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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La patolog&#237;a traum&#225;tica es una de las causas principales de mortalidad y discapacidad entre la poblaci&#243;n m&#225;s joven<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a>&#46; Para disminuir estos efectos adversos se deben planificar y organizar de forma integral de equipos de atenci&#243;n al trauma grave &#40;EATG&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a>&#46; A pesar de la importancia de los EATG&#44; no existe un consenso ni a nivel nacional ni internacional&#44; de c&#243;mo debe organizarse dicha asistencia tanto en la fase prehospitalaria como hospitalaria<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Disponer de un EATG multidisciplinar cohesionado a nivel hospitalario&#44; con la presencia de un l&#237;der que distribuya las tareas por roles entre los diferentes especialistas &#40;m&#233;dicos de urgencias&#44; intensivistas&#44; anestesistas&#44; cirujanos y traumat&#243;logos&#44; enfermer&#237;a&#44; etc&#46;&#41; ha demostrado reducir el tiempo de asistencia y aumentar la probabilidad de supervivencia entre los pacientes traum&#225;ticos m&#225;s graves<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La implicaci&#243;n de las Unidades de Cuidados Intensivos &#40;UCI&#41; formando parte del EATG participando en la asistencia inicial&#44; mejorando los tiempos de asistencia hasta su traslado definitivo y cuidados posteriores es un elemento b&#225;sico en la mejora de la calidad asistencial del paciente traum&#225;tico grave<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La existencia de protocolos de activaci&#243;n basados en la identificaci&#243;n de la inestabilidad del paciente seg&#250;n sus alteraciones fisiol&#243;gicas &#40;hemodin&#225;micas&#44; neurol&#243;gicas y respiratorias&#41; y del reconocimiento de lesiones espec&#237;ficas seg&#250;n su gravedad&#44; ayudan a una correcta activaci&#243;n de los EATG minimizando el infra y sobretriage&#46; Es importante remarcar que la clave principal de la activaci&#243;n recae en el criterio m&#233;dico de la atenci&#243;n prehospitalaria y en urgencias<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cuando un hospital implanta un EATG debe contar con mecanismos de monitorizaci&#243;n de su actividad y analizar los puntos que permitan mejorar la calidad asistencial<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5&#44;9</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los objetivos de nuestro trabajo son evaluar los factores asociados a la activaci&#243;n del EATG en los pacientes que ingresan en UCI&#44; medir su repercusi&#243;n en los tiempos de asistencia&#44; y analizar los grupos de pacientes seg&#250;n su activaci&#243;n y nivel de afectaci&#243;n anat&#243;mica&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Material y m&#233;todos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Estudio prospectivo observacional entre junio de 2017 y mayo de 2019 de pacientes ingresados en una UCI polivalente del hospital Arnau de Vilanova de Lleida&#46; Nuestro centro est&#225; catalogado de nivel IIb al poder dar asistencia al trauma grave &#40;quir&#243;fano de urgencias&#44; radiolog&#237;a convencional con tomograf&#237;a axial computarizada &#91;TAC&#93;&#44; cirug&#237;a general y ortop&#233;dica&#41; con una unidad de UCI y neurocirug&#237;a las 24 horas al d&#237;a&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se comunic&#243; al comit&#233; de &#233;tica del hospital la realizaci&#243;n del estudio &#40;N&#250;mero CEIC-1997&#41;&#46; Se determin&#243; que no era necesario el consentimiento informado de los pacientes ya que los datos recogidos eran imprescindibles para su diagn&#243;stico y seguimiento cl&#237;nico&#46; Se asegur&#243; en todo momento el anonimato de los pacientes&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Criterios de inclusi&#243;n&#58; todos los pacientes mayores de 16 a&#241;os de causa traum&#225;tica ingresados en UCI m&#225;s de 24 horas&#46; Criterios de exclusi&#243;n&#58; pacientes asistidos o trasladados a otro centro hospitalario o datos incompletos&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protocolo de activaci&#243;n</span><p id="par0050" class="elsevierStylePara elsevierViewall">La activaci&#243;n del EATG corre a discrecionalidad del m&#233;dico de urgencias tras comunicaci&#243;n previa de los servicios de emergencias extrahospitalarios o tras una valoraci&#243;n primaria en el &#225;rea de reanimaci&#243;n&#46; El protocolo identifica las lesiones consideradas como espec&#237;ficas y la inestabilidad del paciente &#40;ver definiciones en siguientes p&#225;rrafos&#41; como indicadores de activaci&#243;n&#46; El equipo de EATG est&#225; formado inicialmente por el m&#233;dico de urgencias&#44; intensivista&#44; traumat&#243;logo y cirujano general&#46; Se comparan los pacientes traum&#225;ticos graves ingresados en UCI asistidos por un EATG respecto los que son asistidos &#237;ntegramente por el servicio de urgencias e ingresan posteriormente a criterio del m&#233;dico intensivista&#46; Todos los pacientes fueron tratados seg&#250;n los principios de la &#171;<span class="elsevierStyleItalic">advanced trauma life support</span>&#187; &#40;ATLS&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Variables presentes a la llegada a Urgencias</span><p id="par0055" class="elsevierStylePara elsevierViewall">A su llegada a Urgencias&#44; un paciente se define como inestable si presenta al menos una de las siguientes condiciones&#58; inestabilidad hemodin&#225;mica &#40;hipotensi&#243;n &#91;TAS &#60; 90 mmHg&#93;&#44; necesidad de transfusi&#243;n de hemoderivados y&#47;o parada cardiorrespiratoria&#59; respiratoria &#91;SO<span class="elsevierStyleInf">2</span> &#60; 90&#37; y&#47;o ventilaci&#243;n mec&#225;nica&#93; y neurol&#243;gica &#91;GCS &#8804; 8&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a>&#46; Se establecen como lesiones espec&#237;ficas de activaci&#243;n del EATG aquellas que implican fractura craneal&#44; lesi&#243;n facial o en cuello que pueden obstruir la v&#237;a a&#233;rea&#44; t&#243;rax y pelvis inestable&#44; &#8805; 2 fracturas de huesos largos o amputaciones y las heridas penetrantes en t&#243;rax&#44; abdomen o cuello <a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Variables recogidas al ingreso en UCI</span><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables se recogieron mediante el formulario electr&#243;nico &#40;retrauci&#46;org&#41; que incluye datos demogr&#225;ficos &#40;sexo y edad&#41; y consumo de f&#225;rmacos antitromb&#243;ticos &#40;antiagregantes y anticoagulantes&#41;&#59; tipo de traumatismo &#40;cerrado o penetrante&#41; as&#237; como su mecanismo e intencionalidad&#46; Tipo de atenci&#243;n extrahospitalaria &#40;sistema de emergencia&#44; ambulancia convencional o propios medios&#41; y manejo de v&#237;a a&#233;rea&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se recogieron las variables de frecuencia respiratoria y saturaci&#243;n&#44; tensi&#243;n arterial y nivel neurol&#243;gico &#40;GCS&#41; para el c&#225;lculo &#40;RTS&#41;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a>&#46; Se registraron las lesiones traum&#225;ticas seg&#250;n <span class="elsevierStyleItalic">Abbreviated Injury Scale</span> &#40;AIS 2005&#41; <span class="elsevierStyleItalic">update</span> 2008 para el c&#225;lculo de la gravedad anat&#243;mica &#40;MAIS&#44; ISS&#44; NISS&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a>&#46; La probabilidad de supervivencia se calcul&#243; seg&#250;n metodolog&#237;a TRISS<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Los fracasos org&#225;nicos se definieron como hemodin&#225;mico &#40;PAS &#60; 90 mmHg que precisa aporte de volemia&#44; hemoderivados y soporte activo&#41;&#59; coagulopat&#237;a asociada al trauma es aquel con un aumento del tiempo de protrombina o tromboplastina parcial activada 1&#44;5 veces sobre el control