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PANAMERICAN JOURNAL OF TRAUMA

INSTRUCTIONS FOR AUTHORS

Manuscripts and related correspondence should be sent to either Dr. Kimball Maull MD or Dr. Ricardo Ferrada MD to the following addresses: Kimball Maull, M.D. FACS, Carraway Medical Center, 1600 Carraway Boulevard, Birmingham, Alabama USA.

1. Manuscript. The original typescript and two high-quality copies of all illustrations, legends, tables and references must be submitted. All copy, including references, must be typed double-spaced on 21 x 27 cm, heavy-duty white bond paper. Margins must be at least 1 inch. A computer diskette or CD containing a fi le of the article must be included. Files in Word either for IBM-compatible or Apple are preferred. The diskette should be labeled with the author’s names, the title of the article, the type of computer, and the word processing software used.

2. Title. The title must be short, specifi c and clear. It cannot exceed 45 characters per line, and is limited to two lines. The title page should include the full names, and academic affi liations of all author. Foot notes indicating where the works was done, where orders for reprints should be addressed and those contributing grants for the work should be given at the bottom of the second page. If the manuscript was presented at a meeting, indicate the name of the organization, the place and the date on which it was read.

3. Illustrations. Please send three complete sets of high contrast glossy prints. Figure number, name of senior author, and arrow indicating top should be typed on a gummed label and affi xed to the back of each illustration. Cost of color fi gures, where used, is borne by authors.

4. Summary. A summary of 150 words or less should be submitted in English and Spanish. The summary must include a statement of the problem, methods of study, results and conclusions. A list of key words to be used for indexing should appear at the end of the summary.

5. References. References should be listed in consecutive numerical order as they are cited in the text. Once a reference is cited, all subsequent citations should be to the original number. All references must be cited in the text or tables. References to journal articles should include: authors, title, journal name as abbreviated in Index Medicus, year, volume number, and inclusive page numbers in that order. References to books should include: authors, chapter title, if any; editor in any; title of book; year; city and publisher. Volume and edition numbers, specifi c pages, and name of translator should be included when appropriate. The author is responsible for the accuracy and completeness of the references and for their correct text citation.

6. Originality & copyright. Manuscripts and illustrations submitted for consideration should not have been published elsewhere except for such preliminary material presented to the Panamerican Trauma Society.

INSTRUCCIONES PARA LOS AUTORES

Los manuscritos y la correspondencia se deben enviar a Ricardo Ferrada MD o Kimball Maull MD a las siguientes direcciones:Ricardo Ferrada, M.D., FACS Departamento de Cirugía, Hospital Universitario del Valle, Calle 5 # 36-08, Cali, Colombia, S.A.

1. Manuscritos. Se debe enviar un original del manuscrito y dos copias de todas las ilustraciones, leyendas, cuadros y referencias. Todas las copias, incluso las referencias, deben ser escritas a doble espacio en papel blanco de 21 x 27 cm. Los márgenes deben ser amplios. Se debe incluir un diskette o CD que contenga el artículo. Son preferibles los archivos en Word IBM compatibles o Apple. El diskette debe ser marcado con el nombre del artículo y de los autores, el tipo de sistema operativo y el procesador de palabras utilizado.

2. Título. El título debe ser corto, claro y específi co. No puede exceder de 45 caracteres por línea y está limitado a dos líneas. La página del título incluye el nombre completo y la posición académica de los autores. En la parte inferior de la segunda página se debe indicar dónde se llevó a cabo el trabajo, la dirección para los reimpresos y las donaciones recibidas para su realización. Si el manuscrito se presentó en una reunión científi ca, indicar el nombre de la organización, el lugar y la fecha de presentación.

3. Ilustraciones. Por favor enviar tres copias completas de las ilustraciones en alto contraste en papel brillante. En la parte posterior de cada ilustración anote el número de la fi gura, el autor principal y una fl echa con la punta hacia el borde superior. Si existen fi guras a color, el costo será cubierto por los autores.

4. Resumen. No debe tener más de 150 palabras y debe ser enviado en español y en inglés. El resumen incluye una defi nición del problema, los métodos de estudio, los resultados y las conclusiones. Al fi nal del resumen se debe adjuntar una lista de palabras claves para efectos de índice.

5. Referencias. Las referencias se citan en orden numérico consecutivo, tal como aparecen en el texto, e incluyen el siguiente ordenamiento: autores, título en el idioma original, nombre de la revista en su forma abreviada según el Index Medicus, año de publicación, volumen de la revista y páginas iniciales y fi nales. Se recomienda citar hasta cuatro autores en forma completa. Si hay más de cuatro autores, después del tercero, seguido por una coma, se colocan las palabras latinas et al. Las citas de libros incluyen: autores o editor y así se debe identifi car (ed.), título del libro, edición, ciudad de publicación, la empresa editorial y año. Las referencias deben ser verifi cadas por los autores y ésta es una de sus responsabilidades.

6. Originalidad y derechos de autor. Los manuscritos deben ser inéditos y no haber sido publicados en otra parte, excepto como material presentado a la Sociedad Panamericana de Trauma.


Editors: RICARDO FERRADA, M.D., Cali, ColombiaRAO IVATURY M.D., Richmond, VirginiaDARIO BIROLINI, M.D., Sao Paulo, Brazil

Assistant Editors: SAMIR RASSLAN M.D., Sao Paulo, BrazilANDREW PEITZMAN M.D., Pittsburgh, PennsylvaniaJORGE NEIRA, M.D., Buenos Aires, Argentina

RAFAEL ANDRADE, M.D.Panama, PanamaJUAN ASENSIO, M.D. Los Angeles, CaliforniaCARLOS BARBA, M.D.Hartford, ConnecticutLUIS BAEZ, M.D.Caracas, Venezuela MARY BEACHLEY, R.N.Baltimore, Maryland RICARDO ESPINOZA M.D.Santiago, ChileEUGENE FAIST, M.D. Münich, GermanyDAVID FELICIANO, M.D. Atlanta, GeorgiaALBERTO GARCIA, M.D. Cali, ColombiaLUIS GRANJA MENA, M.D.Quito, Ecuador GERARDO GOMEZ, M.D. Indianapolis, Indiana FRANCISCO HOLGUIN, M.D.Cartagena, Colombia LENWORTH M. JACOBS, M.D. Hartford, ConnecticutTEOFILO LAMA PICO, M.D.Guayaquil, Ecuador CHARLES LUCAS, M.D.Detroit, Michigan ROBERT MACKERSIE, M.D.San Francisco, CaliforniaKATZIUKO MAEKAWA, M.D.Kitasato, Japan KIMBALL MAULL, M.D.Birmingham, Alabama

ERNEST E. MOORE, M.D. Denver, ColoradoDAVID MULDER , M.D.Montreal, CanadaDAVID ORTEGA, M.D.Lima, Peru RENATO POGGETTI, M.D.Sao Paulo, BrazilABRAHAM I RIVKIND, M.D. Jerusalem, Israel AURELIO RODRIGUEZ, M.D. Pittsburgh, PennsylvaniaCLAYTON SHATNEY, M.D.San Jose, California RAUL COIMBRA M.D.San Diego, CaliforniaJOSE MARIO VEGA, M.D.San Salvador, El Salvador

SECTION EDITORS Critical Care:DAVID HOYT, M.D. San Diego, California

Emergengy & DisasterSUSAN BRIGGS, M.D.Boston, Massachusetts

Infection: RONALD MAIER, M.D.Seattle, Washington

Nursing:ROBBIE HARTSOCK, R.N.Baltimore, Maryland

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

Coordinación Editorial:DISTRIBUNAEditorial y Librería Médica Autopista Norte 123 - 93Fax: (57) 2132379Tel: (57) 213-2379 (57) 620-2294 Bogotá - Colombia w w w . l i b r e r i a m e d i c a . c o mImpreso por: Gente Nueva editorial

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

4

ABDOMINAL STAB WOUNDS – SAME PROBLEMS DIFFERENT SOLUTIONS

Ari K. Leppäniemi, MD, PhD, DMCC

Panamerican Journal of Trauma Vol. 15 No. 1 2008 Pages 04 - 9

RESUMEN

El tratamiento de los pacientes con heridas cortopunzantes de abdomen consiste en una serie de decisiones claves basadas en el conocimiento científi co actual. El tratamiento no operatorio de los pacientes con bajo riesgo de una lesión signifi cante es seguro y reduce las laparotomías no terapéu-ticas y su morbilidad asociada. La laparotomía temprana está indicada en los pacientes con signos obvios de san-grado del tracto intraperitoneal, retroperitoneal o gastroin-testinal, o con peritonitis generalizada. En los pacientes con penetración peritoneal demostrada, el riesgo de una lesión signifi cativa de un órgano es sufi cientemente alto para jus-tifi car exploración temprana, aunque un enfoque más con-servador puede estar indicado en pacientes asintomáticos. El papel de la tomografía computarizada no es claro, ya que los benefi cios 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 sci-

entifi c knowledge. Nonoperative management of patients with a low risk of a signifi cant 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 signifi cant organ injury is suffi ciently 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 benefi ts of laparoscopy in excluding diaphragmatic perforations especially after left thoracoab-dominal stab wounds have been demonstrated. If an intact anterior fascia can be seen during local wound exploration, the patient can be discharged, whereas equivocal fi nding 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 fl anks 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 fi nd the most appropriate response in general terms. That

Department of Surgery, University of Helsinki, FinlandCorrespondence 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: +358-9-4717-6431Email: [email protected]

Abdominal stab wounds – same problems different solutions

5

obviously can and needs to be modifi ed according to indi-vidual patients’ characteristics and clinical circumstances.Signifi cant abdominal organ injury can be been defi ned 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 place-ment of sutures or other hemostatic procedures except for temporary packing, and lacerations of major vessels or the mesentery requiring sutures or causing irreversible periph-eral organ ischemia. Laparotomy or laparoscopy performed to treat a signifi cant 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 classifi ed as minor or insignifi cant injuries. Laparotomy or laparoscopy in association with a minor injury as an only fi nding is considered nontherapeutic.

MANDATORY LAPAROTOMY

The fi rst key decision-point is whether all patients with abdominal stab wounds should undergo operative explo-ration. The risk of a signifi cant abdominal organ injury requiring surgical repair after anterior abdominal stab wound is 35-50%, 20-30% in stab wounds of the fl ank and about 15% in thoracoabdominal stab wounds, as confi rmed by numerous studies. In one study comprising 459 patients with truncal stab wounds and a potential for intra- or retro-peritoneal 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 signifi cant morbidity following mandatory laparotomy for abdominal stab wounds lead to the current, widely used selective nonoperative management strategy fi rst suggested by Shaftan in 1960.2-8 The trade off with mandatory lapa-rotomy (no or few missed injuries, high non-therapeutic laparotomy rate) and selective nonoperative management (risk of delayed treatment of signifi cant injuries, lower non-therapeutic laparotomy rate) was studied in a prospec-tive, randomized study that excluded patients requiring immediate operation for major hemorrhage, generalized peritonitis, evisceration, as well as patients with superfi cial 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 lapa-rotomy rate following mandatory exploration was (78%) that refl ects the nature of this preselected group.

