Panamerican Journal of Trauma, Critical Care & Emergency Surgery by Diretoria de Comunicação CoBraLT

Editorial It has been shown in previous studies that isolated vital signs including heart rate (HR) and/or blood pressure (BP) are unreliable in the assessment of hypovolemic shock in these patients. On the contrary, SI (defined as the ratio of HR to systolic blood pressure) has been shown to be a pragmatic and useful tool for diagnosing hypovolemic shock even in the presence of a normal HR or BP. Also, SI is very simple to calculate in the chaotic pre-hospital and/ or trauma bay setting making it a very practical and useful tool. Previous studies have already found that trauma patients with an SI > 0.9 have a greater mortality rate. SI has also been shown to assist in the identification of shock states in polytrauma patients.1 The American College of Surgeons has defined in its training program Advanced Trauma Life Support (ATLS) four classes of hypovolemic shock. This classification is based upon an estimated percentage of blood loss and corresponding vital signs, such as the heart rate, systolic blood pressure and the mental status to allocate each patient to their respective shock class. However, the clinical validity of the ATLS classification of hypovolemic shock has been recently questioned. As an alternative, a classification based on the physiological parameter SI has been proposed by Mutscler et al to differentiate the presence and extent of hypovolemic shock in trauma patients. The purpose of such a classification is to be able to discriminate the patient at risk for early blood transfusions and death more appropriately than the current ATLS classification.2 Despite the evidence that SI is a good pre-hospital tool to identify patients with shock, predicting the need for transfusion after injury remains a significant dilemma. The decision to initiate a massive transfusion protocol in the trauma patient is a risk vs benefit choice often made under duress. There is little evidence to identify which trauma patients will ultimately require activation of a massive transfusion protocol from those who will not. The ability to quickly and accurately identify patients who will benefit and exclude patients at risk of harm is critical. Mutscler and colleagues have also proposed the utility of SI as a potentially helpful decision aid.2 Rady et al also demonstrated that SI correlates with other indices of end organ perfusion, such as central venous oxygen saturation and arterial lactate concentration. These same authors found that in a cohort of 275 adult trauma patients with an SI > 0.9 there was an associated worse outcome. Montoya et al5 independently discovered that in their cohort of 666 patients, those with an ISS > 16 and an arterial lactate > 3, 49 correlated with an SI >0.9. This goes along with the notion that the more severely injured a patient is the greater the possibility of that patient presenting to the trauma bay in hypovolemic shock.3 Sloan et al showed that trauma patients with an SI > 1.0 were 2.3 to 3.1 times more likely to die by 28 days than were patients with SI values below this cutoff (p < 0.001). Zarzaur and colleagues demonstrated that the SI was also a significantly better predictor for 48 hour mortality compared to systolic blood pressure and heart rate.4 Montoya et al were able to further expand on these findings and determined that an SI > 0.9 correlated with an early (<24 hours) mortality of 59.5% (p = 0.027), findings which have never been published before.5 The cardiovascular response in patients with blunt trauma has been speculated to perhaps differ from those with penetrating injuries. As the percentage of penetrating trauma patients was of 53.2% in Group B in Montoyaâ&#x20AC;&#x2122;s et al5 study, the utility of the application of the SI was not independently verified in this subgroup. Further validation specifically in penetrating injuries is required to assess the accuracy of the application of the SI in these patients. Shock index may be used to assess the presence of hypovolemic shock, especially if point-of-care testing technology is not available, as is the case in many Latin-American countries. The practicality of using laboratory values is limited by the time required to obtain these results and the expense of having this point-of-care testing technology available 24/7 at the institution. I propose that a future possible area of study for Montoya et al5 could be a prospective clinical and cost-effectiveness evaluation between thromboelastography (TEG)/arterial lactate concentration and/or Arterial Base Deficit vs SI to determine each ones innate ability to predict the need for massive transfusion in trauma patients. Another short coming of the study was the non-inclusion of the modified shock index (MSI) which is defined as the ratio of HR to mean arterial blood pressure (MAP). Modified shock index is essential because MAP best represents tissue perfusion status. Modified shock index takes into account valuable information related to cardiovascular and hemodynamic stability by incorporating heart rate, systolic and diastolic blood pressure, thus, making it a comprehensive tool for assessing stroke volume and systemic vascular resistance in trauma patients. A high MSI (>1.3) indicates a hypodynamic circulatory state and a low MSI (<0.7) indicates a hyperdynamic state, both of which have been demonstrated to be predictors of mortality.6 Further prospective study to validate the applicability of the SI and MSI is warranted.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery

REFERENCES 1. Moffat B, Vogt KN, Inaba K. The shock index: is it ready for primetime? Crit Care 2013 Oct 3;17(5):196. 2. Mutscler M, Nienaber U, Munzberg M, Wolfl C, Schoechi H, Paffrath T, Bouillon B, Maegele M. The shock index revisitedâ&#x20AC;&#x201D;a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the Trauma Register DGU. Crit Care 2013 Aug 12;17(4):R172. 3. Pasquier P, Dubost C, Malgras B, Kearns K, Merat S. The shock index for pre-hospital identification of trauma patients with early acute coagulopathy and massive bleeding. Crit Care 2015 Mar 27;19(1):152. 4. Sloan EP, Koenigsberg M, Clark JM, Weir WB, Philbin N. Shock index and prediction of traumatic hemorrhagic shock 28-day mortality: Data from the DCLHb resuscitation clinical trials. West J Emerg Med 2014 Nov;15(7):795-802. 5. Montoya KF, Charry JD, Calle-Torro JS, Nunez LR. Poveda: Shock index as a mortality predictor in patients with acute polytrauma Journal of Acute Disease Volume 4, Issue 3, August 2015, Pages 202-204. Presented as an abstract, resident research competetion, PTS Congress Panama City, Panama. November 2014. 6. Singh A, Ali S, Agarwal A, Srivastava RN. Correlation of shock index and modified shock index with the outcome of adult trauma patients: a prospective study of 9860 patients. N Am J Med Sci 2014 Sep;6(9):450-452.

Michael W Parra, MD Trauma Research Director Florida International University School of Medicine Florida Atlantic University School of Medicine Broward Health Level I Trauma Center Fort Lauderdale, FL, USA

PAJT

ORIGINAL RESEARCH

10.5005/jp-journals-10030-1115 A Influência do Gênero nas Características E Gravidade do Trauma

A Influência do Gênero nas Características E Gravidade do Trauma 1

Alina Yukie Handa, 2Cristiane de Alencar Domingues, 3Lilia de Souza Nogueira

RESUMEN

Source of support: Nil

Embora a literatura mostre resultados cada vez mais sugestivos de que as mulheres traumatizadas apresentem melhores desfechos em relação aos homens, algumas conclusões ainda são inconsistentes. Este estudo comparou os sexos (masculino/ feminino) segundo características e gravidade do trauma e identificou a influência desta variável na mortalidade. Trata-se de um estudo retrospectivo, quantitativo, das vítimas de trauma atendidas em um hospital terciário localizado em São Paulo, Brasil, entre janeiro/2006 e dezembro/2010. Os testes QuiQuadrado de Pearson, Mann-Whitney, t-Student e regressão logística múltipla foram aplicados no tratamento dos dados, considerando-se um nível de significância de 5%. A casuística foi composta por 2.380 pacientes, a maioria masculina (79,70%), com idade média de 39,93 anos (DP = 17,81). A causa externa mais frequente foi pedestre traumatizado (24,54%). Atendimento pré-hospitalar foi recebido pela maioria das vítimas (91,22%) e 50,21% dos pacientes foram admitidos na Unidade de Terapia Intensiva (UTI). A taxa de mortalidade hospitalar foi de 16,43%. Diferenças significativas entre os grupos (masculino e feminino) ocorreram em relação ao tipo de trauma, causa externa, admissão na UTI, injury severity score (iss), new injury severity score (NISS), revised trauma score (RTS) e idade. As variáveis NISS, idade e número de regiões corpóreas acometidas foram fatores de risco para mortalidade hospitalar das vítimas de trauma e o tempo de permanência hospitalar foi considerado fator de proteção para este desfecho. O sexo, variável de interesse do estudo, não foi preditor de mortalidade nesta casuística. Como conclusão, variáveis relacionadas às características e gravidade do trauma, além da idade, diferiram entre os sexos e o gênero não foi considerado fator de risco para mortalidade nesta população.

Conflict of interest: None

Palavras chave: Estudo comparativo, Ferimentos e lesões, Mortalidade, Sexo. How to cite this article: Handa YA, de Alencar Domingues C, de Souza Nogueira L. A Influência do Gênero nas Características E Gravidade do Trauma. Panam J Trauma Crit Care Emerg Surg 2015;4(2):43-47.

Nursing Student, 2National Coordinator, 3Professor

1,3

Nursing School of University of São Paulo, São Paulo, Brazil

Brazilian Committee on Trauma, Brazil

Corresponding Author: Alina Yukie Handa, Nursing School of University of São Paulo, São Paulo, Brazil, e-mail: alinayukiehanda@gmail.com

ABSTRACT Although the literature shows results increasingly suggestive that women traumatized present better outcomes compared to men, some conclusions are still inconsistent. This study compared the gender (male/female) according to characteristics and severity of trauma and identified the influence of this variable in mortality. This is a retrospective, quantitative study of trauma victims treated at a tertiary hospital in São Paulo, Brazil, between January/2006 and December/2010. The Pearson Chi-square, Mann-Whitney and t-Student tests, and multiple logistic regression were applied to the processing of data, considering a 5% significance level. The casuistic consisted of 2,380 patients, mostly male (79.70%) with a mean age of 39.93 years (SD = 17.81). The most frequent external cause was injured pedestrians (24.54%). Prehospital care was received by the majority of victims (91.22%) and 50.21% of patients were admitted to the intensive care unit (ICU). The hospital mortality rate was 16.43%. Significant differences between groups (male and female) occurred in the type of trauma, external cause, ICU admission, injury severity score (ISS), new injury severity score (NISS), revised trauma score (RTS) and age. The variables NISS, age and number of body region injured were risk factors for hospital mortality of trauma victims and the length of hospital stay was considered protective factor in the outcome. The gender, variable of interest of the study, was not a predictor of mortality in this study. In conclusion, variables related to the characteristics and severity of trauma, as well as age, differed between males and females and gender was not considered a risk factor for mortality in this population. Keywords: Comparative study, Gender, Mortality, Wounds and injuries.

INTRODUCCIÓN A Organização Mundial da Saúde, por meio de dados da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde (CID-10),1 reconhece os acidentes e violências como causas externas, consideradas problemas de saúde pública e sinalizadas como a grande epidemia do século XXI. Em relação ao gênero, as estatísticas mostram que, de janeiro a agosto de 2013, do número total de internações por causas externas no Brasil, 70% foram do sexo masculino.2 Neste sentido, alguns estudos têm demonstrado que homens e mulheres apresentam diferentes respostas

Note: Paper presented in General Research Competition at the annual congress of Panamerican Trauma Society, Panama City, Panama, November 2015.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):43-47

Alina Yukie Handa et al Tabla 1: Fatores de risco para mortalidade hospitalar de vítimas de trauma. São Paulo, Brasil, 2006 to 2010 Variável Gênero Ref: feminino Idade Tempo de permanência hospitalar Número de regiões corpóreas acometidas NISS

Exp (β)

IC 95% (Exp β)

VIF

0,31 0,03 –0,10 0,41 0,12

1,37 1,03 0,90 1,50 1,13

0,95-2,00 1,02-1,04 0,88-0,92 1,32-1,70 1,11-1,15

0,099 <0,001 <0,001 <0,001 <0,001

1,14 1,48 1,12 1,19

frente às lesões traumáticas.3,4 Pesquisa retrospectiva que analisou 612 vítimas de trauma revelou que os homens, entre 15 e 45 anos, apresentaram significativamente maior incidência de falência múltipla de órgãos, maior tempo de internação na Unidade de Terapia Intensiva (UTI) e no hospital, além de menor taxa de sobrevida em relação às mulheres da mesma faixa etária. Nas vítimas com idade superior a 45 anos, essas diferenças não foram encontradas.3 Outra investigação analisou retrospectivamente 6.763 vítimas de trauma na Austrália e identificou que os homens foram mais gravemente feridos do que as mulheres e tiveram maior tempo de permanência no hospital. Não houve diferença entre os sexos em relação à mortalidade.4 Na tentativa de esclarecer estas diferenças entre os gêneros feminino e masculino e a possível influência protetora do hormônio estrogênio, foi realizada uma pesquisa que estratificou os pacientes de acordo com a idade reprodutiva da mulher, considerando a fases de pré e pós menopausa (< 48 e > 52 anos) e comparou homens e mulheres, vítimas de trauma que apresentaram choque hemorrágico. Os resultados evidenciaram que o sexo feminino apresentou valores significativamente menores de taxa de infecção nosocomial e falência múltipla dos órgãos do que o masculino, tanto no período pré quanto pós menopausa, mostrando que os hormônios femininos não exercem influência sobre estas diferenças.5 Embora a literatura mostre resultados cada vez mais sugestivos de que mulheres apresentam melhores desfechos em relação aos homens após eventos traumáticos, algumas conclusões ainda são inconsistentes perante as diferentes variáveis analisadas e as limitações dos estudos. Neste contexto de indagações e considerando a escassez de pesquisas sobre o tema no Brasil, propõe-se a realização desta pesquisa, cujos resultados contribuirão para fundamentar a prática clínica da equipe que presta assistência ao traumatizado, bem como elaborar estratégias de prevenção.

OBJETIVOS Verificar a associação entre o gênero e as características do trauma e gravidade das lesões, além de identificar a influência desta variável na mortalidade das vítimas.

MÉTODOS Trata-se de um estudo retrospectivo, com abordagem quantitativa das vítimas de trauma atendidas em um hospital terciário localizado na cidade de São Paulo, centro de referência para o atendimento ao traumatizado, entre o período de janeiro de 2006 a dezembro de 2010. Os critérios de inclusão dos pacientes foram: idade igual ou superior a 14 anos, ser vítima de trauma do tipo contuso ou penetrante (V01 – V89 do Capítulo XX da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde – CID 10)1 e ser admitido no hospital nas primeiras 24 horas do evento traumático. Os pacientes transferidos de outros hospitais foram excluídos da casuística. Neste estudo, a variável independente analisada foi o gênero (masculino ou feminino). As variáveis dependentes abordadas foram idade, causa externa segundo o capítulo XX da CID-10, tipo de trauma, tipo de atendimento pré-hospitalar, injury severity score (ISS),6 new injury severity score (NISS),7 revised trauma score (RTS),8 trauma and injury severity score (TRISS),9 número de regiões corpóreas acometidas, tempo de permanência hospitalar, admissão na UTI e condição de saída hospitalar. Na comparação dos grupos (homens e mulheres) em relação às variáveis nominais, foi utilizado o Teste QuiQuadrado de Pearson. Quanto às variáveis quantitativas discretas e contínuas, a comparação dos grupos foi feita pelos Testes de Mann-Whitney ou t-Student, conforme o tipo de distribuição identificada pela análise de Kolmogorov-Smirnov (normal ou não-normal). A regressão logística múltipla foi utilizada para identificar os fatores associados à mortalidade, sendo o gênero considerado variável de interesse. O fator de inflação da variância (VIF) foi aplicado para detectar a possibilidade de multicolinearidade do modelo final. O nível de significância adotado em todas as análises foi de 5%.

RESULTADOS A casuística foi composta por 2.380 pacientes, a maioria do sexo masculino (79,70%), com idade média de 39,93 anos (DP = 17,81), vítimas de trauma contuso (88,23%). A causa externa mais frequente foi pedestre traumatizado (24,54%), seguida por quedas (19,87%) e mototociclistas

PAJT A Influência do Gênero nas Características E Gravidade do Trauma

(17,27%). Atendimento pré-hospitalar foi recebido pela maioria das vítimas (91,22%) e um total de 1.195 pacientes (50,21%) foi admitido na UTI. A taxa de mortalidade hospitalar foi de 16,43%. Diferenças significativas entre os grupos ocorreram em relação ao tipo de trauma (p = 0,009), causa externa (p < 0,001), tipo de atendimento pré-hospitalar (p = 0,004), admissão na Unidade de Terapia Intensiva (p = 0,003), ISS (p = 0,019), NISS (p = 0,015), RTS (0,002) e idade (p < 0,001). Observa-se na Tabla 1 que as variáveis idade, número de regiões corpóreas acometidas e NISS foram fatores de risco para mortalidade hospitalar das vítimas de trauma e o tempo de permanência hospitalar foi considerado fator de proteção para este desfecho. O acréscimo de um ano de vida, uma região corpórea acometida ou um ponto do NISS aumentou a chance de óbito das vítimas em 3%, 50% e 13%, respectivamente. Além disso, a cada dia de internação hospitalar diminuiu a chance de morrer em 10%. O gênero, variável de interesse deste estudo, não foi fator preditivo de mortalidade na população. Os valores do VIF encontrados demonstram que não houve indicação de colinearidade entre as variáveis que permaneceram no modelo final.

CONCLUSÕES Variáveis relacionadas às características e gravidade do trauma, além da idade, diferiram entre os sexos masculino e feminino e o gênero não foi considerado fator de risco para mortalidade nesta população.

REFERÊNCIAS 1. Brasil. Ministério da Saúde. Datasus. CID -10 – Classificação estatística internacional de doenças e problemas relacionados à saúde. Causas externas de morbidade e de mortalidade [texto na Internet]. Brasília; 2014 [citado 2014 jan 10]. Disponível em: Available at: http://www.datasus.gov.br/ cid10/v2008/cid10.htm 2. Brasil. Ministério da Saúde. Datasus. Informações de saúde. Estatísticas de morbidade. Morbidade hospitalar por causas externas no Brasil [texto na Internet]. Brasília; 2014 [citado 2014 jan 10]. Disponível em: Available at: http://tabnet. datasus.gov.br/cgi/tabcgi.exe?sih/cnv/fiuf.def 3. Mostafa G, Huynh T, Sing RF, et al. Gender-related outcomes in trauma. J Trauma 2002;53(3):430-435. 4. Mitchell R, Curtis K, Fisher M. Understanding Trauma as a Men’s Health Issue: sex differences in traumatic injury presentations at a level 1 trauma center in Australia. J Trauma Nurs 2012;19(2):80-88. 5. Sperry JL, Nathens AB, Frankel HL, et al. Characterization of the gender dimorphism after injury and hemorrhagic shock: Are hormonal differences responsible? Crit Care Med 2008; 36(6):1838-1845. 6. Baker SP, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14(3):187-196. 7. Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma 1997;43(6)922-925. 8. Champion HR, Sacco WJ, Copes WS, et al. A revision of the trauma score. J Trauma 1989;29(5):623-629. 9. Boyd CR, Tolson MA, Copes WS. Evaluating Trauma Care: The TRISS Method. J Trauma 1987;27(4):370-378.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):43-47

Alina Yukie Handa et al

INVITED COMMENTARY A Influência do Gênero nas Características E Gravidade do Trauma O presente estudo realizado por Handa et al apresenta uma proposta interessante abordando a influência do gênero nas características e gravidade do trauma causado por causa externas. O tema foi bem desenvolvido e problematizado na introdução demonstrando a importância em analisar essas questões quando estuda-se o trauma como uma doença. A redação é coerente e adequada tendo o objetivo uma boa relação com a problemática abordada na introdução. Entretanto faz-se necessário e importante discutir alguns aspectos apresentados no presente manuscrito. O método estatístico utilizado no estudo foi adequado para esse tipo de análise. Entretanto ao considerar como critério de inclusão trauma admitido no hospital nas primeiras 24 horas após o evento traumático, ao meu ver, os autores possibilitaram que traumatismos menos graves fossem incluídos tornando a amostra pouco representativa em relação a ocorrência de traumas de maior gravidade. Sabe-se que a grande maioria das lesões que colocam a vida do paciente em risco acontecem, habitualmente, nas primeiras horas após o evento traumático. Os resultados encontrados pelos autores foram interessantes, porém foram apresentados de maneira confusa dificultando uma análise mais pormenorizada dos mesmos pelo leitor. Além disso, acredito que a leitura seria mais proveitosa se os autores provessem uma tabla com resultados de ambos os grupos de gênero estudados (masculino e feminino) permitindo ao leitor compreender, mais facilmente, os resultados relatados. A ausência do tópico ‘discussão’, momento em que os autores devem discutir e levantar hipóteses sobre os resultados obtidos, além de analisá-los face aos outros estudos já realizados, dificulta a compreensão da importância dessa temática. Considerando a conclusão desse manuscrito e os demais estudos relacionados na introdução pode-se perceber que a questão do gênero como fator de risco para mortalidade no trauma de causas externas ainda é controverso e deve merecer novos estudos para uma melhor avaliação dessa influência. Sizenando Starling Hospital Surgeon John XXIII Hospital of the State of Minas Gerais Foundation (FHEMIG) Trauma Surgery Coordinator Lifecenter Hospital, Brazil

PAJT A Influência do Gênero nas Características E Gravidade do Trauma

INVITED COMMENTARY The present study published by Handa et al. shows an interesting approach of the influence of gender on the characteristics and severity of trauma by external causes. The theme is well developed and discussed in the introduction, showing the importance of analyzing these questions when trauma is studied as a disease. The writing is coherent and satisfactory. The aim has a good relation with the problem discussed in the introduction. However it is necessary to discuss some aspects of the manuscript. The statistical method used in the study was appropriate for this type of analysis. However, when the authors considered ‘trauma admitted within the hospital in the first 24 hours after the traumatic event’ as an inclusion criterion, they created a possibility that less severe trauma was included, making the sample less representative in relation to the occurrence of more severe traumas. It is known that the major injuries that put the patient’s life at risk, most of the time, occur in the first hours after the traumatic event. The results found by the study were interesting, but they were presented in a confusing way making it difficult to do a more detailed analysis. In addition, the reading would be more advantageous if the authors provided a table with results of both genders (men and women) allowing the reader to understand, more easily, the results presented. The absence of the ‘discussion’ section, where the authors may discuss and analyze the results found from other studies of similar themes, makes the understanding of the importance of this issue more difficult. Considering the conclusion of this manuscript and the others studies mentioned in the introduction, it is noticed that the topic of gender as a risk factor for mortality in trauma by external causes is controversial and deserves further research for a better evaluation of its influence. Sizenando Starling Hospital Surgeon John XXIII Hospital of the State of Minas Gerais Foundation (FHEMIG) Trauma Surgery Coordinator Lifecenter Hospital, Brazil

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):43-47

PAJT 10.5005/jp-journals-10030-1116

Catrina Cropano et al

ORIGINAL RESEARCH

Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe 1

Catrina Cropano, 2Tomaz Mesar, 3David Turay, 4David King, 5Daniel Yeh, 6Peter Fagenholz George Velmahos, 8Marc A de Moya

ABSTRACT Introduction: The management of a pneumothorax (PTX) either by observation or with a tube thoracostomy (TT) has long been dictated by practitioner discretion rather than objective criteria. Many physicians elect to routinely place a TT for traumatic PTX, particularly when patients undergo positive pressure ventilation (PPV). Placement of unnecessary TT exposes patients to avoidable morbidity and may prolong hospitalization. Based on prior work establishing a cutoff, we hypothesized that all PTXs ≤ 35 mm in patients who have no physiologic derangement may be safely observed without TT regardless of the need for PPV. Materials and methods: Retrospective review of all patients diagnosed with a PTX between 1/2009 and 2/2013. All PTXs visible on chest computed tomography (CT) were identified. Any patient with an associated significant hemothorax or those patients who were moribund were excluded. All PTXs were measured by measuring the perpendicular distance of the largest air pocket between the chest wall and the mediastinal or pulmonary structure. Management of the PTX was categorized as observation or TT. Observed PTXs were labeled as success or failure with failure defined as enlargement of the PTX or physiologic deterioration, requiring a TT. Results: Out of 165 PTXs, 17 (10.3%) measured >35 mm, whereas 148 (89.7%) measured ≤35 mm. Of the 17 > 35 mm, 15 (88.2%) received immediate TT. Of the two PTXs >35 mm which were observed, one received a delayed TT for a pleural effusion (6 days after PTX diagnosis) and one (5.9 %) was safely observed. Of the 148 PTXs which measured ≤ 35 mm, 10 (6.8%) received immediate TT. Of the 138 remaining PTXs, 129 (93.5%) were safely managed without TT. Six (4.3%) of the PTXs initially observed eventually required TT placement for enlargement of the PTX. Only one of those six had manifested ongoing desaturations prior to TT. The remaining three cases received TT for reasons unrelated to the PTX. Of the 27 PPV cases in the ≤35 mm cohort, none contributed to the six failures. A cutoff measurement of 35 mm demonstrated a

1-3 8

Research Assistant, Associate Professor

4-6

Assistant Professor, 7Professor

1-8

Department of Surgery, Massachusetts General Hospital Boston, MA, USA

Corresponding Author: Marc A de Moya, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston MA 02114, USA, Phone: 1-617-7244121, e-mail: mdemoya@partners.org

negative predictive value (NPV) of 95.7% in its ability to predict successful observation of the PTX with an area under the receiver operating characteristic (ROC) curve of 0.90. Conclusion: All PTXs measuring ≤35 mm perpendicular to the chest wall without physiologic derangement may be safely observed independent of the need for mechanical ventilation. Keywords: Chest tube, Drainage, Pneumothorax. How to cite this article: Cropano C, Mesar T, Turay D, King D, Yeh D, Fagenholz P, Velmahos G, de Moya MA. Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe. Panam J Trauma Crit Care Emerg Surg 2015;4(2):48-53. Source of support: Nil Conflict of interest: None

RESUMEN Introducción: El manejo del neumotórax, ya sea con observación clínica o con sonda pleural, se ha basado en el juicio clínico y no en criterios objetivos. Muchos prefieren utilizar la sonda pleural de manera rutinaria para los pacientes con un neumotórax traumático, especialmente cuando están bajo ventilación mecánica con presión positiva. La utilización de sonda pleural de manera innecesaria y excesiva expone a los pacientes a importante morbilidad y podría incluso prolongar el tiempo de hospitalización. Algunos estudios previos han establecido un punto de corte y, basándonos en esto, nuestra hipótesis es que todos los pacientes con un neumotórax mayor a 35 mm, sin ninguna alteración fisiológica, pueden ser observados clínicamente sin el uso de sonda pleural, a pesar de que se necesite utilizar ventilación mecánica con presión positiva. Materiales y métodos: Realizamos un estudio retrospectivo de todos los pacientes con diagnostico de neumotórax entre enero del 2009 y febrero del 2013. Todos los pacientes con neumotórax visible en la tomografía computarizada fueron identificados. Los pacientes con hemotorax o clínicamente graves fueron excluidos. Para medir los neumotórax utilizamos la distancia perpendicular entre la pared torácica y el mediastino o pulmón y la bulla de aire más grande. El manejo de los pacientes se categorizo en observación clínica o uso de sonda pleural. Definimos el tratamiento como exitoso o fallido; si el neumotórax creció o hubo algún deterioro fisiológico del paciente que finalmente requirió el uso de sonda pleural, fue considerado como fallido.

Note: Paper presented in General Research Competition at the annual congress of Panamerican Trauma Society, Panama City, Panama, November 2015.

PAJT Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe Resultados: De un total de 165 pacientes con neumotórax, 17 (10.3%) midieron >35 mm y 148 (89.7%) midieron <35 mm. De los 17 >35 mm, 15 (88.7%) fueron tratados inmediatamente con sonda pleural. Los dos pacientes que fueron observados, uno fue tratado con sonda pleural (6 días después del diagnostico) y el otro fue observado sin ninguna complicación. De los 148 que midieron <35 mm, 10 fueron tratados inmediatamente con sonda pleural. De los 138 restantes, 129 (93.5%) fueron tratados exitosamente sin sonda pleural. Seis (4.3%) de los pacientes que fueron inicialmente observados, requirieron eventualmente una sonda pleural por el crecimiento subsecuente del neumotórax. Solo uno de los seis manifestó desaturaciones antes de la colocación de la sonda pleural. Los tres casos restantes recibieron sonda pleural por razones ajenas al neumotórax. De los 27 casos con ventilación mecánica con presión positiva dentro de la cohorte de <35 mm, ninguno contribuyo a los 6 casos considerados como fallos en el manejo. El punto de corte de 35 mm tuvo un valor predictivo negativo (VPN) de 95.7% con un área bajo la curva de 0.90. Conclusiones: Todos los neumotórax que miden < 35 mm perpendiculares a la pared torácica sin ninguna alteración fisiológica pueden ser manejados de manera segura con observación clínica independientemente de si necesitan ventilación mecánica o no. Palabras claves: Drenaje, Neumotórax, Toracostomía.

INTRODUCTION Chest trauma occurs in 20% of polytrauma patients and is attributed to 20 to 40% of all trauma deaths, second only to head and spinal injuries. Aside from rib fractures and pulmonary contusions, a pneumothorax (PTX) is the most common injury in blunt thoracic trauma.1 In the trauma bay, tube thoracostomy (TT) is the most commonly performed invasive procedure for chest trauma patients with respiratory distress without a clear cause or in patients with an initial chest X-ray revealing a hemothorax or pneumothorax.2 A significant proportion of patients with a PTX are not initially managed with TT. Notably, with the widespread adoption of computed tomography scanners in emergency departments, up to 50% of all PTXs are occult PTXs— missed on initial chest X-ray and revealed on a subsequent chest CT study.3 These otherwise ‘missed’ PTXs would be managed conservatively by omission unless the patient developed symptoms of respiratory distress encouraging further diagnostic workup. Management of these patients either by observation or with TT has long been dictated by practitioner discretion rather than objective criteria. This study includes and investigates the management of both overt and occult PTXs. Many physicians elect to routinely perform TT for a traumatic PTX, particularly when patients undergo positive pressure ventilation. Complications following TT are often overlooked and present in more than 10% of

cases, most often related to tube insertion and positioning. Placement of unnecessary TT exposes patients to avoidable morbidity and may prolong hospitalization.4 An increasing body of literature supports observation in stable patients as an acceptable alternative to TT, with failure of observation rates approaching 6%.5 Based on previous work,6 we sought to explore if a PTX measuring ≤ 35 mm in patients who have no physiologic derangement may be safely observed without TT regardless of the need for positive pressure ventilation.

