Pro Hospital General / Pro General Hospital

Para optimizar la asistencia del paciente politraumatizado se crearon en los Estados Unidos los sistemas de trauma. Engloban la asistencia prehospitalaria, determinan los requisitos de un hospital para esta dolencia, estandarizan la formación e implementan los registros. Inicialmente se basó en centros monográficos y posteriormente se acreditó en trauma a hospitales generales que cumplían los requisitos de la Academia Americana de Cirujanos. Éste es el modelo seguido en Europa. La acreditación requiere la calificación de su personal, la dotación de recursos y la existencia de un programa de trauma. Su director es el encargado de la creación de los equipos de trauma, operativos las 24h, la docencia, la elaboración de protocolos y guías, y la coordinación con los sistemas de emergencias prehospitalarios. En España existe una amplia red de hospitales de tercer nivel que sí disponen de un programa de trauma y la consiguiente acreditación permitiría aprovechar estos recursos existentes. Debería elaborarse un sistema de acreditación que universalizara la formación de sus profesionales con los cursos de soporte vital mediante el avance en trauma y la creación a nivel nacional de un registro de esta problemática. La alta tecnificación de estos hospitales, así como su dotación en recursos humanos que contemplan todas las especialidades médicas, quirúrgicas y de servicios centrales aportan un gran valor añadido. La asistencia a los pacientes traumáticos es compleja y multidisciplinaria. Por esto creemos que, bien enmarcada en un programa de trauma, los hospitales generales son el marco idóneo para ofrecerla en excelentes condiciones (AU)

Trauma operative systems were created in United States to optimize polytrauma patients' treatment. These systems include prehospital polytrauma care. They determine hospital requirements to treat this kind of patients, standardize physicians' training and implement hospital registries. Initially, this system was applied only in monographic centers. However, trauma services of General Hospitals that fulfill the requirements were authorized progressively by the American Surgery Academy to fulfill this function. This is the model followed in Europe at present. Accreditation requires the qualification of the stay, with specific health care resources and a detailed trauma program. The director is responsible for organizing the creation of the trauma teams, operating 24h, for teaching, protocols and guides and the coordination of pre-hospital emergency groups. In Spain, there is an extensive network of tertiary hospitals that have trauma programs and their consequent accreditation could make it possible to take advantage of their existing resources. An accreditation system should be elaborated in order to homogenize professional training in trauma emergencies and to create a National Polytraumatic Registry. The high level of technology of these hospitals and of their human resources that include all the medical, surgical specialties and central services provide an added value. Care to the trauma patients is complex and multidisciplinary. Thus, we believe that General Hospitals, within a traumas program, are the best setting to offer it with excellent conditions (AU)

[Pro general hospital]. / Pro Hospital General.

Trauma operative systems were created in United States to optimize polytrauma patients' treatment. These systems include prehospital polytrauma care. They determine hospital requirements to treat this kind of patients, standardize physicians' training and implement hospital registries. Initially, this system was applied only in monographic centers. However, trauma services of General Hospitals that fulfill the requirements were authorized progressively by the American Surgery Academy to fulfill this function. This is the model followed in Europe at present. Accreditation requires the qualification of the stay, with specific health care resources and a detailed trauma program. The director is responsible for organizing the creation of the trauma teams, operating 24h, for teaching, protocols and guides and the coordination of pre-hospital emergency groups. In Spain, there is an extensive network of tertiary hospitals that have trauma programs and their consequent accreditation could make it possible to take advantage of their existing resources. An accreditation system should be elaborated in order to homogenize professional training in trauma emergencies and to create a National Polytraumatic Registry. The high level of technology of these hospitals and of their human resources that include all the medical, surgical specialties and central services provide an added value. Care to the trauma patients is complex and multidisciplinary. Thus, we believe that General Hospitals, within a traumas program, are the best setting to offer it with excellent conditions.

[Percutaneous tracheotomy and cricothyroidotomy in the critical patient]. / Traqueotomías percutáneas y coniotomías quirúrgicas en el paciente crítico.

