Digital archive of theses discussed at the University of Pisa


Thesis etd-06142016-115353

Thesis type
Tesi di specializzazione (5 anni)
Thesis title
Shock emorragico nelle vittime di guerra: analisi della mortalità presso l'Emergency surgical centre for war victims di Kabul
Course of study
relatore Prof. Giunta, Francesco
correlatore Dott.ssa Portella, Gina
  • damage control surgery
  • trauma
  • shock emorragico
  • rimpiazzo volemico
  • emergency
  • damage control resuscitation
  • Afghanistan
  • vittime di guerra
Graduation session start date
L'Emergency surgical centre for war victims in Kabul tratta vittime di guerra sin dal 2001. Grazie ad una rete di First Aid Points in grado di offrire cure sanitarie di base ed un sistema di trasferimento dei politraumatizzati via terra da località remote a Kabul, il centro riceve una media di circa 250 pazienti al mese. Molti di questi sono vittime di trauma penetrante: le ferite da arma da fuoco sono le più frequenti, seguite da altri meccanismi (frammenti di esplosivi, mine, ferite da arma bianca).
Una piccola percentuale di questi pazienti si presenta ipotesa all'ammissione in ospedale, e richiede un adeguato rimpiazzo volemico prima del trattamento chirurgico e dell'ammissione in terapia intensiva. I dati, raccolti in Afghanistan da agosto 2015 a gennaio 2016, descrivono questa popolazione, con particolare attenzione alle caratteristiche demografiche, al meccanismo del trauma, al rimpiazzo volemico, alla terapia chirurgica ed alle cure intensive postoperatorie. Scopo ultimo dello studio è stato quello di analizzare i fattori in grado di condizionare lo sviluppo di complicanze e la mortalità nella tipologia di pazienti trattati.

Emergency surgical centre for war victims in Kabul has been treating war wounded patients since 2001. With a network of First Aid Points offering basic healthcare and a referral system of trauma patients by ambulance from remote locations, an average of 250 patients are admitted to the centre monthly. Many of them have suffered penetrating multiple trauma injuries, with bullets accounting for the most common cause, followed by other mechanisms of injury.
A small percentage of them are hypotensive on arrival, requiring intravenous fluid resuscitation in OPD before surgical treatment and postoperative intensive care admission. This population will be described, and data regarding preoperative fluid resuscitation, surgical treatment and postoperative care will be recorded.
Aim of the study is to describe the characteristics of the patients who presented in our OPD between June 2015 and January 2016 in haemorrhagic shock following penetrating trauma and point out factors who might predict their outcome. A systolic blood pressure of 90 mmHg will be used as a cut-off for defining patients in shock (CIT), being aware that this finding on arrival in OPD is well known to be linked with increased morbidity and mortality (CIT). A significant number of patients were referred to our OPD by ambulance trough the First Aid Points located in provinces surrounding Kabul, this accounting for an amount of patients in extremely critical conditions we might otherwise have not received. Data points will include demographic information, mechanism of injury (shell, bullet, mine or knife), injury severity score (ISS) (6, 7), number of organ injuries, referral from FAP, timing (time injury-OPD, OPD- OT and duration of surgery), body temperature, damage control surgery procedures, amount of fluids received for resuscitation (in the preoperative period and during surgery), units of blood transfused, use of dopamine (alpha doses), ventilator days, ICU stay, length of stay and development of major complications (coagulopathy, acute respiratory distress syndrome, septic shock).
Additional data points to be collected will include (when available) postoperative pH, BE and lactates. The number of organ injuries will be determined by reviewing the patient`s chart, and the operative report. The specific organs assessed will be: lung, diaphragm, liver, gallbladder, spleen, duodenum, ileum/jejunum, colon, pancreas, major artery, major vein, and GU (kidney, ureter, or bladder). An organ will be considered injured if it was described as injured in the operative report or discharge summary. Statistical analysis will be performed in order to identify potential predictors of outcome among our patients and to possibly compare our population with the one described in other studies.