Panamerican Journal of Trauma, Critical Care & Emergency Surgery

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2023 | September-December | Volume 12 | Issue 3

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PERSPECTIVES – IN MEMORIAM

We Celebrate the life of Dr. Leela Kriplani

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:1] [Pages No:ix - ix]

   DOI: 10.5005/pajt-12-3-ix  |  Open Access | 

110

SPECIAL ISSUE INVITATION

Violence – Prevention and Interventions

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:2] [Pages No:vii - viii]

   DOI: 10.5005/pajt-12-3-vii  |  Open Access | 

138

EDITORIAL

Sandro Rizoli

2023—The Current Issue: Looking into 2024

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:2] [Pages No:95 - 96]

   DOI: 10.5005/jp-journals-10030-1437  |  Open Access |  How to cite  | 

86

ORIGINAL RESEARCH

Juan P Ramos, Megan Neumann, Analia Zinco, Pablo Ottolino

Traumatic In-hospital Mortality: Where, How, and When Our Trauma Patients Die?

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:5] [Pages No:97 - 101]

Keywords: Major trauma, Trauma death, Trauma registry, Trauma system

   DOI: 10.5005/jp-journals-10030-1428  |  Open Access |  How to cite  | 

Abstract

Introduction: The analysis of traumatic mortality helps us evaluate critical points in the care of this type of patient, and its identification allows for changes and improvements in their treatment. This is of vital importance in places where there is no trauma system. This study aims to characterize the epidemiology of patients who died from trauma in a reference hospital for this type of patient. Methodology: Retrospective and descriptive study that includes all patients who died from trauma over 15 admitted to the trauma registry between 2018 and 2021. Results: A total of 174 patients who died from severe trauma and managed to receive hospital care were analyzed. The included patients represent an overall mortality of 3%. The primary mechanism of trauma was blunt 61 vs 39% penetrating. Around 44% of the total deaths were secondary to traffic accidents. The leading cause of death during the first hours of care was hemorrhage due to penetrating trauma. In addition, the sample highlights high mortality from traumatic brain injury (TBI) in the resuscitation area. Conclusion: The epidemiological description of mortality due to severe trauma in a highly complex hospital allows the identification of critical points within care. In our cohort, the rapid mortality from penetrating trauma and the high mortality from TBI in the resuscitation area represent a lack of regionalization and a need to improve the prehospital system around a trauma system.

215

ORIGINAL RESEARCH

Gabriela Rivas, Carolina S Guarneri, Marcelo Pontillo, Agustin Colombo, Jimena Bentos, Ricardo Robaina, Federico Kuster, Ismael Rodriguez, Fernando Machado

Massive Whole Blood Transfusion Protocol: Initial Experience at Hospital de Clínicas, “Dr. Manuel Quintela,” Montevideo, Uruguay

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:8] [Pages No:102 - 109]

Keywords: Blood components, Hypovolemic shock, Massive transfusion, Severe trauma

   DOI: 10.5005/jp-journals-10030-1427  |  Open Access |  How to cite  | 

Abstract

Introduction: Massive hemorrhage (MH) is the second determinant of initial mortality in trauma patients. Its treatment requires aggressive resuscitation with blood or its components. New therapeutic schemes have been postulated, within which massive transfusion (MT) stands out. To analyze the initial experience with the application of the TM protocol in adult trauma patients admitted to the Emergency Department of the Hospital de Clínicas “Dr Manuel Quintela.” Materials and methods: A retrospective, observational, and descriptive study was carried out at the Hospital de Clínicas in the period from 1st February 2018 to 2020. Inclusion and exclusion criteria were established. Results: If we only include patients who suffered some type of trauma, the percentage of correct activation rose to 81.6% of the cases. When evaluating the mortality associated with the use of the protocol, it was shown to be significantly lower than in those in which the protocol was used without a clear indication, with a calculated p-value of 0.009. This reflects that there is an association between the need for MT and death. An association was demonstrated between the value of the Assessment of Blood Consumption (ABC) score and death (p = 0.013). Conclusion: Decreases morbidity and mortality in patients who are candidates for MT. Organizes the work group, assigning roles and establishing therapies. Appropriate the rational use of blood components, a finite and scarce good in the world such as blood donation.