In the observation group, the missed signifi cant injury rate was 17%. None of the randomized patients died, there was no signifi cant 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 utility-based trade off analysis showed that selective nonoperative management was a superior strategy in minimizing days in hospital. The study demonstrated that selective nonopera-tive management is a safe management strategy and effec-tive in minimizing the hospital stay.

Selection criteria for nonoperative management

With selective nonoperative management being the pre-ferred strategy the next key decision point involves the cri-teria by which the selection to expectant observation can be reliably made. This has lead to constant refi nement of diag-nostic algorithms utilizing a combination of multiple diag-nostic 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 diffi cult 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 examina-tions, but 28 of these (19%) underwent subsequently a therapeutic operation.22 Although the value of US in dem-onstrating peritoneal fl uid is well demonstrated, its ability to predict the presence of a signifi cant 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 diag-nosis of peritoneal violation in 34%) and the presence of a visceral injury.23 Laparotomy based on CT fi ndings was

Panamerican Journal of Trauma

6 Vol. 15 Number 1 2008

non-therapeutic in 13%. In another series of 32 with a pen-etrating 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 hemoperi-toneum and integrity of solid and hollow viscera.24 One patient (3%) had an extensive liver laceration identifi ed with both US and CT and underwent a therapeutic operation. The remaining patients had no signs of signifi cant 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 fi ndings and diagnostic methods to positively or negatively predict the presence of a signifi cant organ injury after an abdominal stab wound, a retrospective study of 209 con-secutive 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 signifi cant 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 signifi cant injury (PPV of 100%) but the number of patients with these fi ndings is usu-ally small. If peritoneal penetration could be excluded with LWE, the negative predictive value (NPV) was 100%, but PPV only 61%. Similarly, omental evisceration, free fl uid 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 fl uid on US) (p=0.001) were independent risk factors for predicting the presence or absence of a signifi cant 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 penetra-tion would have increased the nontherapeutic laparotomy rate to 30% and decreased the missed injury rate to 11%.

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, diag-nostic 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 superfi cial injuries (intact anterior fascia on LWE), the remaining patients were stratifi ed into two groups based on the risk of a signifi cant organ injury. Patients at high risk (60-70%) with demonstrated peritoneal penetration were randomized into either explorative laparotomy or diag-nostic laparoscopy (DL), whereas low risk patients (<10%) with equivocal LWE fi nding (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%, respec-tively), 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 signifi cant organ injury, there was no signifi cant difference between DL and expectant observation in missed signifi cant 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.


7

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 non-therapeutic 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 effi cacy of DL in excluding occult diaphragmatic injuries following penetrating abdominal trauma.51 Among 38 hemodynami-cally stable patients (37 stab wounds) with thoracoabdom-inal injuries, DL was used in all patients to evaluate the diaphragm, subsequently confi rmed 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 diag-nostic peritoneal lavage) and radiological methods espe-cially 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 asymptom-atic upper abdominal and lower thoracic wounds excluding the upper back, the overall incidence of diaphragmatic inju-ries confi rmed 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 fl ank and presented with herniation of the stomach or small bowel and colon.

MANAGEMENT BASED ON RISK ASSESSMENT

Table 1 summarizes the likelihood of a signifi cant organ injury in different kinds of abdominal stab wounds based on recent literature including patients with stab wounds to

the fl anks, 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, fol-lowing guidelines for the key decision-points are used in managing patients with anterior and fl ank stab wounds at the Meilahti hospital, University of Helsinki, Finland:

Surgical abdomen (hemoperitoneum, peritonitis, GI per-• foration) or pericardial tamponade: immediate operationPatients without surgical abdomen or tamponade: LWE• If fascia intact: discharge• If peritoneal violation obvious or demonstrated on LWE: • laparotomyIf LWE equivocal: observe 24-48 hours• Left thoracoabdominal stab wound: diagnostic laparos-• copy

LWE = local wound exploration

BIBLIOGRAPHY

1. Leppäniemi A, Salo J, Haapiainen R: Complications of negative laparotomy for truncal stab wounds. J Trauma 1995;38:54-58.

2. Shaftan GW: Indications for operation in abdominal trauma. Am J Surg 1960;99:657-664.

3. Forde GA, Ganepola GAP: Is mandatory exploration for penetrating abdominal trauma extinct? The morbidity and mortality of negative exploration in a large municipal hos-pital. J Trauma 1974;14:764-766.

4. Petersen SR, Sheldon GF: Morbidity of a negative fi nding at laparotomy in abdominal trauma. Surg Gynecol Obstet 1979;148:23-26.

5. Thompson JS, Moore EE, van Duzer-Moore S, et al: The evolution of abdominal stab wound management. J Trauma 1980;20:478-484.

Anterior stab wounds 40-50%With peritoneal violation 60-70%Equivocal peritoneal violation 7%Peritoneum intact on LWE 0%Stab wound of the fl ank 20-30%Posterior stab wound 7-15%Thoracoabdominal stab wound 15%Occult diaphragmatic injury 7%Right side 3%Left side 17%

Table 1. Risk of signifi cant organ injury in abdominal stab wounds


8 Vol. 15 Number 1 2008

6. Lee WC, Uddo JF Jr., Nance FC: Surgical judgement in the management of abdominal stab wounds: utilizing the criteria from a 10-year experience. Ann Surg 1984;199:549-554.

7. Demetriades D, Rabinowitz: Indications for operation in abdominal stab wounds: a prospective study of 651 patients. Ann Surg 1987;205:129-132.

8. Sirinek KR, Page CP, Root HD, et al: Is exploratory celiotomy necessary for all patients with truncal stab wounds? Arch Surg 1990;125:844-848.

9. Leppäniemi AK, Haapiainen RK: Selective nonoperative management of abdominal stab wounds: prospective, ran-domized 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 con-servatism in abdominal stab wounds. J Trauma 1988;28:1665-1668.

14. Shorr RM, Gottlieb MM, Webb K, et al: Selective manage-ment of abdominal stab wounds. Arch Surg 1988; 123:1141-1145.

15. De Lacy AM, Pera M, Garcia-Valdecasas JC, et al: Management of penetrating abdominal stab wounds. Br J Surg 1988;75:231-233.

16. Robin AP, Andrews JR, Lange DA, et al: Selective man-agement of anterior abdominal stab wounds. J Trauma 1989;29:1684-1689.

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.

18. Muckart DJJ, McDonald MA: Unreliability of standard quan-titative criteria in diagnostic peritoneal lavage performed for suspected penetrating abdominal stab wounds. Am J Surg 1991; 162:223-227.

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.

22. Soffer D, McKenney MG, Cohn S, et al: A prospective evalu-ation of ultrasonography for the diagnosis of penetrating torso injury. J Trauma 2004;56:953-959.

23. Shanmuganathan K, Mirvis SE, Chiu WC, et al: Penetrating torso trauma: Triple-contrast helical CT in peritoneal viola-tion and organ injury – a prospective study in 200 patients. Radiology 2004;231:775-784.

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 mini-laparoscopy 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 lap-aroscopy in abdominal trauma. J Trauma 1992;33:471-475.

31. Salvino CK, Esposito TJ, Marshall WJ, et al: The role of diag-nostic laparoscopy in the management of trauma patients: a preliminary assessment. J Trauma 1993;34:506-515.

32. Ivatury RR, Simon RJ, Stahl WM: A critical evaluation of laparoscopy in penetrating abdominal trauma. J Trauma 1993;34:822-828.

33. Fabian TC, Croce MA, Stewart RM, et al: A prospec-tive analysis of diagnostic laparoscopy in trauma. Ann Surg1993;217:557-565.

34. Rossi P, Mullins D, Thal E: Role of laparoscopy in the evalu-ation of abdominal trauma. Am J Surg 1993;166:707-711.

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 evalu-ation 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 pen-etrating trauma: the decision to explore. J Laparoendosc Surg 1996;6:285-291.


9

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.

40. Mutter D, Nord M, Vix M, et al: Laparoscopy in the evalua-tion of abdominal stab wounds. Dig Surg 1997;14:39-42.

41. Marks JM, Youngelman DF, Berk T: Cost analysis of diag-nostic laparoscopy vs. laparotomy in the evaluation of pen-etrating 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 laparos-copy 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.

46. Taner AS, Topgul K, Kucukel F, et al: Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients. J Laparoendosc Adv Surg Tech 2001;11:207-211.

47. Taviloglu K: When to operate on abdominal stab wounds. Scand J Surg 2002;91:58-61.

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.

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.

51. Friese RS, Coln E, Gentilello LM: Laparoscopy is suffi cient to exclude occult diaphragm injury after penetrating abdom-inal trauma. J Trauma 2005;58:789-792.

52. Freeman T, Fischer RP: The inadequacy of peritoneal lavage in diagnosing acute diaphragmatic rupture. J Trauma 1976;16:538-543.

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.

54. Muckart DJJ, McDonald MA: Unreliability of standard quan-titative 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 diaphrag-matic 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 fl ank. Surg Gynecol Obstet 1984;159:514-518.

60. Hauser CJ, Hupricj JE, Bosco P, et al: Triple-contrast com-puted tomography in the evaluation of penetrating posterior abdominal injuries. Arch Surg 1987;122:1112-1115.

61. Demetriades D, Rabinowitz B, Sofi anos C, et al: The man-agement of penetrating injuries of the back. A prospective study of 230 patients. Ann Surg 1988;207:72-74.

62. Kirton OC, Wint D, Thrasher B, et al: Stab wounds to the back and fl ank in the hemodynamically stable patient: a decision algorithm based on contrast-enhanced computed tomography with colonic opacifi cation. Am J Surg 197;173:189-193.

63. Boyle EM Jr., Maier RV, Salazar JD, et al: Diagnosis of injuries after stab wounds to the back and fl ank. J Trauma 1997;42:260-265.

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.

10

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 toracoab-dominal 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 pen-etrante 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 diafrag-mática del 17.1%.Conclusiones: La cirugía minimamente invasiva es útil, rápida y menos mórbida para descartar o confi rmar heridas del diafragma en pacientes estables con trauma toracoab-dominal

PALABRAS CLAVE: Trauma, toracoabdominal, diafrag-mática, 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

during three years using thoracoscopy and/or laparoscopy in the approach of this patients.