o valores de fibrin&#243;geno &#60; 150 mg&#47;dL o trombopenia &#60; 100&#46;000 &#956;L en las primeras 24 horas&#59; Insuficiencia respiratoria &#40;PO2&#47;FiO2 &#60; 200&#41; y fracaso renal seg&#250;n clasificaci&#243;n RIFLE con tres niveles de disfunci&#243;n renal aguda&#58; Riesgo&#44; Injuria y Fracaso seg&#250;n los cambios en los niveles plasm&#225;ticos de creatinina o ritmo de diuresis<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Se incluyen tipo de asistencia requerida seg&#250;n necesidad y tipo de cirug&#237;a en las primeras 24 horas&#44; administraci&#243;n de hemoderivados&#44; ventilaci&#243;n mec&#225;nica&#44; y t&#233;cnicas de neuromonitorizaci&#243;n &#40;PIC&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Se realiz&#243; seguimiento de la estancia y mortalidad a 30 d&#237;as tanto en la UCI como durante su ingreso en planta de hospitalizaci&#243;n&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Seg&#250;n activaci&#243;n del EATG y la puntuaci&#243;n de la gravedad de la lesi&#243;n &#40;ISS&#41; &#40;punto corte de 15&#41; se establecieron cuatro grupos de pacientes&#58;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> activado e ISS &#62; 15&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> activado e ISS &#8804; 15&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> no activado e ISS &#62; 15&#44; y<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> no activado e ISS &#8804; 15&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Se midieron los tiempos en minutos de&#58; tiempo TAC &#40;desde ingreso en Urgencias a la realizaci&#243;n del TAC&#41;&#44; tiempo UCI &#40;desde ingreso en Urgencias a la llegada a UCI&#41;&#44; y tiempo quir&#243;fano &#40;desde ingreso en Urgencias a la llegada al quir&#243;fano&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">An&#225;lisis estad&#237;stico</span><p id="par0095" class="elsevierStylePara elsevierViewall">Las variables se describieron como mediana &#40;intervalo intercuartil&#41; o como porcentaje seg&#250;n tipo de variable&#46; La comparaci&#243;n entre grupos se realiz&#243; con las pruebas de Mann-Whitney o <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;significaci&#243;n estad&#237;stica con p &#60; 0&#44;05&#41;&#46; Se realiz&#243; un modelo de regresi&#243;n log&#237;stica binaria multivariante con variable resultado la activaci&#243;n del EATG&#46; Se incluyeron las variables seg&#250;n su significaci&#243;n en el an&#225;lisis univariante&#46; Se utiliz&#243; un sistema de selecci&#243;n por pasos para la selecci&#243;n definitiva de las variables incluidas en el modelo&#46; Tambi&#233;n se realiz&#243; un modelo multivariante basado en &#225;rboles de clasificaci&#243;n tipo <span class="elsevierStyleItalic">Clasiffication and Regression Tree</span> &#40;CART&#41; incluyendo las mismas variables y utilizando como criterio de parada un n&#250;mero m&#237;nimo de registros de 25 en el nodo terminal y un sistema de validaci&#243;n interna cruzada<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a>&#46; C&#225;lculos realizados con el paquete estad&#237;stico SPSS &#40;v&#46;23&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Resultados</span><p id="par0100" class="elsevierStylePara elsevierViewall">El grupo de estudio lo forman 188 pacientes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; El ingreso en UCI fue precedido en 88 pacientes &#40;41&#44;3&#37;&#41; por la activaci&#243;n del EATG&#46; La mortalidad general fue del 10&#44;1&#37;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran las caracter&#237;sticas demogr&#225;ficas y del tipo de traumatismo&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se observan las condiciones de inestabilidad y del tipo de lesi&#243;n valorados a la llegada a Urgencias&#44; y en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> los procedimientos y cirug&#237;as realizados&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Diferencias entre grupo con activaci&#243;n EATG y de no activaci&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">En las <a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 a 3</a> se observan las diferencias &#40;columnas en gris&#41; de las variables estudiadas entre los grupos con activaci&#243;n o no del EATG&#46; Los pacientes que activaron el EATG fueron m&#225;s j&#243;venes&#44; tuvieron un mayor porcentaje de atenci&#243;n m&#233;dica prehospitalaria&#44; sufrieron traumatismos de alta energ&#237;a &#40;tr&#225;fico&#41;&#44; menos ca&#237;das accidentales de baja energ&#237;a&#44; mayor afectaci&#243;n de abdomen y de extremidades inferiores&#44; mayor repercusi&#243;n en fallos org&#225;nicos&#59; y una mayor necesidad de transfusi&#243;n de concentrados de hemat&#237;es y plasma&#46; Se les realizaron m&#225;s intervenciones de neurocirug&#237;a y traumatolog&#237;a&#46; Presentaron una mayor gravedad seg&#250;n ISS y mayor estancia en UCI&#46; No se encontraron diferencias en la mortalidad &#40;10&#44;2 vs&#46; 10&#44;0&#37;&#44; p &#61; 0&#44;959&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Grupos de pacientes seg&#250;n activaci&#243;n y puntuaci&#243;n ISS</span><p id="par0110" class="elsevierStylePara elsevierViewall">Como se aprecia en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se estudiaron cuatro grupos de pacientes seg&#250;n activaci&#243;n del EATG y la puntuaci&#243;n ISS&#46; En las <a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 a 3</a> se observan las diferencias encontradas &#40;columnas en fondo blanco&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Los pacientes del primer grupo &#40;activaci&#243;n e ISS &#62; 15&#41; se caracteriza por ser m&#225;s j&#243;venes&#44; una mayor atenci&#243;n prehospitalaria&#44; traumatismos de alta energ&#237;a&#44; con mayor repercusi&#243;n fisiol&#243;gica y org&#225;nica&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">El segundo grupo &#40;activaci&#243;n e ISS &#8804; 15&#41; tiene valores similares en edad y atenci&#243;n prehospitalaria pero una menor repercusi&#243;n fisiol&#243;gica y org&#225;nica&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">El tercer grupo &#40;no activaci&#243;n e ISS &#62; 15&#41; corresponde a pacientes m&#225;s mayores&#44; con un menor porcentaje de atenci&#243;n prehospitalaria&#44; mayor proporci&#243;n de ca&#237;das accidentales de baja energ&#237;a&#44; mayor afectaci&#243;n neurol&#243;gica&#46; Necesitan m&#225;s neurocirug&#237;a &#40;incluso de craneotom&#237;as descompresivas&#41; pero con menor repercusi&#243;n org&#225;nica que el primer grupo&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El cuarto grupo &#40;no activaci&#243;n e ISS &#8804; 15&#41; son pacientes con mayor estabilidad fisiol&#243;gica y org&#225;nica&#46; Presentan m&#225;s lesiones penetrantes &#40;incluso m&#225;s mecanismo de arma blanca&#41;&#44; poca alteraci&#243;n neurol&#243;gica&#44; mayor afectaci&#243;n de t&#243;rax&#44; y menor necesidad de procedimientos&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Factores asociados a la activaci&#243;n EATG</span><p id="par0135" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> se muestran los factores asociados a la activaci&#243;n del EATG en el modelo de regresi&#243;n log&#237;stica&#46; Se destaca que el padecer una ca&#237;da accidental es un factor que hace menos probable la activaci&#243;n&#46; La atenci&#243;n e intubaci&#243;n prehospitalaria son factores que propician la activaci&#243;n y&#44; la lesi&#243;n grave de extremidades inferiores tambi&#233;n favorece la activaci&#243;n&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">El modelo de &#225;rbol de clasificaci&#243;n CART &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41; selecciona como primera variable la del tipo de mecanismo del traumatismo y se observa que es capaz de separar los traumatismos de alta y baja energ&#237;a&#46; En el grupo de alta energ&#237;a selecciona la edad &#40;punto de corte de 32&#44;5 a&#241;os&#41; y en los