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FAST is essential to decide whether trauma patients need laparotomy, but it has a notable decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture.Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who died. The FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables.Over the 13-year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs 14%, P .05). Patients with positive FAST died more than negative FAST (43% vs 26%); and 4 out of 10 hemodynamically unstable patients who underwent non-therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis.FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduced notably by applying preperitoneal packing.

espanolIntroduccion La exactitud del FAST disminuye notablemente en los pacientes politraumaticos con fractura pelvica. El objetivo es analizar las consecuencias de tomar decisiones terapeuticas basadas en el resultado del FAST en los pacientes politraumaticos con fractura de pelvis. Metodos Estudio descriptivo de pacientes con politraumatismos mayores de 16 anos que han ingresado en el area de criticos o que han fallecido previamente, con fractura pelvica. El resultado del FAST ha sido comparado con un valor realmente positivo o negativo segun el resultado de la laparotomia o de la tomografia computarizada. Resultados En 13 anos, se ha incluido a 263 pacientes politraumaticos con fractura pelvica (ISS medio de 31; mortalidad 19%). El FAST tenia una sensibilidad del 65,2%, una especificidad del 69%, una tasa de falsos negativos del 34,8% y una tasa de falsos positivos del 30,9%. Los pacientes hemodinamicamente inestables tenian el doble de mortalidad que los pacientes estables (27% vs. 14%, p Conclusiones La reducida eficacia del FAST en pacientes con fractura de pelvis nos obliga a cuestionarnos las consecuencias de la toma de decisiones terapeuticas con base en sus resultados. Los pacientes con FAST falsamente positivo tienen una mortalidad mayor, que se puede reducir aplicando un packing preperitoneal. EnglishIntroduction FAST is essential to decide if trauma patients need laparotomy, but has a notably decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture. Methods Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who were fallecimiento. FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables. Results Over the 13–year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs. 14%, p Conclusion FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduce notably applying a preperitoneal packing.

Purpose Persistent occult hypoperfusion after initial resuscitation is strongly associated with increased morbidity and mortality after severe trauma. The objective of this study was to analyze regional tissue oxygenation, along with other global markers, as potential detectors of occult shock in otherwise hemodynamically stable trauma patients. Methods Trauma patients undergoing active resuscitation were evaluated 8 h after hospital admission with the measurement of several global and local hemodynamic/metabolic parameters. Apparently hemodynamically stable (AHD) patients, defined as having SBP ≥ 90 mmHg, HR 2) was measured non-invasively by near-infrared spectroscopy (NIRS) on the forearm. A vascular occlusion test was performed, allowing a 3-min deoxygenation period and a reoxygenation period following occlusion release. Minimal rSO2 (rSO2min), Delta-down (rSO2–rSO2min), maximal rSO2 following cuff-release (rSO2max), and Delta-up (rSO2max–rSO2min) were computed. The NIRS response to the occlusion test was also measured in a control group of healthy volunteers. Results Sixty-six consecutive trauma patients were included. After 8 h, 17 patients were classified as AHD, of whom five were finally considered to have OS and 12 THD. No hemodynamic, metabolic or coagulopathic differences were observed between the two groups, while NIRS-derived parameters showed statistically significant differences in Delta-down, rSO2min, and Delta-up. Conclusions After 8 h of care, NIRS evaluation with an occlusion test is helpful for identifying occult shock in apparently hemodynamically stable patients. Level of evidence IV, descriptive observational study. Trial registration ClinicalTrials.gov Registration Number: NCT02772653.

