Estudio observacional retrospectivo correlacionando las fracturas traumáticas de pelvis y sus lesiones asociadas según la clasificación de Tile / Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification

Introducción: Las fracturas de pelvis por traumatismo de alta energía presentan un alto riesgo de lesiones asociadas que comprometen el pronóstico funcional y vital. El objetivo de este estudio fue analizar la correlación entre las fracturas traumáticas de pelvis y sus lesiones asociadas según la clasificación de Tile. Métodos: Estudio observacional retrospectivo de pacientes que sufrieron fracturas traumáticas de pelvis (tipo A, B o C de la clasificación de Tile) con lesiones asociadas concomitantes, analizando los niveles de hemoglobina, entre 6/2013 y 1/2016. Resultados: Se incluyeron un total de 42 pacientes; de ellos, el 69% (n=29) eran varones, la edad media era de 48 años. El 45% (n=19) sufrió accidentes de tránsito; el 26,2% (n=11) caídas. Hubo una proporción diferente en las lesiones pélvicas: Tile A (n=15, 35,7%), B (n=20, 47,6%) y C (n=7, 16,6%) de los casos. El 54,8% (n=23) fueron intervenidos quirúrgicamente, el 21,4% (n=9) necesitó fijación externa. Se encontraron diferencias significativas entre las fracturas Tile A y de escápula (p=0,032), y las Tile B con fracturas sacras (p=0,033), y con lesiones viscerales (p=0,049), mientras que existía solo una asociación sin significación estadística entre Tile C y fracturas costales. El 61,9% (n=26) necesitó transfusión de sangre; el 9,5% (n=4) presentó shock hipovolémico. Conclusiones: Las fracturas pélvicas Tile A se asociaron a las fracturas de escápula, y las Tile B con fracturas transforaminales del sacro y con lesiones viscerales (pulmonares, hepáticas y génito-urinarias). El número reducido de fracturas Tile C no permite realizar asociación estadística con ninguna enfermedad, si bien son las que presentan mayor alteración hemodinámica y lesiones torácicas. (AU)

Introduction: Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification. Methods: Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016. Results: A total of 42 patients were included; of those 69% (n=29) were males, mean age was 48 years. 45% (n=19) suffered traffic accidents and 26.2% (n=11) falls. There was a different proportion in pelvic injuries: Tile A (n=15, 35.7%), B (n=20, 47.6%), and C (n=7, 16.6%) of cases. 54.8% (n=23) underwent surgery, 21.4% (n=9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P=.032), and Tile B with sacral fractures (P=.033) and visceral injuries (P=.049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n=26) needed blood transfusion; 9.5% (n=4) presented hypovolemic shock. Conclusions: Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries. (AU)

Venous thromboembolism risk among pediatric patients with traumatic brain injury: a nationwide study of 44,128 patients.

OBJECTIVE: Venous thromboembolism (VTE) chemoprophylaxis in pediatric patients with traumatic brain injury (TBI) requires balancing the risk of progression of intracranial bleeding versus the risk of VTE. The identification of VTE risk factors requires analysis of a very large data set. This case-control study aimed to identify VTE risk factors in pediatric patients with TBI in order to develop a TBI-specific association model that can be used for VTE risk stratification in this population. METHODS: The study included patients (aged 1-17 years) from the 2013-2019 US National Trauma Data Bank who were admitted for TBI in order to identify risk factors for VTE. Stepwise logistic regression was used to develop an association model. RESULTS: Of 44,128 study participants, 257 (0.58%) developed VTE. Risk factors associated with VTE included age (OR 1.045, 95% CI 1.010-1.080), body mass index (OR 1.034, 95% CI 1.013-1.055), Injury Severity Score (OR 1.049, 95% CI 1.039-1.059), blood product administration (OR 1.436, 95% CI 1.008-2.046), presence of a central venous catheter (OR 3.333, 95% CI 2.431-4.571), and development of ventilator-associated pneumonia (OR 3.650, 95% CI 2.469-5.396). Based on this model, the predicted VTE risk in pediatric patients with TBI ranged from 0% to 16.8%. CONCLUSIONS: A model that includes age, body mass index, Injury Severity Score, blood transfusion, use of a central venous catheter, and ventilator-associated pneumonia can help to risk stratify pediatric patients with TBI from the standpoint of implementation of VTE chemoprophylaxis.

