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PANAMERICAN JOURNAL OF TRAUMA
Editors:
RICARDO FERRADA, M.D., Cali, Colombia
RAO IVATURY M.D., Richmond, Virginia
DARIO BIROLINI, M.D., Sao Paulo, Brazil
Assistant Editors:
SAMIR RASSLAN M.D., Sao Paulo, Brazil
ANDREW PEITZMAN M.D., Pittsburgh, Pennsylvania
JORGE NEIRA, M.D., Buenos Aires, Argentina
RAFAEL ANDRADE, M.D.
Panama, Panama
JUAN ASENSIO, M.D.
Los Angeles, California
CARLOS BARBA, M.D.
Hartford, Connecticut
LUIS BAEZ, M.D.
Caracas, Venezuela
MARY BEACHLEY, R.N.
Baltimore, Maryland
RICARDO ESPINOZA M.D.
Santiago, Chile
EUGENE FAIST, M.D.
Münich, Germany
DAVID FELICIANO, M.D.
Atlanta, Georgia
ALBERTO GARCIA, M.D.
Cali, Colombia
LUIS GRANJA MENA, M.D.
Quito, Ecuador
GERARDO GOMEZ, M.D.
Indianapolis, Indiana
FRANCISCO HOLGUIN, M.D.
Cartagena, Colombia
LENWORTH M. JACOBS, M.D.
Hartford, Connecticut
TEOFILO LAMA PICO, M.D.
Guayaquil, Ecuador
CHARLES LUCAS, M.D.
Detroit, Michigan
ROBERT MACKERSIE, M.D.
San Francisco, California
KATZIUKO MAEKAWA, M.D.
Kitasato, Japan
KIMBALL MAULL, M.D.
Birmingham, Alabama
ERNEST E. MOORE, M.D.
Denver, Colorado
DAVID MULDER , M.D.
Montreal, Canada
DAVID ORTEGA, M.D.
Lima, Peru
RENATO POGGETTI, M.D.
Sao Paulo, Brazil
ABRAHAM I RIVKIND, M.D.
Jerusalem, Israel
AURELIO RODRIGUEZ, M.D.
Pittsburgh, Pennsylvania
CLAYTON SHATNEY, M.D.
San Jose, California
RAUL COIMBRA M.D.
San Diego, California
JOSE MARIO VEGA, M.D.
San Salvador, El Salvador
VIVIAN LANE, R.N.
Hartford, Connecticut
Orthopedic Trauma:
BRUCE BROWNER, M.D.
Hartford, Connecticut
Pediatrics:
MARTIN EICHELBERGER, M.D.
Washington, D.C.
Plastic Surgery:
DAVID REATH, M.D.
Knoxville, Tennessee
Prehospital Care:
ALEJANDRO GRIFE, M.D.
Mexico, Mexico
SECTION EDITORS
Critical Care:
DAVID HOYT, M.D.
San Diego, California
Emergengy & Disaster
SUSAN BRIGGS, M.D.
Boston, Massachusetts
Infection:
RONALD MAIER, M.D.
Seattle, Washington
Nursing:
ROBBIE HARTSOCK, R.N.
Baltimore, Maryland
Coordinación Editorial:
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w w w. l i b re r i a m e d i c a . c o m
Impreso por: Gente Nueva editorial
PANAMERICAN JOURNAL OF TRAUMA
CONTENT
CONTENIDO
1.
ABDOMINAL STAB WOUNDS – SAME PROBLEMS DIFFERENT SOLUTIONS ......... 4
2.
CIRUGÍA MINIMAMENTE INVASIVA EN TRAUMA TORACO ABDOMINAL EN EL
HOSPITAL DE SAN JOSÉ DE BOGOTÁ COLOMBIA .................................................... 10
3.
COMBINING APPROACHES IN ARTHROPLASTY FOR ACUTE FRACTURES OF
THE ACETABULUM ......................................................................................................... 14
4.
COMPLICACIONES DE LA INGESTIÓN MASIVA DE OVOIDES DE COCAÍNA .......... 19
5.
ECONOMICS OF TRAUMA CARE RE-VISITED ............................................................. 22
6.
EXPERIENCIA CON EL USO INTRAPLEURAL DE PRÓTESIS INFLABLES DE
SILICONA ......................................................................................................................... 28
7.
PENETRATING TRAUMA – SAME PROBLEMS, DIFFERENT SOLUTIONS THE
CNS ................................................................................................................................... 33
8.
MORTALIDAD EVITABLE Y LA ATENCIÓN PREVIA HOSPITALARIA DEL
TRAUMA EN EL MUNICIPIO DE MEDELLÍN, COLOMBIA 2.005 ................................... 43
9.
THE ROLE OF EXTERNAL FIXATION IN THE INITIAL MANAGEMENT OF PELVIC
FRACTURES ..................................................................................................................... 53
10.
UNSTABLE PELVIS- ROLE OF THE INTERVENTIONALIST .......................................... 58
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 04 - 9
ABDOMINAL STAB WOUNDS – SAME PROBLEMS
DIFFERENT SOLUTIONS
Ari K. Leppäniemi, MD, PhD, DMCC
RESUMEN
El tratamiento de los pacientes con heridas cortopunzantes
de abdomen consiste en una serie de decisiones claves
basadas en el conocimiento científico actual. El tratamiento
no operatorio de los pacientes con bajo riesgo de una lesión
significante es seguro y reduce las laparotomías no terapéuticas y su morbilidad asociada. La laparotomía temprana
está indicada en los pacientes con signos obvios de sangrado del tracto intraperitoneal, retroperitoneal o gastrointestinal, o con peritonitis generalizada. En los pacientes con
penetración peritoneal demostrada, el riesgo de una lesión
significativa de un órgano es suficientemente alto para justificar exploración temprana, aunque un enfoque más conservador puede estar indicado en pacientes asintomáticos.
El papel de la tomografía computarizada no es claro, ya que
los beneficios de la laparoscopia para excluir perforaciones
diafragmáticas, especialmente después de que las lesiones
cortopunzantes de la región toracoabdominal izquierda,
han sido demostradas. Cuando se hace la exploración local
de la herida y se descubre una fascia anterior intacta, el
paciente puede ser dado de alta. De otra parte el hallazgo
equívoco o dudoso requiere observación.
Palabras clave: Abdomen, Trauma, Penetrante, Heridas
cortopunzantes, Diagnóstico, Laparotomía, Laparoscopia,
Tratamiento no operatorio, Lesiones desapercibidas,
Lesiones ocultas, Lesiones diafragmáticas, Laparotomía
negativa, Evisceración
SUMMARY
The management of patients with abdominal stab wounds
consists of a series of key decisions based on current sciDepartment of Surgery, University of Helsinki, Finland
Correspondence and requests for reprints:
Ari Leppäniemi, MD. Department of Surgery. Meilahti hospital.
University of Helsinki. Haartmaninkatu 4. P.O. Box 340. 00029
HUS. Finland. Phone: +358-50-427-1281, Fax: +358-9-4717-6431
Email: [email protected]
4
entific knowledge. Nonoperative management of patients
with a low risk of a significant injury is safe and reduces
nontherapeutic laparotomies and associated morbidity.
Early laparotomy is warranted in patients with overt signs
of intraperitoneal, retroperitoneal or gastrointestinal tract
bleeding, or with generalized peritonitis. In patients with
demonstrated peritoneal violation, the risk of a significant
organ injury is sufficiently high to justify early exploration,
although a more conservative approach may be tried in
asymptomatic patients. The role of computed tomography is
not clear, whereas the benefits of laparoscopy in excluding
diaphragmatic perforations especially after left thoracoabdominal stab wounds have been demonstrated. If an intact
anterior fascia can be seen during local wound exploration,
the patient can be discharged, whereas equivocal finding
warrants expectant observation.
Keywords
Abdomen, Trauma, Penetrating, Stab wounds, Diagnosis,
Laparotomy, Laparoscopy, Nonoperative management,
Missed injuries, Occult injuries, Diaphragmatic injuries,
Negative laparotomy, Evisceration
The different management strategies in abdominal stab
wounds can be focused on a small number of key decisions
along the diagnostic pathway. This review outlines our
current knowledge supporting decision-making at those
critical points. The emphasis is on anterior abdominal
stab wounds including stab wounds of the flanks and the
thoracoabdominal region. Posterior stab wounds and
other penetrating injuries of the abdomen, i.e. gunshot and
shotgun wounds require a different approach and will not
be discussed in this review.
Decision- making involves always a trade-off between
positive and negative effects of different options which then
need to be balanced according to the available evidence to
find the most appropriate response in general terms. That
Abdominal stab wounds – same problems different solutions
obviously can and needs to be modified according to individual patients’ characteristics and clinical circumstances.
Significant abdominal organ injury can be been defined as
a full-thickness perforation of the gastrointestinal, biliary
or urinary tract or of the diaphragm, injury penetrating the
pancreatic capsule, active bleeding from the liver, spleen,
kidney, greater omentum or mesentery requiring placement of sutures or other hemostatic procedures except for
temporary packing, and lacerations of major vessels or the
mesentery requiring sutures or causing irreversible peripheral organ ischemia. Laparotomy or laparoscopy performed
to treat a significant organ injury is considered therapeutic.
Abdominal organ injuries not requiring surgical repair,
such as nonbleeding lacerations of the liver, spleen, greater
omentum or the mesentery, or serosal tears not requiring
sutures are classified as minor or insignificant injuries.
Laparotomy or laparoscopy in association with a minor
injury as an only finding is considered nontherapeutic.
MANDATORY LAPAROTOMY
The first key decision-point is whether all patients with
abdominal stab wounds should undergo operative exploration. The risk of a significant abdominal organ injury
requiring surgical repair after anterior abdominal stab
wound is 35-50%, 20-30% in stab wounds of the flank and
about 15% in thoracoabdominal stab wounds, as confirmed
by numerous studies. In one study comprising 459 patients
with truncal stab wounds and a potential for intra- or retroperitoneal organ injury undergoing mandatory laparotomy,
172 (37%) patients underwent a non-therapeutic operation.1
Although there was negligible mortality (one patient died
of an associated thoracic vascular injury), the morbidity
rate was 21%, mostly with wound complications, and the
complications prolonged the hospital stay by 4.6 days on
average.
The high nontherapeutic laparotomy rate and associated
significant morbidity following mandatory laparotomy for
abdominal stab wounds lead to the current, widely used
selective nonoperative management strategy first suggested
by Shaftan in 1960.2-8 The trade off with mandatory laparotomy (no or few missed injuries, high non-therapeutic
laparotomy rate) and selective nonoperative management
(risk of delayed treatment of significant injuries, lower
non-therapeutic laparotomy rate) was studied in a prospective, randomized study that excluded patients requiring
immediate operation for major hemorrhage, generalized
peritonitis, evisceration, as well as patients with superficial
wound not penetrating the anterior fascia.9 The remaining
51 patients (40% of all) underwent either mandatory explo-
ration or expectant observation. The non-therapeutic laparotomy rate following mandatory exploration was (78%)
that reflects the nature of this preselected group.
In the observation group, the missed significant injury rate
was 17%. None of the randomized patients died, there was
no significant difference in hospital morbidity (19% vs.
8%, p=0.26) but a clear difference in the median hospital
length of stay (5 vs. 2 days, p=0.002). In addition, the cost
saved was about USD 2.800 per observed patient. A utilitybased trade off analysis showed that selective nonoperative
management was a superior strategy in minimizing days in
hospital. The study demonstrated that selective nonoperative management is a safe management strategy and effective in minimizing the hospital stay.
Selection criteria for nonoperative management
With selective nonoperative management being the preferred strategy the next key decision point involves the criteria by which the selection to expectant observation can be
reliably made. This has lead to constant refinement of diagnostic algorithms utilizing a combination of multiple diagnostic methods, such as physical examination, local wound
exploration (LWE), diagnostic peritoneal lavage (DPL) and
radiological techniques to accurately stratify patients into
appropriate therapeutic pathways.5-7,10-20 Although DPL was
for many years the golden standard its role has diminished,
and in recent years it has been utilized more in the role of
determining the presence of peritoneal penetration instead
of local wound exploration (LWE) which can be difficult
and tedious, especially in the obese patient or patient with
thick abdominal musculature.21
The reliability of ultrasonography (US) to identify patients
requiring operative management is still controversial. In
one study of 177 patients with penetrating torso injuries
(92 stab wounds), there were 149 negative US examinations, but 28 of these (19%) underwent subsequently a
therapeutic operation.22 Although the value of US in demonstrating peritoneal fluid is well demonstrated, its ability
to predict the presence of a significant organ injury seems
to be less reliable.
Computed tomography (CT) can be incorporated in the
management strategy of abdominal stab wounds. In one
study of 200 patients with penetrating torso trauma (111
with stab wounds), triple-contrast helical CT was used
both to demonstrate peritoneal penetration (CT aided diagnosis of peritoneal violation in 34%) and the presence of
a visceral injury.23 Laparotomy based on CT findings was
5
Panamerican Journal of Trauma
non-therapeutic in 13%. In another series of 32 with a penetrating abdominal stab wounds not requiring immediate
laparotomy, serial US (at admission and 12 hours later) and
helical CT were used to evaluate the presence of hemoperitoneum and integrity of solid and hollow viscera.24 One
patient (3%) had an extensive liver laceration identified with
both US and CT and underwent a therapeutic operation.
The remaining patients had no signs of significant organ
injuries and were treated nonoperatively, and none of those
patients required surgery for a missed injury. Considering
the radiation exposure of a CT scan in view of potentially
avoiding an unnecessary laparotomy is a trade off question
that has not been studied prospectively.
In view of characterizing the abilities of various clinical
findings and diagnostic methods to positively or negatively
predict the presence of a significant organ injury after an
abdominal stab wound, a retrospective study of 209 consecutive patients was performed.25 The overall mortality
and morbidity rates were 1% and 16%, respectively,
and the mean hospital length of stay was 5.8 days. The study
demonstrated that signs of shock or continuous bleeding
as well as generalized peritonitis were good predictors of
a significant injury with a positive predictive value (PPV)
over 80%. Overt signs of bleeding into the gastrointestinal
tract or the presence of bowel content in the stab wound
were very reliable predictors of a significant injury (PPV of
100%) but the number of patients with these findings is usually small. If peritoneal penetration could be excluded with
LWE, the negative predictive value (NPV) was 100%, but
PPV only 61%. Similarly, omental evisceration, free fluid
on US or extraluminal air demonstrated with plain x-rays
had PPV values of 54-72% and NPV values of 60-70%. In
comparison, the male sex had a PPV and NPV of 45% and
71%, respectively.
In a stepwise logistical regression analysis, clinical signs
of generalized peritonitis (p=0.000), major intra-abdominal
hemorrhage (p=0.000) and the presence of at least one of
the signs of peritoneal penetration (omental evisceration,
retained knife, gaping wound with visible peritoneal lesion,
extraluminal air on plain radiographs, free fluid on US)
(p=0.001) were independent risk factors for predicting the
presence or absence of a significant organ injury.
In a trade off analysis, including only the “hard signs”
(major bleeding, peritonitis, GI perforation or bleeding)
would have resulted in nontherapeutic laparotomy rate of
18% and missed injury rate requiring delayed laparotomy
of 24%. Including patients with signs of peritoneal penetration would have increased the nontherapeutic laparotomy
rate to 30% and decreased the missed injury rate to 11%.
6
ROLE OF DIAGNOSTIC LAPAROSCOPY
Diagnostic laparoscopy has been increasingly used in the
evaluation of abdominal stab wounds demonstrating its
ability improve diagnostic accuracy, reduce nontherapeutic
laparotomy rates, shorten the length of hospital stay and
reduce costs.26-46 Most of the studies, however, use no or
historic controls, apply laparoscopy to highly selected
patients and present results achieved by highly skilled and
enthusiastic laparoscopic surgeons. Nevertheless, diagnostic laparoscopy has been included in recently published
algorithms for the management of abdominal stab wounds
mainly to rule out peritoneal penetration or to diagnose and
treat diaphragmatic perforation.47,48
A parallel-group, prospective, randomized study examined
the role of routine diagnostic laparoscopy incorporated
into the diagnostic work up of patients with abdominal
stab wounds.49 Excluding patients requiring immediate
operation for shock or peritonitis, as well as patients with
superficial injuries (intact anterior fascia on LWE), the
remaining patients were stratified into two groups based on
the risk of a significant organ injury. Patients at high risk
(60-70%) with demonstrated peritoneal penetration were
randomized into either explorative laparotomy or diagnostic laparoscopy (DL), whereas low risk patients (<10%)
with equivocal LWE finding (anterior fascia breached but
peritoneal penetration not conclusive) were randomized to
either diagnostic laparoscopy or expectant observation.
Among patients with high risk, DL was converted to
laparotomy in 9/20 patients (45%) with one nontherapeutic
laparotomy (11%), while the nontheraputic laparotomy rate
was 65% in the exploration group. There was no mortality,
the morbidity rates were similar (13% and 10%, respectively), but there was a slight decrease in hospital stay in
the DL group (mean 5.7 vs. 5.1 days, p=0.049). Hospital
costs and sick leave requirements did not differ. Thus, the
laparoscopy-based strategy was safe, prevented 55% of the
laparotomies and resulted in marginal shortening of the
hospital length of stay.
In the parallel group with low risk of a significant organ
injury, there was no significant difference between DL and
expectant observation in missed significant injury rate (11%
vs. 3%, p=0.337), mortality (zero) or morbidity (11% vs. 0,
p=0.101). However, the length of hospital stay (mean 2.6
vs. 1.9 days, p=0.022), hospital costs (mean 4.210 vs. 1.540
EUR, p=0.000) and sick leave requirements (78% vs. 29%,
p=0.001) favored expectant nonoperative management.
Vol. 15 Number 1 2008
Abdominal stab wounds – same problems different solutions
There are six studies that compare DL to explorative
laparotomy in abdominal stab wounds.36,40,43,45,49,50 They
show that a laparoscopy-based strategy reduces the nontherapeutic laparotomy rate from 35-65% to 11-50% by
preventing 54-87% of the laparotomies. The reduction in
hospital length of stay is 0.6-6.6 days.
A recent prospective case series demonstrated the efficacy
of DL in excluding occult diaphragmatic injuries following
penetrating abdominal trauma.51 Among 38 hemodynamically stable patients (37 stab wounds) with thoracoabdominal injuries, DL was used in all patients to evaluate the
diaphragm, subsequently confirmed with laparotomy or
thoracoscopy. There were 7 true-positive, 30 true-negative,
no false-positive and 1 false-negative results. The single
missed diaphragmatic injury occurred in a patient with
hemoperitoneum from associated splenic injury that
obscured the diaphragm and warranted laparotomy.
Diaphragmatic perforations caused by stab wounds seldom
cause initial symptoms unless associated with herniation of
abdominal contents to the thoracic cavity, and are usually
missed by most currently used clinical (including diagnostic peritoneal lavage) and radiological methods especially in patients without other injuries requiring surgical
exploration.52-54 However, occult diaphragmatic injuries
maintain the potential for late visceral herniation and it’s
grave consequences although the natural history of small
diaphragmatic perforations is not well known.55,56
In a retrospective study of 97 patients (47 undergoing
exploration and 50 treated nonoperatively) with asymptomatic upper abdominal and lower thoracic wounds excluding
the upper back, the overall incidence of diaphragmatic injuries confirmed with open or laparoscopic exploration was
9%.57 Excluding patients requiring early surgery for slowly
developing peritoneal signs of associated organ injuries,
the actual incidence of occult diaphragmatic injuries was
7%. In a subgroup analysis of patients with stab wounds
to the left thoracoabdominal area, the incidence of occult
diaphragmatic injuries was 17%. Among nonoperatively
treated patients, there were two patients (4%) with delayed
presentation of missed left-sided diaphragmatic injury 2 and
23 months later, respectively. Both injuries resulted from
stab wounds of the left flank and presented with herniation
of the stomach or small bowel and colon.
the flanks, back and the thoracoabdominal region.58-64 The
risk assessment can be used to guide the decision-making
involved in managing patients with abdominal stab wounds.
Based on the risk assessment and our previous studies, following guidelines for the key decision-points are used in
managing patients with anterior and flank stab wounds at
the Meilahti hospital, University of Helsinki, Finland:
•
•
•
•
•
•
Surgical abdomen (hemoperitoneum, peritonitis, GI perforation) or pericardial tamponade: immediate operation
Patients without surgical abdomen or tamponade: LWE
If fascia intact: discharge
If peritoneal violation obvious or demonstrated on LWE:
laparotomy
If LWE equivocal: observe 24-48 hours
Left thoracoabdominal stab wound: diagnostic laparoscopy
Table 1. Risk of significant organ injury in abdominal stab
wounds
Anterior stab wounds
40-50%
With peritoneal violation
60-70%
Equivocal peritoneal violation
7%
Peritoneum intact on LWE
0%
Stab wound of the flank
20-30%
Posterior stab wound
7-15%
Thoracoabdominal stab wound
15%
Occult diaphragmatic injury
7%
Right side
3%
Left side
17%
LWE = local wound exploration
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MANAGEMENT BASED ON RISK ASSESSMENT
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Table 1 summarizes the likelihood of a significant organ
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Panamerican Journal of Trauma
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torso trauma: Triple-contrast helical CT in peritoneal violation and organ injury – a prospective study in 200 patients.
Radiology 2004;231:775-784.
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Leppäniemi AK, Haapiainen RK: Selective nonoperative
management of abdominal stab wounds: prospective, randomized study. World J Surg 1996;20:1101-1106.
10. Rotschild PD, Treiman RL: Selective management of
abdominal stab wounds. Am J Surg 1966;111:382-387.
11. Oreskovich MR, Carrico CJ: Stab wounds of the anterior
abdomen: analysis of a management plan using local wound
exploration and quantitative peritoneal lavage. Ann Surg
1983;198:411-418.
12. Feliciano DV, Bitondo CG, Steed G, et al: Five hundred open
taps or lavages in patients with abdominal stab wounds. Am
J Surg 1984;148:772-777.
13. Zubowski R, Nallathambi M, Ivatury R, et al: Selective conservatism in abdominal stab wounds. J Trauma 1988;28:16651668.
14. Shorr RM, Gottlieb MM, Webb K, et al: Selective management of abdominal stab wounds. Arch Surg 1988; 123:11411145.
24. Soto JA, Morales C, Munera F, et al: Penetrating stab wounds
to the abdomen: use of serial US and contrast-enhanced CT
in stable patients. Radiology 2001;220:365-371.
25. Leppäniemi AK, Voutilainen PE, Haapiainen RK: Indications
for early mandatory laparotomy in abdominal stab wounds.
Br J Surg 1999;86:76-80.
26. Gazzaniga AB, Stanton WW, Bartlett RH: Laparoscopy in the
diagnosis of blunt and penetrating injuries to the abdomen.
Am J Surg 1976;131:318.
27. Carnevale N, Baron N, Delany HM: Peritoneoscopy as an aid
in the diagnosis of abdominal trauma: a preliminary report. J
Trauma 1977;17:634-641.
28. Berci G, Dunkelman D, Michel SL, et al: Emergency minilaparoscopy in abdominal trauma. An update. Am J Surg
1983;146:261-265.
29. Ivatury RR, Simon RJ, Weksler B, et al: Laparoscopy in the
evaluation of the intrathoracic abdomen after penetrating
injury. J Trauma 1992;33:101-109.
30. Livingston DH, Tortella BJ, Blackwood J, et al: The role of laparoscopy in abdominal trauma. J Trauma 1992;33:471-475.
15. De Lacy AM, Pera M, Garcia-Valdecasas JC, et al:
Management of penetrating abdominal stab wounds. Br J
Surg 1988;75:231-233.
31. Salvino CK, Esposito TJ, Marshall WJ, et al: The role of diagnostic laparoscopy in the management of trauma patients: a
preliminary assessment. J Trauma 1993;34:506-515.
16. Robin AP, Andrews JR, Lange DA, et al: Selective management of anterior abdominal stab wounds. J Trauma
1989;29:1684-1689.
32. Ivatury RR, Simon RJ, Stahl WM: A critical evaluation of
laparoscopy in penetrating abdominal trauma. J Trauma
1993;34:822-828.
17. Rehm CG, Sherman R, Hinz TW: The role of CT scan in
evaluation of for laparotomy in patients with stab wounds of
the abdomen. J Trauma 1989;29:446-450.