Resumen Introduccion Las constantes vitales detectan la presencia de hemorragia al perder grandes cantidades de sangre, lo que comporta una gran morbimortalidad. El Shock Index (SI) es un parametro que detecta el sangrado con puntos de corte de 0,9. El objetivo de este estudio es valorar si un punto de corte de ≥ 0,8 es mas sensible para detectar sangrado oculto, permitiendo iniciar maniobras terapeuticas mas precoces. Metodos Estudio analitico de validacion del SI que incluye pacientes politraumatizados graves mayores de 16 anos. Se registran constantes vitales y escalas predictivas de sangrado: SI, Assessment of Blood Consumption score y Pulse Rate Over Pressure score. Se analiza la relacion del SI con 5 marcadores predictivos de sangrado: necesidad de transfusion masiva, embolizacion angiografica, control del sangrado quirurgico, muerte por shock hipovolemico y «sangrado activo» (presencia de al menos uno de los 4 marcadores anteriores en un paciente). Resultados Recogida prospectiva de datos de 1.402 pacientes politraumatizados durante 10 anos. El Injury Severity Score medio fue de 20,9 (DE 15,8). Hubo una mortalidad del 10%. El SI medio fue de 0,73 (DE 0,29). En total presentaron «sangrado activo» el 18,7% de la serie. El SI medio en los pacientes con «sangrado activo» fue de 0,87, mientras que las constantes vitales estaban dentro de la normalidad. El area bajo la curva ROC del SI para el «sangrado activo» fue de 0,749. Conclusiones El SI con un punto de corte ≥ 0,8 es mas sensible que aquel con el punto de corte ≥ 0,9 y permite iniciar maniobras de reanimacion mas precoces en los pacientes con sangrado oculto.

Introduction Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of ≥0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers. Methods SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor “active bleeding” (defined as the presence of at least one of the 4 markers above). Results Data from 1402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). “Active bleeding” was present in 18.7% of patients. The SI area under the ROC curve for “active bleeding” was 0.749. Conclusions An SI cut-off point ≥0.8 is more sensitive than ≥0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding.

Introduction An occult pneumothorax is found in 2%–15% trauma patients. Observation (without tube thoracostomy) in these patients presents still some controversies in the clinical practice. The objective of the study is to evaluate the efficacy and the adverse effects when observation is performed. Methods A retrospective observational study was undertaken in our centre (university hospital level II ). Data were obtained from a database with prospective registration. A total of 1087 trauma patients admitted in the Intensive Care Unit from 2006 to 2013 were included. Results In this period, 126 patients with occult pneumothorax were identified, 73 patients (58%) underwent immediate tube thoracostomy and 53 patients (42%) were observed. Nine patients (12%) failed observation and required tube thoracostomy for pneumothorax progression or haemothorax. No patient developed a tension pneumothorax or experienced another adverse event related to the absence of tube thoracostomy. Of the observed patients 16 were under positive pressure ventilation, in this group 3 patients (19%) failed observation. There were no differences in mortality, hospital length of stay or intensive care length of stay between the observed and non-observed group. Conclusion Observation is a safe treatment in occult pneumothorax, even in pressure positive ventilated patients.

Resumen Introduccion Alrededor del 2-15% de los pacientes politraumatizados presentan un neumotorax oculto. La aplicacion del tratamiento conservador (observacion) en la practica clinica diaria aun sigue siendo controvertido. Nuestra hipotesis es que es factible realizar un tratamiento conservador. El objetivo de este estudio es evaluar la eficacia y los efectos adversos del tratamiento conservador del neumotorax oculto en nuestro medio. Metodos Estudio observacional retrospectivo (analisis de base de datos con registro prospectivo) realizado en un hospital universitario de nivel II . Inclusion de 1.087 pacientes politraumatizados mayores de 16 anos ingresados en el area de criticos desde 2006 hasta 2013. Resultados En este periodo, 126 pacientes presentaron neumotorax oculto, en 73 (58%) se decidio observacion. En 9 pacientes (12%) fracaso la observacion (precisaron colocacion de drenaje pleural) por aumento del neumotorax o aparicion de hemotorax. De los pacientes observados, 16 fueron ventilados bajo presion positiva. En este grupo fracaso la observacion en 3 pacientes (19%). Ningun paciente presento neumotorax a tension u otro problema relacionado con la ausencia de drenaje. No hubo diferencias entre grupos (observacion vs. drenaje) respecto a mortalidad, estancia hospitalaria ni estancia en la unidad de criticos. Conclusion El tratamiento de eleccion de los pacientes con neumotorax oculto es la observacion clinica. Este tratamiento tambien es factible en los pacientes ventilados bajo presion positiva.