A prospective comparative study of the functional results associated with the use of Björk flap tracheostomy versus standard tracheostomy.

BACKGROUND: Placement of a tracheostomy for patients requiring prolonged mechanical ventilation (PMV) improves patients' comfort, decreases dead space ventilation, allows superior airway hygiene, and reduces the incidence of ventilator-associated pneumonia. Controversy still exists regarding the role of standard tracheostomy (ST) as opposed to the less frequently done Björk flap tracheostomy (BFT). This study compares the functional outcomes of these two techniques. STUDY DESIGN: Seventy-nine patients receiving tracheostomy in a 12-month period: 38 BFT vs. 41 ST. Data included demographics, indications for PMV, ventilator days before tracheostomy, time to and a number of patients who passed the fiberoptic endoscopic evaluation of swallowing (FEES), time to and a number of patients decannulated. RESULTS: Indications in both groups were PMV from trauma (18/38 vs 15/41), pneumonia (13/38 vs 13/41), and ARDS (7/38 vs 11/4), respectively (p > 0.05). Patients in both groups did not differ with regard to age, sex, GCS, duration of PMV before tracheostomy, the time to and a number of patients who passed the 1st FEES. However, the number of days and the number of FEES required before the next successful FEES in the 20 BFT and 21 ST patients who failed the 1st was 9 (4) vs. 16 (5), and 2 (1) vs. 4 (1), respectively (p < 0.05). Additionally, the number of intraoperative complications in aggregate were 0/38 in the BFT as opposed to 6/41 in the ST group (p < 0.05). CONCLUSION: We conclude that BFT may be associated with an overall shorter time to restoration of normal swallowing when compared to ST.

Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification.

INTRODUCTION: Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification. METHODS: Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016. RESULTS: A total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock. CONCLUSIONS: Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Correlation of brain flow variables and metabolic crisis: a prospective study in patients with severe traumatic brain injury.

INTRODUCTION: Current treatment guidelines for patients with severe TBI (sTBI) are aimed at preventing secondary brain injury targeting specific endpoints of intracranial physiology to avoid the development of metabolic crisis. We sought to identify factors contributing to development of metabolic crisis in the setting of a Multi-modality Monitoring and Goal-Directed Therapy (MM&GDTP) approach to patients with severe TBI. METHODS: Prospective monitoring of sTBI patients was performed, with retrospective data analysis. MM&GDTP was targeted to intracranial pressure (ICP) ≤ 20 mmHg, cerebral perfusion pressure (CPP) ≥ 60 mmHg, brain tissue oxygen pressure (PbtO2) ≥ 20 mmHg, and cerebral oxygen extraction measured by bi-frontal Near infrared Spectroscopy (NIRS) > 55%. Brain flow abnormality was defined by one of the following combinations: CPP < 60 mmHg with NIRS < 55% (Type 1), CPP < 60 mmHg with PbtO2 < 20 mmHg (Type 2), or PbtO2 < 20 mmHg with NIRS < 55% (Type 3). Cerebral micro-dialysate was analyzed hourly for glucose, lactate, pyruvate, glutamate, glycerol, and lactate/pyruvate ratio (LPR). Statistical analysis was performed with student t-test, chi-square and Pearson's tests as applicable. RESULTS: A total of 109,474 consecutive minutes of recorded multimodality monitoring was available for analysis. There was a significant difference in the number of minutes of brain flow abnormalities between survivors and non-survivors: 0.8% (875) versus 7.49% (8,199), respectively (p < 0.05). The duration of Type 1-3 flow abnormality per patient was higher in non-survivors (5.7 ± 2.5 h) compared to survivors (0.7 ± 0.6 h) as well as the duration of metabolic crisis, namely, 5.2 ± 2.2 versus 0.6 ± 1.0 h per patient. The occurrence of severe metabolic crisis was associated with a Type 2 flow abnormality (CPP < 60 mmHg and PbtO2 < 20 mmHg), r = 0.97, p < 0.001, but not with Type 1 and 3. CONCLUSIONS: Metabolic crisis can occur despite a MM&GDTP approach aimed at optimizing cerebral blood flow. Severe metabolic crisis is associated to failure to maintain CPP and PbtO2 above 60 and 20 mmHg, respectively. The occurrence of severe metabolic crisis portends a poor prognosis in patients with sTBI.

