Transport of critically ill patients

Intrahospital transport of critically ill patients is often necessary for optimal patient care. The increasing sophistication of nonportable diagnostic tests that aid physicians in diagnosing complex problems require the transport of critically ill patients outside the protective environment of the intensive care unit for prolonged periods. However, transport of intensive care unit patients within the hospital has been associated with a high rate of potentially detrimental complications. Interfacility patient transfers should occur when the benefits to the patient exceed the risks of the transfer. When a patient needs services that exceed the available resources of a facility, the patient should be transferred to a facility with the required resources. The decision to transfer a patient is the responsibility of the attending physician at the referring hospital. In this article, we discussed the role of intrahospital and interhospital transport of the critically ill patient.O transporte intra-hospitalar do paciente crítico faz-se necessário para seu encaminhamento da sala de admissão ao Centro Cirúrgico ou à Unidade de Terapia Intensiva e para a realização de testes diagnósticos não portáteis, partindo da sala de admissão ou da unidade de terapia intensiva. A duração do transporte pode ser prolongada, ficando o paciente fora do ambiente “protegido” de um área de cuidados intensivos, sendo um período de potenciais complicações. O transporte inter-hospitalar deve ocorrer, quando os benefícios esperados para o paciente crítico excedem os riscos inerentes ao transporte e, também, quando o paciente necessita de cuidados que não existam no hospital onde está. A decisão e a efetuação do transporte são responsabilidade do médico que o assiste. Tal transporte envolve a presença de um veículo adaptado com todos os equipamentos necessários para a monitorização e suporte avançado de vida. Neste artigo, os autores discutem o papel do transporte intra e inter-hospitalar do paciente crítico

Trauma severity indices

A caracterização e documentação dos vários graus de lesões traumáticas são os requisitos básicos para a avaliação do sistema de atendimento ao trauma e para o desenvolvimento de iniciativas para o seu controle. Os índices de trauma são valores matemáticos ou estatísticos, quantificados por escores numéricos, que variam de acordo com a intensidade e os tipos de lesões decorrentes do traumatismo, medidos através de parâmetros anatômicos e fisiológicos. Tais índices representam uma importante e essencial ferramenta para estudos clínicos em trauma. Este artigo descreve vários dos índices de trauma mais comumente utilizados e suas aplicações.Characterization and documentation of injury severity are requirements for the evaluation of trauma systems and development of iniciatives in injury control. Many indices employing measures of physiologic or anatomic derangement have been developed to quantify injury severity. Trauma scores represent na important and essential tool for clinical studies in trauma besides their use in the characterization of preventable deaths. This article describes several of the more commonly used indices and their applications

Pediatric trauma patient

The purpose of this chapter is to present those principles of care that impact the integrity of the airway, breathing, and circulation or influence the priorities of advanced trauma life support for the pediatric trauma patient. Assessment and treatment decisions must be made quickly to prevent progression and deterioration to respiratory failure and cardiopulmonary arrest. Definitive evaluation and initial treatment of most other injuries can be safely undertaken after ventilation, oxygenation, and perfusion have been restored. Such definitive care is provided upon completion of the secondary survey, a detailed head-to-toe examination for detection of specific injuries.Este artigo revê os princípios do atendimento inicial ao traumatizado pediátrico, após uma revisão das características específicas da anatomia e fisiologia na infância. Aborda as diferentes situações através das quais o traumatizado pediátrico pode se apresentar e discute as opções que existem em cada fase do atendimento primário, bem como delineia os cuidados definitivos em lesões de alguns sistemas específicos

Trauma in pregnancy

The priorities for management of the pregnant patient are no different than those of the nonpregnancy patient. It is important to follow a methodic evaluation that ensures complete assessment and stabilization of the mother. The mother should be stabilized before the stabilization of the fetus. The physiologic and anatomic changes during the pregnancy can influence outcome. Continuous fetal and maternal monitoring may be necessary. This article discuss about blunt and penetrating abdominal trauma, peritoneal lavage and indications of exploratory laparotomy. Cardiopulmonary resuscitation in pregnancy and perimortem cesarean delivery is considered. Indicators may suggest the presence of domestic violence and should serve to initiate further investigation.Este artigo faz uma revisão das alterações anatômicas e fisiológicas que ocorrem durante a gestação e estabelece os princípios da abordagem à gestante traumatizada, delineando os aspectos da monitorização materna e fetal e as patologias próprias da gestação. Diferenciam-se os traumas contusos e penetrantes, discutindo-se o papel do lavado peritoneal diagnóstico e da laparotomia exploradora. Discutem-se a abordagem da gestante em parada cardiorrespiratória e as indicações de cesárea perimorte, bem como os indícios de violência doméstica

