José Gustavo Parreira

Epidemiologia do trauma facial

OBJECTIVES: This study aims to determine the incidence, etiology, severity of facial trauma and associated injuries enabling a greater understanding of its range and magnitude METHODS: A hundred and sixty four patients were selected with some degree of facial trauma regardless of gender, age and skin color. Data were analyzed by the Pearson x2 statistical method. RESULTS: A male predominance was observed (78%) and its peak age was between 20 and 39 years. The major cause was interpersonal violence (48.1%), followed by fall (26.2%), run overs 6.4%), sports (5.4%), car accidents (4.2%), motorcycle accidents (3.1%), non-fall impacts (2.4%), occupational injuries (1.8%), gunshot wounds (1.2%), unspecific (1.2%). Contusion is the most common injury (23.8%), followed by fractures of the mandible (21.9%), Le Fort/pan facial/complex (17.8%), nasal bones (11.6%), zygoma (10.3%), tooth (9.1%), orbit (4.9%) and maxilla (0.6%). Associated injuries Epidemiologia do trauma facial occurred mostly in run overs, but also because of car accident, fall and interpersonal violence. CONCLUSIONS: The causes of facial trauma are directly related to the age and type of lesion. No evidence was found that the causes were related to gender or severity of the lesion.

Spontaneous intramural small bowel hematoma induced by anticoagulant therapy: review and case report

Of particular note among the causes of abdominal pain that necessitate surgery are appendicitis and intestinal obstruction. The most frequent causes of obstruction are adhesions (60%), hernias (15%), neoplasia (6%) and rare causes (6%). 2 In many cases, surgery comes to represent both a diagnostic and therapeutic measure. In some cases, however, we may be confronted by an obstructive condition in which more conservative measures are recommended. The aim of this article is to highlight the rare occurrence of acute abdominal obstruction due to spontaneous intramural small bowel hematoma resulting from the use of oral anticoagulants by reporting on a case attended at the General Surgery Service of the Clinical Surgery Division III of the Hospital das Clinicas - University of Sao Paulo Medical School (HC – FMUSP), as well as presenting a systematic review of the literature from the last 25 years.

Análise comparativa das características do trauma entre pacientes idosos e não idosos

OBJECTIVE: Assess the characteristics of trauma in the elderly by comparison to a group of younger trauma patients. METHODS: Trauma protocols from June 10, 2008 to March 9, 2009 were evaluated including all trauma patients above 13 years of age admitted in the emergency room. Data on trauma mechanism, concomitant diseases, vital signs upon admission, diagnosed injuries, trauma indexes, exams and treatment was collected. Patients above 60 years of age. were included in the elderly group (group I). Data was compared between this group and the younger patients (group II), using the Students t, chi square and Fisher exact tests, considering p 3) in the head were more frequently observed in group I (11.4% vs 7%) (p=0,023). Some injuries were more frequent in group I: subdural hematomas (2.8% vs 0.8%) (p=0.008), subarachnoid hemorrhage (3.8% vs 1.3%) (p=0.005) and cerebral contusions (5.2% vs 2.3%) (p=0.015). CONCLUSION: In comparison to younger trauma patients, the elderly group was characterized by a higher frequency of falls from their own height, , concomitant diseases and severe injuries in the head, mainly subdural hematomas, cerebral contusions and subarachnoid hemorrhage.OBJECTIVE: Assess the characteristics of trauma in the elderly by comparison to a group of younger trauma patients. METHODS: Trauma protocols from June 10, 2008 to March 9, 2009 were evaluated including all trauma patients above 13 years of age admitted in the emergency room. Data on trauma mechanism, concomitant diseases, vital signs upon admission, diagnosed injuries, trauma indexes, exams and treatment was collected. Patients above 60 years of age. were included in the elderly group (group I). Data was compared between this group and the younger patients (group II), using the Students t, chi square and Fisher exact tests, considering p 3) in the head were more frequently observed in group I (11.4% vs 7%) (p=0,023). Some injuries were more frequent in group I: subdural hematomas (2.8% vs 0.8%) (p=0.008), subarachnoid hemorrhage (3.8% vs 1.3%) (p=0.005) and cerebral contusions (5.2% vs 2.3%) (p=0.015). CONCLUSION: In comparison to younger trauma patients, the elderly group was characterized by a higher frequency of falls from their own height, , concomitant diseases and severe injuries in the head, mainly subdural hematomas, cerebral contusions and subarachnoid hemorrhage. Language: pt

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.