m&#225;s mayores los diferencia seg&#250;n IOT prehospitalaria&#46; Obtiene cuatro grupos de pacientes con probabilidades de activaci&#243;n del EATG entre 20&#44;0 y 82&#44;6&#37;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Estudio de tiempos de actuaci&#243;n</span><p id="par0145" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> se muestran los resultados de los tiempos de actuaci&#243;n seg&#250;n grupos de activaci&#243;n-no activaci&#243;n &#40;A&#41; y seg&#250;n los cuatro grupos descritos&#46; La activaci&#243;n reduce todos los tiempos de actuaci&#243;n&#46; Al separar por los cuatro grupos&#44; vemos que el que obtiene tiempos m&#225;s reducidos es el grupo 2 &#40;activaci&#243;n e ISS &#8804; 15&#41; y el que los presenta m&#225;s largos es el grupo 3 &#40;no activaci&#243;n e ISS &#62; 15&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Discusi&#243;n</span><p id="par0150" class="elsevierStylePara elsevierViewall">Este trabajo muestra la experiencia de la implantaci&#243;n de un EATG en un intento de mejorar la calidad asistencial a los pacientes traum&#225;ticos graves que finalmente ingresan en la UCI&#46; Se analiza cu&#225;les son los factores que intervienen en la activaci&#243;n del EATG&#44; as&#237; como se consigue demostrar un acortamiento en los tiempos de asistencia cuando se activa el EATG&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Cualquier proceso asistencial debe ser monitorizado&#44; evaluado y se deben buscar puntos de mejora<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a>&#46; Un factor clave en la correcta organizaci&#243;n de un EATG es un correcto triage inicial bas&#225;ndonos en protocolos de activaci&#243;n actualizados donde se valora la severidad de los par&#225;metros fisiol&#243;gicos &#40;GCS motor &#60; 6&#44; FC &#62;TAS&#44; Sat &#60; 90&#37;&#41; lesiones anat&#243;micas llamativas &#40;sangrado activo&#44; deformidad craneal&#44; sospecha lesi&#243;n columna&#44; t&#243;rax o pelvis&#44; fractura de dos o m&#225;s huesos largos&#41; y el mecanismo lesional de alta energ&#237;a<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;10&#44;11</span></a>&#46; Monitorizar el nivel de infra y sobretriage es un indicador de calidad de la asistencia al paciente traum&#225;tico<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Cl&#225;sicamente se ha utilizado la matriz de Cribari para valorar el correcto triage de los traumatismos graves &#40;ISS &#62; 15&#41; que deben ser atendidos por un EATG&#44; donde se considera que no se debe superar 5&#37; del infratriage y 35&#37; del sobretriage <a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">En nuestro estudio &#250;nicamente 41&#44;3&#37; de los pacientes ingresados en UCI fue asistido por el EATG&#44; aunque se debe se&#241;alar que 32&#44;4&#37; de los pacientes que ingresaron en UCI ten&#237;an un ISS &#60; 15&#46; Seg&#250;n los criterios de calidad publicados por la SEMICYUC en 2017 95&#37; de los pacientes con traumatismos graves &#40;<span class="elsevierStyleItalic">Revised Trauma Score</span> &#91;RTS&#93; en la selecci&#243;n inicial &#8804; 11 puntos y&#47;o un ISS&#41; &#62; 15 ingresados en UCI deben ser atendidos por el servicio de medicina intensiva<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a>&#46; Se deber&#237;a explorar otras experiencias en otros centros&#44; para poder establecer una cifra ideal del porcentaje de pacientes que deben ser atendidos por el EATG antes de ser ingresados en UCI&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se plantean tres preguntas dependiendo de la activaci&#243;n y el nivel de afectaci&#243;n anat&#243;mica seg&#250;n ISS&#46; La primera pregunta se contesta porque estos pacientes&#44; aun siendo m&#225;s estables&#44; suelen tener traumatismos de alta energ&#237;a y son atendidos por equipos de atenci&#243;n prehospitalaria&#46; La segunda pregunta corresponde a que no se activa el EATG por ser pacientes con traumatismos de baja energ&#237;a&#44; m&#225;s mayores y menor atenci&#243;n prehospitalaria&#44; y la tercera pregunta se contesta por ser un grupo de pacientes que ingresan en un alto porcentaje para monitorizaci&#243;n&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Los factores que se asociaron con la activaci&#243;n del ETAG fueron los pacientes que hab&#237;an sido atendidos inicialmente por un equipo de emergencias prehospitalario&#44; requerir intubaci&#243;n previa y lesiones graves de las extremidades inferiores&#44; principalmente fracturas de pelvis&#46; El modelo CART determina que los traumatismos de alta energ&#237;a tienen m&#225;s probabilidad de activaci&#243;n junto a los pacientes m&#225;s j&#243;venes o intubados en el medio prehospitalario&#46; Un correcto triage de los equipos de emergencias prehospitalarios y una fluida comunicaci&#243;n con el medio hospitalario puede mejorar la activaci&#243;n previa de los equipos de EATG<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;19</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Hay que destacar que el &#250;nico factor que se asoci&#243; con la no activaci&#243;n del EATG fueron los pacientes que hab&#237;an sufrido una ca&#237;da accidental asociado a que no hab&#237;an sido activados los servicios prehospitalarios&#46; Los pacientes mayores&#44; con tratamientos anticoagulantes&#44; que sufren una ca&#237;da accidental tienen una alta morbimortalidad&#44; siendo un subgrupo de pacientes que se deber&#237;a incluir en los protocolos de activaci&#243;n&#46; En nuestra serie la edad media fue superior en el subgrupo de pacientes que no se activ&#243; el EATG<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">20&#44;21</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Actualmente los EATG han demostrado que mejoran los tiempos de asistencia al paciente traum&#225;tico<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a>&#46; En nuestra experiencia la activaci&#243;n del EATG ha logrado disminuir de forma significativa los tiempos de realizaci&#243;n de TAC&#44; intervenciones quir&#250;rgicas emergentes y su traslado definitivo a la unidad de cuidados intensivos&#46; Aunque nuestra experiencia no encuentra diferencias en mortalidad&#44; estudios recientes correlacionan el retraso del ingreso en las UCI con un aumento de la mortalidad y la importancia de realizar una atenci&#243;n cr&#237;tica fuera del entorno de UCI<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Nuestros resultados nos llevan a hacer varias recomendaciones&#46; La importancia de disponer de protocolos de activaci&#243;n actualizados consensuados entre los equipos de atenci&#243;n prehospitalaria como de urgencias&#46; Se debe monitorizar y evaluar los criterios de activaci&#243;n para poder analizar el infra-sobretriage de los pacientes asistidos&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">La principal limitaci&#243;n del estudio se debe al an&#225;lisis de un &#250;nico centro con sus caracter&#237;sticas cl&#237;nico-demogr&#225;ficas espec&#237;ficas y un tama&#241;o limitado de la muestra que puede influir en la generalizaci&#243;n de los resultados&#46; Otra limitaci&#243;n surge de no poder disponer de un control de pacientes asistidos por el EATG que no ingresaron en la UCI&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; instaurar un EATG a nivel hospitalario con una fluida comunicaci&#243;n de todos los servicios implicados en la atenci&#243;n del traumatismo grave logra disminuir los tiempos de asistencia&#46; Ser atendidos por un equipo de emergencias con intubaci&#243;n orotraqueal en la fase prehospitalaria tras sufrir un accidente de alta energ&#237;a con lesiones en las extremidades inferiores son los factores influyen en la activaci&#243;n del EATG&#46; Debemos mejorar la activaci&#243;n de los EATG en los pacientes a&#241;osos que sufren traumatismos de baja energ&#237;a y que no son atendidos por equipos de emergencias&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Contribuci&#243;n de los autores</span><p id="par0205" class="elsevierStylePara