Classificação do atendimento pré-hospitalar pediátrico como instrumento para otimizar a alocação de recursos no atendimento do trauma na cidade de São Paulo, Brasil

PURPOSE: To evaluate the pediatric prehospital care in São Paulo, the databases from basic life support units (BLSU) and ALSU, and to propose a simple and effective method for evaluating trauma severity in children at the prehospital phase. METHODS: A single firemen headquarter coordinates all prehospital trauma care in São Paulo city. Two databases were analyzed for children from 0 to 18 years old between 1998 and 2001: one from the Basic Life Support Units (BLSU - firemen) and one from the Advanced Life Support Units (ALSU - doctor and firemen). During this period, advanced life support units provided medical reports from 604 victims, while firemen provided 12.761 reports (BLSU+ALSU). Pre-Hospital Pediatric Trauma Classification is based on physiological status, trauma mechanism and anatomic injuries suggesting high energy transfer. In order to evaluate the proposed classification, it was compared to the Glasgow Coma Score and to the Revised Trauma Score. RESULTS: There was a male predominance in both databases and the most common trauma mechanism was transport related, followed by falls. Mortality was 1.6% in basic life support units and 9.6% in ALSU. There was association among the proposed score, the Glasgow Coma Score and to the Revised Trauma Score (p<0.0001). CONCLUSION: Pre-Hospital Pediatric Trauma Classification is a simple and reliable method for assessment, triage and recruitment of pediatric trauma resources.OBJETIVO: Avaliar o atendimento pré-hospitalar de crianças e adolescentes em São Paulo, avaliar o banco de dados das Unidades de Suporte Básico (UR) e Avançado (USA) e propor um método simples e eficaz para a avaliação da gravidade do trauma pediátrico na fase pré-hospitalar. MÉTODOS: Uma única central do Corpo de Bombeiros (COBOM) coordena todo o atendimento pré-hospitalar em São Paulo. Dois bancos de dados foram analisados para crianças de 0 a 18 anos de idade, entre 1998 e 2001: um das Unidades de Suporte Básico de Vida (UR- bombeiros) e outra de Unidades de Suporte Avançado (USA - médico e bombeiros). Neste período, o Serviço de Atendimento Médico de Urgência do Estado de São Paulo (SAMU) forneceu relatórios médicos de 604 vítimas, enquanto os bombeiros forneceram relatórios de 12.761 vitimas (UR+USA). A classificação do trauma pré-hospitalar pediátrico é baseada na condição fisiológica, mecanismo de trauma e lesões anatômicas das vítimas. A classificação do trauma pré-hospitalar pediátrico foi comparada à Escala de Coma de Glasgow (GCS) e ao Escore de Trauma Revisado (RTS). RESULTADOS: Houve predominância do sexo masculino em ambos bancos de dados. O mecanismo de trauma mais freqüente foi relacionado a transporte, seguido de quedas. A mortalidade foi 1,6% nas Unidades Básicas e 9,6% no Suporte Avançado. Houve associação entre a classificação do trauma pré-hospitalar pediátrico, Escala de Coma de Glasgow (GCS) e ao Escore de Trauma Revisado (RTS) GCS e RTS (p<0,0001). CONCLUSÃO: A classificação do trauma pré-hospitalar pediátrico é um método simples e confiável para a avaliação, triagem e recrutamento de recursos para o atendimento pré-hospitalar do trauma pediátrico.Universidade Federal de São Paulo (UNIFESP) Department of SurgeryUNIFESP, Department of SurgerySciEL

An evaluation of the professional, social and demographic profile and quality of life of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil

