Retos asistenciales en la atención al paciente traumatizado en España. La necesidad de implementación de la evidencia científica incluyendo la prevención secundaria

Producción CientíficaThe mortality of trauma patients has improved significantly in recent decades due to a combination of factors: medical care, educational campaigns and structural changes. Generalization of both out-of hospital emergence medical services and the hospital care in specific centers for traumatized has undoubtedly contributed to this decline, but other factors such as periodic campaigns to prevent workplace and traffic accidents, as well as improvements in the road network have played a key role. The challenge now is to contain mortality, for which is essential an analysis of the situation to detect potential areas of improvement. The application of diagnostic or therapeutic actions with scientific evidence is associated with lower mortality, but as in other areas of medicine, the application of scientific evidence in trauma patients is barely 50%. Moreover, nearly 90% of trauma deaths occur in the crash site or during the first 72 h of hospitalization, the vast majority as a result of injuries incompatible with life. In these circumstances it is clear that prevention is the most cost-effective activity. As medical practitioners, our role in prevention is mainly focused on the secondary prevention to avoid recidivism, for which it is necessary to identify the possible risk factors (frequently alcohol, illegal drugs, psychotropic medication, etc.) and implement a brief motivational intervention. This activity can reduce recidivism by nearly 50%. In Spain, the activity in this field is negligible; therefore, measures should be implemented for dissemination of secondary prevention in trauma

Alveolar fluid clearance in healthy pigs and influence of positive end-expiratory pressure

Journal Article;INTRODUCTION The objectives were to characterize alveolar fluid clearance (AFC) in pigs with normal lungs and to analyze the effect of immediate application of positive end-expiratory pressure (PEEP). METHODS Animals (n = 25) were mechanically ventilated and divided into four groups: small edema (SE) group, producing pulmonary edema (PE) by intratracheal instillation of 4 ml/kg of saline solution; small edema with PEEP (SE + PEEP) group, same as previous but applying PEEP of 10 cmH2O; large edema (LE) group, producing PE by instillation of 10 ml/kg of saline solution; and large edema with PEEP (LE + PEEP) group, same as LE group but applying PEEP of 10 cmH2O. AFC was estimated from differences in extravascular lung water values obtained by transpulmonary thermodilution method. RESULTS At one hour, AFC was 19.4% in SE group and 18.0% in LE group. In the SE + PEEP group, the AFC rate was higher at one hour than at subsequent time points and higher than in the SE group (45.4% vs. 19.4% at one hour, P < 0.05). The AFC rate was also significantly higher in the LE + PEEP than in the LE group at three hours and four hours. CONCLUSIONS In this pig model, the AFC rate is around 20% at one hour and around 50% at four hours, regardless of the amount of edema, and is increased by the application of PEEP.Ye

Efecto de las drogas alucinógenas, estimulantes y depresoras del sistema nervioso central sobre la gravedad de la lesión en pacientes ingresados por traumatismos

Objective: The effect of drugs other than alcohol on severity of trauma remains unclear. Pooled data analyses in previous studies that grouped substances with opposite effects on the central nervous system (CNS) may have masked the influence of substances on injury severity. The aim was to analyze the effect of stimulant, hallucinogenic and depressant drugs other than alcohol on injury severity in trauma patients. Methods: The presence of alcohol, stimulant drugs (cocaine, amphetamines and methamphetamines), depressant drugs (benzodiazepines, opiates, methadone and barbiturates) and hallucinogenic drugs (THC and PCP) was analyzed in 1187 patients between 16 and 70 years old admitted to a trauma hospital between November 2012 and June 2015. Injury severity was determined prospectively as the Injury Severity Score. A multivariate analysis was used to quantify the strength of association between exposure to substances and trauma severity, using the presence of alcohol as a stratification variable. Results: Drugs other than alcohol were found in 371 patients (31.3%): 32 (2.7%) stimulants, 186 (15.3%) depressants, 78 (6.6%) hallucinogenics and 75 (5.6%) polydrug use. The presence of CNS depressant substances was associated with increased injury severity only in patients also exposed to alcohol, with an adjusted odds ratio of 4.63 (1.37-15.60) for moderate injuries and 7.83 (2.53-24.21) for severe. Conclusion: CNS depressant drugs had a strong influence on injury severity in patients who screened positive for alcohol consumption.Objetivo: No está claro qué efecto tienen las drogas distintas del alcohol sobre la gravedad de los traumatismos. Los análisis incluidos en estudios previos, que agrupan sustancias con efectos opuestos sobre el sistema nervioso central (SNC), pueden haber enmascarado la influencia de estas sobre la gravedad. El objetivo fue analizar el efecto de las drogas alucinógenas, estimulantes y depresoras del SNC, diferentes del alcohol, sobre la gravedad de las lesiones en pacientes ingresados por traumatismos. Métodos: Se analizó la presencia de alcohol, drogas estimulantes (cocaína, anfetaminas y metanfetaminas), depresoras (benzodiacepinas, opiáceos, metadona y barbitúricos) y alucinógenas (THC y PCP) en 1187 pacientes de entre 16 y 70 años de edad ingresados por traumatismo de noviembre de 2012 a junio de 2015. La gravedad del traumatismo se determinó prospectivamente mediante la Injury Severity Score. Se cuantificó la fuerza de la asociación entre la exposición a sustancias y la gravedad del traumatismo mediante un análisis multivariante, utilizando la presencia de alcohol como variable de estratificación. Conclusión: Las drogas depresoras del SNC tuvieron una fuerte influencia en la gravedad del traumatismo en los pacientes que además presentaban resultados positivos para consumo de alcohol.This work was supported by the Dirección General de Tráfico, Spain [No. 0100DGT22389] and the Consejería de Salud, Junta de Andalucía, Spain [No. PI-0691-2013]