Incidence and effects of deep vein thrombosis on the outcome of patients with coronavirus disease 2019 infection.

BACKGROUND: Deep vein thrombosis (DVT) has been reported to occur at different rates in patients with coronavirus disease 2019 (COVID-19). Limited data exist regarding comparisons with non-COVID-19 patients with similar characteristics. Our objective was to compare the rates of DVT in patients with and without COVID-19 and to determine the effect of DVT on the outcomes. METHODS: We performed a retrospective, observational cohort study at a single-institution, level 1 trauma center comparing patients with and without COVID-19. The 573 non-COVID-19 patients (age, 61 ± 17 years; 44.9% male) had been treated from March 20, 2019 to June 30, 2019, and the 213 COVID-19 patients (age, 61 ± 16 years; 61.0% male) had been treated during the same interval in 2020. Standard prophylactic anticoagulation therapy consisted of 5000 U of heparin three times daily for the medical patients without COVID-19 who were not in the intensive care unit (ICU). The ICU, surgical, and trauma patients without COVID-19 had received 40 mg of enoxaparin daily (not adjusted to weight). The patients with COVID-19 had also received enoxaparin 40 mg daily (also not adjusted to weight), regardless of whether treated in the ICU. The two primary outcomes were the rate of deep vein thrombosis (DVT) in the COVID-19 group vs that in the historic control and the effect of DVT on mortality. The subgroup analyses included patients with adult respiratory distress syndrome (ARDS), pulmonary embolism (PE), and intensive care unit patients (ICU). RESULTS: The rate of DVT and PE for the non-COVID-19 patients was 12.4% (71 of 573) and 3.3% (19 of 573) compared with 33.8% (72 of 213) and 7.0% (15 of 213) for the COVID-19 patients, respectively. Unprovoked PE had developed in 10 of 15 COVID-19 patients (66.7%) compared with 8 of 497 non-COVID-19 patients (1.6%). The 60 COVID-19 patients with ARDS had had an incidence of DVT of 46.7% (n = 28). In contrast, the incidence of DVT for the 153 non-COVID-19 patients with ARDS was 28.8% (n = 44; P = .01). The COVID-19 patients requiring the ICU had had an increased rate of DVT (39 of 90; 43.3%) compared with the non-COVID-19 patients (33 of 123; 33.3%; P = .01). The risk factors for mortality included age, DVT, multiple organ failure syndrome, and prolonged ventilatory support with the following odd ratios: 1.030 (95% confidence interval [CI], 1.002-1.058), 2.847 (95% CI, 1.356-5.5979), 4.438 (95% CI, 1.973-9.985), and 5.321 (95% CI, 1.973-14.082), respectively. CONCLUSIONS: The incidence of DVT for COVID-19 patients receiving standard-dose prophylactic anticoagulation that was not weight adjusted was high, especially for ICU patients. DVT is one of the factors contributing to increased mortality. These results suggest a reevaluation is necessary of the present standard-dose thromboprophylaxis for patients with COVID-19.

Predictors of mortality in patients with rib fractures.

BACKGROUND: The aim of this study was to identify risk factors for morbidity and mortality in patients with rib fractures with focus on identifying a more exact age-dependent cut-off for increased morbidity and mortality. METHODS: Retrospective study of patients 16 years or older with rib fractures from blunt trauma. EXCLUSION CRITERIA: patients undergoing rib plating. Initial chest X-ray and Computed Tomography (CT) scans were re-read for the number of rib fractures (NRF) and presence of pulmonary contusion (PC). Data included demographics, mechanism of injury (MOI), NRF, associated injuries, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), Geriatric Trauma Outcome Score (GTOS), presence of pneumothorax, hemothorax, hemo-pneumothorax, PC, Adult Respiratory Distress Syndrome (ARDS), pulmonary complications (ventilator-associated pneumonia, nosocomial pneumonia), and mortality. PC was quantified from CT scans with Mimics. Continuous data were analyzed using Student's t test. Variables significantly different by univariate analysis were analyzed by logistic regression analysis. RESULTS: The study group consisted of 1188 adult trauma patients admitted during a 2-year period; 800 males and 388 females, with a mean age of 54 ± 21. MOI: MVC, 735 (61.8%); falls, 364 (30.6%); other: 89. Mean NRF, 4 ± 2; GCS, GTOS, and ISS, 15 (15-15), 101 (82-124), and 19 ± 9, respectively. Incidence of PC was 329 (27.7%); PTX, HTX, and HTX/PTX, 264 (20.2%), 57 (4.8%), and 147 (12.4%). Flail chest, in 17 (1.4%); 321 required mechanical ventilation. Age, GCS, male gender, and ISS but not NRF and/or PC were predictive of mortality. CONCLUSIONS: Increased mortality in patients with rib fractures starts at 65 years of age without a further increase until age ≥ 80. NRF does not predict increased mortality independent of age. Severe TBI is the most common cause of death in patients 16-75 years, as opposed to respiratory complications in patients 80 years-old or greater.

