Trauma é uma das principais causas de mortalidade no mundo. A principal causa de óbitos das vítimas de trauma, nas primeiras 24 horas após a lesão, é o sangramento maciço. Os pacientes ...politraumatizados podem desenvolver graves distúrbios de coagulação relacionados à perda de grandes volumes de sangue e fatores de coagulação, à reposição volêmica com cristalóides e com concentrados de hemácias, à acidose e à hipotermia. O controle deste tipo de situação tem sido um grande desafio para cirurgiões e intensivistas. Além disto, as vítimas de trauma formam um dos maiores grupos de consumidores de sangue e seus derivados. Recentemente, a adequação destes grandes volumes de transfusão tem sido questionada, principalmente em decorrência da ausência de protocolos bem definidos e testados clinicamente. O objetivo deste artigo foi rever a literatura atual conceituando coagulopatia do trauma e descrevendo as mais recentes orientações para a hemoterapia direcionada às vitimas de trauma.
The public health system of Brazil is structured by a network of increasing complexity, but the low resolution of emergency care at pre-hospital units and the lack of organization of patient flow ...overloaded the hospitals, mainly the ones of higher complexity. The knowledge of this phenomenon induced Ribeirão Preto to implement the Medical Regulation Office and the Mobile Emergency Attendance System. The objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic afflictions in a University Hospital.
The study conducted a retrospective analysis of the medical records of 906 patients older than 13 years of age who entered the Emergency Care Unit of the Hospital of the University of São Paulo School of Medicine at Ribeirão Preto. All presented acute non-traumatic afflictions and were admitted to the Internal Medicine, Surgery or Neurology Departments during two study periods: May 1996 (prior to) and May 2001 (after the implementation of the Medical Regulation Office and Mobile Emergency Attendance System). Demographics and mortality risk levels calculated by Acute Physiology and Chronic Health Evaluation II (APACHE II) were determined.
From 1996 to 2001, the mean age increased from 49 +/- 0.9 to 52 +/- 0.9 (P = 0.021), as did the percentage of co-morbidities, from 66.6 to 77.0 (P = 0.0001), the number of in-hospital complications from 260 to 284 (P = 0.0001), the mean calculated APACHE II mortality risk increased from 12.0 +/- 0.5 to 14.8 +/- 0.6 (P = 0.0008) and mortality rate from 6.1 to 12.2 (P = 0.002). The differences were more significant for patients admitted to the Internal Medicine Department.
The implementation of the Medical Regulation and Mobile Emergency Attendance System contributed to directing patients with higher gravity scores to the Emergency Care Unit, demonstrating the potential of these services for hierarchical structuring of pre-hospital networks and referrals.
Durante o processo de elaboração do conteúdo de uma aula teórica, o palestrante deve selecionar e integrar as noções que deseja transmitir, considerando a capacidade de retenção da platéia. O ...primeiro passo deve ser a definição de objetivos, ou seja, o que se pretende que seja retido ao final da aula. A partir deste conhecimento, o palestrante deverá selecionar pequenas parcelas de informação (tópicos) que embasam o que se quer transmitir, utilizando também ilustrações (evidências). Estes tópicos/evidências devem ser coesos, garantindo uma estrutura de começo-meio-fim para a aula. É fundamental levar em consideração nesta elaboração a capacidade de retenção da platéia, influenciada pela forma como é transmitida a informação, a quantidade de conhecimento transmitido, a duração da atividade e as intervenções que o palestrante pode fazer. Todas estas características fundamentam que o conteúdo deve ser cuidadosamente selecionado, transmitindo-se pouco informação de forma a garantir a retenção.
Embora a formatação de uma aula seja passível de uma grande variabilidade, o conceito de começo-meio-fim deve sempre ser respeitado. A elaboração adequada, respeitando uma sequência lógica, com ...apresentação de tópicos com argumentações precisas e concisas, é um primeiro e largo passo para uma aula bem sucedida. Neste capítulo, procuramos abordar e sugerir aspectos de forma de uma apresentação, para garantir a fluência e a precisão na transmissão das informações.
Bleeding remains a challenge in surgery. A unique drug, recombinant factor VIIa, causes clotting exclusively at bleeding sites. Recombinant factor VIIa has recently been introduced to surgery where ...current evidence, consisting mostly of case reports, suggest remarkable safety and efficacy. The first randomized controlled trials are only now being published with less remarkable results. This manuscript summarizes the current evidence.
