Prehospital and hospital shock indices as predictors of massive blood transfusion during the initial treatment of polytrauma patients. / Índices de shock prehospitalario y hospitalario como predictores de transfusión masiva en la atención inicial del paciente politraumático.

OBJECTIVES: To explore a possible association between the shock index and a need for massive blood transfusion, duration of hospital stay in the critical care unit, and mortality. MATERIAL AND METHODS: Observational study of data for all patients over the age of 18 years with multiple high-energy injuries included in the TraumCat Registry who were treated in Hospital Universitario de Bellvitge between 2012 and 2016. We calculated shock index values before hospital emergency department arrival, on arrival at the hospital, and on admission to the critical care unit for resuscitation. The amount of blood transfused in the first 24 hours was also obtained from the registry. RESULTS: Of 184 polytrauma patients, 75 (41%) received blood transfusions. Median (interquartile range) shock indices were as follows: prehospital, 0.77 (0.61-1.01); on hospital arrival, 0.78 (0.64-1); and on critical care admission, 0.92 (0.76-1.13). Forty-six patients (25%) died. A prehospital shock index of 0.9 was significant, differentiating the amount of blood transfused. The specificity and sensitivity of the cutoff were 73% and 66%, respectively, at the prehospital recording and 74% and 80% on hospital arrival. The areas under the receiver operating characteristic curve and 95% CIs were as follows for prehospital and on-arrival shock indices: 68% (61%- 75%) and 72% (65%-79%). Mortality and hospital stay were not significantly associated with shock indices. CONCLUSION: The shock index is a useful, easy-to-obtain predictor to identify polytrauma patients who need early blood transfusion for optimal treatment. Hospital stay and mortality might be better predicted by other indicators.

OBJETIVO: Establecer la posible relación entre el Índice de Shock (IS) con los requerimientos de transfusión masiva, estancia hospitalaria y en unidad de críticos, y mortalidad. METODO: Estudio observacional de los pacientes mayores de 18 años con traumatismos de alta energía del registro TraumCat atendidos en el Hospital Universitario de Bellvitge entre 2012 y 2016. Se recogió el IS prehospitalario (PH), a la llegada al hospital (H) y en la unidad de reanimación (IS-C), y la cantidad de transfusión las primeras 24 horas. RESULTADOS: Se recogieron 184 pacientes y 75 (41%) recibieron transfusión sanguínea. Las medianas de los IS para todos los pacientes del estudio fueron: IS-PH 0,77 (Q1-Q3; 0,61-1,01), IS-H 0,78 (Q1-Q3; 0,64-1), IS-C 0,92 (Q1-Q3; 0,76-1,13). Fallecieron 46 pacientes (25%). El IS-PH y el IS-H fueron los que diferenciaron de manera significativa la cantidad de transfusión. El valor 0,9 mostró una especificidad/sensibilidad del 73%/66% para el IS-PH y del 74%/80% para el IS-H. El área bajo la curva ROC para el IS-PH y el IS-H fue del 68% (IC 95% 61-75) y del 72% (IC 95% 65-79) respectivamente. No hubo relación significativa de los IS con la mortalidad y la estancia hospitalaria. CONCLUSIONES: El IS es una herramienta útil y accesible para identificar pacientes politraumatizados con requerimientos transfusionales de manera temprana y optimizar el tratamiento. Para evaluar estancias hospitalarias o mortalidad, podrían ser más útiles otros índices.

Neuropatía óptica asociada con lesión de Dieulafoy / Optic neuropathy associated with a Dieulafoy´s lesion

Objetivo: describir el caso de un paciente del Hospital de San José de Bogotá con hemorragia del tracto digestivo superior secundaria a lesión de Dieulafoy, que presentó cuadro compatible con neuropatía óptica anterior isquémica no arterítica (NOIANA). Metodología: se hace una revisión narrativa y búsqueda sistemática de la literatura para determinar las características clínicas, demográficas, tratamiento y pronóstico visual de los pacientes con NOIANA. Materiales y métodos: reporte de caso, revisión narrativa y búsqueda sistemática de la literatura en las bases de datos Medline (vía Ovid) y Embase de NOIANA secundaria a hipovolemia. Se analizaron las variables sociodemográficas, clínicas, diagnóstico, condiciones asociadas, tratamiento y pronóstico visual. El análisis estadístico se realizó mediante frecuencias absolutas y relativas. Resultados: la mejoría de agudeza visual final en los pacientes que presentaron un episodio de NOIANA es incierta. En 42% hubo algún tipo de mejoría de la agudeza visual, independiente del tratamiento recibido. Menos del 50% de los casos clínicos reportados incluidos en este estudio que recibieron tratamiento con corticoides intravenosos mejoraron la visión. Discusión: la NOIANA por choque hipovolémico es una entidad infrecuente y poco reportada que puede generar cambios irreversibles en la agudeza visual, por lo que es importante sospecharla y detectarla para dar un manejo oportuno. Conclusión: este caso de NOIANA es uno de los pocos descritos como secundarios a hemorragia digestiva y el primero asociado con lesión de Dieulafoy.

Objetive: to describe the case of a patient from Hospital de San José in Bogotá with upper gastrointestinal tract bleeding secondary to a Dieulafoy ́s lesion, who presented symptoms compatible with a non-arteritic anterior ischemic optic neuropathy (NA-AION). Methodology: a narrative review and systemic search of the literature was conducted to determine the clinical and demographic characteristics, treatment and visual prognosis in patients with NA-AION. Materials and methods: case report, narrative review and systematic search of the literature in Medline via Ovid and Embase databases on NA-AION secondary to hypovolemia. Sociodemographic and clinical variables, diagnosis, associated conditions, treatment and visual prognosis were analyzed. A statistical analysis was performed using absolute and relative frequencies. Results: improvement of final visual acuity in patients who presented a NA-AION episode was uncertain. In 42% there was some kind of visual acuity improvement regardless of treatment received. Vision improved in less than 50% of the reported clinical cases included in this study that received treatment with intravenous steroids. Discussion: hypovolemic NA-AION is a rare and underreported entity that may generate irreversible changes in visual acuity, so it is important to suspect and detect it to provide timely management. Conclusion: this case of NA-AION is one of the few described as secondary to gastrointestinal bleeding and the first associated with a Dieulafoy ́s lesion.

