Buenos Aires

Sbado, 28 de abril de 2012

Les envo a todos los interesados y creo que hay varios este resumen publicado y las referencias para bajar el artculo completo. El primero habla sobre transporte y el segundo, una modalidad del uso de TC en apendicitis.

Emergency Medicine for April 27, 2012

SUMMARY AND COMMENT

Ground vs. Air Transport for Severely Injured Patients

April 27, 2012 | J. Stephen Bohan, MD, MS, FACP, FACEP

Helicopter transport is associated with a small but real benefit, but it comes at a high cost.
Reviewing: Galvagno SM Jr et al. JAMA 2012 Apr 18; 307:1602

Summary and Comment

Ground vs. Air Transport for Severely Injured Patients

Helicopter transport is associated with a small but real benefit, but it comes at a high cost. To compare outcomes between air and ground transport for adult trauma patients with Injury Severity Scores >15, researchers reviewed the American College of Surgeons National Trauma Data Bank from 2007 to 2009. Only patients who arrived at level I and level II trauma centers alive and had complete data on transport and disposition were included in the analysis. The final study population comprised 62,000 patients transported by air and 162,000 patients transported by ground. Neither the care rendered during transport nor the type of clinician who rendered it was considered. Unadjusted mortality was significantly higher in the helicopter-transport group (12.6% vs. 11.0%). However, the helicopter-transport group had significantly higher Injury Severity Scores and heart rate, with lower respiratory rate, systolic blood pressure, and Glasgow Coma Scale motor scores. In propensity score-matched logistic regression analysis, helicopter transport yielded a 1.5% absolute survival advantage. Sixty-five patients would need to be transported to level I centers by helicopter to save one life, and 69 patients at level II centers. Each life saved would cost approximately US$325,000. Comment: This study is important because it is unlikely that a randomized study will ever be done. The study should not change practice, but it provides good information to guide policy making. Missing from the study is an accounting for accidental deaths during helicopter transport, which might alter the overall result on lives saved versus lives lost, and the additional costs attributable to air transport of patients with lesssevere injury, for whom benefit is unlikely. J. Stephen Bohan, MD, MS, FACP, FACEP Published in Journal Watch Emergency Medicine April 27, 2012

Low-Dose vs. Standard-Dose CT for Appendicitis

Low-dose computed tomography was noninferior to standard-dose CT for evaluating suspected appendicitis in nonobese young adults. The rise in use of computed tomography (CT) for diagnosis of appendicitis has reduced the rate of negative appendectomy without increasing the rate of appendiceal perforation. Despite this advantage, there is concern about radiation exposure, particularly for young patients. Researchers in Korea randomized 891 patients ages 15 to 44 with suspected appendicitis to either low-dose (median dose, 116 mGy) or standard-dose (median dose, 521 mGy) CT with intravenous contrast. Entry criteria were referral for CT by emergency physicians and no contrast allergy, prior cross-sectional imaging for the current symptoms, or history of appendectomy. CT results were interpreted by expert abdominal radiologists or general radiologists, fellows, and residents, depending on time of day.

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Overall, 1.5% of patients were obese. The negative appendectomy rate (the primary end point) was 3.5% in the low-dose group and 3.2% in the standard-dose group. The absolute difference of 0.3 percentage points and relative risk of 1.08 demonstrated noninferiority of the low-dose protocol. Rates of appendiceal perforation did not differ significantly between groups (27% and 23%). Comment: Certainly, the less radiation exposure the better. The performance of the low-dose protocol in this study is encouraging. Unfortunately, the study population included few patients who were overweight or obese. On the basis of these results, low-dose computed tomography scan is a reasonable alternative to standard-dose CT scan for normal-weight patients with suspected appendicitis. However, patients with normal habitus also are good candidates for ultrasound evaluation, which involves no radiation exposure (JW Emerg Med Apr 10 2009). J. Stephen Bohan, MD, MS, FACP, FACEP Published in Journal Watch Emergency Medicine April 25, 2012

CITATION(S):
Kim K et al. Low-dose abdominal computed tomography for evaluating suspected appendicitis. N Engl J Med 2012 Apr 26; 366:1596.

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