elsevierViewall">Neus Montserrat Ortiz&#44; Javier Trujillano Cabello y Luis Servia Goixart participaron en el dise&#241;o del estudio&#46; El an&#225;lisis e interpretaci&#243;n de los datos fue realizado por Javier Trujillano Cabello&#44; Luis Servia Goixart&#44; Neus Montserrat Ortiz&#44; Mariona Badia Castell&#243;&#46; Gabriel Jimenez Jimenez&#44; Judit Vilanova&#44; Jorge Rubio Ruiz&#44; Andres Pujol Freire y Dulce Morales Hernandez colaboraron con la recogida de datos y la revisi&#243;n del manuscrito&#46; Todos los autores leyeron y aprobaron la versi&#243;n final del manuscrito&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicto de intereses</span><p id="par0210" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar los factores asociados a la activaci&#243;n del equipo de asistencia al trauma grave &#40;EATG&#41; en pacientes que ingresan en la Unidad de Cuidados Intensivos &#40;UCI&#41;&#44; medir su repercusi&#243;n en los tiempos de asistencia&#44; y analizar los grupos de pacientes seg&#250;n activaci&#243;n y nivel de afectaci&#243;n anat&#243;mica&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes prospectivo del trauma grave que ingresan en UCI&#46; Desde junio 2017 a mayo 2019&#46; Factores de riesgo de la activaci&#243;n analizados con regresi&#243;n log&#237;stica y &#225;rbol de clasificaci&#243;n tipo CART&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">UCI hospital de segundo nivel&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Pacientes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes ingresados de forma consecutiva&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervenciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables de intereses principales</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Activaci&#243;n del EATG&#46; Variables demogr&#225;ficas&#46; Puntuaci&#243;n de la gravedad de la lesi&#243;n &#40;ISS&#41;&#44; intencionalidad&#44; mecanismo&#44; tiempos de asistencia&#44; complicaciones evolutivas y mortalidad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ingresaron un total de 188 pacientes &#40;46&#44;8&#37; de activaci&#243;n EATG&#41;&#44; edad mediana de 52 &#40;37-64&#41; a&#241;os &#40;activados 47 &#40;27-62&#41; vs&#46; no activados 55 &#40;42-67&#41; p &#61; 0&#44;023&#41;&#44; varones 84&#44;0&#37;&#46; No diferencias en la mortalidad seg&#250;n activaci&#243;n&#46; El modelo log&#237;stico encuentra como factores&#58; la atenci&#243;n &#40;16&#44;6 &#91;2&#44;1-13&#44;2&#93;&#41; e intubaci&#243;n prehospitalaria &#40;4&#44;2 &#91;1&#44;8-9&#44;8&#93;&#41; y&#44; la lesi&#243;n grave de extremidades inferiores &#40;4&#44;4 &#91;1&#44;6-12&#44;3&#93;&#41;&#46; Padecer una ca&#237;da accidental &#40;0&#44;2 &#91;0&#44;1-0&#44;6&#93;&#41; hace menos probable la activaci&#243;n&#46; El modelo CART selecciona el tipo de mecanismo del traumatismo y es capaz de separar los traumatismos de alta y baja energ&#237;a&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los factores asociados con activaci&#243;n del ETAG fueron la atenci&#243;n prehospitalaria&#44; requerir intubaci&#243;n previa&#44; mecanismos de alta energ&#237;a y lesiones graves de extremidades inferiores&#46; Menores tiempos de asistencia si activaci&#243;n sin influir en la mortalidad&#46; Debemos mejorar la activaci&#243;n en pacientes mayores con traumatismos de baja energ&#237;a y sin atenci&#243;n prehospitalaria&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To analyse the factors associated with the activation of the severe trauma care team &#40;STAT&#41; in patients admitted to the ICU&#44; to measure its impact on care times&#44; and to analyse the groups of patients according to activation and level of anatomical involvement&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Prospective cohort study of severe trauma admitted to the ICU&#46; From June 2017 to May 2019&#46; Risk factors for the activation of the STAT analysed with logistic regression and CART type classification tree&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Setting</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Second level hospital ICU&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patients admitted consecutively&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Interventions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">No&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Main variables of interest</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">STAT activation&#44; demographic variables&#44; injury severity &#40;ISS&#41;&#44; intentionality&#44; mechanism&#44; assistance times&#44; evolutionary complications&#44; and mortality&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A total of 188 patients were admitted &#40;46&#46;8&#37; of STAT activation&#41;&#44; median age of 52 &#40;37&#8211;64&#41; years &#40;activated 47 &#40;27&#8211;62&#41; vs&#46; not activated 55 &#40;42&#8211;67&#41;&#44; p &#61; 0&#46;023&#41;&#44; males 84&#46;0&#37;&#46; No difference in mortality according to activation&#46; The logistic model finds as factors&#58; care &#40;16&#46;6 &#40;2&#46;1&#8211;13&#46;2&#41;&#41; and prehospital intubation &#40;4&#46;2 &#40;1&#46;8&#8211;9&#46;8&#41;&#41; and severe lower extremity injury &#40;4&#46;4 &#40;1&#46;6&#8211;12&#46;3&#41;&#41;&#46; Accidental fall &#40;0&#46;2 &#40;0&#46;1&#8211;0&#46;6&#41;&#41; makes activation less likely&#46; The CART model selects the type of trauma mechanism and can separate high and low energy trauma&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Factors associated with STAT activation were prehospital care&#44; requiring prior intubation&#44; high-energy mechanisms&#44; and severe lower extremity injuries&#46; Shorter care times if activated without influencing mortality&#46; We must improve activation in older patients with low-energy trauma and without prehospital care&#46;</p></span>"
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                  \t\t\t\t">NISS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mortalidad hospitalaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TODOSN &#61; 188&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#62; 15N &#61; 63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#8804; 15N &#61; 25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">NO ACTIVN &#61; 100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#62; 15N &#61; 67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#8804; 15N &#61; 33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-valor<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-valor<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Atenci&#243;n prehospitalaria</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">96&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">82&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">74&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Intubaci&#243;n prehospitalaria</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;004&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">INESTABILIDAD &#40;TOTAL&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RCP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GLASGOW &#60; 8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>HEMODIN&#193;MICA&nbsp;\t\t\t\t\t\t\n
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                  """
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ORIGINAL
Implantación de un equipo de asistencia al trauma grave. Análisis de la activación y tiempos de asistencia en pacientes ingresados en UCI
Implementation of a severe trauma assistance team: Analysis of activation and attendance times in patients admitted to the ICU
Neus Montserrat Ortiza,b, Javier Trujillano Cabelloa,b, Mariona Badia Castellóa,b, Judit Vilanova Corsellasa,b, Gabriel Jimenez Jimeneza,b, Jorge Rubio Ruiza,b, Andres Pujol Freirea,b, Dulce Morales Hernandeza,b, Luis Servia Goixarta,b,
Autor para correspondencia
lserviag@gmail.com

Autor para correspondencia.