MATERIALS AND METHODS This is a retrospective medical record review of trauma patients admitted to a level I trauma center over a 4 years period (January 2009 to February 2013) who were diagnosed with a pneumothorax and underwent chest CT imaging upon admission. All PTXs identified on chest CT were identified and measured. The PTX measurement in centimeters spanned the perpendicular distance of the largest air pocket between the chest wall and the mediastinal or pulmonary structure. Excluded patients were those whom were moribund, were younger than 16 years old, did not undergo chest CT or for whom electronic chest CT image was unavailable, had an ipsilateral hemothorax, received TT before undergoing a chest CT, or for those with an indeterminate reason for TT after initial observational management. Management of each PTX was categorized according to the initial management, and was described as either observation or immediate tube thoracostomy. The primary outcome was success of observation. Failure was defined as a PTX initially observed which eventually required TT for either enlargement of the PTX or physiological deterioration of the patient. Physiological deterioration was defined as respiratory rate greater than 30 breaths per minute, SpO2 less than 94% on room air, or heart rate greater than 110 beats per minute and systolic blood pressure less than 90 mm Hg with no other reasonable source of cause. The study was approved by our institutional review board.

RESULTS During the 4 years study period, 2,973 trauma patients were admitted with 416 patients experiencing 461 total pneumothoraces. Two hundred and ninety-six PTXs were excluded for the following reasons: died within 24 hours (19), did not undergo chest CT (160), electronic chest CT unavailable (40), age less than 16 years old (2), ipsilateral hemothorax (9), TT before chest CT (64), and unable to determine reason for TT after initial observational management.2

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Catrina Cropano et al

Among the included 143 patients with 165 PTXs, 115 PTXs (70%) were occult, 33 (20%) were overt, and 17 (10%) could not be categorized as occult or overt. The PTXs were almost evenly distributed among left-sided (83) vs rightsided (82). One hundred and forty PTXs were initially observed and 25 received immediate TT. Mean age of all patients was 47 years, 75% males, and had a mean ISS of 29. Mean size of all PTXs were 14.89 ± 20.04 mm. Categorized by initial management (Flow Chart 1), mean PTX size for TT and observation were 47.912 ± 32.50 and 8.99 ± 7.79 mm, respectively. Sorted by size (Flow Chart 2), 17 (10.3%) PTXs measured >35 mm, whereas 148 (89.7%) measured ≤35 mm. Out of the 17 that measured >35 mm, 15 (88.2%) received immediate TT. Of the two PTXs >35 mm which were observed, one received a delayed TT for a pleural effusion (six days after PTX diagnosis) and one (5.9%) was safely observed. Of the 148 PTXs in 128 patients which measured ≤35 mm, 10 (6.8%) PTXs were managed by immediate TT and 138 were observed. Of those 138 PTXs, 129 (93.5%) were safely managed without TT, and nine received TT. Six (4.3%) of those 138 PTXs initially observed were consiFlow Chart 1: Consort diagram

Table 1: Demographics and clinical outcomes in observation vs TT patients in 128 patients with PTX ≤ 35 mm Demographics Patients with PTX <35 mm Observation N (%) (n = 119) TT (n = 9) p-value Age (mean) 45.94 ± 21.5 51.08 ± 17.5 0.49 Male gender 88 (73.9) 7 (77.8) 1.0 Mechanism of injury — • MVC 58 (48.7) 0 (0) — • Ped struck 7 (5.9) 2 (22.2) — • Falls 35 (29.4) 2 (22.2) — • Others 19 (16.0) 5 (55.6) — ISS (mean) 29.08 29.11 0.99 ICU LOS (days ± SD) 3.2 ± 6.3 3.7 ± 5.7 0.82 HLOS (days ± SD) 9.8 ± 8.6 15.1 ± 19.8 0.12 PPV 21 — — Rib fxs 75 (63.0) 7 (77.8) 0.49 Pulmonary comorbidity 12 (10.1) 3 (33.3) 0.07 Mortality 3 (2.5) 1 (11.1) 0.26

dered failures as they eventually required TT placement specifically for enlargement of the PTX. The remaining three cases received TT for reasons unrelated to the PTX (pleural effusion). Table 1 demonstrates there were no differences in the demographics and clinical outcomes in the observation and TT groups in the ≤35 mm cohort. A cutoff measurement of 35 mm demonstrated a negative predictive value (NPV) of 95.7% in its ability to predict successful observation of the PTX with an area under the receiver operating characteristic (ROC) curve of 0.90 (Graph 1). The positive predictive value and sensitivity were 100%, while specificity was 98.5%. The six failed observations included five (83%) males, mean ISS 18, and mean PTX size of 20.6 ± 7.1 mm. Tube thoracostomy was performed for each of these patients due to progression in size of the PTX, while only one of those six had manifested ongoing desaturations prior to TT. Median time until TT removal was 2.5 days.

Flow Chart 2: *Six of the 9 in the ≤35 mm group who were observed and then received TT were failures. This gives a failure rate of 6/138, or 4.3%

Graph 1: Receiver operating characteristic curve to predict successful observation when PTX measures ≤ 35 mm

PAJT Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe

DISCUSSION Management of a PTX in blunt chest trauma remains a controversial topic. The question of whether observation of a PTX is safe, especially in the setting of positive pressure ventilation, has remained an unanswered one. Moreover, in the absence of physiologic derangement, no standard protocol currently exists to dictate when to invasively intervene in a stable patient. In summary, we have created a predictive model to determine safe and successful observation of a PTX while avoiding TT. This model demonstrates that when measuring the perpendicular distance of the largest air pocket between the chest wall and the mediastinal or pulmonary structure, a cutoff measurement of 35 mm demonstrates a negative predictive value of 95.7%, with an area under the ROC curve of 0.90. While some institutions have described their individual schemas to standardize management of PTXs, the relative complexity and low predictability of these models have not resulted in widespread adoption by the critical care community. De Moya et al6 have previously described a scoring system utilizing air-pocket diameter sizes and anatomical features with a positive predictive value of requiring a chest tube of 78%. Garramone et al7 utilized volumetric measurements, requiring longitudinal measurements on axial CT, which we believe to be more difficult and time consuming. Moreover, in their study, CT scans were limited to abdominal scans and therefore, do not necessarily reveal the entire PTX. Our method, on the other hand, is relatively simple, consisting of a single measurement with no calculation required, and utilizes chest CT scans to visualize the entirety of the thorax. Our results and the relative simplicity of our model designate ours as a rapid and clinician-friendly tool. Observation of a PTX in a patient on positive pressure ventilation has been a highly debated topic in the critical care community. Intuitively, PPV would mandate prophylactic TT to prevent enlargement of a PTX or progression to a tension PTX. Two decades ago, Enderson et al8 performed the first randomized controlled trial comparing TT (n = 19) and observation (n = 21) in patients with an occult PTX. In the observation arm, eight patients on PPV (38%) required TT due to progression of the PTX, and so the authors advised to perform TT in these patients on PPV. In a multi-institutional, prospective study by the American Association for Surgery of Trauma (AAST) of occult PTXs after blunt trauma, PPV was independently associated with an increased risk of observation failure. Conversely, subsequent reports and studies have deemed observation safe with acceptable failure rates. In a randomized controlled trial by Brasel et al,9 e.g.

patients with an occult PTX were randomized to receive tube thoracostomy (n = 18) or undergo observation (n = 21). Eight patients in each arm required PPV, but no differences in progression of PTX was observed. Our study has a few limitations. First, it is a retrospective study and therefore, subjective patient outcome measures, such as reasons for TT placement after initial observation of the PTX, were based on medical record review vs direct physician communication. Additionally, our cohort was in reality a subset sample of patients. We had screened all patients presenting to our institution with a traumatic PTX but excluded many for the reason that the chest CT was not available to be viewed in our electronic medical record system. Lastly, this study lacks long-term follow-up data since patients’ medical records were reviewed up to 7 days after initial insult or to patient discharge if the patient was in house for longer than 7 days.

CONCLUSION A PTX measuring ≤35 mm along the perpendicular distance of the largest air pocket between the chest wall and the mediastinal or pulmonary structure in hemodynamically stable patients may be safely observed, even under mechanical ventilation. Our model to measure PTXs on chest CT scans is a simple, clinician-friendly tool to provide objective criteria for the conservative vs invasive initial management of PTXs.

REFERENCES 1. Rhea JT, Novelline RA, Lawrason J, Sachoff R, Oser A. The frequency and significance of thoracic injuries detected on abdominal CT scans of multiple trauma patients. J Trauma 1989;29(4):502-505. 2. Menger R, Telford G, Kim P, et al. Complications following thoracic trauma managed with tube thoracostomy. Injury 2012 Jan;43(1):46-50. 3. Ball CG, Kirkpatrick AW, et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma 2005;59(4):917-925. 4. Maritz D, Wallis L, Hardcastle T. Complication of tube thoracostomy for chest trauma. S Afr Med J 2009 Feb;99(2):114-117. 5. Moore FO, Goslar PW, Coimbra R, et al. Blunt traumatic occult pneumothorax: is observation safe?—results of a prospective, AAST multicenter study. J Trauma 2011;70(5):1019-1025. 6. De Moya MA, Seaver C, Spaniolas K, et al. Occult pneumothorax in trauma patients: development of an objective scoring system. J Trauma 2007 Jul;63(1):13-17. 7. Garramone RR Jr, Jacobs LM, Sahdev P. An objective method to measure and manage occult pneumothorax. Surg Gynecol Obstet 1991;173(4):257-261. 8. Enderson BL, Abdalla R, Frame SB, et al. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. J Trauma 1993;35(5):726-730. 9. Brasel KJ, Stafford RE, Weigelt JA, et al. Treatment of occult pneumothoraces from blunt trauma. J Trauma 1999;46(6): 987-990.

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Catrina Cropano et al

INVITED COMMENTARY Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe The article by Cropano et al is an interesting work that remarks on the new tendencies in the management of trauma, such as the performance, more commonly every day, of minimally invasive procedures and avoiding nontherapeutic surgical procedures. Evidence indicates that the latter has morbidity and mortality which is not insignificant. Tube thoracostomy (TT) is the most common surgical procedure in chest trauma and has a significant number of complications with a range between 10 and 30% as has been reported in several articles.1-3 In our experience,4 we found 9.2% complications in a period of 7 months with 152 trauma cases analyzed prospectively. These were morbid complications as they required either a second TT or open thoracotomy. The article presented indicates a change of paradigm in chest trauma for insertion of chest tubes, such as ‘the 35 mm rule’. This is a cutting point for observation or perform a TT. Analyzing the article, I have several comments. The study refers to chest trauma in general. Table 1 in the article shows that 81% of the cases were secondary to blunt chest trauma. This is important to know as the behavior of penetrating trauma may be different from blunt trauma and if the variables can be applied to all cases. It is important to note that only 4.3% of the observed patients were failures, i.e. physiologic deterioration or increase of pneumothorax that required a chest tube. It would be nice to know if among these failures there was any due to penetrating trauma. Another aspect not defined in detail are the comorbidities: 12 for the observed arm and three for those treated with TT. A significant comorbidity would be chronic obstructive pulmonary disease (COPD): how many of these patients can be observed without performing TT, how many will deteriorate? These patients are high risk for complications due to the poor quality of their pulmonary parenchyma and poor pulmonary reserve. In summary, this article is a step forward for the reduction of TT in chest trauma. Through clinical assessment and the application of a simple rule, observation of patients can be accomplished safely with a low percentage of failures. To validate the findings of this study, it would be necessary to carry out a prospective and randomized study. Variables, such as trauma mechanisms and comorbidities should be analyzed in detail to avoid deviations in the results.

REFERENCES 1. Menger R, Telford G, Kim P, et al. Complications following thoracic trauma managed with tube thoracostomy. Injury 2012;43(1): 46-50. 2. Ball CG, Kirkpatrick AW, et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma 2005;59(4):917-925. 3. Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J Cardiothorac Surg 2002;22(5):673-678. 4. Díaz RI, Andrade-Alegre R. Factores de Riesgo para el Desarrollo de Complicaciones en las Toracostomías Cerradas por Trauma. Panam J Trauma Critical Care Emerg Surg 2013;2(2):69-73.

Rafael Andrade-Alegre FACS, FCCP Professor Chief Thoracic Surgery Hospital Santo Tomás Panamá, República de Panamá e-mail: toravasc@cwpanama.net

PAJT Pneumothoraces on Computed Tomography Scan: Observation using the 35 Millimeter Rule is Safe

INVITED COMMENTARY El Rol de la Tomografía Computarizada en el Manejo del Neumotórax: Observación Utilizando El Milimétrico Regla 35 Es Seguro El artículo de Copano et al es un trabajo interesante que comenta sobre las nuevas tendencias en el manejo de trauma, tales como el uso diario de los procedimientos mínimamente invasivos y evitar el uso innecesario de procedimientos quirúrgicos. La evidencia indica que este último tiene una importante morbilidad y la mortalidad. La utilización del Tubo de toracotomía (TT) es el procedimiento quirúrgico más común en trauma de tórax y tiene un número significativo de complicaciones con un rango entre 10 y 30%, como se ha reportado en artículos previos.1-3 En nuestra experiencia, hemos4 encontrado 9,2% de complicaciones en un período de 7 meses con 152 casos de trauma analizados prospectivamente. Estas fueron Complicaciones con importante morbilidad ya que requirieron ya sea de un segundo TT o toracotomía abierta. El presente artículo indica un cambio de paradigma en el traumatismo torácico para la inserción de tubos en el pecho, tales como ‘la regla de los 35 mm’. Este es un punto de corte para definir si observamos al paciente o realizamos un TT. Después de analizar el artículo, tengo varios comentarios. El estudio se refiere a un traumatismo torácico en general. La Tabla 1 of the article muestra que el 81% de los casos fueron secundarios a traumatismo torácico. Esta distinción es importante ya que el comportamiento de un traumatismo penetrante puede ser diferente de un traumatismo cerrado y las variables se pueden aplicar a todos los casos. Es importante señalar que sólo el 4,3% de los pacientes observados fueron fracasos, es decir, tuvieron deterioro fisiológico o aumento de neumotórax que requirió un tubo torácico. Sería bueno saber si estos fracasos fueron debido a un traumatismo penetrante. Otro aspecto que no se define con detalle son las comorbilidades: 12 para el grupo observado y tres para los tratados con TT. Una co-morbilidad significativa sería el EPOC: ¿cuántos de estos pacientes pueden ser observadas sin realizar TT, ¿cuántos se deterioran? Estos pacientes tienen alto riesgo de complicaciones debido a la mala calidad de su parénquima pulmonar y su pobre reserva pulmonar. En resumen, este artículo es un paso adelante en la reducción de los TT en el traumatismo torácico. A través de la evaluación clínica y la aplicación de una regla simple, la observación de los pacientes se puede realizar de forma segura con un bajo porcentaje de fracasos. Para validar los resultados de este estudio, sería necesario llevar a cabo un estudio prospectivo y aleatorizado. Las variables, tales como mecanismos de trauma y co-morbilidades deben ser analizados en detalle para evitar efectos de confusión.

Rafael Andrade-Alegre FACS, FCCP Professor Chief Thoracic Surgery Hospital Santo Tomás Panamá, República de Panamá e-mail: toravasc@cwpanama.net

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):48-53

PAJT

ORIGINAL RESEARCH

10.5005/jp-journals-10030-1118 FAST-E en Pacientes Con Trauma Abdominal Cerrado Estable, en un Departamento de Urgencias

FAST-E en Pacientes con Trauma Abdominal Cerrado Estable, en un Departamento de Urgencias en Colombia 1

Diego Alejandro Vivas-Giraldo, 2Gerardo Linares-Mendoza, 3Norberto Navarrete-Aldana Carlos Hernan Carmargo-Mila, 5Karen Stephany-Perdomo, 6Luis Arcadio Cortés-Puentes

RESUMEN El impacto que ha generado el trauma en Colombia a lo largo de la historia, nos ha obligado a mejorar y adaptar diferentes tipos de sistemas de atención en trauma, basados en los lineamientos internacionales, los cuales buscan evitar el significativo aumento en las tasas de mortalidad y discapacidad que se obtienen de este, especialmente en los servicios de Emergencias en los cuales se reciben el 100% de estos pacientes con traumatismo múltiple o politraumatismo, a quienes se les debe dar un abordaje rápido, efectivo y eficaz que beneficie tanto al propio paciente, como al mismo sistema de salud. Dentro de este grupo de pacientes hay un subgrupo que son las pacientes con trauma de abdomen que cursan con estabilidad hemodinámica y además son clasificados de bajo riesgo, ya sea por índices de trauma o por otros métodos como la medición sérica de lactato, los cuales tienen un papel poco despreciable al momento de ver mortalidad y discapacidad por trauma, ya sea penetrante o cerrado; en este trabajo específicamente nos centramos en las personas que consultan al servicio de Emergencias con trauma cerrado de abdomen los cuales son considerados de bajo riesgo, siendo este subgrupo de pacientes uno de los mas difíciles de abordar y enfocar al momento de la valoración inicial, ya que se debe tener la

seguridad de que no hay lesiones que comprometen la vida y por consiguiente estos pacientes puedan ser dados de alta. Una de las practicas que mas se han venido haciendo en los últimos años en la valoración del paciente con trauma de abdomen cerrado es la ultrasonografía (FAST), la cual ha logrado disminuir los tiempos en la toma de decisiones, además de disminuir tasa de complicaciones en estos pacientes; con base en esto se ha implementado en la Fundación Cardioinfantil este procedimiento en el servicio de Emergencias, encabezado por el grupo de ultrasonido a la cabecera del paciente (Emergenciólogos), con lo cual se busca medir el impacto del trauma cerrado de abdomen clasficado de alta energia y de bajo riesgo. Palavras chave: FAST-E, Trauma abdominal cerrado estable. How to cite this article: Vivas-Giraldo DA, Linares-Mendoza G, Navarrete-Aldana N, Carmargo-Mila CH, Stephany-Perdomo K, Cortés-Puentes LA. FAST-E en Pacientes con Trauma Abdominal Cerrado Estable, en un Depar tamento de Urgencias en Colombia. Panam J Trauma Crit Care Emerg Surg 2015;4(2):59-65. Source of support: Nil Conflict of interest: None

ABSTRACT 1

Residente de Medicina de Emergencias, 2,6Especialista en Medicina de Emergencias, 3Especialista en Medicina de Emergencias, 4Especialista en Cirugía General, 5Médico Interno 1

Universidad del Rosario/Fundación Santa fe de Bogotá Especialista en Gerencia Hospitalaria—ESAP 2,6

Fundación Cardioinfantil/Instituto de Cardiología, Brazil

Universidad del Rosario, Candidato a Maestria en Epidemiología Clínica—Universidad Javeriana, Emergenciologo Unidad de Cuidado Intensivo de Quemados—Hospital Simon Bolivar Colombia

To improve and adapt different types of trauma care systems, based on international guidelines and to avoid significant increase in mortality and disability, we focus on a subgroup of patients who are abdominal trauma patients that present with hemodynamic stability. In recent years abdominal ultrasonography (FAST has managed to reduce time in decision-making, and reduce complication rate in these patients. In our observational study of 65 patients with high mechanism blunt thoracoabdominal trauma and negative EFAST, only 3% required further investigation after an observational period with CT scan. Keywords: Blunt abdominal trauma, FAST.

Jefe Departamento de Urgencias Adultos—Fundación Cardioinfantil/Instituto de Cardiología, Brazil 5

Universidad de la Sabana/Fundación Cardioinfantil/Instituto de Cardiología, Brazil Corresponding Author: Diego Alejandro Vivas-Giraldo Residente de Medicina de Emergencias—Universidad del Rosario/Fundación Santa fe de Bogotá, Especialista en Gerencia Hospitalaria—ESAP, e-mail: alejandro_048@ hotmail.com

INTRODUCCIÓN A lo largo del tiempo la consulta de urgencias por trauma ha sido una de las situaciones mas comunes y complejas de manejar en los diferentes hospitales a nivel mundial, permitiendo con este, forjar la creación de diferentes tipos de protocolos, guías y formas de proceder ante este tipo de pacientes, los cuales demandan atención inmediata y,

Note: Paper presented in Resident Research Competition at the annual congress of Panamerican Trauma Society, Panama City, Panama, November 2015.

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Diego Alejandro Vivas-Giraldo et al

eficaz y eficiente por parte del personal de los servicios de urgencias, evitando al máximo la presentación de eventos adversos y complicaciones que deriven en daño a los pacientes.1 Entre este gran número de consultas se encuentran los pacientes con trauma múltiple, el cual se define como la lesión de una o más regiones corporales (AIS no mayor a3,1 sin signos de respuesta inflamatoria sistémica, siendo estos por sus características tanto anatómicas como fisiológicas los mas comúnmente recibidos en las instituciones de salud;1 igualmente es de gran importancia el abordaje de este tipo de trauma ya que existe una alta posibilidad de tener trauma de abdomen cerrado cuando hay trauma múltiple con cinemática de trauma de alta energía, ya sea por colisiones directas, caídas o por ondas expansivas que lesionan el abdomen.1 La cinemática del trauma es muy importante a la hora de abordar pacientes con trauma múltiple ya que ayuda al examinador a sospechar las posibles lesiones asociadas al evento, para esto hay que tener clara la definición de trauma de alta energía, la cual consiste en personas que presentan eyección del vehículo involucrado en el accidente, conductor de motocicleta, que hayan muertos en la escena del accidente, que haya una caída de 6 o más metros de altura, o una caída de 5 o mas escalones, colisiones entre vehículos a maás de 55 km/hora, colisiones de motocicleta a más de 30 km/ hora o colisión auto—peatón a mas de 30 km/hora, y colisión a un niño a cualquier velocidad.4 Teniendo en cuenta que las velocidades entre los vehículos involucrados se suman entre si; por ejemplo, si hay una colisión entre dos vehículos de los cuales uno iba a 40 km/hora y el otro iba a 35 km/hora, la energía total con que estos vehículos se estrellaron fue de 75 km/ hora;4 igualmente se considera trauma de alta energía todo accidente en el cual la extricación de la persona afectada se demore mas de 20 minutos o que tenga un puntaje RTS (revised trauma score) menor o igual a 11 en la escena;4 de igual manera hay otros parámetros para definir trauma de alta energía que pueden ser valorados en la primera intervención al paciente los cuales son los signos vitales y la presencia de lesiones penetrantes en cabeza, cuello, tórax y abdomen, presencia de dos o mas fracturas de huesos largos, amputaciones traumáticas, trauma raquimedular y quemadura de la vía aérea o de más del 20% de la superficie corporal en adultos y el 10% en niños.4 además de lo anterior se deben tener en cuenta los grupos especiales por su mayor vulnerabilidad a la hora de presentar traumatismo múltiple, embarazo, diabetes mellitus, inmunosupresión, anticoagulación, falla cardiaca, disfunción respiratoria y edades extremas (menor 5 años y mayores 65 años), ya que estos grupos

tienen un riesgo aumentado de presentar complicaciones tempranas relacionadas con el trauma.6 Los pacientes con trauma de abdomen cerrado son una entidad compleja de estudiar, debido a las incertidumbre constante de la presencia de lesiones intraabdominales y retroperitoneales que muchas veces tardan o no se manifiestan clínicamente de alguna forma que alarme al personal de urgencias para actuar e intervenirles de inmediato,6 requiriendo entonces largas observaciones en los servicios de urgencias, debido a la baja sensibilidad del examen físico, el cual se debe hacer de forma seriada para lograr un adecuada valoración clínica de pacientes con trauma cerrado de abdomen, sin embargo, esto a costa de periodos de observaciones inclusive superiores a 8 horas en algunos casos.6 Debido a lo anterior, con el paso del tiempo se han instaurado diversos protocolos de manejo de trauma de abdomen cerrado, con los que se busca básicamente localizar lesiones de forma mas rápida y determinar el riesgo de desarrollarlas durante la observación clínica de las mismas, tratando así de definir estos pacientes en menos tiempos,6 sin tener que aumentar el número de complicaciones y eventos adversos, se han utilizado protocolos de observación y tolerancia a la vía a oral,6 protocolos con realización de tomografía de abdomen con medio de contraste para descartar lesiones intraabdominales aunque con el riesgo de complicaciones por aplicación de medio de contraste y las largas horas de espera por la preparación que este estudio requiere,6 y la realización de Ultrasonografía de emergencias con FAST-E para de una forma rápida descartar presencia de líquido libre en la cavidad abdominal.7 En la actualidad, el trauma es la principal causa de muerte dentro de las primeras cuatro décadas de la vida.7 El trauma abdominal aislado o asociado con otros tipos de trauma presentan un importante reto para el medico que atiende urgencias. El traumatismo cerrado de abdomen, se pueden asociar a mayor mortalidad por la dificultad en el diagnostico o al ser los síntomas enmascarados o pasar desapercibidos por otros tipos de trauma.9 Los diagnósticos erróneos o tardíos son el principal riesgo en morbilidad y mortalidad en este tipo de lesiones por lo cual deben ser evaluadas y descartadas en forma organizada y sistemática por un equipo de trauma.9 El conocimiento del mecanismo de trauma permite anticipar lesiones ocultas, dirigir las pruebas diagnosticas e iniciar tratamientos en forma mas rápida.9 Mecanismos de alta energía han sido descritos, asociados a mayor probabilidad de lesiones ocultas, incluidas las abdominales, con mayor riesgo de mortalidad, que requieren estudios diagnósticos y manejo especializado en centros de trauma.9 El manejo del trauma abdominal cerrado con inestabilidad hemodinámica ha sido modificado

PAJT FAST-E en Pacientes Con Trauma Abdominal Cerrado Estable, en un Departamento de Urgencias

positivamente gracias a la valoración ultrasonográfica enfocada al trauma (FAST-E, por sus siglas en inglés), con alta sensibilidad (86%) y especificidad (99%),9 para la detección de líquido libre intraabdominal, secundario a lesiones significativas que requieren manejo quirúrgico. Sin embargo, en el manejo del trauma abdominal cerrado con paciente estable, la utilidad del FAST-E ha sido cuestionada por trabajos que determinaron baja sensibilidad (45%) y especificidad (94%),7,9 que impiden tomar decisiones o plantear manejo quirúrgico. Por lo anteriormente mencionado, se han descrito protocolos que involucran observación prolongada del paciente basados en examen físico seriado y/o evaluación con tomografía abdominal total.9 Recientemente se han descrito estudios de trauma abdominal cerrado en pacientes estables, basados en FAST-E y examen físico normal, con resultados prometedores en pacientes de bajo riesgo.9 Nuestra institución adoptó un protocolo para pacientes estables, con sospecha de trauma abdominal debido al mecanismo peligroso de trauma, basado en FAST-E y examen físico normal sumado a lactato menor a 2.5 mmol/l, como marcador de bajo riesgo, con el cual se busca describir el número de lesiones intra abdominales, re consultas y tiempo promedio de observación en el servicio de urgencias de este grupo de pacientes incluidos en este protocolo de estudio.

OBJETIVO GENERAL Describir los resultados de la práctica clínica actual para el estudio de pacientes adultos con sospecha de trauma abdominal cerrado debido a un mecanismo de trauma de alta energía, hemodinamicamente estable en el Departamento de Emergencias de un hospital de cuarto nivel de complejidad en Bogotá-Colombia.

OBJETIVOS ESPECIFICOS 1.1 Describir los mecanismo de trauma más frecuentemente relacionados con sospecha de trauma cerrado de abdomen con estabilidad hemodinámica. 1.2 Determinar el número de re consultas relacionas por lesiones abdominales no diagnosticada y otras causas posterior al egreso hospitalario de los pacientes valorados con el protocolo de FAST-E y lactato. 1.3 Describir el tiempo promedio de observación de los pacientes valorados con el protocolo de FAST-E y lactato.

METODOLOGÍA Estudio observacional descriptivo, con cohorte histórica. Se analizan los pacientes que ingresaron al Departamento de Emergencias de un hospital de cuarto nivel de

complejidad en Bogotá-Colombia, con trauma múltiple y mecanismo peligroso de alta energía, durante el periodo comprendido desde el 1 de julio de 2013 al 28 de febrero de 2014. Estos pacientes cumplieron los siguientes criterios: ser mayores de 17 años, tener mecanismo de trauma cerrado, estabilidad hemodinámica, lactato sérico menor a 2,5 mmol/L, examen físico sin alteraciones anatómicas abdominales y poseer un RTS mayor a 11. En la práctica clínica institucional los pacientes con los anteriores criterios fueron valorados con un FAST-E. Si el examen no demuestra líquido libre intraabdominal, se clasifico como de baja probabilidad para tener lesiones intraabdominales y no se solicitaron estudios adicionales. Aquellos pacientes en quienes por el mecanismo del trauma y/o el criterio del tratante, se hizo necesario la realización de una tomografía abdominal, fueron excluidos. Se registraron las características demográficas, las lesiones asociadas, el tiempo de observación abdominal, el resultado final durante la observación y si se presento reingresos. En pacientes que requirieron hospitalización por otras causas, se reviso la historia clínica con el fin de determinar si se encontró alguna lesión abdominal no diagnosticada inicialmente. Se realizará una revisión de la base de datos de ingresos primarios asociado a trauma al servicio de Urgencias de FCI. durante durante el periodo comprendido entre el 1 de Julio de 2013 y el 28 de Febrero de 2014. estableciendo total de traslados primarios. Y se eliminaron pacientes con trauma penetrante, Posteriormente se evaluó la gasimetría arterial y los criterios de inclusión. Posteriormente se registran las variables en estudio en un archivo plano de excel. Se hizo seguimeinto telefónico para verifcar si el paciente requirió valoración por Urgencias u hospitalización por causa abdominal y/o otras causas, y si los hallazgos son relevantes (Cirugía abdominal, necesidad de transfusión, necesidad de TAC abdominal) (Se revisará la historia clínica con el fin de determinar si se encontró alguna lesión abdominal no diagnosticada inicialmente). Se realizará un análisis descriptivo de las variables en estudio. Para las variables categóricas se realizará distribución de frecuencias (porcentajes). Para las variables continuas se realizara medidas de tendencia central y dispersión (media y desviación estándar).

IMPACTO Con la realización de este trabajo se busca determinar si con la descripción del uso de protocolo de FAST-E en pacientes con trauma de abdomen cerrado con mecanismo peligroso y con bajo riesgo medido por lactato sérico, se pueda disminuir la toma de imagenes

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):59-65

Diego Alejandro Vivas-Giraldo et al

innecesarias (Tomografía de Abdomen), generando de esta manera disminución en el tiempo de observación de este grupo de pacientes, logrando así plantear nuevas hipotesis para realizar investigaciones a futuro.