Massive retroperitoneal haematoma because of renal cyst rupture, report of a case / Hematoma retroperitoneal masivo por ruptura de quiste renal, reporte de caso

We report the case of an 86-year-old adult man who, as a pedestrian, is hit by a motorcycle, suffering polytrauma; in initial care, he refers to thoraco-abdominal pain and subsequently neurological deterioration. Assessed by a neurosurgeon and general surgeon, a right chest tube is placed and a laparoscopy is performed where there is little bleeding from the abdominal cavity. It shows deterioration of its general state and dies in respiratory failure. During the necropsy procedure there is subarachnoid hemorrhage and cerebral herniation, rib fractures and pneumonic consolidation, a massive retroperitoneal hematoma is observed due to rupture of simple renal cyst.

Reportamos el caso de un hombre de 86 años que, siendo peatón, es atropellado por una motocicleta, sufriendo politraumatismo. En la atención inicial refiere a dolor toracoabdominal y posteriormente deterioro neurológico. Evaluado por un neurocirujano y un cirujano general, se coloca un tubo torácico derecho y se realiza una laparoscopia y observándose poco sangrado de la cavidad abdominal. El paciente muestra deterioro de su estado general y muere por insuficiencia respiratoria. Durante el procedimiento de necropsia se determina hemorragia subaracnoidea y hernia cerebral, fracturas costales y consolidación neumónica, se observa un hematoma retroperitoneal masivo por rotura de quiste renal simple.

Hypotonic enteral electrolyte solutions administered by nasoesophageal tube in continuous flow in dogs dehydrated by water restriction: Part 1 / Soluções eletrolíticas enterais hipotônicas administradas por sonda nasoesofágica em fluxo contínuo em cães desidratados por restrição hídrica: Parte 1

The present study assessed and compared the effects of hypotonic enteral electrolyte solutions administered by nasoesophageal tube in continuous flow in dogs submitted to water restriction on packed cell volume; total serum protein and serum osmolarity concentrations; blood volume; plasma glucose and lactate levels; blood gas analysis, anion gap, and strong ion difference. Six adult dogs were used (four males and two females). All animals were submitted to both proposed treatments in a crossover design 6×2. The treatments were as follows: ESmalt consisting of 5g sodium chloride, 1g potassium chloride, 1g calcium acetate, 0.2g magnesium pidolate, and 9.6g maltodextrin that were diluted in 1.000mL water (measured osmotic concentration of 215mOsm L−1) and ESdext consisting of 5g sodium chloride, 1g potassium chloride, 1g calcium acetate, 0.2g magnesium pidolate, and 9.6g dextrose that were diluted in 1.000mL water (measured osmotic concentration of 243mOsm L−1). All solutions were administered at 15ml kg−1 h−1 for 4 hours. Both solutions increased the plasma volume in dehydrated dogs without causing adverse effects. However, ESmalt was more effective in promoting the increase in blood volume.(AU)

O presente estudo avaliou e comparou os efeitos de soluções eletrolíticas enterais hipotônicas, administradas por sonda nasoesofágica em fluxo contínuo em cães submetidos a restrição hídrica, sobre o hematócrito, proteínas totais séricas, osmolaridade sérica, volemia, glicose e lactato plasmáticos, hemogasometria, ânion gap e DIF. Foram utilizados seis cães adultos (quatro machos e duas fêmeas). Todos os animais foram submetidos aos dois tratamentos propostos, em um delineamento crossover 6×2. Os tratamentos foram os seguintes: SEmalt - 5g de cloreto de sódio, 1g de cloreto de potássio, 1g de acetato de cálcio, 0,2g de pidolato de magnésio e 9,6g de maltodextrina, diluídos em 1.000mL de água (osmolaridade mensurada: 215mOsm L -1 ); SEdext - 5g de cloreto de sódio, 1g de cloreto de potássio, 1g de acetato de cálcio, 0,2g de pidolato de magnésio e 9,6g de dextrose, diluídos em 1.000mL de água (osmolaridade mensurada: 243mOsm L -1 ). Todas as soluções foram administradas no volume de 15mL kg -1 hora -1 , durante quatro horas, em fluxo contínuo. Ambas as soluções aumentaram o volume plasmático em cães desidratados, sem gerar o aparecimento de efeitos adversos. Porém, a SEmalt foi mais eficaz em promover a expansão da volemia.

Indicações e resultados para o uso expandido da oclusão ressuscitativa por balão endovascular da aorta - REBOA / Expanding indications and results for the use of resuscitative endovascular balloon occlusion of the aorta - REBOA

RESUMO A oclusão ressuscitativa por balão endovascular da aorta (REBOA) é utilizada para controlar hemorragias não compressíveis do tronco como uma opção menos invasiva e com menos distúrbios fisiológicos quando comparado à toracotomia de emergência com clampeamento da aorta. Isso permite a melhora dos parâmetros hemodinâmicos até que a cirurgia definitiva seja realizada. É utilizada no trauma como uma medida para prevenir o colapso hemodinâmico em pacientes que estão em choque hemorrágico grave, mantendo a perfusão do cérebro e do coração enquanto diminui o sangramento distal até que o controle da hemorragia possa ser realizado. As principais complicações relatadas são insuficiência renal aguda, amputações de membros inferiores e óbitos. O objetivo desse estudo foi avaliar a expansão do uso do REBOA em situações não traumáticas de outras áreas da medicina, assim como, avaliar os resultados obtidos até o momento. Uma pesquisa online do PubMed, Medline e SciELO foi realizada com o termo "REBOA" nos últimos cinco anos, e os artigos incluídos foram os 14 que descrevem especificamente o uso do REBOA para condições não traumáticas. Os resultados sugerem que o uso do REBOA levou a um melhor controle do sangramento e aumento da pressão arterial, reduzindo a necessidade de transfusão de sangue e permitindo que os pacientes sobrevivam ao tratamento definitivo das lesões. Concluindo, o uso expandido do REBOA para emergências não traumáticas parece ser eficaz, mas estudos prospectivos e protocolos bem estabelecidos devem ser desenvolvidos para maximizar os resultados.