33. Fabian TC, Croce MA, Stewart RM, et al: A prospective analysis of diagnostic laparoscopy in trauma. Ann
Surg1993;217:557-565.
18. Muckart DJJ, McDonald MA: Unreliability of standard quantitative criteria in diagnostic peritoneal lavage performed for
suspected penetrating abdominal stab wounds. Am J Surg
1991; 162:223-227.
34. Rossi P, Mullins D, Thal E: Role of laparoscopy in the evaluation of abdominal trauma. Am J Surg 1993;166:707-711.
19. Nagy K, Roberts R, Joseph K, et al: Evisceration after
abdominal stab wounds: Is laparotomy required? J Trauma
1999;47:622-626.
20. Taviloglu K, Guney K, Ertekin C, et al: Abdominal stab
wounds: The role of selective management. Eur J Surg
1998;164:17-21.
21. Gonzales RP, Turk B, Falimirski ME, et al: Abdominal stab
wounds: diagnostic peritoneal lavage criteria for emergency
room discharge. J Trauma 2001;51:939-943.
8
35. Fernando HC, Alle KM, Chen J, et al: Triage by laparoscopy
in patients with penetrating abdominal trauma. Br J Surg
1994;81:384-385.
36. Dalton JM, DeMaria EJ, Gore DC, et al: Prospective evaluation of laparoscopy in abdominal stab wounds (abstract). J
Trauma 1994;36:149.
37. Ortega AE, Tang E, Froes ET, et al: Laparoscopic evaluation
of penetrating thoracoabdominal traumatic injuries. Surg
Endosc 1996;10:19-22.
38. Ditmars ML, Bongard F: Laparoscopy for triage of penetrating trauma: the decision to explore. J Laparoendosc Surg
1996;6:285-291.
Vol. 15 Number 1 2008
Abdominal stab wounds – same problems different solutions
39. Zantut LF, Ivatury RR, Smith RS, et al: Diagnostic and
therapeutic laparoscopy for penetrating abdominal trauma: a
multicenter experience. J Trauma: 1997;42:825-831.
52. Freeman T, Fischer RP: The inadequacy of peritoneal
lavage in diagnosing acute diaphragmatic rupture. J Trauma
1976;16:538-543.
40. Mutter D, Nord M, Vix M, et al: Laparoscopy in the evaluation of abdominal stab wounds. Dig Surg 1997;14:39-42.
53. Rehm CG, Sherman R, Hinz TW: The role of CT scan in
evaluation of for laparotomy in patients with stab wounds of
the abdomen. J Trauma 1989;29:446-450.
41. Marks JM, Youngelman DF, Berk T: Cost analysis of diagnostic laparoscopy vs. laparotomy in the evaluation of penetrating abdominal trauma. Surg Endosc 1997;11:272-276.
42. Murray JA, Demetriades D, Asensio JA, et al: Occult injuries
to the diaphragm: prospective evaluation of laparoscopy
in penetrating injuries to the lower chest. J Am Coll Surg
1998;187:626-630.
43. Hallfeldt KKJ, Trupka AW, Erhard J, et al: Emergency
laparoscopy for abdominal stab wounds. Surg Endosc
1998;12:907-910.
44. Ertekin C, Onaran Y, Guloglu R, et al: The use of laparoscopy as a primary diagnostic and therapeutic method in
penetrating wounds of lower thoracic region. Surg Laparosc
Endosc Percutan Tech 1998;8:26-29.
45. DeMaria EJ, Dalton JM, Gore DC, et al: Complementary
roles of laparoscopic abdominal exploration and diagnostic
peritoneal lavage for evaluating abdominal stab wounds:
a prospective study. J Laparoendosc Adv Surg Tech
2000;10:131-136.
54. Muckart DJJ, McDonald MA: Unreliability of standard quantitative criteria in diagnostic peritoneal lavage performed for
suspected penetrating abdominal stab wounds. Am J Surg
1991;162:223-227.
55. Reber PU, Schmied B, Seiler CA et al: Missed diaphragmatic injuries and their long-term sequelae. J Trauma
1998;44:183-188.
56. Zierold D, Perlstein J, Weisman ER, et al: Penetrating trauma
to the diaphragm. Natural history and ultrasonographic
characteristics of untreated injury in a pig model. Arch Surg
2001;136:32-37.
57. Leppäniemi A, Haapiainen R: Occult diaphragmatic injuries
caused by stab wounds. J Trauma 2003;53:646-650.
58. Peck JJ, Berne TV: Posterior abdominal stab wounds. J
Trauma 1981;21:298-306.
59. Coppa GF, Davalle M, Pachter HL, et al: Management of
penetrating wounds of the back and flank. Surg Gynecol
Obstet 1984;159:514-518.
46. Taner AS, Topgul K, Kucukel F, et al: Diagnostic laparoscopy
decreases the rate of unnecessary laparotomies and reduces
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Tech 2001;11:207-211.
60. Hauser CJ, Hupricj JE, Bosco P, et al: Triple-contrast computed tomography in the evaluation of penetrating posterior
abdominal injuries. Arch Surg 1987;122:1112-1115.
47. Taviloglu K: When to operate on abdominal stab wounds.
Scand J Surg 2002;91:58-61.
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study of 230 patients. Ann Surg 1988;207:72-74.
48. Smith R: Cavitary endoscopy in trauma: 2001. Scand J Surg
2002;91:67-71.
49. Leppäniemi A, Haapiainen R: Diagnostic laparoscopy in
abdominal stab wounds. J Trauma 2003;55:636-645.
62. Kirton OC, Wint D, Thrasher B, et al: Stab wounds to the back
and flank in the hemodynamically stable patient: a decision
algorithm based on contrast-enhanced computed tomography
with colonic opacification. Am J Surg 197;173:189-193.
50. Cherry RA, Eachempati SR, Hydo LJ, et al: The role of
laparoscopy in penetrating abdominal stab wounds. Surg
Laparosc Endosc Percutan Tech 2005;15:14-17.
63. Boyle EM Jr., Maier RV, Salazar JD, et al: Diagnosis of
injuries after stab wounds to the back and flank. J Trauma
1997;42:260-265.
51. Friese RS, Coln E, Gentilello LM: Laparoscopy is sufficient
to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma 2005;58:789-792.
64. Mariadason JG, Parsa MH, Ayuyao A, et al: Management
of stab wounds to the thoracoabdominal region. A clinical
approach. Ann Surg 1988;207:335-340.
9
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 11 - 13
CIRUGÍA MINIMAMENTE INVASIVA EN TRAUMA TORACO
ABDOMINAL EN EL HOSPITAL DE SAN JOSÉ DE
BOGOTÁ COLOMBIA
* Carlo F. Vallejo M. MD, ** Maikel A. Pacheco T. MD, *** Jorge A. Márquez R. MD.
RESUMEN
Background: Los pacientes con trauma en área toracoabdominal requieren necesariamente la evaluación de una
posible lesión diafragmática, el objetivo de este estudio es
mostrar la experiencia de tres años usando la toracoscopia
y/o laparoscopia en el abordaje de estos pacientes.
Pacientes y métodos: Se describe la experiencia en el
Hospital de San José en Bogotá Colombia mediante un
estudio descriptivo tipo serie de casos. Se incluyó 111
pacientes estables con trauma toracoabdominal penetrante desde el año 2002 al 2005 en quienes se realizó
laparoscopia o toracoscopia para evaluar posibles lesiones
diafragmáticas
Resultados: Se encontró 111 pacientes, la mayoría hombres
(86.4%), con mayor frecuencia heridas por arma corto
punzante (92.7%), se realizó laparoscopia al 71.1% y
toracoscopia al 28.8%, con un porcentaje de lesión diafragmática del 17.1%.
Conclusiones: La cirugía minimamente invasiva es útil,
rápida y menos mórbida para descartar o confirmar heridas
del diafragma en pacientes estables con trauma toracoabdominal
PALABRAS CLAVE: Trauma, toracoabdominal, diafragmática, laparoscopia, toracoscopia.
SUMMARY
Background: Patients with toracoabdominal trauma require
a method for the evaluation of a possible diaphragmatic
injury. The aim of this study is to show the experience
*Residente IV, Cirugía General, Fundación Universitaria de
Ciencias de la Salud, Hospital de San José, Bogota Col. ** Instructor
Asistente, Cirugía General, Fundación Universitaria de Ciencias de
la Salud, Hospital de San José, Bogota. *** Instructor asistente,
Cirugía General, Fundación Universitaria de Ciencias de la Salud,
Hospital de San José, Bogota.
10
during three years using thoracoscopy and/or laparoscopy
in the approach of this patients.
Patients and methods: it’s a description about the experience in the Hospital de San Jose in Bogotá Colombia
through a descriptive study including 111 stable patients
with penetrating thoracoabdominal trauma from 2002 to
2005, whom underwent thoracoscopy and/or laparoscopy
for diagnosis of diaphragmatic wounds
Results: We found 111 patients, 84.6% were males. Stab
wounds were the most often (92.7%). Laparoscopy was
performed in 71% and thoracoscopy in 28.8%. finding
17.1% of diaphragmatic wounds.
Conclusions: Minimally invasive surgery is useful, faster
and lower morbidity for diagnosis of diaphragmatic
wounds in stable patients with penetrating trauma in thoracoabdominal area.
KEY WORDS: Trauma, thoracoabdominal, diaphragmatic,
laparoscopy, toracoscopy.
INTRODUCCION
La importancia del trauma en el área toracoabdominal
radica en el riesgo potencial de lesión del diafragma y
sus consecuencias a corto y largo plazo como las hernias
diafragmáticas las cuales pueden sufrir estrangulación,
perforación y sus respectivas complicaciones infecciosas 1,
lesiones estas que pueden pasar inadvertidas de no hacer
una adecuada evaluación y diagnostico, aumentando así la
morbimortalidad en estos pacientes 2,3; Tradicionalmente se
ha menospreciado la importancia de este tipo de lesiones
pues usualmente el paciente cursa asintomático y es dado
de alta sin descartase lesión en el diafragma. Algunas publicaciones en el mundo reportan un porcentaje de lesión diafragmática entre el 10 y el 20% en trauma toracoabdominal
penetrante 4 , sin embargo estas cifras ascienden hasta un
50% según estudios realizados en el Hospital Universitario
del Valle en Cali (Colombia) 5,6.
cirugía minimamente invasiva en trauma toraco abdominal en el hospital de san josé de bogotá colombia
Las hernias diafragmáticas traumáticas pueden pasar inadvertidas en muchas ocasiones, pero en un gran numero
de pacientes tienen consecuencias dramáticas, desafortunadamente el diagnostico es usualmente tardío, cuando se
presentan complicaciones como las ya mencionadas7, por
esta razón, la valoración de la integridad del diafragma se
hace absolutamente necesario en estos pacientes (figura 1).
Se han propuesto diversos mecanismos para evaluar estas
lesiones como toracotomia, laparotomía, exploración digital
, sin embargo han caído en desuso, los primeros por ser
invasivos, con alta morbilidad (toracotomia y laparotomía),
los últimos por limitarse a un solo hemitorax y por no poder
descartar la lesión en la totalidad de los casos cuando la
exploración es negativa 2,8 , otros métodos gamagráficos aun
se encuentran en experimentación 10,11; El advenimiento de
la cirugía minimamente invasiva ha puesto al alcance una
herramienta útil en el abordaje y manejo de estos pacientes
12,13,15,16
.
5,8
Figura 1. Hernia diafragmática traumática estrangulada diagnosticada 7 años después del trauma.
El presente estudio se muestra la experiencia en el manejo
de estas lesiones con cirugía minimamente invasiva para el
diagnóstico de la lesión diafragmática en pacientes estables
con trauma toracoabdominal penetrante en nuestra institución.
HERIDA TORACOABDOMINAL
ESTABLE
INESTABLE
RX TORAX
CIRUGIA
PACIENTES Y METODOS
Desde el año 2002 al 2005, 111 pacientes estables con herida
toracoabdominal penetrante fueron admitidos en el Hospital
de San José en Bogotá, manejados con cirugía minimamente invasiva para descartar lesiones diafragmáticas. La
elección del procedimiento (toracoscopia o laparoscopia)
dependió del resultado de la radiografía de tórax, es decir, si
el resultado de esta fue positivo (neumotórax o hemotórax)
el paciente fue llevado a toracoscopia y toracostomía y por
el contrario si el resultado fue negativo, el paciente fue
llevado a laparoscopia, el objetivo de aplicar este protocolo
de atención es aprovechar la incisión para la toracostomía
para realizar el procedimiento por vía toracoscópica, por
otra parte, si el paciente presentaba heridas toracoabdominales bilaterales se realizaba laparoscopia (figura 2).
En todos los casos, si el resultado de la laparoscopia o toracoscopia fue positivo para lesión en el diafragma, se realizó
laparotomía para la reparación de la herida y exploración
de probables lesiones asociadas.
POSITIVA
TORACOSCOPIA
HERIDA DE DIAFRAGMA
NEGATIVA
NEGATIVA
LAPAROSCOPIA
HERIDA DE DIAFRAGMA
POSITIVA
LAPAROTOMIA
POSITIVA
NEGATIVA
Figura 2. Algoritmo del abordaje diagnostico de las heridas toracoabdominales.
El tiempo quirúrgico en toracoscopia oscilo entre 12 y 16
minutos con un promedio de 14 minutos y entre 9 y 13 para
11
Panamerican Journal of Trauma
laparoscopia con un promedio de 11 minutos. Se requirió
intubación orotraqueal selectiva en 18 de los 32 pacientes
sometidos a toracoscopia.
en muchas ocasiones hizo que estos pacientes ingresaran
inestables al quirófano y por consiguiente no están incluidos
en el estudio.
RESULTADOS
Un aspecto importante para resaltar es el hecho que ningún
paciente sin herida de diafragma según los hallazgos por
cirugía minimamente invasiva requirió procedimientos
adicionales posteriormente ni mostró alteraciones en los
controles sucesivos en un periodo de seguimiento de 1 año.
Cabe anotar también en este punto que las dos, tanto la laparoscopia como la toracoscopia permitieron la evaluación
de la totalidad de los hemidiafragmas sin lugar a dudas en
ninguno de los casos.
Se encontró 111 pacientes con heridas toracoabdominales
penetrantes hemodinamicamente estables, la gran mayoría
fueron jóvenes entre 15 y 30 años (90%), con predominio
masculino 96 pacientes (86.4%) En 104 (92.8%) las
lesiones fueron causadas por arma corto punzante, se practicó laparoscopia en 79 pacientes (71.1%) y toracoscopia en
32 (28.8%) (tabla 1), se diagnosticó herida diafragmática
en 19 pacientes (17.1%) (tabla 2) los cuales requirieron
laparotomía para la sutura del diafragma y exploración de
posible lesión de órganos adyacentes.
Las heridas fueron en hemitorax izquierdo en 68 pacientes
(61.2%), en hemitorax derecho en 39 pacientes (35.1%) y
bilaterales en 4 pacientes (3.6%). De los 19 pacientes con
herida de diafragma, en 8 se encontró lesión asociada: en 2
casos herida hepática, en 3 herida de colon, en 2 herida de
estomago (uno de los cuales tuvo también herida hepática)
y herida de pulmón en 1 paciente.
Cuando se revisa la literatura disponible sobre otros procedimientos diagnósticos5,8,10,11, se pone en evidencia las
grandes ventajas de la cirugía minimamente invasiva toda
vez que se reduce el tiempo quirúrgico, se logra visualizar
la totalidad de los hemidiafragmas y genera menor morbilidad, reduciendo también la estancia hospitalaria, es así
como los pacientes incluidos en nuestro estudio llevados a
laparoscopia fueron dados de alta dentro de las siguientes
12 a 24 horas posteriores al procedimiento.
CONCLUSIONES
Tabla 1. Distribución por género, mecanismo del trauma y
procedimiento realizado.
PACIENTES
n
HOMBRES / MUJERES
96 (86.4%) / 15 (13.5%)
ARMA CORTOPUNZ. /
ARMA DE FUEGO
103 (92.7%) / 8 (7.2%)
TORACOSCOPIA /
LAPAROSCOPIA
32 (28.8%) / 79 (71.1%)
TOTAL
111
Tabla 2. Resultados del procedimiento (herida del diafragma)
RESULTADO
No. PACIENTES
POSITIVO (herida diafragma)
NEGATIVO
19 (17.1%)
92 (82.8%)
TOTAL
111
DISCUSION
La gran diferencia existente en el numero de pacientes
entre el grupo de lesiones por arma cortopunzante y arma
de fuego está dada por la severidad de las ultimas, que
12
La toracoscopia y/o laparoscopia empleada para el diagnóstico de lesiones del diafragma es un procedimiento fácil de
realizar, eficaz, rápido y al alcance en la mayoría de centros
de trauma 5,12,13,15,16, la experiencia en nuestra institución en
el enfoque y el manejo de estas lesiones gracias a la cirugía
minimamente invasiva durante estos años ha representado
agilidad, eficiencia y seguridad en el diagnostico de estas
heridas y a su vez ha permitido prevenir el desarrollo de
hernias diafragmáticas en estos individuos.
Consideramos que esta forma de evaluar los pacientes con
trauma toracoabdominal penetrante puede ser masivamente
usado en los servicios de trauma toda vez que ofrece las
ya mencionadas ventajas y beneficios sobre otros métodos
diagnósticos empleados.
REFERENCIAS
1.
Meyers BF, McCabe C. Traumatic diaphragmatic
hernia. Occult marker of serious injury. Ann Surg.1993;
218:783-790.
2.
Feliciano D, Cruce P, Mattox K, Bitomdo G. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J
Trauma 1988. 30. 1135-1144
3.
Demetriades D, Murray JA. Traumatic diaphragmatic hernias. Nyhus and Condon’s Hernia. 2002. cap 43. 503-511.
Vol. 15 Number 1 2008
cirugía minimamente invasiva en trauma toraco abdominal en el hospital de san josé de bogotá colombia
4.
D´Angelica M, Morgan AS, Barba CA. Trauma de diafragma.
Trauma. A Rodríguez, R. Ferrada. Sociedad Panamericana
de Trauma. 1997. 325-332
11. Rappaport WD, Lee S, Coates S. Diagnosis of diaphragmatic
injury using intraperitoneal technetium. Am Surg. 1989.
55:621
5.
Currea D, Ferrada R. Trauma Toracoabdominal. Revista
Colombiana de Cirugía. 1996. vol. 11 (1) 9-16.
6.
Chitric M, Currea D, Ferrada R. Resumenes XX congreso
Avances en Cirugía 1994. Trauma abdominal por arma de
fuego y laparotomía no esencial. 1994.
12. Jackson A. Thoracoscopy as an aid to the diagnosis of diaphragmatic injury in penetrating wounds of the lower chest.
a preliminary report. Injury 1976. 7. 213-218.
7.
8.
9.
Cruz C, Minagi H. Large bowel obstruction from traumatic
diaphragmatic hernia: Imaging findings in fours Cases. AJR
2004; 172: 843-845.
Morales C, Villegas M. Value of digital explorations for diagnosis of injuries to the left side of the diaphragm caused by
stab wounds. Arch surg. 2001. 136. 1131-1135
Morales C. Panam J Trauma. Evita la toracoscopia la realización de toracotomias en el paciente con trauma de torax?.
2004. 11. 2. 13-20.
10. Halldorsson A, Esser M, Cappaport W. A new method of
diagnosing diaphragmatic injury using intraperitoneal technetium case report. J trauma 1992; 33: 140-142
13. Murray JA, Demetriades D, Asensio JA. Occult injuries
to the diaphragm. Prospective evaluation of laparoscopy in
penetrating injuries to the lower left chest. JACS 187(6):
626-630, 1998
14. Murray JA, Demetriades D, Cornwell EE. Penetrating left
thoracoabdominal trauma. J Trauma.1997; 43: 624-626.
15. Aronoff R, Reynolds J, Thal E. Evaluation of diaphramatic
injuries. Am J Surg. 1998. 162. 671-675
16. Ochsner MG, Rozycki GS, Lucente F. Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in
thoracoabdominal trauma. A preliminary report. J Trauma.
1993. 34:704-710.
13
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 14 - 18
COMBINING APPROACHES IN ARTHROPLASTY
FOR ACUTE FRACTURES OF THE ACETABULUM
Thomas M. Schaller, MD1 and Thomas Ryan, MD
RESUMEN
INTRODUCTION
La reducción abierta y la fijación interna es el método
preferido para la mayoría de los pacientes con fracturas
inestables o desplazadas de acetábulo. Los problemas
relacionados con la lesión del cartílago o la conminución
extensa (inmanejable) ha llevado a intentar la atroplastia
total de cadera en un solo tiempo en conjunto con métodos
estándares o alternativos de fijación. Típicamente se utiliza
el acceso posterior o posterolateral. Las indicaciones para
realizar una artroplastia aguda total aún se encuentran
en desarrollo. La nueva técnica descrita a continuación
combina los intervalos bien conocidos y aprovecha los
principios clásicos de fijación a efecto de maximizar la
viabilidad de los fragmentos fracturados y la estabilidad de
la cadera.
Open reduction and internal fixation (ORIF) is the preferred treatment option for most patients with displaced
or unstable fractures of the acetabulum (1-4). The role for
total hip arthroplasty (THA) has traditionally been reserved
for subacute/staged use or for salvage of severe post-traumatic arthrosis (5, 6). However, certain patients in specific
clinical scenarios may benefit from the acute use of total
hip arthroplasty. Problems related to severe articular cartilage damage or extensive (unmanageable) comminution
led innovators to attempt single stage THA in conjunction
with standard or alternative methods of fixation (7-14).
Palabras claves: Artroplastia, Fractura acetabular, Acceso
quirúrgico.
SUMMARY
Open reduction and internal fixation is the preferred treatment option for most patients with displaced or unstable
fractures of the acetabulum. Problems related to severe
articular cartilage damage or extensive (unmanageable)
comminution led innovators to attempt single stage total
hip arthroplasty in conjunction with standard or alternative
methods of fixation. The standard posterior or anterolateral
approach is typically used. The indications for performing
acute total hip arthroplasty are still evolving. The novel
technique described below combines well-known intervals
and takes advantage of familiar fixation principles in order
to maximize fracture fragment viability and hip stability.
KEY WORDS Arthroplasty, Acetabular Fracture, Surgical
Approach
1
Bronson Methodist Hospital, Kalamazoo, MI, USA
Order reprints [email protected]
23
The indications for performing acute total hip arthroplasty
are still evolving. It is clear that a combination of factors must be present for one to consider THA as a valid
option. For example, it has been shown that age as an
independent variable, does not preclude a good result from
ORIF using standard fixation techniques and non-extensile
approaches(15). However, the interplay of age/osteopenia,
comminution, articular damage, severe impaction, and
femoral head damage may preclude an acceptable outcome
with ORIF.
In a series of 57 patients (average age of 69 years) total hip
arthroplasty was used for treatment of displaced fractures
of the acetabulum(12). Based upon the Harris hip score,
79% of the patients had good or excellent results, and there
were few major complications. That author’s indications
for THA included:
1. Comminuted fracture of 10 or more fragments Full
thickness abrasive loss of cartilage from the femoral
head
2. Significant impaction or comminuted fractures of the
femoral head
3. Impaction of greater than 40% of the acetabular surface
4. Severe pre-existing degenerative arthritis
5. Significant osteopenia
Panamerican Journal of Trauma
The standard posterior or anterolateral approach is typically used for acute THA following an acetabular fracture.
Use of extended lateral approaches is far less common,
and the use of percutaneous techniques may help minimize
the need for their use(12). The novel technique described
below is best suited for the posterior fracture patterns such
as posterior column plus posterior wall, transverse plus
posterior wall, severe isolated posterior wall, etc. This technique combines well-known intervals and takes advantage
of familiar fixation principles in order to maximize fracture
fragment viability and hip stability.
TECHNIQUE
The patient is positioned lateral on a radiolucent table,
supported by a suction beanbag. The incision is similar to
that of the typical Kocher-Langenbeck incision, only with
slightly less posterior deviation of the proximal extension.
The Gluteus Maximus is split in line with its fibers and the
distal insertion is released and tagged for later repair. The
Sciatic nerve is isolated and the short rotators are released
and tagged for later repair. The posterior column and
wall are now visualized without any further disruption of
remaining capsular attachments. In particular, the capsule
is not opened to allow visualization of the neck for resection. The leg is positioned with hip extension and knee
flexion throughout this first half of the procedure to avoid
undue tension upon the sciatic nerve.