Resumen Introduccion El politraumatismo sigue siendo una de las principales causas de muerte entre los 10 y los 40 anos, causando graves incapacidades en los pacientes que sobreviven. El objetivo de nuestro estudio es realizar un analisis de calidad de la atencion del paciente politraumatizado mediante un estudio epidemiologico. Metodo Registro prospectivo de todos los pacientes politraumaticos atendidos en nuestro hospital, mayores de 16 anos, que ingresan en el area de criticos o mueren antes del ingreso. Resultados Desde marzo del 2006 hasta agosto del 2014, registramos 1.200 politraumatizados. La mayoria fueron hombres (75%), con una mediana de edad de 45 anos. El ISS medio fue de 20,9 ± 15,8 y el mecanismo de accion mas frecuente fue cerrado (94% casos). La mortalidad global fue del 9,8% (117 casos), siendo la muerte neurologica la principal causa de fallecimiento (45,3%), seguida de la muerte por shock hipovolemico (29,1%). En 17 casos (14,5% fallecimiento) la mortalidad fue considerada como evitable o potencialmente evitable un total de 327 pacientes (27,3%) precisaron de tratamiento quirurgico urgente y 106 pacientes (8,8%) precisaron de un tratamiento mediante radiologia intervencionista de caracter urgente. El 18,5% de los pacientes (222) presentaron alguna lesion inadvertida, con un total de 318 lesiones inadvertidas. Conclusion La atencion ofrecida en nuestro centro es correcta. La necesidad de una recogida de datos prospectiva de la atencion global a los pacientes politraumatizados es necesaria e imprescindible para poder evaluar la calidad ofrecida y mejorar los resultados.

Aquest treball preten valorar la utilitat del model de risc d'evisceracio desenvolupat per Van Ramshorst et al. entre els pacients sotmesos a cirurgia abdominal per laparotomia mitja en el Servei de Cirurgia General i de l'Aparell Digestiu de l'Hospital de Sabadell – Corporacio Sanitaria i Universitaria Parc Tauli – Barcelona. El model de risc inclou dades postoperatories que fan perdre capacitat pronostica clinica, per aquest motiu es proposa una modificacio d'aquest model (Van Ramshorst modificat), tenint en compte nomes les variables preoperatories. Podem concloure que mentre el model de risc d'evisceracio de Van Ramshorst et al. es util en la nostra mostra de pacients, la modificacio proposada necessitaria retocs per a millorar la seva capacitat pronostica.

The aim of this study is to determine the usefulness of the risk model developed by van Ramshorst et al., and a modification of the same, to predict the abdominal wound dehiscence's risk in patients who underwent midline laparotomy incisions.Observational longitudinal retrospective study.Patients who underwent midline laparotomy incisions in the General and Digestive Surgery Department of the Sabadell's Hospital-Parc Taulí's Health and University Corporation-Barcelona, between January 1, 2010 and June 30, 2010. Dependent variable: Abdominal wound dehiscence.Global risk score, preoperative risk score (postoperative variables were excluded), global and preoperative probabilities of developing abdominal wound dehiscence.176 patients. Patients with abdominal wound dehiscence: 15 (8.5%). The global risk score of abdominal wound dehiscence group (mean: 4.97; IC 95%: 4.15-5.79) was better than the global risk score of No abdominal wound dehiscence group (mean: 3.41; IC 95%: 3.20-3.62). This difference is statistically significant (P.001). The preoperative risk score of abdominal wound dehiscence group (mean: 3.27; IC 95%: 2.69-3.84) was better than the preoperative risk score of No abdominal wound dehiscence group (mean: 2.77; IC 95%: 2.64-2.89), also a statistically significant difference (P.05). The global risk score (area under the ROC curve: 0.79) has better accuracy than the preoperative risk score (area under the ROC curve: 0.64).The risk model developed by van Ramshorst et al. to predict the abdominal wound dehiscence's risk in the preoperative phase has a limited usefulness. Additional refinements in the preoperative risk score are needed to improve its accuracy.