Predictive Factors for Surgical Site Infections in Patients Undergoing Surgery for Breast Carcinoma.

INTRODUCTION: Operative interventions for breast cancer are generally classified as clean surgeries. Surgical site infections (SSIs), while rare, do occur. This study sought to identify risk factors for SSI, using the National Surgical Quality Improvement Program (NSQIP). METHODS: NSQIP's participant use data files (PUF) between 2012 and 2015 were examined. Female patients with invasive breast cancer who underwent surgery were identified through CPT and ICD9 codes. Non-SSI and SSI groups were compared and the statistical differences were addressed through propensity score weighting. Multivariate logistic regression testing was used to identify predictors of SSI. RESULTS: This study examined 30 544 lumpectomies and 23 494 mastectomies. SSI rate was 1126/54 038 patients (2.1%). In the weighted dataset, mastectomy, diabetes, smoking, COPD, ASA class-severe, BMI >35 kg/m2, and length of stay (LOS) >1 day were associated with an increased odds ratio (OR) of SSI. The OR for SSI was highest after mastectomy with reconstruction (OR 2.626, P < .001; 95% CI 2.073-3.325). Postoperative variables associated with an increased OR of SSIs included systemic infection, unplanned reoperation wound dehiscence, and renal failure. CONCLUSION: Mastectomy, diabetes, smoking, COPD, ASA class-severe, BMI >35 kg/m2, length of stay (LOS) >1 day are associated with an increased OR for SSIs following breast surgery.

Factors associated with severity of accidental hypothermia: A cohort retrospective multi-institutional study.

BACKGROUND: Frequently it is difficult to determine illness severity in hypothermic patients. Our goal was to determine if there are factors associated with illness severity of hypothermic emergency department (ED) patients. METHODS: Multi-hospital retrospective cohort. Consecutive patients in 24 EDs (1-1-2012 to 4-30-2015). Hypothermic patients (≤35 °C) were identified using ICD codes. We used hospital admission as marker of illness severity. Student's t-test was used for differences between mean age and temperature for admitted and discharged patients. We calculated the percent of patients admitted by factor, the difference from overall admission rate and 95% confidence interval (CI) of difference. RESULTS: There were 2094 visits with hypothermia ICD code. Of these, 132 patients had initial rectal temperatures ≤35 °C. Females comprised 42%; the mean age was 55 ± 23 years, and overall admission rate was 62%. The percent of patients with alcohol, trauma and found indoors were 39%, 27% and 27%, respectively. For admitted and discharged patients the mean ages were 60 and 48 years, respectively (p = 0.01), and initial mean temperature 32.3 °C vs. 33 °C, respectively (p = 0.07). Found indoors was associated with an 86% admission rate, a 22% increase (95% CI, 3%-34%) compared to overall admission rate. There was no statistically significant difference in admission rates from overall admission rate based on gender, alcohol or trauma. CONCLUSIONS: For hypothermic ED patients increased severity of illness was associated with older age and found indoors but not associated with initial temperature, gender, alcohol or trauma. These findings may assist physicians in treatment and disposition decisions.

An analysis of 979 patients with pelvic fractures stratified by the presence or absence of solid organ injury.