ABSTRACT Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) is used in trauma surgery for controlling non-compressible torso hemorrhages, as a less invasive option and with fewer physiologic disturbances compared with an invasive emergent thoracotomy for aortic cross-clamping. This can allow improvements in hemodynamic parameters until definitive surgery is performed. REBOA is also used in trauma to prevent hemodynamic collapse in patients who are in severe hemorrhagic shock, as a method to maintain perfusion of the brain and heart while decreasing distal bleeding until hemorrhage control can take place. The major complications reported are acute kidney injury, lower leg amputations, and even death. As experience with REBOA in emergency surgery grows, new indications have been described in the literature. The aim of this study was to assess the expansion of the use of REBOA in other areas of medicine, as well as evaluating the current published series. We performed an online search of PubMed, Medline and SciELO with the term "REBOA" in the last five years, and the articles included were the 14 specifically describing the use of REBOA for non-traumatic conditions. The results suggest that the use of REBOA led to improved bleeding control and increased arterial pressure, reducing blood transfusion requirements and allowing patients to survive to definitive treatment of injuries. In conclusion, the expanded use of REBOA for non-traumatic emergencies appears to be effective. However, prospective studies and well-established protocols for specific indications should be developed to maximize patient outcomes.

Clip Ovesco® como tratamiento de rescate en lesión de Dieulafoy duodenal con sangrado activo / Ovesco clip as a rescue treatment of duodenal Dieulafoy lesion with active bleeding

Las lesiones de Dieulafoy se definen como una anomalía vascular que producen un sangrado en la mucosa proveniente de una arteria submucosa anormalmente larga y tortuosa que se ubican principalmente en estómago (80%), con poca frecuencia a nivel duodenal y constituyen el 6% de los sangrados gastrointestinales no asociados a varices y del 1% al 2% de todos los sangrados gastrointestinales. Reportamos el caso de un paciente masculino de 60 años que ingresó por hematemesis, melena y signos de hipovolemia con hemoglobina de 9 g/dl, que luego de realizar su compensación hemodinámica se le realizó una endoscopía alta que evidenció una lesión de Dieulafoy con sangrado activo severo en la segunda porción duodenal realizándosele inyección con adrenalina al 1:10 000 sobre los bordes de la lesión, pero al no lograrse una hemostasia adecuada se le tuvo que realizar la colocación de un clip ovesco con hemostasia efectiva que se corroboró 24 horas después, a través de una segunda endoscopía para poder egresar al paciente sin complicaciones, ni resangrado.

Dieulafoy's lesions are vascular anomalies that produce gastrointestinal bleeding of the mucosa from an abnormally long and tortuous submucosal artery. It is found predominately in the stomach (80%) and less frequently in the duodenum. They constitute the 6% of all non-variceal bleeding and the 1 to 2% of all gastrointestinal bleeding source. We report a case of a 60-year-old man with hematemesis, melena and signs of hypovolemic shock with a hemoglobin level of 9 g/dL. After adequate fluid resuscitation, an upper endoscopy showed an actively bleeding Dieulafoy lesion in the second portion of the duodenum. After epinephrine injection over lesion borders, an adequate hemostasis was not achieved. An over-the-scope clip was placed. Follow-up endoscopy 24 hours later showed an effective hemostasis and the patient was discharged without complications or re-bleeding.

Hipercloremia y mortalidad en la unidad de cuidados intensivos / Mortality and hyperchloremia in the intensive care unit

Abstract Introduction: Administrating intravenous fluids is one of the most frequent practices in the care of critically ill patients, since most of them present shock or hypotension from any cause. The rapid and aggressive administration of these fluids may lead to adverse results, including acute renal failure and hydroelectrolytic disorders which are highly associated with fatal outcomes. Objectives: To establish the association between hyperchloremia and mortality in patients admitted to the intensive care unit (ICU) of Hospital Universitario de San José between August 2013 and January 2017, in addition to their demographic characteristics, the incidence of chloride abnormalities, and its association to renal failure. Methods: Analytic retrospective cohort study in the adult ICU at the Hospital Universitario de San José from August 1, 2013 to January 31, 2017. Results: A total of 839 patients were evaluated, 210 exposed and 629 not exposed. The relative risk of death for those who developed hyperchloremia was 3.12 (95% confidence interval [CI] 2.16^.49) (P <0.001). The multivariate analysis generated an hazard ratio of 2.31 (95% CI 1.47-3.63) adjusted for age, sex, APACHE II at admission, sepsis, neurocritical state, and development of renal failure. Conclusion: Hyperchloremia is a frequent event in patients in the ICU; it may act as an independent variable for mortality in critical patients.