Fatores preditivos de lesões abdominais em vítimas de trauma fechado

OBJECTIVE: To identify predictors of abdominal injuries in victims of blunt trauma. METHOD: retrospective analysis of trauma protocols (collected prospectively) of adult victims of blunt trauma in a period of 15 months. Variables were compared between patients with abdominal injuries (AIS>0) detected by computed tomography or/and laparotomy (group I) and others (AIS=0, group II). Students t, Fisher and qui-square tests were used for statistical analysis, considering p 3) in head (18.5% vs. 7.9%), thorax (29.2% vs. 2.4%) and extremities (40.0% vs. 13.7%). The highest odds ratios for the diagnosis of abdominal injuries were associated flail chest (21.8) and pelvic fractures (21.0). CONCLUSION: Abdominal injuries were more frequently observed in patients with hemodynamic instability, changes in Glasgow coma scale and severe lesions to the head, chest and extremities.

Fratura de pelve: um marcador de gravidade em trauma

OBJECTIVE To assess whether the presence of a pelvic fracture is associated with greater severity and worse prognosis in victims of blunt trauma. METHODS A retrospective analysis of protocols and records of victims of blunt trauma admitted from June 2008 to March 2009 was separated into two groups: those with pelvic fracture (Group I) and those without it (Group II). Data were collected from pre-hospital admission rates of trauma, laboratory tests, diagnosed lesions, treatment and outcome. We used the Student t test, Fishers exact test and chi-square test for statistical analysis, considering p <0.05 as significant. RESULTS During the study period, 2019 individuals had multiple trauma protocols completed, of which 43 (2.1%) had pelvic fractures. Patients in Group I had significantly lower average blood pressure, higher mean heart rate, lower mean Glasgow Coma Scale, the highest average AIS in the segments head, chest, abdomen and extremities, as well as higher mean ISS and lower mean TRISS and RTS on admission. Group I more frequently presented with traumatic subarachnoid hemorrhage (7% vs. 1.6%), spinal cord injury (9% vs. 1%), thoracic and abdominal injuries, as well as need for laparotomy (21% vs. 1 %), chest drainage (32% vs. 2%) and damage control (9% vs. 0%). Complications were more frequent in group I: ARDS (9% vs. 0%), persistent shock (30% vs. 1%), coagulopathy (23% vs. 1%), acute renal failure (21% vs. 0%) and death (28% vs. 2%). CONCLUSION The presence of a pelvic fracture is a marker of greater severity and worse prognosis in victims of blunt trauma.

Lesões abdominais nos traumatizados com fraturas de bacia

BACKGROUND: To analyze possible abdominal injuries and their impact on the prognosis of patients sustaining pelvic fractures. METHOD: Retrospective chart review including all victims of pelvic fractures due to blunt trauma from 1996 until 2000. Sample was constituted of 224 patients, mean age 34 + 16 years, 137 (61,1%) male. Demographic data, trauma indices, organs injured, treatment and evolution were assessed. Abdominal injuries were graded using Organ Injury Scale (OIS), Abbreviated Injury Scale (AIS) and Abdominal Trauma Index (ATI). Statistical analysis was carried out with students t and chi square tests. RESULTS: Pedestrian struck was the most common mechanism of injury (53%). Mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.0341 ± 1.864 and 20.2 ± 12.8 respectively. Injuries in abdominal organs were found in 95 patients (42,4%), being the bladder the most frequently injured (11%). Sixty three (28,1%) patients had their abdominal injuries graded as AIS > 3, and 54 (24,1%), as OIS > 3. Mean ATI for those sustaining abdominal lesions was 9 ± 8. Fifty five laparotomies were performed, nine of them being non therapeutic. Fifty one patients died (22%), mainly due to hemorrhagic shock. The presence of injuries to abdominal organs were significantly associated with shock upon admission, complex pelvic fractures, external fixation of the pelvic fracture, increased number of complications and higher mortality (p<0.05). CONCLUSION: Abdominal organs are frequently injured in patients sustaining pelvic fractures and, when present, determine worse prognosis.

Análise comparativa entre as lesões encontradas em motociclistas envolvidos em acidentes de trânsito e vítimas de outros mecanismos de trauma fechado

