Independent early predictors of mortality in polytrauma patients: a prospective, observational, longitudinal study

OBJECTIVES: Trauma is an important public health issue and associated with substantial socioeconomic impacts and major adverse clinical outcomes. No single study has previously investigated the predictors of mortality across all stages of care (pre-hospital, emergency room, surgical center and intensive care unit) in a general trauma population. This study was designed to identify early predictors of mortality in severely injured polytrauma patients across all stages of care to provide a better understanding of the physiologic changes and mechanisms by which to improve care in this population. METHODS: A longitudinal, prospective, observational study was conducted between 2010 and 2013 in São Paulo, Brazil. Patients submitted to high-energy trauma were included. Exclusion criteria were as follows: injury severity scor

New technologies and emergency department excellence

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Helicopter emergency medical services (HEMS) for the traumatized in the metropolitan region of Campinas-SP

Orientador: Gustavo Pereira FragaDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: O atendimento pré-hospitalar sofreu enormes avanços nas últimas décadas. Especificamente os conflitos armados contribuíram sobremaneira para a evolução do atendimento ao traumatizado, e dentro desse contexto, espelhando-se em experiências bem sucedidas nos períodos de guerra, o resgate e atendimento de pacientes utilizando o helicóptero foi estabelecido, passando posteriormente a ser amplamente utilizado no ambiente civil. O presente estudo tem por objetivo analisar descrever o perfil de doentes atendidos pelo sistema de resgate aeromédico na Região Metropolitana de Campinas, correlacionando-o ao apresentado na literatura mundial sobre o assunto, avaliando critérios de triagem e acionamento; tempo resposta, tempo de atendimento e de transporte; procedimentos invasivos realizados no APH; gravidade dos doentes; morbidade e mortalidade. Foi realizado estudo prospectivo descritivo, no qual foram analisados prontuários e fichas médicas de pacientes atendidos no período entre julho de 2010 e dezembro de 2012. Nesse período, 242 vítimas foram atendidas pela equipe de RA e levadas ao HC - Unicamp. Dos 242 pacientes, 22 foram excluídos do estudo, sendo que os dados de 220 pacientes foram analisados. Dos 220 casos avaliados, 173 (78,6%) eram do sexo masculino, com média de idade de 32 anos. O trauma contuso foi o mais frequente, acometendo 207 (94,1%) vítimas, sendo que dessas, 66 (30,0%) sofreram acidentes envolvendo motocicletas, 51 (23,2%) envolveram-se em colisões automobilísticas, 32 (14,5%) foram vítimas de quedas de altura, 31 (14,1%) sofreram atropelamentos. O tempo resposta médio foi de 10 ± 4 minutos, variando entre 3 e 48 minutos e o tempo total de pré-hospitalar teve média de 42 ± 11 minutos, variando entre 14 e 109 minutos. Os valores médios dos índices de trauma foram: RTS = 6,2 ± 2,2; ISS = 19,2 ± 12,6; e TRISS = 0.78 ± 0.3. Quarenta e três doentes (19,5%) obtiveram RTS de 7,84 e ISS ? 9, sendo classificados como "supertriados". Do total de pacientes admitidos, 185 (84,1%) receberam alta, com tempo médio de internação de 17,8 dias. O resgate aeromédico é uma importante ferramenta nos sistemas de atendimento a traumatizados. Apesar de sua ampla utilização, questões ainda permanecem em aberto acerca do real benefício desse recurso, e da melhor maneira de empregá-lo. O serviço de RA na cidade de Campinas é o primeiro a ser implantado em uma base no interior do estado de São Paulo, e apresenta dados bastante semelhantes aos apresentados na literatura. Houve um elevado índice de supertriagem, fato que demonstra a necessidade de se aperfeiçoarem os critérios de triagem e acionamento. Apesar do foco do presente estudo não ser a análise de influência do RA na sobrevida do paciente, nem a comprovação de seu custo efetividade, resultados como os descritos acima servem de estímulo para um estudo específico e mais aprofundado sobre o assunto, no contexto nacionalAbstract: Pre-hospital care has suffered enormous advances during the last decades. Armed conflicts have contributed greatly to the evolution of trauma care, and within this context, inspired by the successful experiences during periods of war, the rescue and care of patients using the helicopter was established, passing later to be widely used in the civilian environment. The present study aims at analyzing the profile of patients treated by the aeromedical rescue system in the metropolitan region of Campinas, correlating it to the data available in world literature on this subject. The topics evaluated will be: triage and activation criteria; response time, on scene time and transport time; invasive procedures performed in pre-hospital care; severity of trauma; morbidity and mortality. A prospective descriptive study was conducted, in which were analyzed charts and medical records of patients in the period between July 2010 and December 2012. During this period, 242 victims were treated by the aeromedical rescue team, and brought to the HC-Unicamp. Of the 242 patients, 22 were excluded from the study, and the data of 220 patients were analyzed. Of the 220 cases evaluated, 173 (78.6%) were male, with a mean age of 32 years. Blunt trauma was the most prevalent (207 cases - 94.1%) with the most common causes being motorcycle accidents (66 cases - 30%) and automobile collisions (51 cases - 23.2%). The average response time was 10 ± 4 minutes, varying between 3 and 48 minutes and total pre-hospital time averaged 42 ± 11 minutes, varying between 14 and 109 minutes. The mean values of the indices of trauma were: RTS = 6.2 ± 2.2, ISS = 19.2 ± 12.6 and TRISS = 0.78 ± 0.3. Pre-hospital traqueal intubation was performed in 77 cases (35%) and 43 patients (19.5%) had an RTS of 7.84 and an ISS ? 9, and were classified as overtriage. Of all patients admitted, 185 (84.1%) were discharged. The aeromedical rescue is an important tool in trauma systems. Despite its wide use, questions still remain unanswered about the real benefit of this feature, and the best way to use it. The aeromedical rescue service in the city of Campinas is the first to be stablished at a countryside base in the State of São Paulo, and presents data quite similar to those presented in the literature. There was a high rate of overtriage, a fact that demonstrates the need to improve the triage and activation criteria. Despite the focus of the present study was not the analysis of influence of aeromedical rescue in the survival rates of these patients, nor proof of its cost effectiveness, results like those described above serve as a stimulus for a specific and in-depth study on the subject, in the national contextMestradoFisiopatologia CirúrgicaMestre em Ciência

