Marisa Aparecida Amaro Malvestio

Advanced life support: care provided to motor vehicle crash victims

OBJECTIVE To analyze the performance of Advanced Life Support care mode (ALS) applied to car crash victims using indicators by means of the Revised Trauma Score (RTS) in prehospital phase. METHODS It were analyzed 643 reports of car crash victims cared by public ALS services that occurred in highways of the city of São Paulo, from April 1999 to April 2000. Time intervals assessed were: response time, on-scene time, transport time, and total time. Correct screening decision analysis considered RTS< or = 1 for tertiary hospitals. Changes in RTS and its parameters were observed using the following equation: RTSfinal - RTSinitial. RESULTS AND CONCLUSIONS Of 643 victims, 90.8% were RTS=12 and 5.2% were RTS < or = 0. The response time ranged from 8 to 9 minutes, while on-scene and transport time were higher in RTS < or = 0 cases. Of RTS < or = 0 victims, 45.5% were correctly transported to tertiary hospitals. Screening decision misjudgments were identified. Maintenance or improvement of RTS values occurred in 98.8% of the cases. Respiratory rate was the parameter that showed better improvement followed by systolic blood pressure.

Sobrevivência após acidentes de trânsito: impacto das variáveis clínicas e pré-hospitalares

OBJECTIVE To assess clinical and prehospital variables associated with survival of motor vehicle crash victims. METHODS Study carried out in the city of São Paulo (Southeastern Brazil), from 1999 to 2003. Data from 175 patients, who were aged between 12 and 65 years and had been motor vehicle crash victims, were analyzed. Kaplan-Meier Survival Analysis was used to approach the results at the accident scene with victims scoring <11, according to the Revised Trauma Score. Variables analyzed were: sex, age, injury mechanisms, basic and advanced support procedures, Revised Trauma Score parameters and fluctuations, time elapsed in the prehospital phase and trauma severity according to the Injury Severity Score and Maximum Abbreviated Injury Scale. RESULTS Analysis revealed that victims who were less likely to survive during the hospitalization period showed serious lesions in the abdomen, thorax, or lower limbs, with negative fluctuation of respiratory frequency and Revised Trauma Score in the prehospital phase. In addition, they needed specialized interventions or thoracic compressions. Brain lesions were associated with late death. CONCLUSIONS Recognition of variables involved in the survival of motor vehicle crash victims may help to determine protocols and to make decisions in order to perform pre- and in-hospital interventions and, consequently, maximize survival.OBJETIVO: Analisar as variaveis clinicas e pre-hospitalares associadas a sobrevivencia de vitimas de acidente de trânsito. METODOS: Estudo realizado no municipio de Sao Paulo, SP, de 1999 a 2003. Foram analisados dados de 175 pacientes, entre 12 e 65 anos, vitimados por acidente de trânsito. A Analise de Sobrevivencia de Kaplan-Meier foi utilizada na abordagem dos resultados na cena do acidente com as vitimas de escore <11 segundo o Revised Trauma Score. As variaveis analisadas foram: sexo, idade, mecanismos do acidente, procedimentos de suporte basico e avancado realizados, parâmetros e flutuacoes do Revised Trauma Score, tempo consumido na fase pre-hospitalar e gravidade do trauma segundo o Injury Severity Score e a Maximum Abbreviated Injury Scale. RESULTADOS: A analise identificou que as vitimas que tiveram menor probabilidade de sobrevivencia durante todo periodo de internacao hospitalar apresentaram: lesoes graves no abdome, torax ou membros inferiores, com flutuacao negativa da frequencia respiratoria e do Revised Trauma Score na fase pre-hospitalar e necessitaram de intervencoes avancadas ou compressoes toracicas. As lesoes encefalicas foram associadas ao obito tardio. CONCLUSOES: O reconhecimento das variaveis envolvidas na sobrevivencia de vitimas de acidentes de trânsito pode auxiliar na determinacao de protocolos e na tomada de decisao para a realizacao de intervencoes pre e intra-hospitalares e consequentemente maximizar a sobrevivencia.

