Tourniquet use for civilian extremity hemorrhage: systematic review of the literature

INTRODUCTION

extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications.

METHODS

a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications.

RESULTS

of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised.

CONCLUSIONS

TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

The trauma and acute care surgeon in the COVID-19 pandemic era

The World Health Organization recognized in March 2020 the existence of a pandemic for the new coronavirus that appeared in China, in late 2019, and whose disease was named COVID-19. In this context, the SBAIT (Brazilian Society of Integrated Care for Traumatized Patients) conducted a survey with 219 trauma and emergency surgeons regarding the availability of personal protective equipment (PPE) and the role of the surgeon in this pandemic by means of an electronic survey. It was observed that surgeons have been acting under inadequate conditions, with a lack of basic supplies as well as more specific equipment such as N95 masks and facial shields for the care of potential victims who may be contaminated. The latter increases the risk of contamination of professionals, resulting in potential losses in the working teams. Immediate measures must be taken to guarantee access to safety equipment throughout the country, since all trauma victims and/or patients with emergency surgical conditions must be treated as potential carriers of COVID-19.

Recomendações para cirurgia de emergência durante a pandemia do COVID-19

Introdução: a pandemia provocada pelo 2019 Novel Coronavírus (COVID-19) provocou um desafio global de saúde pública, com repercussões em diversos setores da sociedade. As práticas médicas necessitaram adaptar-se no atendimento ao doente portador do COVID-19 ou suspeito. Métodos: realizou-se pesquisa bibliográfica de publicações e de diretrizes de sociedades médicas em relação às abordagens cirúrgicas de emergência nesta atual pandemia. Resultados: o material bibliográfico ainda é escasso, indefinido e de baixa evidência, mas são adequados neste momento inicial de enfrentamento do COVID-19 no Brasil. Conclusão: para reduzir o risco de contaminação dos profissionais de saúde, as técnicas e decisões cirúrgicas precisam adaptar-se ao cenário de pandemia do COVID-19.

Low-cost synthetic tourniquet training model

OBJECTIVE

to present a low-cost model for bleeding control training with the use of a tourniquet and the results of the training evaluation.

METHOD

low-cost and easy-to-purchase materials, such as upholstery foam, ethylene-vinyl acetate (EVA) sheet, plastic propulsion pump, saline container, water, school paint, serum equipment, rubber tubing for tourniquet, and a leg and an arm of a ghost mannequin, were used. In the model assembly, we created an active bleeding simulation system, which could only be controlled with the correct application of the tourniquet. The model was submitted to professional and academic evaluation.

RESULTS

the model was similar to human anatomy, proved to be practical in the bleeding control training with the use of a tourniquet, and had low cost.

CONCLUSION

the model for bleeding control training had excellent acceptability, was considered viable for educational purposes of tourniquet use, and had low cost.

Alternativas para o estabelecimento de via aérea cirúrgica durante a pandemia de COVID-19

RESUMO Atualmente médicos e profissionais da saúde encontram-se frente a uma pandemia desafiadora causada por uma nova cepa denominada 2019 Novel Coronavírus (COVID-19). A infecção humana pelo COVID-19 ainda não tem o espectro clínico completamente descrito, bem como não se sabe com precisão o padrão de letalidade, mortalidade, infectividade e transmissibilidade. Não há vacina ou medicamento específico disponível. O tratamento é de suporte e inespecífico. No Brasil, assim como no restante do mundo o número de casos de COVID-19 tem crescido de maneira alarmante levando a um aumento do número de internações assim como da mortalidade pela doença. Atualmente os estados com maior número de casos são, respectivamente, São Paulo, Rio de Janeiro, Distrito Federal e Ceará. O objetivo deste trabalho é oferecer alternativas a fim de orientar cirurgiões quanto ao manejo cirúrgico das vias aéreas em pacientes com suspeita e/ou confirmação para infecção pelo COVID-19.

Multiple victims incident simulation: training professionals and university teaching

OBJECTIVE

to describe the teaching strategy based on the Multiple Victims Incident (MVI) simulation, discussing and evaluating the performance of the students involved in the initial care of trauma victims.

METHODS

a cross-sectional, and quantitative study was performed. A realistic MVI simulation involving students, and professionals from nursery and medical schools, as well as a prehospital care team was performed.