In trauma, a single randomized control trial suggests recombinant factor VIIa reduces bleeding and transfusion in blunt trauma, particularly in coagulopathic patients. In cardiac surgery, one randomized control trial, open-label studies and case reports suggest benefit in refractory bleeding. For liver surgery, randomized control trials do not support use in liver transplant or gastrointestinal bleeding. In neurosurgery, one randomized control trial demonstrated improved outcome in intracerebral hemorrhage. In urology, one randomized control trial demonstrated significant reduction in perioperative bleeding. For orthopedics, a single randomized control trial showed no benefit in pelvic/acetabular surgery. In obstetrics/gynecology, limited evidence suggests benefit in massive bleedings.
Current evidence does not yet support recombinant factor VIIa as standard of care in surgery. However, the evidence indicates that recombinant factor VIIa should be used in intracerebral hemorrhage and massive perioperative or traumatic bleeding refractory to conventional therapies. For now, the bedside decision to use recombinant factor VIIa remains a matter of surgical judgment.
Abstract Background Venous thromboembolism (VTE) frequently complicates the recovery of trauma patients, and contributes to morbidity and mortality. Recent studies showed an increase in diagnosis of ...pulmonary embolism (PE) mainly in the early or immediate period after trauma. The clinical significance of those incidental PEs is unclear. Methods The study cohort included all blunt trauma patients who had a contrast-enhanced CT of the chest performed as part of their initial trauma assessment from January 1, 2005 to January 31, 2007 in a large academic Canadian trauma centre. Patients diagnosed with PE at any point during admission were identified using our institutional trauma registry. All chest CT scans and electronic charts were reviewed. Patients were classified according to time of PE detection (immediate, early or late) and symptoms (asymptomatic or symptomatic). The clinical characteristics and hospital course of the patients who were diagnosed with immediate PE were described. Results 1259 blunt trauma patients were reviewed. Six patients presented with immediate PE (0.5%); nine patients were found to have early PE (0.7%) and 13 had late PE (1.0%). All six of the patients with immediate PE were classified as asymptomatic. Five of the nine patients with early PE were symptomatic and all 13 patients who developed late PE were symptomatic. Amongst the six patients with immediate PE, five survived 24 h hospitalisation. Four of them were managed with prophylactic low molecular weight heparin and no other thromboembolic events were observed during admission or after discharge. Conclusions The increased use of advanced CT technology in trauma patients has resulted in an increased diagnosis of incidental PEs that are asymptomatic. The clinical significance and management of these small, incidental PE are uncertain and further studies are needed to clarify the natural history of this controversial finding.
Durante os últimos 30 anos, o curso “Advanced Trauma Life Support” – Suporte Avançado de Vida no Trauma, do American College of Surgeons, tornou-se a principal referência mundial no ensino do ...atendimento inicial ao traumatizado. A partir de uma primeira experiência em Nebraska, em 1978, o curso difundiu-se rapidamente para mais de 25 países, graças a sua abordagem objetiva, prática e dinâmica do ensino das prioridades vitais do traumatizado grave e por sistematizar algumas técnicas cirúrgicas indispensáveis para o sucesso do atendimento. Este modelo de ensino, baseado em simuladores artificiais, em modelos animais e atores humanos se apresenta como alternativa eficiente para o ensino de emergências médicas.
Studies of cardiovascular disease risk prediction by machine learning algorithms often do not assess their ability to generalize to other populations and few of them include an analysis of the ...interpretability of individual predictions. This manuscript addresses the development and internal and external validation of predictive models for the assessment of risks of major adverse cardiovascular events. Global and local interpretability analyses of predictions were conducted towards improving model reliability and tailoring preventive interventions. The models were trained and validated in a retrospective cohort with the use of data from Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Brazil. Data from Beth Israel Deaconess Medical Center, USA, were used for external validation. Eight machine learning algorithms, namely Penalized Logistic Regression, Random Forest, XGBoost, Decision Tree, Support Vector Machine, k-Nearest Neighbors, Naive Bayes and Multi-Layer Perceptron were trained to predict a 5-year risk of major adverse cardiovascular events and their predictive performance was evaluated regarding accuracy, ROC curve (receiver operating characteristic), and AUC (area under the ROC curve). LIME and Shapley values methods interpreted individual predictions. Random Forest showed the best predictive performance in both internal validation (AUC = 0.87; Accuracy = 0.79) and external one (AUC = 0.79; Accuracy = 0.71). Compared to LIME, Shapley values provided explanations more consistent with exploratory analysis and importance of features. Among the machine learning algorithms evaluated, Random Forest showed the best generalization ability, both internally and externally, and Shapley values for local interpretability were more informative than LIME ones, which is in line with our exploratory analysis and global interpretation of the final model. Machine learning algorithms with good generalization and accompanied by interpretability analyses are recommended for assessments of individual risks of cardiovascular diseases and development of personalized preventive actions.
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