OBJECTIVE: To review and compare the complications of percutaneous tracheotomy (TP) and cricothyroidotomy (CT) used to perform tracheal intubation in patients requiring prolonged mechanical ventilation. DESIGN: A prospective, observational study performed from October 2004 to October 2006, and follow-up of course until May 2007. SETTING: Intensive care service from a university-affiliated teaching hospital. PATIENTS: A total of 82 patients in which CT or TP were necessary. Forty-three TP and 39 CT were performed. MAIN MEASUREMENTS: Reason for TP or CT, demographic data, severity scores, ICU length of stay, orotracheal intubation (OTI) days, CT/TP early and late complications and in-hospital evolution were collected. RESULTS: TP/CT were performed due to prolonged ventilation in 62 (76%) patients and because of impaired neurological status in the remaining patients. There were no differences between TP/CT in gender, APACHE II, ICU length of stay, previous OTI days. Patients in the CT group were older (68 +/- 9 vs 54 +/- 15 years, p < 0.001). There were 5 mild adverse events (3 guide angulations and 2 lateral tracheal punctions) after TP, and 1 severe adverse event (pulmonary ventilation problem) after CT. There were no fatal event related with TP/CT. Thirty-four patients were decanulated. Mild local injuries were seen in 8 patients (6 TP vs 2 CT). Only 1 subglottic granuloma was seen late in CT group. CONCLUSIONS: In our experience CT constitutes a safety and feasible alternative to TP when TP is counter-indicated.

Traqueotomías percutáneas y coniotomías quirúrgicas en el paciente crítico / Percutaneous tracheotomy and cricothyroidotomy in the critical patient

Objetivo. Revisar y comparar las complicaciones de las traqueotomías percutáneas (TP) y las coniotomías por disección (CT) como métodos de canulación subglótica de la vía aérea. Diseño. Estudio prospectivo y observacional, desde octubre de 2004 a octubre de 2006 y seguimiento de la evolución hasta mayo de 2007. Ámbito. Servicio de medicina intensiva (SMI) de un hospital universitario. Pacientes. 82 pacientes a los que se realizó canulación subglótica mediante TP (42 casos) o CT (39 casos). Variables de interés. Motivo para la canulación subglótica, datos demograficos, gravedad, días de hospitalización en el SMI, días de intubación orotraqueal (IOT), problemas inmediatos y tardíos, evolución. Resultados. Fueron canulados por ventilación prolongada 62 (76%) pacientes y por depresión neurológica, el resto. No hubo diferencias entre TP y CT en el sexo, la gravedad de la enfermedad medida por APACHE II, los días de estancia en SMI y los días de IOT previos a la realización de la canulación subglótica. Los pacientes del grupo CT tuvieron más edad (68 ± 9 frente a 54 ± 15 años; p < 0,001). Hubo 5 pacientes en el grupo TP con problemas leves (3 por angulación del fiador y 2 por punción traqueal lateral). Hubo 1 caso en el grupo CT con dificultad en la ventilación pulmonar durante el procedimiento. No hubo ningún fallecimiento relacionado con la TP o la CT. Fueron descanulados 34 pacientes; en 8 casos (6 TP y 2 CT) se objetivaron lesiones leves sin repercusión clínica. Se produjo un granuloma subglótico de forma tardía en un paciente con CT. Conclusiones. En nuestra experiencia la CT es una alternativa a la TP cuando ésta no está indicada (AU)

Objective. To review and compare the complications of percutaneous tracheotomy (TP) and cricothyroidotomy (CT) used to perform tracheal intubation in patients requiring prolonged mechanical ventilation. Design. A prospective, observational study performed from October 2004 to October 2006, and follow-up of course until May 2007. Setting. Intensive care service from a university-affiliated teaching hospital. Patients. A total of 82 patients in which CT or TP were necessary. Forty-three TP and 39 CT were performed. Main measurements. Reason for TP or CT, demographic data, severity scores, ICU length of stay, orotracheal intubation (OTI) days, CT/TP early and late complications and in-hospital evolution were collected. Results. TP/CT were performed due to prolonged ventilation in 62 (76%) patients and because of impaired neurological status in the remaining patients. There were no differences between TP/CT in gender, APACHE II, ICU length of stay, previous OTI days. Patients in the CT group were older (68 ± 9 vs 54 ± 15 years, p < 0.001). There were 5 mild adverse events (3 guide angulations and 2 lateral tracheal punctions) after TP, and 1 severe adverse event (pulmonary ventilation problem) after CT. There were no fatal event related with TP/CT. Thirty-four patients were decanulated. Mild local injuries were seen in 8 patients (6 TP vs 2 CT). Only 1 subglottic granuloma was seen late in CT group. Conclusions. In our experience CT constitutes a safety and feasible alternative to TP when TP is counter-indicated (AU)

[Immunosuppressive treatment due to paraquat poisoning]. / Tratamiento inmunosupresor en las intoxicaciones por paraquat.

