Evaluación de la hemorragia y el shock hemorrágico postraumático

Una vez metidos en el abordaje diagnóstico de la hemorragia en politraumatizado, que como vimos, debe ser perentorio, es necesario tomar en cuenta ciertos detalles en este proceso integrado de manejo y evaluación.

El hematocrito

En primer lugar las Guías Europeas de manejo de la hemorragia en el politraumatizado sugieren que el hematocrito como valor aislado no es marcador de hemorragia. El uso del hematocrito para detectar hemorragia oculta ha sido un tema de debate durante mucho tiempo. El hematocrito tiene la limitación de que las medidas de resucitación pueden producir confusión, por el efecto dilucional de las soluciones administradas, como el efecto sobre el mismo valor de la transfusión de concentrado de eritrocitos. Además es un hecho que el hematocrito inicial no refleja la pérdida sanguínea por la misma pérdida y los mecanismos compensadores del paciente, entre los que está la movilización de líquidos desde el espacio intersticial. Por tanto no se recomienda el uso de mediciones únicas de hematocrito como marcador aislado de hemorragia.

Lactato sérico y déficit de bases

Tanto el ácido láctico como el déficit de bases son parámetros sensibles para evaluar la magnitud del sangrado y el shock. El lactato está asociado al pronóstico. El ácido láctico es un marcador indirecto del déficit de oxígeno, la hipoperfusión tisular y la severidad del shock hemorrágico.

El déficit de bases proporciona una estimación indirecta de la acidosis tisular global debida al trastorno de perfusión.

Se ha demostrado que los cambios en las concentraciones de lactato proveen una evaluación temprana y objetiva de la respuesta a la terapia. Así mismo se ha sugerido que las determinaciones repetidas de lactato conforman un índice pronóstico en pacientes con shock circulatorio.

No solo es importante en valor absoluto inicial del lactato, sino la rapidez con la que ese nivel desciende al rango normal, como marcador pronóstico.

Existe una correlación significativa entre el déficit de bases al ingreso, los requerimientos de transfusión y el riesgo de desarrollo de falla de múltiples órganos y muerte. El déficit de bases es un marcador altamente sensible de la extensión del shock postraumático y mortalidad.

Se recomienda la evaluación independiente de ambos parámetros, el lactato y el déficit de bases en el abordaje del shock en trauma.

Evaluación de la coagulación en el shock y pre-shock

Con el fin de detectar el desarrollo de coagulopatía, se recomienda determinar en conjunto y de manera repetida el tiempo parcial de tromboplastina activada, el tiempo y actividad de protrombina, el fibrinógeno y las plaquetas. No debe usarse solamente los dos primeros parámetros para guiar la terapia. Estos pueden ser aún normales aunque ya esté en desarrollo una alteración de la coagulación.

Los equipos portátiles que proporcionan determinación de INR o PTTa parecen ser una opción en los servicios de urgencias y emergencias pero no sustituyen los parámetros mencionados más arriba.

En el próximo post entraremos en el tema del control de la hemorragia y el manejo del shock.

Awesome Presentations at #TTCNYC15

St.Emlyn's - Meducation in Virchester #FOAMed

Back in November 2015 Simon and I had the honour of joining the amazing faculty and participants at the Teaching Course in New York. We’ve already shared some of our thoughts and content, on Educational Theory You Must Know, Being a Better Learner (parts 1, 2 and 3) and there are other fantastic resources scattered […]

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Ever wanted to be a Clinical Forensic Medicine Registrar?

This post is written by Dr Nicola Cunningham, Senior Forensic Physician at Victorian Institute of Forensic Medicine and Emergency Physician at St Vincent’s Hospital, Melbourne.

Ever wondered what it would be like to work in a field like “CSI”?

A term as a Clinical Forensic Medicine Registrar at the Victorian Institute of Forensic Medicine (VFM) is as close as it gets as a doctor to navigating your way through the murky bowels of crime and experiencing the fascinating world of forensic labs, police stations and courts.

We don’t have a theme song by the Who, and we never look as glamorous at two in the morning, but we do have shiny silver cases and get to talk a lot about injuries and DNA. We meet the good, the bad and the bizarre, in a job where no two days are the same.

Clinical Forensic Medicine is a subspecialty that is very well suited to Emergency Medicine training. The work covers a range of areas including toxicology, addiction medicine, gynaecology, sexual health, psychiatry, general practice and custodial health. The work takes us to hospitals, police stations, and prisons, to name a few. When we are not out “on a job”, we are discussing clinical cases, writing up reports, and learning from our colleagues, in a unique building that houses physicians, pathologists, and other forensic specialists working in anthropology, odontology, radiology, entomology, and toxicology. Just down the corridor are the Coroners’ Courts – another rich source of education and expertise for doctors.

The ACEM has long recognised the importance of Clinical Forensic Medicine training for emergency trainees and the posts have been accredited for special skills training since 1996. Initially available for one registrar every six months, it is a rotation that has grown in size and reputation to three registrar positions in recent years. In 2016, twenty years after the first emergency registrar joined our honour roll; fifty-six emergency registrars (as well as a number of registrars from other specialities) have shared our offices and our rosters, and taken away with them many skills and experiences that will continue to serve them well throughout their careers.

