Origen de la hemorragia en pacientes politraumatizados con fractura de pelvis e inestabilidad hemodinámica / Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability

INTRODUCCIÓN: La principal causa de mortalidad en los politraumatizados con fracturas pélvicas es el shock hipovolémico. Analizamos la asociación entre el origen de la hemorragia, mecanismo de acción y tipo de fractura. MÉTODOS: Estudio descriptivo y prospectivo que incluye a pacientes politraumatizados mayores de 16 años, ingresados en el área de críticos o que han fallecido antes de su ingreso, con fractura pélvica e inestabilidad hemodinámica. Se define inestabilidad hemodinámica como PAS < 90 o FC > 100 latidos/min. La fractura pélvica se define según la clasificación de Tile. RESULTADOS: Un total de 157 de 1.088 politraumatizados tenían fractura pélvica. Se ha incluido a 63 pacientes, todos hemodinámicamente inestables. En el 85% de los pacientes precipitados la hemorragia procedía de la propia fractura pélvica, comparado con solo el 44% de las víctimas que sufrieron un (choque). El 65% de los pacientes con fractura de pelvis estable sangraban de lesiones asociadas; el 70% de los pacientes con fractura inestable sangraban de la propia fractura. Existe una interacción entre el mecanismo de acción y el tipo de fractura. La probabilidad de sangrar de la pelvis es mayor en los precipitados (>80%), independientemente del tipo de fractura. La hemorragia de las lesiones asociadas es mayor en un impacto, duplicándose cuando la fractura es estable (91%). CONCLUSIONES: El mecanismo de acción es un factor clave para determinar el origen de la hemorragia en pacientes con fractura de pelvis. Los pacientes precipitados sangran de la propia fractura, mientras que los pacientes con un impacto (choque) pueden sangrar tanto de la propia fractura como de las lesiones asociadas, dependiendo del tipo de fractura

INTRODUCTION: The main cause of mortality in trauma patients with pelvic fractures is hypovolemic shock. We analyzed the association between the source of bleeding, mechanism of action and type of fracture. METHODS: Prospective descriptive study involving trauma patients older than 16 years old, admitted to the intensive care unit or dead before admission, with pelvic fractures and hemodynamic instability. Hemodynamic instability was defined as SBP <90 and/or HR> 100 beats/min. Pelvic fracture was defined by the Tile classification. RESULTS: A total of 157 of 1088 trauma patients had pelvic fracture. We included 63 patients, all hemodynamically unstable. A total of 85% of pelvic fractures after falls from great heights bled from the fracture itself, compared to only 44% of victims of impact (hit). A total of 65% of patients with stable pelvic fracture bled from associated lesions; 70% of patients with unstable fracture bled from the fracture itself. There is an interaction between the mechanism of action and type of fracture. The probability of pelvic bleeding is higher in the precipitated patient (> 80%) regardless of the type of fracture. Bleeding from associated injuries is greater in impact victims, doubling when the fracture is stable (91%). CONCLUSIONS: Mechanism of action is a key to determine the source of bleeding in patients with pelvic fracture. After falls patients bleed from the fracture itself, while patients with an impact (hit) can bleed both from the fracture and associated injuries, depending on the type of fracture

Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability.

INTRODUCTION: The main cause of mortality in trauma patients with pelvic fractures is hypovolemic shock. We analyzed the association between the source of bleeding, mechanism of action and type of fracture. METHODS: Prospective descriptive study involving trauma patients older than 16 years old, admitted to the intensive care unit or dead before admission, with pelvic fractures and hemodynamic instability. Hemodynamic instability was defined as SBP <90 and/or HR> 100 beats/min. Pelvic fracture was defined by the Tile classification. RESULTS: A total of 157 of 1088 trauma patients had pelvic fracture. We included 63 patients, all hemodynamically unstable. A total of 85% of pelvic fractures after falls from great heights bled from the fracture itself, compared to only 44% of victims of impact (hit). A total of 65% of patients with stable pelvic fracture bled from associated lesions; 70% of patients with unstable fracture bled from the fracture itself. There is an interaction between the mechanism of action and type of fracture. The probability of pelvic bleeding is higher in the precipitated patient (> 80%) regardless of the type of fracture. Bleeding from associated injuries is greater in impact victims, doubling when the fracture is stable (91%). CONCLUSIONS: Mechanism of action is a key to determine the source of bleeding in patients with pelvic fracture. After falls patients bleed from the fracture itself, while patients with an impact (hit) can bleed both from the fracture and associated injuries, depending on the type of fracture.

[A prospective study on the incidence of missed injuries in trauma patients]. / Estudio prospectivo de la incidencia de las lesiones inadvertidas en el paciente politraumatizado.