Patients and methods: it’s a description about the experi-ence 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%. fi nding 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 tho-racoabdominal 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 publi-caciones en el mundo reportan un porcentaje de lesión dia-fragmática 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.

*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.

cirugía minimamente invasiva en trauma toraco abdominal en el hospital de san josé de bogotá colombia

11

Las hernias diafragmáticas traumáticas pueden pasar inad-vertidas en muchas ocasiones, pero en un gran numero de pacientes tienen consecuencias dramáticas, desafortu-nadamente 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 (fi gura 1). Se han propuesto diversos mecanismos para evaluar estas lesiones como toracotomia, laparotomía, exploración digital

5,8, 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 gamagráfi cos 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.

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 insti-tución.

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 minimam-ente 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 toracoabdomi-nales bilaterales se realizaba laparoscopia (fi gura 2).

En todos los casos, si el resultado de la laparoscopia o tora-coscopia fue positivo para lesión en el diafragma, se realizó laparotomía para la reparación de la herida y exploración de probables lesiones asociadas.

El tiempo quirúrgico en toracoscopia oscilo entre 12 y 16 minutos con un promedio de 14 minutos y entre 9 y 13 para

Figura 2. Algoritmo del abordaje diagnostico de las heridas tora-coabdominales.

LAPAROTOMIA

NEGATIVA

POSITIVA

NEGATIVA

LAPAROSCOPIAHERIDA DE DIAFRAGMA

HERIDA TORACOABDOMINAL

ESTABLE INESTABLE

RX TORAX CIRUGIA

POSITIVA

TORACOSCOPIAHERIDA DE DIAFRAGMA

POSITIVA

NEGATIVA


12 Vol. 15 Number 1 2008

laparoscopia con un promedio de 11 minutos. Se requirió intubación orotraqueal selectiva en 18 de los 32 pacientes sometidos a toracoscopia.

RESULTADOS

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 prac-ticó 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.

Tabla 1. Distribución por género, mecanismo del trauma y procedimiento realizado.

PACIENTES nHOMBRES / MUJERES

ARMA CORTOPUNZ. / ARMA DE FUEGO

TORACOSCOPIA / LAPAROSCOPIA

96 (86.4%) / 15 (13.5%)

103 (92.7%) / 8 (7.2%)

32 (28.8%) / 79 (71.1%)

TOTAL 111

Tabla 2. Resultados del procedimiento (herida del diafragma)

RESULTADO No. PACIENTESPOSITIVO (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

en muchas ocasiones hizo que estos pacientes ingresaran inestables al quirófano y por consiguiente no están incluidos en el estudio.

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 lap-aroscopia como la toracoscopia permitieron la evaluación de la totalidad de los hemidiafragmas sin lugar a dudas en ninguno de los casos.

Cuando se revisa la literatura disponible sobre otros pro-cedimientos 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 mor-bilidad, 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 La toracoscopia y/o laparoscopia empleada para el diagnós-tico de lesiones del diafragma es un procedimiento fácil de realizar, efi caz, 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, efi ciencia 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 benefi cios 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 diag-nosis of injuries to the diaphragm after penetrating wounds. J Trauma 1988. 30. 1135-1144

3. Demetriades D, Murray JA. Traumatic diaphragmatic her-nias. Nyhus and Condon’s Hernia. 2002. cap 43. 503-511.

cirugía minimamente invasiva en trauma toraco abdominal en el hospital de san josé de bogotá colombia

13

4. D´Angelica M, Morgan AS, Barba CA. Trauma de diafragma. Trauma. A Rodríguez, R. Ferrada. Sociedad Panamericana de Trauma. 1997. 325-332

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.

7. Cruz C, Minagi H. Large bowel obstruction from traumatic diaphragmatic hernia: Imaging fi ndings in fours Cases. AJR 2004; 172: 843-845.

8. Morales C, Villegas M. Value of digital explorations for diag-nosis of injuries to the left side of the diaphragm caused by stab wounds. Arch surg. 2001. 136. 1131-1135

9. Morales C. Panam J Trauma. Evita la toracoscopia la real-ización 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 tech-netium case report. J trauma 1992; 33: 140-142

11. Rappaport WD, Lee S, Coates S. Diagnosis of diaphragmatic injury using intraperitoneal technetium. Am Surg. 1989. 55:621

12. Jackson A. Thoracoscopy as an aid to the diagnosis of dia-phragmatic injury in penetrating wounds of the lower chest. a preliminary report. Injury 1976. 7. 213-218.

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 evalua-tion of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma. A preliminary report. J Trauma. 1993. 34:704-710.

23

COMBINING APPROACHES IN ARTHROPLASTYFOR ACUTE FRACTURES OF THE ACETABULUMThomas M. Schaller, MD1 and Thomas Ryan, MD


RESUMEN

La reducción abierta y la fi jación 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 fi jación. 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 fi jación a efecto de maximizar la viabilidad de los fragmentos fracturados y la estabilidad de la cadera.

Palabras claves: Artroplastia, Fractura acetabular, Acceso quirúrgico.

SUMMARY

Open reduction and internal fi xation is the preferred treat-ment 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 fi xation. 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 fi xation principles in order to maximize fracture fragment viability and hip stability.

KEY WORDS Arthroplasty, Acetabular Fracture, Surgical Approach

INTRODUCTION

Open reduction and internal fi xation (ORIF) is the pre-ferred 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-trau-matic arthrosis (5, 6). However, certain patients in specifi c clinical scenarios may benefi t from the acute use of total hip arthroplasty. Problems related to severe articular car-tilage damage or extensive (unmanageable) comminution led innovators to attempt single stage THA in conjunction with standard or alternative methods of fi xation (7-14).

The indications for performing acute total hip arthroplasty are still evolving. It is clear that a combination of fac-tors 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 fi xation 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. Signifi cant impaction or comminuted fractures of the femoral head

3. Impaction of greater than 40% of the acetabular sur-face

4. Severe pre-existing degenerative arthritis5. Signifi cant osteopenia

1Bronson Methodist Hospital, Kalamazoo, MI, USAOrder reprints [email protected]


24 Vol. 15 Number 1 2008

The standard posterior or anterolateral approach is typi-cally 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 tech-nique combines well-known intervals and takes advantage of familiar fi xation 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 fi bers 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 resec-tion. The leg is positioned with hip extension and knee fl exion throughout this fi rst 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 junc-tion 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 fl exion and hip extension. The fracture is subsequently addressed with standard fi xation techniques, typically lag screws and but-tress plating. [Figure 1] Anatomic restoration of the artic-ular 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 fi xation without impairing the ability to seat the acetabular compo-nent. [Figure 2]

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 fi lling 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 fi xation device (12) the stability of the fracture repair is derived from the extra-articular screws and but-tress 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

Combining approaches in arthroplasty for acute fractures of the acetabulum

25

usual after implantation of the components. Figure 1 is an illustration of the intra-articular view from the lateral approach, after the fi xation is in place. Figure 2 represents

Figure 3 and 4. AP pelvis and lateral x-rays of the hip in skeletal traction.

the posterior, extra-articular view. The hardware placement is tailored to the fracture pattern as surgeon preference and fragment size/location dictates.

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 fi gures 3 and 4.

Selected cuts from the 2 and 3-dimensional reconstructions are seen in fi gures 5-8. No head, chest, or abdominal inju-ries 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.


26 Vol. 15 Number 1 2008

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]

DISCUSSION

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 degen-erative 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 ante-rolateral 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 fi xation along the posterior column and wall. Since the neck resection is carried out through the anterior exposure, no posterior capsule resec-tion 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.

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.

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 reduc-tion 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 replace-ment 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 fi xation 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, Griffi n 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.

Combining approaches in arthroplasty for acute fractures of the acetabulum

27

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 modifi ed cerclage. Early results]. Unfallchirurg 2004;107(11):1050-1056.

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 fi xation 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.

14

COMPLICACIONES DE LA INGESTIÓN MASIVA DE OVOIDES DE COCAÍNADr. 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 tráfi co de cocaína, conocidos vul-garmente 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 tráfi co de drogas ilícitas.

MATERIAL Y MÉTODOS

Se defi ne como correo humano de tráfi co de cocaína, a la persona que en su lugar de origen, ingiere una determinada cantidad de ovoides de cocaína, con el fi n 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.

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 recu-perados los ovoides y de no mediar ninguna complicación quirúrgica ni toxicológica, se traslada al imputado para que continúe el proceso judicial correspondiente.

Estudiamos los pacientes ingresados desde el año 1999 hasta el 2006, separándolos en dos grupos: sin y con com-plicación, 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 trans-forma 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 asfi xia por un ovoide al momento de la ingestión.

CONCLUSIONES

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

Complicaciones de la ingestión masiva de ovoides de cocaína

15

tratamiento medico y enfrentar el tratamiento quirúrgico de manera oportuna y adecuada.

RESUMEN

Palabras claves: Complicaciones, ingestión de ovoides

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.

En base a los correos humanos de estupefacientes, cono-cidos 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 rep-resentan 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-fi lled 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

siguiente peritonitis que signifi ca una prolongada hospital-ización y riesgo vital.

De acuerdo a lo anterior se propone hacer enterotomías lo más bajas posible y dejar ostomías y eventualmente lap-arostomía contenidas (3,4,5).

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 con-traindicación por el cierre primario, a menos que el ciru-jano considere algún factor de riesgo, como en el caso de la intoxicación.

Cada ovoide mide unos tres por uno coma cinco cen-tímetros 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 resist-ente 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 evi-dencias que como tales deben ser ingresadas a la cadena de custodia o entregadas al policía

En el aspecto médico legal es indispensable delimitar res-ponsabilidades, 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 iden-tidad, cargo y fi rma, en ese momento deja de ser respons-abilidad del médico y se transfi ere 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 impor-tantes por lo que resulta indispensable delimitar respons-abilidades muy exactamente. Por otra parte la intoxicación por cocaína que se produce al romperse un ovoide exige un diagnóstico precoz a fi n de establecer oportunamente el


16 Vol. 15 Number 1 2008

recovered. All of the above qualifi es the surgical team to become expert witnesses in a singular position to provide specialized testimony.

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

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.

BIBLIOGRAFÍA

Fuente: google.cl búsqueda: trafi co 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, orga-nización panamericana de la salud, ofi cina 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 Intera-mericana Editores, 2001 México, Unidad 4 capitulo 16

4. Intoxicaciones, epidemiologia, clinica y tratamiento, textos universitarios Facultad de Medicina , Enrique Paris Mancilla, Juan Carlos Río Bustamente, Ediciones Universidad Cató-loica de Chile, Santiago, Chile 2001, Capítulo cocaína pag 162

5. Lo esencial en farmacología, segunda edición, Dawson , Taylor, Reide, gráfi cas Marte, España, Mdrid, editorial Elsevier, cap 6 sistema nerviososo central, abuso de sustan-cias pag 115.

