Gustavo Pereira Fraga

Transfusion of Blood Products in Trauma: An Update

BACKGROUND Blood transfusion in the management of severely injured patients can be lifesaving. These patients are susceptible to developing early coagulopathy, thus perpetuating bleeding. OBJECTIVES This article presents recent advances in both the civilian and military clinical arena to improve the treatment of trauma patients with severe hemorrhage, the use of agents to support coagulation, perspectives on restrictive transfusion strategies, and transfusion-related risks. DISCUSSION Massive blood transfusion is an adjunct to surgical care. The volume of blood products transfused and the ratio of blood components have been associated with increased morbidity and mortality rates. The adverse clinical effects of transfusion and the limited supply of blood products have resulted in modern resuscitation protocols to limit the volume of blood transfused. CONCLUSION A restrictive blood transfusion strategy and the use of hemostatic agents may decrease morbidity and mortality in trauma patients, but insufficient data are available for their use in trauma patients. Massive transfusion should reflect an equal ratio of packed red cells and plasma to limit coagulopathy. Prospective randomized trials are needed to standardize an effective protocol.

A 20-year Experience with Portal and Superior Mesenteric Venous Injuries: Has Anything Changed?

OBJECTIVES To identify predictive factors causing mortality in patients with injuries to the portal (PV) and superior mesenteric veins (SMV). DESIGN Retrospective analysis of prospectively collected data. MATERIALS AND METHODS Adults admitted with blunt or penetrating PV and SMV injuries at an academic level I trauma center during a 20-year period. RESULTS Of 26,387 major trauma victims admitted from 1987 through 2006, 26 sustained PV or SMV injuries (PV=15, SMV=11). Mechanism of injury was penetrating in 19 (73%) and 20 were in shock. Active hemorrhage occurred in 21. Most patients had associated injuries (2.9+/-1.8/patient). Mean Injury Severity Score (ISS) was 27.8+/-16.8. All PV injuries underwent suture repair and 27% of SMV injuries were ligated. Overall mortality was 46% (PV=47%, SMV=45%). Stab wounds had a lower mortality (31%) compared to gunshot wounds (67%) and blunt injuries (57%). Nonsurvivors had a higher ISS (35.8 vs. 20.9; p=0.02), more associated injuries (3.7 vs. 2.2; p=0.02), were older, and had active hemorrhage. Active hemorrhage (p=0.04) was independently related to death while shock on admission (odds ratio=6.1, p=0.61) trended toward higher mortality. CONCLUSION Despite improvements in trauma care, mortality of PV and SMV injuries remains high. Shock, active hemorrhage, and associated injuries were predictive of increased mortality.

Beach and Campfire Burns: A Site of Pleasure and Tragedy

Seasonal use of campground bonfires and beach fire pits is a common practice. A sense of fellowship is derived from this experience. Unfortunately, many people are injured by these fires. It was the objective of this study to quantify and better identify those factors that lead to these injuries. A retrospective review of patients injured from a beach or campground, fire pits, or bonfires was conducted using data from a regional burn registry (1999–2007). Patients sustaining burns serious enough to merit admission were included in this study. Demographic information, circumstances surrounding the injury events, size and location of burn, operative procedures, length of stay, and outcomes were analyzed. There were 3083 patients admitted to the burn center of which 241 met criteria for inclusion in this study. Each year, between 12 and 39 patients were injured by this mechanism; 84% were men. Ages fell into two discrete groups; young age (2–9 years) and adults (18–64 years). Alcohol was a contributing factor in 60.6% of adult burns. The areas of burn, by location and rank order include upper extremities (35.3% of patients), thorax/abdomen/buttocks (32.8%), lower extremities (30.7%), and hands (29.5%). The mean TBSA was 6.1% (1–100%). Approximately 80.7% of the patients sustained combination partial- and full-thickness burns whereas, 4.2% were only partial and 5.1% only full-thickness burns; 36.6% of the patients required skin grafting. The mean length of stay was 8.6 days. There were four fatalities including one suicide. Burn injuries from recreational bonfires remain a problem in our community. Beaches were the most common location for these injuries. Universal safeguards to prevent burn injury should be implemented, including designated areas for fires, protective mechanical barriers to keep children and adults from inadvertently walking or falling into the fire pit. Disposal areas for hot coals from fires or charcoal grills must be furnished and usage strictly enforced. Consideration of the elimination of free-standing beach bonfires should be considered.

Pericardial window used in the diagnosis of cardiac injury

PURPOSE The purpose of the present study is to analyze the results of subxiphoid pericardial window (SPW) and transdiaphragmatic pericardial window (TDP) procedures comparing the two techniques. METHODS During the period of January, 1994 to December, 2004, at UNICAMP, 245 patients underwent a pericardial window (PW) procedure to evaluate the possibility of cardiac injury. We reviewed the medical records of those patients in order to compare both procedures. RESULTS Two hundred and seven patients (84.5%) underwent the SPW procedure, and 38 (15.5%) underwent the TDP procedure. Of the patients who underwent a SPW procedure, 151 (72.9%) had gunshots injuries, and 56 (27.1%) had stab wounds. In the group of patients submitted to TDP procedure, the wound was caused by gunshot in 26 (68.4%). The SPW method has shown a sensitivity of 97.5%, specificity of 95.8%, and an accuracy of 96.1%. The TDP method demonstrated a sensitivity of 100%, specificity of 97% and a 97.4% of accuracy rate. This review showed 8 (3.3%) false positive results. There was a single case (2.6%) of complications directly associated to the TDP, and this patient developed pericarditis. CONCLUSIONS Both techniques presented an equally great result, with high sensitivity and specificity. Both surgical techniques must be carefully done to avoid false positive results.