a Servicio de Medicina Intensiva, Hospital Arnau de Vilanova de Lleida, Lleida, España
b IRBLLeida (Institut de Recerca Biomèdica de Lleida. Fundació Dr. Pifarré), Lleida, España
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          "es" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">&#193;rbol de clasificaci&#243;n tipo CART&#46; Perfiles de pacientes seg&#250;n activaci&#243;n del Equipo de Atenci&#243;n al paciente Traum&#225;tico Grave &#40;EATG&#41;&#46; IOT&#58; Intubaci&#243;n orotraqueal&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La patolog&#237;a traum&#225;tica es una de las causas principales de mortalidad y discapacidad entre la poblaci&#243;n m&#225;s joven<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a>&#46; Para disminuir estos efectos adversos se deben planificar y organizar de forma integral de equipos de atenci&#243;n al trauma grave &#40;EATG&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a>&#46; A pesar de la importancia de los EATG&#44; no existe un consenso ni a nivel nacional ni internacional&#44; de c&#243;mo debe organizarse dicha asistencia tanto en la fase prehospitalaria como hospitalaria<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Disponer de un EATG multidisciplinar cohesionado a nivel hospitalario&#44; con la presencia de un l&#237;der que distribuya las tareas por roles entre los diferentes especialistas &#40;m&#233;dicos de urgencias&#44; intensivistas&#44; anestesistas&#44; cirujanos y traumat&#243;logos&#44; enfermer&#237;a&#44; etc&#46;&#41; ha demostrado reducir el tiempo de asistencia y aumentar la probabilidad de supervivencia entre los pacientes traum&#225;ticos m&#225;s graves<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La implicaci&#243;n de las Unidades de Cuidados Intensivos &#40;UCI&#41; formando parte del EATG participando en la asistencia inicial&#44; mejorando los tiempos de asistencia hasta su traslado definitivo y cuidados posteriores es un elemento b&#225;sico en la mejora de la calidad asistencial del paciente traum&#225;tico grave<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La existencia de protocolos de activaci&#243;n basados en la identificaci&#243;n de la inestabilidad del paciente seg&#250;n sus alteraciones fisiol&#243;gicas &#40;hemodin&#225;micas&#44; neurol&#243;gicas y respiratorias&#41; y del reconocimiento de lesiones espec&#237;ficas seg&#250;n su gravedad&#44; ayudan a una correcta activaci&#243;n de los EATG minimizando el infra y sobretriage&#46; Es importante remarcar que la clave principal de la activaci&#243;n recae en el criterio m&#233;dico de la atenci&#243;n prehospitalaria y en urgencias<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cuando un hospital implanta un EATG debe contar con mecanismos de monitorizaci&#243;n de su actividad y analizar los puntos que permitan mejorar la calidad asistencial<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5&#44;9</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los objetivos de nuestro trabajo son evaluar los factores asociados a la activaci&#243;n del EATG en los pacientes que ingresan en UCI&#44; medir su repercusi&#243;n en los tiempos de asistencia&#44; y analizar los grupos de pacientes seg&#250;n su activaci&#243;n y nivel de afectaci&#243;n anat&#243;mica&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Material y m&#233;todos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Estudio prospectivo observacional entre junio de 2017 y mayo de 2019 de pacientes ingresados en una UCI polivalente del hospital Arnau de Vilanova de Lleida&#46; Nuestro centro est&#225; catalogado de nivel IIb al poder dar asistencia al trauma grave &#40;quir&#243;fano de urgencias&#44; radiolog&#237;a convencional con tomograf&#237;a axial computarizada &#91;TAC&#93;&#44; cirug&#237;a general y ortop&#233;dica&#41; con una unidad de UCI y neurocirug&#237;a las 24 horas al d&#237;a&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se comunic&#243; al comit&#233; de &#233;tica del hospital la realizaci&#243;n del estudio &#40;N&#250;mero CEIC-1997&#41;&#46; Se determin&#243; que no era necesario el consentimiento informado de los pacientes ya que los datos recogidos eran imprescindibles para su diagn&#243;stico y seguimiento cl&#237;nico&#46; Se asegur&#243; en todo momento el anonimato de los pacientes&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Criterios de inclusi&#243;n&#58; todos los pacientes mayores de 16 a&#241;os de causa traum&#225;tica ingresados en UCI m&#225;s de 24 horas&#46; Criterios de exclusi&#243;n&#58; pacientes asistidos o trasladados a otro centro hospitalario o datos incompletos&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protocolo de activaci&#243;n</span><p id="par0050" class="elsevierStylePara elsevierViewall">La activaci&#243;n del EATG corre a discrecionalidad del m&#233;dico de urgencias tras comunicaci&#243;n previa de los servicios de emergencias extrahospitalarios o tras una valoraci&#243;n primaria en el &#225;rea de reanimaci&#243;n&#46; El protocolo identifica las lesiones consideradas como espec&#237;ficas y la inestabilidad del paciente &#40;ver definiciones en siguientes p&#225;rrafos&#41; como indicadores de activaci&#243;n&#46; El equipo de EATG est&#225; formado inicialmente por el m&#233;dico de urgencias&#44; intensivista&#44; traumat&#243;logo y cirujano general&#46; Se comparan los pacientes traum&#225;ticos graves ingresados en UCI asistidos por un EATG respecto los que son asistidos &#237;ntegramente por el servicio de urgencias e ingresan posteriormente a criterio del m&#233;dico intensivista&#46; Todos los pacientes fueron tratados seg&#250;n los principios de la &#171;<span class="elsevierStyleItalic">advanced trauma life support</span>&#187; &#40;ATLS&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Variables presentes a la llegada a Urgencias</span><p id="par0055" class="elsevierStylePara elsevierViewall">A su llegada a Urgencias&#44; un paciente se define como inestable si presenta al menos una de las siguientes condiciones&#58; inestabilidad hemodin&#225;mica &#40;hipotensi&#243;n &#91;TAS &#60; 90 mmHg&#93;&#44; necesidad de transfusi&#243;n de hemoderivados y&#47;o parada cardiorrespiratoria&#59; respiratoria &#91;SO<span class="elsevierStyleInf">2</span> &#60; 90&#37; y&#47;o ventilaci&#243;n mec&#225;nica&#93; y neurol&#243;gica &#91;GCS &#8804; 8&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a>&#46; Se establecen como lesiones espec&#237;ficas de activaci&#243;n del EATG aquellas que implican fractura craneal&#44; lesi&#243;n facial o en cuello que pueden obstruir la v&#237;a a&#233;rea&#44; t&#243;rax y pelvis inestable&#44; &#8805; 2 fracturas de huesos largos o amputaciones y las heridas penetrantes en t&#243;rax&#44; abdomen o cuello <a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Variables recogidas al ingreso en UCI</span><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables se recogieron mediante el formulario electr&#243;nico &#40;retrauci&#46;org&#41; que incluye datos demogr&#225;ficos &#40;sexo y edad&#41; y consumo de f&#225;rmacos antitromb&#243;ticos &#40;antiagregantes y anticoagulantes&#41;&#59; tipo de traumatismo &#40;cerrado o penetrante&#41; as&#237; como su mecanismo e intencionalidad&#46; Tipo de atenci&#243;n extrahospitalaria &#40;sistema de emergencia&#44; ambulancia convencional o propios medios&#41; y manejo de v&#237;a a&#233;rea&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se recogieron las variables de frecuencia respiratoria y saturaci&#243;n&#44; tensi&#243;n arterial y nivel neurol&#243;gico &#40;GCS&#41; para el c&#225;lculo &#40;RTS&#41;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a>&#46; Se registraron las lesiones traum&#225;ticas seg&#250;n <span class="elsevierStyleItalic">Abbreviated Injury Scale</span> &#40;AIS 2005&#41; <span class="elsevierStyleItalic">update</span> 2008 para el c&#225;lculo de la gravedad anat&#243;mica &#40;MAIS&#44; ISS&#44; NISS&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a>&#46; La probabilidad de supervivencia se calcul&#243; seg&#250;n metodolog&#237;a TRISS<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Los fracasos org&#225;nicos se definieron como hemodin&#225;mico &#40;PAS &#60; 90 mmHg que precisa aporte de volemia&#44; hemoderivados y soporte activo&#41;&#59; coagulopat&#237;a asociada al trauma es aquel con un aumento del tiempo de protrombina o tromboplastina parcial activada 1&#44;5 veces sobre el control o valores de fibrin&#243;geno &#60; 150 mg&#47;dL o trombopenia &#60; 100&#46;000 &#956;L en las primeras 24 horas&#59; Insuficiencia respiratoria &#40;PO2&#47;FiO2 &#60; 200&#41; y fracaso renal seg&#250;n clasificaci&#243;n RIFLE con tres niveles de disfunci&#243;n renal aguda&#58; Riesgo&#44; Injuria y Fracaso seg&#250;n los cambios en los niveles plasm&#225;ticos de creatinina o ritmo de diuresis<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Se incluyen tipo de asistencia requerida seg&#250;n necesidad y tipo de cirug&#237;a en las primeras 