Nota: La presentación de la bibliografía es atípica, porque tra-tándose de una patología nueva, no hemos encontrado trabajos acerca del tema tratado.

17

ECONOMICS OF TRAUMA CARE RE-VISITED

Samir Fakhry, MD, Facs


INTRODUCTION

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 hos-pitals. It appears possible for trauma surgeons and trauma centers to be profi table, or at least to break even. There are a number of conditions that increase a center’s likelihood of positive fi nancial 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. Effi cient, 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.

The increasing fi nancial 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.

TRAUMA SYSTEM CHALLENGES: NATIONAL

Trauma care in the United States has received minimal sup-port 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 signifi cant 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.

Historically these diffi cult 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 centers3. Little if any support for the cost of readiness incurred

by trauma centers.

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 signifi cant problem of adequate specialty coverage for trauma and emergency department care. In a recent report

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


18 Vol. 15 Number 1 2008

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 signifi cant diffi culties fi nding 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 profi t hospitals. The ED directors responding to this survey were asked “What is the most signifi cant con-sequence 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 trans-fers of patients between emergency departments” (18%). The survey also revealed that emergency department trans-fers 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 diffi culties that these hospi-tals are encountering in securing adequate on call specialty coverage, three deserve special mention.

These are:1. Lifestyle choices2. 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 sur-gery and in particular, trauma care, have only increased the severity of these challenges8,9. Faced with the need to pro-vide trauma services for their community, hospitals have struggled to meet these challenges. The percentage of hos-pitals 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 fi nancial losses incurred by many trauma centers. In addition to poor reimbursement and uninsured patients, this new category of on-call com-pensation to specialty physicians must be considered in any assessment of the economics of trauma centers, especially those in the private sector.

Trauma System Challenges: State

In 2004, the Virginia House Joint Resolution 183 directed the Joint Legislative Audit and Review Commission

(JLARC) to study the use and fi nancing 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 excep-tionally fi ne 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. 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.

2. The fi nancial 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).

3. 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 physi-cians in private practice (Fig 4). Signifi cant numbers of the on-call private physicians were being paid to be on-call (Fig 5). This was especially true for general/trauma surgeons.

4. 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 (fi g 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.•

5. Public insurers (including Medicare and Medicaid) reimburse trauma care at levels below the actual cost of care (Fig 7).

6. 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.

Economics of trauma care re-visited

19

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 col-lected as fi nes 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.

CONCLUSION

Trauma Centers in America are facing increasing chal-lenges to their operational integrity. Some of these chal-lenges are similar to those faced in past years but there are new challenges that arise predominantly from the diffi culties 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 (espe-cially the sub-specialty crisis) involve reimbursement for on-call coverage. In the long run, such solutions run the

risk of overextending trauma center fi nances (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.

Figure 1. Source: JLARC staff analysis of trauma registry data

Figure 2.

Total Cost ofUncompensated

Care: $20.0 M

Total Cost ofReadiness: $20.0 M

Total Cost ofPublic InsuranceLosses: $12.0 M

$12.0 MUnreimbursed

Readiness Costs ofPrivately-Insured

Patients$5.0 MUnreimbursed

Readiness Costs ofPublicly Insured

Patients

$7.0 MLosses on ClinicalCare Provided toPublicly insured

Patients

$13.6 MLosses on ClinicalCare Provided to

Uninsured Patients

Note: Data exclude Southside Regional Medical Center.

Total = $44 Million

Sources of Losses Incurred by Trauma Centersfor Treatment of Trauma Patients (2003)


20 Vol. 15 Number 1 2008

Figure 3. Note: Includes only those trauma centers reporting staffi ng 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.

Economics of trauma care re-visited

21

Figure 5.

Figure 6. Source: JLARC staff analysis of 2003 trauma center fi nancial data, excluding Southside Regional Medical Center.

Figure 7.


22 Vol. 15 Number 1 2008

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, Greenfi eld, LJ. Physician Impact on the Total Cost of Care. Annals of Surgery, 231:432-435, 2000.

4. Taheri, P, Butz, D, Greenfi eld, LJ. Paying a Premium: How Patient Complexity Affects Costs and Profi t 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/fi les-misc/NFTC_CrisisReport_May04.pdf. Accessed 5/5/06.

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 multi-institutional 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.

28

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 efi cacia del uso de prótesis infl able de silicona para obliterar el espacio residual pleural en pacientes con empiema y fístula broncopleural, empiema y fístula broncopleural posneumonectomía, síndrome pos-neumonectomía, y la utilización de ésta profi lácticamente 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 pró-tesis infl ables 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 fi brotórax secundario a tuberculosis y bronquiectasias, a estos se les introdujeron prótesis de silicona profi láctica-mente. La prótesis de silicona infl able ó silastic utilizadas fueron del mismo tipo corrientemente empleadas para implante mamario. Una vez fi nalizado el procedimiento primario, se introduce en el tórax la prótesis la cual luego se insufl a con solución fi siológica hasta obliterar la cavidad pleural residual. Resultados: Los pacientes fueron seguidos por más de 36 meses y los resultados han sido satisfacto-rios, 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 profi láctica. Conclusión: Este procedimiento es una opción menos invasiva y de menor riesgo en aquellos pacientes muy deteriorados y con compromiso de sus reservas cardio-respiratorias. Su utilización profi láctica 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 pos-neumonectomía

EXPERIENTIAL WITH THE USE OF INTRAPLEURAL SILICONE INFLATABLE PROSTHESIS

Summary

Objective: to determinate the effi cacy of an infl atable intra-pleural silicone prosthesis to obliterate the residual pleural space in patients suffering from: a- Broncho pleural fi stula and empyema, b- Post-pneumonectomy empyema and broncho pleural fi stula, 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 post-pneumonectomy 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 bron-chiectasis and fi bro-thorax secondary to TBC. A silicone or sylastic infl atable prosthesis same as the ones used for breast implant, was introduced into the chest cavity and later on was infl ated or insuffl ated 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 fi stula 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 infl atable silicone prosthesis is a viable alternative in patients with residual pleural space problems specially those with empyema and bronchopleural fi stulae. 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.

Experiencia con el uso intrapleural de prótesis infl ables de silicona

29

Key words: Silicone endothracic prosthesis - emphyma – bronchopulmonar fi stula – pneumonectomy – post-pneumonectomy syndrome.

Introducción

La fístula broncopleural es una de las más importantes complicaciones de la resección pulmonar, conllevando gran morbilidad y signifi cativa mortalidad operatoria. Con el advenimiento de los antimicrobianos contra la tuberculosis y las enfermedades infecciosas broncopulmonares dis-minuyeron las indicaciones quirúrgicas de estas entidades y en consecuencia, se redujeron las complicaciones de empiema y fi stulas broncopleurales. Sin embargo esporá-dicamente aparecen pacientes con los mismos problemas que solían discutirse hace años.

Muy diversos han sido los tratamientos y procedimientos propuestos para eliminar el espacio empiemático residual: se han recomendado el drenaje torácico cerrado o abi-erto, 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 insufi ciencia respiratoria y se caracteriza por disnea progresiva, estridor e infecciones broncopulmonares repetidas.

Presentamos aquí nuestra experiencia con el uso de prótesis infl ables para obliterar el espacio residual.

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 infl able de silicona (Figura 1). En 1de corrección mediastinal posneu-monectomía por tumor carcinoide de bronquio principal derecho también se hizo cardiopexia. Tres pacientes tenían una cavidad empiemática y fístula broncopleural posneumo-nectomía: 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 fi brotórax, 1 derecho, el otro izquierdo

secundarios a bronquiectasias, en ambos se implantaron prótesis profi lácticamente después de la neumonectomía.

Figura 1. Prótesis de silicona insufl ada.

El diagnóstico se realizó por clínica, imágenes, toracocen-tésis 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 fi no No. 16 en el segundo espacio intercostal anterior, para toraco-clisis con solución antiséptica de Gerdex® (gluteraldehido) y rifocina (500mg en 500cc de solución fi siológica 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.

Figura 2. Radiografía de tórax. Se aprecia el tubo delgado (fl echas) de toracoclísis y el tubo grueso de drenaje torácico.


30 Vol. 15 Number 1 2008

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 colo-cación de la prótesis. En la superfi cie anterior de la prótesis se encuentra una válvula de seguridad que permite llenarla con solución fi siológica. 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 vál-vula 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 insufl ar más solución si hiciera falta (Figura 3).

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 mas-culino (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

años; 8 semanas; 4 semanas y 2 semanas respectivamente. En 2 casos la prótesis se instaló profi lácticamente, así como en pacientes con el síndrome posneumonectomía. El tiempo de aparición de los síntomas en el caso del síndrome pos-neumonectomía fue de 4 años. Los 2 pacientes con prótesis profi láctica, no han presentado complicaciones después de 31 y 26 meses de seguimiento.

A todos los pacientes se les practicaron estudios de imá-genes: 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 neumo-nectomía en el síndrome posmediastinal. No se presentaron complicaciones transoperatorias así como no hubo nin-guna 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 impor-tante.

Discusión

Presentamos nuestra experiencia en pacientes con empiemas y fi stulas broncopleural, síndrome posneumonectomía y su tratamiento con una prótesis infl able intratorácica. Un caso con implante de prótesis intratorácica sin neumonec-tomía por un cáncer de mamas con metástasis a pleura y pulmón con empiema y fi stula 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 infec-ción contaminante fue un factor de estimulo inmunológico

Experiencia con el uso intrapleural de prótesis infl ables de silicona

31

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 fi stula bronco-pleural con pobres reservas cardiorrespiratorias y malas condiciones generales, rellenar el espacio pleural residual con prótesis insufl ables 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 sufi cientemente 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 pro-cedimiento 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 fi n 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 fi ebre 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 infl able en el hemitórax izquierdo, pero desapareció al disminuir la presión al retirar líquido. En este lado del tórax se debe ser cuidadoso en no hiperinsufl ar 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 escle-rosantes 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 puru-lento, 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 mediasti-nales dentro del hemitórax de la neumonectomía. La bron-coscopia 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-expan-sible 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


32 Vol. 15 Number 1 2008

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 insufl able intratorácica en este estudio fue exitosa por los logros obtenidos, en con-secuencia recomendamos esta técnica en pacientes en estas mismas condiciones.

CONCLUSIONES

1. Sin ser una muestra signifi cativa, mostramos la expe-riencia de nuestro grupo en la conducta del empiema y fístula broncopleural, síndrome posneumonectomía y profi laxis de las complicaciones de la neumonectomía, mediante el uso del implante de prótesis de silicona infl able.