The focus is then shifted toward the creation of the deep
dissection for the direct lateral approach to the hip. The leg
is brought into a position of knee extension and external
rotation at the hip. The Gluteus Medius is split at the junction of the anterior 2/3 and posterior 1/3. In conjunction
with gradual external rotation of the leg, the sleeve of tissue
consisting of the anterior 2/3 of Gluteus Medius, Gluteus
Minimus, and the anterior capsule is taken down off the
anterior neck of the femur. The neck resection is carried
out per routine, and now the intraarticular view of the
acetabulum is visible.
One may then return to the posterior aspect of the approach
by returning the leg to a position of knee flexion and hip
extension. The fracture is subsequently addressed with
standard fixation techniques, typically lag screws and buttress plating. [Figure 1] Anatomic restoration of the articular surface is not essential, however the reduction must
be adequate to allow stable placement of the acetabular
component. Alternating between the intraarticular view and
posterior view can help with maximizing stable fixation
without impairing the ability to seat the acetabular component. [Figure 2]
24
Figure 1. Intra-articular view of acetabulum, from the direct
lateral approach
Figure 2. Extra-articular view of acetabulum, from the posterior
approach.
The femoral head may be reamed and used as needed for
filling bone defects and creation of an appropriate bed for
impaction of the cup. A multi-hole porous cup is impacted
into the gently reamed acetabulum via the direct lateral
exposure and additional screws may be placed through the
cup into safe zones. The cup should not be considered as
the primary fixation device (12) the stability of the fracture
repair is derived from the extra-articular screws and buttress plates. Once the cup is secured, a porous or cemented
femoral component is placed. The repair of the anterior
tissue sleeve and the short external rotators proceeds as
Vol. 15 Number 1 2008
Combining approaches in arthroplasty for acute fractures of the acetabulum
usual after implantation of the components. Figure 1 is
an illustration of the intra-articular view from the lateral
approach, after the fixation is in place. Figure 2 represents
the posterior, extra-articular view. The hardware placement
is tailored to the fracture pattern as surgeon preference and
fragment size/location dictates.
Figure 3 and 4. AP pelvis and lateral x-rays of the hip in skeletal traction.
Figures 5 – 7. A series of CT images which demonstrate the comminuted nature of the transverse + posterior wall pattern with associated
femoral head impaction.
CASE EXAMPLE
Our patient is a 72 year-old woman involved in a motor
vehicle collision. She has no previous hip pain, but does
have a history of Rheumatoid arthritis and takes daily oral
prednisone. She does not use tobacco or alcohol, and her
hypertension is well controlled with medication. She is
found to have the transverse/posterior wall acetabulum
fracture as seen in figures 3 and 4.
Selected cuts from the 2 and 3-dimensional reconstructions
are seen in figures 5-8. No head, chest, or abdominal injuries are found, and she has no other orthopedic injuries.
Based largely upon her severe femoral head damage, joint
impaction, and osteopenia, she was taken on the third day
post-injury for THA. Gait training therapy was initiated
in the immediate post-operative period, and unrestricted
weight bearing was reserved until post-operative week
eight.
25
Panamerican Journal of Trauma
Figures 8 - 10. The 1 year follow-up AP hip and Judet views of the pelvis.
At twelve months after surgery, the patient has returned
to her pre-injury level of function, with no radiographic
evidence of migration of her components. [Figures 11, 12,
13]
REFERENCES
1.
Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures
of the acetabulum. A retrospective analysis. Clin Orthop
Relat Res 1986(205):230-240.
DISCUSSION
2.
Templeman DC, Olson S, Moed BR, Duwelius P, Matta JM.
Surgical treatment of acetabular fractures. Instr Course Lect
1999;48:481-496.
3.
Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively
within three weeks after the injury. J Bone Joint Surg Am
1996;78(11):1632-1645.
4.
Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H.
Operative treatment of displaced fractures of the acetabulum.
A meta-analysis. J Bone Joint Surg Br 2005;87(1):2-9.
5.
Mears DC, Velyvis JH. Primary total hip arthroplasty after
acetabular fracture. Instr Course Lect 2001;50:335-354.
6.
Jimenez ML, Tile M, Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin North Am
1997;28(3):435-446.
7.
Uhl RL, Lozman J. Primary total hip arthroplasty for
treatment of a geriatric acetabulum fracture. Orthopedics
2004;27(5):485-486.
8.
Beaule PE. Open reduction and internal fixation versus total
hip arthroplasty for the treatment of acute displaced acetabular
fractures. J Bone Joint Surg Am 2002;84-A(11):2103-2104;
author reply 2104-2105.
9.
Beaule PE, Griffin DB, Matta JM. The Levine anterior
approach for total hip replacement as the treatment for an acute
acetabular fracture. J Orthop Trauma 2004;18(9):623-629.
Acute total hip arthroplasty for fractures of the acetabulum
is a procedure with evolving indications and applications.
Certainly the patient’s age, co-morbidities, previous degenerative disease, and presence or absence of osteopenia play
a role in determining if a patient may be an appropriate
candidate for acute THA. Fracture characteristics such as
massive comminution, articular damage of the acetabulum
and/or femoral head, or severe impaction also are central in
the decision-making.
Based upon the literature, the standard posterior or anterolateral approach is typically used for acute THA for an
acetabular fracture. Our technique described above is best
suited for posterior fracture patterns. This approach utilizes
the combination of key aspects of two familiar approaches.
The combination of these approaches allows for the typical
use of standard plate and screw fixation along the posterior
column and wall. Since the neck resection is carried out
through the anterior exposure, no posterior capsule resection is needed. We believe this helps with viability of the
fragments and preservation of posterior stability(16, 17). In
addition, proceeding with acetabular grafting and reaming
through the anterior incision allows great visualization and
direct access without levering against the posterior repair.
26
Vol. 15 Number 1 2008
Combining approaches in arthroplasty for acute fractures of the acetabulum
10. Borens O, Wettstein M, Garofalo R, Blanc CH, Kombot C,
Leyvraz PF, Mouhsine E. [Treatment of acetabular fractures
in the elderly with primary total hip arthroplasty and modified
cerclage. Early results]. Unfallchirurg 2004;107(11):10501056.
11. Hamer AJ, Stockley I. Acetabular fracture treated by primary
hip arthroplasty. Injury 1994;25(6):399-400.
12. Mears DC, Velyvis JH. Acute total hip arthroplasty for
selected displaced acetabular fractures: two to twelve-year
results. J Bone Joint Surg Am 2002;84-A(1):1-9.
13. Mouhsine E, Garofalo R, Borens O, Fischer JF, Crevoisier X,
Pelet S, Blanc CH, Leyvraz PF. Acute total hip arthroplasty
for acetabular fractures in the elderly: 11 patients followed
for 2 years. Acta Orthop Scand 2002;73(6):615-618.
14. Mouhsine E, Garofalo R, Borens O, Blanc CH, Wettstein M,
Leyvraz PF. Cable fixation and early total hip arthroplasty
in the treatment of acetabular fractures in elderly patients. J
Arthroplasty 2004;19(3):344-348.
15. Helfet DL, Borrelli J, Jr., DiPasquale T, Sanders R.
Stabilization of acetabular fractures in elderly patients. J
Bone Joint Surg Am 1992;74(5):753-765.
16. Baumgaertner MR. Fractures of the posterior wall of the
acetabulum. J Am Acad Orthop Surg 1999;7(1):54-65.
17. Sierra RJ, Raposo JM, Trousdale RT, Cabanela ME. Dislocation
of Primary THA Done through a Posterolateral Approach in
the Elderly. Clin Orthop Relat Res 2005;441:262-267.
27
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 19 - 21
COMPLICACIONES DE LA INGESTIÓN
MASIVA DE OVOIDES DE COCAÍNA
Dr. Carlos Fariña Koppe * Dra. Pamela Bórquez Vera**
HIPÓTESIS
En el área jurisdiccional de nuestro Hospital de Urgencia, se
encuentra el Aeropuerto Internacional, esto determina que
todo paciente con patología de urgencia o que se encuentre
implicado en situaciones médico-legales en proceso de
investigación, sea derivado a hacia nuestro hospital.
Un grupo especial de paciente e imputado lo constituyen
los correos humanos de tráfico de cocaína, conocidos vulgarmente como “burreros”.
El propósito del presente trabajo es revisar los conceptos
quirúrgicos, médico-legales y toxicológicos en relación a las
complicaciones derivadas de la ingesta masiva de ovoides
de cocaína en el contexto del tráfico de drogas ilícitas.
MATERIAL Y MÉTODOS
Se define como correo humano de tráfico de cocaína, a la
persona que en su lugar de origen, ingiere una determinada
cantidad de ovoides de cocaína, con el fin de introducirlo sin
ser descubierto en otro país (1). Los ovoides corresponden
a bolsitas de 3 x 1,5 cms. capaces de contener en promedio
10 gramos de cocaína. El contenedor más utilizado son los
preservativos de látex.
Estudiamos los pacientes ingresados desde el año 1999
hasta el 2006, separándolos en dos grupos: sin y con complicación, que puede ser quirúrgica y/o toxicológica .
RESULTADOS
Personas ingresadas 31
Pacientes complicados 6
De las treinta y una personas portadoras de ovoides, se
complicaron un total de seis individuos, lo que los transforma en pacientes. De éstos, cuatro fueron operados con
el diagnóstico de obstrucción intestinal baja, uno por la
ruptura de un ovoide con la concomitante intoxicación
aguda por cocaína y el otro se operó por haber eliminado
un ovoide roto, lo que hizo presumir mala calidad de la
cápsula y posible rotura de otros al interior del intestino.
De 4035 fallecidos periciados durante el año 2006 hay siete
fallecidos por intoxicación por cocaína, cuatro hombres
y tres mujeres. De ellos en cuatro se encontró ovoides en
su aparato digestivo, por lo que supone que eran correos
humanos. Un octavo fallecido, corresponde a una mujer
portadora de ovoides abandonada, pero que no tenía cocaína
en el estudio toxicológico, la causa de muerte sería asfixia
por un ovoide al momento de la ingestión.
CONCLUSIONES
A quienes se les detecta la presencia de ovoides en su
aparato digestivo son ingresados, (no hospitalizados), a
nuestro hospital bajo custodia policial, en una habitación
individual, para iniciar el proceso de eliminación, durante
el cual permanecen al menos dos funcionarios de la Brigada
Antinarcóticos, por orden de la Fiscalía. Una vez recuperados los ovoides y de no mediar ninguna complicación
quirúrgica ni toxicológica, se traslada al imputado para que
continúe el proceso judicial correspondiente.
La obstrucción intestinal por ovoides, generalmente es
baja, más frecuentemente a nivel de colon, se trata como
cualquier obstrucción intestinal por cuerpo extraño, pero
cuidando de no romper ninguno porque la absorción en la
mucosa o en peritoneo es muy fácil, con lo que se genera
una intoxicación aguda.
En el caso de la rotura la manifestación principal es el
efecto adrenalinomimético (2), por lo que en el aparato
digestivo se presenta vasocontricción severa y prolongada,
lo que impide cicatrización de las enterotomías con la con-
*Cirujano de Urgencia ** Becada de Medicina Legal
14
Complicaciones de la ingestión masiva de ovoides de cocaína
siguiente peritonitis que significa una prolongada hospitalización y riesgo vital.
tratamiento medico y enfrentar el tratamiento quirúrgico de
manera oportuna y adecuada.
De acuerdo a lo anterior se propone hacer enterotomías lo
más bajas posible y dejar ostomías y eventualmente laparostomía contenidas (3,4,5).
RESUMEN
Habitualmente el colon está limpio porque, está ocupado
sólo por los ovoides y porque la ingesta de alimentos ha
sido muy limitada durante el viaje, por tanto no hay contraindicación por el cierre primario, a menos que el cirujano considere algún factor de riesgo, como en el caso de
la intoxicación.
En el área jurisdiccional de nuestro hospital, se encuentra
el aeropuerto internacional, por lo que la policía nos deriva
los sospechosos de ser portadores de estupefacientes en su
cuerpo.
Cada ovoide mide unos tres por uno coma cinco centímetros y pesa alrededor de diez gramos, consta de una
cápsula que puede ser un condón o similar de látex u otro
material que cumpla los requisitos, que se supone resistente al movimiento intestinal y las secreciones del aparato
digestivo lo que no siempre ocurre desencadenando como
complicaciones de una intoxicación aguda por cocaína que
puede llevar rápidamente a la muerte.
El hecho de extraer los ovoides desde el tracto digestivo
necesariamente deja al profesional en calidad de testigo
experto, con el inicio del levantamiento de la cadena de
custodia de las evidencias, por lo que lo más práctico es
hacer ingresar al policía encargado al pabellón y allí ir
entregando los ovoides, teniendo como testigos a todo el
personal del quirófano.
Además de los ovoides, las radiografías también son evidencias que como tales deben ser ingresadas a la cadena de
custodia o entregadas al policía
En el aspecto médico legal es indispensable delimitar responsabilidades, para este efecto hemos hecho ingresar a
pabellón, al funcionario policial a cargo del procedimiento,
quien se hará cargo del producto con personal de pabellón
como testigo, con su nombre, número de cédula de identidad, cargo y firma, en ese momento deja de ser responsabilidad del médico y se transfiere a quien corresponda.
Cadena de custodia de los ovoides estudios radiológicos
por que son evidencias
Vemos entonces que el fenómeno de los correos humanos de
estupefacientes, tiene connotaciones médico legales importantes por lo que resulta indispensable delimitar responsabilidades muy exactamente. Por otra parte la intoxicación
por cocaína que se produce al romperse un ovoide exige
un diagnóstico precoz a fin de establecer oportunamente el
Palabras claves: Complicaciones, ingestión de ovoides
En base a los correos humanos de estupefacientes, conocidos vulgarmente como “burreros”, operados, se presenta
las complicaciones de la ingestión de ovoides de cocaína,
se muestra la experiencia de un cirujano de urgencia del
Hospital de Urgencia Asistencia Pública y de una becada
de medicina legal. Se analiza algunos aspectos quirúrgicos
que son distintos a la cirugía habitual, se hace alcances
acerca de la intoxicación aguda por cocaína. Se insiste en
la mecánica médico legal y judicial de este fenómeno.
Destacamos que es un paciente distinto a los habituales, ya
que se trata de un imputado, que se encuentra bajo custodia
policial, a la espera de su formalización, por lo que además
de la relación médico paciente hay una connotación medico
legal, más aún con la recuperación de los ovoides que representan un alto valor económico. Todo lo anterior hace que
el equipo quirúrgico se transforme en un testigo experto de
singular valor pericial.
SUMMARY
The territorial jurisdiction of our hospital includes the
Santiago international airport, from which the police send
us persons suspected of smuggling drugs as internal body
cavity couriers.
We discussed the experience of the authors, an emergency
surgeon and a forensic medicine scholarship holder, based
on experiences of operating human on the couriers to
extract drug-filled packets, commonly known in Spanish
as mules, or “burreros”. Certain surgical aspects different
from usual surgery are analyzed, and comments are made
regarding acute intoxication by cocaine. We underscore the
use of forensic medicine and judicial mechanisms in these
cases. We also stress that these patients are different from
the norm because they are accused suspects, under police
custody and awaiting arraignment on criminal charges.
In addition, the physician-patient relationship takes on
a connotation of forensic medicine, even more so when
considering the high economic value of the drug packets
15
Panamerican Journal of Trauma
recovered. All of the above qualifies the surgical team to
become expert witnesses in a singular position to provide
specialized testimony.
Although this paper does not deal with trauma per se, we
believe that it will be of interest for emergency surgery and
therefore submit it for your consideration.
Key words: drug packet, ingestion, complications.
Figura 1. Aspecto radiológico de obstrucción intestinal secundaria
a ingestión masiva de ovoides. se aprecia la dilatación gaseosa de
intestino delgado y la presencia de numerosos ovoides.
Figuara 2. Ovoides ordenados, listos para su entrega a la policía.
se aprecia su forma y tamaño aproximado y características del
envoltorio. caso de autopsia
BIBLIOGRAFÍA
Fuente: google.cl búsqueda: trafico cocaína ovoides día
16/4/06
1.
Medicina forense de Simpson, Bernard Knight, segunda
edición , manual moderno, México 999 capitulo 25 pag 223
dependencia y abuso de drogas
2.
Protocolos para el manejo del paciente intoxicado, organización panamericana de la salud, oficina regional de la
organización mundial de la salud, RITA-Ministerio de Salud,
2001, capitulo 12 cocaína pag. 304
3.
Manual de toxicología Casarett & Doull Curtis D. Klaassen,
John B. Watkins III Quinta Edición, Mc Graw Hill Interamericana Editores, 2001 México, Unidad 4 capitulo 16
16
4.
Intoxicaciones, epidemiologia, clinica y tratamiento, textos
universitarios Facultad de Medicina , Enrique Paris Mancilla,
Juan Carlos Río Bustamente, Ediciones Universidad Católoica de Chile, Santiago, Chile 2001, Capítulo cocaína pag
162
5.
Lo esencial en farmacología, segunda edición, Dawson
, Taylor, Reide, gráficas Marte, España, Mdrid, editorial
Elsevier, cap 6 sistema nerviososo central, abuso de sustancias pag 115.
Nota: La presentación de la bibliografía es atípica, porque tratándose de una patología nueva, no hemos encontrado trabajos
acerca del tema tratado.
Vol. 15 Number 1 2008
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 22 - 27
ECONOMICS OF TRAUMA CARE RE-VISITED
Samir Fakhry, MD, Facs
INTRODUCTION
TRAUMA SYSTEM CHALLENGES: NATIONAL
Trauma care is expensive with approximately 150,000
deaths annually in the United States and total costs from
motor vehicle crashes alone estimated at as much as $383.6
billion 1. A careful review of the economics of trauma care
should reveal an interesting observation: if one’s ultimate
goal was to become exceptionally rich, it would have been
better to have obtained a business degree than a medical
degree 2. On the other hand it is not necessarily true that
being engaged in the practice of trauma care will result in a
uniformly poor balance sheet for both physicians and hospitals. It appears possible for trauma surgeons and trauma
centers to be profitable, or at least to break even. There are
a number of conditions that increase a center’s likelihood
of positive financial outcomes:
1. Large volumes of severely injured trauma patients 3,4.
An adequately large volume of patients allows a center
to spread overhead costs over more patients and justify
the substantial standby costs of trauma readiness.
2. High quality care and the practice of evidence based
medicine.
3. Efficient, comprehensive documentation, coding and
billing systems for physicians and hospitals.
4. A favorable (or at least tolerable) patient payer mix to
allow adequate reimbursement.
5. Optimally negotiated managed care contracts
6. Availability of specialty coverage for call.
Trauma care in the United States has received minimal support from the federal government. The federal legislation
for the support of trauma systems has never provided more
than about $3.5 million dollars annually. This translates into
approximately $40,000 per state. This funding has been
available inconsistently in the past decade and this year
does not appear promising given the budget constraints that
Congress is encountering. Funding for research in trauma
has always been extremely limited in relationship to the
productive years of life lost or to the overall cost of trauma
to society 6. Following the tragic events of September 11,
2001 significant federal funding became available for the
war on terror and for homeland security. Unfortunately
only a minimal amount of money found its way to trauma
centers in the United States.
Current statistics suggest that 678,000 injured people are
treated in a regional trauma center annually in the United
States. The severity adjusted national norm for per patient
costs in a trauma center is $14,896.00. Total trauma center
costs for hospitals in the United States are estimated at 10.1
billion with trauma center losses estimated at 1 billion 5.
The increasing financial pressures in areas such as those
noted above have forced many trauma centers to close or
reduce their levels of care 5. The outlook for the future is
not rosy.
Historically these difficult economic outcomes were the
result of:
1. Poor patient payer mix in many centers, especially
those in urban regions (managing penetrating trauma)
2. Low rates of reimbursement for the complex care
delivered in trauma centers
3. Little if any support for the cost of readiness incurred
by trauma centers.
Chief, Trauma & Surgical Critical Care Services, Associate Chair
for Research and Education, Department of Surgery, Inova Fairfax
Hospital, Professor of Surgery, Virginia Commonwealth University
– Inova Campus, Falls Church, Virginia
These challenges have forced the closure of many trauma
centers over the years. In addition to the more familiar
problems of previous years, several new threats to trauma
center viability have appeared. Foremost among these is
the significant problem of adequate specialty coverage for
trauma and emergency department care. In a recent report
17
Panamerican Journal of Trauma
from the American College of Emergency Physicians
7
funded by the Robert Wood Johnson Foundation,
“On-call Specialist Coverage in United States Emergency
Departments”, 65.9 % of a large sample of emergency
departments (n=1427) reported that they had significant
difficulties finding adequate on-call specialty coverage for
their emergency departments. It should be noted that 63%
of these hospitals were not trauma centers while 21% were
Level I or Level II trauma centers. 75% of these hospitals
were not for profit hospitals. The ED directors responding
to this survey were asked “What is the most significant consequence of this shortage?” The leading response (27%)
was “risked or harmed patients who need specialists care”
followed by “delay in patient care” (21%) and “more transfers of patients between emergency departments” (18%).
The survey also revealed that emergency department transfers were increasing in 33% of these departments and in
approximately one half of those cases the transfers were
made only because their emergency department did not
have access to a specialist physician. Although there are
many possible reasons for the difficulties that these hospitals are encountering in securing adequate on call specialty
coverage, three deserve special mention.
(JLARC) to study the use and financing of trauma centers in
Virginia. This resulted in part from the coordinated efforts
of a group of trauma center physicians in Virginia, the
Physician’s Injury Reduction Coalition (PIRC). The exceptionally fine report produced by the JLARC in response to
this legislative mandate provides an excellent case study of
the current status of the economics of trauma centers in the
United States 10.
Among the highlights of the JLARC report:
1.
2.
3.
These are:
1. Lifestyle choices
2. Organized efforts by specialty organizations at
securing compensation for on-call coverage for trauma
and emergency department cases
3. Perceived impact of malpractice coverage
The increasing shortages of physicians interested in surgery and in particular, trauma care, have only increased the
severity of these challenges8,9. Faced with the need to provide trauma services for their community, hospitals have
struggled to meet these challenges. The percentage of hospitals around the country providing on call stipends to their
specialty physicians is at an all time high. Hospitals that
choose not to abandon their trauma designation have been
forced to invest increasing amounts of scarce resources into
trauma care. This has added to the financial losses incurred
by many trauma centers. In addition to poor reimbursement
and uninsured patients, this new category of on-call compensation to specialty physicians must be considered in any
assessment of the economics of trauma centers, especially
those in the private sector.
4.
5.
6.
Trauma System Challenges: State
In 2004, the Virginia House Joint Resolution 183 directed
the Joint Legislative Audit and Review Commission
18
Nearly 14,000 patients were treated at designated
trauma centers in Virginia in 2003 (Fig1). The most
common mechanisms of injury were motor vehicle
crashes (35%) and falls (32%). Penetrating injuries
were the third most common injuries but accounted for
only 8% of the total.
The financial analysis of trauma programs in Virginia
revealed that uncompensated care, low reimbursement
rates from public insurers, and readiness costs created
a $44 million loss across Virginia trauma centers in
2003. The cost of readiness was a loss leader among
trauma centers (Fig 2).
Hospital administrators consistently cited physician
availability as the primary issue that could jeopardize
access to trauma centers. The shortage of orthopedic
surgeons was especially pronounced. Not surprisingly,
the majority of trauma coverage was through physicians in private practice (Fig 4). Significant numbers
of the on-call private physicians were being paid to be
on-call (Fig 5). This was especially true for general/
trauma surgeons.
Trauma care has become less attractive to physicians.
Factors related to this problem included:
•
Inadequate reimbursement. This affected private
physicians more than those in university practice.
Trauma patients were more likely to be uninsured
than other patients (fig 6) and their care disrupts
the care of other, more lucrative patients with
higher reimbursement rates.
•
Malpractice concerns.
•
Quality of life issues.
•
The dwindling supply of trauma surgeons.
Public insurers (including Medicare and Medicaid)
reimburse trauma care at levels below the actual cost
of care (Fig 7).
Analysis of triage effectiveness in the State found that
a large number of critically injured trauma patients are
not treated in designated trauma centers, while many
moderately injured patients receive the highest level of
trauma care.