Resumen Introducción: La administración de líquidos endovenosos es de los actos que con mayor frecuencia se realizan en el cuidado de los pacientes críticamente enfermos, dado que gran parte de los mismos cursan con choque o hipotensión de cualquier causa, ésta se realiza de forma agresiva y rápida, dicha administración puede conllevar a eventos desfavorables como la falla renal aguda y alteraciones hidroelectrolíticas que están altamente relacionadas con desenlaces fatales. Objetivos: Establecer la asociación entre hipercloremia y mortalidad en los pacientes hospitalizados en cuidados intensivos del hospital Universitario de San José entre agosto de 2013 y enero de 2017, así como sus características demográficas, incidencia de anormalidades del cloro y su asociación con falla renal. Métodos: Estudio analítico de cohortes retrospectiva, en la Unidad de Cuidados intensivos (UCI) adultos del Hospital Universitario de San José, en el período comprendido entre el 1 de agosto de 2013 y el 31 de enero de 2017. Resultados: Fueron evaluados 839 pacientes, 210 expuestos y 629 no expuestos. El riesgo relativo para muerte en los que desarrollaron hipercloremia fue 3.12 (IC95% 2.16-4.49) (p <0.001). En el análisis multivariado se obtuvo un HR de 2.31 (IC95% 1.473.63) ajustado por las variables de edad, sexo, APACHE II al ingreso, sepsis, estado neurocrítico y desarrollo de falla renal. Conclusiones: La hipercloremia es un evento frecuente durante la atención de los pacientes en la unidad de cuidados intensivos; puede actuar como una variable independiente de mortalidad en los pacientes críticos.

Volume expansion and variation in hemodynamic parameters. / Expansión del volumen y variación en los parámetros hemodinámicos.

OBJECTIVES: To assess correlations among variations in hemodynamic parameters during fluid volume loading. MATERIAL AND METHODS: Prospective observational study in 2 intensive care units. Sixty patients requiring intravenous fluids underwent challenge tests with 300 mL of crystalloids over a 48-hour period. Percent change in hemodynamic parameters after infusion was measured. We used hierarchical cluster and principal component analyses to explore correlations among changes in hemodynamic responses. RESULTS: The parameters that underwent the greatest median (interquartile range) percent changes were central venous pressure (24% [0.0%-41.7%]), pulse pressure (12.9% [0.0%-22.4%]), shock index (5.8% [2.7%-13.7%]), rate-pressure product (5.8% [3.8%-18.8%]), and systemic pressure difference (5.8% [-3.8%-18.8%]). There were strong correlations between percent changes in the following parameters: systolic blood pressure, pulse pressure, rate-pressure product, shock index, and systemic pressure difference. Central venous pressure was not correlated with any of the other hemodynamic parameters. CONCLUSION: The relationships between changes in hemodynamic parameters after fluid loading are complex and must be taken into account if fluids are infused during resuscitation.

OBJETIVO: Determinar la relación entre los parámetros hemodinámicos durante la expansión del volumen. METODO: Estudio observacional y prospectivo en dos unidades de cuidados intensivos. En las primeras 48 horas se realizó una prueba de volumen con 300 ml de cristaloides en 60 pacientes con indicación de fluidos endovenosos. Se evaluaron los cambios en los parámetros hemodinámicos después de la infusión de volumen, y las relaciones entre las variaciones se exploraron con los análisis de clústeres jerárquicos y de componentes principales. RESULTADOS: Los mayores porcentajes de variación se observaron en la presión venosa central [mediana 24% (rango intercuartil (RIC) 0,0-41,7%)], presión del pulso [mediana 12,9% (RIC 0,0-22,4%)], índice de shock [mediana 5,8% (RIC 2,7-13,7%)], producto presión del pulso-frecuencia cardiaca [mediana 5,8% (RIC ­3,8-18,8%)] y diferencia de presiones sistémicas [mediana 5,8% (RIC ­3,8-18,8%)]. Hubo una fuerte correlación entre las variaciones de la presión arterial sistólica, presión del pulso, producto presión del pulso-frecuencia cardiaca, índice de shock y diferencia de presiones sistémicas. La presión venosa central no se correlacionó con ningún parámetro hemodinámico. CONCLUSIONES: Las relaciones entre las variaciones que se producen en los parámetros hemodinámicas después del aporte de volumen son complejas, lo que se debe tener en cuenta durante la reanimación con volumen.

Epidemiological profile of maternal mortality / Perfil epidemiológico de mortalidad materna / Perfil epidemiológico de mortalidade materna

ABSTRACT Objective: To know the epidemiological profile of maternal mortality in Juiz de Fora, a city in the state of Minas Gerais. Data collection was carried out from April to December 2016. Method: Summary of a confidential investigation of maternal mortality on deaths occurred from January 1st, 2005 to December 31, 2015. Results: Eighty-five deaths of women residing in Juiz de Fora were identified and analyzed. The age group was between 20 and 36 years. The women carried out prenatal care (74.1%) with less than six visits (34.0%). Cesarean section was conducted in 38.8% of the childbirths and the obstetric treatment was considered appropriate (32.9%). The first cause of maternal death was hypovolemic shock 12 (14.10%), followed by uterine hypotony 6 (7.0%). Conclusion: Cesarean section rates are high and prenatal adherence is lower than that expected, which could justify the number of deaths in the period studied.

RESUMEN Objetivo: Conocer el perfil epidemiológico de la mortalidad materna en Juiz de Fora, Minas Gerais. Datos recolectados de abril a diciembre de 2016. Método: Resumen de la investigación confidencia de muerte materna, de óbitos ocurridos entre el 1 de enero de 2005 y el 31 de diciembre de 2015. Resultados: Fueron identificadas y analizadas las 85 muertes de mujeres residentes en Juiz de Fora. Su faja etaria correspondía al segmento de 20 a 36 años. Las mujeres hicieron consultas prenatales (74,1%) de menos de seis visitas (34,0%). Se realizó cesárea en 38,8% de los partos, y el tratamiento obstétrico fue considerado correcto (32,9%). La primera causa de muerte materna fue el shock hipovolémico, 12 (14,10%), seguido de hipotonía uterina, 6 (7,0%). Conclusión: La tasa de cesáreas es alta, y la adherencia prenatal es menor a la esperada, lo cual podría justificar el número de óbitos en el período estudiado.

