Variabilidad asistencial en la atención a politraumatizados por accidente de tráfico. Un estudio multicéntrico / Assistential variability in attending traffic accident polytraumatised patients. A multicentre study

Objetivo: Estudio multicéntrico transversal que evalúa la existencia de variabilidad asistencial en algunos aspectos de la asistencia básica prehospitalaria y hospitalaria a pacientes politraumatizados, por accidente de tráfico, en base a información recogida en un registro de pacientes traumáticos. Métodos: 508 pacientes han cumplido los siguientes criterios de inclusión: lesionado en accidente de tráfico, mayor de 18 años, Injury severity score (ISS) > 10, así como ingreso en UCI o fallecido en el hospital, en cinco centros sanitarios de Catalunya durante los años 1999-2000. Resultados: 1. Se han apreciado diferencias estadísticamente significativas en el tiempo de asistencia prehospitalaria tanto si se toma en cuenta la entidad prehospitalaria actuante como el centro hospitalario receptor. 2. El equipo médico actuante varía según centros y pacientes, estando compuesto habitualmente por dos a cuatro especialistas. Anestesiología, Intensivos o Emergencias pueden dirigir la renimación, mientras que Cirugía general, Cirugía ortopédica y Neurocirugía suelen ser el resto de componentes del equipo. 3. No se han observado diferencias estadísticamente significativas entre centros en el tiempo de práctica de la TAC craneal a pacientes con Glasgow Coma Score (GCS) <12, aunque se aprecia mayor retardo y dispersión cuando se toma en cuenta el tiempo desde el lugar del accidente. 4. El 45% de pacientes con diagnósticos de lesión en zona AIS 1 y 2 (cráneo, cara, cuello) al alta hospitalaria llevaban collarín cervical a la llegada al hospital. 5. No se aprecian diferencias estadísticamente significativas entre centros al evaluar el tiempo hasta el tratamiento de lesiones viscerales o fracturas abiertas. Conclusiones: Existe variabilidad asistencial en los pacientes politraumáticos por accidente de tráfico atendidos en los hospitales participantes. Es conveniente la implantación de guías clínicas de tratamiento, así como el desarrollo de un sistema de registro de politraumatizados y la homogeneización de los sistemas asistenciales (AU)

Aims: Cross-sectional multicentre study assessing the existence of assistential variability in some aspects of basic pre-hospitalary care to traffic accident polytramatised patients according to the information recorded a trauma patient registry. Method: Five hundred and eight patients fulfilled the following inclusion criteria: traffic accident victim, of full age, injury severity score (ISS)>10 and either ICU admission or death in hospital, at five Catalonian hospitals in the 1999-2000 period. Results: (1) Statistically significant differences have been observed in the duration of pre-hospitalary care considering both the pre-hospital care entily involved and the receiving hospital. (2) The acting medical team varies among the various hospitals and patients and is usually composed of two to four specialists. Anaesthesia, Intensive Care or Emergency Care may direct the reanimation/resuscitation team, the orther components of the team being usually General Surgery, Orthopaedic Surgery and Neurosurgery. (3) No statiscally significant differences were observed among the various hospitals in preforming a cranial CT scan in patients with Glasgow Coma Score (GCS) <12, althought a greater delay and scatter was seen when considering the time elapsed since the place of the accident. (4) Forty-five percent of the patients with lesions in the AIS 1 and 2 zones (cranium, face, neck) on hospital discharge carried a neck collar on arrival at the hospital. (5) No statiscally significant differences were observed among the various hospitals in the assessment of the time elapsed until management of visceral lesions or open fractures. Conclusions: Assistential variability exists in the care of traffic accident polytraumatised patients attended in the participating hospitals. It is convenient to establish clinical guidelines for treatment, as well as to develop a polytraumatism registry system and to homogenise the assistential systems (AU)

Analysis of the degree of QRS fusion necessary for its visual detection: importance for the recognition of transient entrainment.

BACKGROUND: Fixed fusion is the hallmark for the demonstration of transient entrainment. However, the degree of accuracy of its recognition on the surface ECG is unknown. The purpose of the present study was to evaluate the ability to detect fusion in the QRS complex. METHODS AND RESULTS: While pacing the ventricles at a fixed rate, a model of ventricular fusion was created by introducing late extra stimuli at a second site. In this model, the presence and degree of fusion are known. Pacing sites were the RV apex, outflow tract, and left ventricle in various configurations. We analyzed 433 QRS complexes with different degrees of fusion (or no fusion) in 21 patients. Each QRS was "read" by three investigators blinded to intracardiac recordings but having a reference QRS with no fusion. There was a statistically significant correlation between the degree of fusion and its recognition. Fusion was detected with a sensitivity of 75% and a specificity of 87%. Fusion was accurately detected in all configurations only when >22% of the QRS was fused. In patients with organic left ventricular disease, fusion was better recognized when the driving pacing site was the left ventricle than when it was a right ventricular site. The interobserver agreement was moderate between two pairs of observers and only fair between the remaining pair. CONCLUSIONS: Our results suggest that an accurate detection of ventricular fusion can only be accomplished when fusion occurs during a significant proportion of the QRS duration. The potential lack of recognition of minor degrees of fusion may produce underdetection of transient entrainment.