Acidentes de trânsito: caracterização das vitimas segundo o "Revised Trauma Score" medido no período pré-hospitalar

O estudo descreve idade, sexo, aspectos do mecanismo e procedimentos realizados em. 643 acidentados de trânsito atendidos nas Marginais Tiete e Pinheiros, considerando os valores do Revised Trauma Score (RTS) do periodo pre-hospitalar. As vitimas com RTS=12 somaram 90,8%, com RTS=11, 4,0% e RTS<10, 5,2%. No grupo de RTS<10, destacam-se os atropelamentos (36,4%), os impactos frontais (24,2%), as vitimas projetadas (36,4%) ou presas as ferragens (15,1%), e que receberam o maior percentual de procedimentos de suporte avancado. Os motociclistas e as vitimas do genero masculino e de idade entre 21 e 30 anos predominaram. Espera-se com este estudo, fornecer subsidios para a melhora da assistencia as vitimas de acidente de trânsito.

Predetermining value analysis of the prehospital phase procedures in trauma victims survival

A proposta deste estudo foi analisar o valor predeterminante dos procedimentos realizados, durante o atendimento pre-hospitalar no tempo de sobrevivencia de vitimas de acidentes de trânsito. Dados de 175 vitimas com Revised Trauma Score < 11, atendidas e transportadas pelo suporte avancado a vida a hospitais terciarios, foram submetidas a Analise de Sobrevivencia de Kaplan Meier e a Analise de Riscos Proporcionais de Cox. Identificou-se 4 grupos de procedimentos associados a sobrevivencia: circulatorios basicos; respiratorios avancados; volume reposto e medicamentos. Ate a alta hospitalar, as vitimas, submetidas a entubacao orotraqueal e compressoes toracicas, apresentaram 3,6 e 6,4 vezes maior risco para o obito, respectivamente. A necessidade de realizacao de via aerea definitiva e de reanimacao cardiorrespiratoria na fase pre-hospitalar foi predeterminante de maior risco para o obito. A reposicao de volume inferior a 1000ml foi o unico fator predeterminante com forca protetora para o risco de obito.The aim of this study was to analyze the determining value of the procedures carried out during prehospital care in the survival time of traffic accident victims. Data of 175 victims with Revised Trauma Score pound 11, cared for and transported by advanced life support to tertiary referral hospitals, were submitted to Kaplan-Meier Survival Analysis and to Cox proportional hazards model. Four procedure groups associated with survival were identified: basic circulatory; advanced respiratory; volume replaced and medication. Until hospital discharge, the victims who underwent orotracheal intubation and chest compressions showed 3.6 and 6.4 times higher death hazards, respectively. The need for definitive airway and cardiopulmonary resuscitation in the prehospital phase was predetermining with higher death hazard. The less than 1000 ml intravenous fluid replacement was the only predetermining factor with protective power against death hazard.

Indicadores clínicos e pré-hospitalares de sobrevivência no trauma fechado: uma análise multivariada