Resumen Introduccion La introduccion del libro informatico del residente, de la Asociacion Espanola de Cirujanos (LIR-AEC), nos ha permitido realizar evaluaciones particulares y generales de cada residente. El objetivo ha sido conocer la media de actividades asistenciales, cientificas y quirurgicas segun el programa de la especialidad. Material y metodo Registro de la actividad de los residentes en el LIR-AEC. Se ha cuantificado la actividad general por ano y por rotacion. Se ha analizado la relacion de intervenciones asistidas y realizadas y segun grados de complejidad. La media de actividades cientificas y asistenciales y la de guardias al mes. Resultados Desde 2004, 8 residentes han registrado su actividad en el LIR-AEC. Asisten a una media de 1.514 intervenciones, de las cuales realizan como cirujano 922 (62%). Asisten a 185 intervenciones laparoscopicas, de las que realizan 72 (39%). Como cirujanos, 864 (94%) de los 922 procedimientos son de los niveles 1, 2 y 3 (el 64, el 75 y el 53%, respectivamente). Realizan una media de 5,75 guardias por mes. Acuden de media durante la residencia a un total de 21 cursos y congresos. Participan en un total de 24 comunicaciones y posters, asi como en 6 publicaciones de media en la residencia. Conclusiones El LIR-AEC permite una evaluacion continua de la actividad del residente. Hemos podido conocer la media de actividades que realiza cada residente durante una rotacion y un ano determinados, esto permite conocer con exactitud si se cumplen los minimos definidos.

Resumen Introduccion La evolucion de nuestra especialidad en los ultimos anos obliga a realizar actualizaciones no solo en contenidos, sino en una evaluacion de los conocimientos aprendidos. El objetivo de este articulo es presentar nuestra experiencia en un modelo de evaluacion integral. Se basa en una valoracion de los conocimientos teoricos y las habilidades quirurgicas. Material y metodo El programa de formacion para los MIR que hemos aplicado esta fundamentado en 4 apartados: asistencial, formacion continuada, investigacion (doctorado) y control de la actividad realizada (libro informatico del residente). Permite una evaluacion de los conocimientos teoricos y las habilidades aprendidas al final de cada rotacion. Mediante la creacion del libro informatico del residente que presentamos, se practica cada 6 meses una cuantificacion de la actividad de forma continua y comparada. Resultados En julio de 2004, iniciamos la puesta en marcha de este sistema de evaluacion de la actividad de los residentes. Se entrego a cada uno de ellos su propia base de datos para que iniciara su desarrollo mediante la introduccion de todas las actividades realizadas. Se presentan los resultados de la actividad global y particular de cada residente. Conclusiones El metodo que utilizamos permite seguir la evolucion integral del residente y realizar, al final de cada ano y de la residencia, una valoracion totalmente objetiva. La generalizacion de este metodo o uno similar facilitara la realizacion de comparaciones con otros centros y bajo premisas similares. Por otra parte, podria unificar criterios y determinar desviaciones de formacion.

Polytrauma continues to be one of the main causes of death in the population between 10-40 years of age, and causes severe discapability in surviving patients. The aim of this study is to perform an analysis of the quality of care of the polytrauma patient using an epidemiological study.Prospective registry of all polytrauma patients treated at our hospital over 16 years of age, admitted to the critical care area or dead before admission.From March 2006 to August 2014, we registered 1200 polytrauma patients. The majority were men (75%) with a median age of 45. The mean ISS was 20,9±15,8 and the most common mechanism of injury was blunt trauma (94% cases), The global mortality rate was 9.8% (117 cases), and neurological death was the most frequent cause (45.3%), followed by hypovolemic shock (29,1%). In 17 cases (14,5% of deaths) mortality was considered evitable or potentially evitable, A total of 327 patients (27.3%) needed emergency surgery and 106 patients (8,8%) needed emergency treatment using interventional radiology. 18,5% of patients (222) presented an inadverted injury, with a total of 318 inadverted injuries.Trauma care at our centre is adequate. A prospective registry of the global care of polytrauma patients is necessary to evaluate the quality of care and improve results.

