Brazil

Introduction

For the purposes of this chapter, vascular trauma is considered in the following anatomic distributions, each of which has differing diagnostic and management considerations: (1) cervical or carotid, (2) axillo-subclavian, (3) thoracic, (4) abdominal, and (5) extremity domains. Whereas the majority of vascular injury is managed via an open operative approach, the use of endovascular techniques is common in the metropolitan centers throughout the country. In these instances, stent grafts are often used to treat or “seal” vascular disruption in anatomically-challenging-to-reach vessels such as those in the thorax and thoracic outlet. In Brazil, challenges exist as to the “best training paradigms” to prepare trauma and vascular surgeons. However, a number of Brazilian medical centers and emergency medical systems, working alongside the efforts of professional societies such as the Brazilian Trauma Society (Sociedade Brasileira de Atendimento Integrado ao Politraumatizado, SBAIT), have emphasized the importance of trauma care in the country.

Epidemiology

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. Additionally, a full understanding of the epidemiology of vascular trauma is hampered by the lack of standardized data retrieval and archiving mechanisms or databases.

According to Brazil’s Institute of Geography and Statistics, just over 210 million people live in Brazil. Increasing levels of violence and trauma within certain urban areas and regional locations in Brazil ( Table 37.1 ) were the norm until the most recent decade (2010–19). This trend has lessened recently as rates of violent crime, including homicide, have plateaued or declined in proportion to population growth. Currently, the overall homicide rate fluctuates at around 30 per 100,000 people.

The growth in homicide over these three and a half decades was largely due to death from firearms, whereas deaths from other means remained relatively constant. In the early 1980s, there was an “arms race” associated with an increase in social tension, caused by a massive growth in urban population (following population transition from rural areas), although the 2003 Disarmament Statute helped to limit firearm availability.

We have two types of health care systems in Brazil: public (Sistema Único de Saúde, SUS) and private (health and private plans). About 90% of the Brazilian population rely on the public health system that is maintained by the government. The health system is composed of facilities of varying complexity: basic health units and Emergency Care Units, secondary hospitals, tertiary hospitals and University Hospitals, where some tertiary and university hospitals correspond and function as trauma centers ( Fig. 37.1 ). Systematized, standardized clinical responses to polytraumatized patients began in the public (University) hospitals in the 1980s, with the introduction and expansion of Advanced Trauma Life Support in Brazil. In the last decade, some private hospitals have started to implement trauma care systems based around teams of trauma surgeons. Prehospital emergency care is performed by the Emergency Medical Care Service (Serviço de Atendimento Móvel de Urgência, SAMU), which is structured with basic care units composed of technicians and nurses and advanced units composed of doctors and nurses. An emergency medical response ( ambulância ) is obtained by telephoning 192. However, in some cities such as São Paulo, Rio de Janeiro, and Curitiba, in addition to the SAMU response, prehospital trauma care is performed by physicians and nurses in conjunction with the rescue team of the Fire Department ( Corpo de Bombeiros ), activated by dialing 193.

Urban Setting

The severity of vascular trauma varies, with injuries stemming from military- or combat-related munitions generally cause more extensive damage. Brazilian surgeons generally have little experience of managing severe injury caused by military munitions and explosive devices, although the sporadic use of military-type weapons in the urban setting is a regrettable but new reality that is not unique to Brazil. Although uncommon, vascular trauma resulting from weapons such as the AR-15, AK-47, M16, and even grenades occurs on a sporadic basis in some areas of Brazil ( Fig. 37.2 ), though the proportion of such injuries was seen to decline in a series from the Hospital Municipal Souza Aguiar (1995–2000). This observation was made during a time when the homicide rate was increasing, suggesting that high-velocity munitions remained a significant cause of trauma including lethal injury. In an encouraging and more-recent trend, the rate of violence and the number of high-velocity gunshot wounds currently tended to in the state has plummeted.