24 horas&#44; administraci&#243;n de hemoderivados&#44; ventilaci&#243;n mec&#225;nica&#44; y t&#233;cnicas de neuromonitorizaci&#243;n &#40;PIC&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Se realiz&#243; seguimiento de la estancia y mortalidad a 30 d&#237;as tanto en la UCI como durante su ingreso en planta de hospitalizaci&#243;n&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Seg&#250;n activaci&#243;n del EATG y la puntuaci&#243;n de la gravedad de la lesi&#243;n &#40;ISS&#41; &#40;punto corte de 15&#41; se establecieron cuatro grupos de pacientes&#58;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> activado e ISS &#62; 15&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> activado e ISS &#8804; 15&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> no activado e ISS &#62; 15&#44; y<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> no activado e ISS &#8804; 15&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Se midieron los tiempos en minutos de&#58; tiempo TAC &#40;desde ingreso en Urgencias a la realizaci&#243;n del TAC&#41;&#44; tiempo UCI &#40;desde ingreso en Urgencias a la llegada a UCI&#41;&#44; y tiempo quir&#243;fano &#40;desde ingreso en Urgencias a la llegada al quir&#243;fano&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">An&#225;lisis estad&#237;stico</span><p id="par0095" class="elsevierStylePara elsevierViewall">Las variables se describieron como mediana &#40;intervalo intercuartil&#41; o como porcentaje seg&#250;n tipo de variable&#46; La comparaci&#243;n entre grupos se realiz&#243; con las pruebas de Mann-Whitney o <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;significaci&#243;n estad&#237;stica con p &#60; 0&#44;05&#41;&#46; Se realiz&#243; un modelo de regresi&#243;n log&#237;stica binaria multivariante con variable resultado la activaci&#243;n del EATG&#46; Se incluyeron las variables seg&#250;n su significaci&#243;n en el an&#225;lisis univariante&#46; Se utiliz&#243; un sistema de selecci&#243;n por pasos para la selecci&#243;n definitiva de las variables incluidas en el modelo&#46; Tambi&#233;n se realiz&#243; un modelo multivariante basado en &#225;rboles de clasificaci&#243;n tipo <span class="elsevierStyleItalic">Clasiffication and Regression Tree</span> &#40;CART&#41; incluyendo las mismas variables y utilizando como criterio de parada un n&#250;mero m&#237;nimo de registros de 25 en el nodo terminal y un sistema de validaci&#243;n interna cruzada<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a>&#46; C&#225;lculos realizados con el paquete estad&#237;stico SPSS &#40;v&#46;23&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Resultados</span><p id="par0100" class="elsevierStylePara elsevierViewall">El grupo de estudio lo forman 188 pacientes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; El ingreso en UCI fue precedido en 88 pacientes &#40;41&#44;3&#37;&#41; por la activaci&#243;n del EATG&#46; La mortalidad general fue del 10&#44;1&#37;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran las caracter&#237;sticas demogr&#225;ficas y del tipo de traumatismo&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se observan las condiciones de inestabilidad y del tipo de lesi&#243;n valorados a la llegada a Urgencias&#44; y en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> los procedimientos y cirug&#237;as realizados&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Diferencias entre grupo con activaci&#243;n EATG y de no activaci&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">En las <a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 a 3</a> se observan las diferencias &#40;columnas en gris&#41; de las variables estudiadas entre los grupos con activaci&#243;n o no del EATG&#46; Los pacientes que activaron el EATG fueron m&#225;s j&#243;venes&#44; tuvieron un mayor porcentaje de atenci&#243;n m&#233;dica prehospitalaria&#44; sufrieron traumatismos de alta energ&#237;a &#40;tr&#225;fico&#41;&#44; menos ca&#237;das accidentales de baja energ&#237;a&#44; mayor afectaci&#243;n de abdomen y de extremidades inferiores&#44; mayor repercusi&#243;n en fallos org&#225;nicos&#59; y una mayor necesidad de transfusi&#243;n de concentrados de hemat&#237;es y plasma&#46; Se les realizaron m&#225;s intervenciones de neurocirug&#237;a y traumatolog&#237;a&#46; Presentaron una mayor gravedad seg&#250;n ISS y mayor estancia en UCI&#46; No se encontraron diferencias en la mortalidad &#40;10&#44;2 vs&#46; 10&#44;0&#37;&#44; p &#61; 0&#44;959&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Grupos de pacientes seg&#250;n activaci&#243;n y puntuaci&#243;n ISS</span><p id="par0110" class="elsevierStylePara elsevierViewall">Como se aprecia en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se estudiaron cuatro grupos de pacientes seg&#250;n activaci&#243;n del EATG y la puntuaci&#243;n ISS&#46; En las <a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 a 3</a> se observan las diferencias encontradas &#40;columnas en fondo blanco&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Los pacientes del primer grupo &#40;activaci&#243;n e ISS &#62; 15&#41; se caracteriza por ser m&#225;s j&#243;venes&#44; una mayor atenci&#243;n prehospitalaria&#44; traumatismos de alta energ&#237;a&#44; con mayor repercusi&#243;n fisiol&#243;gica y org&#225;nica&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">El segundo grupo &#40;activaci&#243;n e ISS &#8804; 15&#41; tiene valores similares en edad y atenci&#243;n prehospitalaria pero una menor repercusi&#243;n fisiol&#243;gica y org&#225;nica&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">El tercer grupo &#40;no activaci&#243;n e ISS &#62; 15&#41; corresponde a pacientes m&#225;s mayores&#44; con un menor porcentaje de atenci&#243;n prehospitalaria&#44; mayor proporci&#243;n de ca&#237;das accidentales de baja energ&#237;a&#44; mayor afectaci&#243;n neurol&#243;gica&#46; Necesitan m&#225;s neurocirug&#237;a &#40;incluso de craneotom&#237;as descompresivas&#41; pero con menor repercusi&#243;n org&#225;nica que el primer grupo&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El cuarto grupo &#40;no activaci&#243;n e ISS &#8804; 15&#41; son pacientes con mayor estabilidad fisiol&#243;gica y org&#225;nica&#46; Presentan m&#225;s lesiones penetrantes &#40;incluso m&#225;s mecanismo de arma blanca&#41;&#44; poca alteraci&#243;n neurol&#243;gica&#44; mayor afectaci&#243;n de t&#243;rax&#44; y menor necesidad de procedimientos&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Factores asociados a la activaci&#243;n EATG</span><p id="par0135" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> se muestran los factores asociados a la activaci&#243;n del EATG en el modelo de regresi&#243;n log&#237;stica&#46; Se destaca que el padecer una ca&#237;da accidental es un factor que hace menos probable la activaci&#243;n&#46; La atenci&#243;n e intubaci&#243;n prehospitalaria son factores que propician la activaci&#243;n y&#44; la lesi&#243;n grave de extremidades inferiores tambi&#233;n favorece la activaci&#243;n&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">El modelo de &#225;rbol de clasificaci&#243;n CART &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41; selecciona como primera variable la del tipo de mecanismo del traumatismo y se observa que es capaz de separar los traumatismos de alta y baja energ&#237;a&#46; En el grupo de alta energ&#237;a selecciona la edad &#40;punto de corte de 32&#44;5 a&#241;os&#41; y en los m&#225;s mayores los diferencia seg&#250;n IOT prehospitalaria&#46; Obtiene cuatro grupos de pacientes con probabilidades de activaci&#243;n del EATG entre 20&#44;0 y 82&#44;6&#37;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Estudio de tiempos de actuaci&#243;n</span><p id="par0145" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> se muestran los resultados de los tiempos de actuaci&#243;n seg&#250;n grupos de activaci&#243;n-no activaci&#243;n &#40;A&#41; y seg&#250;n los cuatro grupos descritos&#46; La activaci&#243;n reduce todos los tiempos de actuaci&#243;n&#46; Al separar por los cuatro grupos&#44; vemos que el que obtiene tiempos m&#225;s reducidos es el grupo 2 &#40;activaci&#243;n e ISS &#8804; 15&#41; y el que los presenta m&#225;s largos es el grupo 3 &#40;no activaci&#243;n e ISS &#62; 15&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Discusi&#243;n</span><p id="par0150" class="elsevierStylePara elsevierViewall">Este trabajo muestra la experiencia de la implantaci&#243;n de un EATG en un intento de mejorar la calidad asistencial a los pacientes traum&#225;ticos graves que finalmente ingresan en la UCI&#46; Se analiza cu&#225;les son los factores que intervienen en la activaci&#243;n del EATG&#44; as&#237; como se consigue demostrar un acortamiento en los tiempos de asistencia cuando se activa el EATG&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Cualquier proceso asistencial debe ser monitorizado&#44; evaluado y se deben buscar puntos de mejora<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a>&#46; Un factor clave