The severity assessment of critically ill preeclamptic women: a case-control study

BACKGROUND AND OBJECTIVES: The assessment of illness severity and prognosis of obstetric patients by scoring systems is still a controversial issue. Preeclampsia is a leading cause of severe maternal morbidity and mortality, and a major cause of obstetric admission to intensive care unit. There is paucity of data regarding the predictability of critically ill preeclamptic women and the application of scoring systems to this population. This study aimed to evaluate and compare the application of APACHE II, SAPS II and MPM II scoring systems between a preeclamptic population and a non obstetric female population. METHODS: A case-control study was conducted on 28 preeclamptic women and 56 non obstetric female patients, admitted to a general intensive care unit over a period of 10 years. The predictive accuracy of the prognostic evaluation systems was estimated by the area under the receiver operator characteristic curve. RESULTS: The mortality rate was 21.4% (6:28) for the study group and 35.7% (20:56) for the control group, with an OR = 0.49 (95%CI = 0.17-1.41). The main causes of ICU admission of preeclamptic women were HELLP syndrome, coma and pulmonary edema. In the preeclamptic population, only the MPM II score showed an area under the ROC curve statistically different from 0.500, while in the control group, all scoring systems had their areas under the ROC curves statistically different from 0.500. CONCLUSIONS: The application of APACHE II and SAPS II to evaluate critically ill preeclamptic women may be not appropriate

Severe arrhythmia after lithium intoxication in a patient with bipolar disorder admitted to the intensive care unit

Submitted by Nuzia Santos ([email protected]) on 2014-06-03T17:19:03Z No. of bitstreams: 1 . Severe arrhythmia after lithium intoxication in a patient with bipolar disorder admitted to the intensive care unit.pdf: 685842 bytes, checksum: 9f56126bd0e30f8c65f8d6bee51ecd37 (MD5)Made available in DSpace on 2014-06-03T17:19:03Z (GMT). No. of bitstreams: 1 . Severe arrhythmia after lithium intoxication in a patient with bipolar disorder admitted to the intensive care unit.pdf: 685842 bytes, checksum: 9f56126bd0e30f8c65f8d6bee51ecd37 (MD5) Previous issue date: 2012Universidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Hospital das Clínicas. Departamento de Cirurgia e Anatomia. Divisão de Terapia Intensiva. Ribeirão Preto, SP, BrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Hospital das Clínicas. Departamento de Cirurgia e Anatomia. Divisão de Terapia Intensiva.Fundação Oswaldo Cruz. Centro de Pesquisas René Rachou. Laboratorio de Monitoração e Biomarcadores. Belo Horizonte, MG, BrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Hospital das Clínicas. Departamento de Cirurgia e Anatomia. Divisão de Terapia Intensiva. Ribeirão Preto, SP, BrasilDespite its narrow therapeutic index, lithium remains widely used as a mood stabilizer for the treatment of bipolar disease. The cardiac side-effects of lithium have been well documented, and may induce non-specific T-wave flattening, prolonged QT interval, sinus node dysfunction and also ventricular tachycardia and ventricular fibrillation. We report the case of a 61-year-old male patient diagnosed with bipolar disorder who developed life-threatening cardiac manifestations secondary to severe lithium poisoning. Although hemodialysis was performed and the arrhythmias were adequately treated, the patient died on the sixth day after hospital admission due hemorrhagic complications after tracheostomy

Essential role of CCR2 in neutrophil tissue infiltration and multiple organ dysfunction in sepsis