217

ORIGINAL RESEARCH

Ameer Said, Inbal D Elisha, Gingy R Balmor, Nadav Navo, Adam Laytin, Roman Rysin, Katia Dayan, Mordechai Shimonov

Comparison of Extubation vs Tracheostomy in Patients Ventilated for at Least 14 Days: A Retrospective Observational Study

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:6] [Pages No:110 - 115]

Keywords: Critical care, Late extubation, Late tracheostomy, Mechanical ventilation

   DOI: 10.5005/jp-journals-10030-1429  |  Open Access |  How to cite  | 

Abstract

Aims and background: Prolonged mechanical ventilation is frequently required in severely ill patients. The goal of the study is to describe the outcomes of critically ill patients who are mechanically ventilated for >14 days and the effect of late tracheostomy vs late extubation on their outcome. Patients and methods: A retrospective descriptive study was conducted at a single intensive care unit (ICU) at an academic tertiary medical center. All patients were admitted to the ICU on mechanical ventilation for >14 days over a 5-year period (1st January 2016–31st December 2020). The main outcome measures analyzed were length of ICU stay and inhospital mortality. Results: A total of 179 patients were hospitalized in the ICU for >14 days. Of these, 36 were mechanically ventilated for greater than 14 days, 26 of them eventually underwent a tracheostomy, and 10 were extubated. As compared to the extubated patients, the cohort receiving the tracheostomy all had significantly longer ICU lengths of stay (27 vs 47.5 days, p-value 0.0017), length of hospitalization (29.5 vs 52 days, p-value < 0.05), and total days of mechanical ventilation (21.5 vs 46 days, p-value < 0.05). There was no significant difference between the days of endotracheal (ET) intubation, ventilator-associated pneumonia (VAP), albumin (Alb) and hemoglobin (Hb) levels, ICU death, or discharge. Undergoing tracheostomy resulted in a longer ICU/hospitalization without a change in overall inhospital mortality. Conclusion: Performing late tracheostomy after 14 days may prolong hospitalization without improving inhospital survival. Clinical significance: All efforts should be made to determine the need for, and subsequently perform, a tracheostomy. For whatever reasons, this is delayed beyond 14 days, the team should reevaluate the benefit to the patient and potential for possible ET extubation from mechanical ventilation.

179

CASE REPORT

Ashwin K Raghavan, SaiTeja Mathi, Soundarya Priyadharshini

Benefit of Sole Epidural Anesthesia in a Geriatric Patient with Scoliosis for Emergency Laparotomy: A Case Report

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:4] [Pages No:116 - 119]

Keywords: Arterial hypoxemia, Case report, Epidural anesthesia, Geriatric critical care, Hyperactive airway

   DOI: 10.5005/jp-journals-10030-1432  |  Open Access |  How to cite  | 

Abstract

Anesthetizing a geriatric 80-year-old geriatric age female patient with a body mass index (BMI) of 29 kg/m2 for laparotomy who has a case of coronary artery disease (CAD) with coexisting bronchial asthma poses a major anesthetic challenge. Considering the associated issues like chronic lung disease and CAD managing the anticipated intraoperative complication from intubation till maintenance of the case and our experience in handling laparotomies with extensive epidural analgesia, we recommend that sole epidural anesthesia be considered for managing such patients.

158

ORIGINAL RESEARCH

Ahmed F Ramzee, Ayman El-Menyar, Mohammad Asim, Hassan Al-Thani, Fakhar Shahid, Areen Fino, Yaser M Ata, Hamzah El Baba, Arun P Nair, Muna S Al Maslamani, Ruben Peralta, Sandro Rizoli

Descriptive Analysis of Thromboembolic Events in COVID-19 Patients in Qatar

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:11] [Pages No:120 - 130]

Keywords: Coronavirus disease of 2019, Epidemic, Infarction, Infection, Qatar, Thromboembolic

   DOI: 10.5005/jp-journals-10030-1436  |  Open Access |  How to cite  | 

Abstract

Background: Current literature shows an increased risk of thromboembolic events (TEE) with coronavirus disease of 2019 (COVID-19) infection, possibly due to a unique interplay between the virus and the coagulation system. Materials and methods: A retrospective observational study of all patients with COVID-19 infection in the State of Qatar between February and August 2020 was performed. Analysis of all patients with TEE was carried out to identify other potential inciting factors for TEE. Results: There were 210 out of 16,903 (1.2%) patients with COVID-19 infection who developed TEE. Myocardial infarction (MI) was the most common event (76.2), with 11% deep vein thrombosis (DVT) and <10% with pulmonary embolism (PE), stroke, and other thrombotic events. Conclusion: Our study showed a low incidence of TEE compared to current literature. Patients with a previous history of thrombotic events were at a higher risk of developing a second event. Other significant contributing factors may have had a role in the development of TEE in the rest of the group. This questions the current belief that COVID-19 significantly increases the risk of TEE in the healthy population.