Vol. 15 Number 1 2008
Economics of trauma care re-visited
The JLARC report also offered a variety of potential
methods for the legislature to support Trauma Centers in
Virginia. Partially as a result of this report, the legislature
created a “Trauma Fund” to be supported by monies collected as fines from repeat offenders of DUI laws and
from individuals seeking to reinstate a suspended driver’s
license. It is expected that this fund will raise funds to cover
approximately 10% of Trauma Center losses in Virginia.
risk of overextending trauma center finances (a “slippery
slope”) and do not address the fundamental issues driving
these manpower trends. Other temporary solutions (such
as Virginia’ Trauma Fund) offer short term relief but can
also be exhausted by increasing volumes of patients and
spiraling costs. Fundamental solutions that address the root
causes of this crisis in trauma care must be considered by
policy makers and healthcare professionals to ensure the
viability of our Trauma Centers.
CONCLUSION
Trauma Centers in America are facing increasing challenges to their operational integrity. Some of these challenges are similar to those faced in past years but there
are new challenges that arise predominantly from the
difficulties in securing specialty on-call coverage and
from the dwindling numbers of physicians interested in
caring for trauma patients. These manpower issues are
unlikely to disappear in the foreseeable future since they
are rooted in basic trends affecting Medicine and Surgery.
Most current solutions for the manpower shortages (especially the sub-specialty crisis) involve reimbursement for
on-call coverage. In the long run, such solutions run the
Figure 1. Source: JLARC staff analysis of trauma registry data
Sources of Losses Incurred by Trauma Centers
for Treatment of Trauma Patients (2003)
Total Cost of
Readiness: $20.0 M
Total = $44 Million
$12.0 M
Unreimbursed
Readiness Costs of
Privately-Insured
Patients
$5.0 M
Unreimbursed
Readiness Costs of
Publicly Insured
Patients
$7.0 M
Losses on Clinical
Care Provided to
Publicly insured
Patients
Total Cost of
Public Insurance
Losses: $12.0 M
$13.6 M
Losses on Clinical
Care Provided to
Uninsured Patients
Total Cost of
Uncompensated
Care: $20.0 M
Note: Data exclude Southside Regional Medical Center.
Figure 2.
19
Panamerican Journal of Trauma
Figure 3. Note: Includes only those trauma centers reporting staffing levels for both 2004 and 1999. Does not include Lynchburg General
Hospital, Carilion New River Valley Medical Center and Orthopedic and Neurosurgeon levels at UVA Medical Center.Source: JLARC staff
analysis of survey data.
Figure 4.
20
Vol. 15 Number 1 2008
Economics of trauma care re-visited
Figure 5.
Figure 6. Source: JLARC staff analysis of 2003 trauma center financial data, excluding Southside Regional Medical Center.
Figure 7.
21
Panamerican Journal of Trauma
REFERENCES
1.
Segui-Gomez, M, MaKenzie, E. Measuring the Public Health
Impact of Injuries. Epidemiologic Reviews, 25:3-19, 2003.
2.
Fakhry, SM, Watts, DD. What’s a Trauma Surgeon Worth? A
Salary Survey of the Membership of the Eastern Association
for the Surgery of Trauma. Journal of Trauma, 49:833-38,
2000.
3.
Taheri, P, Butz, D, Griffes, LC, Morlock DR, Greenfield,
LJ. Physician Impact on the Total Cost of Care. Annals of
Surgery, 231:432-435, 2000.
4.
Taheri, P, Butz, D, Greenfield, LJ. Paying a Premium: How
Patient Complexity Affects Costs and Profit Margins. Annals
of Surgery, 229:807-8145, 1999.
5.
National Foundation for Trauma Care. U.S. Trauma Center
Crisis: Lost in the Scramble for Terror Resources. May
2004. At www.traumafoundation.org/public/files-misc/
NFTC_CrisisReport_May04.pdf. Accessed 5/5/06.
22
6.
Committee on Trauma Research, Commission on Life
Sciences, National Research Council and Institute of
Medicine. Injury in America: A continuing Health Problem.
Washington, DC: National Academy Press, 1985.
7.
American College of Emergency Physicians. On-call
Specialist Coverage in United States Emergency Departments,
ACEP Survey of Emergency Departments, 2004.
8.
Fakhry SM, Watts DD, Michetti C, Hunt JP and the EAST
Multi-Institutional HVI Research Group. The Resident
Experience On Trauma: Declining Surgical Opportunities
And Career Incentives? Analysis of data from a large multiinstitutional study. Journal of Trauma, 54:1-8, 2003.
9.
Richardson JD, Miller FB. Will future surgeons be interested
in trauma care? Results of a resident survey. J Trauma,
32:229-235, 1992.
10. The use and Financing of Trauma Centers in Virginia. Joint
Legistlative Audit and Review Commission, Document
number 62 (2004). At http:\\JLARC.state.va.us/reports/
rpt313.pdf. Accessed 5/5/2006.
Vol. 15 Number 1 2008
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 28 - 32
EXPERIENCIA CON EL USO INTRAPLEURAL
DE PRÓTESIS INFLABLES DE SILICONA
Dr. Adolfo E. Urrutia*, Dr. Rafael A. Uzcategui **, Dr. Argenis D´Windt ***, Dr. Franci Padrón****. Dr. Fernando Fernández*****,
Dr. Marcos Romero ******
RESUMEN
Objetivo: Determinar la eficacia del uso de prótesis inflable
de silicona para obliterar el espacio residual pleural en
pacientes con empiema y fístula broncopleural, empiema
y fístula broncopleural posneumonectomía, síndrome posneumonectomía, y la utilización de ésta profilácticamente
en casos con indicación de neumonectomía. Material y
métodos: De febrero de 1998 a diciembre 2005, 7 pacientes
con espacio pleural residual fueron tratados con una prótesis inflables de silicona. Tres tenían un empiema crónico
posneumonectomía, 1 tenia un derrame pleural metastásico
asociado con empiema por contaminación iatrogénica,
otro era 1 caso de síndrome posneumonectomía y 2 eran
enfermos a quienes se les realizó neumonectomía por
fibrotórax secundario a tuberculosis y bronquiectasias, a
estos se les introdujeron prótesis de silicona profilácticamente. La prótesis de silicona inflable ó silastic utilizadas
fueron del mismo tipo corrientemente empleadas para
implante mamario. Una vez finalizado el procedimiento
primario, se introduce en el tórax la prótesis la cual luego
se insufla con solución fisiológica hasta obliterar la cavidad
pleural residual. Resultados: Los pacientes fueron seguidos
por más de 36 meses y los resultados han sido satisfactorios, sin que haya existido recidiva del empiema o de la
fístula; los síntomas han desaparecido y tampoco ha habido
complicaciones en los casos de neumonectomía en los que
se aplicó la prótesis en forma profiláctica.
Conclusión: Este procedimiento es una opción menos
invasiva y de menor riesgo en aquellos pacientes muy
deteriorados y con compromiso de sus reservas cardiorespiratorias. Su utilización profiláctica en casos complejos
que requerirán neumonectomía previene complicaciones.
*Cirujano, Coordinador Cirugía Torácica, Hospital Pedro Iturbe;
Maracaibo, Venezuela. **Jefe Servicio Broncoscopia, Hospital
Pedro Iturbe; Maracaibo, Venezuela. ***Jefe Servicio Cirugía
Torácica; Hospital Coromoto; Maracaibo, Venezuela. ****Jefe
Servicio cirugía Torácica, Centro Medico; Cabimas, Venezuela.
***** Adjunto Servicio Cirugía Torácica, Hospital Pedro Iturbe;
Maracaibo, Venezuela. ****** Jefe Servicio Cirugía Torácica,
Hospital Vangriken; Coro, Venezuela.
Palabras claves: Prótesis endotorácica de silicona. Empiema.
Fístula broncopulmonar. Neumonectomía. Síndrome posneumonectomía
EXPERIENTIAL WITH THE USE OF
INTRAPLEURAL SILICONE INFLATABLE
PROSTHESIS
Summary
Objective: to determinate the efficacy of an inflatable intrapleural silicone prosthesis to obliterate the residual pleural
space in patients suffering from: a- Broncho pleural fistula and
empyema, b- Post-pneumonectomy empyema and broncho
pleural fistula, c- Post-pneumonectomy syndrome, d- its
prophylactic use in patients in whom a pneumonectomy is
indicated. Methods: Seven cases were treated from February
1998 to December of 2005, 3 of them had a chronic postpneumonectomy empyema, another had a residual pleural
effusion from metastasis associated with empyema due to
iatrogenic contamination, 1 more had post-pneumonectomy
syndrome and 2 were pneumonectomy patients with bronchiectasis and fibro-thorax secondary to TBC. A silicone
or sylastic inflatable prosthesis same as the ones used for
breast implant, was introduced into the chest cavity and later
on was inflated or insufflated with saline solution until the
residual pleural space was obliterated. Results: There was
no mortality associated with the procedure. At a follow up
period of 36 months the results have been satisfactory, there
has been no fistula or empyema recurrence; the symptoms
have disappear and the cases in which the prosthesis was
prophylactically employed have had no complications.
Conclusion:, The use of inflatable silicone prosthesis is a
viable alternative in patients with residual pleural space
problems specially those with empyema and bronchopleural
fistulae. This approach can also be utilized prophylactically
in pneumonectomy candidates in whom a complication
might be anticipated. This procedure has advantages since it
is a lesser invasive option and carries less risk even when is
applied to patients with severe compromise of their cardio
respiratory reserves facing a pneumonectomy.
28
Experiencia con el uso intrapleural de prótesis inflables de silicona
Key words: Silicone endothracic prosthesis - emphyma
– bronchopulmonar fistula – pneumonectomy – postpneumonectomy syndrome.
secundarios a bronquiectasias, en ambos se implantaron
prótesis profilácticamente después de la neumonectomía.
Introducción
La fístula broncopleural es una de las más importantes
complicaciones de la resección pulmonar, conllevando gran
morbilidad y significativa mortalidad operatoria. Con el
advenimiento de los antimicrobianos contra la tuberculosis
y las enfermedades infecciosas broncopulmonares disminuyeron las indicaciones quirúrgicas de estas entidades
y en consecuencia, se redujeron las complicaciones de
empiema y fistulas broncopleurales. Sin embargo esporádicamente aparecen pacientes con los mismos problemas
que solían discutirse hace años.
Figura 1. Prótesis de silicona insuflada.
Muy diversos han sido los tratamientos y procedimientos
propuestos para eliminar el espacio empiemático residual:
se han recomendado el drenaje torácico cerrado o abierto, dejar que la fístula cierre espontáneamente, realizar
un tratamiento endoscópico con electrocoagulación o
cauterización con nitrato de plata, ocluir el bronquio
con una mezcla de sangre homóloga y gelfoam, suturar
directamente la fístula más toracoplastia y realizar plastias
musculares asociadas o no a la toracoplastia. Los resultados
obtenidos han sido muy desiguales con todas y cada una de
dichas técnicas. El síndrome posneumonectomía es una rara
complicación y consiste en un excesivo desplazamiento del
mediastino que conduce a un cuadro de grave insuficiencia
respiratoria y se caracteriza por disnea progresiva, estridor
e infecciones broncopulmonares repetidas.
Presentamos aquí nuestra experiencia con el uso de prótesis
inflables para obliterar el espacio residual.
El diagnóstico se realizó por clínica, imágenes, toracocentésis y exámenes de laboratorio incluyendo cultivos. Los
4 casos que cursaron con empiema se trataron con drenaje
cerrado por toracotomía mínima con tubos trócar (argyl
No. 28 o 32). El paciente de derrame pleural metastásico
y empiema crónico, posteriormente se abordó por drenaje
abierto. En 3 casos con empiema crónico se colocó antes
del implante de la prótesis un catéter intratorácico fino No.
16 en el segundo espacio intercostal anterior, para toracoclisis con solución antiséptica de Gerdex® (gluteraldehido)
y rifocina (500mg en 500cc de solución fisiológica en
goteo cada 8 horas), para ayudar a descontaminar el espacio
empiemático residual, hasta lograr escasa o nula salida de
secreciones por el tubo de drenaje (Figura 2), cuando esto
se logra, la temperatura y la cuenta blanca se normalizan.
Antibiótico sobre la base de la sensibilidad.
Materiales y métodos
De febrero de 1998 a diciembre de 2005 (7 años y 10 meses),
se trataron 7 pacientes, 6 posneumonectomía y un caso de
cáncer de mamas y metástasis pleuro-pulmonar, empiema
asociado y fístula broncopleural. En todos se empleó la
técnica del plombaje, utilizando una prótesis de inflable de
silicona (Figura 1). En 1de corrección mediastinal posneumonectomía por tumor carcinoide de bronquio principal
derecho también se hizo cardiopexia. Tres pacientes tenían
una cavidad empiemática y fístula broncopleural posneumonectomía: 1 con cáncer pulmonar, 2 por infección crónica
pulmonar. Había un cuarto caso con diagnóstico de vasculitis
y un quinto paciente con cáncer de mama, derrame pleural
metastásico y empiema por contaminación. Finalmente
había 2 pacientes con fibrotórax, 1 derecho, el otro izquierdo
Figura 2. Radiografía de tórax. Se aprecia el tubo delgado (flechas)
de toracoclísis y el tubo grueso de drenaje torácico.
29
Panamerican Journal of Trauma
Técnica
La colocación intrapleural de la prótesis, se ejecuta en el
pabellón con anestesia general y el paciente intubado. Se
amplía la herida en el sitio de la pared donde emerge el tubo
torácico de drenaje, se resecan subperiósticamente de 3 a
4 cm del arco costal correspondiente a la zona más declive
de la cámara empiemática para ampliar y facilitar la colocación de la prótesis. En la superficie anterior de la prótesis
se encuentra una válvula de seguridad que permite llenarla
con solución fisiológica. Se calcula el volumen de la cámara
empiemática residual midiendo en una radiografía PA la
altura y el diámetro transversal y en la radiografía lateral el
diámetro anteroposterior, se multiplican las 3 mediciones,
lo que cual da el volumen aproximado. Este casi siempre
es de 1 litro y permite elegir el tamaño de la prótesis. Otro
procedimiento de medida es mediante ecografía del espacio
torácico. El líquido se pasa a través de una inyectadora de
60cc ajustada al conector de la prótesis que tiene una válvula de seguridad. Se deja un tubo de drenaje torácico a
sello de agua subacuático durante 2 a 3 días. La válvula de
la prótesis se deja en partes blandas extratorácicas para ser
localizada con facilidad, en caso de ser necesario insuflar
más solución si hiciera falta (Figura 3).
años; 8 semanas; 4 semanas y 2 semanas respectivamente. En
2 casos la prótesis se instaló profilácticamente, así como en
pacientes con el síndrome posneumonectomía. El tiempo
de aparición de los síntomas en el caso del síndrome posneumonectomía fue de 4 años. Los 2 pacientes con prótesis
profiláctica, no han presentado complicaciones después de
31 y 26 meses de seguimiento.
A todos los pacientes se les practicaron estudios de imágenes: Rx y TAC del tórax. La imagen hidroaérea se
observó en los casos de empiema. El desplazamiento delas
estructuras mediastinales hacia el hemitorax de la neumonectomía en el síndrome posmediastinal. No se presentaron
complicaciones transoperatorias así como no hubo ninguna recidiva del empiema ni de la fístula broncopleural.
En un caso la prótesis no lleno toda la cavidad torácica y se
cambio por otra de mayor capacidad. (Figura 4)
Figura 4. Radiografía de tórax, La prótesis no lleno toda la
cavidad torácica, se cambio por otra de mayor capacidad.
Los pacientes fueron seguidos directamente durante 36
meses sin que se presentara ninguna complicación importante.
Discusión
Figura 3. Radiografía de tórax. Se observa la válvula de seguridad
en la región extratorácica.
Resultados
De los 7 pacientes tratados 5 correspondieron al sexo masculino (71.4%) y 2 al femenino (28.6%), los extremos de
las edades de esta casuística estuvieron entre 20 y 60 años.
Cuatro pacientes posneumonectomía se complicaron con
fístula broncopleural y su aparición cronológica fue a los 7
30
Presentamos nuestra experiencia en pacientes con empiemas
y fistulas broncopleural, síndrome posneumonectomía y
su tratamiento con una prótesis inflable intratorácica. Un
caso con implante de prótesis intratorácica sin neumonectomía por un cáncer de mamas con metástasis a pleura y
pulmón con empiema y fistula broncopleural donde todos
los intentos de tratamiento con cirugía de la mama, radio y
quimioterapia para impedir la progresión de la enfermedad
fracasaron y la pleurodesis no fue satisfactoria. La infección contaminante fue un factor de estimulo inmunológico
Vol. 15 Number 1 2008
Experiencia con el uso intrapleural de prótesis inflables de silicona
celular para estabilizar su enfermedad de base. La causa de
este empiema fue iatrogénica, por lo tanto debe enfatizarse
el uso de técnicas estériles durante la toracocentesis. Otros
autores señalan incidencia de empiema iatrogénico (1,2).
En este paciente con empiema crónico y fistula broncopleural con pobres reservas cardiorrespiratorias y malas
condiciones generales, rellenar el espacio pleural residual
con prótesis insuflables es una alternativa a ser considerada
por los neumólogos y cirujanos del tórax en razón de la
evolución favorable de su empiema.
Cuando la fístula broncopleural aparece en un paciente
después de una neumonectomía, el drenaje cerrado no es
suficientemente efectivo para que cierre espontáneamente,
planteándose la necesidad de aplicar procedimientos
quirúrgicos más agresivos. Generalmente son pacientes
con alto riesgo por su mal estado general. Somos de la
opinión que el implante de prótesis mamaria intratorácica
es una alternativa para este tipo de pacientes, por conseguir
el efecto reductor del espacio pleural residual con un procedimiento inocuo.Es importante lograr la esterilización
de la cámara pleural a través de toracoclisis con una mezcla
de soluciones antisépticas y rifocina por varios días con el
fin de garantizar un riesgo menor de recidivas y éxito del
implante.
El diagnóstico temprano de empiema posneumonectomía
puede ser difícil, así ocurrió en un caso, debido a que los
signos y síntomas eran inicialmente pocos, con fiebre de 38
grados y leucopenia. La presencia de una imagen hidroaérea
en la radiografía simple del tórax no es diagnóstico de
empiema y fístula broncopleural, pero si se acompaña de
signos asociados, el diagnóstico es sugestivo.
La TAC puede precisar el sitio de la fístula. Un paciente
presentó disfagia con la prótesis inflable en el hemitórax
izquierdo, pero desapareció al disminuir la presión al retirar
líquido. En este lado del tórax se debe ser cuidadoso en no
hiperinsuflar la prótesis.
La video broncoscopía y la broncoscopia rígida deben
ser incluidos en los procedimientos de estudio, porque
ayudan a precisar la presencia de la fístula broncopleural
y sospechar el diagnóstico de empiema post-operatorio,
además de evaluar la longitud del muñón bronquial y la
presencia residual de cáncer (3,4). Algunos grupos han
realizado tratamiento endoscópico con sustancias esclerosantes o taponamiento con material tisular de gelfoam
o pegamento tisular (5-8), con resultados diferentes, en
1 de nuestros casos este procedimiento fracasó. Si el
empiema es sospechado se debe practicar toracocentesis
y enviar muestras al laboratorio para cultivo de aerobios
y anaerobios y tinción de Gram. Si el material es purulento, es imperativo la colocación de un tubo de drenaje
torácico numero 28-32. El Streptoccoccus pneumoniae, la
Klebsiella y la Pseudomona aeruginosa son los organismos
más frecuentemente encontrados, en coincidencia con otros
trabajos (9). El empiema posneumonectomía puede ocurrir
años después de la operación, en uno de nuestros casos
ocurrió 7 años después, pero generalmente es en el periodo
temprano del post-operatorio. (10,11).
El termino síndrome posneumonectomía fue acuñado por
primera vez por Wasserman en un paciente con disnea y
estridor un año después de una neumonectomía (12). En un
paciente de esta casuística fue la disnea progresiva asociada
al estridor, 7 años después de una neumonectomía derecha.
(Figura 5)
Figura 5. Radiografía de tórax preoperatoria, se aprecia la extrema
desviación cardio-mediastinal hacia el lado derecho, columna
desnuda. Prótesis traqueal y en bronquio principal izquierdo.
El tratamiento quirúrgico del Síndrome Posneumonectomía
esta dirigido hacia la corrección de la distorsión del bronquio
principal por el desplazamiento de las estructuras mediastinales dentro del hemitórax de la neumonectomía. La broncoscopia permite la colocación de prótesis endoscópicas y
logra la corrección del estridor, particularmente en aquellos
casos que cursan con traqueobroncomalacia. A un paciente
con este diagnóstico se le colocó una prótesis auto-expansible bronquial en la tráquea y en el bronqueo principal
izquierdo, mejorando la sintomatología respiratoria. Dos
meses después hizo nuevamente disnea y cuadro repetido
de infección respiratoria baja. Siete meses mas tarde se
retiró la prótesis bronquial y se colocó otra prótesis para
mantener la luz de la tráquea y del bronquio principal. En
esa ocasión se programó toracotomía para reubicación de
31
Panamerican Journal of Trauma
la tráquea y bronquio principal izquierdo con plombaje del
espacio vacío con el uso de prótesis mamaria expansible
de silicona combinado con cardiopexia; hoy tiene 6 años
de seguimiento con excelentes resultados. La corrección
mediastinal combinada con cardiopexia y plombaje del
espacio vacío de la neumonectomía es una efectiva opción
del tratamiento (13-15). (Figura 6)
Figura 6. Radiografía de tórax post-operatoria con la prótesis
de silicona intrapleural, el borde del corazón se observa en el
hemitórax izquierdo en posición correcta.
En los pacientes con empiema y fístula broncopleural así
como en los casos de síndrome post-neumonectomía y
aquellos que ameriten neumonectomía, el tratamiento con
la implantación de la prótesis insuflable intratorácica en
este estudio fue exitosa por los logros obtenidos, en consecuencia recomendamos esta técnica en pacientes en estas
mismas condiciones.
CONCLUSIONES
1.
2.
3.
4.
32
Sin ser una muestra significativa, mostramos la experiencia de nuestro grupo en la conducta del empiema y
fístula broncopleural, síndrome posneumonectomía y
profilaxis de las complicaciones de la neumonectomía,
mediante el uso del implante de prótesis de silicona
inflable.
En pacientes con empiema crónico y fístula bronco
pleural con pocas reservas cardiorrespiratorias y malas
condiciones, rellenar el espacio pleural residual con
prótesis insuflables, es una alternativa a ser considerada por los neumólogos y cirujanos torácicos.
Es un procedimiento inocuo, una técnica sencilla, y de
escasa morbilidad y nula mortalidad.
En enfermos con el síndrome postneumonectomía, la
corrección mediastinal combinada con cardiopexia y
5.
plombaje del espacio vacío de la neumonectomía, es
una efectiva opción de tratamiento.
El ideal es diseñar una prótesis adaptable a la forma y
capacidad del hemitórax correspondiente.
REFERENCIAS
1.
Cano V, Nuñez Pérez R, Cardozo R. Patología de la Pleura.
2ª Edic. Interamericana McGraw-Hill. Mexico 1995. Pag.
29-65
2.
Alfageme I, Muñoz F, Peña N, Umbria S. Empyema of the
thorax in adults. Chest 1993; 103:839-843.
3.
McManigle Je, Fletcher Gl, Tenholder, Mf. Bronchoscopy in
the management of bronchopleural fistula. Chest 1990; 97:
1235-1238.
4.
York El, Lewall Db, Hirji M, Gelfand ET, Modry DL.
Endoscopy diagnosis and treatment of postoperative bronchopleural fistula. Chest 1990; 97: 1390-1392.
5.
Nicholas JM, Dulchasvsky SA. Successful use of autologous
fibrin gel in traumatic bronchopleural fistula. J Trauma 1992;
32: 87-88.
6.
Onotera RT, Unruch HW. Closure of post-pneumonectomy
bronchopleural fistula with fibrin sealant: tórax 1988; 43:
1015-1016.
7.
Yaman M, Goklen AN; Besirli K, Boskurt K. Endoscopic
treatment of bronchus stump fistula with fibrin sealant following pneumonectomy. Chest 1991; 100: 288-289.
8.
Yasuda Y, Mori A, Kato H. Intratoracic fibrin glue for posoperative pleuropulmonary fistula. Ann Thorac Surg 1991, 51:
242-243.
9.
Brook I, Frazier E. Aerobic and anaerobic microbiology of
empyema. Chest 1993; 103: 1502-1507.