BACKGROUND: Pelvic fractures (PF) require high force mechanism and their severity have been linked with an increase in the incidence of associated injuries within the abdomen and chest. Our goal is to assess the impact of solid organ injury (SOI) on the outcome of patients with PF and to identify risk factors predictive of morbidity and mortality among these patients. STUDY DESIGN: We conducted a single-center retrospective review of medical records of patients 16 years or older admitted to our level 1 trauma center with pelvic fracture with and without OI associated from blunt trauma between 1/1/2010-7/31/2015. RESULTS: 979 patients with PF were identified. 261/979 (26.7%) had at least one associated SOI. The grade of the SOI ranged from I to III in 246 patients, grade IV in five patients and grade V in 10 patients with SOI sustained a higher pelvic AIS grade and required a statistically significant greater amount of blood products (BP). Thoracic and urogenital injuries were also more common. The mortality of patients with PF was not affected by the presence of SOI. Increasing age, Injury Severity Score, Glasgow Coma Scale, hypothermia and the amount of BP transfused were predictive of mortality. CONCLUSIONS: The presence of SOI did not affect the outcome of patients with pelvic fracture, although our results may be linked to the limited number of patients with high grade SOI. The degree of pelvic AIS is predictive of associated injuries within the abdomen and chest.

In-Site Monocyte Implantation in Bone Grafting for Maxillary Atrophy Reconstruction: A Preliminary Observational Proof of Concept Study.

PURPOSE: The main objective of this study, involving 11 patients, is to share our experience on an integrated treatment modality, namely, the use of cellular therapy simultaneously with surgical reconstruction. Published works show that the implantation of monocytes in ischemic tissue enhances healing by providing neo-angiogenesis, a key mechanism in tissue regenerative processes. MATERIALS AND METHODS: Our approach included the utilization of autologous monocytes and endothelial precursor cells in the bone graft itself to improve the success rate of the integration of the bone graft and its long-term viability/survival by promoting angiogenesis. We compared the standard regenerative procedures, namely sinus lift grafting performed with xenogeneic particle bone graft and posterior mandible grafting performed with on-lay or in-lay autologous cortical/medullary bone-block graft harvested from the iliac crest, with and without the use of cellular implementation. We evaluated results by both radiological and histological assessment. RESULTS: Autologous cortical/medullary bone-block graft had a different response to implementation with monocytes, showing a better osteointegration than expected conversely to the xenogeneic particle bone graft. CONCLUSIONS: Monocytes seem to improve autologous bone-block graft according to the "Therapeutic Angiogenesis" concept. Implementation with monocytes does not always improve xenogeneic particle bone graft.

Comparación entre tromboelastografía y test de coagulación convencionales: ¿deberíamos abandonar los test de coagulación convencional en el paciente politraumatizado? / Comparison between thromboelastography and conventional coagulation test: Should we abandon conventional coagulation tests in polytrauma patients?

INTRODUCCIÓN: TEG mide in vivo la potencia viscoelástica de la coagulación en sangre total; comparado con los TCC, estos no reflejan la influencia plaquetaria. Nuestro objetivo fue comparar TEG vs. TCC en pacientes politraumáticos estratificados por mecanismo lesional (ML) y estado previo de coagulación. MÉTODOS: Estudio retrospectivo y observacional de 230 pacientes politraumáticos, en un Hospital Universitario Nivel 1 de Trauma, realizándose TEG y TCC a su llegada. Los pacientes se dividieron según ML: multitraumatismo (MT), traumatismo craneoencefálico (TCE) aislado y MT + TCE. Se analizó la correlación entre TEG-TCC en todos los grupos y un análisis de subgrupo de los pacientes anticoagulados, utilizándose ANOVA, Spearman y regresión lineal según correspondía. Se definió la significación estadística como p < 0,05. RESULTADOS: Coagulación según TEG: normal (28,7%), hipercoagulación (68,3%) e hipocoagulación (3%). No hubo diferencias en parámetros de coagulación por TEG entre grupos. La coagulación no estaba afectada por edad, ISS o presencia de shock. Los TCC estaban alterados en 63,6% pacientes con TEG normal. La TEG fue normal o hipercoagulación en 21/23 pacientes anticoagulados con warfarina e INR elevado, y en 10/11 pacientes anticoagulados con NAO. TEG fue normal o hipercoagulación en 21/23 pacientes anticoagulados con warfarina, estratificado por INR (2 pacientes), y 2 pacientes presentaron TEG con hipocoagulación. La mortalidad fue del 5,2% (58,3% TCE severo). CONCLUSIONES: TEG es más útil que los TCC en pacientes politraumáticos, incluyendo a pacientes anticoagulados. El TCE podría aumentar la incidencia de hipercoagulabilidad en traumatismos. Los TCC no son útiles des del punto de vista terapéutico