Rationale: Sepsis is defined as a systemic inflammatory response to infection, which in its severe form is associated with multiple organ dysfunction syndrome (MODS). The precise mechanisms by Which MODS develops remain unclear. Neutrophils have a pivotal role in the defense against infections; however, overwhelming activation of neutrophils is known to elicit tissue damage. Objectives: We investigated the role of the chemokine receptor CCR2 in driving neutrophil infiltration and eliciting tissue damage in remote organs during sepsis. Methods: Sepsis was induced in wild-type mice treated with CCR2 antagonist (RS504393) or CCR2(-/-) mice by cecal ligation and puncture (CLP) model. Neutrophil infiltration into the organs was measured by myeloperoxidase activity and fluorescence-activated cell sorter. CCR2 expression and chemotaxis were determined in neutrophils stimulated with Toll-like receptor agonists or isolated from septic mice and patients. Measurements and Main Results: CCR2 expression and responsiveness to its ligands was induced in circulating neutrophils during CLP-induced sepsis by a mechanism dependent on Toll-like receptor/nuclear factor-kappa B pathway. Genetic or pharmacologic inhibition of CCR2 protected mice from CLP-induced mortality. This protection was associated with lower infiltration of neutrophils into the lungs, heart, and kidneys and reduced serum biochemical indicators of organ injury and dysfunction. Importantly, neutrophils from septic patients express high levels of CCR2, and the severity of patient illness correlated positively with increasing neutrophil chemotaxis to CCR2 ligands. Conclusions: Collectively, these data identify CCR2 as a key receptor that drives the inappropriate infiltration of neutrophils into remote organs during sepsis. Therefore, CCR2 blockade is a novel potential therapeutic target for treatment of sepsis-induced MODS.</p

Tétanos grave asociado con choque séptico en una paciente anciana ingresada en la unidad de cuidados intensivos

Submitted by Nuzia Santos ([email protected]) on 2014-06-03T13:34:14Z No. of bitstreams: 1 125.pdf: 1025274 bytes, checksum: e07c02b22066dbc1915e59db3967e982 (MD5)Made available in DSpace on 2014-06-03T13:34:14Z (GMT). No. of bitstreams: 1 125.pdf: 1025274 bytes, checksum: e07c02b22066dbc1915e59db3967e982 (MD5) Previous issue date: 2012Universidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Hospital das Clínicas. Departamento de Cirurgia e Anatomia. Divisão de Terapia Intensiva. Ribeirão Preto, SP, Brasil.Universidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Hospital das Clínicas. Departamento de Cirurgia e Anatomia. Divisão de Terapia Intensiva. Ribeirão Preto, SP, Brasil.Universidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Hospital das Clínicas. Departamento de Cirurgia e Anatomia. Divisão de Terapia Intensiva. Ribeirão Preto, SP, Brasil.Universidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Hospital das Clínicas. Departamento de Cirurgia e Anatomia. Divisão de Terapia Intensiva. Ribeirão Preto, SP, Brasil.Fundação Oswaldo Cruz. Centro de Pesquisas René Rachou. Fundação Oswaldo Cruz Belo HorizonteUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Hospital das Clínicas. Departamento de Cirurgia e Anatomia. Divisão de Terapia Intensiva. Ribeirão Preto, SP, Brasil.Nós relatamos um caso de tétano grave associado a choque séptico em uma paciente de 61 anos admitida na Unidade de Terapia Intensiva (UTI) após perfurar o pé direito. A paciente apresentou perda de força muscular, paresia em membro inferior direito e disfagia. A paciente evoluiu com espasmos musculares generalizados, dispnéia e insuficiência respiratória. O espasmo intenso levou ao uso prolongado de ventilação mecânica invasiva, sedação e bloqueador neuromuscular. A evolução favorável deste caso está provavelmente relacionada aos avanços na gestão de UTI e uma equipe médica e de enfermagem bem treinadas.We report a case of severe tetanus associated with septic shock in a 61-year-old female admitted to the Intensive Care Unit (ICU) after perforating injury in the right foot. The patient presented with loss of muscle strength, paresis in the right lower limb and dysphagia. The patient’s conditions worsened, progressing to generalized muscle spasms, dyspnea, and respiratory failure. Intense spasm made the prolonged use of invasive mechanical ventilation, sedation, and neuromuscular blockers necessary. The favorable outcome in the present case is probably related to advances in ICU management and well-trained medical and nursing staff.Se presenta un caso de tétanos relacionado con choque séptico grave en una paciente de 61 años ingresada en la Unidad de Cuidados Intensivos (UCI) después de perforar el pie derecho. El paciente tenía pérdida de fuerza muscular, parálisis de la pierna derecha y disfagia. El paciente desarrolló espasmos musculares generalizados, disnea e insuficiencia respiratoria. El espasmo intenso llevó al uso prolongado de ventilación mecánica, sedación y bloqueo neuromuscular. La evolución favorable de este caso está probablemente relacionada con los avances en la gestión de cuidados intensivos y un personal médico y de enfermería bien capacitado