en la correcta organizaci&#243;n de un EATG es un correcto triage inicial bas&#225;ndonos en protocolos de activaci&#243;n actualizados donde se valora la severidad de los par&#225;metros fisiol&#243;gicos &#40;GCS motor &#60; 6&#44; FC &#62;TAS&#44; Sat &#60; 90&#37;&#41; lesiones anat&#243;micas llamativas &#40;sangrado activo&#44; deformidad craneal&#44; sospecha lesi&#243;n columna&#44; t&#243;rax o pelvis&#44; fractura de dos o m&#225;s huesos largos&#41; y el mecanismo lesional de alta energ&#237;a<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;10&#44;11</span></a>&#46; Monitorizar el nivel de infra y sobretriage es un indicador de calidad de la asistencia al paciente traum&#225;tico<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Cl&#225;sicamente se ha utilizado la matriz de Cribari para valorar el correcto triage de los traumatismos graves &#40;ISS &#62; 15&#41; que deben ser atendidos por un EATG&#44; donde se considera que no se debe superar 5&#37; del infratriage y 35&#37; del sobretriage <a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">En nuestro estudio &#250;nicamente 41&#44;3&#37; de los pacientes ingresados en UCI fue asistido por el EATG&#44; aunque se debe se&#241;alar que 32&#44;4&#37; de los pacientes que ingresaron en UCI ten&#237;an un ISS &#60; 15&#46; Seg&#250;n los criterios de calidad publicados por la SEMICYUC en 2017 95&#37; de los pacientes con traumatismos graves &#40;<span class="elsevierStyleItalic">Revised Trauma Score</span> &#91;RTS&#93; en la selecci&#243;n inicial &#8804; 11 puntos y&#47;o un ISS&#41; &#62; 15 ingresados en UCI deben ser atendidos por el servicio de medicina intensiva<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a>&#46; Se deber&#237;a explorar otras experiencias en otros centros&#44; para poder establecer una cifra ideal del porcentaje de pacientes que deben ser atendidos por el EATG antes de ser ingresados en UCI&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se plantean tres preguntas dependiendo de la activaci&#243;n y el nivel de afectaci&#243;n anat&#243;mica seg&#250;n ISS&#46; La primera pregunta se contesta porque estos pacientes&#44; aun siendo m&#225;s estables&#44; suelen tener traumatismos de alta energ&#237;a y son atendidos por equipos de atenci&#243;n prehospitalaria&#46; La segunda pregunta corresponde a que no se activa el EATG por ser pacientes con traumatismos de baja energ&#237;a&#44; m&#225;s mayores y menor atenci&#243;n prehospitalaria&#44; y la tercera pregunta se contesta por ser un grupo de pacientes que ingresan en un alto porcentaje para monitorizaci&#243;n&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Los factores que se asociaron con la activaci&#243;n del ETAG fueron los pacientes que hab&#237;an sido atendidos inicialmente por un equipo de emergencias prehospitalario&#44; requerir intubaci&#243;n previa y lesiones graves de las extremidades inferiores&#44; principalmente fracturas de pelvis&#46; El modelo CART determina que los traumatismos de alta energ&#237;a tienen m&#225;s probabilidad de activaci&#243;n junto a los pacientes m&#225;s j&#243;venes o intubados en el medio prehospitalario&#46; Un correcto triage de los equipos de emergencias prehospitalarios y una fluida comunicaci&#243;n con el medio hospitalario puede mejorar la activaci&#243;n previa de los equipos de EATG<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;19</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Hay que destacar que el &#250;nico factor que se asoci&#243; con la no activaci&#243;n del EATG fueron los pacientes que hab&#237;an sufrido una ca&#237;da accidental asociado a que no hab&#237;an sido activados los servicios prehospitalarios&#46; Los pacientes mayores&#44; con tratamientos anticoagulantes&#44; que sufren una ca&#237;da accidental tienen una alta morbimortalidad&#44; siendo un subgrupo de pacientes que se deber&#237;a incluir en los protocolos de activaci&#243;n&#46; En nuestra serie la edad media fue superior en el subgrupo de pacientes que no se activ&#243; el EATG<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">20&#44;21</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Actualmente los EATG han demostrado que mejoran los tiempos de asistencia al paciente traum&#225;tico<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a>&#46; En nuestra experiencia la activaci&#243;n del EATG ha logrado disminuir de forma significativa los tiempos de realizaci&#243;n de TAC&#44; intervenciones quir&#250;rgicas emergentes y su traslado definitivo a la unidad de cuidados intensivos&#46; Aunque nuestra experiencia no encuentra diferencias en mortalidad&#44; estudios recientes correlacionan el retraso del ingreso en las UCI con un aumento de la mortalidad y la importancia de realizar una atenci&#243;n cr&#237;tica fuera del entorno de UCI<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Nuestros resultados nos llevan a hacer varias recomendaciones&#46; La importancia de disponer de protocolos de activaci&#243;n actualizados consensuados entre los equipos de atenci&#243;n prehospitalaria como de urgencias&#46; Se debe monitorizar y evaluar los criterios de activaci&#243;n para poder analizar el infra-sobretriage de los pacientes asistidos&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">La principal limitaci&#243;n del estudio se debe al an&#225;lisis de un &#250;nico centro con sus caracter&#237;sticas cl&#237;nico-demogr&#225;ficas espec&#237;ficas y un tama&#241;o limitado de la muestra que puede influir en la generalizaci&#243;n de los resultados&#46; Otra limitaci&#243;n surge de no poder disponer de un control de pacientes asistidos por el EATG que no ingresaron en la UCI&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; instaurar un EATG a nivel hospitalario con una fluida comunicaci&#243;n de todos los servicios implicados en la atenci&#243;n del traumatismo grave logra disminuir los tiempos de asistencia&#46; Ser atendidos por un equipo de emergencias con intubaci&#243;n orotraqueal en la fase prehospitalaria tras sufrir un accidente de alta energ&#237;a con lesiones en las extremidades inferiores son los factores influyen en la activaci&#243;n del EATG&#46; Debemos mejorar la activaci&#243;n de los EATG en los pacientes a&#241;osos que sufren traumatismos de baja energ&#237;a y que no son atendidos por equipos de emergencias&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Contribuci&#243;n de los autores</span><p id="par0205" class="elsevierStylePara elsevierViewall">Neus Montserrat Ortiz&#44; Javier Trujillano Cabello y Luis Servia Goixart participaron en el dise&#241;o del estudio&#46; El an&#225;lisis e interpretaci&#243;n de los datos fue realizado por Javier Trujillano Cabello&#44; Luis Servia Goixart&#44; Neus Montserrat Ortiz&#44; Mariona Badia Castell&#243;&#46; Gabriel Jimenez Jimenez&#44; Judit Vilanova&#44; Jorge Rubio Ruiz&#44; Andres Pujol Freire y Dulce Morales Hernandez colaboraron con la recogida de datos y la revisi&#243;n del manuscrito&#46; Todos los autores leyeron y aprobaron la versi&#243;n final del manuscrito&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicto de intereses</span><p id="par0210" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar los factores asociados a la activaci&#243;n del equipo de asistencia al trauma grave &#40;EATG&#41; en pacientes que ingresan en la Unidad de Cuidados Intensivos &#40;UCI&#41;&#44; medir su repercusi&#243;n en los tiempos de asistencia&#44; y analizar los grupos de pacientes seg&#250;n activaci&#243;n y nivel de afectaci&#243;n anat&#243;mica&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes prospectivo del trauma grave que ingresan en UCI&#46; Desde junio 2017 a mayo 2019&#46; Factores de riesgo de la activaci&#243;n analizados con regresi&#243;n log&#237;stica y &#225;rbol de clasificaci&#243;n tipo CART&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">UCI hospital de segundo nivel&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Pacientes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes ingresados de forma consecutiva&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervenciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables de intereses principales</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Activaci&#243;n del EATG&#46; Variables demogr&#225;ficas&#46; Puntuaci&#243;n de la gravedad de la lesi&#243;n &#40;ISS&#41;&#44; intencionalidad&#44; mecanismo&#44; tiempos de asistencia&#44; complicaciones evolutivas y mortalidad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ingresaron un total de 188 pacientes &#40;46&#44;8&#37; de activaci&#243;n EATG&#41;&#44; edad mediana de 52 &#40;37-64&#41; a&#241;os &#40;activados 47 &#40;27-62&#41; vs&#46; no activados 55 &#40;42-67&#41; p &#61; 0&#44;023&#41;&#44; varones 84&#44;0&#37;&#46; No diferencias en la mortalidad seg&#250;n activaci&#243;n&#46; El modelo log&#237;stico encuentra como factores&#58; la atenci&#243;n &#40;16&#44;6 &#91;2&#44;1-13&#44;2&#93;&#41; e intubaci&#243;n prehospitalaria &#40;4&#44;2 &#91;1&#44;8-9&#44;8&#93;&#41; y&#44; la lesi&#243;n grave de extremidades inferiores &#40;4&#44;4 &#91;1&#44;6-12&#44;3&#93;&#41;&#46; Padecer una ca&#237;da accidental &#40;0&#44;2 &#91;0&#44;1-0&#44;6&#93;&#41; hace menos probable la activaci&#243;n&#46; El modelo CART selecciona el tipo de mecanismo del traumatismo y es capaz de separar los traumatismos de alta y baja energ&#237;a&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los factores asociados con activaci&#243;n del ETAG fueron la atenci&#243;n prehospitalaria&#44; requerir intubaci&#243;n previa&#44; mecanismos de alta energ&#237;a y lesiones graves de extremidades inferiores&#46; Menores tiempos de asistencia si activaci&#243;n sin influir en la mortalidad&#46; Debemos mejorar la activaci&#243;n en pacientes mayores con traumatismos de baja energ&#237;a y sin atenci&#243;n prehospitalaria&#46;</p></span>"