RESULTADOS Se evaluaron un total de 114 pacientes con sospecha de trauma abdominal a quienes se les realizó FAST-E, de los cuales se descartaron 8 por ser trauma penetrante, 6 por inestabilidad hemodinámica y 35 por tener alteraciones en el examen físico y/o gases arteriales que requirieron TAC abdominal. Un total de 65 pacientes cumplieron los criterios de inclusión de los cuales la mayoría fueron traumas por atropellamiento de peatón y/o bicicleta (29,2%) y traumas en motocicleta (21,5%), seguidos por colisiones a alta velocidad (13,8%). El valor promedio de lactato de estos pacientes fue de 1,49 y se requirió en promedio 7,7 horas de observación para que fueran clasificados de baja probabilidad de tener lesiones intraabdominales. Al revisar la base de datos de estos pacientes se encontró que 10 (15,3%) pacientes tuvieron una hospitalización mayor a 48 horas sin mención de lesiones abdominales diagnosticadas a posteriori, 18 (27,6%) pacientes reingresaron por otra causa relacionadas al trauma, principalmente en extremidades sin necesidad de estudiar lesiones abdominales adicionales y 2 (3%) pacientes reingresaron por dolor abdominal con TAC normal.

DISCUSIÓN Los pacientes con mecanismo de trauma de alta energía, como los pacientes de nuestra descripción, a pesar de no tener criterios fisiológicos o anatómicos de severidad, pueden aún tener lesiones ocultas. El presentar un mecanismo de trauma peligroso, tienen una sensibilidad baja (50% a 70%), con valores predictivos positivos del 16,1%, para detectar traumas con ISS > 16. Por lo anterior estos pacientes deben ser trasladados para ser valorados por un equipo de trauma, que utilice estrategias para descartar lesiones ocultas, incluyendo las intraabdominales. El FAST-E se considera una examen fácil de realizar, sin riesgos potenciales para el paciente, reproducible a cualquier momento y evita la necesidad de transportar al paciente fuera del Departamento de Emergencias. A pesar de esto, no ha demostrado ser una herramienta efectiva en el roll-out y/o roll-in de pacientes con trauma abdominal cerrado estable. Sin embargo, como sugiere Byars y colaboradores, podría ser llegar a comprobarse la utilidad del FAST-E en cierto tipo de pacientes de bajo riesgo. En su estudio Byars y colaboradores, reporta que aproximadamente el 9,2% de los pacientes con examen físico normal y

FAST-E negativo, presentaban alguna alteración en la tomografía, sin configurar lesiones significativas de intervención quirúrgica o de mortalidad. En nuestra práctica clínica, nosotros agregamos el lactato menor a 2,5 como indicador de bajo riesgo y estos pacientes fueron observados por aproximadamente 8 horas, sin haber evidencia de lesiones abdominales significativas registradas en la historia clínica. Sólo se registraron 2 reingresos por sintomatología abdominal relacionada al trauma, sin embargo en ningún paciente presentó alguna lesión demostrable con tomografía.

CONCLUSIÓN El papel del FAST-E en pacientes con trauma abdominal cerrado estables hemodinámicamente y de bajo riesgo debe replantearse. En nuestra descripción los pacientes con un mecanismo de trauma peligroso, con lactato menor a 2,5 mmol/dl, examen físico normal, FAST-E negativo y observación aproximada de 8 horas, no presentaron lesiones intraabdominales que requirieran estrategias diagnosticas adicionales. Este protocolo debe ser valorado prospectivamente involucrando mayor número de pacientes con el fin de confirmar la seguridad de dicha practica clínica.

REFERENCIAS 1. Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA 2012 Apr;307(14):1517-1527. 2. Simon Fleming. Accuracy of FAST scan in blunt abdominal trauma in a major London trauma centre. Int J Surg 2012; 10:470-474. 3. Schurink GW, Bode PJ, van Luijt PA, van Vugt AB. The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study. Injury 1997;28(4):261e5. 4. Sheng AY. Focused assessment with sonography in trauma and abdominal computed tomography utilization in adult trauma patients: trends over the last decade. Emerg Med Int 2013. 5. Natarajan B. FAST scan: is it worth doing in hemodynamically stable blunt trauma patients?. Surgery 2010;148:695-701. 6. FAST Enough? A Validation Study for Focused Assessment with Sonography for Trauma Ultrasounds in a Level II Trauma Center GALEN HOLMES. 7. Focused Assessment with Sonography in Trauma and Abdominal Computed Tomography Utilization in Adult Trauma Patients: Trends over the Last Decade. 8. Marx JA, Isenhour JL. Abdominal Trauma. In: Emergency Medicine Concepts and Clinical Practice. 6th ed. Marx. JA Eds. Elsevier; 2006. 9. Davis JJ, Cohn I Jr, Nance FC. Diagnosis and management of blunt abdominal trauma. Ann Surg 1976;183(6):672. 10. Gebhard F, Huber-Lang M. Polytrauma pathophysiology and management principles. Langenbecks Arch Surg 2008;393(6): 825-831. 11. Newgard CD, Lewis RJ, Kraus JF, McConnell KJ. Seat position and the risk of serious thoracoabdominal injury in lateral

PAJT FAST-E en Pacientes Con Trauma Abdominal Cerrado Estable, en un Departamento de Urgencias

12.

13.

14. 15.

16.

17.

18. 19.

20.

21.

motor vehicle crashes. Accid Anal Prev 2005 Jul;37(4):668-674. Epub 2005 Apr 2. Newgard CD, Lewis RJ, Jolly BT. Use of out-of-hospital variables to predict severity of injury in pediatric patients involved in motor vehicle crashes. Ann Emerg Med 2002 May;39(5):481-491. Newgard CD, Lewis RJ, Kraus JF. Steering wheel deformity and serious thoracic or abdominal injury among drivers and passenger sinvolved in motor vehicle crashes. Ann Emerg Med 2005;45(1):43. Brasel KJ, Nirula R. What mechanism justifies abdominal evaluation in motor vehicle crashes?. J Trauma 2005;59(5):1057. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Holmes JF, Mao A, Awasthi S, McGahan JP, Wisner DH, Kuppermann N. Ann Emerg Med 2009 Oct;54(4):528-533. Takishima T, Sugimoto K, Hirata M, Asari Y, Ohwada T, Kakita A. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg 1997;226(1):70. Mofidi M, Hasani A, Kianmehr N. Determining the accuracy of base deficit in diagnosis of intra-abdominal injury in patients with blunt abdominal trauma. Am J Emerg Med 2010 Oct;28(8):933-936. Charles A. Sepsis Biomarkers in Polytrauma Patients. Crit Care Clin 2011;27:345-354. Martin MJ. Discordance between lactate and base deficit in the surgical intensive care unit: which one do you trust? Am J Surg 2006;191:625-630. Schnüriger B, Inaba K, Barmparas G, Eberle BM, Lustenberger T, Lam L, Talving P, Demetriades D. Serial white blood cell counts in trauma: do they predict a hollow viscus injury? J Trauma 2010;69(2):302. Mele TS, Stewart K, Marokus B, O’Keefe GE. Evaluation of a diagnostic protocolus in screening diagnostic peritoneal lavage with selective use of abdominal computed tomography in blunt abdominal trauma. J Trauma 1999;46(5):847.

22. Bhagvan S, Turai M, Holden A, Ng A, Civil I. Predicting hollow viscus injury in blunt abdominal trauma with computed tomography. World J Surg 2013 Jan;37(1):123-126. 23. Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Radiology 2012;265(3):678. 24. Holmes JF, McGahan JP, Wisner DH. Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults withblunt trauma. Am J Emerg Med 2012 May;30(4):574-579. 25. Heilbrun ME, Chew FS, Tansavatdi KR, Tooze JA. The role of negative CT of the abdomen and pelvis in the decision to admit adults from the emergency department after blunt trauma. J Am Coll Radiol 2005 Nov;2(11):889-895. 26. Holmes JF, Wisner DH, McGahan JP, Mower WR, Kupperman N. Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma. Ann Emerg Med 2009;54(4):575. 27. American College of Emergency Physicians. Emergency ultrasound imaging criteria compendium. American College of Emergency Physicians. Ann Emerg Med 2006;48(4): 487. 28. Blackbourne LH, Soffer D, McKenney M, Amortegui J, Schulman CI, Crookes B, Habib F, Benjamin R, Lopez PP, Namias N, Lynn M, Cohn SM. Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma. J Trauma 2004;57(5):934. 29. Instituto nacional de medicina legal y ciencias forenses. Boletines estadísticos mensuales. Comparativo 2010—2011 Muertes violentas según contexto; 2012 (Consultado por ultima vez Agosto de 2014). Disponible en www. medicinalegal.gov.co 30. Physical examination combined with focused assessment with sonography for trauma examination to clear hemodynamically stable blunt abdominal trauma patients. Am J Emerg Med 2013 Oct; 31(10):1527-1528. 31. Guía de Trauma abdominal penetrante. Universidad del valle. Diciembre de 2003.

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Diego Alejandro Vivas-Giraldo et al

INVITED COMMENTARY Dr Vivas re : ‘Fast-E En Pacientes Con Trauma Abdominal Cerrado Estable, En Un Departamento De Urgencias En Colombia’ Dr Vivas presents an important issue. Can EFAST be enough to rule out important injuries in our blunt trauma patients? He brings us an observational study of 65 patients with high mechanism blunt thoraco-abdominal trauma and negative EFAST, of whom only 3% required further investigation after an observational period with CT scan. This is an interesting concept since this examination has been used in unstable patients to triage to the operating room; not as the sole tool to rule out injuries and discharge patients home. In places with almost unlimited resources; it seems patients tend to receive more and more radiological studies and with it radiation that might; or might not be necessary. Overtime, the numbers that indicate the vital signs in the monitors have gotten larger and larger, and sometimes the physicians hands further and further away from the patient’s body.1-5 Performing serial ultrasound exams, forces the physician to touch the patient. As it was described previously by experts, such as Dr Rozycki, this is an extension of the physical exam. A visual stethoscope. I congratulate Dr Vivas for asking this difficult question, especially since in medicine we must adapt the tools to the environment we live in order to provide for the best patient care. With less resources less capacity for expensive tests. Although as an ultrasound enthusiast I would love to endorse the concept he advocates for in his paper, unfortunately; the short follow-up and the small number of patients in this study prevents me from doing so at the present time. I will, however, encourage Dr Vivas curiosity, and add a challenge. If you add to the EFAST a cardiac view—not only to look for effusion but to evaluate fluid status and contractility, now you will also have a portable hemodynamic monitor in your hands. This might make the process of triage faster and more informed. Congratulations on a wonderfully written paper, and I am looking forward your future research in this matter.

REFERENCES 1. Ferrada P, Anand RJ, Whelan J, Aboutanos MA, Duane T, Malhotra A, et al. Limited transthoracic echocardiogram: so easy any trauma attending can do it. J Trauma 2011;71(5):1327-1331. 2. Ferrada P, Vanguri P, Anand RJ, Whelan J, Duane T, Aboutanos M, et al. A, B, C, D, echo: limited transthoracic echocardiogram is a useful tool to guide therapy for hypotension in the trauma bay—a pilot study. J Trauma Acute Care Surg 2013;74(1):220-223. 3. Ferrada P, Evans D, Wolfe L, Anand RJ, Vanguri P, Mayglothling J, et al. Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay. J Trauma Acute Care Surg 2014; 76(1):31-37. 4. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg 1998;228(4):557-567. 5. Rozycki GS, Ochsner MG, Feliciano DV, Thomas B, Boulanger BR, Davis FE, et al. Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study. J Trauma 1998;45(5):878-883.

Prof Paula Ferrada Richmond, Virginia USA

PAJT FAST-E en Pacientes Con Trauma Abdominal Cerrado Estable, en un Departamento de Urgencias

INVITED COMMENTARY Dr Vivas re : ‘Fast-E En Pacientes Con Trauma Abdominal Cerrado Estable, En Un Departamento De Urgencias En Colombia’ Dr Vivas presenta un cuestionamiento importante. ¿Puede EFAST ser suficiente para diagnosticar lesiones importantes en nuestros pacientes con traumatismo abdominal cerrado? Él nos trae un estudio observacional de 65 pacientes con alto mecanismo contundente de trauma toraco-abdominal y examen de EFAST negativo, de los cuales sólo el 3% requirió más investigación después de un período de observación con TAC. Este es un concepto interesante ya que este examen se ha usado en pacientes inestables como traige para la sala de operaciones; no como la única herramienta para descartar lesiones completamente. En lugares con recursos casi ilimitados; parece pacientes tienden a recibir más y más estudios radiológicos y con esto también radiación que puede; o no podría ser necesaria. Con el tiempo, los números que indican los signos vitales en los monitores han vuelto más y más grande, y en ocasiones las manos de los médicos alejándose más y más del cuerpo del paciente. La realización de exámenes de ultrasonido de serie, obliga al médico a tocar al paciente.1-5 Como se describió previamente por expertos como la Dra. Rozycki, es una extensión del examen físico. Un estetoscopio visual. Felicito Dr Vivas por hacer esta pregunta difícil, sobre todo porque en la medicina hay que adaptar las herramientas para el medio ambiente en que vivimos con el fin de proporcionar la mejor atención al paciente. Con menos recursos también existe menor capacidad para pruebas costosas. Aunque como un entusiasta de ultrasonido me encantaría avalar el concepto que defiende en su artículo, desafortunadamente; el corto seguimiento y el pequeño número de pacientes en este estudio me impide hacerlo en el momento actual. Sin embargo, le animaré al Dr Vivas su curiosidad, y le quiero añadir un desafío. Si se agrega a la EFAST una vista-cardiaca no sólo para buscar derrame sino para evaluar el estado del fluido y la contractilidad, ahora también tendrá un monitor hemodinámico portátil en sus manos. Esto puede hacer que el proceso de triaje más rápido y mejor informado. Felicitaciones por un trabajo maravillosamente escrito, y estaré pendiente en leer su investigación futura en esta materia.

Prof Paula Ferrada Richmond, Virginia, USA

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):59-65

PAJT 10.5005/jp-journals-10030-1119

Eduardo Rissi Silva et al

ORIGINAL RESEARCH

Prospective Evaluation of a Protocol of Whole Body CT based only in Mechanism of Injury in Major Trauma Patients 1

Eduardo Rissi Silva, 2Felipe Rossi, 3Newton Djin Mori, 4Diogo FV Garcia, 5Edvaldo Utiyama

ABSTRACT Background: There is an important increase in the use of whole body computed tomography (WBCT) around the world although its benefits are still controversial. We hypothesized that the use of a WBCT protocol in the major trauma patients based on mechanism of injury alone would reduce the number of injuries that would have been missed if CT was only done based on clinical findings. Study design: A prospective observational study with the inclusion of 144 patients with major blunt trauma during 5 months at our academic center. Data were collected from all patients including: epidemiology, clinical status on scene and at the emergency department, time of the scan (including patient handling), clinical findings during initial assessment and WBCT scan findings, dividing exams in with or without findings (normal). Looking for findings that would go unnoticed if CT was done based on clinical findings. Glasgow coma scale (GCS) 15 and GCS <15 were compared and data are presented as absolute values of mean ± SD. Analysis of data was done with Chi-square test (p < 0.05). Results: One hundred forty-four patients with major trauma that were included in the protocol. Normal CT scan was found in 44 cases and 100 scans had at least one positive finding associated with the trauma and 35 CTs (25%) had at least one injury that would be missed without the WBCT protocol. Glasgow coma scale of 15 patients and those with 14 or less were compared regarding the number of normal vs positive scan (p = 0.45) and for scans with unnoticed injuries (p = 0.1) and there was no difference between the two groups. Conclusion: A significant number of injuries would have been missed if a WBCT scan protocol based on mechanism of injury was not used in our center. There was no difference in the number of probably missed injuries in patients with a GCS = 15 or those with GCS ≤ 14. Keywords: Computed tomography, Major trauma evaluation, Whole body computed tomography.

How to cite this article: Silva ER, Rossi F, Mori ND, Garcia DFV, Utiyama E. Prospective Evaluation of a Protocol of Whole Body CT based only in Mechanism of Injury in Major Trauma Patients. Panam J Trauma Crit Care Emerg Surg 2015;4(2):66-69. Source of support: Nil Conflict of interest: None

INTRODUCTION Trauma is the 4th cause of death in the world killing more than 5 million people every year. In Brazil, the investments made in care, research and prevention of trauma are inversely proportional to the rapid progression of trauma and violence. The use of whole body computed tomography (WBCT) scanning is rapidly increasing around the world, especially in North America and Europe. In Sweden, for example, 94% of its hospitals have been using major trauma CT scanning since 2001. Nowadays that is possible due to modern multichannels CT scans that allows a fast exam without impairing the evaluation of major trauma patients, and still acquiring good quality images. Despite the rapid increase in WBCT conducted, the benefit of this technology in the care of the major trauma is still controversial. It could provide earlier diagnosis, leading to a faster transfer to the OR, resulting in better outcomes, as it is known that delayed surgical procedures are one of the causes of preventable deaths in trauma. Another fact that supports the use WBCT is the earlier hospital discharge of patients with major trauma and a normal exam. On the other hand we cannot oversee the use of radiation, higher costs and the risks of transporting unstable patients to the scan.

Hypothesis 1,2

Resident, 3,4Associate Physician, 5Professor

1-5

Department of General Surgery and Trauma, Das Clinical Hospital and Faculty of Medicine, University of Sao Paulo, Brazil Corresponding Author: Eduardo Rissi Silva, Resident Department of General Surgery and Trauma, Das Clinical Hospital and Faculty of Medicine, University of Sao Paulo Brazil, e-mail: eduardorissisilva@gmail.com

We hypothesized that the use of a WBCT protocol in the major trauma patients based on mechanism of injury alone would reduce the number of injuries that would have been missed if CT was only done based on clinical findings associated with the thorax and pelvis X-ray. We also sought to examine if there was a difference between patients with a GCS of 15 or less.

Note: Paper presented in Resident Research Competition at the Annual Congress of Panamerican Trauma Society, Panama City, Panama, November 2015.

PAJT Prospective Evaluation of a Protocol of Whole Body CT based only in Mechanism of Injury in Major Trauma Patients Table 1: Targeted regions for CT scan before and after WBCT Before WBCT Protocol Head/cervical - GCS score < 15 - Age > 60 years - Age < 5 years - Vomiting > two episodes - Coagulation disorders - Amnesia - Mechanism of trauma

Thorax Chest X-ray alterations: - Widening mediastinum - Clavicle fracture - Suspected vascular injury

Abdomen/pelvis - Abdominal pain - FAST + - Pelvic X-ray with fracture - Hematuria

MATERIAL AND METHODS We performed a prospective observational study starting in June/2013 with the inclusion of 144 patients with major blunt trauma during 5 months at our academic center. Constituted the sample of the present study all patients with major trauma treated in the emergency room of our service with indication of whole body CT by the protocol. Patients transferred from other services and with more than 12 hours after injury were excluded. Before the introduction of our protocol CT scans were targeted to specific body regions and performed based on clinical findings (Table 1).

Whole Body CT Protocol - Road traffic collision with presumed high-energy trauma (> 50 km/h). - Evidenced by extrication or death at the scene. - Victim ejected from the vehicle. - Pedestrian struck. - Fall from height > 3 meters. - Unknown mechanism of trauma. - Patient physical examination unconditionally reliable

We prospectively collected data from all patients including: patient age and sex, mechanism of injury, respiratory rate, blood pressure, heart rate and Glasgow coma scale (GCS) on scene and at the emergency department, time of the scan (including patient handling), clinical findings during initial assessment and WBCT scan findings. A senior radiologist saw all scans. We divided exams in with or without findings (normal). We also considered normal (without significant findings) those exams with the following findings: subgaleal hematoma, mild softtissues injuries and limb fractures. For analyzing the findings that would go unnoticed without the protocol the scans were divided by body

Table 2: Results of the injuries that would go unnoticed without the protocol of WBCT Findings WBCT Normal CT Positive CT Findings by body segments Head/Neck

Positive 60 (42%)

Negative 84

Thorax

58 (40%)

Abdomen

26 (18%)

118

Pelvis/vertebrae

28 (19%)

116

WBCT with possible missed injuries

35 (25%)

44 100 Injuries that would have been missed 3 (2%) - Internal carotid dissection - Thrombosis of the left jugular vein - Internal carotid dissection 12 (8%) - Hemothorax (x2) - Moderate pneumothorax (x2) - Superior mediastinum hematoma - Traumatic aortic rupture - Minor pneumothorax (x6) 8 (6%) - Dissection of bilateral iliac arteries - Hepatic trauma (2x Grade III) - Splenic trauma (1x Grade III) - Renal trauma (2x Grade I + Grade II) - Aortic dissection with no perfusion of left kidney 12 (8%) - Fracture of T12 - Fractures of T5–7 - Fractures of T11–12, L3–4 - Fractures of T8–10 - Fracture of L5 + pubic branches + sacrum - Fractures of L1–2 - Left psoas hematoma with active bleeding - Fractures of L1–4 - Fracture of L3 - Fractures of T5, T6, T9 - Fractures of L1, L5

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):66-69

Eduardo Rissi Silva et al

segments: head/neck, thorax, abdomen, pelvis/thoracic and lumbar vertebras. Head and neck missed injuries were only those found on the angiography phase of the CT scan. Thoracic mild injuries as: simple costal fractures and small pulmonary contusions were not included in the analysis. In the abdomen we only considered as possible missed injuries those found in patients that had normal abdominal exam and/or negative FAST and/or no hematuria. Pelvic and vertebrae injuries were only included in patients without any clinical finding during initial assessment. We compared patients with a GCS 15 and GCS < 15, and between body segments. Data are presented as absolute values of mean ± SD unless otherwise stated. Analysis of categorical independent non-parametric data was done with Chi-square test (p < 0.05).

RESULTS We had a total of 144 patients in the 5 months period of the study with major trauma that were submitted to whole body CT scan. Of those 120 (83%) were men and mean age was 25 years (±17). The mean time to start the scan after indication was 59 minutes (±48) and 30 minutes (±13) for completing the exam and returnig to the ED. The main mechanism of injury was fall from height greater than 3 m in 42 cases (29%), followed by motorcycle accidents in 33 (23%), runovers in 32 (22%), car accidents in 29 (20%) and aggression in 7 (5%). A normal CT scan was found in 44 cases and 100 scans had at least one positive finding associated with the trauma and 35 exams (25%) had at least one injury that would be missed without the WBCT protocol (comparer com outros dados). In Table 2, we show the results of the injuries that would go unnoticed without the protocol of WBCT divided by body segments. We compare patients with a GCS of 15 and those with 14 or less regarding the number of normal vs positive scan (p = 0,45) and for scans with unnoticed injuries (p = 0,1) and there was no difference between the two groups.

DISCUSSION A significant number of injuries would have been missed if a WBCT scan protocol based on mechanism of injury was not used in our center. There was no difference in the number of probably missed injuries in patients with a GCS = 15 or those with GCS ≤14.

REFERENCES 1. World Health Organization—Department of Measurement and Health Information Cause-specific mortality, 2008.

2. Rasslan S, Birolini D. O trauma como modelo de doença. Revista do Colégio Brasileiro de Cirurgiões 1998;25:III-III. 3. Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the US than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am 1983 Aug;249(2):28-35. PubMed PMID: 6623052. 4. Ruchholtz S, Waydhas C, Schroeder T, Piepenbrink K, Kuhl H, Nast-Kolb D. The value of computed tomography in the early treatment of seriously injured patients. Chirurg 2002 Oct;73(10):1005-1012. PubMed PMID: 12395159. Epub 2002/10/24. Stellenwert der Computertomographie in der fruhen klinischen Behandlung schwer verletzter Patienten ger. 5. Cowan I, Cresswell C, Liu H, Siew T, Ardagh M, Than M. Selective versus mandatory whole-body computed tomography scanning in the multiply injured patient. Emerg Med Australas 2012 Feb;24(1):115-116. PubMed PMID: 22313570. Epub 2012/02/09. Eng. 6. Wurmb TE, Quaisser C, Balling H, Kredel M, Muellenbach R, Kenn W, et al. Whole-body multislice computed tomography (MSCT) improves trauma care in patients requiring surgery after multiple trauma. Emerg Med J 2011 Apr;28(4):300-304. PubMed PMID: 20659885. Epub 2010/07/28. Eng. 7. Self ML, Blake AM, Whitley M, Nadalo L, Dunn E. The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries. Am J Surg 2003 Dec;186(6):609-613; discussion 13-14. PubMed PMID: 14672766. 8. Sierink JC, Saltzherr TP, Reitsma JB, Van Delden OM, Luitse JS, Goslings JC. Systematic review and meta-analysis of immediate total body computed tomography compared with selective radiological imaging of injured patients. Br J Surg 2012 Jan;99 (Suppl 1):52-58. PubMed PMID: 22441856. Epub 2012/03/28. Eng. 9. van Vugt R, Kool DR, Deunk J, Edwards MJ. Effects on mortality, treatment, and time management as a result of routine use of total body computed tomography in blunt high-energy trauma patients. The Journal of Trauma and Acute Care Surgery 2012 Mar;72(3):553-559. PubMed PMID: 22491536. Epub 2012/04/12. Eng. 10. Tillou A, Gupta M, Baraff LJ, Schriger DL, Hoffman JR, Hiatt JR, et al. Is the use of pan-computed tomography for blunt trauma justified? A prospective evaluation. J Trauma 2009 Oct;67(4):779-787. PubMed PMID: 19820586. Epub 2009/10/13. Eng. 11. Brenner DJ, Elliston CD. Estimated radiation risks potentially associated with full-body CT screening. Radiology 2004 Sep;232(3):735-738. PubMed PMID: 15273333. 12. Winslow JE, Hinshaw JW, Hughes MJ, Williams RC, Bozeman WP. Quantitative assessment of diagnostic radiation doses in adult blunt trauma patients. Ann Emerg Med 2008 Aug; 52(2):93-97. PubMed PMID: 18328598. Epub 2008/03/11. Eng. 13. Yeguiayan JM, Yap A, Freysz M, Garrigue D, Jacquot C, Martin C, et al. Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma. Crit Care 2012 Jun 11;16(3):R101. PubMed PMID: 22687140. Epub 2012/06/13. Eng.

PAJT Prospective Evaluation of a Protocol of Whole Body CT based only in Mechanism of Injury in Major Trauma Patients

INVITED COMMENTARY Trauma care emphasizes the early detection and treatment of injury in the initial assessment of the patient. Computed tomography (CT) has revolutionized the field of imaging and medicine and it is associated with reduced missed injury rates and reduced delays to definitive management. The introduction of multislice CT in 1998 made wholebody CT (WBCT) technically feasible, with high diagnostic safety, and substantial reduction in scan time. Many trauma centers have advocated the use of WBCT in the primary phase of trauma care, replacing plain radiography. Nowadays many trauma guidelines consider the practice of WBCT scan as a standard of care in the early stage of trauma management in order to analyze the extent of injury. Huber-Wagner et al published a retrospective data from the trauma registry of the German Trauma Society and showed in this multicenter analysis that the use of WBCT in early trauma care significantly decreased the probability of death in trauma patients. The liberal use of CT is not without potential consequences. Whether the advantages of this technique justify its use against cost and radiation exposure associated to the increase of individualâ&#x20AC;&#x2122;s risk of cancer is controversial. Protocols for WBCT with single-pass acquisition sequence to scan the head, neck, chest, abdomen, and pelvis result in lower radiation exposure than do segmented, partially overlapping protocols. In this prospective study, the authors from Sao Paulo, Brazil, presented the initial experience after adopt a new protocol considering the mechanism of injury with high energy to indicate WBCT. The criteria followed before WBCT protocol considered mechanism of trauma only to perform head and cervical CT and thorax and pelvic X-rays were decisive to triage the patients to WBCT. The study started in June 2013, but is possible that segmental scan CT was performed in selected cases based on mechanism of trauma before this period. There is no unified imaging protocol for the trauma patient and the differences in the type of CT machines and automatic injectors have resulted in a variety of imaging protocols. The authors should give more details about their WBCT protocol, like the CT scanner characteristics, slice thickness, contrast protocol and if iterative reconstructions were available. In the present study, the WBCT was evaluated by a senior radiologist, but we know if you have more senior professionals evaluating the exams is possible to increase a little more the accuracy. Evaluating 144 cases the authors identified normal WBCT in 30.5% of cases. Some studies have advocated the selective use of WBCT according to clinical judgment to significantly reduce the number of WBCT scans for blunt trauma, considering the exam unjustified in the absence of a clinical indication. The incidence of at least one injury that would be missed without the WBCT protocol was 25%. This is in accordance with the literature. The study identified more findings in thorax CT, mainly pneumothorax, what can be dangerous in asymptomatic patients. Other studies have suggested that the occult injuries found on routine CT scanning might have little impact on patient management or prognosis. Other important finding in the present study was the same incidence of normal or positive scan, and the same incidence of unnoticed injuries in the two groups: patients with Glasgow coma scale (GCS) of 15, and patients with GCS less than 15. We can conclude that even in asymptomatic trauma patients after high-energy mechanism is possible to identify injuries at WBCT. There are some limitations of the present study. A relatively small but acceptable cohort of patients was examined in order to compare the two protocols. Although the results reached interesting conclusions, further studies with larger cohorts of patients are warranted to answer the question if routine WBCT for patients with high-energy blunt trauma is necessary. Gustavo Fraga MD Professor, University of Campinas, Brazil

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):66-69

PAJT 10.5005/jp-journals-10030-1120

Jorge Hernán Montenegro Muñoz et al

ORIGINAL RESEARCH

Enseñanza-Aprendizaje de Trauma en Colombia: Un Análisis de Planes de Estudio de Pregrado 1

Jorge Hernán Montenegro Muñoz, 2Adriana Fernanda Romero Ortiz, 3Karen Yahaira Solano Ramos Edovan Gonzalez Medina, 5Sandra Lucia Lozano Álvarez, 6Andrés Mariano Rubiano Escobar

RESUMEN Introduccion: La enseñanza en la prevención, promoción y atención urgente del paciente con trauma ha sido poco implementada en la educación médica de Latinoamérica. La preparación del personal médico y paramédico es fundamental para que el manejo de éste tipo de pacientes sea la adecuada y con calidad. El propósito de este estudio es identificar el estado actual de la enseñanza en el tema específico de cuidado de trauma y violencia tanto de las universidades públicas y privadas colombianas en sus programas académicos de pregrado de Medicina y Enfermería. Materiales Y métodos: Se trata de un estudio descriptivo, con datos obtenidos a través de la revisión del currículo de los programas de pregrado en enfermeria y medicina con registro vigente en el Sistema Nacional de Información de la Educación Superior (SNIES) de Colombia hasta Noviembre de 2013. Se realizaron análisis de frecuencia y bivariados. Resultados: Se analizaron los currículos de 60 Programas Académicos de Enfermería y 52 de Medicina. Solo 7 (13.4%) programas de medicina y 2 (3.3%) de enfermería contaban con asignaturas o materias relacionadas con manejo especifico del paciente con trauma o víctima de violencia. Dentro de los programas de medicina 3 (42.9%) pertenecen al sector público ubicandose la mayor parte en la región central del país. En uno de los currículos se identificaron 3 asignaturas cuyo objetivo es el abordaje y manejo del paciente con trauma. En cuanto a enfermeria los 2 programas hacían parte de la misma Universidad pero en sedes diferentes. Conclusion: Teniendo en cuenta que la violencia y el trauma son un problema de salud pública en Colombia, los diferentes

1,3,4

Estudiante de Medicina, 2Estudiante de Enfermeria, Medico de Cuidado Crítico, 6Neurocirujano de cuidado crítico y trauma; Profesor de Neurociencias y Neurocirugía, Universidad El Bosque, Bogotá, Colombia 5

1-4

Universidad Surcolombiana, Neiva, Colombia

Director de Programa de Cuidado Prehospitalario, Universidad del Valle, Cali, Colombia 6

Director Médico y de Investigación, Fundación MEDITECH Neiva, Colombia Corresponding Author: Andres Mariano Rubiano Escobar Neurocirujano de cuidado crítico y trauma, Profesor de Neurociencias y Neurocirugía, Universidad El Bosque, Bogotá (Colombia), Director médico y de investigación, Fundación MEDITECH, Neiva, Colombia, Phone: +573006154775, e-mail: rubianoam@gmail.com

programas académicos en salud deberían contar dentro de su curriculo con asignaturas que incluyan aspectos tan relevantes como la promocion, prevencion, atención y rehabilitación de este grupo de pacientes. Sin embargo dicha cátedra solo esta presente en unos pocos los programas de medicina y enfermería, siendo necesario realizar ajustes al curriculo para lograr su inclusión, con el objetivo de mejorar la atención integral y el desarrollo de políticas públicas. Palabras claves: Educación médica, Cuidado del trauma, Sistemas de atención de emergencias. How to cite this article: Muñoz JHM, Ortiz AFR, Ramos KYS, Medina EG, Álvarez SLL, Escobar AMR. EnseñanzaAprendizaje de Trauma en Colombia: Un Análisis de Planes de Estudio de Pregrado. Panam J Trauma Crit Care Emerg Surg 2015;4(2):70-76. Source of support: Nil Conflict of interest: None

ABSTRACT Introduction: Teaching of prevention, promotion and acute care of the trauma patient has low implementation in Latin American medical education. Preparation of medical and paramedical personnel is fundamental for the appropriate and qualified management of these patients. The purpose of this study is to identify the actual status of medical teaching in this specific topic of trauma and violence care, present in medicine and nursing undergraduate academical programs of private and public universities from Colombia. Materials and methods: This is a descriptive study with obtained data from curriculum reviews of medicine and nursing undergraduate programs with actual registry into the National System for Upper Education Information (SNIES) from Colombia, until November 2013. Bivariate and frequency analyses were performed. Results: Curriculum of 60 medicine and 52 nursing academic programs were analyzed. Only seven (13.4%) medical programs and two (3.3%) nursing programs have courses related to specific management of patients with trauma or violence. Within them, three medicine programs (42.9%) mostly from the public sector were located in the center of the country. In one of the curriculum, three courses including management of patients with trauma were identified. The two programs of nursing were part of the same university but in different cities. Conclusion: Given that violence and trauma is a public health problem in Colombia, health academic programs should have in

Note: Paper presented in Student Research Competition at the annual congress of Panamerican Trauma Society, Panama City, Panama, November 2015.