10. Kerr WF. Late-oncet postpneumonectomy empyema. Thorax
1997; 32: 149-154.
11. Kutty CP, Varkey B. Empyema seven year after pneumonectomy. JAMA 1979;242:2332-2324.
12. Wasserman Km Jamplis RW, Lash H, Brown HV, Clearly
MG, Lafair J.Postpneumonectomy syndrome surgical correction using silastic implants. Chest 1979; 75: 78-81.
13. Casanova J, Mariñan M , Rumbero JC. Corrección quirúrgica de un síndrome postneumonectomía con compromiso
vascular. Arch Bronconeumol 2002; 38: 51-54
14. Birdi I, Baghhai M, Well FC. Surgical correction of postpneumonectomy stridor by saline breast implantation. Ann
thorac surg 2001; 71: 1704-17-06.
15. Kelly RF, Hunter DW, Maddau Ma. Postpneumonectomy
Syndrome after left pneumonectomy. Ann thorac surg 2001;
71: 701-703.
Vol. 15 Number 1 2008
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 33 - 42
PENETRATING TRAUMA – SAME PROBLEMS,
DIFFERENT SOLUTIONS
THE CNS
Peter Letarte, MD, FACS
RESUMEN
En la Segunda Guerra Mundial los principios de manejo
de las heridas por arma de fuego eran: 1. Salvar la vida
en peligro inmediato, 2. Prevención de la infección, 3.
Preservación del tejido nervioso, y 4. Restauración de
las estructuras anatómicas. (44). Si bien es cierto nuestro
conocimiento respecto del significado de estos objetivos y
como alcanzarlos ha cambiado, los principios permanecen
como una buena lista de chequeo para enfrentar una lesión
penetrante, una vez se completa la reanimación inicial. Esta
lista junto con una comprensión moderna de cómo determinar quien debería ser salvado, proporciona al clínico un
buen conjunto de herramientas para enfocar estos difíciles
pacientes de trauma
PROVIDER ATTITUDE – APPROACHING THE
VICTIM OF PENETRATING BRAIN INJURY
The resuscitation and management of the victims of penetrating traumatic brain injury differs very little from the
resuscitation of other Traumatic Brain Injury (TBI) with
one very large exception. This exception is that many victims of PBI present very close to death. In the first moments
of the resuscitation, providers must often decide weather to
resuscitate the patient or not. This hesitation on the part of
seasoned providers is due to their acute insight into the fact
that they have no way of predicting weather their efforts
will result in bringing the victim back from deaths door or
needlessly delaying their journey through it.
The lethality of firearm related TBI is indisputable. Centers
for Disease Control funded surveillance programs have
found that in selected states, firearms were responsible for
only 9.7% of the overall TBI and yet accounted for 44%
of the TBI mortality. That such a small percentage of the
total TBI could account for such a large percentage of the
deaths is explained by the 90.4% lethality of firearm related
TBI(1).
Given this high lethality, it is easy to see how providers
could easily develop the prejudice that all penetrating
injury is lethal. The fundamental principle in treating PBI
is to avoid such dogmatism. While no one can predict the
outcome of any given resuscitation, careful application of
the known literature can, hopefully, allow the practitioner to
proceed with greater confidence and, perhaps, make better
decisions from patient to patient and at various stages of
the resuscitation.
RESUSCITATION DECISION MAKING
It is not always necessary to make a life or death decision
all at once when resuscitating PBI. Many practitioners feel
pressure to make such a decision upon presentation. In many
cases this is not the best approach. With time, many PBI
patients declare themselves for better or for worse. Starting
the resuscitation often provides needed care to those who
will benefit from it and usually makes little difference to
those who are destined to die.
It also gives the provider more time to assess the severity
of the injury and make a more thoughtful decision on the
patient’s salvagability. It is important to understand that
the information needed to determine if the patient is salvageable is often obtained from the resuscitation. Glasgow
Coma Score can not be determined until the blood pressure
is normal, depressed mental status may be due to mass effect
from hemorrhage or the intrinsic injury from the projectile,
ICP may not rise until blood pressure is restored. The list
is long of the parameters needed to determine viability that
can not be obtained until resuscitation has been started.
Thus the resuscitation and the viability decision are complexly intertwined. To simply call off the resuscitation on
the assumption that all PBI is lethal deprives the patient of
the careful evaluation they deserve.
Chief, Section of Neurosurgery, Heinz VA Medical Center, Maywood,
Illinois
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Panamerican Journal of Trauma
It is important to remember too that much of what we
believe about the viability of PBI, we have learned from
the military. But the civilian environment in which most of
us practice is not the battlefield. In the battlefield, resources
are scarce and the facilities to save severely injured victims, such as those with PBI are not available. Under these
circumstances, many PBI victims die. But in the civilian
world the same victim who in the military setting might
be under the care of a medic for many hours may well
find themselves in a well equipped and staffed emergency
department within minutes. To apply the triage rules of an
austere environment in this setting is ludicrous. Providers
in this setting are required to set their own standards for
what might be possible in a resource rich environment and
for when it is time to stop even though “all the kings’ horses
and all the king’s men” are available. The blind application
of rules from another place and time is not appropriate.
This paper will follow the course of the resuscitation of a
PBI victim and will highlight what is known about each
stage of the resuscitation in hopes that this will make decision making a bit easier.
History
Several features of the history may offer clues as to the
salvagability of the patient.
Age
Most practitioners suspect that elderly people do not survive
head injury as well as younger people. This assumption is
born out by the fact that the elderly, while not sustaining
TBI in the greatest numbers, have the highest death rate
from TBI of any group in the United States(2).
In general, older patients have higher fatality rates in
response to head injury than younger patients(3). As an
illustration of the effect of age on the susceptibility to
TBI, it is interesting to note that falls are the major cause
of TBI in both children and the elderly. Children have a
death rate from falls of 0.1-0.2/100,000 and are most often
discharged from the Emergency Department. The elderly
have a death rate from falls of 21.7/100,000 and are most
often hospitalized(2).
One might suspect that the elderly also have higher mortality
rates when they are the victims of PBI. Only two studies
directly address this question. Kaufman and Siccardi have
shown higher mortality in patients over 49(4;5). Multiple
other studies have shown better outcomes in younger
patients, but the results have not been statistically significant.
34
In fact, there is very little data on PBI which includes
older patients. Many studies exclude patients on whom
resuscitation is not attempted and it is likely that in many
settings, resuscitation is not attempted on older victims
of PBI, creating a self fulfilling prophesies. Furthermore,
many elderly PBI victims are the victims of self inflicted
gun shot wounds. Available data seems to show that suicide
is a more lethal mode of PBI, leading to a higher mortality
in its victims(6). In addition, physicians are also reluctant
to resuscitate suicide victims. It is possible that for these
reasons, little data is available on the outcome of attempted
resuscitation for PBI in older individuals. Non the less, the
Guidelines for the Management of Penetrating Brain Injury
state at the Class III level that increasing age correlates
with mortality after penetrating brain injury(7).
Cause of Injury
Various types of PBI occur depending on the setting, and
caution should be exercised when extrapolating from one
setting to another. Civilian gunshot wounds tend to be from
lower caliber weapons as opposed to military PBI which
tends to be caused by shrapnel, shell fragments and debris,
all of which can impact at various energy levels. Lastly,
suicide, which is close range PBI, is a somewhat unique
mechanism. Studies have shown that victims of suicide
have a higher mortality than victims of assault or accidental
shooting. This can be understood based on mechanism, but
it is also possible, as mentioned above, that provider bias
results in a tendency to be less aggressive with the resuscitation of suicide victims(6).
Mode of Injury
It is useful to classify PBI into tangential, perforating or
penetrating injuries. Failure to make this distinction can
result in over estimation of the severity of a penetrating
injury.
Tangential injury occurs when the bullet glances off of the
skull, sometimes driving bone into the brain. Tangential
injuries have a lower mortality rate(8). Providers should
avoid the error of viewing a tangential injury in the same
light as a perforating injury.
A penetrating injury occurs when the projectile enters the
calvarium, often driving bone before it into the brain. A
perforating injury occurs when the projectile also exits the
brain, creating a tract completely across the head. Traditional
teaching on PBI has held the injuries crossing the midline
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Penetrating trauma – same problems, different solutions the cns
are the most lethal and some Class III data support the
assertion that perforating injuries are more lethal(7;8).
of the 19 patients with GCS 6-8 had a good outcome and
14 died. Two of 8 patients with GCS 9-15 had a favorable
outcome and 3 died(11).
Caliber of Weapon
Large volumes of experimental work in PBI have focused
on the role of caliber, projectile characteristics and kinetics
in determining lethality in PBI(9). Much of the forensic discussion of PBI surrounds these issues. Interestingly, there
is little epidemiologic data to support the assertions of this
research(7). While it is most likely correct that caliber, range
and kinetics play a key role in the outcome from PBI, this
has not been demonstrated with epidemiologic tools. The
most likely reason is that in actual shootings, range, angle,
wind and other factors so corrupt the fundamental kinetics
of the event that the well controlled kinetics of the laboratory are rarely duplicated in the field. For example, while
caliber is a determinant of energy delivered to the brain, so
is range and any given weapon can be fired at an infinite
number of ranges from the impact point. Understanding
this leads to the understanding that knowing the caliber
of the weapon used does not necessarily add significantly
one’s knowledge about the energy delivered to the brain.
Physical Examination
A rapid physical assessment soon after presentation of the
patient can offer clues to the patient’s potential salvagability,
help to determine if resuscitation should be aggressively
pursued, and begin the formation of a therapeutic plan.
NEUROLOGICAL FINDINGS
GCS as Predictor
An accurate GCS is critical to the early assessment of the
victims of PBI. In general, GCS correlates with the outcome from PBI(7). Specifically, the victims of PBI who
present with a GCS of 3-5 have only a small chance of an
acceptable outcome. Kaufmann published a Class III study
comparing treatment at two institutions. Of the 190 patients
included in this study, 106 had a GCS of 3 on presentation,
62 a GCS of 4 and 22 a GCS of 5. Of the patients with GCS
3, 101 died and none had a favorable outcome. For the 62
GCS 4 patients, 55 died and 1 had a favorable outcome.
One patient with GCS 5 had a favorable outcome and 10 of
the patients died(10).
In a prospective study from the Trauma Coma Data Bank,
Aldrich found similar results with 116 of 123 patients with
GCS 3-5 dieing and 1 of 123 having a good outcome. Two
At the same time several studies have shown a reasonable
prognosis for patients with PBI and GCS 13-15. Aarabi,
Brandvold, Grahm and Kaufman have all reported high
percentages of favorable outcomes for PBI victims with
GCS 13-15(4;8;12;13).
The poor odds of a good outcome must be taken into account
when making a resuscitation decision on a patient with
GCS 3-5. Complicating the decision process is the fact that
often a GCS useful to the salvagability decision can not be
obtained until resuscitation has been initiated. Specifically,
a useful prognostic GCS can not be obtained until the blood
pressure has been restored. This means that patients who
present hypotensive must be resuscitated prior to obtaining a
meaningful GCS. Complicating the issue further is the fact
that hypotension is also a known poor prognostic indicator
for PBI(7). In settings with very short prehospital times,
victims of PBI who under other circumstances might be
considered GSW fatalities may now present to the ER very
close to death. The challenge to the provider is to decide
if an attempt should be made at resuscitation, if only to
obtain an accurate GCS, or if the patient should be allowed
to quickly expire.
Similarly, victims of PBI who present with hematomas or
other mass lesions in the head present the provider with the
dilemma of weather or not to take the patient to the OR in
the hope that removal of the mass lesion will improve the
GCS. This effort can either result in an improved GCS or
an unacceptable survival for the patient.
Kaufman et al examined this problem in their previously
mentioned study of 190 patients. Of the 130 patients with
GCS 3-5 who were treated without an operative attempt,
all but 1 died. That patient, who presented with a GCS of 5,
obtained a GOS of 3 for a final outcome.
Of the 60 patients for whom an operative attempt was
made, 5 of 21 patients with a GCS of 3 survived, 4 with a
GOS of 3 and 1 with a GOS of 2. Seven of 24 patients with
a GCS of 4 survived, 1 with a GOS of 4, a relatively good
outcome, 4 with a GOS of 3 and 2 with a GOS of 2. The
numbers for GCS 5, of which there were 15 patients were
11 survivors, 1 with GOS 4 and the remaining 10 divided 5
each to GOS 2 and 3(10).
Although this is Class III data, it reminds us that good
outcomes in patients with GCS 3-5 are possible but rare
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Panamerican Journal of Trauma
if operative intervention is attempted but that the cost of
being wrong is to save someone for a less than desirable
outcome.
Of equal importance is to remember that victims of PBI
with GCS 13-15 have highly survivable injuries with good
life quality. Being blinded by the fact that the mechanism
of injury is PBI and failing to appreciate the fact that GCS
13-15 patients have an excellent prognosis is an unacceptable error.
An accurate GCS must be obtained quickly upon presentation and a decision on how much resuscitation is needed to
obtain it is one of the first tasks facing the practitioner.
Pupil Reactivity
Asymmetric, unilateral or bilaterally fixed or dilated pupils
have been associated with poor outcomes in TBI. Puppillary
dilation is often associated with cerebral swelling and herniation and so with a poor prognosis.
In PBI the same associations are felt to hold. Shaffrey
found that patients who presented with bilaterally fixed and
dilated pupils had a 79% mortality, those with a unilaterally fixed and dilated pupil, 50% and those with bilaterally
reactive pupils, 5%(14). Kaufman found a similar association between pupillary reactivity and mortality(4). Both
of these studies were Class III studies. Other studies have
observed similar relationships but have failed to demonstrate significance(15;16).
Immediate assessment of GCS and pupillary reactivity are
the best first steps in attempting to estimate the survivability
of a PBI. Polin, however, has pointed out that GCS and
pupillary reactivity may be coupled, that is measuring both
may not add any predictive value over measuring one(17).
While this statistical observation adds to our understanding
of the salvagability assessment, in practice both observations are commonly used in making it.
SYSTEMIC OBSERVATIONS
Several systemic features of the patient’s presentation can
be used to estimate survivability.
Respiratory Distress
It is commonly known and commonly observed that patients with PBI who present with a depressed respiratory rate
are in extremis. Two studies have confirmed this observation with Class III data. Both Kaufman and Jacobs have
36
found respiratory distress to be associated with increased
mortality(7;10;18).
As the resuscitation is started, noting the patient’s respiratory status can provide further estimates of potential survivability.
Hypotension
Similarly, patients who present with hypotension are at
greater risk for a poorer outcome. Kaufman demonstrated
this to statistical significance in a Class III study(10). Another
study by Kaufman and one by Byrnes also demonstrated
this association, though not to statistical significance(4;16).
Aldrich failed to show this association(7;11).
Byrnes also showed that patients with hypertension,
SBP>150, also had a poorer prognosis in PBI (16).
Coagulation Studies
Abnormalities in coagulation studies may be a marker for
poor outcome in PBI. Kaufman noted this in one study and
Shaffrey confirmed this observation in a retrospective multivariate analysis(4;14;17). In the Shaffrey study, a single
abnormal PT or PTT was associated with 80% mortality,
as opposed to a 7.4 % mortality for patients without such
an abnormality. Coagulation abnormalities were highly
predictive of mortality in a linear regression model in this
study(14).
It is postulated that release of tissue thromboplastin by the
penetrating injury leads to these coagulation abnormalities
and can lead to DIC. Levy observed that PBI victims with
DIC suffered 85% mortality(19).
RESUSCITATION
The intertwining of the decision to resuscitate and the
actual resuscitation has been discussed above. The actual
resuscitation of a victim of PBI is therefore the same as any
other trauma resuscitation with the large exception of the
issue of whether the resuscitation should be started at all. It
is the author’s practice, where possible, to start the resuscitation being keenly attuned to the factors discussed above.
As the resuscitation progresses, the patient often declares
themselves, either by expiring, by manifesting multiple
poor prognostic indicators or by demonstrating viability or
improving.
If the patient can be stabilized by securing airway and
breathing and restoring blood pressure, then a more accurate reassessment of GCS and pupillary function can occur.
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Penetrating trauma – same problems, different solutions the cns
In addition, the patient will be ready to obtain a head CT,
which will lead to the next major decisions in their care.
COMPUTED TOMOGRAPHY
tion by the tract has been shown to have a strong association with mortality (12;14;22). The odds ratios for death
with ventricular penetration range from 3.35 to 27.5(7). .
Ventricular penetration is another feature of importance
when estimating salvagability from CT.
History
Computed tomography plays a crucial role in the management of PBI. CT scanning of PBI was widely used
for the first time during the Israeli-Lebanon campaign of
1982-1985. Due to the close proximity of the battlefront to
established large medical centers within Israel, CT scanning was routinely available to the victims of PBI from
this conflict(12;20). The doctrines developed from this and
other experiences have had a large impact on the management of PBI.
CT scanning provides both prognostic and operative
planning information. Once again, in order to obtain the
information offered by CT the resuscitation must proceed
at least to the point where a CT scan can be obtained.
CT SCAN AS PROGNOSTIC TOOL
Assessment of Bullet Tract
For most of the 20th century it has been known that penetrating GSW, that is GSW that traverse the entire cranium
and exit, have the worst prognosis. With the application
of CT scanning to the management of PBI, this observation can be refined. One CT observation, which in multiple Class III studies has portended higher mortality, has
been bihemispheric involvement of the missile tract. With
bihemispheric lesions, odds ratios for increased mortality
range from 1.18 to 20.05 (4;5;7;10-15;18;20-26).
One exception worth noting is bilateral frontal lobe involvement. Kaufman noted a mortality of 12% in this group
and good outcomes of 30%, considerably better than the
outcomes for bihemispheric lesions in general (10). This
observation is particularly important because it reminds us
of the dangers of thoughtless application of rules such as
the bihemispheric rule when triaging patients. Projectiles
traversing both frontal lobes will do considerably less
damage and survival will be better. Giving such a patient
the same grim prognosis as one with biventricular involvement would be an error.
Conversely, if the tract is further posterior in the brain, more
critical structures will be damaged. Such a posterior tract
is likely to traverse the ventricles and ventricular penetra-
Another way to assess mortality risk from the tract of the
projectile is to look for multilobe involvement. Multilobe
involvement of the tract is common in PBI. Patients with
unilobe involvement have a better prognosis. The negative
predictive value of only unilobular involvement ranges
from 77% to 98% (7).
Shaffrey approached the relationship of tract to mortality by
dividing the brain with midline axial, saggital and coronal
planes. Mortality was then related to the number of planes
crossed. As the number of planes crossed increased, so did
mortality. Crossing the saggital, and axial planes increased
mortality, crossing the mid-coronal plane did not(14).
CT and the Assessment of Cerebral Edema
Evidence of cerebral edema on CT carries the same significance in PBI that it does in non-penetrating injury. Aldrich’s
analysis of the Trauma Coma Data Bank specifically looked
at PBI and found increased mortality with basal cistern
effacement but not with midline shift (11). Kaufman also
failed to find a relationship with midline shift and mortality
(4).
INTRACRANIAL HEMATOMAS
As with all intracranial injury, the mass effect from an
intracranial hematoma is a potentially reversible cause of
cerebral injury. The quandary in the context of penetrating
cerebral injury is whether the patient’s depressed mental
status is due to the mass effect from the hematoma or from
other injury from the projectile. The only way to determine
this is to remove the hematoma. If the depressed mental
status was largely due to the mass effect, this will improve
the patient’s outcome. If it was not, this act may save the
patient for an unacceptable outcome. As discussed in the
section on GCS, in the context of a low GCS, the later is the
most common outcome.
Shaffrey found a relationship between the presence of intracranial hematoma and outcome (14). Mancuso failed to
find such a relationship in PBI, reinforcing the idea that in
PBI many other factors may impact on the patient’s survivability (27).
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Panamerican Journal of Trauma
As noted above, injury to the ventricles is a poor prognostic
indicator and ventricular hematomas also carry a poor prognosis (4;14;24). The presence of blood in the ventricles can
increase the odds of death 2.83 to 96.9 times (7).
Levy found a significant relationship with subarachnoid
hemorrhage and mortality (28). Such a relationship has also
been observed in non penetrating brain injury. Aldrich and
Kaufman also found such a relationship but the statistical
correlation with mortality was not as strong(10;11).
OPERATIVE MANAGEMENT
Once the decision has been made for aggressive management of the patient, a decision must be made about operative intervention. It is important when making this decision
to remember what surgery can accomplish for the victims
of PBI. The goals of surgery for the victim of PBI are to
remove mass effect, control bleeding, control infection, to
prevent CSF leak and to close the scalp. Any or all of these
tasks may need to be performed.
Historically, aggressive debridement of bullet tracts in PBI
has been advocated. The rational for this practice was to
limit infection and post traumatic seizures. Evaluation of
the outcomes from management of PBI in Vietnam and
subsequent conflicts has revealed significant morbidity
from the practice of extensive searches for bullet and bone
fragments in the brain(29-31). In addition, there is evidence that the risk of infection is not higher in patients with
retained fragment(32), neither is the increased risk of post
traumatic epilepsy felt to warrant the morbidity of such a
search (33). For these reasons, aggressive removal of all
bone and bullet fragments is not a goal for surgery.
CT as Operative Planning Tool
Once the decision to aggressively manage the patient has
been made, the CT scan changes from being a prognostic
tool to a planning tool. The CT can be used to identify bone
and missile fragments, assess the bullet trajectory, identify
sources of mass effect, such as hematomas or edema, to
identify possible cranial sinus injury and to identify potential venous sinus injury. All of this information is critical to
surgical planning.
Positioning
Positioning for surgery for PBI often includes preparing the
entire head for surgery. Both the entrance and exit wounds
need to be explored and access to the entire head is often
needed. If the cranial air sinuses are involved, the face may
38
need to be included in the field as well. Access to the neck
should be included should vascular access be required. The
leg should be prepped to allow harvesting of fascia lata
graft.
Removal of Mass Effect
Removal of mass effect in PBI is no different than in TBI.
Standard incisions and bone flaps are used where possible
but are often modified to accommodate the complex scalp
lacerations and skull fractures that accompany PBI.
Control of Bleeding
Standard trauma hemorrhage control can be more difficult
in PBI because of venous sinus disruption. Sinus disruption may also be common with the skull fractures which
accompany many PBI injuries, and from missile injury
to the brain. Since rapid exanguination is possible from
these injuries, every effort should be made to identify them
preoperatively. If identified, preparations should be made
to manage them. Various vessel clips and sutures should
be available. Various vascular shunts designed for venous
sinus shunting may be available. A Fogerty catheter can
be useful in occluding the sinus while it is repaired. Most
importantly, a surgeon with good experience in managing
venous bleeding should be in the operating suite since the
rapidity of venous sinus bleeding leaves little time for
exploration of the learning curve.
Control of Infection
The largest advances in the 20th century in the management
of PBI have occurred in the reduction in the infection rate.
Antibiotics have had a great deal to do with this, but equally
important was has been the development of good surgical
techniques focused on limiting post operative infection.
While retained bullet and bone fragments may not have a
large impact on the post operative infection rate, CSF leak
does. The practice of tight dural closure, developed during
World War II, has likely contributed greatly to modern
improvements in the infection rate. Tight dural closure is a
mainstay of surgery for PBI.
Another source of CSF leak and infection can be dural
disruption from fractures to the cranial air sinus. These
fractures need to be identified on CT prior to surgery. At
surgery the sinuses should be cranialized and packed. All
CSF leaks should be closed.
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Wound Debridement
The entrance and exit wounds should be identified. All
obvious bone, debris and necrotic brain should be removed
and the tract should be generously irrigated. While obvious
fragments in the tract may be removed, aggressive dissection of the brain in an attempt to identify fragments
is to be avoided. Carey pointed out that in Vietnam, even
with aggressive searches for fragments, many were left
behind(31). As noted above, the morbidity from this practice is now felt to be excessive and the practice is discouraged.
Closure of the Scalp
Lastly the scalp should be closed. The scalp lacerations
which result from PBI are often complex. Scalp incisions for
PBI operations should be planned to allow for complex scalp
repair at the end of the case. Plastic surgery assistance, either
at the time of original surgery or subsequent to that surgery
is sometimes needed.
