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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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