192

ORIGINAL RESEARCH

Enmanuel G de la Cruz, Raul B Cruz, Carlos A Mejía Picasso

MESS Scale in Peripheral Vascular Trauma of the Lower Extremities: Experience at the High Specialty Regional Hospital Dr Gustavo A Rovirosa Perez

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:5] [Pages No:131 - 135]

Keywords: Femoral artery, Ischemia, Mangled extremity severity score scale, Vascular anastomosis, Vascular trauma of extremities

   DOI: 10.5005/jp-journals-10030-1434  |  Open Access |  How to cite  | 

Abstract

Background: It is necessary to count on guides to decide whether to value an injured extremity, between saving it or amputating it, which is why Johansen et al. created its acronyms in English; the mangled extremity severity score (MESS) has the objective of determining the need to perform amputation objectively. The objective is to determine the usefulness of MESS in the management of peripheral vascular lesions of the lower extremity treated at the Hospital Dr Gustavo A Rovirosa Perez. Study design: The study was descriptive, retrospective, longitudinal, and nonexperimental. This includes patients with traumatic vascular injuries of the lower extremities, managed with revascularization. The variables are age, sex, MESS score, injury mechanism, injured vessel, and time between injury and surgery. Data is captured and analyzed on a table in the Excel software version 2019. Results: With a sample of 12 patients, 100% were male patients, and 58.3% were aged between 20 and 40 years. Around 66.6% were penetrating trauma, 58.3% due to PAF, and 8.3% due to blunt force. A total of 50% of all MESS points <7. All 16.6% went to the gym with time <6 hours of evolution. Finding lesions of the left popliteal artery in five patients, four of the right femoral artery, and three of the left femoral artery. The management in 58.4% was with autologous saphenous vein injection, and four patients had primary anastomosis. Conclusion: The literature reports a better prognosis in injuries with ischemia window time <6 hours. Therefore, it is necessary to consider the presence or absence of signs of irreversible ischemia and nervous impairment that impede the functionality of the extremities. Studies report that MESS has a predictive value of <50% for indications of amputation in patients with scores >7; however, it achieves a predictive value of salvation from the upper end of 100% in scores <7.

157

ORIGINAL RESEARCH

Andrea Villarreal-Juris, Ramiro Villarreal-Juris, Jaime Dyer-Rolando

Lower Limb Trauma: Salvage Through Vacuum-assisted Closure in an Ecuadorian Tertiary Hospital

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:8] [Pages No:136 - 143]

Keywords: Degloving injuries, Limb salvage, Lower limb, Vacuum-assisted closure

   DOI: 10.5005/jp-journals-10030-1433  |  Open Access |  How to cite  | 

Abstract

Introduction: Major trauma causes shear, compressive, and torsional forces to the lower limbs, resulting in complex and devastating soft tissue and bone injuries that challenge the most experienced surgeons. For such injuries, the standard of care is early debridement and coverage, which in recent years has been ubiquitously done using vacuum-assisted closure (VAC). Objective: Describe the short-term outcomes of adult patients with devastating lower limb injuries from January to December 2022 at the Luis Vernaza Hospital in Ecuador. Materials and methods: Observational, retrospective, and analytical study. Data was obtained from electronic medical records and analyzed using Statistical Package for the Social Sciences (SPSS) 27.0. Yan's classification was used. Management was early wound excision and coverage using VAC. Main outcomes—wound healing; limb mobility at 180–190 days; infection; length of stay; days-to-skin graft; and mean total surgical time. Results: A total of 13 patients were included, all male, mean age—31.4 years (20–45 years), mean length of stay—38.9 days (24–65 days). The most common mechanism of injury was motorcycle (58.85%); the left lower limb was the most affected (61.5%); 53.9% of injuries were pattern 2B and 46.1% pattern 3, which increased length of stay (p = 0.004); mean total surgical time (p = 0.349), days-to-skin graft (p = 0.002); and a 4x higher probability of secondary healing [odds ratio (OR)—4.031, p = 0.005]. No significant difference was observed in conventional vs silver-impregnated foam dressings and infection, length of stay, days-to-skin graft, and mean total surgical time. Minor infection significantly increased days-to-skin graft (p = 0.002). All patients had limb mobility by 180–190 days follow-up and none underwent amputation. Conclusion: The VAC appears to be a useful tool in managing catastrophic lower limb injuries (including pattern 3). Early VAC coverage allows early large defect coverage until surgical reconstruction, may reduce infection, and preserve mobility thus aiding limb salvage.