Paraquat is the most important member of the bipyridyl compound. It is directly caustic in nature and it exerts its herbicidal activity by inhibiting the reduction of NADP to NADPH during photosynthesis, a process in which superoxide, singlet oxygen, hydroxyl, and peroxide radicals are formed. Human tissue toxicity likely results from a similar oxidative mechanism. After oxidative destruction, recruitment of inflammatory cells leads to late onset and irreversible pulmonary fibrosis. Ingestion greater than 20-40 mg/kg of paraquat concentrate should be aggressively managed with the administration of intestinal decontaminants and hemoperfusion. Low-inspired oxygen therapy should be given until it becomes impractical in the face of hypoxemia. Administration of immunodepressive therapy, steroids and cyclophosphamide, should be considered. In addition, there should be intermittent assessment of pulmonary function and of plasma and urinary concentrations of paraquat.

Tratamiento inmunosupresor en las intoxicaciones por paraquat / Immunosuppressive treatment due to paraquat poisoning

El paraquat es el agente más importante de la familia de los biperidilos. Es directamente cáustico en la naturaleza, su actividad es herbicida mediante la reducción del NADP a NADPH durante la fotosíntesis, un proceso de superoxidación que genera radicales oxi, hidroxil y radicales peróxidos. La toxicidad en tejidos humanos resulta de forma parecida por la alteración del proceso oxidativo. Tras la destrucción oxidativa, el reclutamiento de las células inflamatorias conducen a un proceso tardío de fibrosis pulmonar. La ingesta mayor de 20-40 mg/kg de concentrado de paraquat requiere de un tratamiento agresivo con descontaminación intestinal y hemoperfusión. Igualmente, la limitación del aporte de oxígeno a bajo flujo según la hipoxemia tolerable. La administración de terapia inmunosupresora con esteroides y ciclofosfamida debe ser considerada. Igualmente debe ser controlada de forma intermitente la función pulmonar y los niveles de paraquat en plasma y orina

Paraquat is the most important member of the bipyridyl compound. It is directly caustic in nature and it exerts its herbicidal activity by inhibiting the reduction of NADP to NADPH during photosynthesis, a process in which superoxide, singlet oxygen, hydroxyl, and peroxide radicals are formed. Human tissue toxicity likely results from a similar oxidative mechanism. After oxidative destruction, recruitment of inflammatory cells leads to late onset and irreversible pulmonary fibrosis. Ingestion greater than 20-40 mg/kg of paraquat concentrate should be aggressively managed with the administration of intestinal decontaminants and hemoperfusion. Low-inspired oxygen therapy should be given until it becomes impractical in the face of hypoxemia. Administration of immunodepressive therapy, steroids and cyclophosphamide, should be considered. In addition, there should be intermittent assessment of pulmonary function and of plasma and urinary concentrations of paraquat

Uso de oximas en la intoxicación por organofosforados / Use of oximes in organophosphorate poisoning

No disponible

Endocarditis tricuspídea en válvula nativa por Candida albicans / Native tricuspid valve endocarditis caused by Candida albicans

No disponible

Tratamiento de las intoxicaciones por metanol y por etilenglicol / Treatment of methanol and ethylenglycol poisoning

No disponible

AMAN o síndrome axonal difuso / AMAN or diffused axonal syndrome

Presentamos un caso clínico de neuropatía axonal motora aguda en un varón adulto, la orientación diagnóstica fue corroborada por electromiografía y detección de anticuerpos específicos GM1. El rasgo semiológico predominante fue la plejÍa generalizada, en la que participaba la musculatura respiratoria por lo que precisó ventilación mecánica prolongada. El paciente presentó varias infecciones intercurrentes, motivo finalmente de su éxitus (AU)

[Cranioencephalic trauma in adults: clinical and radiologic features]. / Traumatismo craneoencefálico del adulto: aspectos clínicos y radiológicos.

