Penetrating cardiac trauma: 20-y experience from a university teaching hospital.

BACKGROUND: Penetrating traumas, including gunshot and stab wounds, are the major causes of cardiac trauma. Our aim was to describe and compare the variables between patients with penetrating cardiac trauma in the past 20 y in a university hospital, identifying risk factors for morbidity and death. METHODS: Review of trauma registry data followed by descriptive statistical analysis comparing the periods 1990-1999 (group 1, 54 cases) and 2000-2009 (group 2, 39 cases). Clinical data at hospital admission, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS) were recorded. RESULTS: The incidences of penetrating cardiac injuries were steady within the period of study in the chosen metropolitan area. The two groups were similar regarding age, mechanism of trauma (gunshot × stab), and ISS. Group 1 showed lower systolic blood pressure at admission (mean 87 versus 109 mm Hg), lower GCS (12.9 versus 14.1), lower RTS (6.4 versus 7.3), higher incidence of grade IV-V cardiac lesions (74% versus 48.7%), and were less likely to survive (0.83 versus 0.93). The major risk factor for death was gunshot wound (13 times higher than stab wound), systolic blood pressure < 90 mm Hg, GCS < 8, RTS < 7.84, associated injuries, grade IV-V injury, and ISS > 25. We observed a tendency in mortality reduction from 20.3% to 10.3% within the period of observation. CONCLUSIONS: Several associated factors for mortality and morbidity were identified. In the last decade, patients were admitted in better physiological condition, perhaps reflecting an improvement on prehospital treatment. We observed a trend toward a lower mortality rate.

Trauma de duodeno: análise de fatores relacionados à morbimortalidade / Duodenal trauma: factors related to morbimortality

OBJETIVO: Avaliar os fatores preditivos de morbimortalidade em pacientes com trauma duodenal. MÉTODOS: Estudo descritivo retrospectivo de 77 pacientes com lesão traumática de duodeno, em um hospital universitário, de janeiro de 1990 a dezembro de 2005. As lesões Grau I foram excluídas. RESULTADOS: O mecanismo de trauma foi penetrante em 87 por cento dos casos e fechado em 13 por cento, sem diferença estatisticamente significativa na mortalidade nestes grupos. Atraso maior que seis horas entre o trauma e a cirurgia foi observado em 7,8 por cento dos casos e não influenciou na evolução dos pacientes. O reparo primário da lesão duodenal foi realizado em 84,4 por cento dos pacientes e os procedimentos complexos em 15,6 por cento, com maior índice de mortalidade no último grupo. A média do ATI foi de 34,5 e a do ISS foi de 22,8. As taxas de morbidade e de mortalidade foram, respectivamente, 61 por cento e 27,3 por cento. A maioria dos pacientes que evoluíram a óbito apresentou-se com choque hipovolêmico na admissão, possuia baixo RTS, elevados ATI e ISS, e baixo TRISS quando comparados aos sobreviventes. Choque hipovolêmico, RTS alterado, lesões associadas e probabilidade de sobrevivência menor que 50 por cento foram considerados fatores independentes associados à mortalidade. CONCLUSÃO: A morbidade associada ao trauma duodenal neste estudo foi dependente de lesões intra-abdominais associadas, contaminação da cavidade peritoneal e reparos complexos da lesão duodenal. A apresentação fisiológica do paciente, gravidade das lesões (ISS > 25) e TRISS foram importantes fatores preditivos de morbidade e mortalidade em traumatizados com lesão duodenal.