2. En pacientes con empiema crónico y fístula bronco pleural con pocas reservas cardiorrespiratorias y malas condiciones, rellenar el espacio pleural residual con prótesis insufl ables, es una alternativa a ser consid-erada por los neumólogos y cirujanos torácicos.

3. Es un procedimiento inocuo, una técnica sencilla, y de escasa morbilidad y nula mortalidad.

4. En enfermos con el síndrome postneumonectomía, la corrección mediastinal combinada con cardiopexia y

plombaje del espacio vacío de la neumonectomía, es una efectiva opción de tratamiento.

5. 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 fi stula. Chest 1990; 97: 1235-1238.

4. York El, Lewall Db, Hirji M, Gelfand ET, Modry DL. Endoscopy diagnosis and treatment of postoperative bron-chopleural fi stula. Chest 1990; 97: 1390-1392.

5. Nicholas JM, Dulchasvsky SA. Successful use of autologous fi brin gel in traumatic bronchopleural fi stula. J Trauma 1992; 32: 87-88.

6. Onotera RT, Unruch HW. Closure of post-pneumonectomy bronchopleural fi stula with fi brin sealant: tórax 1988; 43: 1015-1016.

7. Yaman M, Goklen AN; Besirli K, Boskurt K. Endoscopic treatment of bronchus stump fi stula with fi brin sealant fol-lowing pneumonectomy. Chest 1991; 100: 288-289.

8. Yasuda Y, Mori A, Kato H. Intratoracic fi brin glue for posop-erative pleuropulmonary fi stula. 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 pneumonec-tomy. JAMA 1979;242:2332-2324.

12. Wasserman Km Jamplis RW, Lash H, Brown HV, Clearly MG, Lafair J.Postpneumonectomy syndrome surgical cor-rection using silastic implants. Chest 1979; 75: 78-81.

13. Casanova J, Mariñan M , Rumbero JC. Corrección quirúr-gica de un síndrome postneumonectomía con compromiso vascular. Arch Bronconeumol 2002; 38: 51-54

14. Birdi I, Baghhai M, Well FC. Surgical correction of postp-neumonectomy 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.

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PENETRATING TRAUMA – SAME PROBLEMS, DIFFERENT SOLUTIONS THE CNSPeter 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 signifi cado 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 deter-minar 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 pen-etrating 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 vic-tims of PBI present very close to death. In the fi rst 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 fi rearm related TBI is indisputable. Centers for Disease Control funded surveillance programs have found that in selected states, fi rearms 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 fi rearm 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 confi dence 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 benefi t 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 sal-vageable 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 com-plexly 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


34 Vol. 15 Number 1 2008

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 battlefi eld. In the battlefi eld, resources are scarce and the facilities to save severely injured vic-tims, 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 fi nd 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 deci-sion 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 signifi -cant.

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 fulfi lling prophesies. Furthermore, many elderly PBI victims are the victims of self infl icted 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 resusci-tation 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

Penetrating trauma – same problems, different solutions the cns

35

are the most lethal and some Class III data support the assertion that perforating injuries are more lethal(7;8).

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 dis-cussion 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 labora-tory are rarely duplicated in the fi eld. For example, while caliber is a determinant of energy delivered to the brain, so is range and any given weapon can be fi red at an infi nite 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 signifi cantly 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 out-come from PBI(7). Specifi cally, 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

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).

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. Specifi cally, 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 fi nal 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


36 Vol. 15 Number 1 2008

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 unaccept-able error.

An accurate GCS must be obtained quickly upon presenta-tion and a decision on how much resuscitation is needed to obtain it is one of the fi rst tasks facing the practitioner.

Pupil Reactivity

Asymmetric, unilateral or bilaterally fi xed or dilated pupils have been associated with poor outcomes in TBI. Puppillary dilation is often associated with cerebral swelling and her-niation and so with a poor prognosis.

In PBI the same associations are felt to hold. Shaffrey found that patients who presented with bilaterally fi xed and dilated pupils had a 79% mortality, those with a unilater-ally fi xed and dilated pupil, 50% and those with bilaterally reactive pupils, 5%(14). Kaufman found a similar asso-ciation between pupillary reactivity and mortality(4). Both of these studies were Class III studies. Other studies have observed similar relationships but have failed to demon-strate signifi cance(15;16).

Immediate assessment of GCS and pupillary reactivity are the best fi rst 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 observa-tions 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 pati-ents with PBI who present with a depressed respiratory rate are in extremis. Two studies have confi rmed this observa-tion with Class III data. Both Kaufman and Jacobs have

found respiratory distress to be associated with increased mortality(7;10;18).

As the resuscitation is started, noting the patient’s respira-tory status can provide further estimates of potential sur-vivability.

Hypotension

Similarly, patients who present with hypotension are at greater risk for a poorer outcome. Kaufman demonstrated this to statistical signifi cance in a Class III study(10). Another study by Kaufman and one by Byrnes also demonstrated this association, though not to statistical signifi cance(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 confi rmed this observation in a retrospective mul-tivariate 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 resusci-tation 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 accu-rate reassessment of GCS and pupillary function can occur.


37

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

History

Computed tomography plays a crucial role in the man-agement of PBI. CT scanning of PBI was widely used for the fi rst 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 scan-ning was routinely available to the victims of PBI from this confl ict(12;20). The doctrines developed from this and other experiences have had a large impact on the manage-ment 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 pen-etrating 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 observa-tion can be refi ned. One CT observation, which in mul-tiple 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 involve-ment. 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 involve-ment 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-

tion by the tract has been shown to have a strong associa-tion 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.

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 signifi -cance in PBI that it does in non-penetrating injury. Aldrich’s analysis of the Trauma Coma Data Bank specifi cally looked at PBI and found increased mortality with basal cistern effacement but not with midline shift (11). Kaufman also failed to fi nd 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 in-tracranial hematoma and outcome (14). Mancuso failed to fi nd such a relationship in PBI, reinforcing the idea that in PBI many other factors may impact on the patient’s surviv-ability (27).


38 Vol. 15 Number 1 2008

As noted above, injury to the ventricles is a poor prognostic indicator and ventricular hematomas also carry a poor prog-nosis (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 signifi cant 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 manage-ment of the patient, a decision must be made about opera-tive 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 confl icts has revealed signifi cant morbidity from the practice of extensive searches for bullet and bone fragments in the brain(29-31). In addition, there is evi-dence 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 poten-tial 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

need to be included in the fi eld 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 fl aps are used where possible but are often modifi ed to accommodate the complex scalp lacerations and skull fractures that accompany PBI.

Control of Bleeding

Standard trauma hemorrhage control can be more diffi cult in PBI because of venous sinus disruption. Sinus disrup-tion 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 identifi ed, 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 identifi ed on CT prior to surgery. At surgery the sinuses should be cranialized and packed. All CSF leaks should be closed.


39

Wound Debridement

The entrance and exit wounds should be identifi ed. 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 dis-section 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 prac-tice is now felt to be excessive and the practice is discour-aged.

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.

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 aneu-rysms. 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 angiog-raphy. Angiography is the best way to detect post traumatic aneurysms. Such aneurysms can develop as late as two

weeks after the injury and an early negative cerebral angio-gram 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 fi rst 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 avail-able 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%.

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 approxi-mate 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.


40 Vol. 15 Number 1 2008

Antiseizure Prophylaxis for Penetrating Brain Injury

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 pen-etrating TBI(40-42). In addition, early seizures in the TBI literature are defi ned as seizures in the fi rst 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).

Current guidelines for antiepileptic therapy after TBI distin-guish 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 fi rst week after injury. They do not appear to be effective in reducing the incidence of posttraumatic epi-lepsy, that is, maintenance of TBI victims on prophylactic doses of anticonvulsant medications beyond the fi rst 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 con-tradictory. Salazar in his analysis of the Vietnam Head Injury Study Data, found a signifi cant relationship between retained metal and PTE(33). Aarbi, however, in a retrospec-tive univariate analysis of predictors of PTE in 489 victims in the Iran-Iraq war failed to identify retained metal frag-ments 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 fi rst seizure until 5 or more years after the injury, 80% will have their fi rst 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,

50% of patients who do develop PTE will stop having seizures(38).

SUMMARY

In World War II the principles of management for pen-etrating 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 accom-plish 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 diffi cult of trauma victims.

REFERENCES

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6. Kaufman HH, Schwab K, Salazar AM. A national survey of neurosurgical care for penetrating head injury. Surg Neurol 1991; 36(5):370-377.

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41

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11. Aldrich EF, Eisenberg HM, Saydjari C, Foulkes MA, Jane JA, Marshall LF et al. Predictors of mortality in severely head-injured patients with civilian gunshot wounds: a report from the NIH Traumatic Coma Data Bank. Surgical Neurology 1992; 38(6):418-423.

12. Brandvold B, Levi L, Feinsod M, George ED. Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese confl ict, 1982-1985. Analysis of a less aggres-sive surgical approach. [Review] [23 refs]. Journal of Neurosurgery 1990; 72(1):15-21.

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14. Shaffrey ME, Polin RS, Phillips CD, Germanson T, Shaffrey CI, Jane JA. Classifi cation of civilian craniocerebral gunshot wounds: a multivariate analysis predictive of mortality. J Neurotrauma 1992; 9 Suppl 1:S279-S285.

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18. Jacobs DG, Brandt CP, Piotrowski JJ, McHenry CR. Transcranial gunshot wounds: cost and consequences. Am Surg 1995; 61(8):647-653.

19. Levy ML, Masri LS, Lavine S, Apuzzo ML. Outcome pre-diction after penetrating craniocerebral injury in a civilian population: aggressive surgical management in patients with admission Glasgow Coma Scale scores of 3, 4, or 5. Neurosurg 1994; 35(1):77-84.

20. Levi L, Borovich B, Guilburd JN, Grushkiewicz I, Lemberger A, Linn S et al. Wartime neurosurgical experience in Lebanon, 1982-85. I: Penetrating craniocerebral injuries. Isr J Med Sci 1990; 26(10):548-554.

21. Cavaliere R, Cavenago L, Siccardi D, Viale GL. Gunshot wounds of the brain in civilians. Acta Neurochir (Wien ) 1988; 94(3-4):133-136.

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27. Mancuso P, Chiaramonte I, Passanisi M, Guarnera F, Augello G, Tropea R. Craniocerebral gunshot wounds in civilians. Report on 40 cases. J Neurosurg Sci 1988; 32(4):189-194.

28. Levy ML, Masri LS, Levy KM, Johnson FL, Martin-Thomson E, Couldwell WT et al. Penetrating craniocerebral injury resultant from gunshot wounds: gang-related injury in children and adolescents. [Review] [2 refs]. Neurosurg 1993; 33(6):1018-1024.