INTRODUCTION: TEG provides an in-vivo assessment of viscoelastic clot strength in whole blood compared with CCT, which may not reflect the influence of platelets. The aim of this study was to compare TEG vs. CCT in trauma patients stratified by mechanism of injury (MOI) and pre-existing coagulation status. METHODS: A retrospective, observational study of 230 polytrauma patients admitted to a University Hospital Level 1 Trauma Center, with TEG and CCT on admission stratified by MOI: multiple trauma (MT), isolated traumatic brain injury (TBI) or MT+TBI. Statistical analysis included correlation between TEG and CCT in all groups and a subgroup analysis of anticoagulated patients. Data were analyzed with ANOVA, Spearman and lineal regression when appropriate. Statistical significance was accepted at P < 0.05. RESULTS: TEG was normal in 28.7%, hypercoagulable in 68.3%, hypocoagulable in 7%. There was no difference in TEG status among the groups. The coagulation status was not affected by age, ISS or shock. The CCT were abnormal in 63.6% of patients with normal TEG. Normal or hypercoagulable-TEG was found in 21/23 patients on Coumadin who had elevated INR and in 10/11 patients on NOAC. An analysis of the 23 patients on Coumadin stratified by INR showed a normal or hypercoagulable-TEG in 21/23 patients. Only 2 patients had a hypocoagulable-TEG. Mortality was 5.2% (58.3% severe TBI). CONCLUSIONS: TEG is more useful than CCT in polytrauma patients, including patients on anticoagulants. TBI could increase the incidence of hypercoagulability in trauma. CCT are not useful from the standpoint of treatment

Comparison between thromboelastography and conventional coagulation test: Should we abandon conventional coagulation tests in polytrauma patients? / Comparación entre tromboelastografía y test de coagulación convencionales: ¿deberíamos abandonar los test de coagulación convencional en el paciente politraumatizado?

INTRODUCTION: TEG provides an in-vivo assessment of viscoelastic clot strength in whole blood compared with CCT, which may not reflect the influence of platelets. The aim of this study was to compare TEG vs. CCT in trauma patients stratified by mechanism of injury (MOI) and pre-existing coagulation status. METHODS: A retrospective, observational study of 230 polytrauma patients admitted to a University Hospital Level 1 Trauma Center, with TEG and CCT on admission stratified by MOI: multiple trauma (MT), isolated traumatic brain injury (TBI) or MT+TBI. Statistical analysis included correlation between TEG and CCT in all groups and a subgroup analysis of anticoagulated patients. Data were analyzed with ANOVA, Spearman and lineal regression when appropriate. Statistical significance was accepted at P<0.05. RESULTS: TEG was normal in 28.7%, hypercoagulable in 68.3%, hypocoagulable in 7%. There was no difference in TEG status among the groups. The coagulation status was not affected by age, ISS or shock. The CCT were abnormal in 63.6% of patients with normal TEG. Normal or hypercoagulable-TEG was found in 21/23 patients on Coumadin who had elevated INR and in 10/11 patients on NOAC. An analysis of the 23 patients on Coumadin stratified by INR showed a normal or hypercoagulable-TEG in 21/23 patients. Only 2 patients had a hypocoagulable-TEG. Mortality was 5.2% (58.3% severe TBI). CONCLUSIONS: TEG is more useful than CCT in polytrauma patients, including patients on anticoagulants. TBI could increase the incidence of hypercoagulability in trauma. CCT are not useful from the standpoint of treatment.

Mortality rates of severe traumatic brain injury patients: impact of direct versus nondirect transfers.