O objetivo do estudo foi identificar os indicadores clinicos e pre-hospitalares associados a sobrevivencia de vitimas de trauma fechado. Foram utilizadas a analise de sobrevivencia de Kaplan Meier, e de Riscos Proporcionais de Cox, para analisar a associacao de 33 variaveis ao obito precoce e tardio, propondo modelos multivariados. Os modelos finais ate 48h pos-trauma evidenciaram altos coeficientes de risco promovidos pelas lesoes abdominais, Injury Severity Score >25, procedimentos respiratorios avancados e compressoes toracicas pre-hospitalares. No modelo ate 7 dias, a pressao arterial sistolica na cena do acidente, se menor de 75mmHg, foi associada a maior risco de obito e se ausente, foi associada ao mais elevado risco de obito apos 7 dias. A reposicao de volume pre-hospitalar apresentou efeito protetor em todos os periodos. Os resultados sugerem que a magnitude da hipoxemia e da instabilidade hemodinâmica diante da hemorragia, influenciaram de forma significante o obito precoce e tardio desse grupo de vitimas.The aim of the study was to identify the clinical and prehospital indicators associated to the survival of blunt trauma victims. The Kaplan Meier survival analysis and the Cox proportional hazards model were used to analyze the association of 33 variables to early and late death, proposing multivariate models. The final models until 48 hours post-trauma showed high rates of risk promoted by abdominal injuries, Injury Severity Score > or = 25, advanced respiratory procedures and prehospital chest compressions. In the model up to 7 days, a systolic blood pressure in accident site lower than 75 mmHg was associated with increased risk of death, and if absent it was associated with higher risk of death after 7 days. The prehospital volume replacement showed a protective effect in all periods. Results suggest that the magnitude of hypoxemia and hemodynamic instability due to bleeding had a significant influence on early and late death in this group of victims.

Análise do valor predeterminante dos procedimentos da fase pré-hospitalar na sobrevivência das vítimas de trauma

A proposta deste estudo foi analisar o valor predeterminante dos procedimentos realizados, durante o atendimento pre-hospitalar no tempo de sobrevivencia de vitimas de acidentes de trânsito. Dados de 175 vitimas com Revised Trauma Score < 11, atendidas e transportadas pelo suporte avancado a vida a hospitais terciarios, foram submetidas a Analise de Sobrevivencia de Kaplan Meier e a Analise de Riscos Proporcionais de Cox. Identificou-se 4 grupos de procedimentos associados a sobrevivencia: circulatorios basicos; respiratorios avancados; volume reposto e medicamentos. Ate a alta hospitalar, as vitimas, submetidas a entubacao orotraqueal e compressoes toracicas, apresentaram 3,6 e 6,4 vezes maior risco para o obito, respectivamente. A necessidade de realizacao de via aerea definitiva e de reanimacao cardiorrespiratoria na fase pre-hospitalar foi predeterminante de maior risco para o obito. A reposicao de volume inferior a 1000ml foi o unico fator predeterminante com forca protetora para o risco de obito.The aim of this study was to analyze the determining value of the procedures carried out during prehospital care in the survival time of traffic accident victims. Data of 175 victims with Revised Trauma Score pound 11, cared for and transported by advanced life support to tertiary referral hospitals, were submitted to Kaplan-Meier Survival Analysis and to Cox proportional hazards model. Four procedure groups associated with survival were identified: basic circulatory; advanced respiratory; volume replaced and medication. Until hospital discharge, the victims who underwent orotracheal intubation and chest compressions showed 3.6 and 6.4 times higher death hazards, respectively. The need for definitive airway and cardiopulmonary resuscitation in the prehospital phase was predetermining with higher death hazard. The less than 1000 ml intravenous fluid replacement was the only predetermining factor with protective power against death hazard.

Clinical and prehospital survival indicators in blunt trauma: a multivariate analysis