RESUMO Objetivo: Conhecer o perfil epidemiológico da mortalidade materna em Juiz de Fora, Minas Gerais. A coleta de dados foi realizada de abril a dezembro de 2016. Método: Resumo da investigação confidencial de morte materna, de óbitos ocorridos entre 1º de janeiro de 2005 e 31 de dezembro de 2015. Resultados: Foram identificadas e analisadas as 85 mortes de mulheres residentes em Juiz de Fora. A faixa etária foi compreendida entre 20 e 36 anos. As mulheres tiveram pré-natal (74,1%), com menos de seis visitas (34,0%). A cesariana foi realizada em 38,8% dos partos, e o tratamento obstétrico foi considerado correto (32,9%). A primeira causa de morte materna foi o choque hipovolêmico 12 (14,10%), seguido de hipotonia uterina 6 (7,0%). Conclusão: A taxa de cesariana é alta e a aderência pré-natal é menor do que a esperada, o que poderia justificar o número de óbitos no período estudado.

Ruptura traumática de la arteria vertebral por herida penetrante en el cuello / Traumatic rupture of the vertebral artery caused by penetrating neck injury

Introducción: la exanguinación es una entidad clínica dramática que requiere rapidez de pensamiento y acción para obtener buenos resultados.Presentación del caso: se reporta el caso de un paciente de 13 años que sufrió accidente automovilístico y fue atendido en el Hospital Pediátrico "Eliseo Noel Camaño", de la provincia de Matanzas, Cuba. El niño llegó con múltiples traumas en miembros superiores e inferiores, y una herida penetrante en el cuello que requirió tratamiento quirúrgico inmediato para controlar hemorragia. Se necesitó un acceso multidisciplinario de intensivistas, anestesiólogos, cirujanos pediátricos, neurocirujanos y cirujanos vasculares, porque la cuantía del sangrado y la localización de la lesión hicieron sospechar una afección traumática de la arteria vertebral. El niño sobrevivió a la lesión exanguinante, y actualmente se encuentra en proceso de recuperación.Conclusiones: la lesión penetrante del cuello puede provocar ruptura traumática de la arteria vertebral, entidad infrecuente que requiere alta sospecha diagnóstica para lograr éxito en su tratamiento. Consideramos vital la visión multidisciplinaria, en la que deben prevalecer maniobras seguras, rápidas y eficientes(AU)

Introduction: exsanguination is a dramatic clinical condition that requires quick analysis and action to achieve good results.Case report: this is a 13 years/old patient who suffered a car accident and was seen at "Eliseo Noel Camano" pediatric hospital in Matanzas province, Cuba. The teenager had many upper and lower limb traumas and a penetrating neck injury that required immediate surgery to control hemorrhage. It was necessary to involve intensive care experts, anesthesiologists, pediatric surgeons, neurosurgeons, and vascular surgeons because the amount of bleeding and the location of injury aroused the suspicion of traumatic damage of the vertebral artery. The teenager managed to survive from the exsanguinating injury and is currently in his recovery process.Conclusions: the penetrating neck injury may cause traumatic rupture of the vertebral artery, an uncommon condition that requires great diagnostic suspicion in order to succeed in treatment. It is vital to have a multidisciplinary vision in which safe, rapid and effective procedures should prevail(AU)

Ruptura traumática de la arteria vertebral por herida penetrante en el cuello / Traumatic rupture of the vertebral artery caused by penetrating neck injury

Introducción: la exanguinación es una entidad clínica dramática que requiere rapidez de pensamiento y acción para obtener buenos resultados.Presentación del caso: se reporta el caso de un paciente de 13 años que sufrió accidente automovilístico y fue atendido en el Hospital Pediátrico Eliseo Noel Camaño , de la provincia de Matanzas, Cuba. El niño llegó con múltiples traumas en miembros superiores e inferiores, y una herida penetrante en el cuello que requirió tratamiento quirúrgico inmediato para controlar hemorragia. Se necesitó un acceso multidisciplinario de intensivistas, anestesiólogos, cirujanos pediátricos, neurocirujanos y cirujanos vasculares, porque la cuantía del sangrado y la localización de la lesión hicieron sospechar una afección traumática de la arteria vertebral. El niño sobrevivió a la lesión exanguinante, y actualmente se encuentra en proceso de recuperación.Conclusiones: la lesión penetrante del cuello puede provocar ruptura traumática de la arteria vertebral, entidad infrecuente que requiere alta sospecha diagnóstica para lograr éxito en su tratamiento. Consideramos vital la visión multidisciplinaria, en la que deben prevalecer maniobras seguras, rápidas y eficientes(AU)

Introduction: exsanguination is a dramatic clinical condition that requires quick analysis and action to achieve good results.Case report: this is a 13 years/old patient who suffered a car accident and was seen at Eliseo Noel Camano pediatric hospital in Matanzas province, Cuba. The teenager had many upper and lower limb traumas and a penetrating neck injury that required immediate surgery to control hemorrhage. It was necessary to involve intensive care experts, anesthesiologists, pediatric surgeons, neurosurgeons, and vascular surgeons because the amount of bleeding and the location of injury aroused the suspicion of traumatic damage of the vertebral artery. The teenager managed to survive from the exsanguinating injury and is currently in his recovery process.Conclusions: the penetrating neck injury may cause traumatic rupture of the vertebral artery, an uncommon condition that requires great diagnostic suspicion in order to succeed in treatment. It is vital to have a multidisciplinary vision in which safe, rapid and effective procedures should prevail(AU)