[Primary coronary angioplasty in acute anterior myocardial infarction: immediate results]. / Angioplastia primaria en el infarto agudo de miocardio de localización anterior: resultados inmediatos.

BACKGROUND: Some reports have indicated that primary angioplasty not contaminated by previous intravenous infusion of thrombolytic agents represents an efficient approach to the treatment of acute myocardial infarction. PATIENTS AND METHODS: As a part of a more ambitious protocol aiming to compare primary angioplasty and intravenous recombinant tissue plasminogen activator, we performed direct coronary angioplasty in 33 patients (18 randomized to angioplasty and 15 because of contraindication to thrombolysis) that were admitted to our hospital with acute myocardial infarction with less than 5 hours elapsed from the onset of pain and with clear electrocardiographic criteria of anterior infarction. RESULTS: In 30 of the 33 patients (90.9%) the left anterior descending artery was recanalized and TIMI 2 flow in 17 and 3 in 13 was obtained. The average time elapsed from the onset of pain to the opening of the artery was 228 +/- 70 (120-390) minutes and from the time of admission to the coronary care unit to complete reperfusion 91 +/- 43 minutes (33-120). Thirty one patients (93.9%) were discharged from the hospital and two (6.1%) died. There was only one hemorrhagic complication without sequelae. CONCLUSIONS: Primary coronary angioplasty in acute anterior myocardial infarction is an efficient, safe and not so difficult therapeutic strategy. Even though it requires a complex around the clock on call set up it is specially useful in specific subsets of patients.

[Usefulness of transesophageal echocardiography in the critical patient]. / Utilidad de la ecocardiografía transesofágica en el paciente crítico.

To assess the usefulness and safety of transesophageal echocardiography in critically ill patients, we analysed the transesophageal echocardiography studies in 60 of such cases (age: 58 +/- 11 and 38 males). Every patient underwent a previous transthoracic echocardiogram, that was considered inadequate for diagnostic purposes. Thirty patients (50%), were on mechanical ventilation and 17 patients (28%) showed hypotension and/or shock. Forty patients (66%) were at special care units and in 31 (52%) of them, pulmonary and systemic pressures, and continuous analysis of venous pressure of oxygen were available. Indications for study were: 17 patients with clinical suspicion of aortic dissection (confirmed in 5 cases): 9 patients infective endocarditis (4 cases showed valvular vegetations); 6 patients with mitral prosthesis dysfunction (confirmed in 4 cases); complicated acute myocardial infarction (MI) in 8 patients (2 cases with mitral insufficiency, 3 with left ventricular dysfunction, 1 with right ventricular MI, 1 with left ventricular pseudoaneurysm and other with isolated inferior MI); in 11 patients the study was performed to evaluate the result of cardiac transplantation immediately (< 4 h) and it showed 2 cases of left ventricular dysfunction; 3 patients were studied for severe cardiac dysfunction of unknown etiology (a dilated cardiomyopathy was confirmed in one and ruled out in the other, and one patient showed signs of restrictive situation); there were other causes in the rest. The procedure could be completely performed in all cases. In conclusion in critically ill patients the transesophageal echocardiography has a great usefulness and minimal complications.

[Changes in the physiologic pattern of mitral prosthesis regurgitation in the presence of a prosthetic dysfunction]. / Alteração do padrão fisiológico de regurgitação protésica mitral em presença de disfunção.

AIM OF STUDY: Evaluation by transesophageal echocardiography of the effect on the characteristics of physiological regurgitant jets (JF) resulting from prosthetic disfunction due to pathologic regurgitation (JF). PATIENTS AND METHODS: We studied 69 consecutive patients with the diagnosis of prosthesis in mitral position using transesophageal echocardiography and color doppler codification. The patients were divided in two groups (N and D groups) according to the presence of prosthesis disfunction by pathologic regurgitation. In each patient we determined planimetric areas and atrial peak depth of each JF and also the sum of JF planimetric areas of each mitral prosthesis. When pathological regurgitation was present we calculated the highest planimetric area, severity degree and atrial peak depth in each JP. RESULTS: The planimetric area in each JF of group N was 330 +/- 167 mm2 and in group D 117 +/- 116 mm2 (p less than 0.001). The sum of the areas of JF in group N was 474 +/- 204 mm2 and in group D 254 +/- 176 mm2 (p less than 0.01). The atrial depth of JF in group was 32 +/- 15 mm and in group D 26 +/- 18 mm (p less than 0.01). In group D 29% of the patients had mild pathological regurgitation, 10% moderate and 61% severe. The maximum planimetric area of JP in group D was 1078 +/- 1007 mm2 with atrial depth of 37 +/- 28 mm. CONCLUSION: The pathological regurgitation in disfunction prosthesis in mitral position has a significant reduction effect in the dimension of prosthesis physiologic regurgitation jets. This transesophageal echocardiographic observation makes it possible to characterize and clarify more precisely the different types of mitral prosthesis jets.

Acute hematogenous osteomyelitis of the rib.

Two cases of acute hematogenous osteomyelitis of the rib are presented. In one case the etiologic agent was Staphylococcus aureus coagulase-positive and in the other it was Bacteroides corrodens. Although an uncommon disease, hematogenous osteomyelitis should be considered in the differential diagnosis of destructive lesions of the rib. Anaerobic and aerobic cultures should be obtained for bacteriologic analysis.