Effect of a brief intervention for alcohol and illicit drug use on trauma recidivism in a cohort of trauma patients

OBJETIVO Estime la efectividad de las intervenciones breves para reducir la reincidencia de traumas en pacientes hospitalizados que tuvieron resultados positivos en la prueba de alcohol y / o uso de drogas ilícitas. Metodos Estudio de cohorte dinámico basado en datos de registro de 1818 pacientes incluidos en un programa de detección e intervención breve para el uso de alcohol y drogas ilícitas para pacientes hospitalizados con traumatismos. Del análisis de los datos surgieron tres subcohortes: los pacientes que obtuvieron un resultado negativo, los que obtuvieron un resultado positivo y se les ofreció una intervención breve, y los que obtuvieron un resultado positivo y no se les ofreció una intervención breve. El seguimiento duró de 10 a 52 meses. Se calcularon la supervivencia libre de traumatismo, los índices de tasa de riesgo ajustados (aHRR) y los índices de tasa de incidencia ajustados (aIRR), y se utilizó un análisis de efecto causal promedio más completo (CACE). RESULTADOS Encontramos un mayor riesgo acumulativo de reincidencia de trauma en el subcohort que dio positivo. En esta subcohorte, se obtuvo un aHRR de 0,63 (IC del 95%: 0,41-0,95) para el grupo que ofreció una intervención breve en comparación con el grupo que no recibió intervención. El análisis CACE produjo una reducción estimada del 52% en la reincidencia del trauma asociada con la intervención breve. CONCLUSIÓN La breve intervención ofrecida durante la hospitalización en pacientes con trauma positivos por el uso de alcohol y / o drogas ilícitas puede reducir a la mitad la incidencia de reincidencia del trauma.OBJECTIVE Estimate the effectiveness of brief interventions in reducing trauma recidivism in hospitalized trauma patients who screened positive for alcohol and/or illicit drug use. METHODS Dynamic cohort study based on registry data from 1818 patients included in a screening and brief intervention program for alcohol and illicit drug use for hospitalized trauma patients. Three subcohorts emerged from the data analysis: patients who screened negative, those who screened positive and were offered brief intervention, and those who screened positive and were not offered brief intervention. Follow-up lasted from 10 to 52 months. Trauma-free survival, adjusted hazard rate ratios (aHRR) and adjusted incidence rate ratios (aIRR) were calculated, and complier average causal effect (CACE) analysis was used. RESULTS We found a higher cumulative risk of trauma recidivism in the subcohort who screened positive. In this subcohort, an aHRR of 0.63 (95% CI: 0.41–0.95) was obtained for the group offered brief intervention compared to the group not offered intervention. CACE analysis yielded an estimated 52% reduction in trauma recidivism associated with the brief intervention. CONCLUSION The brief intervention offered during hospitalization in trauma patients positive for alcohol and/or illicit drug use can halve the incidence of trauma recidivism.• Dirección General de Tráfico. Beca 0100DGT22389, para Enrique Fernández Mondéjar • Junta de Andalucía. Beca PI-0691-2013, para Raquel Vilar López • Ministerio de Educación, Cultura y Deportes. Beca FPU13/00669, para Juan Francisco Navas PérezpeerReviewe

Correction: Management of bleeding following major trauma: a European guideline

SCOPUS: er.jinfo:eu-repo/semantics/publishe

Dinámica cardio-respiratoria tras la supresión de la ventilación mecánica en diferentes grupos de pacientes

Reducción altaUniv. Granada, Facultad de Medicina. Leída el 06-07-198