes traumatizados, nos limites de suas reservas fisiológicas. Este conceito se estendeu para as lesões torácicas, onde manobras relativamente simples, podem abreviar o tempo operatório de doentes in extremis. Este artigo tem como objetivo, revisar as diversas técnicas de controle de dano em órgãos torácicos, que devem ser de conhecimento do cirurgião que atua na emergência.

Aplication of videothoracoscopy in trauma - experience of a service / Aplicação da videotoracoscopia no trauma - experiência de um serviço

Objective: To evaluate patients with chest trauma submitted to videothoracoscopy during hospitalization. In 2007, the Trauma Surgery Group was created in the General Surgery Department of the Hospital Municipal Lourenço Jorge of Rio de Janeiro-RJ, and started following all trauma victims who were admitted to the Hospital. Methods : We conducted a retrospective analysis of patients submitted to thoracoscopy from July 2007 to May 2015, based on a database started at the beginning of this period and on data collection from patients who underwent thoracoscopy. We evaluated the following parameters: procedure effectiveness, indication of the procedure, conversion rate, complications and mortality. We included patients who presented post-traumatic pleural collections, such as retained hemothorax and pleural empyema, and penetrating injury in the thoracoabdominal transition. All patients were hemodynamic stable and signed an informed consent. Results: In the analyzed period 53 patients were submitted to videothoracoscopy; 24 had penetrating trauma (45.3%) and 29, blunt (54.7%), with a predominance of males (75.5%). The procedure was performed in 26 cases of retained hemothorax (49%), 14 cases of empyema (26.5%) and in 13 patients for evaluation of injury in the thoracoabdominal transition (24.5%). The thoracoscopy was effective in resolution of 36 cases (80%), without need for further procedure. There was a conversion rate of 15.5% and 3 procedure complications related (6.6%). Mortality was nil. Conclusion: In this series, videothoracoscopy proved that this diagnostic and therapeutic procedure is safe and effective, if performed by a surgeon with appropriate training, especially when it is indicated in cases of retained hemothorax and evaluation of penetrating thoracoabdominal trauma.

Objetivo: avaliar os resultados obtidos com o emprego da videotoracoscopia na avaliação dos traumas toracoabdominais e no tratamento das complicações do trauma torácico. Métodos: análise retrospectiva dos pacientes submetidos à videotoracoscopia no período de julho de 2007 a maio de 2015, com base em banco de dados criado no início deste período e na coleta dos dados dos pacientes submetidos à videotoracoscopia. Foram avaliados: a eficácia e as indicações do procedimento, a taxa de conversão, as complicações e mortalidade. Foram incluídos os pacientes que apresentavam coleções pleurais pós-traumáticas, como hemotórax retido e empiema pleural, e lesões penetrantes na transição toracoabdominal. Todos os pacientes submetidos apresentavam estabilidade hemodinâmica e consentimento informado do procedimento. Resultados: no período analisado, 53 pacientes foram submetidos à toracoscopia, dentre estes, 24 traumas penetrantes (45,3%) e 29 contusos (54,7%) com predominância do sexo masculino (75,5%). O procedimento foi realizado em 26 casos de hemotórax retido (49%), 14 empiemas (26,5%) e em 13 pacientes para avaliação de lesões da transição toracoabdominal (24,5%). A toracoscopia foi eficaz na resolução de 36 casos (80%) sem necessidade de novo procedimento. Houve uma a taxa de conversão de 15,5% e três complicações relacionadas ao procedimento (6,6%). A mortalidade foi nula. Conclusão: apesar da série ainda ser pequena, a videotoracoscopia é um procedimento factível, com várias indicações e aplicações em pacientes traumatizados e, na nossa série, a mortalidade foi nula e a incidência de complicações, pequena.

Critical analysis of thoracotomies performed in the emergency room in 10 years / Análise crítica das toracotomias realizadas na sala de emergência durante 10 anos

OBJECTIVE: To conduct a critical analysis of thoracotomies performed in the emergency rooms. METHODS: We analyzed mortality rates and survival as outcome variables, mechanism of injury, site of injury and anatomic injury as clinical variables, and gender and age as demographic variables of patients undergoing thoracotomy in the emergency room after traumatic injury. RESULTS: Of the 105 patients, 89.5% were male. The average age was 29.2 years. Penetrating trauma accounted for 81% of cases. The most common mechanism of trauma was wound by a firearm projectile (gunshot), in 64.7% of cases. Patients with stab wounds (SW) accounted for 16.2% of cases. Overall survival was 4.7%. Survival by gunshot was 1.4%, and by SW, 23.5%. The ERT following blunt trauma showed a 100%mortality. CONCLUSION: The results obtained in the Emergency Hospital of Porto Alegre POA-HPS are similar to those reported in the world literature. .

OBJETIVO: realizar uma análise crítica das toracotomias realizadas nas salas de emergência. MÉTODOS: foram analisadas as taxas de mortalidade e sobrevida como variáveis de desfecho, mecanismo de trauma, local da lesão e lesões anatômicas como variáveis clínicas, sexo e idade como variáveis demográficas dos pacientes submetidos à toracotomia, na sala de emergência, após lesão traumática. RESULTADOS: análise de 105 pacientes mostrou que 89,5% eram do sexo masculino. A média de idade foi 29,2 anos. O trauma penetrante respondeu por 81% dos casos. O mecanismo de trauma mais frequente foi o ferimento por projétil de arma de fogo (FPAF) com 64,7% dos casos. Os pacientes com ferimento por arma branca (FAB) responderam por 16,2% dos casos. A sobrevida global foi 4,7%. A sobrevida por FPAF foi 1,4% e por FAB, de 23,5%. A TSE por trauma contuso obteve mortalidade de 100%. CONCLUSÃO: os resultados obtidos no Hospital de Pronto Socorro de Porto Alegre HPS-POA são semelhantes aos relatados na literatura mundial. .