POST OPERATIVE CARE
Intracranial Pressure Monitoring
With the extensive cerebral injury which often attends PBI,
elevated ICP is common afterwards. Initially, it has been
observed that ICP elevation will not occur in PBI victims
until they are resuscitated. The physiology of elevated
ICP after PBI is not well understood. Cerebral swelling
appears to develop rapidly after injury, perhaps due to loss
of autoregulation in the brain. It can not be assumed that
the mechanisms of cerebral swelling are the same in TBI
and PBI, however, at our current state of knowledge the
treatments are the same. There is no evidence that ICP
monitoring improves outcome after PBI but given our
knowledge of the physiology and anatomy of PBI, it would
appear to have the same utility in PBI as it does in TBI.
weeks after the injury and an early negative cerebral angiogram does not exclude an aneurysm later in the patient’s
course. Any patient who develops delayed or unexplained
subarachnoid hemorrhage or other delayed bleeding should
be suspected of harboring a post traumatic aneurysm and
should undergo cerebral angiography.
Management of Cerebrospinal Fluid Leaks
Half of all CSF leaks may occur at sites remote from the
entry or exit sites in PBI. These CSF leaks will not be
apparent at surgery and will manifest after surgery. 72% of
these leaks will appear within 2 weeks of surgery and 44%
will seal spontaneously (36).
Antibiotic Prophylaxis for Penetrating Brain
Injury
Infection is a major risk after PBI. As noted above, the first
efforts in infection control occur at surgery.
The vast majority of the data on infections in PBI is in patient
populations in the post antibiotic era. The data that is available from the preantibiotic era tells us that in World War I
the infections rate after PBI was 58.1%. With the use of
Sulpha in World War II the rate dropped to 21-31% and
once penicillin was available it dropped to 5.7 -13%. All of
this is military data. Current military rates are reported at
4-11%. Current civilian rates are at 1-5% (37).
The rate of brain abscess formation in the military was
8.5% during World War II, it is currently 1.6-3.1% in the
military and less than 1% in the civilian world.
Half (55%) of all intracranial infections occur within 3
weeks of the injury and 90% occur within 6 weeks (37).
Factors affecting infection risk are CSF leaks, air sinus
wounds and wound dehiscence. In the presence of cranial
air sinus wounds the infection rate is 29%. With CSF leak,
it has been reported at 49%.
Post Traumatic Aneurysms
As noted above PBI can lead to serious vascular injury in
addition to venous sinus tears. A not uncommon result of
this injury can be delayed post traumatic cerebral aneurysms. Between 3 and 33% of all victims of PBI may have
a Post Traumatic Aneurysm(34;35).
Providers of care to the victims of PBI should be aware of
this and have a low threshold for obtaining cerebral angiography. Angiography is the best way to detect post traumatic
aneurysms. Such aneurysms can develop as late as two
Because of the high infections rates with this injury, long
term antibiotics are commonly used. It is presumed that
without this practice that the infection rates would approximate the World War I rates, although the role of improved
surgical techniques, including tight dural closure, may
play a larger role in this improvement than is appreciated
(37). No data exists to support this assumption since all
modern data on patient outcomes is obtained on patient on
antibiotics. A study which withheld antibiotics from some
patients would raise ethical concerns and is unlikely to be
done.
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Panamerican Journal of Trauma
Antiseizure Prophylaxis for Penetrating Brain
Injury
50% of patients who do develop PTE will stop having
seizures(38).
A major rational for extensive debridment of penetrating
head injuries was the prevention of post traumatic seizures.
In fact, the victims of PBI appear to have an increased risk
for posttraumatic epilepsy which appears to be even greater
than for close TBI.
In PBI, 30-50% of victims develop PTE(38;39). This is
slightly higher than the estimates of 4-42% for non penetrating TBI(40-42). In addition, early seizures in the TBI
literature are defined as seizures in the first 7 days after
injury, when the vast majority of early seizures occur(42).
There is data in the PBI literature implying a slightly higher
incidence of seizures in the second week after injury, but
the numbers in these studies are low(40).
SUMMARY
Current guidelines for antiepileptic therapy after TBI distinguish between two uses for antiepileptic drugs post injury,
treatment and prophylaxis. Antiepileptic drugs do appear
to be effective in treating an established post traumatic
seizure disorder and in preventing immediate post injury
seizures in the first week after injury. They do not appear to
be effective in reducing the incidence of posttraumatic epilepsy, that is, maintenance of TBI victims on prophylactic
doses of anticonvulsant medications beyond the first week
of therapy does not appear to reduce the incidence of post
traumatic seizures. The recommendation in TBI is to treat
the patient with anticonvulsants for seven days and then
discontinue the medication, only restarting it if seizures
develop(43).
Ultimately, follow the same logic as for non penetrating
TBI and in the absence of contradictory data, the Guidelines
for the Management of Penetrating Brain Injury does not
recommend prophylactic anticonvulsants(40).
The data on retained metal fragments and epilepsy is contradictory. Salazar in his analysis of the Vietnam Head
Injury Study Data, found a significant relationship between
retained metal and PTE(33). Aarbi, however, in a retrospective univariate analysis of predictors of PTE in 489 victims
in the Iran-Iraq war failed to identify retained metal fragments as a predictor of PTE(40).
Lastly, the risk of PTE after PBI appears to decline with
time. While 18% of victims may not have their first seizure
until 5 or more years after the injury, 80% will have their
first seizure within 2 years of the injury and 95% of patients
will remain seizure free if they remain seizure free for 3
years following injury(38;39). Followed out to 15 years,
40
In World War II the principles of management for penetrating gunshot wounds were 1) Immediate saving of life
2) prevention of infection 3) preservation of nervous tissue
and 4) restoration of anatomic structures(44). While our
understanding of what these goals mean and how to accomplish them has changed, this list remains a good check list
of how to approach penetrating injury, once the decision to
resuscitate has been made. This list, coupled with a modern
understanding of how to determine who should be saved
should equip the clinician with a good set of tools with
which to approach these most difficult of trauma victims.
REFERENCES
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Thurman DJ, Alverson C, Browne D, Dunn KA, Guerrero
J, Johnson R et al. Traumatic Brain Injury in the United
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Disease Control and Prevention, National Center for Injury
Prevention and Control. Ref Type: Report
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Langlois JA, Rutland-Brown W, Thomas KE. Traumatic
Brain Injury in the United States: Emergency Department
Visits, Hospitalizations, and Deaths. 2004. Centers for
Disease Control and Prevention, National Center for Injury
Prevention and Control. Ref Type: Report
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Adekoya N, Thurman DJ, White DD, Webb KW. Surveillance
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Vol. 15 Number 1 2008
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 43 - 52
MORTALIDAD EVITABLE Y LA ATENCIÓN PREVIA
HOSPITALARIA DEL TRAUMA EN EL MUNICIPIO
DE MEDELLÍN, COLOMBIA 2.005
Marta Lía Valencia S1, Germán González E2, Nelson Armando Agudelo V3, Liliana Acevedo A4, Isabel Cristina Vallejo Z5
RESUMEN
El nivel de la atención hospitalaria de los pacientes con
trauma debe ser definido por la severidad de las lesiones.
Se realizó un estudio retrospectivo de todas las muertes por
trauma (N=1.666) ocurridas en el Municipio de Medellín
en el año 2.005 evaluadas por necropsias. De estas 1.666
muertes 742 (44,5%) presentaron atención hospitalaria
mientras que 912 (54,7%) no. Para aquellas que recibieron
atención hospitalaria, los hospitales de primer nivel de atención trataron pacientes con lesiones moderadas 14,8% (ISS
25 -29) y lesiones fatales 8,3% (ISS ≥50). Para que aquellos
que no recibieron atención hospitalaria las distribución
del ISS fue: 1-24 110 (12%), 25-49 564(62%) y ≥50 238
(26%). No se obtuvo información de atención hospitalaria
12 (0,7%). Los resultados muestran un número significativo de pacientes con trauma que no fueron atendidos en el
nivel de atención apropiado y un número significativo de
muertes evitables ISS 1-24 110 (12%) que no recibieron
atención hospitalaria. Es necesario establecer una red de
urgencias que coordine el cuidado pre-hospitalario y hospitalario de las victimas de trauma y que asegure que estos
pacientes tengan el cuidado apropiado de sus lesiones y de
esta manera prevenir la mortalidad.
Palabras claves: Mortalidad, Heridas y Traumatismos, Índice
de Severidad de la Enfermedad, Atención Hospitalaria,
Mortalidad Hospitalaria, Servicios de Salud, Centros
Traumatológicos, Servicios de Urgencias en Hospital
(Fuente: DeCS, BIREME)
ABSTRACT
The level of hospital care for trauma patients should be
defined by the injury severity. We conducted a retrospective
review including autopsy report assessment of all trauma
related deaths (N=1.666) that occurred in the municipality of
Medellín in 2.005. Of these 1.666 deaths 742 (44,5%) were
treated in a hospital while 912 (54,7%) were not. For those
treated at the hospital, the primary health care services level
treated patients with moderate injures 14,8% (ISS 25-49)
and lethal injures 8,3% (ISS ≥50). For those not treated
at the hospital the ISS distribution was 1-24 110 (12%),
25-49 564 (62%), ≥50: 238 (26%). Hospital admission data
were missing for 12 (0,72%). The results show that a significant number of trauma patients were not treated at the
appropriate health care service level and another significant
number with preventable deaths ISS 1-24 110 (12%) did
not receive hospital care in Medellín. It is necessary to
create an emergency network that coordinates pre-hospital
and in-hospital care for trauma victims to ensure that they
receive appropriate care for their injuries and mortality is
prevented.
Key words: Mortality, Wounds and Injuries, Severity of
Illness Index, Hospital Care, Hospital Mortality, Health
Services, Trauma Centers, Emergency Service, Hospital
(DeCS, BIREME)
INTRODUCCIÓN
El trauma es el evento que causa más muertes en la
población productiva de los países desarrollados y en vía
de desarrollo (1). El trauma produce dolor, incapacidad,
secuelas o muerte además del impacto social y económico
que sufren las personas y las comunidades alrededor de
los afectados. No solo representa un alto costo directo,
sino que además disminuye las expectativas de desarrollo
en cada individuo y familia afectada, con el consiguiente
costo social de difícil cuantificación global (1) y en términos de años de vida productivos perdidos, el trauma es
la más seria enfermedad en América (1). El trauma afecta
a todas las edades, sin embargo los traumas intencionales
afectan más a los hombres adultos jóvenes y los traumas no
intencionales principalmente el accidental, afectan más a
los niños y adultos mayores. La mortalidad por trauma en
la ciudad de Medellín, ha sido una de las primeras causas
de defunción desde hace más de una década. En el año
2.005, el trauma como consecuencia de una agresión en los
hombres se presenta como la segunda causa de defunción
con una tasa 67,9 por 100.000 habitantes y los accidentes
43
Panamerican Journal of Trauma
de transporte como la cuarta causa con una tasa de 26,4
por 100.000 habitantes en este mismo grupo (2). Medellín,
con una población de 2.093.624 habitantes posee 47 instituciones de salud con servicios de urgencias, en donde cada
vez es mas frecuente que el personal de salud tenga que
atender pacientes con lesiones traumáticas.
MATERIALES Y MÉTODOS
La primera hora del paciente con trauma es conocida como
el periodo de oro, en el cual los servicios de urgencias
indicados según la severidad del paciente deben iniciar
una atención definitiva y oportuna (3). Cuando un paciente
con trauma no es trasladado a la institución indicada en
el momento oportuno, su probabilidad de morir aumenta.
La atención hospitalaria de los pacientes con trauma debe
realizarse de acuerdo a la gravedad y severidad en el nivel
de atención apropiado (4). En la ciudad son deficientes los
mecanismos de articulación entre los servicios de urgencias
y no existen verdaderas redes de servicios de urgencia en
trauma suficientemente organizados, a pesar de la alta incidencia de estos eventos.
La información se registró en un formulario “encuesta de
muertes evitables”. Este formulario incluyo variables relacionadas con las características de persona, atención previa
en una IPS (Institución Prestadora de Servicios de Salud),
la manera de la muerte, el mecanismo de la misma y el
diagnóstico final. Para la codificación de los diagnósticos
se utilizó la novena clasificación de enfermedades CIE 9 y
se evaluó el AIS, a partir de la descripción de cada lesión.
Para el análisis del ISS se consideraron todos los diagnósticos por trauma tanto el principal, los segundos, terceros y
cuartos diagnósticos de defunción por esta causa.
La evaluación cuantitativa del trauma ha incrementado en los
últimos 20 años y la aplicación de las escalas de severidad han
sido utilizadas para proponer programas de prevención (5).
The Abbreviated Injury Scale (AIS) es la escala anatómica
más empleada para medir la severidad de las lesiones. Este
índice con su derivado el Injury Severity Score (ISS), son
utilizados para evaluar la calidad y cuantificar los cuidados
médicos en los servicios de urgencias (6). El ISS se considera
como el estándar de oro para evaluar la gravedad de las
lesiones. Es un método que ofrece la ventaja de ser de bajo
costo, de amplia reproducibilidad, de uso relativamente fácil y
un importante predictor de trauma (7). Estos índices proveen
bases científicas para determinar la severidad de los pacientes
con trauma que pudieran requerir cuidados en un tercer nivel
de atención hospitalaria (alta complejidad) o en un centro de
trauma, y de aquellos que pudieran requerir una atención en
un nivel de baja atención (8). Se estudio la mortalidad evitable por trauma mediante el Injury Severity Score (ISS) y la
atención previa hospitalaria en el Municipio de Medellín, a
partir del análisis retrospectivo todas las muertes por trauma
(1.666) evaluadas por necropsia en el año 2.005. Este estudio
se realizó como parte del estudio “Los problemas de acceso
a los servicios de salud de urgencia y la necesidad de los
Sistemas Regionalizados de Atención. Medellín y Bogotá,
2005 -2006”. Los resultados del estudio se utilizaron para el
diseño de la propuesta de la red de urgencias por trauma de
la ciudad. También para proponer actividades de prevención
y control, proponer un sistema de vigilancia epidemiológica
y de información de urgencias y para elaborar un prototipo
de modelación dinámica que orientará el diseño de políticas
y toma de decisiones en las redes de urgencias.
44
Se realizó un estudio descriptivo retrospectivo del total de
muertes por trauma (1.666) evaluadas por necropsia independiente de la ocurrencia del evento en el Municipio de
Medellín en el año 2.005.
Las fuentes de información fueron los reportes y las actas de
levantamiento de necropsia. Para el análisis de las necropsias y codificación del AIS se contó con profesionales del
área de la salud en medicina y enfermería. Estos profesionales fueron previamente capacitados y estandarizados en la
evaluación y codificación AIS.
Se utilizaron métodos estadísticos descriptivos en cuanto
a distribuciones porcentuales de frecuencias y se realizó
un análisis comparativo bivariado. Para la evaluación de la
mortalidad evitable se utilizó el AIS y el ISS. Se consideraron muertes evitables (con lesiones menores o moderadas)
aquellas con un ISS de 1-24; muertes potencialmente evitables con alguna probabilidad de haberse podido evitar (con
lesiones mayores) aquellas con un ISS de 25-49 y muertes
no evitables cuya probabilidad de evitar es muy poco probable (con lesiones fatales) aquellas con un ISS ≥50 (9, 10).
En la atención previa según los criterios establecidos para
la atención hospitalaria (11), fueron consideradas las IPS de
nivel 1 de atención de baja complejidad, las IPS de nivel 2
de atención de mediana complejidad y las IPS de nivel 3 de
atención de alta complejidad.
Se diseñó una base de datos en el programa ACCESS, la cual
fue validada previa implantación. Para el análisis estadístico univariado y bivariado se utilizó el paquete estadístico
SPSS 14.0® y la hoja electrónica Excel versión 2.003. Para
el cálculo ISS se utilizó una base de datos en SPSS®, la cual
contenía un algoritmo que estaba programado a partir de la
lógica para este cálculo del ISS. Cada código asignaba el
valor del ISS utilizando expresiones lógicas. Se realizaron
comparaciones con el test ji-cuadrado de Pearson.
Vol. 15 Number 1 2008
Mortalidad evitable y la atención previa hospitalaria del trauma en el Municipio de Medellín, Colombia 2.005
Resultados
El mayor número de muertes por trauma se presentaron en
hombres 85,1%(1.419). Las personas mas afectadas fueron
los adultos jóvenes entre los 25 a 29 años y los de 20 a
24 años con 277 muertes (16,3%) y 255 muertes (15,3%)
respectivamente. Figura 1
Figura 1. Mortalidad por trauma según edad y género. Municipio de Medellín, 2.005 Fuente: Reportes de necropsias. Instituto Nacional de
Medicina Legal y Ciencias Forenses Regional Noroccidente. Municipio de Medellín, 2.005
Las muertes fueron principalmente potencialmente evitables con lesiones mayores ISS 25 -49 con 1.133 muertes
(68%), seguidas de las muertes fatales ISS ≥50 con 348
muertes (20,9%) y de las muertes evítales con lesiones
menores o moderadas ISS 1 – 24 con 185 muertes (11,1%).
Figura 2
Figura 2. Mortalidad por trauma según Injury Severity Score
(ISS). Municipio de Medellín 2.005. Fuente: Reportes de necropsias. Instituto Nacional de Medicina Legal y Ciencias Forenses
Regional Noroccidente. Municipio de Medellín, 2.005
El homicidio aportó el mayor número de lesiones con 879
muertes (52,8%). La distribución de la lesiones ocasionadas
por el homicidio presentaron un comportamiento similar y
estas fueron de todos los tipos ocasionando muertes que
fueron evitables, potencialmente evitables y no evitables
en similar proporción. La segunda causa responsable de
lesiones fueron los accidentes de tránsito con 446 muertes
(26,8%) y ocasionando lesiones primordialmente de tipo
fatal (ISS ≥50) 31,3%, sin embargo un número importante
de estas fueron de tipo moderada (ISS 25 – 49) con muertes
potencialmente evitables 27,9%. Las lesiones ocasionadas
por las causas accidentales y el suicidio fueron más de tipo
leve (ISS 1 -24) con 39 muertes (21,1%). Figura 3
.
El arma de fuego causo el mayor número de lesiones con
654 muertes (39,3%). Estas lesiones fueron mas de tipo fatal
con 164 muertes (47,1%) y con muy escasa probabilidad de
sobrevivir (ISS ≥50). Sin embrago el arma de fuego generó
un importante número de lesiones mayores consideradas
como muertes potencialmente evitables 40,1% (ISS 25 -49).
45
Panamerican Journal of Trauma
Chi-cuadrado de Pearson 0,0000
Figura 3. Injury Severity Score (ISS) y manera de la muerte. Municipio de Medellín, 2.005. Fuente: Reportes de necropsias.
Instituto Nacional de Medicina Legal y Ciencias Forenses Regional Noroccidente. Municipio de Medellín, 2.005
El arma blanca generó 201 muertes (12,1%), con lesiones
especialmente de tipo leve (ISS 1 24) 25,9% muertes con
una alta probabilidad de ser evitadas. Las caídas generaron
un importante número de muertes 162 (9,7%) que fueron
principalmente de tipo mayor con muertes potencialmente
evitables (ISS 25 -49) 11,3%. Tabla 1.
Injury Severity Score (ISS) y la atención hospitalaria
Tabla 1. Injury Severity Score (ISS) y mecanismo de la muerte. Municipio de Medellín, 2.005
Intervalos clasificación ISS
Mecanismo
1-24
Número
Arma de fuego
25-49
%
Número
36
19,5
Arma blanca
48
Caída
17
Total
≥50
%
Número
454
40,1
164
25,9
123
10,9
30
9,2
128
11,3
17
%
Número
47,1
%
654
39,3
8,6
201
12,1
4,9
162
9,7
Arma contundente
5
2,7
35
3,1
4
1,1
44
2,6
Quemadura
1
0,5
5
0,4
7
2,0
13
0,8
Tóxico
0
0,0
6
0,5
0
0,0
6
0,4
Otro
56
30,3
58
5,1
15
4,3
129
7,7
Sin dato
22
11,9
324
28,6
111
31,9
457
27,4
Total
185
100,0
1133
100,0
348
100,0
1666
100,0
Chi-cuadrado de Pearson 0,000 Fuente: Reportes de necropsias. Instituto Nacional de Medicina Legal y Ciencias Forenses Regional
Noroccidente. Municipio de Medellín, 2.005
46
Vol. 15 Number 1 2008
Mortalidad evitable y la atención previa hospitalaria del trauma en el Municipio de Medellín, Colombia 2.005
Entre las personas murieron por lesiones como consecuencia
de un trauma 742 (44,5%) tuvieron una única y primera
atención hospitalaria. En este grupo 45 (62,5%) personas
que presentaron lesiones menores y moderadas (ISS 1 – 24)
recibieron hospitalaria en una IPS de nivel 3 y 83 personas
(14,8%) con lesiones mayores (ISS de 25 a 49) con muertes
potencialmente evitables fueron atendidas en un nivel 1.
Figura 4.
Figura 4. Única atención hospitalaria de los pacientes con trauma según Injury Severity Score (ISS) y nivel de atención. Municipio
de Medellín, 2.005. Fuente: Reportes de necropsias. Instituto Nacional de Medicina Legal y Ciencias Forenses Regional Noroccidente.
Municipio de Medellín, 2.005
166 (9,96%) personas que murieron como consecuencia de
un trauma presentaron hasta dos atenciones hospitalarias.
La segunda atención hospitalaria se presento más en los
terceros niveles de atención en similar proporción en todo
tipo de lesión. El 90% (118) de estas personas con lesiones
de tipo mayor (ISS 25 – 49) con muertes potencialmente
evitables fueron atendidas en un nivel 3 en su segunda
atención hospitalaria. También se observa como algunas
personas con esta severidad fueron atendidas aunque en
menor proporción, en niveles 1 y 2. Aquellas personas con
lesiones menores o moderadas (ISS 1 – 24) presentaron
también hasta dos atenciones hospitalarias. El 88,9% de
las personas con esta severidad, con una muerte evitable,
fueron atendidas en un nivel 3. Las personas con lesiones
fatales con poca probabilidad de evitar la muerte (ISS ≥50)
presentaron hasta dos atenciones hospitalarias y el 94,14%
fueron atendidas en un nivel 3 durante su segunda atención
hospitalaria. Figura 5.
Figura 5. Segunda atención hospitalaria de los pacientes con trauma según Injury severity Score (ISS) y nivel de atención. Municipio
de Medellín, 2.005. Fuente: Reportes de necropsias. Instituto Nacional de Medicina Legal y Ciencias Forenses Regional Noroccidente.
Municipio de Medellín, 2.005
47
Panamerican Journal of Trauma
El total de personas que murieron como consecuencia de
un trauma y que presentaron hasta tres atenciones hospitalarias fueron atendidas por tercera vez en un nivel 3. La
tercera atención hospitalaria se presentó en las personas con
lesiones mayores y con una muerte posiblemente evitable.
Tabla 2.
Las personas que murieron como consecuencia de un
trauma 912 (54,7%) no recibieron atención hospitalaria;
de estas el 62% presentaron lesiones mayores (ISS 25 49) con muertes potencialmente evitables. Es importante
considerar las personas con lesiones menores con muertes
evitables 12%, que no recibieron atención hospitalaria
12%. Figura 6.
Injury Severity Score (ISS) y la no atención
hospitalaria
Tabla 2. Tercera atención hospitalaria de los pacientes con trauma según Injury severity Score (ISS) y nivel de atención. Municipio de
Medellín, 2.005
Nivel
Intervalos clasificación ISS
1 - 24
25 - 49
Total
≥50
Número
%
Número
%
Número
%
Número
%
Nivel 1
0
0,0
0
0,0
0
0,0,
0
0,0
Nivel 2
0
0,0
0
0,0
0
0,0
0
0,0
Nivel 3
1
100
7
100
1
100
9
100
Total
1
100
7
100
1
100
9
100
Fuente: Reportes de necropsias. Instituto Nacional de Medicina Legal y Ciencias Forenses Regional Noroccidente. Municipio de Medellín,
2.005
La no atención hospitalaria prevaleció en las personas que
presentaron lesiones por homicidio 70,0%. Las personas
con lesiones mayores con una muerte potencialmente evitable (ISS 25 -49), no recibieron atención hospitalaria en un
73,0%. La no atención hospitalaria también se presentó en
las personas con lesiones por accidente de tránsito 13,3%,
siendo las personas con lesiones fatales (ISS ≥50) quienes
menos atención hospitalaria recibieron. Sin embargo,
el 12,4% de las personas con lesiones por accidente de
transito con lesiones mayores con muertes potencialmente
evitables (ISS 25 -49) tampoco recibieron atención hospitalaria. Las personas con lesiones por suicidio y con una alta
probabilidad de sobrevida por presentar lesiones menores
(ISS 1-24), fueron quienes menos atención hospitalaria
recibieron 18,1%. Tabla 3.