O objetivo do estudo foi identificar os indicadores clinicos e pre-hospitalares associados a sobrevivencia de vitimas de trauma fechado. Foram utilizadas a analise de sobrevivencia de Kaplan Meier, e de Riscos Proporcionais de Cox, para analisar a associacao de 33 variaveis ao obito precoce e tardio, propondo modelos multivariados. Os modelos finais ate 48h pos-trauma evidenciaram altos coeficientes de risco promovidos pelas lesoes abdominais, Injury Severity Score >25, procedimentos respiratorios avancados e compressoes toracicas pre-hospitalares. No modelo ate 7 dias, a pressao arterial sistolica na cena do acidente, se menor de 75mmHg, foi associada a maior risco de obito e se ausente, foi associada ao mais elevado risco de obito apos 7 dias. A reposicao de volume pre-hospitalar apresentou efeito protetor em todos os periodos. Os resultados sugerem que a magnitude da hipoxemia e da instabilidade hemodinâmica diante da hemorragia, influenciaram de forma significante o obito precoce e tardio desse grupo de vitimas.The aim of the study was to identify the clinical and prehospital indicators associated to the survival of blunt trauma victims. The Kaplan Meier survival analysis and the Cox proportional hazards model were used to analyze the association of 33 variables to early and late death, proposing multivariate models. The final models until 48 hours post-trauma showed high rates of risk promoted by abdominal injuries, Injury Severity Score > or = 25, advanced respiratory procedures and prehospital chest compressions. In the model up to 7 days, a systolic blood pressure in accident site lower than 75 mmHg was associated with increased risk of death, and if absent it was associated with higher risk of death after 7 days. The prehospital volume replacement showed a protective effect in all periods. Results suggest that the magnitude of hypoxemia and hemodynamic instability due to bleeding had a significant influence on early and late death in this group of victims.

Survival after motor vehicle crash: impact of clinical and prehospital variables

OBJECTIVE To assess clinical and prehospital variables associated with survival of motor vehicle crash victims. METHODS Study carried out in the city of São Paulo (Southeastern Brazil), from 1999 to 2003. Data from 175 patients, who were aged between 12 and 65 years and had been motor vehicle crash victims, were analyzed. Kaplan-Meier Survival Analysis was used to approach the results at the accident scene with victims scoring <11, according to the Revised Trauma Score. Variables analyzed were: sex, age, injury mechanisms, basic and advanced support procedures, Revised Trauma Score parameters and fluctuations, time elapsed in the prehospital phase and trauma severity according to the Injury Severity Score and Maximum Abbreviated Injury Scale. RESULTS Analysis revealed that victims who were less likely to survive during the hospitalization period showed serious lesions in the abdomen, thorax, or lower limbs, with negative fluctuation of respiratory frequency and Revised Trauma Score in the prehospital phase. In addition, they needed specialized interventions or thoracic compressions. Brain lesions were associated with late death. CONCLUSIONS Recognition of variables involved in the survival of motor vehicle crash victims may help to determine protocols and to make decisions in order to perform pre- and in-hospital interventions and, consequently, maximize survival.OBJETIVO: Analisar as variaveis clinicas e pre-hospitalares associadas a sobrevivencia de vitimas de acidente de trânsito. METODOS: Estudo realizado no municipio de Sao Paulo, SP, de 1999 a 2003. Foram analisados dados de 175 pacientes, entre 12 e 65 anos, vitimados por acidente de trânsito. A Analise de Sobrevivencia de Kaplan-Meier foi utilizada na abordagem dos resultados na cena do acidente com as vitimas de escore <11 segundo o Revised Trauma Score. As variaveis analisadas foram: sexo, idade, mecanismos do acidente, procedimentos de suporte basico e avancado realizados, parâmetros e flutuacoes do Revised Trauma Score, tempo consumido na fase pre-hospitalar e gravidade do trauma segundo o Injury Severity Score e a Maximum Abbreviated Injury Scale. RESULTADOS: A analise identificou que as vitimas que tiveram menor probabilidade de sobrevivencia durante todo periodo de internacao hospitalar apresentaram: lesoes graves no abdome, torax ou membros inferiores, com flutuacao negativa da frequencia respiratoria e do Revised Trauma Score na fase pre-hospitalar e necessitaram de intervencoes avancadas ou compressoes toracicas. As lesoes encefalicas foram associadas ao obito tardio. CONCLUSOES: O reconhecimento das variaveis envolvidas na sobrevivencia de vitimas de acidentes de trânsito pode auxiliar na determinacao de protocolos e na tomada de decisao para a realizacao de intervencoes pre e intra-hospitalares e consequentemente maximizar a sobrevivencia.

