Antonio Marttos

Is the FAST exam reliable in severely injured patients

INTRODUCTION Highly sensitive and accurate for the detection of injuries requiring intervention in haemodynamically unstable patients, FAST may underestimate intra-abdominal injuries in stable patients with blunt abdominal trauma. Diminished accuracy of ultrasound has been reported in different cohorts of multiple injured patients. We hypothesised that multiple injured patients with a high Injury Severity Score (ISS) will have a decreased accuracy of FAST for the assessment of blunt abdominal trauma. METHODS Data from the trauma registry of a Level 1 trauma centre were retrospectively reviewed. All haemodynamically stable blunt trauma patients who underwent both FAST and CT scan of abdomen from January 1, 2000 to January 1, 2005 were included in the cohort. All patients were divided into three groups according to their ISS: Group 1 included patients with an ISS from 1 to 14, Group 2 included patients with an ISS from 16 to 24, and Group 3 consisted of patients with ISS>or=25. RESULTS 3181 patients with blunt abdominal trauma included into the study were divided into the three groups according to the ISS. The mean ISS was 7.9+/-3.97, 19.6+/-2.48 and 41.3+/-11.95 in Groups 1, 2 and 3, respectively. The accuracy of ultrasound was 90.6% in the group of patients with the highest ISS (>or=25) compared with 97.5 and 97.1 for Groups 1 and 2 (p<0.001). Similarly, ultrasound had a significantly lower sensitivity, specificity, PPV and NPV for patients in Group 3 compared with the first two groups (p<0.001). There was a significantly lower sensitivity in Group 2 compared with Group 1 (p<0.001), but no differences in specificity, accuracy, PPV or NPV were demonstrated. CONCLUSION Patients with high ISS are at increased risk of having ultrasound-occult injuries and have a lower accuracy of their ultrasound examination than patients with low and moderate ISS.

Penetrating Cardiac Injuries: A Historic Perspective and Fascinating Trip Through Time

ardiac injuries have been described since ancient times. he earliest known descriptions of cardiac injuries appear n Homer’s Iliad(Fig. 1). It contains specific references to xsanguination as a cause of death and foreign bodies imaled in the heart. The poetic description of the death of arpedon includes an episode of exsanguinating hemorhage from a cardiac injury, “Not so Patroclus’ never erring arts; Aim’d at his breast, it peers at the mortal part, Where he strong fibers bind the solid heart.” The Iliad also records an observation describing the ardiac impulse transmitted through a spear that had transixed the heart of Alkathoos, “The hero Idomeneus smote im in the midst of the breast with the spear. . . and he fell ith a crash, and the lance fixed in his heart that, still eating, shook the butt end of the spear.” Beck classified the history of wounds of the heart acording to three historical periods. First, the period of mysicism, in which wounds to the heart were described, but ere considered uniformly fatal. This was followed by a eriod of observation and experiment, culminating in the eriod of suture, which began in 1882. Hippocrates stated hat all wounds of the heart were deadly. Authors such as vid, Celsus, Pliny, Aristotle, and Galen regarded hem as absolutely and necessarily fatal. According to Ar-

Interrupções e distrações na sala de cirurgia do trauma: entendendo a ameaça do erro humano

OBJECTIVE To understand the human factor as a threat to the security of trauma patients in the operating room, bringing to the operating room some important rules already applied in the field of aviation. METHODS The sample included 50 cases of surgical trauma patients prospectively collected by observers in shifts of 12 hours, for six months in a Level I trauma center in the United States of America. Information regarding the type of trauma, severity score and mortality were collected, as well as determinants of distractions / interruptions and the volume of noise in the operating room during surgery. RESULTS There was an average of 60 interruptions or distractions during surgery, most often triggered by the movement of people in the room. In more severe patients (ISS> 45), subjected to damage control, the incidence of distractions was even greater. The average noise in the trauma surgery room was very high, close to the noise of a hair dryer. CONCLUSION Interruptions and distractions are frequent and should be studied by the trauma surgeon to develop prevention strategies and lines of defense to minimize them and reduce their effects.

Enhancing trauma education worldwide through telemedicine

Advances in information and communication technologies are changing the delivery of trauma care and education. Telemedicine is a tool that can be used to deliver expert trauma care and education anywhere in the world. Trauma is a rapidly-evolving field requiring access to readily available sources of information. Through videoconferencing, physicians can participate in continuing education activities such as Grand Rounds, seminars, conferences and journal clubs. Exemplary programs have shown promising outcomes of teleconferences such as enhanced learning, professional collaborations, and networking. This review introduces the concept of telemedicine for trauma education, and highlights efforts of programs that are utilizing telemedicine to unite institutions across the world.

Utilizing telemedicine in the trauma intensive care unit: does it impact teamwork?