Muscle graft as a substitute for peripheral nerve graft in rats Enxerto de músculo como substituto de nervo periférico em ratos

PURPOSE: To evaluate the applicability of the use of autogenous muscle treated in various ways, as a substitute of the nerve grafts. METHODS: Rats were divided into seven groups that received, as a treatment for a standard nerve injury, the following types of grafts: fresh muscle, muscle fixed with 10% formaldehyde, muscle frozen in a freezer, muscle frozen in refrigerator, nerveless muscle, peripheral nerve and a group was without any treatment. It assessed the histological appearance of the nerve fibers in the segment repaired. RESULTS: The evaluation of the segment nervous repaired showed nerve fibers through the graft in almost all groups, but the methodology employed has not adequately characterized the differences between the groups. CONCLUSION: This study showed the migration of nerves fibers through all grafts used.<br>OBJETIVO: Avaliar a aplicabilidade do uso de músculo autógeno, tratado de diversas maneiras, em substituição aos enxertos de nervo. MÉTODOS: Os ratos foram separados em sete grupos que receberam, como tratamento a uma lesão nervosa padronizada, os seguintes tipos de enxertos: músculo fresco, músculo fixado com formol 10%, músculo congelado em freezer, músculo congelado em refrigerador, músculo denervado, nervo periférico e um grupo ficou sem qualquer tratamento. Foi avaliado o aspecto histológico das fibras nervosas no segmento reparado. RESULTADOS: A avaliação do segmento nervoso reparado mostrou que existiam axônios em quase todos os grupos, mas a metodologia empregada não possibilitou caracterizar adequadamente as diferenças entre os grupos. CONCLUSÃO: Este estudo mostrou a migração de axônios por meio de todos os enxertos utilizados

Independent early predictors of mortality in polytrauma patients: a prospective, observational, longitudinal study

OBJECTIVES: Trauma is an important public health issue and associated with substantial socioeconomic impacts and major adverse clinical outcomes. No single study has previously investigated the predictors of mortality across all stages of care (pre-hospital, emergency room, surgical center and intensive care unit) in a general trauma population. This study was designed to identify early predictors of mortality in severely injured polytrauma patients across all stages of care to provide a better understanding of the physiologic changes and mechanisms by which to improve care in this population. METHODS: A longitudinal, prospective, observational study was conducted between 2010 and 2013 in São Paulo, Brazil. Patients submitted to high-energy trauma were included. Exclusion criteria were as follows: injury severity score <16, <18 years old or insufficient data. Clinical and laboratory data were collected at four time points: pre-hospital, emergency room, and 3 and 24 hours after hospital admission. The primary outcome assessed was mortality within 30 days. Data were analyzed using tests of association as appropriate, nonparametric analysis of variance and generalized estimating equation analysis (p<0.05). ClinicalTrials.gov: NCT01669577. RESULTS: Two hundred patients were included. Independent early predictors of mortality were as follows: arterial hemoglobin oxygen saturation (p<0.001), diastolic blood pressure (p<0.001), lactate level (p<0.001), Glasgow Coma Scale score (p<0.001), infused crystalloid volume (p<0.015) and presence of traumatic brain injury (p<0.001). CONCLUSION: Our results suggest that arterial hemoglobin oxygen saturation, diastolic blood pressure, lactate level, Glasgow Coma Scale, infused crystalloid volume and presence of traumatic brain injury are independent early mortality predictors