PAJT Enseñanza-Aprendizaje de Trauma en Colombia: Un Análisis de Planes de Estudio de Pregrado their curriculum, courses that include aspects such promotion, prevention, care and rehabilitation of this group of patients. But these courses are only present in a few programs in medicine and nursing, being necessary to make adjustments to the curriculum in order to improve the overall care and the health public policy development. Keywords: Emergency Medical system, Medical education, Trauma care.

INTRODUCCION El trauma es considerado una pandemia de la sociedad actual. Cada año, genera alrededor de 1.2 millones en muertes en sólo incidentes de tránsito siendo la octava causa de muerte en el grupo poblacional entre 15 y 29 años.1 Ocasiona 182 millones de años de vida perdidos, ajustados en función de la discapacidad por la enfermedad traumática y 500 años de pérdida de productividad anual por cada 100.000 habitantes.2 La Organización Mundial de la Salud considera que para el 2020 será alrededor del 20% de todos los problemas de salud en el mundo, con un aumento en un 40% al 2030.3 En Colombia, durante el año 2013 se presentaron 26.623 muertes debidas a trauma; la violencia fue la principal causa, con una tasa de mortalidad por homicidio de 56.5 casos por 100.000 habitantes, ubicándose por encima de la tasa promedio mundial que es de 6,9 por cada cien mil habitantes.4 La creciente conciencia del costo social y económico de este problema, ha aumentado el interés en las lesiones por causa externa como una amenaza significativa para la salud pública,5 implementando estrategias con miras a prevenirlas y controlarlas. La educación y la promoción son herramientas claves para desarrollar estrategias de prevención y atención integral.6 Experiencias como la del Colegio Americano de Cirujanos con su curso de educación continua ATLS (Soporte Avanzado en Trauma) se ha asociado a una disminución en la mortalidad de pacientes con lesiones severas de un 34 a 67% en diferentes países.6 Contar con procesos formales de educación durante la formación del personal de salud tanto a nivel de pre y postgrado, permite mejorar la atención inicial del mismo.5,7,8 Las Instituciones Universitarias buscan formar profesionales de manera integral que permitan responder a las necesidades de cada ciudad, región y país, para ello diseñan, aplican y actualizan su currículo siguiendo directrices gubernamentales y de acuerdo a la disponibilidad de recursos educativos que faciliten el proceso de enseñanza y aprendizaje. Este currículo se desarrolla mediante cursos y asignaturas con objetivos específicos. La enseñanza médica y de enfermería ha utilizado diferentes metodologías que permiten

preparar escenarios y casos clínicos, facilitando al estudiante exponerse de manera repetida hasta adquirir las competencias exigidas por su disciplina de manera que puedan luego abordar pacientes reales sin poner en riesgo la seguridad del mismo. La simulación médica ha sido usada en los programas de pre y post grado, existiendo experiencias exitosas que justifican su creciente uso en las facultades de salud a nivel mundial.9,10 Desafortunadamente, el uso de estas metodologías en temáticas específicas relacionadas con problemas de salud que generan una alta carga de enfermedad en áreas como Latinoamérica, no ha sido muy generalizado. Este es el caso de los cursos de formación específica para la atención integral del trauma. El objetivo principal de este estudio fue conocer el estado actual de la educación en trauma establecida dentro de los planes curriculares de estudio de programas académicos de medicina y enfermería de pregrado de instituciones de educación universitaria colombianas.

MATERIALES Y METODOS Se realizó un estudio descriptivo que incluyó el análisis de los programas académicos de pregrado tanto de medicina como enfermería con registro vigente en el Sistema Nacional de Información de la Educación Superior (SNIES) de Colombia a Noviembre de 2013.11 Se construyó un formato de recolección donde se consignaron variables como ubicación geográfica de la institución y el programa, carácter académico, haciendo referencia a si era una institución tecnológica o universitaria y si pertenecía al sector público o privado. Los datos se obtuvieron al revisar la información consignada en las páginas web de los programas académicos utilizando las palabras trauma, lesión, herida y violencia; para la asignatura o curso se tuvo en cuenta el nombre de la misma, tiempo de dedicación presencial y no presencial, duración dentro del semestre y el número de créditos definido por el Ministerio de Educación de Colombia como la unidad de medida del trabajo académico que debe realizar el estudiante en cada una de las actividades formativas establecidas como requisito para la obtención de título en un programa de pregrado. La información recolectada fue luego digitada en una base de datos y analizados mediante el programa estadístico SPSS versión 19 (SPSS—IBM—USA), realizando análisis de frecuencia y análisis bivariado.

RESULTADOS Colombia cuenta con 288 instituciones de educación superior registradas en el SNIES de las cuales 81 tienen carácter de universidad,12 existiendo 64 programa de enfermería y 72 de medicina.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):70-76

Jorge Hernán Montenegro Muñoz et al

Luego de la búsqueda de la información en la página web se analizaron 60 currículos de enfermería y 52 de medicina, cuyas características generales se muestran en la Tabla 1. Respecto a los programas de medicina, 7 (13.4%) tienen dentro de su currículo asignaturas relacionadas con el cuidado del paciente con trauma, la mayor parte pertenecen a instituciones Universitarias y tres (42.9%) son del sector público. En cuanto a la ubicación geográfica por regiones, 3 (43%) están en la región Andina, 1 (14%) en la región Caribe y 3 (43%) en la región Pacífica. El programa de la Universidad del Valle tiene dentro de su currículo 3 asignaturas referentes al tema. Algunos nombres de los cursos son: Trauma y violencia, Ortopedia y trauma y Trauma y quemados, Medicina crítica y trauma, Abordaje integral del trauma. Todos tienen componente teórico y práctico, sin tener el dato del tipo de la metodología empleada ni si se usa simulación clínica como estrategia. Las asignaturas son dictadas en diferentes semestres de formación dada la particularidad y autonomía de cada currículo para su organización. De las 7 asignaturas analizadas, 5 (55,6%) asignaturas tuvieron 3 créditos, 2 (22.2%) 2 créditos y las 2 restantes 4 y 20 créditos. El promedio y la mediana del total de horas por asignatura fueron 307.7 y 146 respectivamente. La duración promedio fue de 13 semanas, con mediana de 16 semanas.

Los 2 programas de enfermería con asignatura relacionada al cuidado del paciente traumatizado y la violencia, pertenecen a la misma universidad pero se ubican en diferentes sedes de la región central andina. Es una institución del sector privado con registro de alta calidad. La asignatura se denomina enfermería del trauma, desarrollada en 288 horas durante 16 semanas y tiene 10 créditos académicos.

DISCUSION Aun cuando la Organización Mundial de Salud viene desarrollando estrategias con el fin de prevenir los eventos traumáticos y disminuir las secuelas, sigue siendo una de las causas más frecuentes de morbimortalidad a nivel mundial, teniendo un impacto mayor en países con mediano y bajo ingreso. El diseño de los programas académicos y la formulación de sus currículos dentro de las instituciones universitarias y en particular en las facultades de salud, deben enfocarse en los problemas y enfermedades prevalentes de cada región y país. Nuestro país no es ajeno a la problemática del trauma y la baja tasa de programas de prevención se evidencia con un gran déficit en la formación de los futuros actores de la salud en este tema en particular. Estudios realizados demuestran que el manejo preventivo y adecuado en los pacientes con trauma, es

Tabla 1: Características de programas activos de medicina y enfermería en Colombia Descripción de programas Carácter académico Sector Reconocimiento del ministerio

Duración del programa en semestres

Ubicación del programa por regiones

Institución universitaria/escuela tecnológica Universidad Oficial Privado Registro Alta Calidad Registro Calificado No disponible 8 9 10 11 12 13 14 Media Amazonía (Amazonas, Caquetá, Guainía, Guaviare, Meta, Putumayo, Vaupés, Vichada) Andina (Antioquia, Boyacá, Caldas, Cundinamarca, Huila, Norte de Santander, Quindío, Risaralda, Santander, Tolima) Caribe (Atlántico, Bolívar, Cesar, Córdoba, Guajira, Magdalena, Sucre) Insular (San Andrés y Providencia, Islas de San Bernardo, Gorgona, Malpelo) Orinoquía (Arauca, Casanare, Meta, Vichada) Pacífico (Cauca, Chocó, Nariño, Valle del Cauca)

Medicina n = 52 (%) 7 (13.5) 45 (86.5) 18 (34.6) 34 (65.4) 21 (40.4) 31 (59.6) 0 0 0 3 (5.8) 0 39 (75) 8 (15.4) 2 (3.8) 12.12 0

Enfermería n = 60 (%) 12 (20) 48 (80) 24 (40) 36 (60) 22 (36.7) 36 (60) 2 (3.3) 25 (41.7) 9 (15) 26 (43.3) 0 0 0 0 9.02 0

30 (57.6)

36 (60)

11 (21.1)

12 (20)

1 (1.9) 10 (19.2)

3 (5) 9 (15)

PAJT Enseñanza-Aprendizaje de Trauma en Colombia: Un Análisis de Planes de Estudio de Pregrado

fundamental para disminuir riesgos y complicaciones.13,14 Sin embargo cuando el personal no está capacitado no se puede esperar una adecuada respuesta al implementar estrategias preventivas. En el ámbito del trauma se han desarrollado protocolos para la mejoras de calidad en la atención,5,15,16 pero no se ven representadas muchas veces en la información que reciben los estudiantes de áreas de la salud. En el año 2004, en Estados Unidos solo la cuarta parte de universidades incluían cursos específicos para formar a los estudiantes en trauma.17 En nuestro estudio, solo el 3% de los programas de enfermería y 13% de medicina presentan en sus currículos alguna materia o asignatura relacionada con el manejo del paciente traumatizado. Debido a la importancia que genera la prevención del trauma, se ha hace imperativo la constante practica en la investigación y la transmisión de los conocimientos a los futuros médicos y enfermeras. En el decreto 0917 de mayo 22 de 2001, del Ministerio de Educación de Colombia, el artículo 7 hace énfasis en la preparación de profesionales íntegros con capacidad de responder a las necesidades de su contexto y brindar sus servicios con calidad. Esto no sería una realidad si hablamos de la formación específica para atender víctimas de trauma y violencia. Un estudio realizado por el colegio médico americano (AMC) muestra que los estudiantes reciben una formación limitada en temas relacionados con las lesiones, trauma, abuso de sustancias psicoactivas, medicina ocupacional y violencia intrafamiliar. En este estudio muchos estudiantes de medicina expresaron que la instrucción en temas relacionados con las lesiones era insuficiente y el tiempo dedicado a estas era inadecuado, similar a ello la asociación de escuelas de salud pública (ASPH) en el periodo 2002–2003 resaltó la escasa presentación de temas, y planteó la necesidad de tener profesores capacitados en trauma para la adecuada ilustración de los estudiantes.5 Al igual que las investigaciones anteriormente mencionadas y realizadas en los Estados Unidos, nuestro estudio indica, que son pocos los programas de medicina y enfermería que tienen una asignatura en su currículo relacionada con la prevención y el manejo de pacientes con trauma en Colombia. Además, estas asignaturas tienen una intensidad horaria y duración bastante bajas para las necesidades de la enseñanza específica del manejo de este problema en el contexto Colombiano. Las horas dedicadas y el número de créditos para cada una de ellas varían desde 2 a 20, sin ser homogéneos entre los programas, ya que cada uno de ellos tiene la autonomía para definirlos. Teniendo en cuenta que el crédito es una unidad de medida del trabajo académico que debe realizar el estudiante en cada una de las

actividades formativas, menos del 10% del tiempo total de formación tanto de los médicos como de las enfermeras es dedicado a la enseñanza y aprendizaje del trauma. En el estudio de West y col,18 se describió la importancia de enfocarse en el manejo del trauma mediante el uso de simuladores, los cuales refuerzan la teoría con la adecuada práctica, formando así enfermeras más capacitadas, con pensamiento crítico para atender pacientes severamente comprometidos. Las Instituciones universitarias colombianas, cuentan con laboratorios de simulación como parte de su estrategia pedagógica, pero no queda claro si son utilizados para la formación de médicos y enfermeras para adquirir competencias en el paciente con trauma. Actualmente se han publicado pocas investigaciones relacionadas a la preparación temprana en pregrado de médicos y enfermeras en el manejo del paciente traumatizado en Latinoamérica. Estas deben realizarse, especialmente en los países donde los índices de mortalidad y discapacidad asociada a trauma y violencia reflejan el gran impacto de esta enfermedad en la salud pública nacional.

LIMITACIONES A pesar que el SNIES registra datos específicos de los programas de educación superior en Colombia, fue necesario comprobar la información recolectada debido a inconsistencia en un programa que no se encontraba activo. Al limitarse la búsqueda a la información disponible en la web, existe la posibilidad de que existan ajustes en programas que no estén registrados en sus páginas, pero se considera que el registro existente en el SNIES es el vigente para cada programa de formación.

CONCLUSION En Colombia son pocos los programas de medicina y enfermería que contienen en sus planes de estudio asignaturas enfocadas en la prevención y el manejo adecuado de un paciente traumatizado, a pesar de que esta enfermedad genera una alta carga al sistema de salud pública del país. Sería lógico el proponer reformar o modificar los planes de estudio para incluir estas asignaturas con una intensidad horaria adecuada con el fin de formar médicos y enfermeras calificados en el manejo integral del paciente traumatizado, especialmente en países donde el trauma y la violencia sean un problema de salud pública.

REFERENCIAS 1. Norton R, Kobusingye O. Lesiones. N Engl J Med 2013 May 2;368(18):1723-1730. 2. Byass P, de Court, Graham WJ, Laflamme L, McCaw-Binns A, Sankoh OA, et al. Reflexiones sobre la carga global de enfermedad estimada en 2010. PLoS Med 2013;10(7):e1001477.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):70-76

Jorge Hernán Montenegro Muñoz et al 3. Mathers CD, Loncar D. Proyecciones de la carga de mortalidad y morbilidad entre 2002 y 2030. PLoS Med 2006 Nov;3(11):e442. 4. Instituto Nacional de Medicina Legal y Ciencias Forenses. Datos oficiales sobre la violencia en Colombia 2013. Forensis (Datos para la Vida). 2014; Vol 15(1) July: 1-556. (Donwloaded on September 29th of 2014. Available at: http:// www.medicinalegal.gov.co/documents/10180/188820/ FORENSIS+2013+1-+lesiones+de+causa.pdf/8fde3e7c-f9e8488a-8592-0916b81caaef). 5. Mock C, Kobusingye O, Joshipura M, Nguyen S, ArreolaRisa C. Fortalecimiento trauma y cuidados críticos a nivel mundial. Curr Opin Crit Care 2005 Dec;11(6):568-575. 6. Dagal A, Greer SE, McCunn M. Disparidades Internacionales en el tratamiento de traumas. Curr Opin Anaesthesiol 2014 Apr;27(2):233-239. 7. Yoshii I, Sayegh R, Lotfipour S, Vaca FE. Necesidad de Educación de la prevención de lesiones en el currículo de la escuela de medicina. West J Emerg Med 2010 Feb;11(1):40-43. 8. Aboutanos MB, Rodas EB, Aboutanos SZ, Mora FE, Wolfe LG, Duane TM, et al. Educación de trauma y cuidado en la selva de Ecuador, donde no hay soporte vital avanzado en trauma. J Trauma 2007 Mar;62(3):714-719. 9. Lee SK, Pardo M, Gaba D, Sowb Y, Dicker R, Straus EM, et al. Evaluación de la formación en trauma con un simulador de paciente: un estudio prospectivo, aleatorizado. J Trauma 2003 Oct;55(4):651-657. 10. Knudson MM, Khaw L, Bullard MK, Dicker R, Cohen MJ, Staudenmayer K, et al. Formación de trauma en simulación: traducir habilidades de tiempo SIM a tiempo real. J Trauma 2008 Feb;64(2):255-263. 11. Ministerio de educación de Colombia. Sistema nacional de información de la educación superior (SNIES). 2013. (Donwloaded on May 07th of 2013. Available at: http://snies. mineducacion.gov.co/consultasnies/institucion/buscar. jsp?control=0.362411307245603).

12. Ministerio de educación de Colombia. Sistema nacional de información de la educación superior (SNIES) - Resumen de indicadores de Educación Superior. 2014. (Donwloaded on September 29th of 2014. Available at: http://www. mineducacion.gov.co/sistemasdeinformacion/1735/w3article-212350.html). 13. Zafarghandi MR, Modaghegh MH, Roudsari BS. Muerte de trauma prevenible en Teherán: una estimación de calidad de la atención del trauma en hospitales universitarios. J Trauma 2003 Sep;55(3):459-465. 14. Goh AY, Lum LC, Abdel-Latif ME. El impacto del médico de cuidado intensivo 24 horas que provee de personal en la mezcla del caso ajustado a la mortalidad en cuidados intensivos pediátricos. Lancet 2001 Feb 10;357(9254):445-446. 15. Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. Indicadores de calidad para evaluar la atención de trauma: una revisión del alcance. Arch Surg 2010 Mar;145(3):286-295. 16. Vergnion M, Lambert JL. Un protocolo de atención de trauma en el servicio de emergencia incluyendo proyección de imagen TCMD. Acta Anaesthesiol Belg 2006;57(3):249-252. 17. Ryan D, Sabharwal R. Association of American Medical Colleges. Formación de los futuros médicos sobre lesiones: informe del Grupo Consultivo sobre Educación de Control y prevención de lesiones para los estudiantes de medicina. 2005:1-18 (Donwloaded on September 28th of 2014. Available at: https://members.aamc.org/eweb/DynamicPage.asp x?Action=Add&ObjectKeyFrom=1A83491A-9853-4C8786A4-F7D95601C2E2&WebCode=PubDetailAdd&DoNot Save=yes&ParentObject=CentralizedOrderEntry&Parent DataObject=Invoice%20Detail&ivd_formkey=69202792-63d74ba2-bf4e-a0da41270555&ivd_prc_prd_key=05F06B72-57614164-9005-49C7943C71EA) 18. West MM, Bross G, Snyder M. Atención de trauma complejo en un currículo de enseñanza desafía el pensamiento crítico y juicio clínico--cómo las enfermeras pueden ayudar. J Trauma Nurs 2007 Jul;14(3):131-135.

PAJT Enseñanza-Aprendizaje de Trauma en Colombia: Un Análisis de Planes de Estudio de Pregrado

INVITED COMMENTARY Em atenção a sua solicitação, envio-lhe algumas considerações a respeito do artigo original ‘ENSEÑANZAAPRENDIZAJE DE TRAUMA EM COLOMBIA: UM ANÁLISIS DE PLANES DE ESTUDO DE PREGRADO’, de autoria de Jorge Hernán Montenegro Muñoz e colaboradores.

QUANTO AO TEMA Seguramente trata-se de um tema de grande importância tendo em vista o impacto médico e social do trauma em Colômbia assim como em outros países da América Latina. A título de exemplo, no Brasil os traumatismos, particularmente os devidos a violências interpessoais (ferimentos por armas de fogo e agressões), constituem-se na primeira causa de morte na população na faixa etária de zero a 40 anos e tem aumentado progressivamente. A semelhança com o que ocorre na Colômbia, são poucas as escolas de medicina e de enfermagem que destinam carga horária significativa voltada para a prevenção e as bases do tratamento das vítimas de traumas. Por estes motivos, creio que a publicação deste trabalho poderá servir de estímulo para o estudo deste assunto em outros países da América Latina.

QUANTO AOS MATERIAIS E MÉTODOS A estratégia utilizada foi satisfatória e permitiu reunir dados numericamente consistentes.

RESULTADOS Analisando os dados da Tabla 1, acredito que seria interessante esclarecer as diferenças entre ‘Institución universitária/ escuela tecnológica’ e ‘Universidad’. Também não ficou claro o significado do ‘Reconocimiento del ministério’ e da ‘Duración del programa en semestres’. Tive dificuldade em entender a primeira frase após a tabla (Respecto a los programas de medicina, 7 (13.4%) tienen dentro de su currículo asignaturas relacionadas con el cuidado del paciente con trauma, la mayor parte pertenecen a instituciones Universitarias y tres (42.9%) son del sector público), pois os números são diferentes dos apresentados na tabla. Da mesma forma, não ficou clara a correlação entre os números apresentados na tabla (‘Ubicación del programa por regiones’) e os comentários do texto. Em síntese, creio que o texto deveria ser revisto para que fosse mais claro e mais accessível a leitores de outros países.

DISCUSSÃO Em princípio, a análise dos dados é aceitável e incentiva a reflexão a respeito deste tema.

QUANTO AO TEXTO Embora seja de leitura fácil, creio que seria interessante que o texto fosse revisto e aprimorado. Além disso, na discussão, tive dificuldade em entender o significado de ‘AMC’ e de ‘ASPH’, siglas que constam do texto e que se referem a entidades norte americanas.

REFERENCIAS São satisfatórias em número, qualidade e datas de publicação. Dario Birolini São Paulo, Brazil

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):70-76

Jorge Hernán Montenegro Muñoz et al

INVITED COMMENTARY ON THE THEME Surely, this is a very important issue in view of the medical and social impact of trauma in Colombia as well as in other Latin American countries. For example, in Brazil injuries, particularly those due to interpersonal violence (injuries by firearms and assaults), constitute the leading cause of death in the population aged zero to 40 years and has increased steadily. In similarity with what is happening in Colombia, there are few schools of medicine and nursing that dedicate significant workload to the prevention and treatment of trauma victims. For these reasons, I believe that the publication of this work may serve as a stimulus for the study of this subject in other Latin American countries.

AS THE MATERIALS AND METHODS The strategy was satisfactory and brought together numerically consistent data.

RESULTS Analyzing the data in Table 1, I believe it would be interesting to clarify the differences between ‘Institución universitária/escuela tecnológica’ e ‘Universidad’. Also, it was unclear the meaning of ‘Reconocimiento del ministerio’ and ‘Duración del program en semestres’. I had difficulty understanding the first sentence after table 1 (Respecto a los programas de medicina, 7 (13.4%) tienen dentro de su currículo asignaturas relacionadas con el cuidado del paciente con trauma, la mayor parte pertenecen a instituciones Universitarias y tres (42.9%) son del sector público), because the numbers are different from those presented in the table. Similarly, it was not clear the correlation between the numbers shown in the table (‘Ubicación del programa por regiones’) and text comments. In summary, I believe that the text should be revised to be more clear and more accessible to readers from other countries.

DISCUSSION In principle, the data analysis is acceptable and encourages reflection on this theme.

ON THE TEXT While it is easy to read, I think it would be interesting that the text be revised and improved. In addition, in the text of discussion, I had difficulty understanding the meaning of ‘AMC’ and ‘ASPH’ acronyms cited in the text and referring to North American organizations.

REFERENCES The references are satisfactory in number, quality and publication dates. Dairo Birolini São Paulo, Brazil

PAJT

ORIGINAL RESEARCH

10.5005/jp-journals-10030-1121 Prevalencia del Consumo de Alcohol en Traumatizados Atendidos Cali, Colombia

Prevalencia del Consumo de Alcohol en Traumatizados Atendidos Cali, Colombia 1

Juan Calle, 2Álvaro Sánchez, 3Alberto García, 4Mónica Morales

RESUMEN Introducción: La ingesta alcohólica se asocia con riesgo de trauma y reincidencia. La información local es escasa. Se determinarán la prevalencia del consumo de alcohol y las características asociadas, en traumatizados atendidos en dos hospitales de Cali, Colombia. Métodos: Estudio observacional analítico del registro de trauma de dos hospitales de Cali, Colombia, entre enero y diciembre de 2012. Se incluyeron sujetos de 14 años o más, con lesiones de causa externa violenta, accidental, autoinflingida o por tránsito. Se excluyeron embarazadas, reclusos o personas con lesiones por agentes químicos, ambientales, o tóxicos. Se efectuó un análisis univariado y multivariado de variables asociadas con la probabilidad de reporte positivo de alcohol. Resultados: Se incluyeron 10290 pacientes, 63.4% hombres. El trauma contuso fue más frecuente (59%), seguido por tránsito (12%), arma blanca (16%) y arma de fuego (9%). El reporte de ingesta alcohólica fue más frecuente en: hombres (OR 6.88 I.C. 95% 3.17–4.9), lesionados durante la madrugada, (OR: 7.54 IC 95% 6.43–8.84) pacientes no asegurados, (OR 3.31, IC 95% 2.69–4.08), individuos entre 20 y 44 años (OR 1.61 IC 95% 1.39–1.85), pacientes con ISS ≥9, (OR 2.58, IC 95% 2.18–3.05), lesiones por tránsito o mecanismos penetrantes (OR 4.46, IC 95% 3.86–516), lesiones no relacionadas con el trabajo 23.68 (16.1–34.8) y atención en el hospital público 12.66 (10.46–15.32). Las asociaciones con la falta de aseguramiento y con ISS ≥9 desaparecieron en la RLM.

Estudiante de Medicina, 2Residente de Cirugía General Profesor Asociado, Escuela de Medicina, Facultad de salud 4 Estadística 3

Departamento de Medicina, Universidad ICESI, Cali, Colombia

Departamento de Cirugía, Universidad CES, Medellín, Colombia

Departamento de Cirugía, Universidad del Valle, Cirugía de Trauma y Emergencias, Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia 4

Registro de Trauma, Universidad del Valle, Cali, Colombia

Corresponding Author: Alberto García, Profesor Asociado Escuela de Medicina, Facultad de Salud, Departamento de Cirugía Universidad del Valle, Cirugía de Trauma y Emergencias Cuidados Intensivos, Fundación Valle del Lili Colombia, e-mail: alberto.garcia@correounivalle.edu.co

Conclusiones: Encontramos una prevalencia mayor de consumo de alcohol en los lesionados en la madrugada, hombres, adultos de edad media, víctimas de trauma por tránsito o penetrante, lesiones no relacionadas con el trabajo y atención en el hospital público. Palabras claves: Alcohol/abuso de sustancias, Control del trauma, Heridas y lesiones, olitraumatismo, Prenención del trauma. How to cite this article: Calle J, Sánchez Á, García A, Morales M. Prevalencia del Consumo de Alcohol en Traumatizados Atendidos Cali, Colombia. Panam J Trauma Crit Care Emerg Surg 2015;4(2):77-86. Source of support: Nil Conflict of interest: None declared

ABSTRACT Introduction: Alcohol intake is associated with risk for trauma, and recidivism. The local information is scarce. This study evaluates the prevalence of alcohol and associated features among trauma patients in two hospitals in Cali, Colombia. Materials and methods: Analytical observational registry trauma of two hospitals in Cali, Colombia, between January and December 2012. Subjects aged 14 or more were included. We excluded pregnant prisoners or people with injuries from chemical, environmental, or toxic agents. Univariate and multivariate analysis of variables associated with the probability of reporting positive for alcohol. Results: The 10,290 patients were included, 63.4% were men. Blunt trauma was most common (59%), followed by traffic crashes (12%), stab (16%) and firearms (9%). Alcohol consumption was more frequent in: men (OR 6.88, 95% CI 3.17– 4.9), injured during AM, (OR: 7.54; 95% CI 6.43–8.84) patients insured, (OR 3.31, 95% CI 2.69–4.08), among individuals 20 and 44 years (OR 1.61 95% CI 1.39–1.85), patients with ISS ≥9 (OR 2.58, 95% CI 2.18–3.05), or traffic injuries penetrating mechanisms (OR 4.46, 95% CI 3.86 –516), injuries not work-related 23.68 (16.1–34.8) and in public hospitals 12.66 (10.46–15.32). Partnerships with the lack of insurance and ISS≥9 disappeared in the multivariate regression. Conclusion: We found a higher prevalence of alcohol consumption in the injured at dawn, men, middle-aged adults, victims of trauma transit or penetrating injuries unrelated to work and care in the public hospital. Keywords: Alcohol/substance abuse, Control trauma, Wounds and injuries.