        "secciones" => array:8 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Dise&#241;o"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "&#193;mbito"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Pacientes"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Intervenciones"
          ]
          5 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Variables de intereses principales"
          ]
          6 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          7 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To analyse the factors associated with the activation of the severe trauma care team &#40;STAT&#41; in patients admitted to the ICU&#44; to measure its impact on care times&#44; and to analyse the groups of patients according to activation and level of anatomical involvement&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Prospective cohort study of severe trauma admitted to the ICU&#46; From June 2017 to May 2019&#46; Risk factors for the activation of the STAT analysed with logistic regression and CART type classification tree&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Setting</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Second level hospital ICU&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patients admitted consecutively&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Interventions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">No&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Main variables of interest</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">STAT activation&#44; demographic variables&#44; injury severity &#40;ISS&#41;&#44; intentionality&#44; mechanism&#44; assistance times&#44; evolutionary complications&#44; and mortality&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A total of 188 patients were admitted &#40;46&#46;8&#37; of STAT activation&#41;&#44; median age of 52 &#40;37&#8211;64&#41; years &#40;activated 47 &#40;27&#8211;62&#41; vs&#46; not activated 55 &#40;42&#8211;67&#41;&#44; p &#61; 0&#46;023&#41;&#44; males 84&#46;0&#37;&#46; No difference in mortality according to activation&#46; The logistic model finds as factors&#58; care &#40;16&#46;6 &#40;2&#46;1&#8211;13&#46;2&#41;&#41; and prehospital intubation &#40;4&#46;2 &#40;1&#46;8&#8211;9&#46;8&#41;&#41; and severe lower extremity injury &#40;4&#46;4 &#40;1&#46;6&#8211;12&#46;3&#41;&#41;&#46; Accidental fall &#40;0&#46;2 &#40;0&#46;1&#8211;0&#46;6&#41;&#41; makes activation less likely&#46; The CART model selects the type of trauma mechanism and can separate high and low energy trauma&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Factors associated with STAT activation were prehospital care&#44; requiring prior intubation&#44; high-energy mechanisms&#44; and severe lower extremity injuries&#46; Shorter care times if activated without influencing mortality&#46; We must improve activation in older patients with low-energy trauma and without prehospital care&#46;</p></span>"
        "secciones" => array:8 [
          0 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Design"
          ]
          2 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "Setting"
          ]
          3 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "Patients"
          ]
          4 => array:2 [
            "identificador" => "abst0065"
            "titulo" => "Interventions"
          ]
          5 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Main variables of interest"
          ]
          6 => array:2 [
            "identificador" => "abst0075"
            "titulo" => "Results"
          ]
          7 => array:2 [
            "identificador" => "abst0080"
            "titulo" => "Conclusions"
          ]
        ]
      ]
    ]
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        "etiqueta" => "Figura 1"
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        "mostrarFloat" => true
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Diagrama de flujo de pacientes incluidos en el grupo de estudio&#46; Se observan cuatro grupos seg&#250;n activaci&#243;n del equipo de atenci&#243;n al trauma grave &#40;EATG&#41; y puntuaci&#243;n ISS&#46; Se plantean tres preguntas a contestar&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "es" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">&#193;rbol de clasificaci&#243;n tipo CART&#46; Perfiles de pacientes seg&#250;n activaci&#243;n del Equipo de Atenci&#243;n al paciente Traum&#225;tico Grave &#40;EATG&#41;&#46; IOT&#58; Intubaci&#243;n orotraqueal&#46;</p>"
        ]
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        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 946
            "Ancho" => 2508
            "Tamanyo" => 185727
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Tiempos de atenci&#243;n &#40;TAC&#44; quir&#243;fano y UCI&#41;&#46; Valores como medianas&#44; en las tablas con intervalo intercuartil&#46; &#40;A&#41; Diferenciados en grupo de activaci&#243;n y de no activaci&#243;n&#46; &#40;B&#41; Diferenciados seg&#250;n activaci&#243;n y nivel de gravedad con punto de corte de ISS&#46;</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">ACT&#58; activado&#59; NA&#58; no activado&#46;</p> <p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Diferencias significativas &#40;&#42;&#41; p &#60; 0&#44;05 y &#40;&#42;&#42;&#41; p &#60; 0&#44;01 seg&#250;n test de Mann-Whitney o Kruskal-Wallis&#46;</p>"
        ]
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      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at1"
            "detalle" => "Tabla "
            "rol" => "short"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Valores expresados como porcentajes o mediana &#40;rango intercuartil&#41;&#46;</p><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">EATG&#58; equipo de asistencia al trauma grave&#59; ISS&#58; <span class="elsevierStyleItalic">Injury Severity Score</span>&#59; NISS&#58; <span class="elsevierStyleItalic">New Injury Severity Score</span>&#59; TRISS&#58; <span class="elsevierStyleItalic">Trauma and injury severity score</span>&#46; PRECOG&#58; Tratamiento cr&#243;nico con antiagregantes a anticoagulantes&#46;</p>"
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#8804; 15N &#61; 25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#62; 15N &#61; 67&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#8804; 15N &#61; 33&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-valor<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Edad &#40;a&#241;os&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47 &#40;27-62&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">52 &#40;27-63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">51 &#40;36-63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;073&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sexo &#40;&#37; masculino&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Estancia UCI &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#8804; 15N &#61; 25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">NO ACTIVN &#61; 100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#62; 15N &#61; 67&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISS &#8804; 15N &#61; 33&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-valor<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-valor<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Atenci&#243;n prehospitalaria</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">98&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">97&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Intubaci&#243;n prehospitalaria</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">INESTABILIDAD &#40;TOTAL&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">54&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">64&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">50&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;033&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;127&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-valor<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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