156

ORIGINAL RESEARCH

Paola A Alfaro Carmona, Gonzalo A Monroy Cortés, Felipe Cruz Escudey

Analysis of Deaths Due to Polytrauma in Chile over the Last 25 Years (1997–2022)

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:8] [Pages No:144 - 151]

Keywords: Epidemiology, Mortality, Multiple trauma

   DOI: 10.5005/jp-journals-10030-1430  |  Open Access |  How to cite  | 

Abstract

Aims and background: Globally, trauma is the leading cause of death in individuals under 45 years of age. However, there is limited research on this topic in Chile and no nationwide studies on polytrauma. This underscores the need for further research. The aim is to analyze the temporal evolution and potential geographical variability of mortality attributed to polytrauma in Chile over the last 25 years. Materials and methods: This was a cross-sectional, observational, quantitative study of routine Chilean records, which are mandatorily reported and publicly anonymized, available on the website of the Department of Health Statistics and Information (DEIS). All records under code T00-T07 [International Statistical Classification of Diseases and Related Health Problems (ICD-10)] were included in the analysis (nonprobabilistic convenience sampling). Variables studied were gender, age, region, external cause, date, and place of death. Specific mortality rates (SMR) and age-adjusted rates were calculated with statistical significance (p < 0.05) using Statistical Software for Data Science (STATA)—16. Ethical approval was not required. Results: A total of 38,955 death records were analyzed. The SMR for the period was 8.45 per 100,000 inhabitants, peaking in 2008 at 10.03 per 100,000. The SMR for men was 13.62 per 100,000, and for women, it was 3.47 per 100,000; in both cases, the rates were highest between the ages of 20 and 44. Relative risk: 3.92 (p < 0.01). The OHiggins region had the highest SMR at 13.67 per 100,000, while the Magallanes region had the lowest at 5.35 per 100,000. The most common cause was “pedestrian injured in transport accident” (32.73%). Most deaths occurred on public roads, on Mondays, and during the month of February. Conclusion: Deaths attributed to polytrauma in the Chilean population are distributed differently across various variables. A rising trend has been observed since 2020. Further studies are necessary to delve into the reasons for geographical variability and the mechanisms of trauma.

213

ORIGINAL RESEARCH

Community and Internet-driven Development of the Spanish Language Version of the Injured Trauma Survivor Screen

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:10] [Pages No:152 - 161]

Keywords: Depression, Development study, Injured Trauma Survivor Screen, Posttraumatic stress disorder, Risk screen, Spanish language, Traumatic injury

   DOI: 10.5005/jp-journals-10030-1431  |  Open Access |  How to cite  | 

Abstract

Aims and background: The goal of this study was to develop a clinically appropriate translation of the Injured Trauma Survivor Screen (ITSS) from English to Spanish that retained the original intent of each item while creating a culturally valid screening tool. Materials and methods: This was a cross-sectional study of an existing screen developed to detect risk for posttraumatic stress disorder (PTSD) and depression following injury. Participants were recruited from a local clinic (n = 8) and online via Amazon's MTurk platform (n = 100) and were asked to translate each of the nine items of the ITSS screen from English into Spanish. The most frequent translations for each item were selected for the draft screen. The draft screen was back-translated by five bilingual individuals. Only two wording changes were made to the draft screen due to the back translations. Results: The forward translation that resulted from the internet sample provided the product that was then back-translated by five predetermined bilingual individuals. Two changes were made to the end product following the back translation. Conclusion: The Injured Trauma Survivor Screen–Spanish (ITSS-S) constitutes a strong, methodical translation of a clinical screen for PTSD and depression risk. As such, it has preliminary clinical utility and readiness for further validation. Clinical significance: A Spanish-language version of the ITSS that was methodologically rigorously forward and back-translated can increase access to formalized screening and intervention for PTSD and/or depression. Future work is needed to further understand the validity and reliability of ITSS-S.

261

CASE REPORT

Mackenzie Snyder, Sayuri P Jinadasa

Migration of Retained Bullet Fragments Inducing Recurrent Hemoptysis: A Case Report

[Year:2023] [Month:September-December] [Volume:12] [Number:3] [Pages:3] [Pages No:162 - 164]

Keywords: Case report, Gunshot wound, Hemoptysis, Retained bullet migration, Retained bullet

   DOI: 10.5005/jp-journals-10030-1435  |  Open Access |  How to cite  | 

Abstract

Aim: We present a case of bullet fragments migrating into the endotracheal space and discuss the assessment of patients with retained bullets. Background: Many patients who have sustained a gunshot wound (GSW) have retained bullets. Bullets that are not encountered during operative management are rarely removed because of the secondary injuries and complications that removal can cause. Bullets rarely migrate, and thus, the secondary complications from migration are not often considered when patients later present with complications. Case description: A patient initially presented with multiple GSWs and had several retained bullets and bullet fragments in the mediastinum. Over the next 3 years, he presented numerous times with hemoptysis, cough, and chest pain but no clear etiology. Eventually, it was recognized that a collection of bullet fragments had eroded through the tracheal wall. Conclusion: Migration of bullets and/or bullet fragments into the bronchi or trachea should be considered in patients who have a history of GSW to the mediastinum and present with hemoptysis or pneumonia. Clinical significance: This patient presentation shows that bullet migration can occur at any time after injury, and delays in considering the diagnosis and initiating the appropriate workup can result in a delay in diagnosis.

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