INTRODUCTION: Missed injuries in trauma patients are injuries not identified during a primary and secondary trauma survey (Advanced Trauma Life Support, ATLS). These injuries are important because of the delay in correct treatment. There is a particularly important sub-group consisting of clinically significant missed injuries, which may cause serious complications in the patient or even death. MATERIAL AND METHOD: A prospective study on missed injuries and clinically significant missed injuries. The study includes all trauma patients older than 16 years admitted to the resuscitation area or who had died during the first 24 hours. We collected injuries, time of their diagnosis and their treatment for each patient. For injuries detected later than 24 hours (i.e. missed injuries) we specified whether it was a clinically significant missed injury and its possible cause. RESULTS: From March of 2006 to January of 2007, 122 trauma patients were recorded with a mean Injury Severity Store of 20 +/- 15.8. Of those, 40.3% had some missed injury, fractures being the most frequent miss (42.7%), followed by chest and abdominal injuries. A clinically significant injury (38.7% of all missed injuries) were found in 17% of trauma patients, the most frequent being spine, abdominal and chest injuries. There is a statistically significant relationship between the presence of missed injuries, high ISS and intubation before or after admission to hospital. CONCLUSIONS: The rate of missed injuries and clinically significant missed injuries is high. Severe trauma patients and intubated patients have higher rates of missed injuries.

Estudio prospectivo de la incidencia de las lesiones inadvertidas en el paciente politraumatizado / A prospective study on the incidence of missed injuries in trauma patients

Introducción. Las lesiones inadvertidas en el paciente politraumatizado son aquellas no identificadas durante la revisión primaria y la secundaria (Advanced Trauma Life Support, ATLS). La importancia de estas lesiones radica en el retraso del inicio del tratamiento adecuado. Hay un subgrupo especialmente importante constituido por las lesiones inadvertidas clínicamente relevantes, que comportan complicaciones graves o incluso la muerte del paciente. Material y método. Estudio prospectivo de las lesiones inadvertidas y de las clínicamente relevantes, que incluye a todos los politraumatizados mayores de 16 años ingresados en el área de críticos o aquellos que han fallecido durante las primeras 24 h. Para cada enfermo se recogen sus lesiones, el momento del diagnóstico y su tratamiento. En las lesiones detectadas después de las primeras 24 h, lesiones inadvertidas, se especifica si la lesión es clínicamente relevante y su posible causa. Resultados. De marzo de 2006 a enero de 2007 se han recogido 122 politraumatizados con una media ± desviación estándar del índice de severidad (ISS) de 20 ± 15,8. El 40,3% de los pacientes presentaba alguna lesión inadvertida, con más frecuencia las fracturas (42,7%), seguidas por las lesiones torácicas y abdominales. El 17% de los pacientes presentaba alguna lesión inadvertida clínicamente relevante (el 38,7% de todas las lesiones inadvertidas), entre ellas, las más frecuentes son las lesiones de columna, las abdominales y las torácicas. Hay una relación estadísticamente significativa entre la aparición de lesiones inadvertidas, ISS elevados y pacientes intubados antes o tras el ingreso. Conclusiones. La incidencia de lesiones inadvertidas y lesiones inadvertidas clínicamente relevantes es elevada. Los politraumatizados más graves y los intubados presentan una mayor incidencia de lesiones inadvertidas (AU)

Introduction. Missed injuries in trauma patients are injuries not identified during a primary and secondary trauma survey (Advanced Trauma Life Support, ATLS). These injuries are important because of the delay in correct treatment. There is a particulary important sub-group consisting of clinically significant missed injuries, which may cause serious complications in the patient or even death. Material and method. A prospective study on missed injuries and clinically significant missed injuries. The study includes all trauma patients older than 16 years admitted to the resuscitation area or who had died during the first 24 hours. We collected injuries, time of their diagnosis and their treatment for each patient. For injuries detected later than 24 hours (i.e. missed injuries) we specified whether it was a clinically significant missed injury and its possible cause. Results. From March of 2006 to January of 2007, 122 trauma patients were recorded with a mean Injury Severity Store of 20 ± 15.8. Of those, 40.3% had some missed injury, fractures being the most frequent miss (42.7%), followed by chest and abdominal injuries. A clinically significant injury (38.7% of all missed injuries) were found in 17% of trauma patients, the most frequent being spine, abdominal and chest injuries. There is a statistically significant relationship between the presence of missed injuries, high ISS and intubation before or after admission to hospital. Conclusions. The rate of missed injuries and clinically significant missed injuries is high. Severe trauma patients and intubated patients have higher rates of missed injuries (AU)

[Intraabdominal hypertension and decompressive surgery. Clinical experience]. / Hipertensión abdominal y cirugía descompresiva. Experiencia clínica.

