Key Words:
Brazil , trauma , South America , vascular injury , hemorrhage
Introduction
Like elsewhere in the world, vascular trauma is the most challenging aspect of care in the multiply injured patient in Brazil. The breadth and complexity of vascular injury, including its propensity to result in shock or profound ischemia and its tendency to be associated with injuries to other tissues or organs, requires a multidisciplinary approach focused on life- and limb-saving maneuvers. Further complicating the landscape of vascular-injury management in this region of the world are rapidly evolving diagnostic and therapeutic options, including noninvasive computed tomography (CT) imaging and less-invasive endovascular interventions. New concepts related to damage control vascular surgery are also evolving and together with advances in resuscitation provide the opportunity for better survival following this complex injury pattern. It’s the premise of these authors that, amid all the changing paradigms in vascular trauma, management of the injury pattern should remain focused on the patient and the physiology and not simply focused on the anatomy of the vascular disruption. The objective of this review is to provide insight into the epidemiology of trauma in Brazil and the implications of vascular injury in that spectrum. In this chapter, the authors also describe some regionally unique aspects of diagnosis and treatment of this injury pattern ( Fig. 34-1 ).
Epidemiology
The epidemiology of trauma in Brazil has its roots in both the military and the civilian settings. Currently, urban violence, automobile crashes, and work-related accidents are responsible for most injuries in Brazil; a notable amount of those injuries are to major vascular structures. Concomitant with this experience, better lifesaving interventions and early resuscitation strategies have been established in many of the larger emergency rooms in Brazil. As in other countries, there is a disparity of capacity to manage vascular trauma between the larger, better-equipped centers and those in more remote or austere locations. Additionally, a full understanding of the epidemiology of vascular trauma is hampered by the lack of standardized data retrieval and archiving mechanisms or databases.
Trauma in Brazil
According to Brazil’s Institute of Geography and Statistics, just over 190 million people live in Brazil. Until the most recent decade (2000 to 2010), there were increasing levels of violence and trauma within certain urban areas and regional locations in Brazil ( Table 34-1 ). This trend has lessened recently as the rate of violent crimes including homicide have remained steady or declined in proportion to population growth. In Brazil, since 2003, there has been a decrease in the death rate from homicide; and, since 2005, the rate of homicide has fluctuated around a level of 26 per 100,000 people.
| State | 2000 | 2010 * | ||
|---|---|---|---|---|
| Rate | Position | Rate | Position | |
| Alagoas | 25,6 | 11° | 66,8 | 1° |
| Espirito Santo | 46,8 | 3° | 50,1 | 2° |
| Pará | 13,0 | 21° | 45,9 | 3° |
| Pernambuco | 54,0 | 1° | 38,8 | 4° |
| Amapá | 32,5 | 9° | 38,7 | 5° |
| Paraíba | 15,1 | 20° | 38,6 | 6° |
| Bahia | 9,4 | 23° | 37,7 | 7° |
| Rondônia | 33,8 | 8° | 34,6 | 8° |
| Paraná | 18,5 | 16° | 34,4 | 9° |
| Distrito Federal | 37,5 | 7° | 34,2 | 10° |
| Sergipe | 23,3 | 12° | 33,3 | 11° |
| Mato Grosso | 39,8 | 5° | 31,7 | 12° |
| Amazonas | 19,8 | 14° | 30,6 | 13° |
| Ceará | 16,5 | 17° | 29,7 | 14° |
| Goiás | 20,2 | 13° | 29,4 | 15° |
| Roraima | 39,5 | 6° | 27,3 | 16° |
| Rio de Janeiro | 51,0 | 2° | 26,2 | 17° |
| Mato Grosso do Sul | 31,0 | 10° | 25,8 | 18° |
| Mato Grosso do Norte | 9,0 | 24° | 22,9 | 19° |
| Tocantins | 15,5 | 19° | 22,5 | 20° |
| Maranhão | 6,1 | 27° | 22,5 | 21° |
| Acre | 19,4 | 15° | 19,6 | 22° |
| Rio Grande do Sul | 16,3 | 18° | 19,3 | 23° |
| Minas Gerais | 11,5 | 22° | 18,1 | 24° |
| São Paulo | 12,2 | 4° | 13,9 | 25° |
| Piauí | 8,2 | 25° | 13,7 | 26° |
| Santa Catarina | 7,9 | 26° | 12,9 | 27° |
Urban Conflicts
Like other areas of the world, the mechanism of vascular trauma in Brazil differs widely depending on whether the injury occurs in a military setting or as a result of urban violence. Subsequently, the severity of vascular trauma also varies; injuries stemming from military- or combat-related munitions generally cause more extensive damage. In the absence of a recent major war, the broad-scale experience of Brazilian surgeons dealing with severe injury caused by military munitions including those from explosive devices has been practically nonexistent. The sporadic use of military-type weapons in the urban setting is a regrettable but new reality that is not unique to Brazil. Knowledge of the type of weaponry that is responsible for a particular type of injury can provide information regarding the velocity and type of projectiles or munition. Although uncommon, vascular trauma resulting from weapons such as the AR-15, AK-47, M16, and even grenades does occur on a sporadic basis in some areas of Brazil ( Fig. 34-2 ).