29. Hammon WM. Analysis of 2187 consecutive penetrating wounds of the brain from Vietnam. J Neurosurg 1971; 34(2 Pt 1):127-131.

30. Chaudhri KA, Choudhury AR, al Moutaery KR, Cybulski GR. Penetrating craniocerebral shrapnel injuries during “Operation Desert Storm”: early results of a conservative surgical treatment. Acta Neurochir (Wien ) 1994; 126(2-4):120-123.

31. Carey ME, Young HF, Rish BL, Mathis JL. Follow-up study of 103 American soldiers who sustained a brain wound in Vietnam. J Neurosurg 1974; 41(5):542-549.

32. Gonul E, Baysefer A, Kahraman S, Ciklatekerlioglu O, Gezen F, Yayla O et al. Causes of infections and management results in penetrating craniocerebral injuries. Neurosurg Rev 1997; 20(3):177-181.

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34. Aarabi B. Traumatic aneurysms of brain due to high velocity missile head wounds. Neurosurgery 1988; 22(6 Pt 1):1056-1063.

35. Aarabi B. Management of traumatic aneurysms caused by high-velocity missile head wounds. [Review] [263 refs]. Neurosurgery Clinics of North America 1995; 6(4):775-797.

36. Meirowsky AM, Caveness WF, Dillon JD, Rish BL, Mohr JP, Kistler JP et al. Cerebrospinal fl uid fi stulas complicating missile wounds of the brain. J Neurosurg 1981; 54(1):44-48.

37. Antibiotic prophylaxis for penetrating brain injury. [Review] [40 refs]. J Trauma 2001; 51(2 Suppl):S34-S40.

38. Salazar AM, Jabbari B, Vance SC, Grafman J, Amin D, Dillon JD. Epilepsy after penetrating head injury. I. Clinical corre-


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lates: a report of the Vietnam Head Injury Study. Neurology 1985; 35(10):1406-1414.

39. Caveness WF, Meirowsky AM, Rish BL, Mohr JP, Kistler JP, Dillon JD et al. The nature of posttraumatic epilepsy. J Neurosurg 1979; 50(5):545-553.

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41. Annegers JF, Hauser WA, Coan SP, Rocca WA. A population-based study of seizures after traumatic brain injuries. New England Journal of Medicine 1998; 338(1):20-24.

42. Temkin NR, Dikmen SS, Wilensky AJ, Keihm J, Chabal S, Winn HR. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures.[see comment]. New England Journal of Medicine 1990; 323(8):497-502.

43. Bullock R, Chesnut RM, Clifton G, Ghajar J, Marion DW, Narayan RK et al. Guidelines for the management of severe head injury. Brain Trauma Foundation. [Review] [46 refs]. European Journal of Emergency Medicine 1996; 3(2):109-127.

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43

MORTALIDAD EVITABLE Y LA ATENCIÓN PREVIA HOSPITALARIA DEL TRAUMA EN EL MUNICIPIO DE MEDELLÍN, COLOMBIA 2.005Marta 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 defi nido 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 aten-ción 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 signifi ca-tivo de pacientes con trauma que no fueron atendidos en el nivel de atención apropiado y un número signifi cativo 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 hos-pitalario 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 defi ned 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 sig-nifi cant number of trauma patients were not treated at the appropriate health care service level and another signifi cant 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 cuantifi cación global (1) y en tér-minos 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


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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 insti-tuciones 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.

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 defi nitiva 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 defi cientes los mecanismos de articulación entre los servicios de urgencias y no existen verdaderas redes de servicios de urgencia en trauma sufi cientemente organizados, a pesar de la alta inci-dencia de estos eventos.

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 cuantifi car 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 científi cas 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 evi-table 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.

MATERIALES Y MÉTODOS

Se realizó un estudio descriptivo retrospectivo del total de muertes por trauma (1.666) evaluadas por necropsia inde-pendiente de la ocurrencia del evento en el Municipio de Medellín en el año 2.005.

La información se registró en un formulario “encuesta de muertes evitables”. Este formulario incluyo variables rela-cionadas 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 fi nal. Para la codifi cación de los diagnósticos se utilizó la novena clasifi cación 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 diagnós-ticos por trauma tanto el principal, los segundos, terceros y cuartos diagnósticos de defunción por esta causa.

Las fuentes de información fueron los reportes y las actas de levantamiento de necropsia. Para el análisis de las necrop-sias y codifi cación del AIS se contó con profesionales del área de la salud en medicina y enfermería. Estos profesion-ales fueron previamente capacitados y estandarizados en la evaluación y codifi cación 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 consider-aron muertes evitables (con lesiones menores o moderadas) aquellas con un ISS de 1-24; muertes potencialmente evita-bles 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 prob-able (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 estadís-tico 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.

Mortalidad evitable y la atención previa hospitalaria del trauma en el Municipio de Medellín, Colombia 2.005

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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

Las muertes fueron principalmente potencialmente evi-tables 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

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).

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

Figura 2. Mortalidad por trauma según Injury Severity Score (ISS). Municipio de Medellín 2.005. Fuente: Reportes de necrop-sias. Instituto Nacional de Medicina Legal y Ciencias Forenses Regional Noroccidente. Municipio de Medellín, 2.005


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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.

MecanismoIntervalos clasifi cación ISS

Total1-24 25-49 ≥50Número % Número % Número % Número %

Arma de fuego 36 19,5 454 40,1 164 47,1 654 39,3Arma blanca 48 25,9 123 10,9 30 8,6 201 12,1Caída 17 9,2 128 11,3 17 4,9 162 9,7Arma contundente 5 2,7 35 3,1 4 1,1 44 2,6Quemadura 1 0,5 5 0,4 7 2,0 13 0,8Tóxico 0 0,0 6 0,5 0 0,0 6 0,4Otro 56 30,3 58 5,1 15 4,3 129 7,7Sin dato 22 11,9 324 28,6 111 31,9 457 27,4Total 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

Tabla 1. Injury Severity Score (ISS) y mecanismo de la muerte. Municipio de Medellín, 2.005

Injury Severity Score (ISS) y la atención hospitalaria

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

Chi-cuadrado de Pearson 0,0000


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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)

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

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.

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


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El total de personas que murieron como consecuencia de un trauma y que presentaron hasta tres atenciones hospi-talarias 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.

Injury Severity Score (ISS) y la no atención hospitalaria

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.

Nivel Intervalos clasifi cación ISSTotal1 - 24 25 - 49 ≥50

Número % Número % Número % Número % Nivel 1 0 0,0 0 0,0 0 0,0, 0 0,0Nivel 2 0 0,0 0 0,0 0 0,0 0 0,0Nivel 3 1 100 7 100 1 100 9 100Total 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

Tabla 2. Tercera atención hospitalaria de los pacientes con trauma según Injury severity Score (ISS) y nivel de atención. Municipio de Medellín, 2.005

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

La no atención hospitalaria prevaleció en las personas que presentaron lesiones por homicidio 70,0%. Las personas con lesiones mayores con una muerte potencialmente evi-table (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 hospita-laria. 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

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 fi nal 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


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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 con-secuencia 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 inves-tigada, certifi cada y reportada por un médico forense.

Manera o causa

Intervalo de clasifi cación del ISS

Total1 - 24 25 - 49 ≥50

Número % Número % Número % Número %Homicidio 61 55,4 412 73,0 166 69,7 639 70,0Accidente de Transito 1 0,9 70 12,4 51 21,4 122 13,3Suicidio 20 18,1 33 5,8 10 4,2 63 6,9Otra causa accidental 21 19,0 33 5,8 8 3,3 62 6,8Indeterminada 7 6,3 12 2,1 2 0,8 21 2,3Violencia sin manera 0 0,0 4 0,7 1 0,4 5 0,5Total 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

Tabla 3. Manera de la muerte según Injury severity Score (ISS) y la no atención hospitalaria. 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 indi-viduo, en la familia y en la sociedad (15).

La calidad asistencial esta basada en los conocimientos cientí-fi cos 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 cuantifi cación 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 ser-vicios de urgencias por niveles de complejidad, los niveles 1 son los considerados de baja complejidad donde se real-izan 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 mod-eradas 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 con-trarreferencia de otros niveles. En este nivel se atienden


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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 recibi-eron 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 may-ores 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 equi-padas 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 clasifi cación 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 aten-didas oportunamente en el nivel adecuado.

Sampalis ha comparado el resultado de los pacientes sev-eramente 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

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 dismi-nución 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 signifi cativas (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 evi-tables, incrementaron su riesgo de morir al no ser trans-portados directamente desde sitio donde ocurrió el evento hacia un nivel de complejidad mayor para su atención. Este riesgo también puedo incrementarse en aquellos que tuvi-eron transferencia o remisión hospitalaria.

En nuestro estudio también se pudo evidenciar que pacientes con lesiones leves (62,50%) con muertes evitables muri-eron 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 asocia-ción 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 cardiovas-cular 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 incremen-taran 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 infl uenciado 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 signifi cativo 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


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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 hospi-talaria 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 clasifi -cación 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 clasifi cación 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 defi nitivo (21).

Se ha demostrado que luego del establecimiento de los centros regionalizados del trauma, la mortalidad por esta causa se reduce signifi cativamente. 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 (anest-esiólogos, médicos de urgencias y enfermeras), la alta tec-nología 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 urgen-cias 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 científi cos actuales teniendo en cuenta los recursos disponibles. El análisis de la mor-talidad es uno de los parámetros de calidad asistencial mas utilizados. La cuantifi cación de las defunciones hos-pitalarias, 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 pre-hospitalario 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 fi nanciado 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 codifi cación 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, Colorado S y González G. Factores de riesgo de infección intervenibles en el cuidado médico y de enfermería de pacientes con trauma en un hospital de tercer nivel de aten-ción, Medellín, Colombia, 1.999. Investigación y educación en enfermería. Universidad de Antioquia 2.000; 15(2): 289-307

2. Alcaldía de Medellín. Secretaria de Salud. Situación de Salud en Medellín, Indicadores Básicos 2.005. Medellín; 2.006. p. 45 -55

3. Sampalis JS, Lavoie A, Williams JI, Mulder DS, Kalina M. Impact of on-site care, pre-hospital time and level of in-hospital care on survival in severely injured patients. Journal of Trauma 1.993; 34(2):252-261.

4. Rendón F, Bejarano M. Remisiones en el Valle del Cauca. Análisis y pautas para orientar la red de servicios, 2.003 – 2.004. Revista Colombia Médica 2005; 36: 23-28


52 Vol. 15 Number 1 2008

5. West T, Frederick P, Cummings P, Gregory J, Ronald V. Harborview Assessment for risk o mortality: An improved measure of injury severity on the basis of ICD – 9 – CM. J trauma 2.000; 49:530 – 41.