BACKGROUND: Direct transport of patients with severe traumatic brain injury (sTBI) to trauma centers (TCs) that can provide definitive care results in lower mortality rates. This study investigated the impact of direct versus nondirect transfers on the mortality rates of patients with sTBI. METHODS: Data on patients with TBI admitted between January 1, 2012, and December 31, 2013, to our Level I TC were obtained from the trauma registry. Data included patient age, sex, mechanism, and type of injury, comorbidities, Glasgow Coma Scale, Injury Severity scores, prehospital time, time to request and to transfer, time to initiation of multimodality monitoring and goal-directed therapy protocol, dwell time in the emergency department (EDT), and mortality. Data, reported in means ± standard deviation, were analyzed with the Student t-test and chi-square. Statistical significance was accepted at a P value < 0.05. RESULTS: sTBI direct transfer to TC versus transfer from non-TCs (NTC): Of the 1187 patients with TBI admitted to our TC, 768 (64.7%) were admitted directly from the scene, whereas 419 (35.3%) were admitted after secondary transfer. One hundred seventy-one (22.2%) of the direct transfers had Glasgow Coma Scale < 8 (sTBI) and 92 (21.9%) of the secondary transfers had sTBI. The transfer time: Time from scene to arrival to the EDT was significantly shorter for TC versus NTCs 43 ± 14 versus 77 ± 26 min, respectively (P < 0.05). EDT dwell time before transfer and time from injury to arrival to TC were 4.2 ± 2.1 and 6.2 ± 8.3 h, respectively. Mortality: There was a statistically significant lower mortality for patients with sTBI transferred directly from the scene to TCs as opposed to patients secondarily transferred, 33/171 (19.3%) versus 33/92 (35.8%), respectively (P < 0.05). CONCLUSIONS: To decrease TBI-related mortality, patients with suspected sTBI should be taken directly to a Level I or II TC unless they require life-saving stabilization at NTCs.

Management of esophageal injuries secondary to trauma.

Traumatic esophageal injuries occur less than 10% of the time in the setting of blunt or penetrating trauma. The purpose of this literature review is to provide an update on the most recent changes involving the diagnosis and treatment of esophageal injuries. A literature search was conducted using PubMed, to identify articles written in English language with the terms "non- iatrogenic", "esophageal", "trauma", "diagnosis", "management", and "prognosis". Case reports and articles involving non-traumatic esophageal perforations were excluded. Fifty pertinent articles in English language from 1947 to 2015 were selected for review. Based on the review of all articles, we designed a diagnostic and therapeutic algorithm to facilitate the diagnosis and management of the traumatic esophageal injury.

Orientación terapéutica del traumatismo pancreático: revisión de la literatura / Management of pancreatic trauma: a literature review

La lesión pancreática es un evento infrecuente y de difícil diagnóstico en fase temprana, por lo que el cirujano debe tener siempre presente esta posibilidad después de un traumatismo abdominal debido a las consecuencias que acarrean las lesiones desapercibidas. Dada su localización retroperitoneal es habitual la lesión asociada de otros órganos y estructuras vasculares abdominales, que junto con las lesiones extraabdominales explican la alta morbimortalidad de estos pacientes. El objetivo de este trabajo es presentar una descripción concisa de la incidencia de estas lesiones, los mecanismos lesionales, los métodos diagnósticos recomendados, las indicaciones de las diferentes modalidades terapéuticas conservadoras, endoscópicas y quirúrgicas disponibles, y realizar un análisis de las complicaciones específicas del páncreas y de la mortalidad en estos pacientes, basándonos en una revisión de la literatura de los últimos 60 años, habiendo identificado 6.364 pacientes. Dada la localización retroperitoneal del páncreas, es habitual la lesión asociada de otros órganos y estructuras vasculares abdominales, que junto con las lesiones extraabdominales explican la alta morbimortalidad de estos pacientes

Pancreatic injury is an uncommon event often difficult to diagnose at an early stage. After abdominal trauma, the surgeon must always be aware of the possibility of pancreatic trauma due to the complications associated with missed pancreatic injuries. Due to its retroperitoneal position, asociated organs and vascular injuries are almost always present, which along with frequent extra abdominal injuries explain the high morbidity and mortality. The aim of this study is to present a concise description of the incidence of these injuries, lesional mechanisms, recommended diagnostic methods, therapeutic indications including nonoperative management, endoscopy and surgery, and an analysis of pancreas-specific complications and mortality rates in these patients based on a 60-year review of the literature, encompassing 6,364 patients. Due to pancreatic retroperitoneal position, asociated organs and vascular injuries are almost always present, which along with frequent extraaabdominal injuries explain the high morbidity and mortality of these patients