Management of retained hemothoraces after chest tube thoracostomy for trauma

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Preoperative progressive pneumoperitoneum for a giant incisional hernia: report of a case with a rare complication

Em pacientes com hérnias incisionais gigantes, a correção da hérnia se torna um desafio devido às diversas alterações anatômicas e fisiológicas. O risco de desenvolvimento de complicações como a síndrome de compartimento abdominal após a hernioplastia levou à busca por opções técnicas. Uma alternativa viável para evitar essas complicações é induzir pneumoperitônio progressivo pré-operatório (PPP) visando adaptar o organismo ao aumento do conteúdo abdominal. É relatado caso de um paciente com hérnia incisional gigante submetido à PPP que complicou com pneumomediastino sintomático. Apesar de ser frequentemente bem tolerada pelos pacientes, deve-se ter em mente que a indução de PPP pode resultar em complicações graves.In patients with giant incisional hernias, many anatomical and physiological changes turn hernia repair into quite a challenge. The possibility of developing complications as abdominal compartment syndrome after hernioplasty has prompted surgeons to seek for technical options. A tempting alternative is to induce progressive preoperative pneumoperitoneum (PPP) aiming to adapt the organism to an increase in the abdominal content. We describe the case of a patient with giant incisional hernia submitted to PPP. The patient complicated with a very symptomatic pneumomediastinum. Despite being frequently well tolerated, it is important to make a point that the induction of PPP may result in severe complications

Fatores associados ao óbito em pacientes submetidos à “Onda Vermelha”: ênfase na toracotomia de emergência

Objective: To identify and analyze the factors associated with death, with a focus on performing laparotomy alone or associated with emergency thoracotomy. Method: Prospective longitudinal study of patients submitted to the “Onda Vermelha” protocol, after admission to the Risoleta Tolentino Neves Hospital, from 2011 to 2015. Descriptive analyses, Student’s t-test, χ2 test, and regression multiple binary logistics were used to identify predictors of death. Results: One hundred and thirty-two patients were studied, of which 47 (35.6%) died. The average age was 28 years old. The majority was male (90.9%), with penetrating trauma predominating in the study sample (91.7%). The trauma scores were compatible with moderate severity trauma. The average time of hospitalization and stay in the intensive care unit exceeded 10 days. Laparotomy and thoracotomy occurred in 72.7 and 28% of cases, respectively. Complications were severe for 38.6% of patients, and the most common lesions were gastrointestinal (48.5%) and abdominal vessels (28.8%). Thoracotomy, severe complications and abdominal vessel injury were more frequent among patients who died (p<0.001). Factors associated to death were: emergency thoracotomy (OR=6.9, p=0.002), severe complications (OR=6.1, p=0.010), and lesions to the abdominal and pelvic vessels (OR=16.8, p<0.001). Conclusion: Emergency thoracotomy was associated with higher odds of death, regardless of other factors, as well as the mechanism of penetrating trauma, complications and injuries to the abdominal and pelvic vessels. Survival in the presence of thoracotomy was 25.7% for victims of penetrating trauma.Objetivo: Identificar e analisar os fatores associados ao óbito, com enfoque para a realização da laparotomia isolada ou associada à toracotomia de emergência. Método: Estudo longitudinal prospectivo de pacientes submetidos ao protocolo “Onda Vermelha”, após admissão no pronto-atendimento do Hospital Risoleta Tolentino Neves, de 2011 a 2015. Foram feitas análises descritivas, teste t de Student, teste do χ2, e regressão logística binária múltipla para identificação dos fatores preditores de óbito. Resultados: Foram estudados 132 pacientes, dos quais 47 (35,6%) morreram. A média de idade foi 28 anos. A maior parte era do sexo masculino (90,9%), predominando trauma penetrante (91,7%). Os escores de trauma foram compatíveis com moderada gravidade. Os tempos médios de internação e de permanência em unidade de terapia intensiva superaram 10 dias. A laparotomia e a toracotomia ocorreram em 72,7 e 28% dos casos, respectivamente. As complicações foram graves para 38,6% dos pacientes; e as lesões mais comuns foram gastrointestinais (48,5%) e em vasos abdominais (28,8%). A toracotomia, as complicações graves e a lesão dos vasos abdominais foram mais frequentes entre pacientes que morreram (p<0,001). Os fatores preditores para óbito foram toracotomia de emergência (OR=6,9; p=0,002), complicações severas (OR=6,1; p=0,010) e lesões em vasos abdominais e pélvicos (OR=16,8; p<0,001). Conclusão: A toracotomia de emergência está associada à maior chance de óbito, independente de outros fatores, assim como o mecanismo de trauma penetrante, as complicações e as lesões em vasos abdominais e pélvicos. A sobrevivência na presença da toracotomia foi de 25,7% para as vítimas de traumas penetrantes

Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

ABSTRACT Objective: to identify and analyze factors associated with plasma creatine phosphokinase (CPK) levels in trauma victims with progression to rhabdomyolysis. Methods: we conducted a prospective, longitudinal study, with 50 patients submitted to the “Red Wave” protocol, with evolution to rhabdomyolysis after hospital admission. We studied the variables age, gender, trauma scores, mechanism and outcome, CPK at admission and final, intervals of days between laboratory evaluations, surgery and complications. We stratified CPK values in <500U/L, ≥500 - <1000 U/L, and ≥1000U/L, with calculation of the difference between the initial and final values. Results: at admission, 83% of patients (n=39) had CPK≥1000U/L, with predominance of blunt trauma and thoracic injury (p<0.05), as well as orthopedic fracture, acute renal failure and gastrointestinal bleeding, CPK being lower in those without acute renal injury, with a trend towards statistical significance. There were no differences in final CPK stratification. Factors that were independently associated with the greater CPK variation were, positively, hospitalization time greater than one week and compartment syndrome, and negatively, acute renal injury. Conclusion: the CPK level of 1000U/L remains the lower limit, with importance for early intervention in worsening conditions such as digestive hemorrhage, acute renal injury and compartment syndrome, which implied greater absolute differences between initial and final CPK, in addition to blunt trauma, thoracic injury and orthopedic fracture