Note: Paper presented in Student Research Competition at the Annual Congress of Panamerican Trauma Society, Panama City, Panama, November 2015.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):77-86

Juan Calle et al

INTRODUCCIÓN En el mundo 16 000 personas mueren diariamente por causas traumáticas, y más del 90% de estas muertes ocurren en países de bajo y mediano desarrollo.1 La carga que representa el trauma no se debe solo a la mortalidad que genera, sino también a la alta carga en morbilidad que genera;2 en algunos países llegando a ocupar el 30% de las incapacidades laborales,3 lo que convierte al trauma en general como un problema de salud publica.2 El comportamiento de las causas de mortalidad debida a lesiones traumáticas difiere según el grado de desarrollo del país.4 Por ejemplo, los eventos de transito ocupan la primera causa de mortalidad en los países de desarrollados, mientras que en los países en vía de desarrollo son las lesiones adquiridas por violencia interpersonal.4 En Colombia los traumatismos intencionales y no intencionales generan el 33% de las consultas en los servicios de urgencias de todo el país, además causaron 1 de cada 3 muertes en los últimos 10 años,5,6 siendo la causa violenta la primera, aunque viene con tendencia a la disminución, acompañándose con un aumento concomitante en las causas relacionadas con lesiones relacionadas con eventos de transito.5,6 Según el Instituto Nacional de Medicina Legal, el impacto en los años de vida potencialmente perdidos (AVPP) fueron de 969,150 años para el 2012, del cual el 70% se debió a trauma relacionado con violencia y 20% relacionado con eventos de transito.6 El consumo de alcohol en el mundo, en Las Américas, en Sudamerica y en países latinos de Norte América como México, se ha asociado en general con el trauma violento y el relacionado con eventos de transito, debido a que propicia comportamientos agresivos y afecta la coordinación de las personas.7-9 Un ejemplo es que 1 de cada 3 lesiones intencionales, 1 de cada 4 lesiones no accidentales, 24% de los homicidios, 11% de suicidios y 20% de eventos de tránsito se han relacionado con el consumo de alcohol.10 En Colombia, el alcohol es la sustancia psicotóxica de mayor uso. Se sabe que más de 90% de la población adulta Colombiana consume con cierta frecuencia algún tipo de bebida alcohólica.11 El patrón de consumo asociado es de tipo problemático, y el 15% se encuentran a riesgo de dependencia.12,13 El consumo de alcohol en Colombia además es aceptado y socialmente permitido, a pesar de sus consecuencias perjudiciales.14 A pesar de que se tiene evidencia suficiente que promueve el control sobre el consumo de alcohol, y existen programas relacionados con la prevención y control en este ámbito, los datos

oficiales reportan un aumento en el consumo durante la última década.15 En este contexto, el alcohol juega un papel muy importante, pues desde hace varias décadas se ha conocido que el consumo de alcohol facilita la expresión de comportamientos imprudentes, de tendencias violentas, de alteraciones sensomotoras,16 que incrementan el riesgo de trauma interpersonal, personal o vehicular,7,17-24 con el agravante de que la severidad del trauma sufrido tiende a ser mayor en las personas que han consumido alcohol comparado con las que no.17-21 Teniendo en cuenta esta asociación se ha estudiado que el evento traumático podría considerarse un marcador de dependencia al alcohol,19 y que una vez se sufre una lesión relacionada con el consumo alcohólico, el paciente presenta un mayor riesgo de volver a consultar por trauma.19,25-31 La evidencia actual orienta a la búsqueda activa en forma de tamización del consumo de alcohol. Se ha identificado que hasta el 46% de los pacientes en el servicio de trauma podrían haber ingerido alcohol, y que el evento traumático podría servir como oportunidad para realizar intervenciones en relación con el consumo de alcohol.19,25-28,32 Gentillelo et al demostró que las intervenciones de tipo motivacional realizada en el servicio de urgencias en los pacientes que han sufrido trauma relacionado con consumo de alcohol son efectivas. Los pacientes con consumo leve a moderado de alcohol, mostraron una disminución del 83% para el consumo de alcohol, del 47% para las consultas de urgencias y de un 48% para las hospitalizaciones.32 Estudios más recientes del mismo autor demuestran que la intervención realizada en el servicio de urgencias es además costo efectiva.32,33 En Cali, la magnitud de esta asociación en nuestro medio es casi completamente desconocida. En 1997 Pérez M y García A,34 reportaron positividad de la alcoholemia en 25% de 501 fallecimientos por trauma en un periodo de 4 meses del año 1995. En 2001 García A y colaboradores, encontraron la realización de alcoholemia en 83% de muertos por trauma durante 1998, el examen fue positivo en 22.5% de los casos, con una mayor proporción en los grupos de agresión por arma blanca y golpes y en lesiones de tránsito de ocupantes de automóvil y motocicleta. Bejarano M y Rendón LF encontraron antecedente de consumo de alcohol en 10.6% de pacientes traumatizados en un servicio de urgencias. La proporción fue progresivamente mayor en mayores de 13 años y se asoció con violencia intencional.35 Calle-Toro y colaboradores reportaron antecedente de ingesta alcohólica en 22.4% de los lesionados por tránsito en un hospital público y en 5.6% de los atendidos en un hospital privado.36

PAJT Prevalencia del Consumo de Alcohol en Traumatizados Atendidos Cali, Colombia Tabla 1: Características de los pacientes incluídos Total de Pacientes (N = 10290) Datos Sociodemográficos Edad en años Rango 14–89 Mediana [RIQ*] 32 [23–47] 20–44 4441 43.2% (42.2–44.1) <20 o >44 5849 56.8% (55.9–57.8) Género (n, % IC 95%**) Masculino 7034 68.3% (67.5–69.3) Femenino 3256 31.7% (30.7–32.5) Mecanismo de trauma (n, % IC 95%) Arma de Fuego 890 8.7% (8.1–9.1) Arma Blanca 1611 15.7% (15.0–16.4) Tránsito 1206 11.7% (11.1–12.3) Contundente 6023 59.2% (58.3–60.2) Otros contundentes 560 5.4% (5.0–5.9) Atención en el Hospital Público 3874 37.7% (36.7–38.6) Ingreso entre 12 AM y 6 AM 909 8.8% (8.3–9.4) Sin seguridad Social (n, % IC 95%) 569 5.5% (5.1–6.0) Evento no relacionado con el trabajo 6377 62.0% (61.0–62.9) Información Clinica ISS¶ Rango 1–75 Mediana [RIQ] 1 [1–4] ISS < 9 (n, % IC 95%) 9095 88.4% (87.8–89.0) ISS ≥ 9 (n, % IC 95%) 1195 11.6% (11.0–12.2) RTS§ Rango 0–7.8 Mediana [RIQ] 7.8 [7.8–7.8] Desenlaces Ingesta de alcohol positiva (n, % IC 95%) 928 9.0% (8.5–9.6) Hospitalización (n, % IC 95%) 3047 29.6% (28.7– 0.5) Cirugía (n, % IC 95%) 1870 18.2% (17.4–18.9) Muerte (n, % IC 95%) 158 1.5% (1.3–1.8) *RIQ, Rango inter-cuartílico; **IC 95%, Intervalo de confianza del 95%; ¶ISS, Injury severity score; §RTS, Revised trauma score

En la presente investigación se analizan la prevalencia de ingesta alcohólica y los factores asociados con una mayor exposición en dos centros de trauma en Cali, Colombia, con el fin de obtener información útil para implementar estrategias preventivas en este grupo de pacientes.

MATERIALES Y MÉTODOS Se revisó el registro de trauma del Hospital universitario del Valle y la Fundación Valle del Lili, en Cali, Colombia, desde el 1 de Enero hasta el 31 de Diciembre del 2013. Los datos fueron transferidos para su análisis al paquete estadístico STATA™ 12 (StataCorp, Texas—USA). Se incluyeron pacientes mayores de 14 años, con lesiones de causa externa por causa violenta, accidental, autoinflingida o relacionada con tránsito. Se excluyeron mujeres en embarazo, personas recluídas en la cárcel o lesiones de causa externa ocasionadas por la exposición de agentes químicos, ambientales, o tóxicos. Fueron

excluídos también los sujetos con el mecanismo apropiado en quienes no se registraron lesiones (ISS = 0). Se tabularon la edad, el genero, el día de la semana, la hora, el lugar en el cual se presentó, el mecanismo y tipo de trauma involucrado, la región anatómica comprometida, severidad del trauma medida con los puntaje de RTS (puntaje de trauma revisado) e ISS (puntaje de severidad de las lesiones), necesidad de hospitalización general y en UCI, necesidad de cirugía, mortalidad y hospital donde fue atendido: Fundación Valle del Lili, hospital privado de 550 camas que denominaremos Hospital 1 y Hospital Universitario del Valle, Hospital público de 770 camas, que denominaremos Hospital 2. Análisis estadístico: Las variables continuas son presentadas como rangos y promedio—desviación estándar o mediana—rango intercuartílico, de acuerdo con su distribución normal o no. Las variables categóricas son presentadas como proporciones e IC de 95%.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):77-86

Juan Calle et al Tabla 2: Variables asociadas con una mayor probabilidad de ingesta alcohólica

Edad en años < 20 o > 44 20 a 44 Género (n, %) Mujer Hombre Mecanismo de lesión (n, %) Mecanismos contusos Penetrante o tránsito Ingreso entre 12 AM y 6 AM (n, %) Ausente Presente Seguridad Social (n, %) Con seguridad social Sin seguridad social Evento asociado al trabajo (n, %) Asociado al trabajo No relacionado con el trabajo Atención en el hospital público No Si ISS > 9 (n, %) No Si RTS Mediana [RIQ] RTS <7.8 No Si

Ingesta Alcohólica

Regresión logística simple OR (95%CI) p

Regresión logística multivariable* OR (95%CI) p

306 622

6.9% 10.6%

1.61 (1.39–1.85)

0.000

1.97 (1.68–2.32)

0.000

107 821

3.3% 11.7%

6.88 (3.17–4.79)

0.000

2.74 (2.20–3.43)

0.000

292 636

4.4% 17.2%

4.46 (3.86–5.16)

0.000

1.74 (1.47–2.06)

0.000

614 314

6.7% 34.5%

7.54 (6.43–8.84)

0.000

3.68 (3.07–4.419)

0.000

798 130

8.2% 22.9%

3.31 (2.69–4.08)

0.000

27 901

0.7% 14.1%

23.68 (16.1–34.8)

0.000

9.41 (6.26–14.14)

0.000

129 799

2.0% 20.6%

12.66 (10.46–15.32)

0.000

4.63 (3.74–5.72)

0.000

713 215 7.8

7.8% 18.0% 2.58 (2.18–3.05) [7.8–7.8] 0.73 (0.67–0.79)

0.000 0.000

789 139

8.1% 24.7%

0.000

0.75

0.69

0.000 3.71 (3.03–4.56)

2.09 (1.62–2.69)

* Regresión logística multivariable con eliminación hacia atrás. Variables con p < 0.1 fueron conservadas en el modelo. OR, odds ratio; CI, Intervalo de confianza; RIQ, rango inter-cuartílico

Para el análisis de las asociaciones la edad y en ISS fueron categorizadas. La asociación entre las diferentes variables y el reporte de ingesta alcohólica se hizo de manera univariada mediante la prueba de Chi 2. Las variables identificadas con una asociación significativa (p < 0.1) fueron analizadas mediante regresión logística multivariada (RLM), con retiro gradual de las variables, manteniendo en el modelo aquellas con una p < 0.1.

RESULTADOS Fueron atendidos durante 2012, 15466 pacientes, de los cuales se excluyeron 3253 por edad < 14 años, 48 por mecanismo de lesión, 467 por ausencia de lesiones traumáticas al examen y 1408 por falta de información acerca de ingesta alcohólica. Los 10290 sujetos restantes constituyen la base del presente análisis. 7034 eran hombres (68.4%, IC 95% 67.5 –69.3). La edad fluctuó entre 14 y 89 años (mediana 32, RIQ 23–47). Los mecanismos de trauma más comunes fueron los contusos (58.5%, IC 95% 57.6–59.5), lesiones por tránsito

(11.7%, IC 95% 11.1–12.3), heridas por arma blanca (15.7%, IC 95% 15.4–26.4) y heridas por arma de fuego (8.7%, IC 95% 8.1–9.2) (Tabla 1). La información sobre aseguramiento se describió en 10093 casos (98.1%). En la mayoría (94.4, IC 95% 93.9–94.8) (Tabla 1). Es ISS fluctuó entre 1 y 75, con una mediana de 1 y un RIQ entre 1 y 4. Presentaron un ISS de 9 o más 1195 pacientes (11.65% IC 95% 11.0–12.2) (Tabla 1). El RTS osciló entre 0 y 7.8 con una mediana de 7.8, y un RIQ 7.8–7.8 (Tabla 1). Se registró ingesta de bebidas alcohólicas en 928 pacientes (9.0%, IC 95% 8.5–9.6). Esta fue reportada con mayor frecuencia en el Hospital 2: 20.6%, IC 95% 19.4–21.9 versus 2.0, IC 95% 1.7–2.4 (Tabla 1).

ANÁLISIS DE LAS ASOCIACIONES En el análisis univariado los hombres mostraron una prevalencia mayor de ingesta alcohólica (OR 6.88 I.C. 95% 3.17–4.9). Un hallazgo semejante evidenciaron los individuos lesionados durante la madrugada, (OR: 7.54

PAJT Prevalencia del Consumo de Alcohol en Traumatizados Atendidos Cali, Colombia

IC 95% 6.43–8.84). Los pacientes no asegurados también mostraron una asociación significativa (OR 3.31, IC 95% 2.69–4.08) (Tabla 2). Los pacientes menores de 20 años y los mayores de 44, tuvieron una prevalencia baja de consumo alcohólico, a favor de los individuos entre 20 y 44 años (OR 1.61 IC 95% 1.39–1.85). El análisis de la relación con el RTS como variable continua mostró una reducción de la probabilidad de haber sido expuesto al alcohol en la medida que el puntaje fisiológico era más alto (OR 0.73, IC 95% 0.67–0.79) (Tabla 2). La categorización de esta variable mostró un incremento de la exposición a alcohol entre quienes tuvieron alteraciones del puntaje (OR 3.71 IC 95% 3.03– 4.56) (Tabla 2). La asociación con la severidad del trauma no fue muy intensa. La mayor prevalencia ocurrió en los pacientes con ISS ≥9, (OR 2.58, IC 95% 2.18–3.05) (Tabla 2). Los lesionados por tránsito o por mecanismos penetrantes presentaron una asociación positiva (OR 4.46, IC 95% 3.86–516), igual que quienes sufrieron sus lesiones en eventos no relacionados con el trabajo 23.68 (16.1–34.8). Quienes recibieron atención en el hospital público reportaron más frecuentemente consumo de alcohol (OR 12.66 IC 95% 10.46–15.32) (Tabla 2). En el modelo de RLM, persistieron las asociaciones encontradas con el grupo etáreo de 20 a 44 años, con el género masculino, la hora del trauma, las lesiones no relacionadas con el trabajo, la alteración fisiológica y con la atención en el Hospital 2. Las asociaciones con la falta de aseguramiento y con ISS ≥9 desaparecieron en la RLM (Tabla 2). Requirieron hospitalización 3047 pacientes, cirugía 1870 y 158 fallecieron.

DISCUSION En el periodo de observación se encontró que el 9% de las personas que tuvieron un auto-reporte positivo para el consumo de alcohol, que es cercana a la prevalencia encontrada en el informe de alcohol y trauma en el servicio de urgencias de la Organización de Naciones Unidas y en el informe de la Organización Panamericana de la Salud, donde reportan valores entre 10–20%.37,38 Se debe tener en cuenta que los valores de los autoreportes suelen ser más bajos que los que se encuentran cuando se realizan pruebas de detección de consumo mediante pruebas de aliento o sangre, 39 y cerca de la mitad de los pacientes con alcoholemia positiva, tienen consumo positivo para otra sustancia psicotrópica como marihuana, cocaína, y opiáceos,37 los cuales no fueron objeto de evaluación para esta población.

Comparando los dos hospitales en los cuales se tomaron los datos, se encontró que el hospital público presenta 10 veces más auto-reporte positivo comparado con el privado, lo que concuerda con los patrones de consumo alcohólico en los estratos económico-sociales más bajos que suelen consumir de manera mas frecuente e intensa. 37,38 Aunque el mecanismo de trauma más frecuentemente encontrado en los dos centros fue el contuso (55%), seguido por el relacionado con eventos de transito (14%), y los debidos a lesiones por arma blanca (13%) y de fuego (11%); fueron estos dos últimos los que más se asociaron con un auto-reporte de consumo de alcohol positivo. Este resultado es consistente con lo descrito en otros estudios, en donde las personas que consumen alcohol sufren mas frecuentemente lesiones violentas y relacionadas con eventos de transito, con un OR de 15.0 (95% IC, 5.8–39.1) para lesiones intencionales y un OR de 4.2 (95% IC, 2.7–6.5) para lesiones no intencionales,19,37,38,40,41 con tendencia al aumento con dosis de alcohol mayores.38 Otras características sociodemográficas más frecuentemente relacionadas con el consumo alcohólico en nuestro estudio fueron el ser hombre, tener entre 20 y 44 años, no tener un aseguramiento de salud, y encontrarse realizando actividades de ocio. Estas características también se han descrito en otras poblaciones, específicamente en uno realizado en 19 países de todos los continentes y con 5410 pacientes en el que se describe que el ultimo consumo se realizo entre 30–60 minutos previos al trauma, lo cual ocurre en sectores públicos, y se presenta tanto en personas con patrón de consumo ocasional como el consumidor habitual.37,38 Otro estudio encontró que la mayoría de estos pacientes se han sentido embriagados previo al evento traumático, y se encontraban festejando algún evento.42 En cuanto a la relación entre el consumo de alcohol y la severidad del trauma sufrido, a diferencia de lo reportado en la literatura,17,43-46 en nuestros pacientes la asociación con la severidad del trauma fue errático, en tanto que la relación con la severidad del deterioro fisiológico fue muy consistente. La identificación de un grupo considerable de pacientes con probabilidad muy baja de haber sido expuestos a bebidas alcohólicas y otros grupos con alta prevalencia de consumo de alcohol permitirían focalizar los esfuerzos, permitiendo un mejor rendimiento de los recursos invertidos. Nuestros hallazgos deben ser confirmados con estudios diseñados específicamente para el efecto.

REFERENCIAS 1. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, et al. Global patterns of mortality in young people:

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):77-86

Juan Calle et al a systematic analysis of population health data. Lancet 2009; 374(9693):881-892. 2. Naci H, Chisholm D, Baker TD. Distribution of road traffic deaths by road user group: a global comparison. Inj Prev 2009;15(1):55-59. 3. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009;373(9682):2223-2233. 4. Bhalla K, Harrison J, Abraham J, Borse NN, Lyons R, Boufous S, et al. Data sources for improving estimates of the global burden of injuries: call for contributors. PLoS Med 20 de enero de 2009;6(1):e1-e1. 5. Gutierrez-Martinez MI, Villin RE Del, Fandiño A, Oliver RL. The evaluation of a surveillance system for violent and nonintentional injury mortality in Colombian cities. Int J Inj Contr Saf Promot 2007;14(2):77-84. 6. Posada J, Ben-Michael E, Herman A, Kahan E, Richter E. Death and injury from motor vehicle crashes in Colombia. Rev Panam Salud Publica 2000;7(2):88-91. 7. Rehm J, Gmel G, Sempos CT, Trevisan M. Alcohol-related morbidity and mortality. Alcohol research and health: the Journal of the National Institute on Alcohol Abuse and Alcoholism 2003;27(1):39-51. 8. Darke S. The toxicology of homicide offenders and victims: A review. Drug Alcohol Rev 2010;29(2):202-215. 9. Blomberg RD, Peck RC, Moskowitz H, Burns M, Fiorentino D. The Long Beach/Fort Lauderdale relative risk study. J Saf Res 2009;40(4):285-292. 10. Room R, Babor T, Rehm J. Alcohol and public health. Lancet 2005;365(9458):519-530. 11. Herrán OF, Ardila MF, Valle U. Consumo de alcohol, riesgo de alcoholismo y alcoholismo en Bucaramanga, Colombia, 2002-2003. Colombia Médica 2005;36:158-167. 12. Herrán AM. Categories of alcohol consumers and the criteria for classification. Biomed 2009 Dec;29(4):635-646. 13. Herrán, Ardila MF BD. Test for assessing levels of alcohol consumption in Bucaramanga, Colombia: design and validation. Biomed 2008;28(1):25-37. 14. Social FES. Estudio Nacional de Salud Mental Colombia 2003. 2003. Acceso en http://onsm.ces.edu.co/uploads/ files/1243030_EstudioNacionalSM2003.pdf, Mayo de 2015. 15. Herrán OF, Ardila MF. Validity and reproducibility of two semi-quantitative alcohol frequency questionnaires for the Colombian population. Public Heal Nutr 2006;9(6):763-770. 16. Buikhuisen W, Plas-Korenhoff C, Bontekoe EHM. Alcohol and Violence. En: Moffitt T, Mednick S, editores. Biological Contributions to Crime Causation SE - 15. Springer Netherlands; 1988. p. 261-276. 17. Watt K, Purdie DM, Roche AM MR. Injury severity: role of alcohol, substance use and risk-taking. Emerg Med Australas 2006;18(2)108-117. 18. Watt K, Purdie DM, Roche AM MR. Risk of injury from acute alcohol consumption and the influence of confounders 1999;99(10):1262-1273. 19. Borges G, Cherpitel C, Orozco R, Bond J, Ye Y, Macdonald S, et al. Multicentre study of acute alcohol use and non-fatal injuries: data from the WHO collaborative study on alcohol and injuries. Bull World Health Organ 2006;84(6):453-460. 20. Borges G, Cherpitel CJ, Orozco R, Bond J, Ye Y, Macdonald S GN, Stockwell T, Cremonte M, Moskalewicz J, Swiatkiewicz GPV. Acute alcohol use and the risk of non-fatal injury in sixteen countries. Addict 2006;101(7):993-1002.

21. Andelic N, Jerstad T, Sigurdardottir SS. Effects of acute substance use and pre-injury substance abuse on traumatic brain injury severity in adults admitted to a trauma centre. J Trauma Manag Outcomes 2010;4:6. 22. Desapriya E, Pike I, Raina P. Severity of alcohol-related motor vehicle crashes in British Columbia: case - control study. Int J Inj Contr Saf Promot 2006;13(2):89-94. 23. Taylor B, Irving HM, Kanteres F, Room R, Borges G, Cherpitel C, et al. The more you drink, the harder you fall: A systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together. Drug Alcohol Depend 2010;110(1):108-116. 24. Cherpitel CJ, Bond J, Ye Y, Borges G, MacDonald S, Stockwell T, et al. Alcohol-related injury in the ER: a cross-national metaanalysis from the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP). J Stud Alcohol 2003;64(5):641-649. 25. Rivara FP, Jurkovich GJ, Gurney JG, Seguin D, Fligner CL, Ries R, et al. The magnitude of acute and chronic alcohol abuse in trauma patients. Arch Surg 1993;128(8):903-907. 26. Soderstrom CA, Dischinger PC, Smith GS, Hebel JR, McDuff DR, Gorelick DA, et al. Alcoholism at the time of injury among trauma center patients: vehicular crash victims compared with other patients. Accident; analysis and prevention 1997 Nov;29(6):715-721. 27. Soderstrom CA, Dischinger PC, Smith GS, McDuff DR, Hebel JR, Gorelick DA. Psychoactive substance dependence among trauma center patients. JAMA 1992;267(20):2756-2759. 28. Babor TF, Caetano R. Evidence-based alcohol policy in the Americas: strengths, weaknesses, and future Challenges. Rev Panam Salud Publica 2005;18(4-5):327-337. 29. Shandro JR, Rivara FP, Wang J, Jurkovich GJ, Nathens AB, MacKenzie EJ. Alcohol and risk of mortality in patients with traumatic brain injury. J Trauma 2009;66(6):1584-1590. 30. Caufeild J, Singhal A, Moulton R, Brenneman F, Redelmeier D, Baker AJ. Trauma recidivism in a large urban Canadian population. J Trauma 2004;57(4):872-876. 31. Rivara FP, Koepsell TD, Jurkovich GJ, Gurney JG, Soderberg R. The effects of alcohol abuse on readmission for trauma. JAMA 1993;270(16):1962-1964. 32. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, Daranciang E, Dunn CW, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg 1999;230(4):473-480. 33. Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals. Ann Surg 2005; 241(4):541-550. 34. García F, Pérez A. Factores modificadores de la alcoholemia. Revista Clínica Española 1998;198:57-60. 35. Bejarano M, Rendón F. Lesiones de causa externa en menores y mayores de 18 años en un hospital colombiano. Rev Panam Salud Publica 2009;25(3):234-241. 36. Calle-Toro JS, Ordonez C, Sánchez ÁI, Sanjuan J, Badiel M, Pino L, et al. Epidemiología de Lesiones Relacionadas con Colisiones de Vehículos Motorizados en dos Centros de Referencia del Suroccidente Colombiano. Reporte del Registro Internacional de Trauma de la Sociedad P. Rev Panam Trauma 2013;16-22. 37. Ponziak, Vladimir, Paden M. Alcohol and Injury in Emergency Departments, 2007. Summary of the Report from the WHO Collaborative Study on Alcohol and Injuries. WHO 2007;1-18.

PAJT Prevalencia del Consumo de Alcohol en Traumatizados Atendidos Cali, Colombia 38. Cherpitel CJ, Borges G, Giesbrecht N. Prevención de los traumatismos relacionados con el alcohol en las Américas: de los datos probatorios a la acción política 2013;1-189. 39. Skinner HA, Holt S, Sheu WJ, Israel Y. Clinical versus laboratory detection of alcohol abuse: the alcohol clinical index. Br Med J (Clin Res Ed) 1986;292(6537):1703-1708. 40. Watt K, Purdie DM, Roche AM, McClure R. Acute alcohol consumption and mechanism of injury. Journal of Studies on Alcohol 2006;67(1):14-21. 41. Borges G, Orozco R, Cremonte M, Buzi-Figlie N, Cherpitel C, Poznyak V. Alcohol and violence in the emergency department: a regional report from the WHO collaborative study on alcohol and injuries. Salud publica de Mexico 2008; 50(Suppl 1):S6-S11. 42. Cherpitel CJ, Bond J, Ye Y, Borges G, Room R, Poznyak V, et al. Multi-level analysis of causal attribution of injury to

alcohol and modifying effects: Data from two international emergency room projects. Drug Alcohol Depend 2006;82(3): 258-268. 43. Blondell RD, Looney SW, Krieg CL, Spain DA. A comparison of alcohol-positive and alcohol-negative trauma patients. J Stud Alcohol 2002;63(3):380-383. 44. Cassiani CA, Mayerly Cubides Á, Varona B, Tatiana M, Marimón Trespalacios W. Alcohol and trauma: a priority publ ic hea lt h problem. Sa lud Un i nor te 2012;28(1): 131-149. 45. Watt K, Purdie DM, Roche AM, McClure RJ. The relationship between acute alcohol consumption and consequent injury type. Alcohol Alcohol 2005;40(4):263-268. 46. Watt K, Purdie DM, Roche AM, McClure RJ. Risk of injury from acute alcohol consumption and the influence of confounders. Addiction 2004;99(10):1262-1273.

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INVITED COMMENTARY La ingesta de alcohol se ha asociado con certeza a la incidencia de lesiones traumáticas. Muchas sociedades ha expresado a través de su política de salud publica la preocupación por el descuidado uso del alcohol durante actividades que requieren lucidez mental. Este estudio es un ejemplo íntegro del valor de los registros de trauma dentro de la amplitud de un centro de trauma reconociéndolo como un vehículo de transformación social. Esta información del panorama demográfico de la población afectada por el consumo de alcohol por ejemplo confirma los resultados de estudios previos en donde pacientes que sufren lesiones debido a traumatismos por motoras, se caracterizan por presentar las edades de 30-49 años, llegar al hospital tarde en la noche y no usar el casco de protección.1,2 Se ha encontrado que hasta casi la mitad de las admisiones a un centro de trauma están relacionadas al consumo de alcohol y/o el uso de drogas ilícitas. Además, estudios han confirmado que un gran número de fallecidos a causa de un evento traumático esta relacionado al consumo de alcohol (mas del 40%).2 Desafortunadamente, pacientes con lesiones relacionadas al consumo de alcohol presentan un mayor uso de los recursos hospitalarios, con un aumento significativo en la carga financiera. Compañías aseguradoras en muchos de los estados de los Estados Unidos por ejemplo no proporcionan cobertura por lesiones relacionadas al consumo de alcohol, trasladando estos gastos a los centros de trauma y/o los proveedores.3 Una de las partes mas importantes de esta información es la evidencia de la reincidencia de los pacientes del trauma y su relación al consumo de alcohol. Los mayores valores de la reincidencia fueron encontrados en pacientes los cuales presentaban el uso de alcohol o drogas ilícitas el día que ocurrió el trauma y en víctimas de violencia interpersonal, definido como los que tuvieron heridas por arma blanca, de fuego o agresiones personales. McCoy y et al encontraron que el 25% de la población estudiada presentaba una reincidencia del trauma. La población afectada consistía de 75% varones, 36% desempleados, 26% sin seguranza y 90% solteros.4 Esta información es vital para el desarrollo de programas de prevención específicos para la comunidad en general, pero en específico a la que presenta el comportamiento no deseado. Los autores han investigado con bastante precisión las características demográficas de la población afectada. Una de las recomendaciones es la revisión de la data para indagar el porcentaje de los pacientes que sufrieron de un evento traumático por más de una ocasión. Una parte esencial de la información es investigar el porcentaje de la población con mas alta incidencia de sufrir un trauma en relación al uso de alcohol. Es imperativo reconocer este tipo de problema social ya que el impacto en los años de vida potencialmente perdidos afecta de forma considerable el golpe económico no solo de la unidad familiar, pero de la sociedad en general. Seria interesante conocer si los autores planifican utilizar las intervenciones breves de tipo motivacional descritas y utilizadas por la mayoría de los centros de trauma de los Estados Unidos. Gentilello et al demostró que un 27% de todos los pacientes con lesiones son candidatos para una breve intervención relacionada al uso de alcohol. Si estas intervenciones fueran ofrecidas rutinariamente a estos pacientes a través de la nación (EU), se podría llegar a un ahorro potencial neto de 1.82 billones de dólares anualmente.5 Este tipo de estudios demográficos procedentes de los centros de trauma a través de Sur América utilizando los registros de trauma son una evidencia contundente del compromiso de estas instituciones no solamente con la comunidad y la sociedad en general, si no también con el mejoramiento del manejo del paciente politraumatizado. Exhortamos a los centros de trauma que continúen con esta misión y compromiso a través de las naciones panamericanas.