OBJECTIVE: To describe the profile of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil and to evaluate their quality of life.METHODS: Both a semi-structured questionnaire with 57 questions and the SF-36 questionnaire were sent to research departments within SAMU in the Brazilian state capitals, the Federal District and inland towns in Brazil.RESULTS: Of a total of 902 physicians, including 644 (71.4%) males, 533 (59.1%) were between 30 and 45 years of age and 562 (62.4%) worked in a state capital. Regarding education level, 45.1% had graduated less than five years before and only 43% were specialists recognized by the Brazilian Medical Association. Regarding training, 95% did not report any specific training for their work at SAMU. The main weaknesses identified were psychiatric care and surgical emergencies in 57.2 and 42.9% of cases, respectively; traumatic pediatric emergencies, 48.9%; and medical emergencies, 42.9%. As for procedure-related skills, the physicians reported difficulties in pediatric advanced support (62.4%), airway surgical access (45.6%), pericardiocentesis (64.4%) and thoracentesis (29.9%). Difficulties in using an artificial ventilator (43.3%) and in transcutaneous pacing (42.2%) were also reported. Higher percentages of young physicians, aged 25-30 years (26.7 vs 19.0%; p48 h per week (12.8 vs 8.6%; p<0.001), and were non-specialists with the shortest length of service (<1 year) at SAMU (30.1 vs 18.2%; p<0.001) who were hired without having to pass public service exams* (i.e., for a temporary job) (61.8 vs 46.2%; p<0.001). Regarding quality of life, the pain domain yielded the worst result among physicians at SAMU.CONCLUSIONS: The doctors in this sample were young and within a few years of graduation, and they had no specific training in prehospital emergencies. Deficiencies were mostly found in pediatrics and psychiatry, with specific deficiencies in the handling of essential equipment and in the skills necessary to adequately attend to prehospital emergencies. A disrespectful labor scenario was also found; the evaluation of quality of life showed a notable presence of pain on the SF-36 among physicians at SAMU and especially among doctors who had worked for a longer length of time at SAMU.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina (UNIFESP/EPM) Departamento de CirurgiaFaculdade de Medicina de São José do Rio Preto Departamento de CirurgiaDuke University School of Medicine Division of CardiologyUNIFESP, EPM, (UNIFESP/EPM) Depto. de CirurgiaSciEL

Development and validation of a questionnaire to assess the knowledge of mechanical ventilation in urgent care among students in their last-year medical course in Brazil

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach’s alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach’s alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil

Crossed testicular ectopia

Crossed testicular ectopia (CTE) is a rare anomaly, characterized by migration of one testis towards the opposite inguinal canal. Presented here is a case of crossed ectopia of the right testis, treated by extraperitoneal transposition of the gonad and right orchiopexy. Embriology and surgical findings suggest that CTE is a common consequence of many unclear ethiologic factors, specially mechanical ones, and can be associated with Muller duct persistence. Review of literature suggests a classification of CTE into 3 types: I - associated with inguinal hernia alone; II - associated with persistent mullerian remnants; III - associated with other anomalies without mullerian remnants. Treatment includes transeptal orchiopexy or extraperitoneal transposition of the testis, research for mullerian remnants and other anomalies, and long term postoperative follow-up, due to the risk of becoming malignant.INTRODUÇÃO: A ectopia testicular cruzada (ETC) é uma anomalia rara, caracterizada pela descida de um testítulo no canal inguinal do lado oposto. Apresentamos um caso de ectopia cruzada do testículo direito, tratado por transposição extraperitoneal da gônada e orquipexia direita. CONCLUSÃO: Os conhecimentos embriológicos e os achados cirúrgicos sugerem que a ETC seja uma conseqüência comum de vários fatores etiológicos, sobretudo fatores mecânicos, e pode causar persistência do ducto de Müller. Após extensa revisão da literatura,sugerimos uma classificação da ETC em 3 tipos: 1 - associada somente à hérnia inguinal; II associada a remanescentes mullerianos; III - associada a outras anomalias, sem remanescentes mullerianos. O tratamento inclui orquipexia trans-septal ou transposição trans-abdominal do testículo, pesquisa de remanescentes mullerianos e outras anomalias, e seguimento pós-operatório a longo prazo, devido a risco de malignização.Escola Paulista de Medicina Department of Surgery Pediatric Surgery DivisionUNIFESP, EPM, Department of Surgery Pediatric Surgery DivisionSciEL

Entrapped victims in motor vehicle collisions: characteristics and prehospital care in the city of São Paulo, Brazil

OBJECTIVE: To examine the severity of trauma in entrapped victims and to identify risk factors for mortality and morbidity. INTRODUCTION: Triage and rapid assessment of trauma severity is essential to provide the needed resources during prehospital and hospital phases and for outcome prediction. It is expected that entrapped victims will have greater severity of trauma and mortality than non-entrapped subjects. METHODS: A transverse, case-control, retrospective study of 1203 victims of motor vehicle collisions treated during 1 year by the prehospital service in São Paulo, Brazil was carried out. All patients were drivers, comprising 401 entrapped victims (33.3%) and 802 non-entrapped consecutive controls (66.7%). Sex, age, mortality rates, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), corporal segments, timing of the prehospital care and resource use were compared between the groups. The results were analysed by &#967;2, Zres, analysis of variance and Bonferroni tests. RESULTS: Entrapped victims were predominantly men (84.8%), aged 32±13.1 years, with immediate mortality of 10.2% and overall mortality of 11.7%. They had a probability of death at the scene 8.2 times greater than that of non-entrapped victims. The main cause of death was hemorrhage for entrapped victims (45.2%) and trauma for non-entrapped victims. Of the entrapped victims who survived, 18.7% had a severe GCS (OR = 10.62), 12% a severe RTS (OR = 9.78) and 23.7% were in shock (OR = 3.38). Entrapped victims were more commonly transported to advanced life support units and to tertiary hospitals. CONCLUSION: Entrapped victims had greater trauma severity, more blood loss and a greater mortality than respective, non-entrapped controls

Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians

OBJECTIVE: To present self-assessments of knowledge about mechanical ventilation made by final-year medical students, residents, and physicians taking qualifying courses at the Brazilian Society of Internal Medicine who work in urgent and emergency settings. METHODS: A 34-item questionnaire comprising different areas of knowledge and training in mechanical ventilation was given to 806 medical students, residents, and participants in qualifying courses at 11 medical schools in Brazil. The questionnaire’s self-assessment items for knowledge were transformed into scores. RESULTS: The average score among all participants was 21% (0-100%). Of the total, 85% respondents felt they did not receive sufficient information about mechanical ventilation during medical training. Additionally, 77% of the group reported that they would not know when to start noninvasive ventilation in a patient, and 81%, 81%, and 89% would not know how to start volume control, pressure control and pressure support ventilation modes, respectively. Furthermore, 86.4% and 94% of the participants believed they would not identify the basic principles of mechanical ventilation in patients with obstructive pulmonary disease and acute respiratory distress syndrome, respectively, and would feel insecure beginning ventilation. Finally, 77% said they would fear for the safety of a patient requiring invasive mechanical ventilation under their care. CONCLUSION: Self-assessment of knowledge and self-perception of safety for managing mechanical ventilation were deficient among residents, students and emergency physicians from a sample in Brazil

Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians

OBJECTIVE: To present self-assessments of knowledge about mechanical ventilation made by final-year medical students, residents, and physicians taking qualifying courses at the Brazilian Society of Internal Medicine who work in urgent and emergency settings. METHODS: A 34-item questionnaire comprising different areas of knowledge and training in mechanical ventilation was given to 806 medical students, residents, and participants in qualifying courses at 11 medical schools in Brazil. The questionnaire's self-assessment items for knowledge were transformed into scores. RESULTS: The average score among all participants was 21% (0-100%). Of the total, 85% respondents felt they did not receive sufficient information about mechanical ventilation during medical training. Additionally, 77% of the group reported that they would not know when to start noninvasive ventilation in a patient, and 81%, 81%, and 89% would not know how to start volume control, pressure control and pressure support ventilation modes, respectively. Furthermore, 86.4% and 94% of the participants believed they would not identify the basic principles of mechanical ventilation in patients with obstructive pulmonary disease and acute respiratory distress syndrome, respectively, and would feel insecure beginning ventilation. Finally, 77% said they would fear for the safety of a patient requiring invasive mechanical ventilation under their care. CONCLUSION: Self-assessment of knowledge and self-perception of safety for managing mechanical ventilation were deficient among residents, students and emergency physicians from a sample in Brazil.Univ Fed Sao Paulo UNIFESP, Dept Cirurgia, Sao Paulo, SP, BrazilUniv Fed Paraiba, Dept Cardiol, Joao Pessoa, Paraiba, BrazilUniv Evangel Anapolis, Anapolis, Go, BrazilDuke Univ, Med Ctr, Duke Clin Res Inst, Durham, NC USAUniv Fed Sao Paulo UNIFESP, Dept Cirurgia, Sao Paulo, SP, BrazilWeb of Scienc

Renal tumor and trauma: a pitfall for conversative management

PURPOSE: Conservative management has been largely used for renal trauma. Although this approach is safe and highly recommended, it can hide a pre-existing unknown condition, such as tumors or urinary malformations. A high index of suspicion is needed for early recognition of these conditions. We present four cases treated at the Pediatric Oncology Institute - Federal University of São Paulo, which have been initially treated conservatively for renal trauma. MATERIALS AND METHODS: We reviewed all 218 renal cases of renal tumors treated at our institution in a 22-year period, searching for associated trauma events. RESULTS: Four cases of renal tumors were initially treated conservatively for blunt renal trauma of low energy mechanism. Patients' ages ranged from 7 to 12 years old. Two patients had no previous symptoms, one patient had hematuria and another had an abdominal mass. Computerized Axial Tomography (CT) of the abdomen revealed disparate magnitude of the renal bleeding to the low energy mechanism of trauma. All patients underwent surgical treatment. Kidney specimens showed Wilms tumor in three cases and renal carcinoma in one. CONCLUSIONS: The association between renal tumors and trauma should be suspected when renal trauma hemorrhage on abdominal CT scan does not match the low energy mechanism of blunt abdominal trauma. The key for a successful diagnosis of renal tumor or congenital malformations is the high index of suspicion for these conditions.Federal University of São Paulo Surgery DepartmentUNIFESP, Surgery DepartmentSciEL