Hemotórax / Hemothorax

El hemotórax es una patología que de no ser diagnosticada y tratada a tiempo amenaza la vida del paciente, "los traumas torácicos son el 25% de los tipos de trauma en los pacientes politraumatizados" (Greenfield, 2011).Por lo tanto, es de suma importancia realizar un adecuado examen físico primario y secundario, para así poder descartar lesiones que ameriten una actitud resolutiva de emergencia; asimismo, el diagnóstico es clínico y radiológico, siempre tomando en consideración la condición global del paciente. Lo anterior, para elegir el método más práctico, rápido y fidedigno para apoyar el diagnóstico clínico; el tratamiento con sello de tórax es el manejo de elección inicial, el cual dependiendo de la evolución clínica del paciente seguirá una serie de métodos para realizar la completa evacuación del mismo y evitar, en la medida de lo posible, las complicaciones. Además, es de gran interés realizar un tratamiento rápido y eficaz para evitar que el líquido se coagule, lo cual puede producir un empiema o fibrotórax. Por esta razón, todos los proveedores de la salud, en especial los médicos encargados de emergencias y los cirujanos deben tener en mente el probable desarrollo de un hemotórax en pacientes quienes sufran síntomas inexplicables de hipovolemia, específicamente en politraumatizados, por esto se debe conocer a profundidad las características de esta patología.

Hemothorax is a disease in which if not diagnosed and treated in time, threatens the patient's life. Thoracic traumas account for 25% of trauma in politraumatized patients (Greenfield, 2011), it is paramount to perform an adequate first and secondary physical examination, so we can rule out any problems that merit an emergency operative attitude. The diagnosis is clinical and radiological, taking always into consideration the overall condition of the patient, to choose the most convenient treatment, the fastest and most reliable method to support the clinical diagnosis. The chest tube is the initial choice method, depending on the clinical evolution of the patient a number of other methods can be perform in order to complete the evacuation of the collection and avoid as much as possible the complications; it is very important to make a fast and effective treatment to prevent the liquid from clotting, which can cause empyema or fibrothorax. All health providers and more the physicians in charge of the emergency department and the surgeons, should keep in mind the likely development of a hemothorax in patients suffering unexplained symptoms of hypovolemia in trauma cases, that is why is important to know in depth the characteristics of this disease.

Validação de um modelo experimental de transfusão de glóbulos vermelhos estocados homólogos em suínos e avaliação de seus efeitos cardiorrespiratórios e inflamatórios na hemorragia aguda / Validation of homologous stored red blood cell transfusion in swine and evaluation of cardiorespiratory and inflammatory effects in acute hemorrhage

Objetivos: Transfusão de sangue é fundamental para a sobrevida de pacientes selecionados, porém é associada a complicações. A literatura é controversa em relação aos efeitos pulmonares, hemodinâmicos e inflamatórios da transfusão de glóbulos vermelhos (GV). Este estudo teve dois objetivos principais: 1- validar um modelo de transfusão homologa de GV estocados em suínos com hipovolemia aguda por hemorragia controlada; 2- avaliar os efeitos agudos da transfusão de GV nas trocas gasosas, mecânica respiratória, hemodinâmica e na resposta inflamatória pulmonar e sistêmica. Métodos: Este estudo foi dividido em duas etapas: 1.Coleta, processamento e estocagem por 14 dias de GV provenientes de um suino Agroceres®, avaliado antes (in vitro) e após (in vivo - marcação com cromato de sódio radioativo) à sua transfusão em suínos sadios , um autólogo e quatro homologos (n=cinco); 2. Outro grupo de suínos foi submetido à hemorragia aguda controlada (25% de sua volemia) e então dividido em dois grupos: grupo transfusão (n= oito) recebeu duas unidades de GV e solução de ringer lactato (RL) para restabelecer a volemia; grupo controle (n=oito) que recebeu somente RL. Ambos os grupos foram seguidos até 6horas após o final da ressuscitação volêmica. Dados hemodinâmicos e respiratórios foram coletados a cada hora após o inicio do estudo. Mediadores inflamatórios e expressão de RNAmensageiro(RNAm) foram medidos no plasma e no tecido pulmonar. Resultados: Houve recuperação de 97,5%±19% dos GV marcados com cromato de sódio radioativo 24 horas após a transfusão. Houve aumento significativo da saturação venosa mista, conteúdo arterial de oxigênio e dos níveis de hemoglobina e hematócrito no grupo transfundido comparado ao controle. Os parâmetros medidos para a avaliação da microcirculação e as trocas gasosas foram similares em ambos os grupos. Observou-se um aumento significativo na energia gasta na histerese pulmonar no grupo controle quando comparado ao grupo transfundido (p=0,002),...

Objectives: Blood transfusion is critical to the survival of selected patients, but may be associated with complications. Previous data related to pulmonary, hemodynamic and inflammatory effects of red blood cells (RBC) are still controversial. This study has two main objectives: 1- Validate a homologous stored red blood cell transfusion model in swine with acute hypovolemia by controlled bleeding; 2- Assess the acute effects of RBC transfusion on gas exchange, respiratory mechanics and hemodynamics, pulmonary and systemic inflammatory response. Methods: This study was divided into two phases: 1. Collection, processing and storing RBC from Agroceres® swines for 14 days and evaluation before (in vitro) and after (in vivo - labelling with radioactive sodium chromate) transfusion in one autologous and four homologous healthy swines (n = five); 2. Controlled acute hemorrhage (25% of blood volume) of sixteen pigs and then allocation in two groups: transfusion group (n = eight) received two units of RBC and Lactaded Ringer's solution (RL) to restore blood volume; control group (n = eight) that received only LR. Both groups were followed up to 6 hours after the end of resuscitation. Hemodynamic and respiratory data were collected hourly after the start of the study. Inflammatory mediators and messenger RNA(mRNA) expression were measured in plasma and lung tissue. Results: The 24-hour recovery of RBC labeled with radioactive sodium chromate was 97.5% ± 19%. We found significant increase of mixed venous oxygen saturation, oxygen arterial content, and hemoglobin and hematocrit levels in the transfused group compared to control. There were no significant differences between the two groups in microcirculation and gas exchange. There was a significant increase in the energy spent in lung hysteresis in the control group compared to the transfused group (p=0,002), as well as a tendency to decrease inspiratory energy in the transfusion group. The...