Discusión
Figura 6. Injury severity Score (ISS) y no atención hospitalaria
en muertes por trauma. Municipio de Medellín, 2.005. Fuente:
Reportes de necropsias. Instituto Nacional de Medicina Legal
y Ciencias Forenses Regional Noroccidente. Municipio de
Medellín, 2.005
48
Desde el punto de vista forense la muerte se divide en
dos grupos en función de la participación de las personas
para la ocurrencia de esta: la muerte natural y la muerte
violenta. La muerte natural se considera el resultado final
de un proceso patológico, por lo tanto no existió alguna
fuerza exógena al cuerpo para que ocurriera la muerte.
La muerte violenta por el contrario es consecuencia de la
participación de un agente exógeno o extraño sobre cuerpo
y esta se subdivide en tres apartados o etiología médico
Vol. 15 Number 1 2008
Mortalidad evitable y la atención previa hospitalaria del trauma en el Municipio de Medellín, Colombia 2.005
legal, en función de la participación de la tercera persona
en su producción: a) Muerte suicida donde el propio sujeto
se ocasiona la muerte, b) muerte homicida como resultado
de la acción de una persona distinta al difunto y c) la muerte
accidental cuando el fallecimiento se produce como consecuencia de negligencia, imprudencia, inobservancia de
deberes por parte de la victima o de terceras personas o por
causas ajenas a la acción humana (12). Cuando una muerte
ocurre como consecuencia de un trauma o por circunstancia
inusual o sospechosa, la causa de la muerte debe ser investigada, certificada y reportada por un médico forense.
Tabla 3. Manera de la muerte según Injury severity Score (ISS) y la no atención hospitalaria. Municipio de Medellín, 2.005
Intervalo de clasificación del ISS
Manera o causa
1 - 24
25 - 49
≥50
Total
Número
%
Número
%
Número
%
Número
%
Homicidio
61
55,4
412
73,0
166
69,7
639
70,0
Accidente de Transito
1
0,9
70
12,4
51
21,4
122
13,3
Suicidio
20
18,1
33
5,8
10
4,2
63
6,9
Otra causa accidental
21
19,0
33
5,8
8
3,3
62
6,8
Indeterminada
7
6,3
12
2,1
2
0,8
21
2,3
Violencia sin manera
0
0,0
4
0,7
1
0,4
5
0,5
Total
110
100
564
100
238
100
912
100
Fuente: Reportes de necropsias. Instituto Nacional de Medicina Legal y Ciencias Forenses Regional Noroccidente. Municipio de Medellín,
2.005
Las muertes por trauma son consecuencia a una exposición
aguda a agentes físicos como una fuerza o energía mecánica,
calor, electricidad, agentes químicos y radiaciones ionizantes,
en una proporción tal que excede la tolerancia del cuerpo.
Una muerte por trauma también puede ser consecuencia
de la falta repentina de una sustancia esencial como el
oxígeno en caso de un ahogamiento (13). El trauma es una
causa importante de acceso a los servicios de urgencias de
la ciudad y una importante proporción de estos traumas
son debido agresiones, accidentes de tránsito, accidentes
el hogar y traumas de tipo ocupacional. La mortalidad por
trauma intencional en la ciudad ha sido una causa de muerte
importante desde hace más de una década (14).
En la ciudad el 85,1% de las muertes por trauma evaluadas
por necropsias en el año 2.005, se presentaron en hombres
especialmente en adultos jóvenes entre los 20 a 24 y los
25 a 29 años. Algunos estudios han demostrando que los
hombres en Medellín sufren una pérdida de años de vida
potenciales perdidos nueve veces mayor que las mujeres
como consecuencia de las lesiones (15). Esta situación ha
generado un impacto social y económico, tanto en el individuo, en la familia y en la sociedad (15).
La calidad asistencial esta basada en los conocimientos científicos actuales teniendo en cuenta los recursos disponibles. El
análisis de la mortalidad es uno de los parámetros de calidad
asistencial más utilizados (16) (17). La cuantificación de las
defunciones hospitalarias, el conocimiento de las causas y su
evaluación permiten tomar medidas encaminadas a mejorar
la calidad de atención en los servicios de salud (16) (17).
Según los criterios establecidos para la atención en los servicios de urgencias por niveles de complejidad, los niveles
1 son los considerados de baja complejidad donde se realizan procedimientos sencillos para eventos urgentes y la
atención de lesiones leves y algunas moderadas. Este nivel
de atención debe contar con médicos generales, enfermeras
profesionales y auxiliares de enfermería dentro del personal
de atención de urgencias. Entre las actividades de este nivel
se encuentran las pequeñas cirugías, electro cardiogramas
y la utilización de medicamentos esenciales (11). El nivel 2
considerado de mediana complejidad, apoya al nivel local
de atención básica en las áreas de diagnóstico, tratamiento
y administración. Este nivel atiende las urgencias moderadas y algunas severas, incluye especialidades como
gineco-obstetricia, pediatría, medicina interna, cirugía
general, anestesiología y algunas subespecialidades como
ortopedia y traumatología y, salud mental. En este nivel los
pacientes en los servicios de urgencias son atendidos por
médicos generales y especialistas y otros profesionales que
se encuentren disponibles y cuenta con ambulancias (11).
El nivel 3 de mayor complejidad, debe atender urgencias
graves y complejas que pueden llegar espontáneamente
o por medio de mecanismos como la referencia o la contrarreferencia de otros niveles. En este nivel se atienden
49
Panamerican Journal of Trauma
y ejecutan actividades de alta tecnología, posee Unidades
de Cuidados Intensivos (UCI) y posee especialistas como
cardiólogos, neurólogos y neumólogos entre otros (11).
Con el análisis del ISS de las muertes por trauma y la
atención previa hospitalaria, pudo evidenciarse que una
proporción de personas con lesiones mayores con un ISS
de 25 a 49 o con lesiones fatales con un ISS mayor o igual
a 50 que debieron ser atendidas en un nivel 3 de atención
fueron atendidas en niveles 1. En el caso de las personas
con ISS 25 a 49 con una muerte potencialmente evitable,
el 14% murieron durante la única atención hospitalaria en
un nivel 1 de atención. Otras personas (1,53%) con este
valor de ISS, presentaron hasta dos atenciones hospitalarias
siendo la última en un nivel 1. Se observó que el 100% de
las personas que presentaron un ISS ≥50 presentaron hasta
tres atenciones hospitalarias siendo la última a un nivel 3
de atención.
Estos resultados pueden indicar que los pacientes no recibieron una atención hospitalaria de acuerdo a la severidad
y al nivel de atención apropiado para su cuidado médico.
Es posible que los pacientes con lesiones de cráneo mayores fueran atendidos en un nivel 1 de atención, que no
posee los recursos necesarios (18). También pudo ocurrir
que aquellos pacientes con lesiones intraabdominales que
pueden requerir transfusión sanguínea fueron atendidos en
un nivel 1 de atención, que no cuenta con bancos de sangre
o con disponibilidad de quirófanos y cirujanos (18).
En la ciudad puede estar ocurriendo que los pacientes están
siendo transportados a los hospitales más cercanos. En este
caso estos pacientes con lesiones más severas pudieron
ser trasladados al hospital más cercano sin considerar la
gravedad de las lesiones y la disponibilidad de los recursos
de la institución. Es importante considerar que en Medellín
se esta planeando el montaje de la atención prehospitalaria,
que actualmente cuenta con algunas ambulancias equipadas con la tecnología necesaria y personal entrenado para
la atención y trasporte de eventos traumáticos. El montaje
de la atención prehospitalaria en la ciudad que incluya la
detección y la ubicación del paciente, la clasificación de la
información, el triage y la estabilización del herido (19),
permitiría que los pacientes sean atendidos en la institución
apropiada en forma oportuna acorde con la severidad y así
disminuir las muertes que pueden ser evitables si son atendidas oportunamente en el nivel adecuado.
Sampalis ha comparado el resultado de los pacientes severamente lesionados que fueron transportados directamente
desde la escena a un nivel mayor de complejidad, con aquellos
que fueron transferidos desde otro nivel de complejidad y
50
se ha evidenciado una reducción del riesgo de mortalidad
(transferidos 8,9%, transporte directo 4,8%, odds ratio
1,96%; IC 95% 1,53-2,50). También han evidenciado una
disminución de la mortalidad en los servicios de urgencias
(pacientes transferidos 3,4%, pacientes con trasporte directo
1,2%; odds ratio 2,96%; IC 95% 1,90 - 4,6), y una disminución de la mortalidad después de la admisión (pacientes
transferidos 5,5%, pacientes con trasporte directo 3,6%;
odds ratio 1,57; IC 95% 1,17-2,11). Todas estas diferencias
fueron estadísticamente significativas (p <0,003) (20). Otros
estudios han evidenciado que los tiempos prehospitalarios
prolongados pueden incrementar la mortalidad en pacientes
con trauma mayor (20).
En Medellín puede estar ocurriendo que aquellos pacientes
con lesiones moderadas con muertes potencialmente evitables, incrementaron su riesgo de morir al no ser transportados directamente desde sitio donde ocurrió el evento
hacia un nivel de complejidad mayor para su atención. Este
riesgo también puedo incrementarse en aquellos que tuvieron transferencia o remisión hospitalaria.
En nuestro estudio también se pudo evidenciar que pacientes
con lesiones leves (62,50%) con muertes evitables murieron durante la primera y única atención hospitalaria en
un nivel 3 de atención. Esta situación también se presentó
en pacientes con lesiones moderadas (64,1%) con muertes
potencialmente evitables y que fueron atendidos en una
IPS de nivel 3. En Medellín, un estudio realizado en una
institución nivel 3 de atención (1) (22) se observó asociación entre la muerte y los pacientes con trauma con factores
como: el trauma de cráneo (RD 4,23 p 0,001), edad mayor
de 55 años (RD 3,04 p. 0,0002), la enfermedad cardiovascular de base (RD 2,52 p. 0,034), la remisión previa con
cánula (RD 5,16 p. 0,0043) , la remisión previa con un tubo
endocraneal (RD 8,11 p. 0,0003) y la remisión previa con
catéter vesical (RD 3,4 p. 0,0092) de las fases escenario y
prehospitalaria. La severidad fue controlada en este estudio
(1) (21). Es posible que los anteriores factores incrementaran el riesgo de morir en aquellas personas con lesiones
leves o moderadas que fueron atendidas en niveles 3 de
atención. En este grupo el riesgo de morir también pudo
ser influenciado por el tiempo entre el evento y la llegada al
hospital, el tiempo entre la llegada al hospital y la primera
atención médica y la estancia hospitalaria (22).
Respecto a la no atención hospitalaria, los resultados
muestran que un número significativo de pacientes con una
mortalidad prevenible (ISS 1 – 24) no recibieron atención
hospitalaria (12%). También observó que las personas con
lesiones generadas por homicidio (70%) recibieron menos
atención hospitalaria, muchas de ellas con lesiones leves
Vol. 15 Number 1 2008
Mortalidad evitable y la atención previa hospitalaria del trauma en el Municipio de Medellín, Colombia 2.005
y moderadas, consideradas como muertes evitables o
potencialmente evitables si hubieran sido atendidas en una
institución de salud de acuerdo a su severidad. También se
observó que una proporción de personas que presentaron
accidente de tránsito (13%), no recibieron atención hospitalaria y en especial en personas con lesiones moderadas o
mayores con muertes potencialmente evitables.
Todo lo anterior incrementa la necesidad de la atención
prehospitalaria en la ciudad y el uso de índices para clasificación de los pacientes y el transporte al nivel de atención
indicado. Es importante tener en cuenta la coherencia en las
remisiones con el diagnóstico de la remisión y el nivel de
atención de la institución receptora (4)
Las guías para el desarrollo de los centros de trauma,
incluyen la clasificación de los hospitales de acuerdo con
el nivel de complejidad y la designación de los niveles 3 de
atención como centros regionales de trauma donde deben
ser trasladados los pacientes con lesiones más severas (21).
La designación de los nivel 3 como centros de trauma y el
establecimiento del triage son los aspectos mas importantes
del sistema regionalizado del trauma. Ambos son necesarios
con el propósito de reducir el tiempo entre la ocurrencia de
la lesión y el cuidado médico definitivo (21).
Se ha demostrado que luego del establecimiento de los
centros regionalizados del trauma, la mortalidad por esta
causa se reduce significativamente. Son características de
los niveles 3 designados como centros regionalizados de
trauma: la disponibilidad continua de cirujanos, el equipo
médico con entrenamiento en atención de trauma (anestesiólogos, médicos de urgencias y enfermeras), la alta tecnología que incluye las unidades de cuidados intensivos, la
investigación y la enseñanza relacionada con el cuidado del
trauma (21). Adicionalmente, el efecto de la red de urgencias sobre los pacientes con trauma contribuye al buen
manejo en los niveles de atención y a agilizar las distintas
etapas de la atención médica (23).
La calidad asistencial promueve que la asistencia ofrecida
este basada en conocimientos científicos actuales teniendo
en cuenta los recursos disponibles. El análisis de la mortalidad es uno de los parámetros de calidad asistencial
mas utilizados. La cuantificación de las defunciones hospitalarias, el conocimiento de las causas y su evaluación
permiten tomar medidas tendientes a mejorar la asistencia.
Los resultados de este estudio soportan la necesidad de
establecer una red urgencias que coordine el cuidado prehospitalario y hospitalario de las víctimas del trauma, de
tal forma que los pacientes puedan recibir una atención
oportuna, en la institución indicada según su severidad y
tipo de urgencia y de esta manera prevenir la mortalidad.
La red de urgencias podrá contribuir a un buen manejo de
los pacientes en los niveles de atención según el sistema
general de salud, disminuir las consultas en los servicios de
urgencias y agilizar las distintas etapas de atención médica
(23). Para el planteamiento de la red de urgencias en la
ciudad, el tipo de población objetivo, sus necesidades en
salud y el modelo de atención son aspectos importantes a
tener en cuenta (4).
Financiación
Este estudio fue financiado por el Instituto Colombiano para
el Desarrollo de la Ciencia y la Tecnología (COLCIENCIAS)
(contrato número 313 del 2.004) y la Universidad de
Antioquia de Medellín, Colombia. Con apoyo de Instituto
Nacional de Medicina Legal y Ciencias Forenses Regional
Noroccidente del Municipio de Medellín, Alcaldía de
Medellín - Secretaría de Salud, y la Facultad Nacional de
Salud Pública de la Universidad de Antioquia de Medellín
Colombia.
AGRADECIMIENTOS
Directivas, profesionales y personal de archivo del Instituto
Nacional de Medicina Legal y Ciencias Forenses Regional
Noroccidente del Municipio de Medellín, profesionales que
participaron en el análisis de las necropsias y codificación
del AIS, COLCIENCIAS, Alcaldía de Medellín -Secretaría
de Salud, Universidad de Antioquia - Facultad Nacional de
Salud Pública de Medellín Colombia.
BIBLIOGRAFÍA
1.
Valencia ML, Morales M, Arroyave Marta, Montoya W,
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intervenibles en el cuidado médico y de enfermería de
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en enfermería. Universidad de Antioquia 2.000; 15(2):
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- Facultad Nacional de Salud Pública; 1.999. p. 1 – 28
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for future research. American Journal of Emergency Medicine
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de cirugía general. Cirugía Española 2.006; 80 (2):78-82
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http://db.doyma.es/cgi-bin/wdbcgi.exe/doyma/mrevista.
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Severidad de Lesiones) con resultado final del tratamiento.
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8. Champion H, Sacco W. Advances in trauma. EN: Champion
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Sampalis JS. Measuring injury severity. Montreal: McGill
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Mackenzie Ellen. Injurity severity scales: Overview and
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Servicios de Urgencias en el Sistema Distrital de Salud.
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12. Crespo, S. Análisis comparativo del certificado médico de
defunción en los periodos de 1.989 – 1.992 y 1.996 – 1.997
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doctoral]. Barcelona: Departamento de psiquiatría y medicina
forense. Universidad Autónoma de Barcelona; 2.002. p 1199 (en línea) [consultado 2.007 marzo 12] Disponible en:
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Wamer M. Deaths: injuries, 2002. National Vital Statistics
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Judicial DECIPOL. Muertes violentas por homicidios.
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Mulder D. Direct transport to tertiary trauma centre vs
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21. Valencia ML, Morales M, Arroyave Marta, Montoya W,
Colorado S y González G. Factores de riesgo de infección
intrahospitalaria en pacientes mayores de 12 años hospitalizados por causa traumática en el Hospital Universitario San
Vicente de Paúl, Medellín, 1999. Revista Epidemiológica de
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23. Zamudio A, Castro I. Efecto de la red de urgencias sobre el
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Vol. 15 Number 1 2008
Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 53 - 57
THE ROLE OF EXTERNAL FIXATION IN THE INITIAL
MANAGEMENT OF PELVIC FRACTURES
Gary L. Schmidt, M.D., Gregory T. Altman, M.D., Daniel T. Altman, M.D.
RESUMEN
El manejo de un paciente con disrupción del anillo pélvico
empieza con la evaluación según el protocolo del ATLS.
A continuación se lleva a cabo una buena evaluación
ortopédica incluyendo una clasificación precisa de la fractura pélvica. En conjunto con el cirujano encargado de la
resucitación, el cirujano ortopédico determinará la mejor
forma de conseguir una estabilidad hemodinámica según
las características de la fractura. La estabilización de las
fracturas pélvicas se puede conseguir de varias maneras. En
el manejo inicial de estas devastadoras lesiones se pueden
utilizar sábanas circunferenciales, clamp pélvico y fijación
externa.
Palabras claves: Fractura pélvica, sábana circunferencial
pélvica anti-choque, clamp pélvico, fijador externo, trauma,
inestabilidad del anillo pélvico.
ASSESSMENT
Pelvic ring disruptions are frequently the result of high
energy trauma. Therefore patients being evaluated for pelvic
fractures should be assessed according to the Advanced
Trauma Life Support (ATLS) protocol. Patients with pelvic
injuries may require massive fluid volume resuscitation.1,2
In the event of hemodynamic compromise, a circumferential sheet or a pelvic sling may be applied to the pelvis to
aid in resuscitation.3-5 Once adequate hemodynamic stability is established, the trauma surgeon may proceed with
the primary survey.
The orthopaedic evaluation of all trauma patients should
include examination of all four extremities (including
neurovascular status, range of motion of large joints, and
palpation for osseous integrity), the spine, and the pelvis.
Manual compression of the pelvis may allow clinical
detection of pelvic ring disruptions. In addition to clinical
examination, patients with possible pelvic injuries should
have an AP pelvis radiograph taken during the initial phase
of treatment. This radiograph should be a guide to further
decisions regarding diagnostic and therapeutic interventions. When the patient is sufficiently stabilized, complete
radiographic evaluation of a pelvic ring injury will include
an AP pelvis, pelvic inlet and outlet views, as well as a CAT
scan with fine cuts (1-2 mm) through the bony pelvis.
Classification
Pelvic fractures have been classified by several authors.6-8
Tile classified pelvic fractures into three major groups
(figure 1).6 Group A consists of those injuries that do not
disrupt the pelvic ring and therefore are stable fractures.
This group is then further subdivided based on avulsion
injuries, iliac wing fractures, or sacro-coccygeal fractures
which do not affect ring integrity. Group B fractures are
those that are rotationally unstable but vertically stable.
These injuries have incomplete disruption of the posterior
pelvic arch with maintenance of the strong posterior sacroiliac or posterior sacrotuberous and sacrospinous ligaments.
These posterior pelvic ligaments confer vertical stability to
the pelvis despite the arch disruption. This group of fractures is then subdivided based on whether the deformity is
internally or externally rotated and whether it is unilateral
or bilateral. Group C fractures are unstable fractures in both
rotational and vertical orientations.
A
STABLE
POSTERIOR ARCH
INTAC
B
ROTATIONALLY
INCOMPLETE
UNSTABLE;
POSTERIOR ARCH
VERTICALLY STABLE DISCRUPTION;
MOST POSTERIOR
LIGAMENTS INTACT
C
UNSTABLE;
ROTATIONAL
AND VERTICALLY
UNSTABLE
POSTERIOR ARCH
DISRUPTED;
POSTERIOR
LIGAMENTS TORN
Figure 1.
53
Panamerican Journal of Trauma
There is complete disruption of the posterior pelvic arch
including the aforementioned important posterior pelvic
ligaments. Again this group is sub-classified based upon
the precise location of the fracture and whether the fracture
is unilateral or bilateral.
Young and Burgess classified pelvic injuries according to
the deforming force which caused the injury.8 Based on the
morphology of the fractures on radiographs they categorized
pelvic ring disruptions into anterior-posterior compression
(APC), lateral compression (LC), vertical shear (VS) or
combined (C) type injuries. These categories are further subdivided based on the radiographic details of the injury.
Perhaps the most detailed system for classifying pelvic
fractures is that of the Orthopaedic Trauma Association.7
Although useful for assuring unanimity when different
observers are comparing fractures in research, this system is
not widely utilized in daily clinical practice.
Regardless of the classification system used, the orthopaedic
surgeon should interpret the initial AP pelvis radiograph to
define the personality of the pelvic injury sustained. Utilizing
this notion of the stability of the fracture, the orthopaedic
surgeon should work in concert with the trauma surgeon to
guide further treatment algorithms.
Treatment Algorithm
In the pelvic fracture patient with stable hemodynamics,
initial observation may be appropriate depending on the
nature of the injury (for example with a Tile Group A fracture). Conversely, a patient who is hemodynamically stable
may be best treated with emergent pelvic stabilization if
the nature of the injury can be predicted to result in significant internal hemorrhage. For the patient with persistent
hemodynamic compromise, a circumferential pelvic sheet
may aid in the resuscitation as mentioned previously. In the
setting of other concomitant injuries, consideration should
be given to the most likely source of hemorrhage. Intraperitoneal hemorrhage may be evaluated via CAT scan
or deep peritoneal lavage. Retroperitoneal hemorrhage
commonly occurs with specific types of pelvic fractures.
According to Young and Burgess, APC-III injuries require
the most massive volume resuscitiation.2
In those pelvic injuries which require immediate intervention, the decision to perform angiography prior to skeletal
stabilization is controversial. Bassam et al. reported that
hemodynamically unstable patients with unstable pelvic
fractures should undergo immediate angiography if laparotomy is not indicated.10 Conversely, Cook et al. advocated
early skeletal stabilization to limit pelvic volume prior to
laparotomy when possible.11 Multiple authors have pro54
vided evidence that external fixation can improve outcomes
in patients who sustain fractures which result in increased
pelvic volume.12-14 Cook et al. preferred the use of angiography in patients who were hemodynamically refractory to
skeletal stabilization and laparotomy. This decision should
be the result of a discussion between the orthopaedic surgeon and the resuscitating trauma surgeon. Consideration
should be given to whether the fracture is amenable to
rapid skeletal stabilization, how much internal hemorrhage
can be anticipated, and what concomitant injuries may be
contributing to blood loss. In addition, institutional factors
must be considered including the time required to perform
successful angiography or the rapidity with which mechanical pelvic stabilization can be achieved.
SKELETAL STABILIZATION
When considering stabilization of the pelvis, it is necessary to
first ascertain the integrity of the posterior pelvic ligaments.
Those fractures which lack posterior stability will require
treatment both anteriorly and posteriorly in order to restore
normal pelvic biomechanics. In cases where the posterior
ligaments are not violated, only anterior stabilization may be
indicated. The first and simplest step in treating an unstable
pelvic fracture involves application of a circumferential sheet
wrapped snugly at the level of the greater trochanters. This
sheet may then be maintained during transport, radiography
or even laparotomy. The circumferential pelvic sheet has
supplanted the use of pneumatic antishock garments which
were used previously in the field and were associated with
multiple complications including skin necrosis and compartment syndrome.15
Although commercially available pelvic slings are manufactured, there is no evidence to suggest that they are more
efficacious than a standard circumferential sheet.