RESULTS

it was possible to notice that the classification according to the START method (Simple Triage and Rapid Treatment) was correct in 94.1% of the time from the analysis of 17 preestablished checklists. Following the primary evaluation with the ABCDE mnemonic, all steps were performed correctly in 70%. However, there was only supply of oxygen in high flow in 64.7% of the examination. The search for visible and hidden bleeding was performed in 70.6% of the examination. The neurological evaluation with the Glasgow coma scale and pupillary evaluation occurred in 70.6% of the victims. The victims exposure was performed in 70.6% of the examination.

CONCLUSION

a simulated environment allows the consolidation and improvement of professional skills, especially when we are talking about a poorly trained area during the undergraduate program, such as the MVI. Early training and teamwork encourage clinical thinking, integration and communication, essential abilities when facing chaotic situations.

LIVER TRANSPLANTATION IN HEPATITIS DELTA: SOUTH AMERICA EXPERIENCE

BACKGROUND

The Amazon region is one of the main endemic areas of hepatitis delta in the world and the only one related to the presence of genotype 3 of the delta virus.

OBJECTIVE

To analyze the profile, mortality and survival of cirrhotic patients submitted to liver transplantation for chronic hepatitis delta virus and compare with those transplanted by hepatitis B virus monoinfection.

METHODS

Retrospective, observational and descriptive study. From May 2002 to December 2011, 629 liver transplants were performed at the Walter Cantídio University Hospital, of which 29 patients were transplanted due to cirrhosis caused by chronic delta virus infection and 40 by hepatitis B chronic monoinfection. The variables analyzed were: age, sex, MELD score, Child-Pugh score, upper gastrointestinal bleeding and hepatocellular carcinoma occurrence before the transplantation, perioperative platelet count, mortality and survival.

RESULTS

The Delta Group was younger and all came from the Brazilian Amazon Region. Group B presented a higher proportion of male patients (92.5%) compared to Group D (58.6%). The occurrence of upper gastrointestinal bleeding before transplantation, MELD score, and Child-Pugh score did not show statistical differences between groups. The occurrence of hepatocellular carcinoma and mortality were higher in the hepatitis B Group. The survival in 4 years was 95% in the Delta Group and 75% in the B Group, with a statistically significant difference (P=0.034). Patients with hepatitis delta presented more evident thrombocytopenia in the pre-transplantation and in the immediate postoperative period.

CONCLUSION

The hepatitis by delta virus patients who underwent liver transplantation were predominantly male, coming from the Brazilian Amazon region and with similar liver function to the hepatitis B virus patients. They had a lower incidence of hepatocellular carcinoma, more marked perioperative thrombocytopenia levels and frequent episodes of upper gastrointestinal bleeding. Patients with hepatitis by delta virus had lower mortality and higher survival than patients with hepatitis B virus.

Immunosuppressive monocytes (CD14+/HLA-DRlow/-) increase in childhood precursor B-cell acute lymphoblastic leukemia after induction chemotherapy

In tumor microenvironment, immunosuppression is a common event and results from the inhibition of activated immune cells and generation of cells with immunosuppressive capacity, as some subtypes of monocytes. The aim of this study was to evaluate the presence of immunosuppressive CD14⁺/HLA-DR^low/- monocytes in pediatric patients with the diagnosis of B-cell acute lymphoblastic leukemia (B-ALL) and, moreover, verify whether the chemotherapeutic treatment has any effect on these cells. Peripheral blood (PB) and bone marrow (BM) samples were collected from 15 untreated pediatric patients. The presence of CD14⁺/HLA-DR^low/- monocytes was evaluated at diagnosis and in the end of induction chemotherapy by flow cytometry. CD14⁺/HLA-DR^low/- monocytes increase was observed in 60% (9/15) of the patients at the end of the induction therapy. We were able to detect an increase in CD14⁺/HLA-DR^low/- monocytes values in BM and PB samples of pediatric patients with B-ALL. This increase was observed in the end of induction chemotherapy, which leads us to believe that these changes probably could have been induced by the inflammatory process engendered by the cytotoxic treatment or by drugs used in the chemotherapy treatment. This finding may be useful to guide new therapeutic approaches contemplating immunomodulatory drugs that act in the depletion of immunosuppressive monocytes.