BACKGROUND: To analyse extracranial complications and basic variables in head-injury patients, such as Glasgow coma score (GCS), intracranial pressure (ICP) and cranial computerized tomography (CT), in relation to the outcome of these patients. PATIENTS AND METHODS: 64 consecutive patients (47 males and 17 females) with head injury, admitted from January 1992 to May 1994, were studied in this prospective study. Mean age was 37 +/- 18 years. Overall mortality was 23% (15/64). Student-t and Chi-square tests were used for statistical analysis, and p < 0.05 was considered statistical significant. RESULTS: Overall GCS was 7 +/- 3, survivors presenting GCS of 7.7 +/- 2.9 and non-survivors 4.7 +/- 1.5 (p = 0.04). CT were classified as follows: diffuse injury, 4 patients (7%); focal injury, 32 (53%), and mixed injury 24 (40%). Depending on the presence or absence of mesencephalic cisterns in the CT, GSC was 7.6 +/- 2.8 and 4.3 +/- 1.4, respectively (p = 0.04). Subarachnoid hemorrhage (SAH) was associated to a GCS of 6.3 +/- 2.5 and its absence to 8 +/- 3.3 (p = 0.03). The absence of mesencephalic cisterns and SAH were more frequent in the non-survivors, 72% and 32% (p = 0.01 and 0.04), respectively. ICP was recorded in 42 patients. Regarding to ICP, mortality was: 6.7% with ICP < or = 20 mmHg, 37% with ICP 21-30, 44% with ICP 31-40 and 67% with ICP > 50 mmHg (p = 0.03). Diabetes insipidus, cardiorespiratory arrest, shock, prolonged mechanical ventilation, SDRA and sepsis were the most frequent extracranial complications in non-survivors. CONCLUSIONS: There is an association between the outcome of head-injury patients with the GCS and ICP values. Absence of mesencephalic cisterns and SAH were radiologic signs of poor prognosis. Patients who died had more extracranial complications.

[Methanol and ethylene glycol poisoning. Study of 18 cases]. / Intoxicación por metanol y etilenglicol. Estudio de 18 observaciones.

BACKGROUND: The present study reviews acute intoxication by methanol and ethylenglycol analyzing its form of presentation, treatment applied and prognosis. METHODS: A retrospective study performed in 5 hospitals from the Barcelona area (Spain) from January 1984 to December 1993 is reported. RESULTS: Eighteen patients, 16 intoxicated by methanol and 2 by ethylenglycol were reviewed. The blood levels of methanol on admission ranged from 350 to 4,600 mg/l (mean = 1,649 +/- 1,220 mg/l). The clinical course was initially characterized by alteration of the level of consciousness (in 61% the index of Glasgow of coma was < or = 7) and development of metabolic acidosis (pH < or = 6.80 in 44% of cases). Eighty-seven percent of patients intoxicated by methanol had visual disorders. Treatment consisted in the administration of ethanol, bicarbonate and extrarenal exchange. Mortality was 44%, being greater among patients with the lowest initial pH (p = 0.0001) and with the lowest concentration of bicarbonates (p < 0.03). The patients with lower pH (r2 = 0.65, p < 0.002) and with a lower value of blood bicarbonate (r2 = 0.87; p < 0.0001) on admission were significantly more severe. Sequelae are present in 55% of the survivors. CONCLUSIONS: Intoxication by methanol and ethylenglycol cause severe metabolic acidosis, with high anion and osmolar gaps which may rapidly lead to death or to sequelae in survivors if diagnosis is delayed and specific treatment is not initiated early.

[Respiratory insufficiency in acute pancreatitis]. / Insuficiencia respiratoria en la pancreatitis aguda.

BACKGROUND: Acute respiratory failure (ARF) is one of the systemic complications of acute pancreatitis (AP). The severity of AP may be objectified by the Ranson index and the radiologic alterations showed by abdominal computerized tomography (CT). The aim of the present was to study the relation between both problems. METHODS: Two hundred ninety-five cases of AP attended between November 1983 and August 1987 were revised. Ranson criteria were used to qualify the 295 AP and the abdominal CT in 85 cases. ARF was defined as PaO2 less than 60 mmHg breathing air at room temperature. The severity of ARF was classified by the respiratory index (RI: PaO2/FIO2) with ARF being considered as severe when less than 200. In 100 cases of AP the thoracic radiologic alterations were objectified and evaluated in order to know their relation with ARF. RESULTS: ARF was the most frequent complication (28%) of AP, being severe in 8%. Pleural effusion was the radiologic alteration most frequently observed (23 patients). In 28% there was no correlation between the radiology and the presence of ARF. The correction of ARF was achieved in 85% of the patients with a mask of O2 less than 40%. Mean ARF was 227. A correlation was found between ARF and the severity of the episode of AP and the changes observed in the abdominal CT. CONCLUSIONS: Acute respiratory failure is the most frequent complication of acute pancreatitis and correlates with the severity of the episode of the latter; classification of the episode of acute respiratory failure by respiratory index is of use.