BACKGROUND: Duodenal injuries remain one of the most complex challenges for trauma surgeons. The aim of this study is to evaluate factors that predict morbidity and mortality for duodenal trauma patients. METHODS: A registry-based retrospective analysis of data identified 77 patients with duodenal injuries in a University Hospital from January 1990 to December 2005. Grade I injuries were excluded. RESULTS: The injury trauma mechanism was penetrating in 87 percent and blunt in 13 percent. There was no difference in mortality based on trauma mechanisms. Delayed operation more than 6 hours after injury was observed in 7.8 percent of patients, and it was not related to patient outcomes. We performed primary simple repair for duodenal injury in 84.4 percent and complex repair in 15.6 percent of the patients. The latter had higher morbidity. Mean ATI was 34.5 and mean ISS was 22.8. Overall morbidity and mortality rate were, respectively, 61 percent and 27.3 percent. Most of no survivors were with hypovolemic shock at admission, they had lower RTS, higher ATI and ISS, and they had lower TRISS than survivors. Hypovolemic shock, altered RTS, associated injuries, and probability of survival less than 50 percent were independently factors related to death. CONCLUSION: Morbidity following duodenal trauma was more dependent on associated intra-abdominal injuries, abdominal contamination and complex repair. Physiologic presentation, associated injuries (ISS > 25), and TRISS were important factors for predicting morbidity and mortality for traumatic duodenal injuries.

Comportamento da pressão intracraniana, da perfusão cerebral e dos parâmetros hemodinâmicos durante a síndrome do compartimento abdominal em cães / Intracranial and cerebral perfusion pressures and hemodinamic parameters behaviour during abdominal compartment syndrome in dogs

OBJETIVO: Estudar as alterações hemodinâmicas e as repercussões sobre o sistema nervoso central ocasionados pela síndrome do compartimento abdominal. MÉTODO: Utilizou-se cães sem raça definida submetidos à anestesia geral e monitorização das pressões arterial média(PAM), intracraniana(PIC), de perfusão cerebral(PPC), da artéria pulmonar(PAP) e venosa central(PVC), do débito cardíaco(DC) e da freqüência cardíaca(FC). Aumentou-se a pressão intra-abdominal(PIA) para níveis de 10,20,30 e 40cmH2O . Após atingir-se nível PIA=40cmH2O realizou-se a descompressão cirúrgica da cavidade abdominal. Em cada etapa realizou-se a medida dos parâmetros PIA, PIC, PAM, PPC, PVC e DC. RESULTADOS: Observou-se que o aumento da PIA causou as seguintes alterações fisiológicas: aumento progressivo da PIC; aumento da PAM até PIA=20cmH2O e diminuição progressiva da mesma após PIA= 40cmH2O; aumento da PPC até PIA=10cmH2O e diminuição progressiva da mesma após PIA= 30cmH2O; aumento progressivo da PVC; diminuição progressiva do DC após PIA= 30cmH2O; Após a descompressão da cavidade, notou-se o retorno da PIC, PAM, PPC, PVC e do DC para valores próximos aos dos iniciais (antes do aumento da PIA). CONCLUSÕES: Concluímos que o aumento da PIA provocou alterações nos sistemas cardiovascular e nervoso central, que foram revertidas após a descompressão cirúrgica da cavidade abdominal.

BACKGROUND: The abdominal compartment syndrome and its repercussion on hemodynamic and central nervous system repercussions were studied experimentally in an animal model. METHODS: Eigth dogs were operated under general anesthesia. Intracranial pressure(ICP), mean arterial pressure(MAP), cerebral perfusion pressure(CPP), central venous pressure(CVP) and cardiac output(CO) were studied. Baseline measurements were obtained, and then an abdominal pucture was performed in order to raise the IAP by air insufflations. The IAP was initially increased to 10cmH2O and further elevated by increments of 10cmH2O. All parameters were measured after a 15 minute stabilization period of each pressure increase. When the abdominal pressure reached 40cmH2O, all parameters were measured again and decompression of the abdominal cavity was carried on. Final measurements were then obtained. RESULTS: The increase of IAP caused the following physiologic changes: ICP progressively increase; initial MAP increase until 20cmH2O IAP and decrease at 40cmH2O; initial CPP increased until 10cmH2O intra-abdominal pressure and progressively decreased beyond 30cmH2O; CVP progressive increase; CO decrease beyond 30cmH2O. ICP, MAP, CPP, CVP and CO returned to near baseline level after abdominal surgical decompression. CONCLUSION: The progressive increase of IAP is associated with several hemodynamic and central nervous system changes, that returned to near initial values after abdominal cavity surgical decompression.