REFERENCIAS 1. Liu HT, Liang CC, Rau CS, Hsu SY, Hsieh CH. eCollection 2015.Alcohol-related hospitalizations of adult motorcycle riders. World J Emerg Surg 2015 Jan 7;10(1):2. 2. Carrasco CE, Godinho M, Berti de Azevedo Barros M, Rizoli S, Fraga GP. Fatal motorcycle crashes: a serious public health problem in Brazil. World J Emerg Surg 2012 Aug 22;7 Suppl 1:S5. 3. O’Keeffe T1, Rhee P, Shafi S, Friese RS, Gentilello LM Trauma Acute C. Alcohol use increases diagnostic testing, procedures, charges, and the risk of hospital admission: a population-based study of injured patients in the emergency department. Am J Surg 2013 Jul;206(1):16-22.

PAJT Prevalencia del Consumo de Alcohol en Traumatizados Atendidos Cali, Colombia 4. McCoy AM, Como JJ, Greene G, Laskey SL, Claridge JA. A novel prospective approach to evaluate trauma recidivism: the concept of the past trauma history. The Journal of Trauma and Acute Care Surgery 2013 Jul;75(1):116-121. 5. Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Annals of Surgery 2005 Apr;241(4):541-550.

Manuel Lorenzo Professor, Department of Surgery Methodist Hospital, Dallas, Texas, USA

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Juan Calle et al

INVITED COMMENTARY Alcohol ingestion has been associated with an increased incidence of traumatic injuries. This association has led to the development of public health policies limiting alcohol use during activities that require mental clarity. The development of such policies is a perfect example of how vital a trauma registry is to a trauma center; the registry becomes an instrument for the trauma center to affect social transformation. The trauma registry was used to abstract data confirming previous literature showing motorcycle crashes suffered most characteristically by individuals between the ages of 30â&#x20AC;&#x201C;49 years old, crashes occurring at nighttime and by those not wearing a helmet.1,2 Almost half of the admissions to a trauma center and more than 40% of traumatic fatalities are related to the use of alcohol and/or illicit drugs.2 Consequently, alcohol-related injuries result in increased use of hospital resources and a significant financial burden. A number of insurance companies in the United States, for example, do not provide coverage to patients with traumatic injuries due to alcohol use, therefore, transferring those costs to the trauma center and/or the providers.3 The authors have demonstrated with significant precision the demographic characteristics of their trauma population. There was a higher incidence of trauma recidivism in patients that used alcohol and/or illicit drugs. McCoy et al found a 25% of recidivism among their trauma population with its cohort shown to be 75% male, 36% unemployed, 26% uninsured and 90% single.4 This data is key to developing specific prevention programs for the community, allowing to target groups showing the undesirable behavior. One of the recommendations for the authors of this manuscript is to include in their analysis the percentage of alcohol-related recidivism. It is imperative to recognize this social issue as its potential impact in the lost life-years is a considerable economic loss not only for the family unit but also for society in general. It would be interesting to know if the authors are planning to use the brief alcohol interventions used by most of the trauma centers in the United States. Gentilello, et al showed that 27% of all the injured patients are candidates for a brief alcohol intervention. It is estimated that routine patient interventions can result in a potential net saving of $1.82 billion dollars annually.5 Use of trauma registries to produce demographic studies by South American trauma centers is strong evidence of their commitment not only to care of the trauma patient but to the community and society as a whole. We encourage such trauma centers to continue with this mission and commitment across the panamerican nations.

REFERENCES 1. Liu HT, Liang CC, Rau CS, Hsu SY, Hsieh CH. eCollection 2015.Alcohol-related hospitalizations of adult motorcycle riders. World J Emerg Surg 2015 Jan 7;10(1):2. doi: 10.1186/1749-7922-10-2. 2. Carrasco CE, Godinho M, Berti de Azevedo Barros M, Rizoli S, Fraga GP. Fatal motorcycle crashes: a serious public health problem in Brazil. World J Emerg Surg 2012 Aug 22;7 Suppl 1:S5. doi: 10.1186/1749-7922-7-S1-S5. Epub 2012 Aug 22. 3. Oâ&#x20AC;&#x2122;Keeffe T1, Rhee P, Shafi S, Friese RS, Gentilello LM Trauma Acute C. Alcohol use increases diagnostic testing, procedures, charges, and the risk of hospital admission: a population-based study of injured patients in the emergency department. Am J Surg 2013 Jul;206(1):16-22. doi: 10.1016/j.amjsurg.2012.08.014. Epub 2013 Apr 3. 4. McCoy AM, Como JJ, Greene G, Laskey SL, Claridge JA. A novel prospective approach to evaluate trauma recidivism: the concept of the past trauma history. The Journal of Trauma and Acute Care Surgery 2013 Jul;75(1):116-121. 5. Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Annals of Surgery 2005 Apr;241(4):541-550.

Manuel Lorenzo Professor, Department of Surgery Methodist Hospital, Dallas, Texas, USA

PAJT

REVIEW ARTICLE

Complex Perineal Injuries in Blunt Trauma Patients: The10.5005/jp-journals-10030-1122 Value of a Damage Control Approach

Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach 1

Frederico José Ribeiro Teixeira Jr, 2Sérgio Dias do Couto Netto, 3Francisco Salles Collet e Silva Newton Djin Mori, 5Belchor Fontes, 6Renato Sergio Poggetti, 7Dario Birolini 8 Celso Oliveira Bernini, 9Edivaldo M Utiyama 4

ABSTRACT Purpose: In a previous work, we presented a protocol for the management of patients with complex pelviperineal injuries (CPI) resulting from blunt trauma. This treatment protocol included: early hemorrhage control, surgical debridement of devitalized tissue, selective loop transverse colostomy according to the location of the perineal wound, distal colonic irrigation with saline solution, pulsatile saline solution irrigation of the perineal wound, maintenance of the perineal wound open, management of bone fractures and visceral injuries, surgical revisions at intervals of 24 to 48 hours, presumptive antibiotic therapy, early nutritional support, and definitive repair of wound defect and visceral injuries after infection control and metabolic recovery. In order to determine whether the evolution of the authors’s protocol for the assessment and management of patients with CPI is associated with improved patient outcome we conduct this review. Materials and methods: The medical records of 42 patients with CPI resulting from blunt trauma admitted in the level I trauma center at the HC-USPSM, were reviewed. Demographic data, mechanism of trauma, revised trauma score (RTS) and injury severity score (ISS), classification of perineal injuries, associated systemic trauma, infection complications and mortality rates (overall, early and late) were collected. Results: The early mortality was 19% and the late mortality was 17%. The overall mortality was 36%. Patients who died had higher average ISS (average ISS = 45) comparing to patients who survived (average ISS = 25) with significant statistical difference (p < 0.05). Damage control principles applied to CPI was the standard of care and a selective approach to perform fecal stream diversion were used. Conclusion: The results of this study showed that the use of this protocol was effective and reinforced the importance of the priority in early control of hemorrhage, early fecal diversion

Attending Surgeon, 2-6General Surgeon, 7Former Professor General Surgeon and Director of Emergency Service 9 General Surgeon and Director of Division 8

1-6,8,9

Faculty of Medicine, Division of Surgical Clinic III, Hospital Das Clínicas—University of São Paulo, São Paulo, Brazil 7

Department of General Surgery, Faculty of Medicine, Division of Surgical Clinic III, Hospital Das Clinicas—University of São Paulo, São Paulo, Brazil Corresponding Author: Frederico José Ribeiro Teixeira Jr Attending Surgeon of Division of Surgical Clinic III, Department of Surgery, Hospital Das Clínicas, University of São Paulo, São Paulo Brazil, e-mail: fredteixeirajr@gmail.com

in selected cases, multiple surgical perineal revisions, and avoidance of complex visceral injury repair at the first surgical intervention. Keywords: Blunt trauma, Complex pelviperineal injuries, Open pelvic fracture, Pelvic injury, Perineum. How to cite this article: Teixeira Jr FJR, do Couto Netto SD, Collete e Silva FS, Mori ND, Fontes B, Poggetti RS, Birolini D, Bernini CO, Utiyama EM. Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach. Panam J Trauma Crit Care Emerg Surg 2015;4(2):87-95. Source of support: Nil Conflict of interest: None

RESUMEN Propósito: En un trabajo previo, hemos presentado un protocolo para el manejo de pacientes con lesiones pelviperineales complejas (CPI) resultantes de traumatismo cerrado. Este protocolo de tratamiento incluye: control de la hemorragia precoz, el desbridamiento quirúrgico de tejido desvitalizado, colostomía en asa selectiva a nivel de colon transverso de acuerdo con la localización de la herida perineal, la irrigación del colon distal con solución salina, riego pulsátil con solución salina de la herida perineal, el mantenimiento de la herida perineal abierta, tratamiento de las fracturas óseas y lesiones viscerales, las revisiones quirúrgicas con intervalos de 24 a 48 horas, terapia presuntiva con antibióticos, soporte nutricional precoz y la reparación definitiva del defecto de heridas y lesiones viscerales después de control de la infección y la recuperación metabólica. Con el fin de evaluar si la aplicación del protocolo para la evaluación y manejo de los pacientes con CPI se asocia con una mejor evolución de los pacientes, es que realizamos esta revisión. Materiales y métodos: Se revisaron las historias clínicas de 42 pacientes con CPI resultante de un traumatismo cerrado, admitidos en el centro de trauma del HC-USPSM. Se recogieron los siguientes datos: datos demográficos, mecanismo del trauma, revised trauma score (RTS) y el injury severity score (ISS), clasificación de las lesiones perineales, asociación o no de trauma sistémico, complicaciones infecciosas y mortalidad (global, temprana y tardía). Resultados: La mortalidad precoz fue del 19% y la tardía fue de 17%. La mortalidad global fue de 36%. Los pacientes fallecidos tuvieron mayor promedio de ISS (ISS = 45) en comparación con los pacientes que sobrevivieron (ISS = 25), con diferencia estadística significativa (p < 0,05). El principio de control de daños fue el “standard of care” en las CPI, realizándose un enfoque selectivo para la colostomía derivativa.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):87-95

Frederico José Ribeiro Teixeira Jr et al Conclusión: Los resultados de este estudio mostraron que el uso de este protocolo fue efectivo y reforzó la importancia de que la prioridad es el control temprano de la hemorragia, colostomía derivativa temprana en casos seleccionados, múltiples revisiones perineales quirúrgicas y evitar la reparación de las lesiones viscerales complejas en el primera intervención quirúrgica. Palabras claves: Fractura pélvica abierta, Lesiones pelviperineales complejas, Lesión pélvica, Perineo, Traumatismo cerrado.

INTRODUCTION The management of complex perineal injuries (CPI) continues to pose a challenge for surgeons despite advances in the field of trauma care. Although rare CPI may present with a myriad of soft-tissue, visceral and skeletal lesions demanding complex diagnostic and treatment workup. Stratification of mortality in two peaks is necessary to understand the critical points in the management of this surgical problem.1-7 Exsanguination may results in recalcitrant retroperitoneal hemorrhage from tears of the sacral plexus, associated intra-abdominal solid organ trauma and extensive perineal soft-tissue injuries which are the most frequent cause of early death (first 24 hours) in these patients.8 Following hemorrhage control, the surgeon usually faces other problems, such as massive contamination of soft tissues of the perineum, complex visceral pelvic injuries and open fractures. Soft-tissue infection following severe trauma patients with physiological deterioration often leads to sustained sepsis in compromised hosts, resulting in multiple organ dysfunction syndrome, a frequent cause of death.9,10 If the patient survives, chronic disability in physical functions may be present for several years after trauma.11 Forty two patients with CPI were admitted in the level one trauma center at the HC-USPSM. This paper reviews our current experience in the initial treatment of this unique patient population, their clinical presentation and outcomes after introduction of a protocol of assessment and management initiated in the eighties. Results of the two previous published series from our hospital were reviewed to compare overall, early and late mortality rates.4

MATERIALS AND METHODS These patients were admitted with CPI secondary to blunt trauma at the surgical emergency department of the HC-USPSM. Clinical data were collected by reviewing the medical records and operative charts under an institutional review board approved protocol. Data collected included: injury mechanism, associated injuries of the pelvis (rectum, anus and genitourinary tract) and associated systemic trauma. Stratification of severity was

calculated using the injury severity score (ISS).12,13 The degree of immediate clinical deterioration was scored using the revised trauma score (RTS). Patients with closed pelvic fractures, penetrating gun shot or stab wounds of the perineum, isolated injuries to the genitalia, puncture wounds of the perineum or superficial (skin and subcutaneous fat) perineal lacerations barely extending to the pelvis were excluded. Trauma patients who had blunt pelvic trauma with continuity to a deep wound into the perineum, pubis and area over the sacrum extending to the thighs inferiorly, to the patella or posteriorly to the mid thigh were all included following the definition of expanded perineum proposed by Kusminsky et al.3 Pelvic and perineal anatomic location of the injuries was categorized in tree anatomic zones according to Faringer et al.14 The clinical relevance of this classification is complicated by the presence of wounds which fall into more than one area. Associated open pelvic fractures were classified by the presence of pelvic ring disruption.15 Mortality was stratified in early (first 24 hours after admission) and late (later than 24 hours). Diagnosis of wound sepsis was obtained clinically by purulent discharge and progressive necrosis or by positive cultures of tissues removed during sequential surgical revisions. Sepsis syndromes categorized criteria for recognition of systemic inflammatory response syndrome (SIRS) of the American College of Chest Physicians.16 After patient admission, the trauma staff and surgical residents performed the initial assessment according the advanced trauma life support (ATLS) outlined by the American College of Surgeons (ACS).17 During the primary survey, contemporary maneuvers for bleeding control from perineal and pelvic injuries, such as packing bleeding wounds and pelvic stabilization with sheets were selectively performed according to the presence of active hemorrhage from soft tissue lacerations or clinical evidence of open book fractures respectively. After initial assessment and management in the trauma room, hemodynamic unstable patients were immediately taken to the operate room. Laparotomy was performed first in hypotensive patients who had a grossly positive diagnostic peritoneal lavage (mostly performed during the first 2 years of the study) or a positive focused assessment for the sonographic examination of the trauma (FAST), with the intent to avoid intra-abdominal exsanguination and missed injuries. Stable patients underwent computed axial tomography. However, emphasis to early transportation to the operating room was a rule, with specific attention to the critical ill patient. Multiple sources of bleeding and the resultant physiological deterioration in patients who present with these devastating injuries offer

PAJT Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach

opportunity to practice the involve concept of damage control surgery. The abbreviated laparotomy varied, because there was no specific protocol and was left to the discretion of the attending surgeon. After laparotomy, the patients were positioned with abduction of the legs (lithotomy position) to allow definitive control of hemorrhage from soft tissue injuries by ligature of identifiable vessels and packing of diffuse bleeding areas. At this moment, the trauma surgeon performs meticulous inspection of perianal tissues, examination of the vaginal vault and rectal digital examination, with assessment of anal sphincter tone, content of the ampulla recti and localization of the prostate. Early orthopedic consultation for fixation of unstable pelvic fractures was performed only after intra-abdominal and perineal source of hemorrhage were excluded or resolved. Patients with persistent hypotension despite external fixation of pelvic fractures with ring disruption underwent selective angiography and transcatheter angioembolization. After hemorrhage control, the trauma staff initiates surgical debridement of dirty and devitalized areas of the perineum and subsequent pulsatile irrigation with warm saline until complete removal of gross particles deposited into the deep wound. The wound was intentionally left open and covered with dressings commonly used in burned areas. A selective loop transverse colostomy was performed according to the anatomic location of the perineal soft tissue injury with subsequent saline irrigation of the distal colon. Faringer zone I injuries involving the anus and rectum or deep gluteal and perineal injuries in proximity of the anal margin required loop transverse colostomy to reduce continuous fecal contamination in the open soft tissue defects. Diversion of the fecal stream was also required occasionally in Faringer zone II and III injuries when the trauma staff judged necessary. No attempt at definitive repair of anal, rectal, urethral or soft tissue injuries was performed during the initial operation. Priority on ongoing resuscitation to obtain physiological and metabolic recovery and reduce the secondary systemic inflammatory response in ICU dictated the policy of abbreviated operative interventions. Early supportive nutritional therapy and presumptive broad-spectrum antibiotics were utilized in all patients who survived more than 24 hours. Antibiotics were administered before operation and continued when progressive soft-tissue infection, necrosis or open fractures were present. Definitive antibiotic therapy was guided by positive cultures. Surgical revisions were made at intervals of 24 to 48 hours. Multiples surgical revisions were required when persistent contaminated soft tissue injuries were present.

After infection control and guided by the plastic surgery team consultation, definitive repair of perineal defects was conducted utilizing secondary closure, split-thickness skin grafts or rotation myocutaneous flaps. Definitive treatment of others visceral and osseous injuries were also performed by urology, general surgery or orthopedics teams.

STATISTICAL ANALYSIS Numerical data are presented as mean ± SD (standard deviation). Differences in means were assessed using Student’s test or Wilcoxon rank sum test. Differences in proportions were tested using X-test or Fisher’s exact test. All statistical analysis was performed using significance set at p < 0.05.

RESULTS Mechanism of Injury Demographics and Trauma Scoring The predominant mechanism of injury was pedestrian struck by an automobile (n = 25) followed by motor vehicle crashes (n = 07), motorcycle collisions (n = 04), falls (n = 04) and industrial traumatic incidents (n = 02). The 42 patients included in the present comprised 26 males and 16 females, with a mean age of 26 (4–77) years old. The injury severity expressed in terms of ISS for the 42 patients, varied from 13 to 70 (mean = 36), and in terms of RTS varied from 3.97 to 7.84 (mean = 7.23). The mean ISS value for the 15 patients who did not survive was 45 (27–70) that was significantly higher (p < 0.0001 compared to the mean ISS of 25 (13–43) for the survivors. The mean RTS value for the 15 nonsurvivors was of 6.67 (3.97–7.84) that was significantly lower when compare to the average RTS of 7.56 (4.94–7.84) which was identified in the 27 survivors (p = 0.02). Thus, the ISS and RTS values confirm the higher severity of the nonsurvivors, presented in Table 1. Table 1: Mortality, revised trauma score (p = 0.002) and injury severity score (p = 0.0001) Deaths No Yes

N 27 15

Median RTS 7.84 (4.94–7.84) 4.23 (3.97–7.84)

OR 0.64 1.40

Median ISS 22 (13–43) 48 (27–70)

OR 9.52 12.95

Table 2: Farringer’s perineal wound classification Zone I II III I + II I + III I + II + III

N 20 4 7 4 3 4

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):87-95

Percentage 48 9.5 17 9.5 7 9.5

Frederico JosĂŠ Ribeiro Teixeira Jr et al

Classification of Pelvic Fractures and Anatomic Location of Perineal Soft-tissue Injuries Associated open fractures of the pelvis were identified in 28 (66%) patients. Pelvic ring disruption was present in 20 patients. One traumatic hemipelvectomy was identified in the open fracture group of patients. Stratifying the perineal wound location by zones in accordance with the classification proposed by Faringer et al, we found a predominance of Faringer zone I injuries (n = 20). Following are the anatomic limits of the Faringer zone I: between the pubic tubercles (anterior limit), extending parallel to the inguinal creases and continuing posteriorly over the sacrum. Injuries of Faringer zone II were less common (n = 4) and is defined by the following anatomic limits: medial thigh bounding laterally on the anterior thigh by a line drawn between the anterior superior iliac spine extending to the medial patella inferiorly by the mid thigh including the groin creases. Faringer zone III injuries (n = 7) are defined by injuries localized in the posterolateral buttock inferior to the iliac crest. Injuries extending to more than one zone were observed in 11 patients (Table 2).

Open Fractures Management, Hemorrhage Control of Pelvic Injuries and Indication of Diverting Colostomy External stabilization to control persistent pelvic hemorrhage was necessary in 21.4% of patients with open pelvic fractures. One patient was submitted to late external stabilization of an open-book pelvic fracture. Immediate external hemipelvectomy was performed in one young female because of a devitalized leg. The young female patient suffered a traumatic ejection from the car compartment resultant from a high speed motor vehicle crash. After multiples surgical revisions a definitive repair with polypropilene onlay mesh over the pelvic wound prevented evisceration. Cutaneous defect was covered with split-thickness skin grafts. Retroperitoneal hemorrhage from pelvic trauma was identified in 17 patients during laparotomy (12 Zone III Table 3: Sites of injuries and mortality Injuries Ano rectal Urogenital Both Pelvic ring disruption Without pelvic ring disruption

N 15 18 9 20 8

<24 H 33% 16% 22% 30% 13%

Deaths >24 H 20% 16% 22% 15% 25%

Overall 53% 32% 44% 45% 38%

and 05 Zone II retroperitoneal hematomas). In one patient, unilateral internal iliac artery injury was identified into the expansible zone III hematoma requiring ligature of the vessel. Pelvic packing was required in three patients. Selective transcatheter angioembolization was required in two patients. One patient developed bilateral buttock necrosis after bilateral hypogastric artery embolization and died secondary to septic complications. Fecal stream diversion was selective performed in 25 patients (59.5%). Selectively loop transverse colostomy was the most performed modality of fecal stream diversion (n = 21). Loop transverse colostomy was required in 12 patients with Faringer zone I injuries (60% of the patients with zone I injuries), one patient with Faringer zone II (25% of the patients with zone II injuries), two patients with Faringer zone III (28.6% of the patients with zone III injuries), six patients with wounds extending for more than one zone (54.5% of the patients with more than one zone). Of note, all patients with wounds extending to the three zones required fecal stream diversion. In four patients, end colostomies and stump rectal closure were performed as part to the damage control strategy because these hypotensive patients were submitted to segmental rectal and sigmoid resection. Colostomy related complications (prolapsed colostomy) occurred in two (7.4%) patients.

Associated Visceral Pelvic, Perineal, Intra-abdominal and Extra-abdominal Injuries (Tables 3 and 4) Visceral injuries diagnosed during perineal examination were most common in the genitourinary tract (n = 18) presented in 43% of patients. Urethral injuries were present in 10 (24%) patients. All of the urethral injuries were in male and associated with open fractures with pelvic disruption (open book fractures). Suprapubic catheters were placed at the initial procedure in all patients with urethral injuries. Injuries of the anus and low rectum occurred in 15 (36%) patients. In nine (22%) patients combined injuries of the genitorurinary tract, anus and rectum were diagnosed during perineal examination. Intra-abdominal visceral injuries were found in 23 (55%) patients. Seven (17%) intra-abdominal solid organ injuries were identified during laparotomy. One patient required Table 4: Pelvic sites of injuries Sites of injuries Urethra Vagina Bladder Testicles Penis

N 10 7 5 3 2

Percentage 37 26 19 11 8

PAJT Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach Table 5: HC-USPSM comparative series among pelvic trauma patients Authors Birolini D et al35 Birolini D et al4 Present paper

N 10 38 72

Deaths <24 H >24 H 20% 50% 13% 19% 19% 17%

Overall 70% 32 % 36%

Infection 50% 19% 17%

splenectomy, another patient required nephrectomy, four patients had hepatic lacerations and two required perihepatic packing. One patient had a pancreatic injury. Hollow visceral injuries were identified in 14 (33%) patients. Five patients had small bowel injuries treated with resections, four had rectal (n = 2) and sigmoid (n = 2) lacerations requiring segmental resections, and five patients had intraperitoneal bladder ruptures requiring repair. Abdominal wall injuries were present in six (14%) patients. In three patients, traumatic evisceration with partial loss of abdominal wall components were initially treated by temporary abdominal closure using Bogota bags silos. Associated extremity fractures were present in 41 (98%) patients.

Septic and Others Complications Septic complications occurred in 26 patients (62%). Perineal wound infection occurred in 15 (36%) patients. Four (9.5%) patients developed ventilator associated pneumonia. Three (11%) patients developed urinary tract infections. Central venous catheter related infections developed in seven (17%) patients. Two (5%) patients developed an intracavitary abscess and one patient, developed meningitis. Seven (17%) patients developed septic shock. Bacteriological investigation resulted in 42 positive cultures. Pseudomonas aeruginosa was the most common agent isolated in cultures (37%) followed by Staphylococcus sp. (30%), Acinetobacter baumannii (30%) and Escherichia coli (19%). Six patients developed acute respiratory failure secondary to acute lung injury. Deep venous thrombosis occurred in three patients requiring Greenfield filter placement. Three patients developed acute renal failure requiring hemodialysis and one developed a perforated duodenal ulcer requiring laparotomy.

Overall, Early and Late Mortality An overall mortality of 35.7% (n = 15) was observed in the patient series. Eight (19%) patients died within 24 hours (early mortality) of arrival at the hospital due to exsanguination. Seven patients (16.7%) died after 24 hours (late mortality) from the arrival at the hospital and were related to septic complications. In three septic patients

deaths occurred after development of pulmonary embolism. The mortality in patients with open pelvic fractures was 42%. Mortality in patients with Faringer zone I injuries was 25% (n = 5), 25% (n = 1) in Faringer zone II, 57% (n = 4) in Faringer zone III, 42% (n = 3) in injuries extending to more than one zone, and 50% (n = 2) when all three zones were involved (Table 2). Comparing results related to mortality of our current series with the first two previous published series (first series = 1978 – 1980 and second series = 1981 – 1988) we observed an improvement in overall mortality since the introduction of the protocol (initiated in 1981) with no significant difference in the late mortality in the last two series (Table 5).