Pelvic clamps have been designed for the emergent stabilization of pelvic ring disruptions.16 These devices have been
shown to be as effective as external fixators in restoring
pelvic volume and reducing pubic diastasis but may be
more prone to cause significant complications.17 The
theoretical advantage of these clamps is that they could be
applied posteriorly to recreate normal sacroiliac relationships. Unfortunately, a posteriorly placed clamp in addition to anterior stabilization equipment makes the practical
care of a poly-traumatized patient difficult to say the least.
In reality, posterior pelvic stability is typically restored
via internal fixation. Normally this will not be able to be
performed during the initial evaluation phase of a trauma
patient. Newer percutaneous techniques may result in more
rapid fixation of posterior pelvic injuries. Percutaneous posterior pelvic fixation has been shown to be efficacious18 but
Vol. 15 Number 1 2008
The Role of External Fixation in the Initial Management of Pelvic Fractures
also technically demanding.19 Sufficient vertical stability
is not conferred by the application of external fixation of
any type. In cases of vertical shear injuries, a distal femoral
traction pin should be applied to the ipsilateral femur to
effect reduction of the superiorly migrated hemi-pelvis.
Anterior pelvic external fixation is indicated in lesions
which increase pelvic volume.20,21 Specifically, this would
include APC II & III, LC II & III, VS and combined injuries
using the Young and Burgess system. According to the Tile
system, open-book type injuries (including B1 and B3-1)
and all type C fractures would be amenable to provisional
external fixation. Consideration must be given in regards
to the posterior aspect of the pelvis as anterior symphyseal
compression may in fact widen posterior pelvic displacement (figure 2). Dickson et al found a 67% rate of skeletal
deformity after external fixation of the pelvis.30 Grimm
et al. showed that application of an external fixator fails
to have a significant effect on retroperitoneal pressures
until large volumes of fluid have been lost.22 In a cadaveric model they showed that external fixation did little to
provide pressure induced tamponade of arterial bleeding.
However an external fixator may stabilize clot formation
within the pelvis, oppose fractured bleeding bony surfaces,
and facilitate patient transfer and mobilization.
instability may preclude the use of internal fixation even in
a delayed fashion. Nonetheless, external fixation has been
shown to be biomechanically inferior to internal fixation.26
The literature varies widely in regards to the safety of pelvic
external fixation. Tucker et al. reported 94% of pins were
accurately contained between the iliac cortical tables when
placed under fluoroscopic guidance.25 Others have reported
significantly higher rates of complications with the use of
pelvic fixators.27 Hupel et al. showed that obese patients
were less likely to be successfully treated with use of an
external fixator.28
Complications
The treatment of pelvic fractures is fraught with complications. The usual fracture-related complications of
thromboembolism, infection, non-union, mal-union and
persistent pain are all frequently found in patients with
pelvic fractures. As such, patients suffering pelvic fractures
should routinely receive deep venous thrombosis prophylaxis, appropriate peri-operative intravenous antibiotics,
protected weight bearing status, and adequate analgesia.
However, in addition, all patients with pelvic fractures
should be scrutinized for commonly associated injuries.
In particular, genitourinary and lumbosacral nerve injuries
should be ruled out. This will require routine vaginal and
rectal examinations of all patients as well as the liberal use
of retrograde cystography. At times, concomitant genitourinary injury may preclude the application of pelvic internal
fixation (figure 3). Permanent nerve injury after pelvic
disruption has been found to have an incidence of 10 to
15%.9 However, in unstable vertical shear type injuries the
incidence is much higher.29 Lastly, loss of fixation occurs
not infrequently during the treatment of pelvic fractures.
This is likely a result of the large physiological forces experienced across the pelvis in combination with the limited
bone stock available for achieving fixation. By utilizing
conservative weight bearing status during early patient
mobilization, this complication can be limited.
Figure 2. An example of a patient who suffered a concomitant
genitourinary injury. Here the suprapubic catheter precludes
anterior pelvic fixation.
Multiple frame constructs have been considered for
providing adequate stabilization in a timely fashion.23-25
External fixation is primarily used as provisional fixation
but may be a definitive treatment in certain circumstances.
Large anterior abdominal wounds, open pelvic fractures,
concomitant genitourinary injuries or critical hemodynamic
Figure 3. Application of an external fixator to this pelvic ring disruption resulted in widening of the posterior injury on the left.
55
Panamerican Journal of Trauma
SUMMARY
The assessment of a patient with a pelvic ring disruption
begins with evaluation via ATLS protocol. Appropriate
orthopaedic evaluation is then undertaken including precise classification of the pelvic fracture. In concert with
the resuscitating trauma surgeon, the orthopaedic surgeon
will determine the best means of obtaining hemodynamic
stability given the personality of the fracture. Skeletal stabilization in unstable pelvic fractures can be accomplished
in several manners. Circumferential sheets, pelvic clamps,
and external fixation all may be utilized in the initial treatment of these devastating injuries.
Key Words: pelvic fracture, shock, circumferential pelvic
anti-shock sheeting, pelvic clamp, external fixator, trauma,
pelvic ring instability
REFERENCES
1.
Starr AJ, Griffin DR, Reinert CM, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J
Orthop Trauma 2002;16(8):553-561.
2.
Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in
multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome.
J Trauma 1989;29(7):981-1000.
the management of hemorrhage from major fractures of the
pelvis. J Bone Joint Surg Br 2002;84(2):178-182.
12. Riemer BL, Butterfield SL, Diamond DL, et al. Acute mortality associated with injuries to the pelvic ring: the role of
early patient mobilization and external fixation. J Trauma
1993;35(5):671-677.
13. Routt ML, Simonian PT, Ballmer F. A rational approach to
pelvic trauma: resuscitation and early definitive stabilization.
Clin Orthop 1995;318:61-74.
14. Klein SR, Saroyan RM, Goldstein JA, et al. Emergent treatment of pelvic fractures: comparison of methods for stabilization. Clin Orthop 1995;318:75-80.
15. Mattox KL, Bickell W, Pepe P, et al. Prospective MAST
study in 911 patients. J Trauma 1989;29(8):1104-1112.
16. Ganz R, Krushell RJ, Jakob RP, et al. The antishock pelvic
clamp. Clin Orthop 1991;267:71-78.
17. Ghanayem AJ, Stover MD, Goldstein JA, et al. Emergent
treatment of pelvic fractures: comparison of methods for
stabilization. Clin Orthop 1995;318:75-80.
18. Ebraheim NA, Coombs R, Jackson WT, et al. Percutaneous
computed tomography-guided stabilization of posterior
pelvic fractures. Clin Orthop 1994;307:222-228.
19. Routt ML, Simonian PT, Mills WJ. Iliosacral screw fixation:
early complications of the percutaneous technique. J Orthop
Trauma 1997;11(8):584-589.
20. Poka A, Libby EP. Indications and techniques for external
fixation of the pelvis. Clin Orthop 1996;329:54-59.
3.
Routt ML, Falicov A, Woodhouse E, et al. Circumferential
pelvic antishock sheeting: a temporary resuscitation aid. J
Orthop Trauma 2002;16(1):45-48.
4.
Simpson T, Krieg JC, Heuer F, et al. Stabilization of pelvic
ring disruptions with a circumferential sheet. J Trauma
2002;52(1):158-161.
22. Grimm MR, Vrahas MS, Thomas KA. Pressure-volume characteristics of the intact and disrupted pelvic retroperitoneum.
J Trauma 1998;44(3):454-459.
5.
Ramzy AI, Murphy D, Long W. Initial management of
unstable fractures. J Emerg Med Serv 2003;28(5):68-78.
23. Mears DC, Fu FH. Modern concepts of external skeletal fixation of the pelvis. Clin Orthop 1980;151:65-72.
6.
Tile M. Fractures of the Pelvis and Acetabulum. Baltimore:
Williams & Wilkins, 1984.
24. Slatis P, Karaharju EO. External fixation of the pelvic girdle
with a trapezoid compression frame. Injury 1975;7:53-56.
7. Orthopaedic Trauma Association. Fracture and dislocation
compendium. J Orthop Trauma 1996;10(suppl 1):68-70.
25. Tucker MC, Nork SE, Simonian PT, et al. Simple anterior
pelvic external fixator. J Trauma 2000;49(6):989-994.
8.
Burgess AR, Eastridge BJ, Young JWR, et al. Pelvic ring
disruptions: Effective classification system and treatment
protocols. J Trauma 1990;30:848-856.
26. Vrahas MS, Wilson SC, Cummings PD, et al. Comparison
of fixation methods for preventing pelvic ring expansion.
Orthopedics 1998;21(3):285-289.
9.
Weis EB. Subtle neurological injuries in pelvic fractures. J
Trauma 1984;24:983-985.
27. Palmer S, Fairbank AC, Bircher M. Surgical complications
and implications of external fixation of pelvic fractures.
Injury 1997;28(9):649-653.
10. Bassam D, Cephas GA, Ferguson KA, et al. A protocol for
the initial management of unstable pelvic fractures. Am Surg
1998;64(9):862-867.
11. Cook RE, Keating JF, Gillespie I. The role of angiography in
56
21. Tile M. Acute pelvic fractures: II. Principles of management.
J Am Acad Orthop Surg 1996;4:152-161.
28. Hupel TM, McKee MD, Waddell JP, et al. Primary external
fixation of rotationally unstable pelvic fractures in obese
patients. J Trauma 1998;45(1):111-115.
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The Role of External Fixation in the Initial Management of Pelvic Fractures
29. Huittinen VM, Slatis P. Fractures of the pelvis, trauma mechanism, types of injury, and principles of treatment. Acta Chir
Scand 1972;138:563-569.
30. Dickson K, Matta J. Skeletal deformity following external
fixation of the pelvis. AAOS Annual Meeting– Scientific
Program, 1998.
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Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 58 - 62
UNSTABLE PELVIS- ROLE OF THE INTERVENTIONALIST
MALCOLM K. SYDNOR MD
Complicated pelvic fractures carry a high mortality,
ranging from 6-18%, usually secondary to severe hemorrhage1. While the mortality rate is less than 5% for hemodynamically stable patients, it has been reported around
38% for hypotensive patients2. Bleeding may originate
from arteries, veins, cancellous bone, or crushed soft
tissue. With the exception of arterial hemorrhage, all of
these sources can be controlled with fracture stabilization
by external fixation devices. Hemodynamic resuscitation in
the ICU is not a viable option as these patients will become
hypercoagulable and continue to bleed. Surgical treatment
for exsanguinating pelvic bleeding has not been widely
accepted for multiple reasons: opening the pelvis will
release the tamponade on the retroperitoneal hematoma and
may cause uncontrollable venous hemorrhage, bleeding
vessels are difficult to find and control, and internal iliac
artery proximal ligation will not be effective due to the rich
supply of pelvic collaterals. Pelvic packing after external
fixation is often employed when severe pelvic bleeding
is found, particularly after exploratory laparotomy to
treat concomitant intra-abdominal injuries. Pelvic arterial
angiography and embolization was first described in 1972
by Margolies et al3 when autologous blood clot was used
to successfully treat active arterial bleeding in the internal
iliac arteries. The primary embolic agents now in use are
Gelfoam pledgets and platinum or stainless steel coils.
With the development of microcatheter technology, a wide
variety of pelvic and other arterial injuries can be rapidly
and successfully treated with selective and superselective
angiographic techniques.
PELVIC FRACTURES
Lateral compression fractures occur in 65% of cases and are
usually stable without significant ligamentous injury. These
fractures tend to decrease the volume of the pelvis and only
require angiography in 1% of cases4. Anteroposterior, and
Assistant Professor, Vascular & Interventional Radiology,
Medical College of Virginia, Virginia Commonwealth University,
Richmond, Virginia
particularly vertical shear and combined injuries more often
result in ligamentous injury and increased pelvic volume. A
3cm diastasis of the pubic symphysis doubles the volume
of the pelvis to 8 Liters5. These injuries require angiography in up to 20% of cases4.Overall, between 5 and 15%
of patients with pelvic fractures will require angiographic
intervention5-9.
TRIAGE
Despite fracture classification, studies have shown that
fracture pattern does not always correlate with the need
for arterial embolization10; clinical status remains the most
important determinant and many of these patients rapidly
develop a bleeding diathesis due to massive transfusions
and hypothermia. It is important to aggressively treat the
coagulopathy and hypothermia and maintain blood pressure with vasopressors but not to volume overload with
crystalloid/colloid infusion since this can lead to increased
bleeding by disrupting fresh clot and cause other problems11. External fixation is also very important to stabilize
ligamentous injury and to decrease the pelvic volume.
Thirty-one percent of these patients have an associated
intra-abdominal injury12 and most stable patients undergo
a CT scan. For visualization of pelvic bleeding (based on
active extravasation or a large retroperitoneal hematoma)
with single-channel helical CT scanners, the reported sensitivity and specificity are 90% and 98%, respectively. This
will likely improve with the advent and increasing availability of multichannel detector CT13-14. Patients with CT
scans suspicious for active pelvic bleeding should undergo
emergent angiography and patients with pelvic fractures
and negative CT’s who have a persistent transfusion
requirement of greater than 4-6U in 24 hours should also
undergo angiography5-7,15.
Hemodynamically unstable patients with mechanically
unstable pelvic fractures and negative abdominal sonogram
or supra-umbilical diagnostic peritoneal lavage (DPL) will
58
Unstable pelvis- role of the interventionalist malcolm k. sydnor MD
often undergo external fixation and then proceed to angiography. The exception to this is the patient who is rapidly
deteriorating despite resuscitation. These patients may be
taken to the OR depending on the time it takes to put the
Interventional Radiology team in place. During this scenario, the IR team should be ready to receive the patient
from the OR.
Patients with pelvic hemorrhage and concomitant positive
sonogram or DPL will often be taken to the OR for exploratory laparotomy to treat the unknown intra-abdominal
injury which may be felt to be more life threatening. This
may increase the retroperitoneal bleed by partially releasing
the tamponade16. In this circumstance, the IR team should
be immediately ready to receive the patient from the OR.
Alternatively, and depending on the clinicalscenario, the
patient with polytrauma can be brought to the IR suite
for extensive angiographic evaluation and treatment of an
abdominal injury in conjunction with the pelvic injury16.
These are decisions made by the trauma surgeon based on
the independent circumstances of each patient including
patient status, extent of injuries, and availability of the
IR team. A patient with pelvic bleeding should never be
considered “too unstable” to go to the IR suite and every
effort possible should be made to equip the IR suite with
the necessary inventory to take care of the decompensating
trauma patient.
to allow for security of the vascular access and rapid catheter exchanges.
Once the access site has been established, a 5 French
Pigtail catheter is advanced into the distal abdominal aorta
and pelvic angiography is performed in at least the AP
projection with prolonged filming and contrast injections
of approximately 8cc’s per second for a total of 32cc’s.
This allows for an anatomic overview and severe pelvic
extravasation may be visualized in order to direct the next
catheterization to the site of most significant injury.
A negative aortogram does not exclude injury and both
internal iliac arteries as well as both external iliac arteries
should be interrogated. The internal iliac arteries are often
best cannulated with a Cobra 2 catheter over an angled tip
hydrophilic glidewire. Prolonged filming and injection rates
of around 5 to 8cc’s per second for a total of 15 to 24cc’s
are utilized. Sometimes a 4 French glide catheter will help
to catheterize diminutive internal iliac arteries in patients
with diffuse vasoconstriction (Figure 1A-B).
PELVIC ARTERIOGRAPHY
As the patient is transferred to the IR suite, the Interventional
Radiologist should review all of the imaging findings in
order to determine, in conjunction with the Trauma Surgeon,
whether additional angiographic evaluation is warranted.
No time should be wasted as the unstable patient is transferred to the angiography table; sometimes pelvic external
fixation can be performed at this point under fluoroscopy.
The common femoral artery is the preferred access site.
There is often a femoral arterial line in place which can
also be rewired for a larger sheath to save time and prevent
further needle sticks in coagulopathic patients. A 6 French
sheath is often necessary in order to work with a 5 French
catheter system while measuring continuous intra-arterial
pressures through the sheath. Occasionally, due to extreme
pelvic and/or femoral injuries, a brachial access may be
necessary. Rarely, in elderly patients with severe atherosclerotic disease, it may be necessary to access both femoral
arteries rather than negotiate a tortuous aortic bifurcation.
Whatever the access site, a sheath should always be placed
Figure 1. 17 year old unstable female status post MVA. Digital
Subtraction Angiogram (DSA) demonstrates diffuse vasoconstriction and multiple areas of extravasation from both internal
iliac arteries (A). There is resolution of contrast extravasation
after selective bilateral Gelfoam embolization using a 4 French
Cobra catheter (B).
The most commonly injured vessels in order of frequency
are the superior gluteal, internal pudendal, obturator, inferior gluteal, lateral sacral, iliolumbar, external iliac, deep
circumflex iliac, and inferior epigastric4.
During digital subtraction angiography, care should be
taken not to confuse bowel gas, ureteral peristalsis, normal
uterine blush, or the bulbospongiosal stain at the base of the
penis for arterial injury. The spectrum of traumatic arterial
injury includes transection, intimal disruption, pseudoan-
59
Panamerican Journal of Trauma
eurysm, or arteriovenous fistula which may be identified
angiographically as active extravasation of contrast or
staining, vascular irregularity, abrupt vessel cutoff, or early
venous filling. Abrupt vessel cutoff is often difficult to
distinguish from spasm. This can be treated with empiric
embolization or close observation, depending on the hemodynamic status of the patient.
precision (Figure 3A-B). The use of gelfoam powder or
other particulate embolic agents should be avoided as they
are far more likely to cause tissue ischemia. Occasionally
there may also be a need for balloon occlusion catheters
and covered stents, particularly with injuries to the external
iliac artery, common femoral artery, or superficial femoral
artery (Figure 4A-B).
PELVIC ARTERIAL EMBOLIZATION
Complications include those that are access site related
as well as non-target embolization and tissue necrosis.
Inadvertent reflux of Gelfoam into the profunda femoris
artery or other muscular branches will most likely be
clinically silent. However, significant Gelfoam embolization down the leg is likely to cause an ischemic limb. This
complication can often be treated in the angiography suite
with suction embolectomy.
The interventional radiologist should be constantly aware
of the hemodynamic status of the patient. If there are multiple areas of injury or midline bleeding in the unstable
patient, rapid Gelfoam embolization of both internal iliac
arteries should be performed (Figure 2A-D). If the patient
is relatively stable and only one or a few areas of injury are
visualized, more elegant embolization with a 4 French or
microcatheter system could be performed.
Figure 3. 27 year old male unstable male status post MVA. DSA
demonstrates massive extravasation of contrast from the proximal
posterior division of the left internal iliac artery (A). There was
decreased but residual (white arrow) extravasation after coil
(black arrow) embolization (B). The 4th left sided lumbar artery
was also selectively catheterized (C) and embolized with Gelfoam
(D).
Figure 2. 42 year old unstable male status post MVA. DSA demonstrate active midline perineal extravasation of contrast before
(A, B) and after (C, D) bilateral internal pudendal Gelfoam embolization.
The ideal embolic agent should match medium sized arteries
and resorb with time. The most suitable agent to serve this
purpose is Gelfoam, which can be rapidly prepared by cutting into small pledgets, soaking in contrast, and injecting
through a 1cc syringe. For larger vacular injuries or AV fistulas, platinum or stainless steal coils can be deployed with
60
Figure 4. The same patient as Figure 3 had early filling of the
left femoral vein secondary to an arteriovenous fistula (A) which
was successfully excluded with a covered stent in the proximal
Superficial Femoral artery(B).
Vol. 15 Number 1 2008
Unstable pelvis- role of the interventionalist malcolm k. sydnor MD
Tissue ischemia becomes a concern when both internal iliac
arteries are embolized. While Velmahos et al17 published a
series or 30 bilateral internal iliac artery embolizations in
2000 with no such complications, Suzuki et al18 recently
reported 12 cases of gluteal necrosis in a series of 165 bilateral internal iliac embolizations. At least six of these did
not have gluteal injuries on admission and therefore were
attributed to the embolization and three of these six patients
died due to sepsis. Long term follow-up data after bilateral
embolization has not been reported. While these potential
complications are concerning, the risks are outweighed by
the alternative of continued extravasation with subsequent
exsanguination.
After embolization, the hemodynamic status of the patient
often dramatically improves. Repeat views should then be
obtained with the same catheterization level and image
obliquity in which the injury was seen prior to treatment.
In addition, a pelvic flush arteriogram from the distal
abdominal aorta should be performed to ensure adequate
treatment and to evaluate for other injuries or collateral
filling of the same site of injury. Special attention should be
paid to the external iliac artery injection as frequent pelvic
collaterals including replaced obturator branches frequently
originate from the inferior epigastric artery (Figure 5A-B).
Midline bleeds can receive flow from both internal iliac
arteries as well as an external iliac branch. The source of a
lateral pelvic bleed may be from a lumbar, iliac circumflex,
or profunda femoris branch4.
Figure 5. This is a 54 year old male with persistent hemodynamic
instability after bilateral internal iliac artery embolization. DSA
demonstrates extravasation from a branch of the right inferior
epigastric artery (A). The stump of the inferior epigastric artery
(arrow) is visualized following Gelfoam embolization (B).
Upon examination of the five most recent series17, 19-22 of
pelvic embolizations for trauma (ranging between 15 and
65 pelvic embolizations), there were a total of 152 pelvic
embolizations performed with technical success in 147
cases (97%). Mortality for these series ranged from14 to
46% and most deaths were attributable to concomitant
injuries other than the pelvic bleed. There were three (2%)
reported angiographic complications in these series. Only
a small percentage of these patients underwent external
pelvic fixation prior to angiography.
CONCLUSIONS
The treatment for acute hemorrhage after an unstable
pelvic fracture involves close coordination between the
trauma, orthopedic, and interventional radiology services
and includes control of hypotension and coagulopathy,
pelvic stabilization, and percutaneous pelvic arterial embolization. When pelvic hemorrhage is the paramount issue,
the faster the patient can be mobilized to the Interventional
Radiology suite for embolization the better, regardless of
stability. When the patient is taken to the OR for a concomitant intra-abdominal injury, the IR team should be ready
to receive the patient from the OR for subsequent pelvic
embolization. The role of IR for treatment of concomitant
abdominal organ injury continues to evolve and depends in
part on how fast the IR team can be mobilized.
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10. Sarin EL, Moore JB, Moore EE, ShannonMR, Ray CE,
Morgan SJ, Smith WR. Pelvic fracture pattern does not
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end-organ function at 72 hours. Shock. 2001; 15(1):16-23.
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Vol. 15 Number 1 2008
MANUAL DE TRAUMA
AUTORES:
Andrew B. Peitzman
Michael Rhodes
C. William Schwab
Dinald M. Yealy
Timothy C. Fabian
Edición: 2009
EN PREPARACIÓN
AUTORES:
RICARDO FERRADA
AURELIO RODRIGUEZ
Andrew B. Peitzman
Juan Carlos Puyana
Rao Ivatury
Edición: 2009
ULTRASONIDO EN
EMERGENCIAS Y TRAUMA
(USET)
ULTRA-SOM EM
EMERGENCIAS E TRAUMA
(USET)
AUTORES:
Juan Carlos Puyana
Andrés M. Rubiano
Jorge Hernando Ulloa
Mayla A. Perdomo
Edición: 2008
AUTORES:
Juan Carlos Puyana
Andrés M. Rubiano
Jorge Hernando Ulloa
Mayla A. Perdomo
Edición: 2009
NEUROTRAUMA Y
NEUROINTENSIVISMO
CUIDADO INTENSIVO Y
TRAUMA
AUTORES:
Andrés Rubiano
Rafael Perez
Edición: 2008
AUTORES:
Carlos Ordoñez
Ricardo Ferrada
Ricardo Buitrago
2da Edición: 2009
EN PREPARACIÓN
TRAUMA
EN PREPARACIÓN
TÍTULOS PUBLICADOS
EN TRAUMA
RESPUESTA MÉDICA
AVANZADA A DESASTRES
EDITORES:
Susan M. Briggs
Jorge A. Neira
Manuel Lorenzo
Edición: 2009
GUÍA PARA LA
ESCENA: APH Y
TRAUMA
AUTOR:
Andres Rubiano
Edición: 2006
ADQUIERALOS EN:
Editorial Médica Distribuna · Bogotá: Autopista Norte N° 123 - 93 L: 1
Tel: (1) 6202294 - 21583335 · Fax: (1) 2132379 · Apartado Aéreo: 265006
[email protected] · [email protected]
63