6. Mackenzie E. Injury severity scales: Overview and directions for future research. American Journal of Emergency Medicine 1984; 2 (6): 537 – 47

7. Agúndez J, Cardona F. Comparación de ISS (Escala de Severidad de Lesiones) con resultado fi nal del tratamiento. Cirujano General 2.000; 22:9-17

8. Champion H, Sacco W. Advances in trauma. EN: Champion H, Sacco W. Trauma severity scales. Chicago: year book medical publishes Inc; 1.989; 11. p. 1 – 18

9. Sampalis JS. Measuring injury severity. Montreal: McGill University Health services research department of epidemi-ology and biostatistics; 1.988. p. 1-19

10. Mackenzie Ellen. Injurity severity scales: Overview and directions for future research. American Journal of Emergency Medicine. 1.984; 4 (5):4

11. Secretaría Distrital de Salud – Organización Panamericana de la Salud/ Organización Mundial de la Salud. Manual de Normas Técnico-Administrativas para la Prestación de Servicios de Urgencias en el Sistema Distrital de Salud. Santa fe de Bogotá: OPS; 1.994.

12. Crespo, S. Análisis comparativo del certifi cado médico de defunción en los periodos de 1.989 – 1.992 y 1.996 – 1.997 EN: Sabadell. Interpretación según legislación vigente [Tesis doctoral]. Barcelona: Departamento de psiquiatría y medicina forense. Universidad Autónoma de Barcelona; 2.002. p 1- 199 (en línea) [consultado 2.007 marzo 12] Disponible en: http://www.tdx.cesca.es/TESIS_UAB/AVAILABLE/TDX-1026105-120916//sca1de1.pdf

13. Miniño A, Anderson R, Fingerthut L, Broudreaut M and Wamer M. Deaths: injuries, 2002. National Vital Statistics Reports 2006; 54(10):1-30

14. Departamento de Investigaciones Criminológicas y Apoyo Judicial DECIPOL. Muertes violentas por homicidios. Comparativo 1.997 – 1.996. Medellín: Alcaldía de Medellín - Secretaria de Gobierno; 1.997. p. 1-40

15. Londoño J, Grisales H, Fernández S, Agudelo B y Sánchez J. Años potenciales de vida perdidos en la población de Medellín 1.984 – 1.986. Medellín: Universidad de Antioquia - Facultad Nacional de Salud Pública; 1.999. p. 1 – 28

16. Dubois R, Moxley J, Draper D, Brook R. Hospital inpa-tient mortality. Is it a predictor of quality? N Eng J Med. 1.987;317:1674-80.

17. Romaguera A, Moleiro A, De casro X, Belloso N, Taouragt E, Carrera R y Sierra C. Análisis de la mortalidad como her-ramienta de mejora de la calidad asistencial en un servicio de cirugía general. Cirugía Española 2.006; 80 (2):78-82 (en línea) [consultado 2.007 marzo 12]. Disponible en: http://db.doyma.es/cgi-bin/wdbcgi.exe/doyma/mrevista.fulltext?pident=13091091

18 Zimmer – Gembeck M, Southard P, Hedges J, Mullins R, Rowland D, Stone JV, Trunkey DD. Triage in an established trauma system. J Trauma 1.995; 39: 922-28

19. Colombia. El consejo de Santa Fe de Bogotá, D.C. Acuerdo 16 de 1.991. Por el cual se establece el Sistema Distrital de Atención en Urgencias. Bogotá: El Consejo; 1.991

20. Sampalis JS, Denis R, Frechette P, Fleiszer D, Brown R, Mulder D. Direct transport to tertiary trauma centre vs transfer from lower level facility: impact on mortality among trauma victims. Journal of Trauma 1.997; 43(2):288-296

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 hospitali-zados por causa traumática en el Hospital Universitario San Vicente de Paúl, Medellín, 1999. Revista Epidemiológica de Antioquia 2.000; 25 (4): 43-55

22. Sampalis JS. Lavoive A, Boukas S, Tamiz H, Nikolis A, Frechette P et al. Trauma Center Designation: Initial impact on trauma – related mortality. J Trauma 1.995; 39:232-38

23. Zamudio A, Castro I. Efecto de la red de urgencias sobre el tiempo de atención del paciente traumatizado en el Hospital Universitario del Valle Cali, Colombia. Revista Colombia Médica 1.994; 25:23-5

53

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 clasifi cación precisa de la frac-tura 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 fi jación externa.

Palabras claves: Fractura pélvica, sábana circunferencial pélvica anti-choque, clamp pélvico, fi jador 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 fl uid volume resuscitation.1,2 In the event of hemodynamic compromise, a circumferen-tial sheet or a pelvic sling may be applied to the pelvis to aid in resuscitation.3-5 Once adequate hemodynamic sta-bility 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 interven-tions. When the patient is suffi ciently 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 fi ne cuts (1-2 mm) through the bony pelvis.

Classifi cation

Pelvic fractures have been classifi ed by several authors.6-8 Tile classifi ed pelvic fractures into three major groups (fi gure 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 sacro-iliac or posterior sacrotuberous and sacrospinous ligaments. These posterior pelvic ligaments confer vertical stability to the pelvis despite the arch disruption. This group of frac-tures 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 UNSTABLE; VERTICALLY STABLE

INCOMPLETE POSTERIOR ARCH DISCRUPTION; MOST POSTERIOR LIGAMENTS INTACT

C

UNSTABLE;ROTATIONAL AND VERTICALLY UNSTABLE

POSTERIOR ARCH DISRUPTED; POSTERIOR LIGAMENTS TORN

Figure 1.


54 Vol. 15 Number 1 2008

There is complete disruption of the posterior pelvic arch including the aforementioned important posterior pelvic ligaments. Again this group is sub-classifi ed based upon the precise location of the fracture and whether the fracture is unilateral or bilateral.

Young and Burgess classifi ed 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 sub-divided 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 classifi cation system used, the orthopaedic surgeon should interpret the initial AP pelvis radiograph to defi ne 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 frac-ture). 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 sig-nifi cant 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. Intra-peritoneal hemorrhage may be evaluated via CAT scan or deep peritoneal lavage. Retroperitoneal hemorrhage commonly occurs with specifi c 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 interven-tion, 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 laparo-tomy 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 pro-

vided evidence that external fi xation can improve outcomes in patients who sustain fractures which result in increased pelvic volume.12-14 Cook et al. preferred the use of angiog-raphy in patients who were hemodynamically refractory to skeletal stabilization and laparotomy. This decision should be the result of a discussion between the orthopaedic sur-geon 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 mechan-ical pelvic stabilization can be achieved.

SKELETAL STABILIZATION

When considering stabilization of the pelvis, it is necessary to fi rst 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 fi rst 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 fi eld and were associated with multiple complications including skin necrosis and compart-ment syndrome.15

Although commercially available pelvic slings are manu-factured, there is no evidence to suggest that they are more effi cacious than a standard circumferential sheet.

Pelvic clamps have been designed for the emergent stabili-zation of pelvic ring disruptions.16 These devices have been shown to be as effective as external fi xators in restoring pelvic volume and reducing pubic diastasis but may be more prone to cause signifi cant complications.17 The theoretical advantage of these clamps is that they could be applied posteriorly to recreate normal sacroiliac relation-ships. Unfortunately, a posteriorly placed clamp in addi-tion to anterior stabilization equipment makes the practical care of a poly-traumatized patient diffi cult to say the least. In reality, posterior pelvic stability is typically restored via internal fi xation. 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 fi xation of posterior pelvic injuries. Percutaneous pos-terior pelvic fi xation has been shown to be effi cacious18 but

The Role of External Fixation in the Initial Management of Pelvic Fractures

55

also technically demanding.19 Suffi cient vertical stability is not conferred by the application of external fi xation 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 fi xation is indicated in lesions which increase pelvic volume.20,21 Specifi cally, 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 fi xation. Consideration must be given in regards to the posterior aspect of the pelvis as anterior symphyseal compression may in fact widen posterior pelvic displace-ment (fi gure 2). Dickson et al found a 67% rate of skeletal deformity after external fi xation of the pelvis.30 Grimm et al. showed that application of an external fi xator fails to have a signifi cant effect on retroperitoneal pressures until large volumes of fl uid have been lost.22 In a cadav-eric model they showed that external fi xation did little to provide pressure induced tamponade of arterial bleeding. However an external fi xator may stabilize clot formation within the pelvis, oppose fractured bleeding bony surfaces, and facilitate patient transfer and mobilization.

Figure 2. An example of a patient who suffered a concomitant genitourinary injury. Here the suprapubic catheter precludes anterior pelvic fi xation.

Multiple frame constructs have been considered for providing adequate stabilization in a timely fashion.23-25 External fi xation is primarily used as provisional fi xation but may be a defi nitive treatment in certain circumstances. Large anterior abdominal wounds, open pelvic fractures, concomitant genitourinary injuries or critical hemodynamic

instability may preclude the use of internal fi xation even in a delayed fashion. Nonetheless, external fi xation has been shown to be biomechanically inferior to internal fi xation.26 The literature varies widely in regards to the safety of pelvic external fi xation. Tucker et al. reported 94% of pins were accurately contained between the iliac cortical tables when placed under fl uoroscopic guidance.25 Others have reported signifi cantly higher rates of complications with the use of pelvic fi xators.27 Hupel et al. showed that obese patients were less likely to be successfully treated with use of an external fi xator.28

Complications

The treatment of pelvic fractures is fraught with com-plications. 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 prophy-laxis, 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 genitouri-nary injury may preclude the application of pelvic internal fi xation (fi gure 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 fi xation occurs not infrequently during the treatment of pelvic fractures. This is likely a result of the large physiological forces expe-rienced across the pelvis in combination with the limited bone stock available for achieving fi xation. By utilizing conservative weight bearing status during early patient mobilization, this complication can be limited.

Figure 3. Application of an external fi xator to this pelvic ring dis-ruption resulted in widening of the posterior injury on the left.


56 Vol. 15 Number 1 2008

SUMMARY

The assessment of a patient with a pelvic ring disruption begins with evaluation via ATLS protocol. Appropriate orthopaedic evaluation is then undertaken including pre-cise classifi cation 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 sta-bilization in unstable pelvic fractures can be accomplished in several manners. Circumferential sheets, pelvic clamps, and external fi xation all may be utilized in the initial treat-ment of these devastating injuries.

Key Words: pelvic fracture, shock, circumferential pelvic anti-shock sheeting, pelvic clamp, external fi xator, trauma, pelvic ring instability

REFERENCES

1. Starr AJ, Griffi n DR, Reinert CM, et al. Pelvic ring disrup-tions: prediction of associated injuries, transfusion require-ment, 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: classifi cation by mechanism is key to pat-tern of organ injury, resuscitative requirements, and outcome. J Trauma 1989;29(7):981-1000.