OBJETIVO: Realizar uma analise comparativa entre as lesoes encontradas em motociclistas envolvidos em acidentes de trânsito e vitimas de outros mecanismos de trauma fechado. METODOS: Analise dos protocolos (colhidos prospectivamente) dos traumatizados com idade superior a 13 anos, admitidos de 10/06/2008 a 01/09/2009, vitimas de trauma fechado. Foram coletadas informacoes sobre mecanismo de trauma, dados vitais a admissao, exames complementares, lesoes e tratamento. A estratificacao da gravidade do trauma e das lesoes foi realizada pelo calculo dos indices de trauma: RTS, escala de coma de Glasgow (ECG), AIS, ISS e TRISS. Comparamos as variaveis entre os motociclistas (grupo A) e os demais (grupo B). Consideramos graves as lesoes com AIS > 3. Para a analise estatistica, utilizamos os testes t de Student, Mann Whitney, qui-quadrado e Fisher, considerando p < 0,05 significativo. RESULTADOS: Foram incluidos no estudo 3.783 vitimas de trauma fechado, com idade de 14 a 99 anos, sendo 76,0% do sexo masculino. Os mecanismos de trauma mais frequentes foram os acidentes com motociclistas (24,4%) e atropelamentos (22,6%). Na comparacao das variaveis entre os grupos A e B, observamos que os motociclistas apresentaram, significativamente, (p < 0,05), menor media etaria (28,9 ± 8,5 anosvs. 42,4 ± 18,5 anos) e menor media de AIS em segmento cefalico (0,3 ± 0,9 vs. 0,8 ± 1,1), como tambem, maior media da ECG a admissao (14,5 ± 1,9vs. 14,2 ± 2,2), de AIS em extremidades (1,5 ± 1,2 vs. 0,9 ± 1,2), de RTS (7,8 ± 0,5 vs. 7,7 ± 0,6) e de TRISS (0,98 ± 0,1 vs. 0,97 ± 0,1). O genero masculino foi significativamente mais frequente no grupo A (87,9%vs. 72,6%). Na comparacao das lesoes entre os grupos, notamos que os motociclistas apresentaram, significativamente, (p < 0,05), menor frequencia de hematomas extradurais (0,6% vs. 2,1%), hematomas subdurais (0,9% vs. 2,1%), hemorragia subaracnoidea (0,9% vs. 2,2%), contusao encefalica (1,2% vs. 3,6%) e lesoes graves em crânio (4,8%vs. 9,4%), bem como maior frequencia de lesao axonal difusa (1,6%vs. 0,7%), fraturas de membros superiores (7,9%vs. 4,4%), inferiores (7,7%vs. 5,2%), e lesoes graves em extremidades (20,6%vs. 12,6%). CONCLUSAO: Em comparacao as vitimas dos demais mecanismos de trauma, os motociclistas apresentaram menor frequencia e gravidade das lesoes em segmento cefalico, bem como maior frequencia e gravidade das lesoes em extremidades.

Pesquisa nacional sobre condutas na pancreatite aguda

BACKGROUND: to evaluate as AP is managed by the Brazilian surgeon. METHODS: A questionnaire has been sent to 2,000 members of the Brazilian College of Surgeons, with 618 (30.9%) answers obtained. The questionnaire consisted of questions related to the experience of the surgeon and in particular to the treatment of AP. RESULTS: One hundred and eighty-two interviewed (33.6%) answered to treat up to five cases per year and 147 (27.2%) treat six to ten cases per year. The most cited criteria used for the definition of severe AP was clinical evaluation for 306 (57.4%) interviewed, followed by the Ranson criteria for 294 (55.2%) and CT scan for 262 (49.2%). Regarding the use of CT, 275 (51.5%) interviewed answered that make use of CT scan for all patients with AP. The parenteral nutritional support was the method of choice indicated for 248 (46.6%) interviewed. The infection of fluid collection and/or pancreatic necrosis was the main reason for surgical treatment with 447 (83.6%) answers. The optimum period to operate a patient with severe AP was considered up to seven days for 278 (54.2%) interviewed. With relation to antibiotics, 371 (68.6%) said that they use antibiotics in the treatment of severe AP. CONCLUSION: These findings demonstrate a wide variation in the treatment of AP in Brazil. Little experience of the surgeons and controversial issues are the main factors responsible for this lack of standardization. A national Consensus based on new concepts and worldwide experience is crucial to adjust these thoughts.

Comparative analysis between identified injuries of victims of fall from height and other mechanisms of closed trauma

OBJECTIVE to identify predictors of death in blunt trauma patients sustaining pelvic fractures and, posteriorly, compare them to a previously reported series from the same center. METHOD Retrospective analysis of trauma registry data, including blunt trauma patients older than 14 y.o. sustaining pelvic fractures admitted from 2008 to 2010. Patients were assigned into group 1 (dead) or 2 (survivors). We used Students t, qui square and Fishers tests for statistical analysis, considering p<0.05 as significant. Posteriorly, we compared predictors of death between both periods. RESULTS Seventy-nine cases were included. Mean RTS, ISS and TRISS were, respectively, 6.44 + 2.22, 28.0 + 15.2 e 0.74 + 0.33. Nineteen patients died (24,0%). Main cause of death was hemorrhage (42,1%). Group 1 was characterized by (p<0.05) lower systolic blood pressure and Glasgow coma scale means on admission, higher heart rate, head AIS, extremity AIS and ISS means, as well as, higher frequency of severe head injuries and complex pelvic fractures. Comparing both periods, we notice that the anatomic and physiologic severity of injury increased (RTS and ISS means). Furthermore, there was a decrease in the impact of associated thoracic and abdominal injuries on the prognosis and an association of lethality with the presence of complex pelvic fractures. CONCLUSION There were significant changes in the predictors of death between these two periods. The impact of thoracic and abdominal associated injures decreased while the importance of severe retroperitoneal hemorrhage increased. There was also an increase in trauma severity, which accounted for high lethality.