BACKGROUND The aim of this study was to examine the impact of a telemedical robot on trauma intensive care unit (TICU) clinician teamwork (i.e., team attitudes, behaviors, and cognitions) during patient rounds. MATERIALS AND METHODS Thirty-two healthcare providers who conduct rounds volunteered to take surveys assessing teamwork attitudes and cognitions at three time periods: (1) the onset of the study, (2) the end of the 30-day control period, and (3) the end of the 30-day experimental period, which immediately followed the control period. Rounds were recorded throughout the 30-day control period and 30-day experimental period to observe provider behaviors. For the initial 30 days, there was no access to telemedicine. For the final 30 days, the rounding healthcare providers had access to the RP-7 robot (Intouch Health Inc., Santa Barbara, CA), a telemedical tool that can facilitate patient rounds conducted away from bedside. RESULTS Using a one-tailed, one-way repeated-measures analysis of variance (ANOVA) to compare trust at Times 1, 2, and 3, there was no significant effect on trust: F(2, 14)=1.20, p=0.16. When a one-tailed, one-way repeated-measures ANOVA to compare transactive memory systems (TMS) at Times 1, 2, and 3 was conducted, there was no significant effect on TMS: F(2, 15)=1.33, p=0.15. We conducted a one-tailed, one-way repeated-measures ANOVA to compare team psychological safety at Times 1, 2, and 3, and there was no significant effect on team psychological safety: F(2,15)=1.53, p=0.12. There was a significant difference in communication between rounds with and without telemedicine [t(25)=-1.76, p<0.05], such that there was more task-based communication during telerounds. Telemedicine increased task-based communication and did not negatively impact team trust, psychological safety, or TMS during rounds. CONCLUSIONS Telemedicine may offer advantages for some teamwork competencies without sacrificing the efficacy of others and may be adopted by intact rounding teams without hindering teamwork.

Surgical telepresence: the usability of a robotic communication platform

IntroductionThe benefits of telepresence in trauma and acute surgical care exist, yet its use in a live, operating room (OR) setting with real surgical cases remains limited.MethodsWe tested the use of a robotic telepresence system in the OR of a busy, level 1 trauma center. After each case, both the local and remote physicians completed questionnaires regarding the use of the system using a five point Likert scale. For trauma cases, physicians were asked to grade injury severity according to the American Association for the Surgery of Trauma (AAST) Scaling System.ResultsWe collected prospective, observational data on 50 emergent and elective cases. 64% of cases were emergency surgery on trauma patients, almost evenly distributed between penetrating (49%) and blunt injuries (51%). 40% of non-trauma cases were hernia-related. A varied distribution of injuries was observed to the abdomen, chest, extremities, small bowel, kidneys, spleen, and colon. Physicians gave the system high ratings for its audio and visual capabilities, but identified internet connectivity and crowding in the operating room as potential challenges. The loccal clinician classified injuries according to the AAST injury grading system in 63% (n=22) of trauma cases, compared to 54% (n=19) of cases by the remote physicians. The remote physician cited obstruction of view as the main reason for the discrepancy. 94% of remote physicians and 74% of local physicians felt comfortable communicating via the telepresence system. For 90% of cases, both the remote and local physicians strongly agreed that a telepresence system for consultations in the OR is more effective than a telephone conversation.ConclusionsA telepresence system was tested on a variety of surgical cases and demonstrated that it can be an appropriate solution for use in the operating room. Future research should determine its impact on processes of care and surgical outcomes.

Closed (Blunt) Compared to Open (Penetrating) Pulmonary Contusion–A National Trauma Data Bank Review

Results: A total of 12,884 patients with pulmonary contusions were identified. The closed pulmonary contusion was present in 12,329 patients, open pulmonary contusion in 555 patients. Patients with closed pulmonary contusions were older with a mean age of 38.00 ± 22.23 versus 30.58 ± 12.88. Patients with closed pulmonary contusion had a higher injury severity score (ISS) 21.60 ± 0.22 versus 18.64 ± 1.08, p = 0.001. Closed pulmonary contusion was associated with increased ventilator days 3.09 ± 0.13, p = 0.052, intensive care unit (ICU) days 5.11 ± 0.15 versus 4.01 ± 0.69, p = 0.003 and hospital length of stay 0.65 ± 0.25 versus 9.37 ± 0.99, p = 0.032.

Perioperative Radiologic Evaluation of Patients with Difficult Abdominal Wall Defects

The complexity of abdominal defects necessitating operative repair has increased exponentially in recent years. In addition, there has been increasing adoption of advanced operative techniques, such as a variety of component separation techniques. Finally, there has been an explosion in the available prosthetic materials, both synthetic and biologic, to augment the repair. As a consequence of these factors, surgeons are currently taking on increasingly challenging abdominal wall defects than ever before. Careful preoperative imaging is crucial to every aspect of the management of these patients. Imaging aids in establishing the diagnosis, especially in patients with a large body habitus or in whom the presence of tenderness precludes an adequate clinical examination. Ultrasonography, in both the supine and standing positions and with and without the Valsalva maneuver, and computed tomography are most useful here. In the rare instance of concern for a hernia in the pregnant patient, magnetic resonance imaging might be required. Computed tomography is critical for operative planning. It can detect the presence of domain loss, necessitating a preoperative pneumoperitoneum. It also allows precise assessment of the size of the defect, relative size of the rectus abdominus muscle, and the size and state of the lateral abdominal wall musculature. This is a key step in determining the component separation technique that is ideal for the particular defect. Ultrasonography can be used intraoperatively to determine the location of the linea semilunaris for accurate placement of the initial incision in performing an endoscopic component separation. Ultrasonography and computed tomography are also critical in the detection of postoperative complications, including seromas, abscesses, and inflammatory reactions to the mesh used. Finally, ultrasonography and computed tomography are valuable in the detection of recurrence.