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.

5. Ramzy AI, Murphy D, Long W. Initial management of unstable fractures. J Emerg Med Serv 2003;28(5):68-78.

6. Tile M. Fractures of the Pelvis and Acetabulum. Baltimore: Williams & Wilkins, 1984.

7. Orthopaedic Trauma Association. Fracture and dislocation compendium. J Orthop Trauma 1996;10(suppl 1):68-70.

8. Burgess AR, Eastridge BJ, Young JWR, et al. Pelvic ring disruptions: Effective classifi cation system and treatment protocols. J Trauma 1990;30:848-856.

9. Weis EB. Subtle neurological injuries in pelvic fractures. J Trauma 1984;24:983-985.

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

the management of hemorrhage from major fractures of the pelvis. J Bone Joint Surg Br 2002;84(2):178-182.

12. Riemer BL, Butterfi eld SL, Diamond DL, et al. Acute mor-tality associated with injuries to the pelvic ring: the role of early patient mobilization and external fi xation. J Trauma 1993;35(5):671-677.

13. Routt ML, Simonian PT, Ballmer F. A rational approach to pelvic trauma: resuscitation and early defi nitive stabilization. Clin Orthop 1995;318:61-74.

14. Klein SR, Saroyan RM, Goldstein JA, et al. Emergent treat-ment of pelvic fractures: comparison of methods for stabili-zation. 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 fi xation: early complications of the percutaneous technique. J Orthop Trauma 1997;11(8):584-589.

20. Poka A, Libby EP. Indications and techniques for external fi xation of the pelvis. Clin Orthop 1996;329:54-59.

21. Tile M. Acute pelvic fractures: II. Principles of management. J Am Acad Orthop Surg 1996;4:152-161.

22. Grimm MR, Vrahas MS, Thomas KA. Pressure-volume char-acteristics of the intact and disrupted pelvic retroperitoneum. J Trauma 1998;44(3):454-459.

23. Mears DC, Fu FH. Modern concepts of external skeletal fi xa-tion of the pelvis. Clin Orthop 1980;151:65-72.

24. Slatis P, Karaharju EO. External fi xation of the pelvic girdle with a trapezoid compression frame. Injury 1975;7:53-56.

25. Tucker MC, Nork SE, Simonian PT, et al. Simple anterior pelvic external fi xator. J Trauma 2000;49(6):989-994.

26. Vrahas MS, Wilson SC, Cummings PD, et al. Comparison of fi xation methods for preventing pelvic ring expansion. Orthopedics 1998;21(3):285-289.

27. Palmer S, Fairbank AC, Bircher M. Surgical complications and implications of external fi xation of pelvic fractures. Injury 1997;28(9):649-653.

28. Hupel TM, McKee MD, Waddell JP, et al. Primary external fi xation of rotationally unstable pelvic fractures in obese patients. J Trauma 1998;45(1):111-115.

The Role of External Fixation in the Initial Management of Pelvic Fractures

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29. Huittinen VM, Slatis P. Fractures of the pelvis, trauma mecha-nism, types of injury, and principles of treatment. Acta Chir Scand 1972;138:563-569.

30. Dickson K, Matta J. Skeletal deformity following external fi xation of the pelvis. AAOS Annual Meeting– Scientifi c Program, 1998.

58

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 hemor-rhage1. While the mortality rate is less than 5% for hemo-dynamically 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 fi xation 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 diffi cult to fi nd and control, and internal iliac artery proximal ligation will not be effective due to the rich supply of pelvic collaterals. Pelvic packing after external fi xation 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 fi rst 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 signifi cant ligamentous injury. These fractures tend to decrease the volume of the pelvis and only require angiography in 1% of cases4. Anteroposterior, and

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 angiog-raphy in up to 20% of cases4.Overall, between 5 and 15% of patients with pelvic fractures will require angiographic intervention5-9.

TRIAGE

Despite fracture classifi cation, 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 pres-sure 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 prob-lems11. External fi xation 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 sen-sitivity and specifi city are 90% and 98%, respectively. This will likely improve with the advent and increasing avail-ability 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

Assistant Professor, Vascular & Interventional Radiology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia

Unstable pelvis- role of the interventionalist malcolm k. sydnor MD

59

often undergo external fi xation and then proceed to angiog-raphy. 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 sce-nario, 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 explor-atory 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.

PELVIC ARTERIOGRAPHY

As the patient is transferred to the IR suite, the Interventional Radiologist should review all of the imaging fi ndings 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 trans-ferred to the angiography table; sometimes pelvic external fi xation can be performed at this point under fl uoroscopy. 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 athero-sclerotic 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

to allow for security of the vascular access and rapid cath-eter 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 fi lming 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 signifi cant 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 fi lming 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).

Figure 1. 17 year old unstable female status post MVA. Digital Subtraction Angiogram (DSA) demonstrates diffuse vasocon-striction 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, infe-rior gluteal, lateral sacral, iliolumbar, external iliac, deep circumfl ex 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-


60 Vol. 15 Number 1 2008

eurysm, or arteriovenous fi stula which may be identifi ed angiographically as active extravasation of contrast or staining, vascular irregularity, abrupt vessel cutoff, or early venous fi lling. Abrupt vessel cutoff is often diffi cult to distinguish from spasm. This can be treated with empiric embolization or close observation, depending on the hemo-dynamic status of the patient.

PELVIC ARTERIAL EMBOLIZATION

The interventional radiologist should be constantly aware of the hemodynamic status of the patient. If there are mul-tiple 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 2. 42 year old unstable male status post MVA. DSA dem-onstrate active midline perineal extravasation of contrast before (A, B) and after (C, D) bilateral internal pudendal Gelfoam embo-lization.

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 cut-ting into small pledgets, soaking in contrast, and injecting through a 1cc syringe. For larger vacular injuries or AV fi s-tulas, platinum or stainless steal coils can be deployed with

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 superfi cial femoral artery (Figure 4A-B).

Complications include those that are access site related as well as non-target embolization and tissue necrosis. Inadvertent refl ux of Gelfoam into the profunda femoris artery or other muscular branches will most likely be clinically silent. However, signifi cant Gelfoam emboliza-tion down the leg is likely to cause an ischemic limb. This complication can often be treated in the angiography suite with suction embolectomy.

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 4. The same patient as Figure 3 had early fi lling of the left femoral vein secondary to an arteriovenous fi stula (A) which was successfully excluded with a covered stent in the proximal Superfi cial Femoral artery(B).

Unstable pelvis- role of the interventionalist malcolm k. sydnor MD

61

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 bilat-eral 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 fl ush arteriogram from the distal abdominal aorta should be performed to ensure adequate treatment and to evaluate for other injuries or collateral fi lling 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 fl ow 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 circumfl ex, 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 fi ve 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 fi xation 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 embo-lization. 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 concom-itant 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.

REFERENCES

1. Mucha P Jr, Welch TJ. Hemorrhage in major pelvic fractures. Surg Clin North Am 1988; 68(4):757-773.

2. Naam NH, Brown WH, Hurd R, Burdge RE, Kaminski DL. Major pelvic fractures. Arch Surg 1983; 118(5):610-616.

3. Margolies MN, Ring EJ, Waltman AC, et al. Arteriography in the management of hemorrhage from pelvic fractures. N Engl J Med. 1972; 287(7):317-321.

4. Kaufman JA. Abdominal Aorta and Iliac Arteries. In: The Requisites: Vascular and Interventional Radiology. Philadelphia: Mosby, 2004:246-285.

5. Agnew SG. Hemodynamically unstable pelvic fractures. Orthop Clin North Am 1994;25(4):715-721.

6. Kaufman JA, Waltman AC. Angiographic Management of Hemorrhage in Pelvic Fractures. In: Abrams’ Angiography Interventional Radiology. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2005:1004-1018.

7. Ben-Menachem Y, Coldwell DM, Young JWR, et al. Hemorrhage associated with pelvic fractures: causes, diag-nosis, and emergent management. AJR Am J Roentgenol 1991;157(5):1005-1014

8. Cryer HM, Miller FB, Evers BM, et al. Pelvic fracture clas-sifi cation: correlation with hemorrhage. J Trauma 1988; 28(7):973-80.

9. Burgess AR, Eastridge BJ, Young JWR, et al. Pelvic ring disruptions: effective classifi cation system and treatment protocols. J Trauma 1990; 30(7):848-856.


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10. Sarin EL, Moore JB, Moore EE, ShannonMR, Ray CE, Morgan SJ, Smith WR. Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma 2005; 58(5):973-7.

11. Stern SA, Wang X, Mertz M, et al. Under-resuscitation of near lethal uncontrolled hemorrhage: effects on mortality and end-organ function at 72 hours. Shock. 2001; 15(1):16-23.

12. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002; 195(1):1-10.

13. Pereira SJ, O’Brien DP, Luchette FA, et al. Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture. Surgery 2000; 128(4):678-685.

14. Stephen DJ, Kreder HJ, Day AC, et al. Early detection of arterial bleeding in acute pelvic trauma. J Trauma 1999; 47(4):638-642.

15. Panetta T, Sclafani SJ, Goldstein AS, et al. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 1985; 25(11):1021-1029.

16. Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S. The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showing transient response to fl uid resuscitation. J Trauma 2004; 57(2):271-6.

17. Velmahos GC, Chahwan S, Hanks SE, Marray JA, Berne TV, Asensio J, Demetriades D. Angiographic embolization of bilateral internal iliac arteries to control life-threatening hemorrhage after blunt trauma to the pelvis. Am Surg 2000; 66(9)858-62.

18. Suzuki T, Shindo M, Kaaoka Y, Kobayashi I, Nishimaki H, Yamamoto S, Uchino M, Takahira N, Yokoyama K, Soma K. Clinical characteristics of pelvic fracture patients with gluteal necrosis resulting from transcatheter arterial embolization. Arch Orthop Trauma Surg. 2005; 125(7):448-52.

19. Agolini S, Shah K, Jaffe J, et al. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 1997;43(3):395-399

20. Wong YC, Wang LJ, ng CJ, Tseng IC, See LC. Mortality after successful transcatheter arterial embolization in patients with unstable pelvic fractures: rate of blood transfusion as a pre-dictive factor. J Trauma. 2000; 49(1)71-5.

21. Velmahos GC, Toutouzas KG, Vassiliu P, Sarkisyan G, Chan LS, Hanks SH, Berne TV, Demetriades D. J Trauma 2002; 53(2):303-8.

22. Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D. Early embolization and vasopressor administration for man-agement of life-threatening hemorrhage from pelvic fracture. J Trauma 2005; 58(5):978-84.

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NEUROTRAUMA Y NEUROINTENSIVISMOAUTORES:Andrés RubianoRafael PerezEdición: 2008

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