The use of lactic acid as marker of occult hyperfusion and its relationship with multiorgan failure (MOF) and/or mortality is a subject of debate.A prospective study was conducted on multiple injury patients over 16 years of age in critical care areas. The lactic acid was measured at the beginning and at 24 hours of the trauma and associating it with the patient morbidity and mortality.A total of 342 patients, with a mean injury severity score of 24.1, were included. The patients who survived had an initial, and 24 hours after the trauma, lactic acid of 27.8 mg/dl and 17.9 mg/dl, respectively, (normal values less than 22 mg/dl), increasing to 36.5mg/dl and 40.2mg/dl, respectively, in those who died. There were no differences between the initial lactic acid in patients with and without MOF, being increased at 24 hours in those who had MOF (17.8 vs 26.7). The patients with a lactic acid that got worse or remained abnormal at 24 hours had a higher mortality than those in which it remained the same or improved (25% - 17.1% vs 6.3% - 0.8%), with the percentage of patients with MOF also increasing (40.6% - 32.8% vs 14.9% - 11.1%). In haemodynamically stable patients, there was also a higher mortality when the lactic acid got worse or remained abnormal in the first 24 hours (23.8% - 19.2% vs 8.8% - 0%), as well as a higher percentage of MOF (38.1% - 26.9% vs 10.9% - 7.6%).The lactic acid results in the first 24 hours of the multiple injury patient are associated with mortality and MOF, even when the patient is haemodynamically stable.

Introduction The introduction of the Spanish Association of Surgeons resident's electronic book (AEC-E-Book), has meant that we can perform particular and overall assessments of each resident. The objective of this article has been to find out the mean health care, scientific, and surgical activities according to the speciality program. Material and method A register of the activities of residents in the AEC-E-Book. The overall activity per year and per rotation has been measured. The relationships of assisted interventions performed and their level of complexity have been analysed. The mean scientific and health care activities and the mean on-call periods per month. Results A total of 8 residents have registered their activity in the AEC-E-Book since the year 2004. They assisted in a mean of 1514 operations, of which 922 were performed as surgeon (62%). They assisted in 185 laparoscopic interventions, of which they performed 72 (39%). As surgeon, 864 (94%) of the 922 procedures 64% were level 1, 75% level 2, and 53% were level 3. They were on-call a mean of 5.75 times per month. They attended a total of 21 courses and congresses during residency. They took part in 24 presentations and posters, as well as in 6 journal publications during residence. Conclusions The AEC-E-Book enables the activity of the resident to be continually assessed. We have been able to find out the mean activities carried out by each resident during a particular rotation and year, thus being able to know exactly if they have fulfilled the defined minimums

pondencia. co: jhermoso@tauli.cat (J. Hermoso Bosch) Varon de 59 anos con antecedente de exodoncia hace un mes sin complicaciones. Presenta fiebre, astenia y dolor abdominal, se lo trata con analgesia y antibioticos sin mejoria, por lo que ingresa para completar estudio. Se realiza una ecocardiografia transtor acica por sospecha confirmada de endocarditis que muestra fraccion de eyeccion del 40%. En la TC de abdomen (fig. 1) se observan abscesos espl enicos multiples, que se puncionan con cultivo positivo para Streptococcus mitis. Debido a empeoramiento clinico con insuficiencia cardiaca, hipotension e insuficiencia renal se le practica esplenectomia, sin identificacion de germen en pieza quirurgica (fig. 2). Tiene una evolucion torpida por patologia cardiaca, y se le da el alta hospitalaria al mes de la intervencion.