Indicadores clínicos y prehospitalarios de supervivencia al trauma cerrado: un análisis multivariado

O objetivo do estudo foi identificar os indicadores clinicos e pre-hospitalares associados a sobrevivencia de vitimas de trauma fechado. Foram utilizadas a analise de sobrevivencia de Kaplan Meier, e de Riscos Proporcionais de Cox, para analisar a associacao de 33 variaveis ao obito precoce e tardio, propondo modelos multivariados. Os modelos finais ate 48h pos-trauma evidenciaram altos coeficientes de risco promovidos pelas lesoes abdominais, Injury Severity Score >25, procedimentos respiratorios avancados e compressoes toracicas pre-hospitalares. No modelo ate 7 dias, a pressao arterial sistolica na cena do acidente, se menor de 75mmHg, foi associada a maior risco de obito e se ausente, foi associada ao mais elevado risco de obito apos 7 dias. A reposicao de volume pre-hospitalar apresentou efeito protetor em todos os periodos. Os resultados sugerem que a magnitude da hipoxemia e da instabilidade hemodinâmica diante da hemorragia, influenciaram de forma significante o obito precoce e tardio desse grupo de vitimas.The aim of the study was to identify the clinical and prehospital indicators associated to the survival of blunt trauma victims. The Kaplan Meier survival analysis and the Cox proportional hazards model were used to analyze the association of 33 variables to early and late death, proposing multivariate models. The final models until 48 hours post-trauma showed high rates of risk promoted by abdominal injuries, Injury Severity Score > or = 25, advanced respiratory procedures and prehospital chest compressions. In the model up to 7 days, a systolic blood pressure in accident site lower than 75 mmHg was associated with increased risk of death, and if absent it was associated with higher risk of death after 7 days. The prehospital volume replacement showed a protective effect in all periods. Results suggest that the magnitude of hypoxemia and hemodynamic instability due to bleeding had a significant influence on early and late death in this group of victims.

ANÁLISIS DEL VALOR PREDETERMINANTE DE LOS PROCEDIMIENTOS DE LA FASE PREHOSPITALARIA EN LA SOBREVIVENCIA DE LAS VÍCTIMAS DE TRAUMA

A proposta deste estudo foi analisar o valor predeterminante dos procedimentos realizados, durante o atendimento pre-hospitalar no tempo de sobrevivencia de vitimas de acidentes de trânsito. Dados de 175 vitimas com Revised Trauma Score < 11, atendidas e transportadas pelo suporte avancado a vida a hospitais terciarios, foram submetidas a Analise de Sobrevivencia de Kaplan Meier e a Analise de Riscos Proporcionais de Cox. Identificou-se 4 grupos de procedimentos associados a sobrevivencia: circulatorios basicos; respiratorios avancados; volume reposto e medicamentos. Ate a alta hospitalar, as vitimas, submetidas a entubacao orotraqueal e compressoes toracicas, apresentaram 3,6 e 6,4 vezes maior risco para o obito, respectivamente. A necessidade de realizacao de via aerea definitiva e de reanimacao cardiorrespiratoria na fase pre-hospitalar foi predeterminante de maior risco para o obito. A reposicao de volume inferior a 1000ml foi o unico fator predeterminante com forca protetora para o risco de obito.The aim of this study was to analyze the determining value of the procedures carried out during prehospital care in the survival time of traffic accident victims. Data of 175 victims with Revised Trauma Score pound 11, cared for and transported by advanced life support to tertiary referral hospitals, were submitted to Kaplan-Meier Survival Analysis and to Cox proportional hazards model. Four procedure groups associated with survival were identified: basic circulatory; advanced respiratory; volume replaced and medication. Until hospital discharge, the victims who underwent orotracheal intubation and chest compressions showed 3.6 and 6.4 times higher death hazards, respectively. The need for definitive airway and cardiopulmonary resuscitation in the prehospital phase was predetermining with higher death hazard. The less than 1000 ml intravenous fluid replacement was the only predetermining factor with protective power against death hazard.