Many of our ex-registrars have enjoyed the work so much, they have embarked on the Master of Forensic Medicine, or are working towards a Fellowship with the Faculty of Clinical Forensic Medicine (Royal College of Pathologists of Australasia), or have continued to work occasional shifts on the after-hours roster.

In fact, some of us have never left.

Dr Nicola Cunningham
B. Med, MForensMed, FFCFM (RCPA), FACEM
Senior Forensic Physician, Victorian Institute of Forensic Medicine
Emergency Physician, St Vincent’s Hospital Melbourne

Clinical Forensic Medicine Registrar positions with VIFM are available starting from 1st August 2016 and starting in 2017:

Download (PDF?DL=1, 263KB)

Download (PDF?DL=1, 747KB)

 

The post Ever wanted to be a Clinical Forensic Medicine Registrar? appeared first on LITFL: Life in the Fast Lane Medical Blog.

#SettimanaPS2016: Una grande partecipazione per l’edizione di quest’anno

@SilviaAlparone

 

Si è chiusa domenica 29 maggio l’edizione 2016 della Settimana nazionale Simeu del Pronto soccorso. La terza edizione della manifestazione, partita nel 2014, ha registrato una notevole partecipazione della popolazione alle iniziative promosse dalla società scientifica e una crescente attenzione delle istituzioni e dei mezzi di comunicazione ai singoli eventi a livello locale e ai dati e allo spirito dell’iniziativa a livello nazionale.

Il tema di quest’anno, dedicato al paziente anziano fragile, ha colto nel segno: l’argomento sensibile sia dal punto di vista sanitario che sociale, trattato con l’opportuna diffusione di dati e con un ricco corredo di informazioni relative ai percorsi di cura esistenti e necessari per migliorare il servizio, ha ottenuto lo scopo di attirare l’attenzione sul problema in sè e sul tema del ruolo del pronto soccorso in generale.

Particolarmente gratificanti per gli organizzatori, per la risposta del pubblico coinvolto, le molte iniziative di confronto che si sono tenute nei centri anziani, con la partecipazione attiva degli iscritti anche ai momenti di formazione sulle tecniche di primo soccorso in caso di necessità.

Molto diversificata e particolarmente creativa l’offerta dei calendari delle singole regioni. Oltre all’iniziativa della Basilicata di cui abbiamo parlato in un post precedente e dello spettacolo di Livorno, è da segnalare a Bergamo un flash mob che si è svolto nei corridoi dell’Ospedale papa Giovanni XXIII.

L’evento conclusivo a Roma all’outlet di Valmontone, centro commerciale alle porte della capitale, ha coinvolto il pubblico presente, salutando idealmente tutti i partecipanti ai molti eventi delle diverse regioni e dando

appuntamento alla prossima edizione della Settimana del Pronto Soccorso nella primavera del 2017!!!

Napoli

 

 

 

 

 

 

 

 

 

Vercelli

Barletta

Genova

Tasty Morsels of EM 066 – Pneumothorax

pneumothorax

From this lovely review and update paper in Lancet Resp Med. Found this via Josef Liebman’s EMU. One of the slightly more obscure FOAMed resources but he always seems to pluck out some papers i’d never find on my own.

Primary v Secondary:

  • this classification (that forms the mainstay of classification in the hallowed BTS guidelines) dates back to the early 20th century and was mainly used to distinguish those with PTX from TB (who would go to a sanitarium for a year) vs those with PTX from other causes.
  • In reality, there is much more likely to be a continuum between the truly idiopathic PTX and the secondary PTX from severe COPD. Most of those that we call primary PTX probably aren’t and if you look hard enough you will find a cause
  • they don’t say this to totally undermine the binary separation but it’s worth knowing that things are a little bit more complicated than that.

Causes:

  • in the young tall non smoker telling them that their primary PTX is from a single ruptured bleb is probably not true. There is some evidence that there are areas of the visceral pleura have “pores” that permit air leak into the pleural cavity
  • cannabis smoking causes lots of destructive lung disease and lots of PTX
  • Birt-Hogg-Dube syndrome. Only included for your next dinner party conversation…

Management:

  • not entirely clear how expanding a lung is meant to fix the hole in the visceral pleura as there’s no reason to believe that bringing the visceral and parietal pleura together will cause a spontaneous pleurodesis
  • as a result it’s not clear if we really have to intervene at all and the aussies are now trialling a conservative approach for even large PTX.
  • blood patching – not just for post LP headaches. Some data and theory on putting some autologous blood in the pleural cavity in the hope it helps the visceral hole heal. It seems like hocus pocus but then so does blood patch for LP headache and it seems to work…
  • we should probably use Heimlich (he of the maneuver) flutter valves more for OPD management. I think these are great but you’d need a fairly clear follow up mechanism in place.

Recurrence:

  • some debate over this. Some studies said 20% some more recent better data says 40% for a primary PTX. If it’s that high then  perhaps we should be thinking about interventions to prevent recurrence (which seems to be mainly VATS i think)
  • after a VATS recurrence is low, some debate on the number but the paper quoted numbers from 2-5%

 

 

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