DISCUSSION The main clinical endpoint in the management of major trauma is survival. However, mortality resulting from CPI is related to multiple clinical factors and influence of many variables.18-21 Older studies stratified mortality in two peaks, early and late, aiming to assemble the predominant causes of death in each of these periods.22 However, few studies stratified risk factors of overall mortality.21,22 In the last four decades, a limited number of publications have shown the treatment results of CPI secondary to blunt trauma. Mortality rates were reported to be as high as 50% in the 1970s and 1980s, due to uncontrolled early hemorrhage, or late sepsis secondary to contamination of the soft tissue wounds, open fracture or multiple organ dysfunction due to systemic infection.1-3,23,24 The lack of a protocol of assessment and management was evident in the earlier series.1-3 Development of a protocol of assessment and management of CPI in our hospital was initiated in 1981 resulting in lower mortality rates. Surgical principles, such as early control of intra-cavitary bleeding, avoidance of continuing wound fecal contamination using mandatory diverting colostomy and colonic saline irrigation, maintenance of pelvic wound open and periodic routine debridement were outlined.4 In the studies where a protocol of management is followed, overall mortality rates range from 18 to 37%.19,22,25 The current study examined the association of specific demographic, clinical factors and interventional therapies in CPI and mortality rates. This retrospective analysis may not have statistical power to identify significant differences for specific outcomes or recommend a level one scientific evidence therapeutic intervention. It is difficult to create good evidence-based protocols when there are so few large series dealing with this rare

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Frederico JosĂŠ Ribeiro Teixeira Jr et al

injury. However, a historical comparison between the older and the current series allows some conclusions about the evolutionary management of this complex surgical problem and suggest the need of prospective and comparative multi-institutional studies to obtain more robust clinical recommendations.22 Hemorrhage control is a significant priority in the initial management of CPI. Exsanguination represents the first cause of early mortality.20-22,25,26,35 Anatomical basis of the pelvis and the high kinetics energy transfer of force related to the traumatic incident are responsible for the genesis of significant hemorrhage. The fractured pelvis and retroperitoneum are estimated to have the capacity to hold up to 4 liters of fluid. Violation of the pelvic space by abdominal surgery can increase pelvic volume by 15%, with loss of the tamponade effect provided by the peritoneum. Retroperitoneal hematoma can expand out of the pelvis into the abdomen or anteriorly through the surgical abdominal wound. Open perineal wounds in the patient with an open-book pelvic fracture allow an additional route of decompression of pelvic hemorrhage, potentially circumventing the tamponading tissue effects that assist in hemorrhage control in patients with closed fractures.22,25 Additionally, bleeding sources may be multiple in CPI. The sequencial approach to hemorrhage control outlined in the ATLS protocol is adopted in our service.17 Use of pelvic compression methods, such as placement of a pelvic orthopedic device (POD) or binders to control pelvic fracture hemorrhage in the trauma room, have been reported to reduce transfusions and length of hospital stay, and represent an additional therapeutic option.20-22,25,26 In the specific situation of CPI, another source of bleed is perineal laceration and the application of antiseptic pressure dressings to obvious bleeding sites in the trauma room is also advised.7 If intra-peritoneal bleeding is identified, immediate laparotomy is prioritized.7,19,26 Concomitance of CPI and intra-abdominal hemorrhage is an expected event. Associated visceral injuries were present in 55% of patients and these data are similar to other recent series.21 In six patients, visceral resections or packing were required to stop major bleeding. Pelvic packing is strongly considered by the staff when Zone III retroperitoneal hematomas are identified during laparotomy, representing a valuable maneuver of surgical damage control in patients with hypothermia and coagulopathy. This maneuver has been advocated by other groups in damage control surgery.19,22,25 After control of the intraperitoneal source of bleeding, immediate external pelvic fixation is performed when unstable pelvic ring fractures are present. Improved

outcome has been demonstrated with early pelvic stabilization.19,20-22,25 Open pelvic fractures are very common injuries associated in patients with CPI. In the present series, 66.6% of the patients had associated pelvic fractures and the overall mortality in open pelvic fractures patients were 42%. In other reported series, presence of open pelvic fracture represents a factor for high mortality rates in the population of patients with CPI.19,20,25 In the most recent publication reviewed, overall mortality due open pelvic fractures varies between 13 to 50% essentially were caused by exsanguinations or sepsis.26,27 Substantial high kinetic energy transfers results in shear forces responsible for degloving soft tissue injuries, lacerated vessels and fractures of pelvic bones commonly observed in CPI. Pedestrian struck by a motor vehicle causes devastating perineal injury when an individual is trapped between a fixed surface and a moving vehicle. In the present study, pedestrian struck by a motor vehicle was responsible for 60% of CPIs. Pedestrian struck by car was the predominant trauma mechanism in other recently published series.21 In 41 patients with open pelvic fractures and perineal soft tissues injuries, pedestrian struck by car was the causative factor in 20%.19 Hanson at al stated that half of their 43 patients with open fractures were pedestrian involved in collisions with motor vehicles.22,28 Motor vehicle and motorcycle collisions were also responsible for devastating injuries of the perineum. Extremely hazardous injuries may result when unrestrained individuals are ejected from the car and one leg is trapped into the car compartment. 22 One of our patients suffered this kind of mechanism with resultant traumatic hemipelvectomy reflecting how extensive bone injuries can be present. In a series recently reported of by Dente et al, one patient also presented in emergency department with traumatic hemipelvectomy.29 When a hypotensive patient presents with traumatic hemipelvectomy and the leg is not completed separated from the pelvis, amputation is necessary if major nerves were severely injuried and ischemia of the member was identified. This is a formidable example of a damage control rationale. Limb-sparing procedures in this setting may result in septic complications and death.20,22 Rieger et al (1998) published a comprehensive literature report on 67 survivors of this injury, demonstrating that these severely injured patients have a good chance of being successfully rehabilitated to an active and productive role in society.30 Another interventional therapy to hemorrhage control is transcatheter embolization. Although the management tenets for pelvic fractures have not changed greatly in the last 10 years, widespread availability of angiography has

PAJT Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach

given the trauma surgeon another option when dealing with these critically injured patients.20,25 Selective pelvic angiography and transcatheter embolization is indicated when injuries of the major branches of the iliac arteries are present.23,25 Although transcatheter embolization is a minimally invasive intervention, this is usually indicated in CPI after control of more obvious sources of bleeding and may result in serious complications when bilateral internal iliacal embolization is necessary.20 It is noted that the majority of patients who are bleeding from the pelvis have venous injuries, for which angiography is not helpful. The need for therapeutic angiography in a patient with an open pelvic fracture is associated with poor outcome.20,25 After bilateral internal iliac embolization one of our patients developed bilateral buttock necrosis. The above mentioned patient already had a profound perineal laceration grossly contaminated and developed a progressive soft tissue pelvic necrosis resulting in lethal sepsis. The second step in the damage control surgical intervention is limitation of the contamination of peritoneal cavity, pelvis and perineum. Traditionally, diversion of the fecal stream was a paradigm treatment of CPI since Raffa and Christensen reported in 1976 a decrease in mortality from 58 to 25% if colostomy was performed early 22. Mandatory diverting colostomy is an example of interventional therapy conceptualized as a surgical dogma on the management of CPI in the eighties.1-3,22 Maull and Sachatello advocated the use of diverting colostomies with intent to ameliorate the incidence of pelvic sepsis.1,22 Clinical retrospective studies published in the nineties questioned the role of mandatory diversion of the fecal stream recommending the procedure in a selective basis, according to the anatomic location of the perineal wound.14,22 Woods et al found that diverting colostomy does not necessarily reduce the incidence of local infective complications. They noted abdominopelvic infections in 27% of patients who underwent fecal diversion, compared with 29% in patients who did not.31 In 1998, Woods questioned the role of colostomies to reduce pelvic infection recommending only when transmural laceration of the rectum and large perineal soft tissue injuries were present.22,31 After years of debate mandatory colostomies has been part of a multidisciplinary approach to protect the perineal wound independent of the presence of rectal transmural laceration. Duschene et al published in a series of patients with open-book pelvic fractures

and open perineal wounds significant higher incidence of pelvic sepsis was observed despite the mandatory indication of diverting colostomies.21 In our current series, diversion of the fecal stream was performed selectively. Mortality rates were not significant different when comparisons were made with the older series where colostomies were performed mandatorily.22 The selective use of diverting colostomy is now addressed according the stratification of perineal injury location as proposed by Faringer et al14 and presence of anoretal injury, transverse loop colostomy were the standard approach. Although no comparative studies address the advantage of loop transverse colostomy over other enteric stomas, the location of the stoma in the upper right abdominal quadrant is distant of the external orthopedic device when unstable open fractures are present facilitating the care of the stoma. In some patients, extension of the soft tissue injuries to the lower abdominal quadrants or exposition of the fractured bone (iliac crest, pubic) may preclude the choice of a loop sigmoidostomy. Colonic diversions are preferred over ileostomy. High outflow of enteric juice by ileostomy may influence the nutritional recovery. Also, when colonic decompression is necessary and a colostomy is preferred. Although there is no evidence of the benefit of distal colonic irrigation, this is possible by a loop colonic stoma. Another interventional procedure used to limit contamination is suprapubic cystostomy. Unequivocal clinical evidence of urethral injuries mandates temporary urinary diversion until definitive repair. Otherwise, if retrograde cystourethrogram is positive for a urethral injury suprapubic cystostomy tube needs to be inserted during the emergency operation, to ensure diversion of the urinary flow, in order to prevent sepsis from infected urine.20,22,32 No attempt of definitive primary repair of anorectal and genitalia is advised. The role of the multispecialty approach is necessary to the definitive repair of the multiple injuries but should not take the place of addressing early causes of death, such as severe acidosis, secondary hypothermia and recalcitrant coagulopathy. Refinements in the definition and classification of the perineal injuries secondary to blunt trauma from previous studies offer information about the clinical relevance of the perineal injury itself in the context of multisystemic trauma.20,22 Current series now adopt the classification of location of perineal injuries proposed by Faringer to stratify severity, predict complications and as additional criteria to indicate diversion of the fecal stream.14 The perineal region (zone I) is the most common area of open soft tissue injury reported in the literature.22,33 In the current series, 20 patients presented with Zone I CPI.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):87-95

Frederico José Ribeiro Teixeira Jr et al

A meticulous examination of rectum, anus and genitalia is crucial. Missed injuries are not uncommon. Numerous case reports in the literature focus on missed open injuries in pelvic fractures, possibly resulting in damaging complications, such as vesicovaginal fistulae.7,22,33 In the current series, 42.8% patients presented with urogenital injuries and 35.7% presented with anorectal injuries. Incidence of anorectal and urogenital injuries in the literature range from 18 to 64% and 24 to 57% respectively.7,20,22 Maintenance of the pelvic wound open and periodic debridements in the operating room using generous irrigation of warm saline and packing the exposed areas with burns dressings is recommended to keep the wound clean and allow the development of granulation tissue. Except in one case of traumatic hemipelvectomy with loss of pelvic floor and potential risk of evisceration, we used a polypropylene on lay mesh to cover the defect. Actually vacuum sealed dressings, which allow adequate drainage of the wound have been used as proposed by several series.20,22 Debridement margins are determined by dermal capillary bleeding witnessed at the time of graft harvest, as has been established in other regions of the torso and extremities. Application of full, or split, thickness skin graft, harvested from the excised flap.20,22,34 Scoring trauma patients by anatomical injuries can offer prognostic relevant information defining severity. Of note in this series, high values of ISS reflect the clinical severity of the group studied. The average ISS was 36 for the all group studied (13–70). The overall ISS of patients with open pelvic fractures is reported to range between 25 and 48 11, 22, 23, 28. Septic complications were the most commonly observed complication with hemodynamic compromised in 17% patients of the current series. Of note, one of the patients developed meningitis which has been reported in the literature as a potential septic complication when extensive compromise of sacral plexus occurs.22 Prophylactic administration of broad-spectrum intravenous antibiotics is introduced in the early management in the trauma room and was later be adjusted according to microbiological sensitivity testing.

CONCLUSION In conclusion, we document our recent experience with CPI in a level I trauma center. This entity, although rare, continues to a significant source of morbidity in trauma patients. Despite some differences in the protocol of assessment and management adopted in our previous series, the

essentials are still the same and the results on mortality are similar. Our current data reveal a slight reduction in late mortality rate. In the present series, development of serious infection with hemodynamic compromise occur in 16.6% of the patients against 22.9% in the previous series although it does not have statistical significance. The need for different specialists as urologists, orthopedists, plastic surgeons and others are inherent but the coordination of therapeutics procedures according to priorities must be done by the trauma team staff. Definitive repair of anatomical structures in the initial setting of treatment may be deleterious because physiological deterioration due to hemorrhage is common. In addition, the progressive inflammatory response due to massive blunt trauma and the superimposed sustained infection trigger a complex cascade of immunologic and metabolic events and represent the typical panorama of traumatic shock. Complex perineal injuries should be viewed as a continuing challenge in which the staged physiologic surgery proposed in accordance with the damage control principles represents until now the best way of treatment. New modalities of treatment and prospective controlled trials are need.

REFERENCES 1. Maull KI, Sachatello CR, Ernst CB, et al. The deep perineal laceration- an injury frequently associated with open pelvic fractures: a need for aggressive surgical management. J Trauma 1977 Sep;17(9):685-696. 2. Rothenberger D, Velasco R, Strate R, et al. Open pelvic fracture: a lethal injury. J Trauma 1978 Mar;18(3):184-187. 3. Kusminsky RE, Shbeeb I, Makos G, et al. Blunt pelviperineal injuries an expanded role for diverting colostomy. Dis Colon Rectum 1982 Nov-Dec;25(8):787-790. 4. Birolini D, Steimann E, Utiyama E, et al. Open pelviperineal trauma. J Trauma 1990 Apr;30(4):492. 5. Kudsk KA, McQueen MA, Voeller GR, et al. Management of complex perineal soft-tissue injuries. J Trauma 1990 Sep;30(9):1155-1159. 6. Tscherne H, Pohleman T, Gänsslen A, et al. Crush injuries of the pelvis. Eur J Surg 2000 Apr;166(4):276-282. 7. Kudsk KA, Hanna MK. Management of complex perineal injuries. World J Surg 2003 Aug;27(8):895-900. 8. Ferrera PC, Hill DA. Good outcomes of open pelvic fractures. Injury 1999;35(3):36-39. 9. Sinnott R, Rhodes M, Brader A. Open pelvic fracture: an injury for trauma centers. Am J Surg 1992 Mar;163(3):283-287. 10. Davidson BS, Simmons GT, Williamson PR, et al. Pelvic fractures associated with open perineal wounds: a survivable injury. J Trauma 1993 Jul;35(1):36-39. 11. Brenneman FD, Katyal D, Boulanger B, et al. Long-term outcomes in open pelvic fractures. J Trauma 1997 Mar;42(5): 773-777. 12. Baker SP, O’Neil B, Haddon W, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974 Mar;14(3):187-196.

PAJT Complex Perineal Injuries in Blunt Trauma Patients: The Value of a Damage Control Approach 13. Baker SP, O’Neil B. The injury severity score. An update. J Trauma 1976 Nov;16(11):882-885. 14. Faringer P, Mullins R, Feliciano D, et al. Selective fecal diversion in complex open pelvic fractures from blunt trauma. Arch Surg 1994 Sep;129(9):958-963. 15. Penal GF, Tile M, Waddel J, Garside H. Pelvic disruption: assessment and classification. Clin Orthop Relat Res 1980 Sep;(151): 12-21. 16. Bone RC, Balk RA, Cerra FB, et al. Definitions of sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992 Jun;101(6):1644-1655. 17. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support. Chicago, III: American College of Surgeons; 1997. 18. Arvieux C, Thony F, Broux C. Management of severe pelvic and perineal trauma. J Visceral Surg 2012 Aug;149(4):e227-e238. 19. Dong JL, Zhou DS. Management and outcome of pelvic fractures: a retrospective study of 41 cases. Care Injury 2011 Oct; 42(10):1003. 20. Arvieux C, Thony F, Brouux F, et al. Current management of severe pelvic and perineal trauma. J Visceral Surg 2012; (149);e227-e238. 21. Duschene JC, Bharmal HD, Dini AA, et al. Open-book pelvic fractures with perineal open wounds: a significant morbid combination. Am Surg 2009 Dec;75(12):1227-1233. 22. Grotz MRW, Allami MK, Harwood P. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005 Jan;36(1):1-13. 23. Katsoulis E, Drakoulakis E, Giannoudis PV. Management of open pelvic fractures. Current Orthopedics 2005;19(5): 345-353. 24. Wessem KJP, Mackay PJ, King KL. Selective faecal diversion in open pelvic fractures: Reassessment based on recent experience. Injury 2012 Apr;43(4):522-525.

25. Cothren CC, Osborn PM, Moore EE, et al. Preperitonial pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma-Injury Infection and Critical Care; 2007 April;62(4):834-842. 26. Hasankhani EG, Kashani FO. Treatment outcomes of open pelvic fractures associated with extensive perineal injuries. Clin Orthop Surg 2013 Dec;5(4):263-268. 27. Wei R, Cao X, Tu D. Clinical treatment of open pelvic fracture associated with perineal injury. Zhongguo Xiu Fu Chongn Jian Wai Ke Za Zhi 2012;26(5):550-553. 28. Hanson PB, Milne JC, Chapman MW. Open fractures of the pelvis: review of 43 cases. J Bone Joint Surg Br 1991 Mar;73(2): 325-329. 29. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of pelvic fractures in the moder era. Am J Surg 2005 Dec;190(6): 830-835. 30. Rieger H, Winde G, Brung E, Senninger N. Open pelvic fracture—an indication for laparotomy? Chirurg 1998 Mar; 69(3):278-283. 31. Woods RK, O’Kefe G Rhee P, et al. Open pelvic fracture and fecal diversion. Arch Surg 1998 Mar;133(3):281-286. 32. Koraitim MM. Pelvic fracture urethral injures: the unresolved controversy. J Urol 1999 May;161(5):1433-1441. 33. Brenneman FD, Kaytal D, Boulanger BR, et al. Long-term outcome in open pelvic fractures. J Trauma 1997 May;42(5): 773-777. 34. Govaert G, Siriwardhane M, Hatzifotis M. Prevention of pelvic sepsis in major open pelviperineal injury. Injury 2012 Apr;43(4):533-536. 35. Birolini D, Morimoto RY, Utiyama EM, et al. Complex pelviperineal injuries. AMB Rev Assoc Med Bras 1985 MayJun;31(5-6):91-97.

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PAJT 10.5005/jp-journals-10030-1123

Ana Cláudia Marchi Barros et al

OBSERVATIONAL RETROSPECTIVE STUDY

Análise Retrospectiva de Pacientes Vítimas de Trauma Cervical Penetrante Submetidos À Cervicotomia 1

Ana Cláudia Marchi Barros, 2Guilherme Damaceno Pereira, 3Marília França Madeira Manfrinato Mariane Christina Savio, 5Camila de Souza Justini, 6Rafaela de Araujo Molteni 7 Fábio Henrique de Carvalho, 8Adonis Nasr 4

RESUMO Objetivos: As lesões cervicais penetrantes são, em sua maioria, causadas por armas de fogo ou armas brancas, e o conceito de um manejo cirúrgico seletivo é o empregado atualmente no tratamento destes pacientes. O presente trabalho tem como objetivos avaliar o perfil demográfico dos pacientes vítimas de traumas cervicais penetrantes submetidos à cervicotomia, quanto à presença ou não de lesão, o tipo de lesão encontrada durante o ato cirúrgico, além da evolução e mortalidade. Métodos: Foram estudadas 57 vítimas de trauma cervical penetrante atendidas no Hospital do Trabalhador, em Curitiba (Brasil), nos períodos de abril de 2009 até março 2014, que foram submetidas à cervicotomia. Resultados: Os principais mecanismos de trauma foram: ferimento por arma branca (52,6%), ferimento por arma de fogo (40%); 61% deles ocorreram em zona II. 91% dos pacientes eram do sexo masculino, com uma média de idade de 33,1 anos. 43,8% destes apresentavam alguma lesão associada e 46% realizaram exame de imagem pré-operatório. Em 82,5% das cervicotomias foi encontrada lesão. As injúrias mais comuns foram: vascular (68%), de vias aéreas (47%) e de esôfago (11%). O tempo operatório médio foi de 118 minutos. 17,5% dos pacientes apresentaram algum tipo de complicação pós-operatória. O tempo médio de internamento foi de 9 dias. Óbito ocorreu em 7% dos pacientes, sendo que todos estes apresentavam lesões associadas. Conclusão: Homens adultos jovens são os mais acometidos. Todos os pacientes que foram à óbito apresentavam algum tipo de lesão associada, mostrando que a cervicotomia foi terapêutica quando existiam lesões cervicais isoladas. No entanto, em uma parte (17,5%) dos pacientes submetidos à cirurgia, nenhuma lesão foi encontrada. Isto mostra que, apesar dos avanços tecnológicos referentes aos exames complementares, mais estudos são necessários para orientar

1-5

Medical Student, 6General Surgeon, and Professor

7,8

Trauma Surgeon

1-8

Department of General and Trauma Surgery, Hospital do Trabalhador – Universidade Federal do Paraná (UFPR) Curitiba, Paraná, Brazil Corresponding Author: Ana Cláudia Marchi Barros, Medical Student at Universidade Federal do Paraná, Avenida João Gualberto, 1313 ap 305 80030001, Curitiba, Paraná, Brasil e-mail: anaclaudiamarchibarros@gmail.com

a conduta frente ao paciente vítima de trauma cervical penetrante. Palavras claves: Cervicotomia, Hard signs, Trauma cervical. How to cite this article: Barros ACM, Pereira GD, Manfrinato MFM, Savio MC, de Souza Justini C, de Araujo Molteni R, de Carvalho FH, Nasr A. Análise Retrospectiva de Pacientes Vítimas de Trauma Cervical Penetrante Submetidos À Cervicotomia. Panam J Trauma Crit Care Emerg Surg 2015; 4(2):96-102. Source of support: Nil Conflict of interest: None

ABSTRACT Objectives: Penetrating neck injuries are, for the majority caused by firearms or knives and the concept of a selective surgical management is the current approach in treating these patients. The present work aims to evaluate the demographic profile of patients suffering from cervical penetrating trauma for the presence or absence of injury, the type of injury found during surgery, plus the outcomes. Materials and methods: We studied 57 patients with cervical trauma penetrating treated at Hospital worker in Curitiba (Brazil), in the period April 2009 to March 2014. Results: The main trauma mechanisms were: stab wound (52.6%), injury by firearm (40%); 61% of them occurred in zone II. 91% of patients were male, with an average age of 33.1 years. 43.8% of them had some associated injury. 46% underwent preoperative imaging. In 82.5% who had surgery injury was found. Common were: vascular (68%), airway (47%) and esophagus (11%). Mean operative time was 118 minutes. 17.5% of patients had some type of complication postoperatively. The average time of hospitalization was 9 days. Death occurred in 7% of patients, all of them had associated injuries. Conclusion: Men young adults are the most affected. All patients who died presented some type of injury associated. Operation was therapeutic when there were isolated cervical lesions. However, in 17.5% of patients undergoing surgery, no lesion was found. More studies are needed to guide the management of patients with cervical penetrating trauma. Keywords: Cervical trauma, Cervicotomy, Hard signs.

INTRODUÇÃO A região cervical é muito vulnerável tanto pela ausência de proteção óssea como por sua anatomia, a qual reúne

Note: Paper presented in Student Research Competition at the Annual Congress of Panamerican Trauma Society, Panama City, Panama, November 2015.

PAJT Análise Retrospectiva de Pacientes Vítimas de Trauma Cervical Penetrante Submetidos À Cervicotomia

muitas estruturas vitais, incluindo traqueia, esôfago, tireoide e vasos sanguíneos calibrosos. Traumas desta região podem causar lesões graves com alta morbimortalidade.1 O trauma penetrante de pescoço pode ser causado por ferimentos por armas de fogo (FAF), por armas brancas (FAB) ou por outros detritos penetrantes (vidro e estilhaços). Consideram-se ferimentos penetrantes os que ultrapassam o músculo platisma. Quando o platisma encontra-se intacto a lesão é considerada superficial. Até a década de 40, todas as lesões penetrantes de pescoço eram tratadas de modo conservador, com taxas de mortalidade chegando aos 35%.3 Em uma tentativa de reduzir as elevadas taxas de mortalidade, a abordagem cirúrgica foi adotada, inclusive para os pacientes estáveis. Esta nova conduta gerou queda na taxa de mortalidade, mas também um incremento no número de explorações cirúrgicas negativas. Além disso, após a guerra, com o avanço dos métodos diagnósticos de imagem e com a predominância de lesões menos severas, surgiu o conceito do manejo cirúrgico seletivo, tendo como ponto de apoio o emprego de exames complementares radiológicos e endoscópicos. Essa série de mudanças levou a uma quebra de paradigma no manejo de lesões cervicais penetrantes. Avanços contínuos também no manejo perioperatório e em anestesia contribuíram para melhores resultados no tratamento das lesões.2 O manejo da lesão cervical penetrante depende do estado hemodinâmico do paciente e do nível anatômico da injúria.4 O pescoço é dividido em três zonas: I, II e III (Figura 1). A zona I vai das clavículas ou esterno até a borda inferior da cartilagem cricoide; a zona II vai da

Figura 1: Divisão anatômica da região cervical1 Tabla 1: Sinais de lesão grave ou ‘hard signs’8 Comprometimento de via aérea Enfisema subcutâneo massivo/escape de ar pela ferida Hematoma pulsátil ou em expansão Sangramento ativo Choque Déficit neurológico Hematêmese

cricoide ao ângulo da mandíbula e a zona III do ângulo da mandíbula até a base do crânio.5,6 A borda posterior do músculo esternocleidomastoideo é usada como divisão de pescoço anterior e posterior. Manifestações clínicas significativas de lesões de estruturas importantes são: disfagia (traqueia e/ou esôfago); rouquidão (nervo laríngeo recorrente, laringe); sangramento orofaríngeo, nasofaríngeo ou ambos (lesão vascular); déficit neurológico e hipotensão arterial (não específico).2 Na presença de instabilidade hemodinâmica4,7 ou dos chamados ‘hard signs’, isto é, sinais indicativos de lesão grave, a transferência para a sala de cirurgia deve ser imediata, com eventual realização de procedimentos necessários para garantia de via aérea definitiva e/ou controle de sangramento ativo importante ainda na sala de emergência (Tabla 1).8 O presente trabalho tem como objetivo avaliar o perfil epidemiológico e características das lesões das vítimas de trauma cervical penetrante que foram submetidas à cervicotomia em um centro de trauma.

MÉTODOS Foi realizada a análise restrospectiva de prontuários de pacientes vítimas de trauma atendidas no pronto socorro do Hospital do Trabalhador, local de referência em atendimento de trauma, localizado em Curitiba-PR (Brasil), no período de 1º de abril de 2009 a 31 de marco de 2014. O levantamento dos prontuários foi realizado por meio da busca no sistema eletrônico Hospub dos procedimentos ‘tratamento cirúrgico de lesões traumáticas da região cervical’, ‘traqueorrafia’, ‘esofagorrafia’ e ‘laringorrafia’. Foram selecionados apenas os pacientes vítima de trauma cervical penetrante, sendo excluídos as vítimas de trauma contuso e os pacientes submetidos aos procedimentos acima por causas não traumáticas, com um total de 57 pacientes. Os dados analisados foram identificação do paciente, sexo, idade, mecanismo de trauma (arma de fogo ou arma branca), topografia da ferida (zona cervical I, II ou III), sinais e sintomas presentes na admissão (enfisema subcutâneo, hematoma em expansão, rouquidão, hemoptise, sangramento ativo e choque hipovolêmico), realização de exames de imagem préoperatórios, lesão encontrada durante o ato operatório, tempo cirúrgico, necessidade de internamento em Unidade de Terapia Intensiva, tempo de internamento e desfecho do caso. Os dados foram incluídos em uma Tabla Excel Microsoft ® e apresentados na forma de estatística descritiva.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2015;4(2):96-102

Ana Cláudia Marchi Barros et al

Gráfico 1: Mecanismos de trauma dos pacientes do estudo

RESULTADOS Foram incluídos no estudo um total de 57 pacientes, com idade média de 33,1 anos (9-65 anos), sendo 91% do sexo masculino. O mecanismo de trauma mais comum foi por arma branca, sendo 30 pacientes, responsáveis por 52,6% dos casos; seguidos pelos ferimentos de arma de fogo em 23 pacientes, sendo 40% dos casos; os por estilhaço de vidro durante acidentes automobilísticos somam 3 pacientes, o equivalente a 5,3% das vítimas e 1 caso (1,7%) vítima de trauma direto por objeto de trabalho (Gráfico 1). Em relação à localização do ferimento, a mais frequentemente lesada foi a zona II, em 35 (61,4%) das 57 vítimas. A seguir, a zona III, foi lesada em 3 casos (5,3%). Nenhum paciente foi atendido com lesão isolada em zona I. Dois (3,4%) pacientes apresentaram lesão em zona I, sendo um caso associado à lesão em zona II e outro à lesão em zona III. Associação de lesões em zona II e III foi encontrada em 4 casos (7%). Em 12 (21%) prontuários não foram encontradas informações a respeito da zona cervical atingida. Dos 57 pacientes, 12 (21%) foram admitidos hemodinamicamente instáveis, 5 (42%) destes após resposta a reposição volêmica tornaram-se estáveis e foram enviados à angiotomografia cervical e, em função dos achados do exame, encaminhados ao centro cirúrgico. Os outros 7 (58%) não responderam à reposição volêmica sendo prontamente encaminhados à cervicotomia, sem a realização de exames complementares. Dos 12 pacientes Tabla 2: Pacientes com sinais sugestivos de lesão grave (hard signs) Enfisema subcutâneo Hematoma em expansão Choque Sangramento ativo Disfonia Exposição de tireoide Escape de ar pela lesão

16 2 12 23 4 1 1

28% 3,50% 21% 40,30% 7% 1,70% 1,70%

admitidos em choque hipovolêmico, 5 apresentaram lesão vascular à cervicotomia—o que justificava tal achado no exame (2 deles com lesão em carótida, outros 2 em veia jugular externa e 1 em veia jugular interna), 3 apresentavam lesão em vias aéreas e a instabilidade hemodinâmica pode ser explicada pelos ferimentos associados e, os outros 4 apresentaram cervicotomia não terapêutica, sendo o choque hipovolêmico em função das lesões associadas. Nenhum dos pacientes do grupo hemodinamicamente instáveis e em que a cervicotomia foi não terapêutica realizaram exames de imagem préoperatórios. A maioria dos pacientes atendidos, 79% (45 pacientes), encontravam-se estáveis hemodinamicamente e foram submetidos à cirurgia em função de dados positivos no exame físico na admissão (64%), reavaliações (13%) ou em exames de imagem. 47% destes (21 pacientes) foram submetidos à angiotomografia cervical antes do procedimento cirúrgico. Em 40 pacientes (70%), achados de exame físico foram sugestivos de lesão: enfisema subcutâneo (28%), hematoma em expansão (3,5%), choque (21%), sangramento ativo (40,3%), disfonia (7%), exposição de tireoide (1,7%) e escape de ar pela lesão (1,7%). Dos pacientes com choque hipovolêmico, apenas 1 (1,7%) apresentava ferimento cervical isolado (Tabla 2). Dos 57 pacientes, 25 (43,8%) apresentaram lesões associadas, sendo que 10 (40%) destes sofreram outros FAF, 9 (36%) outros FAB, 5 (25%) fratura óssea, 2 (8%) traumatismo crânioencefálico e outros 2 (8%) ferimentos corto-contusos em membros ou face. Lembrando que alguns pacientes sofreram mais que um tipo de lesão associada. O tempo médio de cirurgia foi de 118 minutos, sendo que esse tempo inclui o de procedimentos complementares. Quando apenas a cervicotomia foi realizada, o tempo cirúrgico médio foi de 98 minutos. A cervicotomia foi não terapêutica em 10 pacientes (17,5%), sendo que em quatro destes foi realizada angiotomografia cervical préoperatória. Em relação às lesões cervicais encontradas durante a cirurgia (Tabla 3), a mais comum foi a vascular, encontrada em 32 pacientes (68%), seguida das lesões de vias aéreas, em 22 casos (46,8%); lesões esofágicas, em 5 casos (10,6%); lesões de tireoide, em 4 casos (8,5%) e 3 casos (6,3%) de lesão nervosa. Tabla 3: Lesões encontradas durante cervicotomia Vascular Vias aéreas Esôfago Tireoide Sistema nervoso

32 22 5 4 3

68% 46,80% 10,60% 8,50% 6,30%

PAJT Análise Retrospectiva de Pacientes Vítimas de Trauma Cervical Penetrante Submetidos À Cervicotomia

As lesões vasculares foram de veia jugular interna em 15 (46,8%) pacientes; veia jugular externa em 14 (43,7%); artéria carótida em 2 (6,2%); artéria vertebral em 1 (3,1%); artéria submandibular em 1 (3,1%); artéria lingual em 1 (3,1%); artéria facial em 1 (3,1%) e artéria tireoidiana em 1 (3,1%). Um dos paciente apresentava fratura do osso hioide associada. A taxa de morbidade foi de 17,5%, com complicações presentes em 10 pacientes. A paralisia de pregas vocais ocorreu em 5 (50%) casos, a fístula traqueoesofágica esteve presente em 3 (30%) pacientes; alterações neurológicas em 4 (40%) pacientes e 1 (10%) caso de pseudoaneurisma de carótida. O tempo médio de internamento foi de nove dias, sendo de 4,5 dias nos pacientes vítimas de trauma cervical isolado. Dos 57 pacientes, 24 (42,1%) necessitaram de cuidados em unidade de terapia intensiva, sendo que metade (12) deles apresentavam lesões associadas. Três (7%) pacientes evoluíram para óbito, todos com lesões associadas, sendo o êxito letal em dois deles decorrente de choque hipovolêmico e em outro, morte encefálica por TCE grave associado.