Total knee arthroplasty: indication of blood transfusion according to hematimetric variation and clinical symptoms of hypoperfusion

Objective: To analyze the relationship between hematimetric variation and the presence of clinical symptoms of hypoperfusion for indicating blood transfusion in patients undergoing total knee arthroplasty. Methods: A retrospective analysis was conducted on data gathered from the medical files of 55 patients with a diagnosis of gonarthrosis, who underwent total knee arthroplasty at a hospital orthopedics and traumatology service between February 2011 and December 2012. The patients studied presented unilateral joint degeneration and fitted into the indications for surgical treatment. All the patients underwent a preoperative cardiological evaluation, presenting a pattern of ASA I–III and absence of blood dyscrasia, and preoperative hemoglobin measurements were made. However, no minimum hematimetric value was established for the surgical treatment; there were only clinical criteria for blood perfusion. Results: Among the 55 patients, 35 were female and 20 were male, and the mean age was 68 years. Six patients underwent homologous blood transfusion, because of their clinical condition of tissue hypoperfusion, persistent hypotension, loss of consciousness, sweating and coercible vomiting. They presented postoperative hemoglobin of 7.5–8.8 g/dL. Conclusion: For patients with falls in hemoglobin counts greater than 20% and values lower than 9 g/dL after the surgery, there is a possible need for blood transfusion, which should only be indicated when accompanied by major symptoms of tissue hypoperfusion...

Objetivo: Analisar a relação entre a variação hematimétrica e a presença de sintomas clínicos de hipoperfusão para a indicação de transfusão sanguínea em pacientes submetidos a artroplastia total do joelho. Métodos: Fez-se uma análise retrospectiva dos dados coletados nos prontuários de 55 pacientes com diagnóstico de gonartrose submetidos a artroplastia unilateral total do joelho feita pelo serviço de ortopedia e traumatologia de um hospital de fevereiro de 2011 a dezembro de 2012. Os pacientes estudados apresentaram degeneração articular unilateral e se enquadraram na indicação para o tratamento cirúrgico. Todos foram submetidos a avaliação pré-operatória cardiológica e manteve-se um padrão correspondente a ASA-I até III, ausência de discrasia sanguínea e mensuração de hemoglobina pré-operatória. Porém, não foi estabelecido valor hematimétrico mínimo para o tratamento cirúrgico, apenas critérios clínicos de perfusão sanguínea. Resultados: Dos 55 pacientes, 35 do sexo feminino e 20 do masculino, com média de 68 anos, apenas seis foram submetidos a transfusão sanguínea homóloga, decorrente do quadro clínico de hipoperfusão tecidual, hipotensão persistente, perda da consciência, sudorese e vômitos coercíveis e apresentaram hemoglobina pós-operatória entre 7,5 e 8,8 g/dL. Conclusão: Pacientes com queda acima de 20% na contagem de hemoglobina e valores abaixo de 9 g/dL após a cirurgia sugerem uma possível necessidade de transfusão sanguínea, que só deve ser indicada quando acompanhada de sintomas maiores de hipoperfusão tecidual...

Fisiopatologia do choque / Pathophysiology of circulatory shock

O presente artigo tem por objetivo apresentar, de maneira didática e sistematizada, os mecanismos fisiopatológicos da síndrome do choque circulatório.

Rotura uterina en la semana 19 de gestación por placenta percreta / Uterine rupture at week 19 of gestation placenta percreta

La rotura uterina durante el embarazo es una complicación obstétrica con graves consecuencias para la madre y el feto. La rotura uterina por placenta percreta es inusual. Comunicamos el caso de una paciente de 30 años, con embarazo de 19 semanas, quien ingresó por dolor abdominal de 24 horas de evolución, a predominio en la región hipogástrica, que durante su evolución padeció afectación hemodinámica y aumento del dolor abdominal. Por ultrasonido se observó líquido libre en la cavidad abdominal y mediante la laparotomía se encontró rotura uterina, se extrajo la placenta y el feto dentro de la bolsa amniótica y se realizó histerectomía. El diagnostico se confirmó mediante estudio histopatológico. (AU)

Uterine rupture during pregnancy is an obstetric complication with serious consequences for the mother and fetus. Uterine rupture is unusual placenta percreta. We report the case of a patient of 30 years, with 19 weeks pregnant, was admitted with abdominal pain 24 hours after onset, predominantly in the hypogastric region, during its evolution suffered hemodynamic compromise and increased abdominal pain. By ultrasound revealed free fluid in the abdominal cavity by laparotomy and uterine rupture was found, the placenta and the fetus within the amniotic sac was removed and hysterectomy was performed. The diagnosis was confirmed by histopathology. (AU)

Manejo del sangrado perioperatorio en niños. Revisión paso a paso / Management of perioperative bleeding in children. Step by step review

Introducción: Un reemplazo apropiado de las pérdidas sanguíneas es esencial para la reducción de la morbimortalidad en el paciente quirúrgico pediátrico.Objetivo: Revisión no sistemática de la literatura sobre el manejo del sangrado perioperatorio en niños. Metodología: Se realizó una revisión de la literatura no sistemática, en las bases de datos de Pubmed, Medline, Ovid y Cochrane, sobre artículos que describieran el manejo del sangrado perioperatorio en niños. Resultados: Es necesario estar preparados en las situaciones donde se espera un sangrado masivo. Se deben conocer las indicaciones de la terapia transfusional, prevenir y manejar las complicaciones de la transfusión masiva y utilizar los hemostáticos perioperatorios cuando estén indicados.