INTRODUCTION: Increased intraabdominal pressure (IAP) is associated with higher complication and mortality rates. Decompressive surgery is the most effective treatment for abdominal hypertension in trauma and septic patients with IAP. OBJECTIVE: To establish the association between IAP, complications, and mortality and to evaluate morbidity and mortality after decompressive surgery. MATERIAL AND METHOD: We performed a prospective, analytical, longitudinal study designed in 2 phases. In the first phase, 17 patients (mean age = 66 years, range: 39-78) admitted to the intensive care unit who underwent abdominal surgery were studied. In the second phase, 47 patients (mean age = 65 years, range: 48-78) underwent decompressive surgery, 6 for abdominal trauma and 41 for postoperative peritonitis. In both phases, all patients were fitted with urinary, arterial, and pulmonary artery catheters. The following variables were recorded: hemodynamic, respiratory and renal parameters; IAP, APACHE II, complications, and mortality. RESULTS: Patients with complications had significantly higher mean IAP (12.3 mm Hg; 95% CI, 10.7-13.9) than those without complications (7.9 mm Hg; 95% CI, 4.7-11.1) (p = 0.004). Patients that survived had a significantly lower mean IAP (8.7 mm Hg; 95% CI, 5.9-11.5) than those that died (12.4 mm Hg; 95% CI, 10.2-14.7) (p = 0.03). In patients who underwent decompressive surgery, a significant difference was found between APACHE II predicted mortality (40.4%) and observed mortality (25.5%) (p = 0.02). One patient with decompressive surgery developed an intestinal fistula. CONCLUSIONS: Controlling IAP, prophylaxis against abdominal hypertension, recognizing abdominal hypertension and decompressive surgery are new parameters and new concepts to be considered in the treatment of critical surgical patients.

Hipertensión abdominal y cirugía descompresiva. Experiencia clínica / Intraabdominal hypertension and decompressive surgery. Clinical experience

Introducción. El aumento de la presión intraabdominal (PIA) se relaciona con un mayor número de complicaciones y mortalidad. La cirugía descompresiva es el mejor método para el tratamiento de los pacientes traumáticos y sépticos afectos de hipertensión abdominal. Objetivo. Establecer la relación entre PIA, complicaciones y mortalidad. Evaluar la morbilidad y la mortalidad tras cirugía descompresiva. Material y método. Estudio prospectivo, longitudinal y analítico diseñado en dos fases: 17 pacientes ingresados en la unidad de cuidados intensivos e intervenidos de cirugía abdominal. Edad, 66 (39-78) años. Colocación de sonda vesical, catéter arterial y catéter de arteria pulmonar. Registro de parámetros hemodinámicos, respiratorios y renales. Registro de la presión intraabdominal y del APACHE-II, complicaciones y mortalidad. Segunda fase: 47 pacientes sometidos a cirugía descompresiva, 6 por trauma abdominal y 41 por peritonitis postoperatorias. Edad, 65 (48-78) años. Idéntica metodología. Resultados. La PIA media de los pacientes complicados fue significativamente mayor que la de los que no presentaron complicaciones, 12,3 mmHg (intervalo de confianza [IC] del 95%, 10,7-13,9) y 7,9 mmHg (IC del 95%, 4,7-11,1; p = 0,004). PIA media de los pacientes que sobrevivieron, 8,7 mmHg (IC del 95%, 5,9- 11,5) y 12,4 mmHg de los que fallecieron (IC del 95%, 10,2-14,7; p = 0,03). La diferencia entre la mortalidad esperada por el APACHE-II de los pacientes sometidos a cirugía descompresiva (40,4%) y la observada (25,5%) es significativa (p = 0,02). Una fístula intestinal en los pacientes con cirugía descompresiva. Conclusiones. Controlar la presión intraabdominal, reconocerla, su profilaxis y la cirugía descompresiva constituyen nuevos parámetros y nuevos conceptos que tener en cuenta en el tratamiento de los pacientes quirúrgicos críticos (AU)

Introduction. Increased intraabdominal pressure (IAP) is associated with higher complication and mortality rates. Decompressive surgery is the most effective treatment for abdominal hypertension in trauma and septic patients with IAP. Objective. To establish the association between IAP, complications, and mortality and to evaluate morbidity and mortality after decompressive surgery. Material and method. We performed a prospective, analytical, longitudinal study designed in 2 phases. In the first phase, 17 patients (mean age = 66 years, range: 39-78) admitted to the intensive care unit who underwent abdominal surgery were studied. In the second phase, 47 patients (mean age = 65 years, range: 48-78) underwent decompressive surgery, 6 for abdominal trauma and 41 for postoperative peritonitis. In both phases, all patients were fitted with urinary, arterial, and pulmonary artery catheters. The following variables were recorded: hemodynamic, respiratory and renal parameters; IAP, APACHE II, complications, and mortality. Results. Patients with complications had significantly higher mean IAP (12.3 mm Hg; 95% CI, 10.7- 13.9) than those without complications (7.9 mm Hg; 95% CI, 4.7-11.1) (p = 0.004). Patients that survived had a significantly lower mean IAP (8.7 mm Hg; 95% CI, 5.9-11.5) than those that (..) (AU)