DISCUSSÃO Os traumatismos da região cervical se destacam por sua elevada complexidade e alta morbidade. Não há no corpo outro segmento que contenha estruturas representativas de tantos sistemas em um espaço tão confinado como o pescoço: sistemas respiratório, digestivo, vascular, nervoso central e periférico, linfático e endócrino. As lesões penetrantes de pescoço correspondem a 5 a 10% dos casos de trauma na emergência e apresentam o mesmo perfil de vítimas de trauma em geral—homens jovens. Neste estudo os pacientes apresentaram idade média de 33,1 anos, sendo 91% do sexo masculino. A incidência de zona lesada foi de II (61,4%), seguida da III (5,3%) e da I (3,4%), similar à apresentada na literatura. A abordagem do trauma cervical penetrante mudou substancialmente no decorrer das últimas décadas, da exploração cirúrgica mandatória ao tratamento conservador. O manejo inicial é decisivo no sucesso do tratamento do paciente. Deve-se considerar a mortalidade oriunda de lesões vasculares graves, que chega a 50%, e as complicações tardias, como pseudoaneurismas e fístulas artério-venosas, que podem afetar os resultados em longo prazo. Assim sendo, o manejo correto, no momento adequado, é fundamental. De acordo com o Western Trauma Association, a abordagem inicial deve seguir o guideline do ATLS (Advanced Life Trauma Support), com enfoque nas lesões que geram risco de morte imediato e com prioridade de tratamento.

Pacientes com estabilidade hemodinâmica e sem sinais de lesões graves podem ser manejados com uma conduta conservadora, através da realização de exames de imagem e exame físico seriado. Na suspeita de lesão, o tratamento é determinado pela localização da lesão e pela situação hemodinâmica do paciente.5 Pacientes instáveis devem ser submetidos à cervicotomia exploradora. Em pacientes hemodinamicamente estáveis, o local do ferimento irá determinar seu manejo. Ferimentos em zona I (das clavículas até a cartilagem cricoide) devem receber avaliação de possíveis lesões vasculares, com angiotomografia de cervical e tórax; de vias aéreas, com fibrobroncoscopia e; do aparelho digestório, com endoscopia digestiva alta. Em caso positivo, deve-se proceder ao reparo da lesão, seja por cervicotomia exploradora ou por procedimentos endovasculares. Pacientes com ferimentos em zona II, estáveis hemodinamicamente, e sem sintomas, podem ser observados sem necessidade de exames complementares. Quando se suspeita de lesão cervical, seja pela presença de enfisema subcutâneo, hematoma em região cervical, alterações vocais ou pelo trajeto do ferimento, deve-se realizar uma angiotomografia da região cervical. Neste caso, assim como em ferimentos da zona I, os achados do exame radiológico guiarão a conduta. Por último, pacientes hemodinamicamente estáveis com ferimento de zona III devem ser submetidos à angiotomografia cervical e de crânio para investigação de danos vasculares e aerodigestivos. Lesões vasculares são manejadas com embolização ou colocação de ‘stent’, por meio de procedimentos endovasculares. Na suspeita de lesões de vias aéreas e/ou do tubo digestivo, os procedimentos endoscópicos são indicados, pois apresentam maior sensibilidade no seu diagnóstico em relação aos exames contrastados.9,10 Atualmente, o trauma cervical penetrante, apresenta uma taxa de mortalidade de 3 a 6%, sendo muito menos que no passado—11% na primeira guerra mundial. Neste estudo, a taxa de mortalidade, 7%, foi similar à encontrada na literatura e decorrente parcialmente de lesões associadas. A lesãos de grandes vasos (carótida, subclávia e jugular) é a principal causa de morte nos ferimentos penetrantes cervicais. Exsanguinação é a causa de morte mais comum e a estrutura mais comumente atingida é a artéria carótida 3,4, sendo afetada em 6 a 17% dos pacientes.7,11 No presente estudo os vasos foram as estruturas mais frequentemente lesadas, especialmente as veias jugulares internas, externas e as carótidas, em 46%, 43% e 6% dos casos, respectivamente.

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As injúrias traumáticas dessa região englobam um grande número de lesões em adultos e continuam sendo de difícil manejo.3 Enquanto a intervenção cirúrgica é necessária em 15 a 20% dos casos (presença dos ‘hard sings’ ou de instabilidade hemodinâmica) a conduta frente ao paciente estável ainda é tema de discussão.3,8,12,13 Neste estudo, 79% dos pacientes se encontravam estáveis hemodinamicamente e foram submetidos à cervicotomia em função de dados do exame físico na admissão (64%), de avaliações subsequentes (13%) ou dos resultados de exames de imagem, ressaltando a importância do exame físico seriado. Os exames de imagem não permitiram o desaparecimento das cervicotomias não terapêuticas, realizadas em dez pacientes nesse estudo, sendo que em 4 deles havia sido realizada angiotomografia cervical. O fato de a interpretação dos exames de imagens ser feita pelo cirurgião do trauma e não por um radiologista, em grande parte dos casos, pode influenciar na decisão por exploração em casos com exames de imagem duvidosos. Apesar da morbidade associada à procedimentos cirúrgicos, a não realização de uma intervenção em pacientes com lesões potencialmente fatais é uma conduta associada à morbidade ainda maior. Assim, em pacientes estáveis hemodinamicamente, deve-se levar em consideração o mecanismo de trauma e o trajeto dos ferimentos penetrantes, assim como a apresentação clínica e o resultado de exames de imagem para, em conjunto, optar-se ou não pela intervenção cirúrgica.8 Enquanto que no manejo de vítimas de trauma cervical com instabilidade hemodinâmica a cervicotomia exploradora tem seu papel bem estabelecido, em pacientes estáveis esta opção está em declínio em função do advento

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de técnicas endovasculares e dos avanços dos exames de imagem. No entanto, estudos Isto mostra que mais estudos são necessários para determinar critérios mais objetivos na indicação da cervicotomia exploradora nesses pacientes.

REFERENCIAS 1. Moore KL, Dalley AF. Anatomia orientada para clínica. 2006. Rio de Janeiro. Guanabara Koogan. 5. ed. 2. Alterman DM, Daley BJ, Selivanov V. Penetrating Neck Trauma. Medscape, 2008. Disponível em: http://emedicine. medscape.com/article/433306-overview#a0112. 3. Thal ER, Meyer DM. Penetrating neck trauma. Curr Probl Surg 1992 Jan;29(1):1-56. 4. McConnell DB, Trunkey DD. Management of penetrating trauma to the neck. Adv Surg 1994;27:97-127. 5. Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma 1969;9(12):987-999. 6. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979;19(6):391-397. 7. Demetriades D, Asensio JA, Velmahos G, Thal E. Complex problems in penetrating neck trauma. Surg Clin North Am 1996;(80):76-661. 8. Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association Critical Decisions in Trauma: penetrating neck trauma. J Trauma Acute Care Surg. Pittsburgh, Pennsylvania. 2013:75(6):936-940. 9. Offiah C, Hall E. Imaging assessment of penetrating injury of the neck and face. Insights Imaging 2012;3(5):419-431. 10. Ahmed N, Massier C, Tassie J, Whalen J, Chung R. Diagnosis of penetrating injuries of the pharynx and esophagus in the severely injured patient. J Trauma 2009;67(1):152-154. 11. Mittal VK, Paulson TJ, Colaiuta E, et al. Carotid artery injuries and their management. J Cardiovasc Surg (Torino) 2000;(3): 41-423. 12. Asensio JA, Valenziano CP, Falcone RE, Grosh JD. Management of penetrating neck injuries. The controversy surrounding zone II injuries. Surg Clin North Am 1991;(2):71-267. 13. Bryant AS, Cerfolio RJ. Esophageal trauma. Thorac Surg Clin 2007;17(1):63.

PAJT Análise Retrospectiva de Pacientes Vítimas de Trauma Cervical Penetrante Submetidos À Cervicotomia

INVITED COMMENTARY La aproximación terapéutica del paciente con trauma cervical penetrante ha permanecido en constante cambio y evolución a través del tiempo. A mediados del siglo pasado, la mortalidad por trauma cervical penetrante alcanzaba cifras superiores al 30%, lo que llevo a un ejercicio indiscriminado del manejo quirúrgico y como consecuencia a un aumento del número de exploraciones negativas que llego a alcanzar el 45% donde el denominador era la totalidad de los pacientes. Con el advenimiento de nuevos instrumentos y ayudas diagnosticas, se introdujo el concepto de cirugía selectiva con el fin de reducir el número de exploraciones negativas. En la actualidad, la propuesta es ser aun más selectivo que la cirugía selectiva, primero agotando los recursos y ayudas diagnosticas disponibles antes de operar al paciente. El presente trabajo nos muestra la experiencia de 5 años de una institución hospitalaria en Curitiba-Brasil en el manejo del trauma cervical penetrante, y a través de ella podemos contrastar sus resultados con la actualidad en el manejo de esta entidad. La tasa de exploraciones negativas reportadas en el estudio fue del 17,5%, la cual a nuestro juicio continúa siendo elevada si se tiene en cuenta la cantidad de recursos diagnósticos disponibles en la actualidad. Sin embargo, no hay que desconocer la brecha que puede existir en la obtención, disponibilidad y oportunidad de los recursos diagnósticos por parte de algunas instituciones. Esta limitante puede ser aún más importante en países en vía de desarrollo (como la mayoría de los de la región) y por supuesto en zonas marginadas o de difícil acceso. Adicional al elevado porcentaje de exploraciones negativas, se suman el de intervenciones quirúrgicas innecesarias. En este grupo se ubican aquellos pacientes llevados a cervicotomías con lesiones que probablemente hubieran podido recibir manejo no quirúrgico, porcentaje que también es elevado en el presente trabajo. Estos resultados, contrastan con las recomendaciones actuales donde se trata de evitar las intervenciones quirúrgicas innecesarias. Teniendo en cuenta lo anterior, el enfoque del paciente con trauma cervical penetrante debe ser el siguiente: Pacientes inestables hemodinamicamente o con la presencia de algún ‘signo duro’ deben ser llevados a cirugía. Por otra parte, aquellos que no cumplan alguna de estas indicaciones, antes de considerar llevarlos a cirugía, se les debe realizar una arteriografía contrastada si se sospecha una lesión de la carótida; una laringoscopia/broncoscopia si la sospecha es de lesión en tráquea o un esofagograma contrastado y endoscopia si se sospecha compromiso esofágico. La tomografía axial computarizada (TAC) multicorte de cuello ha venido reemplazando estos exámenes, y hoy se ha convertido en el manejo diagnostico de primera línea, desplazando así a los exámenes anteriormente mencionados a ser ayudas diagnosticas de segunda línea exclusivamente cuando el TAC no logre ser conclusivo o aun existan dudas sobre la presencia de lesión. Es importante la observación y el seguimiento de estos pacientes mediante un examen físico exhaustivo el cual no debe ser reemplazado. El advenimiento y los avances en la realización de procedimientos endovasculares, han posicionado esta rama de la medicina como una alternativa en el manejo de los pacientes con trauma cervical penetrante. Los hallazgos encontrados en el TAC serán el punto de partida para definir que pacientes se benefician de esta opción terapéutica, y con esto evitar de nuevo intervenciones quirúrgicas innecesarias. Los avances en esta disciplina sumada a la rapidez con la que se están obteniendo las imágenes del TAC, permiten incluso que pacientes hemodinamicamente inestables puedan ser llevados a la realización del TAC e incluso posterior a ello brindarles manejo endovascular. Adoptar las recomendaciones actuales en el manejo del trauma cervical penetrante contribuirá a que esta entidad logre mantener bajas tasas de mortalidad con menor número de exploraciones quirúrgicas negativas y de exploraciones quirúrgicas innecesarias. Es importante conocer la epidemiologia institucional, local y regional del trauma. Para ello se han hecho esfuerzos por fortalecer los registros de trauma y bases de datos que permitan recolectar esta información y poder tomar decisiones acertadas basadas en datos propios. En el capítulo de trauma cervical penetrante, trabajos como este ayudan a conocer en detalle los mecanismos y características del trauma, así como su manejo y desenlaces, que nos ayudan a retroalimentar nuestra práctica clínica y así detectar potenciales oportunidades de mejora. Se debe estimular y promover la realización de más estudios, cada vez más amplios, que caractericen estos perfiles demográficos y contribuyan a realizar cambios y acciones en nuestra práctica clínica. Professor Carlos Ordonez Jefe del Departamento de Cirugía. Universidad del Valle, Cali, Colombia Cirujano de Trauma y Emergencias. Hospital Unuversitario del valle, Fundación Valle del Lili, Cali, Colombia

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INVITED COMMENTARY The therapeutic approach of patients with penetrating wounds to the neck has been in continuous change and evolution over time. In the middle of the last century, mortality rate from penetrating cervical trauma reached more than 30%, which led to an indiscriminate exercise of surgical management due to an increased number of negative explorations (45%) (denominator = all patients). With the introduction of new tools and diagnostic imaging, the concept of selective surgery was introduced in order to reduce the number of negative explorations. Now, the proposal is to be even more selective than selective surgery, using the available diagnostic resources before operating on the patient. This paper shows a 5-year experience of a hospital in Curitiba, Brazil in the management of penetrating cervical trauma, and through it we can compare their results with today´s guidelines in the management of this condition. The negative exploration rate reported in the study was 17.5%, which in our view remains high, if you consider the amount of diagnostic resources available. However, we must not ignore the gap that may exist in the obtaining, availability and promptness of diagnostic resources by some institutions. This limitation may be even more important in developing countries (like most of the region) and of course in remote areas. In addition to the high percentage of negative explorations, there is the problem of unnecessary surgeries. This group of unnecessary surgeries is composed of patients who had cervical exploration for injuries that probably did not require surgical management. The percentage of this group, is high in the present study, in contrast to the current recommendations to avoid unnecessary surgeries. The approach to patients with penetrating wounds to the neck must be: hemodynamic instability or the presence of a ‘hard sign’ as indications for the operating room. Those that do not meet any of these criteria, before surgery, should undergo a computed tomography (CT) arteriography if a carotid injury is suspected; a laryngoscopy/bronchoscopy if a trachea injury is suspected or an esophagogram and esophageal endoscopy if an esophageal injury is suspected. Cervical multislice CT has begun to replace these tests, and today is considered to be the first-line diagnostic tool, thus displacing the above tests to a second-line alternative, only when the CT fails to be conclusive or if there is doubt about the presence of any injury. It is important to observe and supervise patients through a comprehensive physical examination which should not be neglected. The introduction and development of endovascular procedures have positioned this branch of medicine as an alternative in the management of patients with penetrating cervical trauma. Computed tomography findings will be the starting point for defining which patients may benefit from this alternative and thereby avoid unnecessary surgeries. Discipline development and rapid CT scanning, allow us even to take hemodynamically unstable patients to the scanner suite and bring them for an endovascular management. These recommendations in the current management of penetrating cervical trauma may contribute to a lower mortality rate with fewer negative explorations and unnecessary surgical explorations. It is important to know the institutional, local and regional epidemiology of trauma. To this end, efforts have been made to strengthen trauma registries and databases that allow to collect this information and help decision making. In penetrating cervical trauma. Work like this manuscript helps to know in detail trauma mechanisms and characteristics, as well as their management and outcomes, and help us to feedback our clinical practice and thus identify potential improvement opportunities. It should encourage and promote further studies, ever wider, which characterize these demographic profiles and contribute to make changes in our current clinical practice. Professor Carlos Ordonez Jefe del Departamento de Cirugía. Universidad del Valle, Cali, Colombia Cirujano de Trauma y Emergencias. Hospital Unuversitario del valle, Fundación Valle del Lili, Cali, Colombia

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CASE REPORT

10.5005/jp-journals-10030-1124 Traumatic Abdominal Hernia Masquerading as Strangulated Spigelian Hernia

Traumatic Abdominal Hernia Masquerading as Strangulated Spigelian Hernia 1

D Nagarajan, 2Malarvizhi Chandrasekhar, 3Jim Jebakumar, 4Aravind Menon

ABSTRACT

INTRODUCTION

Spigelian hernia is a rare hernia constituting 0.1 to 2% of all hernias and needs high degree of clinical suspicion to diagnose. It has high chances of strangulation and hence operative management is advised. Traumatic abdominal wall hernia (TAWH) is yet another type of rare hernia usually occurring due to blunt trauma. This patient presented with TAWH with features of strangulation, at the anatomical site of Spigelian hernia mimicking a strangulated Spigelian hernia. He underwent emergency exploratory laparotomy, resection and anastomosis of involved small bowel segment with anatomical repair of defect. Patient recovered uneventfully in postoperative period.

Abdominal wall hernia caused by blunt trauma are a rare group of hernias encountered in clinical practice. Traumatic abdominal wall hernia (TAWH) is one among the rarer hernias with around 50 cases reported worldwide.2,3 The etiology in most of the cases is due to blunt trauma to abdomen causing shear force to separate or tear the supporting muscle layers of the abdomen resulting in a hernia. Three types of such hernias have been described by Wood et al: (i) high energy trauma causing large defect, (ii) low energy trauma causing small defect, (iii) deceleration injuries1 causing bowel loop herniation. Spigelian hernia is yet another rare hernia constituting 0.1 to 2% of all hernias and needs high degree of clinical suspicion to diagnose.1 This patient presented with a strangulated TAWH at the anatomical site of Spigelian hernia. Preoperative imaging studies were reported as strangulated Spigelian hernia. Intraoperatively, the abdominal wall defect with a peritoneal rent was identified, anatomical repair was done with resection and anastomosis of involved bowel segment. This case is reported for its rarity of presentation and to emphasize the importance of history and physical examination in preoperative planning even in the setting of an emergency surgery.

Keywords: Post-traumatic, Spigelian, Strangulated hernia, Trauma, Traumatic hernia. How to cite this article: Nagarajan D, Chandrasekhar M, Jebakumar J, Menon A. Traumatic Abdominal Hernia Masquerading as Strangulated Spigelian Hernia. Panam J Trauma Crit Care Emerg Surg 2015;4(2):103-106. Source of support: Nil Conflict of interest: None

RESUMEN Una hernia Spiegeliana es rara que constituye una 0,1 a 2% de todas hernias y necesita de un alto grado de sospecha clínica para el diagnóstico. Cuenta con altas posibilidades de estrangulamiento y por lo tanto se aconseja menejo quirúrgico. Hernias traumáticas de la pared abdominal (TAWH) es otro tipo de hernia rara que ocurre generalmente debido a traumatismo. Este paciente se presentó con TAWH con características de estrangulamiento, en el sitio anatómico de hernia de Spiegel imitando una hernia de Spiegel estrangulada. Se sometió a laparotomía exploratoria de emergencia, resección y anastomosis de segmento del intestino delgado involucrado con la reparación anatómica del defectos. El paciente se recuperó sin problemas en el postoperatorio. Palabras clave: postraumático, Spiegel, hernia estrangulada, Trauma, hernia traumática. Palabras claves: Hernia estrangulada, Hernia traumática, Postraumático, Spiegel, Trauma.

Professor, 2,3Assistant Professor, 4Postgraduate

1-4

Department of General Surgery, Stanley Medical College Chennai, Tamil Nadu, India Corresponding Author: Aravind Menon, Postgraduate Department of General Surgery, Stanley Medical College Chennai, Tamil Nadu, India, Phone: 04425281351, e-mail: aravindmenonk@gmail.com

CASE REPORT A 29-year-old male presented to the emergency ward with complaints of abdominal pain, constipation and vomiting for 10 days. On eliciting history, he gave history of a road traffic accident 15 days back and sustaining blunt injury to anterior abdominal wall with handle bar of autorickshaw along with multiple lacerations to anterior abdominal wall which was sutured in a private clinic on the day of injury. Post-trauma, he was asymptomatic for 5 days. On examination, he had tenderness in the region of left iliac fossa. A mass of size 3 cm diameter with ill defined borders was palpable in the left iliac fossa in the subcutaneous plane and was irreducible. In addition, he had tachycardia and gross dehydration and was febrile. A probable diagnosis of strangulated Spigelian hernia was made keeping in mind the anatomical site as well as the history of trauma. He was resuscitated with intravenous fluids. Blood investigations revealed raised total count with leukocytosis.

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Fig. 1: Preoperative computerized tomograph mimicking a strangulated Spigelian hernia

Computerized tomograph of the abdomen was reported as strangulated Spigelian hernia with dilated bowel loops (Fig. 1). We planned for an exploratory laparotomy. The abdomen was opened through a midline incision and the following findings were noted on exploration:

1. Rent in the peritoneum with disruption of muscle layers causing interparietal herniation and obstruction of bowel loops (proximal ileum) and dilatation of proximal bowel (Fig. 2 to 4). 2. Absence of any hernial sac containing the bowel loops ruling out a Spigelian hernia (Fig. 3). 3. Other solid organs and hollow viscera were normal. The muscle tear was enlarged with cautery and obstructed bowel loops were taken out through the rent in the peritoneum. Though the loops were healthy, a constricting ring was found to obstruct normal peristalsis (Fig. 4). Keeping in mind the young age of the patient, the involved 20 cm of bowel including the constriction ring was resected and primary ileoileal anastomosis was done. The tear in the peritoneum and muscle layers which caused the hernia was repaired by layered suturing (Fig. 5). Patient developed wound infection in the 4th postoperative day which was managed conservatively with antibiotics. Patient recovered well and was discharged on 14th postoperative day.

Fig. 3: Traumatic hernia with bowel loops as content

Fig. 4: Obstructed bowel loops with constriction ring

Fig. 2: Bowel loops herniating through the peritoneal rent

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PAJT Traumatic Abdominal Hernia Masquerading as Strangulated Spigelian Hernia

Fig. 5: After primary tension-free layered repair of the defect

DISCUSSION Traumatic abdominal wall hernia was first described by Selby3 in 1906. It was defined as immediate appearance of hernia through the disrupted muscle and fascia after blunt abdominal trauma, and failure of the injury to penetrate the skin by Damschen et al.6 The only available classification for these hernia is by Wood et al who classified it into three types: 1. Large defect usually caused from high velocity, high energy blunt force; commonly associated with visceral injury, e.g. fall from height. 2. Small defect associated with low velocity, low energy impact; visceral injuries less common, e.g. two wheeler handle bar injury. 3. Bowel loop herniation due to decelaration injuries. These are extremely rare. The clinician must examine the patient with a high index of suspicion as most cases of TAWH are associated with visceral injuries. History is very contributory and a proper history can clinch the diagnosis. Computerized tomograph preferably contrast enhanced, is the investigation of choice.4,5 Management is invariably surgical as chances for obstruction or strangulation is relatively high. High velocity injuries usually demand a thorough exploratory laparotomy as these are associated with visceral injuries. Many surgeons debate the necessity of this.7 Small hernias may be operated by local incisions.8 In the event of suspected visceral injury, diagnostic laparoscopy and proceed is a reliable option.5 We follow early exploration and repair for cases of traumatic hernia in our center. Some surgeons prefer delayed reconstruction of the abdominal wall9 defect though we do not recommend this. This is due to the probability that the trauma sustained to the muscles and

fascia may go for secondary contracture causing a difficulty in approximation of the defect and undue tension in delayed repair. We did an anatomical repair of the defect safely with absorbable sutures as we could achieve tension free approximation. Nonabsorbable sutures may have an advantage though previous reports show no disadvantages in using absorbable sutures.10-12 The option of prosthetic mesh repair has been highlighted by many authors.13,14 We agree that mesh repair has its own advantages in preventing long-term recurrence after traumatic hernia repair.4 But in cases of emergency surgery if tension free layer by layer repair is achievable, it is to be preferred as it saves much of the operating time in an emergency setting required for a mesh repair. However, repair of large defects may be reinforced with a prosthetic mesh to avoid long-term complication of recurrence in the absence of intra-abdominal sepsis.15 We leave the choice of primary repair or prosthetic mesh repair to the specificity of the case and surgeonâ&#x20AC;&#x2122;s preference. Overall, the trauma surgeons must have a good knowledge of the entity of TAWH for timely diagnosis and to choose the correct management for the benefit of the patient. We recommend early timely surgical exploration with layered anatomical tension-free repair of the defect as a safe management option in such patients.

REFERENCES 1. Montes IS, Deysine M. Spigelian and other common hernia repairs. Surg Clin North Am 2003;83(5):1235. 2. Lane CT, Cohen AJ, Cinat ME. Management of traumatic abdominal wall hernia. Am Surg 2003;69(1):73-76. 3. Selby CD. Direct abdominal hernia of traumatic origin. JAMA 1906;47(18):1485-1486. 4. Choi HJ, et al. Traumatic abdominal wall hernia: a case study highlighting surgical management. Yonsei Med J 2007; 48(3):549-553. 5. Aravinda PS, et al. Traumatic Spigelian hernia: a rare clinical scenario. J Clin Diag Res 2014 May;8(5):D01-ND02. 6. Damschen DD, Landercasper J, Cogbill TH, Stolee RT. Acute traumatic abdominal hernia: case reports. J Trauma 1994; 36(2):273-276. 7. Perez VM, Mc Donald AD, Ghani A, Bleacher JH. Handlebar hernia: a rare traumatic abdominal wall hernia. J Trauma 1998;44(3):568. 8. Goliath J, Mittal V, McDonough J. Traumatic handlebar hernia: a rare abdominal wall hernia. J Pediatr Surg 2004; 39(10):e20-e22. 9. Kubalak G. Handlebar hernia: case report and review of literature. J Trauma 1994;36(3):438-439. 10. Shiomi H, Hase T, Matsuno S, Izumi M, Tatsuto T, Ito F, et al. Handlebar hernia with intra-abdominal extraluminal air presenting as novel form of traumatic abdominal wall hernia: report of a case. Surg Today 1999;29(12):1280-1284.

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D Nagarajan et al 11. Fraser N, Milligan S, Arthur RJ, Crabbe DC. Handlebar hernia masquerading as an inguinal hematoma. Hernia 2002;6(1): 39-41. 12. Iunuma Y, Yamazaki Y, Hirose Y, Kinoshita H, Kumagai K, Tanaka T, et al. A case of a traumatic abdominal wall hernia that could not be identified until exploratory laparoscopy was performed. Pediatr Surg Int 2005;21(1):54-57.

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13. Vargo D, Schurr M, Harms B. Laparoscopic repair of a traumatic ventral hernia. J Trauma 1996;41(2):353-355. 14. Mancel B, Aslam A. Traumatic abdominal wall hernia: an unusual bicycle handlebar injury. Pediatr Surg Int 2003;19(11):746-747. 15. Santora TA, Roslyn JJ. Incisonal hernia. Surg Clin North Am 1993;73(3):557-570.

PAJT

LETTER-TO-EDITOR

10.5005/jp-journals-10030-1125 Depressed Fracture Involving the Posterior Fossa in a Child

Depressed Fracture Involving the Posterior Fossa in a Child Amit Agrawal

Depressed fracture involving the posterior fossa is an uncommon sequel of head injury.1-4 A 4-year-old female child presented 8 hours after with the history of fall while playing from 4â&#x20AC;&#x2122; height at home on her back. She had loss of consciousness for 1 hour and multiple episodes of vomiting. There was no history of ear, nasal, oral bleed or seizures. Her general and systemic examination was unremarkable. The child was dull. Her glasgow coma scale (GCS) was E4, V5, and M6. Pupils were bilateral equal and reacting to light. There were no motor or sensory deficits. There was palpable depression over left occipital region with bogginess and tenderness. A computed tomography scan brain with bone window revealed significant depressed fracture of left occipital bone with mass effect (Figs 1 and 2). The patient underwent elevation of the depressed fracture (Figs 3A and B). She recovered completely. The most common cause of posterior fossa fracture in children is fall followed by road traffic accidents.1 In contrast to adults (because of multiple layers of muscle and soft-tissue covering the suboccipital region)2,3 children have thin skull and relatively less soft-tissue in the suboccipital region which make them more vulnerable to sustain posterior fossa depressed fractures.1 It has been estimated that 16% of children may have skull fractures and the presence of a skull fracture can increase the risk of an underlying intracranial injury by fourfold.5 Brainstem and cerebellar compression can lead to brainstem dysfunction 2,6 which can be fatal.6 In addition, these patients can have associated with cervical spinal cord injuries.2 As for any given case of suspected head injury, the CT scan is the investigation of choice to investigate a case of suspected posterior fossa fracture.7 We need to remember that the posterior fossa is a crowded space

C Professor Department of Neurosurgery, Narayana Medical College and Hospital, Sasaram, Bihar, India Corresponding Author: Amit Agrawal, Professor Department of Neurosurgery, Narayana Medical College and Hospital, Sasaram, Bihar, India, Phone: 2658898, e-mail: dramitagrawal@gmail.com

Figs 1A to C: Axial CT sections of brain: showing depressed fracture of occipital bone on left side with inward displacement of the fracture fragments causing mild mass effect over the left cerebellar hemisphere and effacement of fourth ventricle on same side

and has a relatively small volume and hence any lesion has the potential to further reduce its volume leading to rise in intracavitary pressure.6 Most of the patients

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Amit Agrawal

with posterior fossa depressed fractures can be managed conservatively.4 The indications for neurosurgical intervention are neurological deficit (s) due to mass effect and compression of the underlying neural structures, compound injuries or cosmetic deformity.6 Usually in neurologically well preserved and uncomplicated cases the outcome is excellent,1,4 however significant compression of the brainstem structures is associated with poorer outcome.6 A

Figs 2A and B: Axial CT scan sections bone window showing segmental inward depressed fracture involving the occipital bone on left in detail

B Figs 3A and B: Intraoperative photographs: (A) communized depressed fracture fragments involving occipital bone and (B) occipital bone after elevation of the fractured fragments

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REFERENCES 1. Colak A, Berker M, Ozcan OE. Occipital depression fractures in childhood. A report of 14 cases. Childs Nerv Syst 1991;7(2): 103-105. 2. Motozaki T, Otsuka S, Sato S, Nakao S, Ban S, Fukumitsu T, Yamamoto T. [Unusual case of depressed fracture of the posterior cranial fossa associated with the syndrome of acute central cervical spinal cord injury]. No Shinkei Geka 1986; 14(8):1005-1008. 3. Motozaki T, Yamamoto T. Unusual case of depressed fracture in the posterior cranial fossa associated with the syndrome of acute central cervical spinal cord injury. Neurosurgical Review 1989;12(Suppl 1):595-599. 4. Karasawa H, Furuya H, Naito H, Sugiyama K, Ueno J, Kin H. Acute hydrocephalus in posterior fossa injury. J Neurosurg 1997;86(4):629-632. 5. Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Pediatrics 1997; 99(5):E11. 6. Bharath R, Arivazhagan A, Pruthi N, Bhat DI. Rare case of closed depressed fracture of the posterior fossa in an adult causing brainstem dysfunction: management dilemmas. Neurol India 2011;59(5):778-779. 7. Schutzman SA, Greenes DS. Pediatric minor head trauma. Annals of Emergency Medicine 2001;37:65-74.