Introduction: Appropriate replacement of blood losses is essential to reduce morbidity and mortality in the surgical pediatric patient. Objective: Non-systematic reviewof the literature on the management of perioperative bleeding in children. Methodology: A systematic literature review using Pubmed, Medline, Ovid and Cochrane databases was completed on articles describing the management of perioperative bleeding in children. Results: Readiness is a must in situations where massive bleeding is expected. You should be knowledgeable about the indications for transfusion therapy, the prevention and management of complications of massive transfusion and the use of perioperative hemostatic agents when indicated.

Ventilação mandatória intermitente sincronizada versus ventilação com suporte pressórico e volume garantido em coelhos induzidos à hemorragia aguda / Synchronized intermittent mandatory ventilation versus volume assured pressure support ventilation in rabbits induced to acute hemorrhage

Avaliaram-se os efeitos da ventilação mandatória intermitente sincronizada (SIMV) e da ventilação com pressão de suporte e volume garantido (VAPSV) sobre os parâmetros cardiorrespiratórios em coelhos anestesiados com propofol e submetidos à hipovolemia aguda. Vinte animais da raça Nova Zelândia foram distribuídos aleatoriamente em dois grupos: GM sob SIMV e GV sob VAPSV. Na medicação pré-anestésica, foram administradas quetamina (15mg/kg) e xilazina (1mg/kg) intramuscular. O propofol foi administrado na indução (8mg/kg) e na manutenção anestésica (0,5mg/kg/min). Em seguida, em cada grupo foi iniciada a modalidade ventilatória. Após 30 minutos da indução, os coelhos foram submetidos à hipovolemia, retirando-se 12mL/kg de sangue arterial. A primeira mensuração das características (M0) foi efetuada 40 minutos após a indução anestésica, seguida de mensurações em intervalos de 10 minutos depois da hipovolemia (M1 a M6). A partir de M3, o débito cardíaco foi maior em GM. Em ambos os grupos, as pressões arteriais e pressão venosa central diminuíram a partir de M1, enquanto a pressão arterial de oxigênio no sangue arterial aumentou a partir de M4. O esforço respiratório foi maior no GV em todos os momentos estudados. Conclui-se que a SIMV e a VAPSV foram seguras quanto à oxigenação arterial, garantindo uma adequada troca gasosa. Contudo, a SIMV mostrou-se a mais indicada em coelhos hipovolêmicos por manter melhor a estabilidade hemodinâmica, com a vantagem de proporcionar menor trabalho respiratório.

The effects of synchronized intermittent mandatory ventilation (SIMV) versus volume assured pressure support ventilation (VAPSV) on cardiorespiratory parameters in propofol-anesthetized rabbits induced to acute hypovolemia were evaluated. Twenty New Zealand white rabbits were randomly allotted to: GM under SIMV and GV under VAPSV. In premedication, ketamine (15mg/kg) and xylazine (1mg/kg) were administered intramuscularly. Propofol was used to induce (8mg/kg) and to maintain anesthesia (0.5mg/kg/min). Following, according to each group, the ventilation mode was started. After thirty minutes of anesthesia induction, rabbits were induced to hypovolemia by removing 12ml/kg of arterial blood. The initial measurement of parameters (M0) was recorded thirty minutes after anesthesia induction. Additional recordings were performed at 10-minute intervals after hypovolemia induction (M1 to M6). Cardiac output (CO) was bigger in GM. In both groups, arterial pressures and central venous pressure (CVP) decreased from M1, while arterial partial pressure of oxygen (PaO2) increased from M4. The respiratory effort was greater in GV at all times studied. In conclusion, VAPSV and SIMV were safe for arterial oxygenation and provided adequate gas exchange. However, the SIMV is more appropriate for hypovolemic rabbits, because it maintains hemodynamic stability and promotes lower respiratory work.

Shock hipovolémico en la emergencia / Hipovolemic shock on emergency

El trauma se encuentra entre las primeras causas de mortalidad en nuestro país. La muerte se produce principalmente por obstrucción de la vía aérea, shock especialmente hemorrágico y traumatismo craneoencefálico. La importancia de una adecuada y correcta atención del choque en los primeros minutos o la primera hora del accidente, hace que la mortalidad en este período pueda disminuir y como resultado de este mejor manejo inicial, disminuir la mortalidad tardía (por sepsis y falla orgánica múltiple); es lo que se conoce como hora dorada para el médico emergencista. Una adecuada atención durante el preoperatorio, transoperatorio y postoperatorio debe ser una máxima para el médico emergencista, a fin de reducir los riesgos de la anestesia y el estado de choque; la reanimación con fluidos isotónicos y la combinación con aminas presoras que mantengan una presión arterial media que garantice una perfusión a órganos dianas, no solo garantiza la vida, sino minimiza las complicaciones posteriores como la IRA (Insuficiencia Renal Aguda), DMO, FMO (disfunción y fallo múltiple de órganos)(AU)

Trauma is among the first causes of mortality in our country. Death takes place mainly due to airway obstruction, hemorrhagic shock and cranioencephalic trauma. The importance of a suitable and correct attention of the shock in the first minutes or hour after the accident, has an influence on the decrease of mortality in this period and this initial attention may result on the diminishing delayed mortality (due to sepsis and multiple organic failure), which is known as the precious hour for emergency doctors. A suitable attention before, during and after the surgery must be a maxim for emergency doctors, in order to reduce the risks of anesthesia and the shock state. Resuscitation with isotonic fluids and the combination with pressor amines to maintain an average blood pressure that grants the perfusion to target organs reveilles not only guarantees life, but minimizes later complications like ARF (Acute Renal Failure), MOM, MOF (multiple organs malfunction and failure)(AU)