Search

Abstract Introduction Hemorrhage is a major cause of preventable trauma deaths, and the ABC approach is widely used during the primary survey. We hypothesize that prioritizing circulation over intubation (CAB) can improve outcomes in patients with exsanguinating injuries. Methods A prospective observational study involving international trauma centers was conducted. Patients with systolic blood pressure below 90 who were intubated within 30 min of arrival were included. Prioritizing circulation (CAB) was defined as delaying intubation until blood products were started, and/or bleeding control was performed before securing the airway. Demographics, clinical data, and outcomes were recorded. Results The study included 278 eligible patients, with 61.5% falling within the “CAB” cohort and 38.5% in the “ABC” cohort. Demographic and disease characteristics, including age, sex, ISS, use of blood products, and other relevant factors, exhibited comparable distributions between the two cohorts. The CAB group had a higher proportion of penetrating injuries and more patients receiving intubation in the operating room. Notably, patients in the CAB group demonstrated higher GCS scores, lower SBP values before intubation but higher after intubation, and a significantly lower incidence of cardiac arrest and post-intubation hypotension. Key outcomes revealed significantly lower 24-hour mortality in the CAB group (11.1% vs. 69.2%), a lower rate of renal failure, and a higher rate of ARDS. Multivariable logistic regression models showed a 91% reduction in the odds of mortality within 24 h and an 89% reduction at 30 days for the CAB cohort compared to the ABC cohort. These findings suggest that prioritizing circulation before intubation is associated with improved outcomes in patients with exsanguinating injuries. Conclusion Post-intubation hypotension is observed to be correlated with worse outcomes. The consideration of prioritizing circulation over intubation in patients with exsanguinating injuries, allowing for resuscitation, or bleeding control, appears to be associated with potential improvements in survival. Emphasizing the importance of circulation and resuscitation is crucial, and this approach might offer benefits for various bleeding-related conditions.

Abstract Surgeons in their daily practice are at the forefront in preventing and managing infections. However, among surgeons, appropriate measures of infection prevention and management are often disregarded. The lack of awareness of infection and prevention measures has marginalized surgeons from this battle. Together, the Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) have jointly completed an international declaration, highlighting the threat posed by antimicrobial resistance globally and the need for preventing and managing infections appropriately across the surgical pathway. The authors representing these surgical societies call all surgeons around the world to participate in this global cause by pledging support for this declaration for maintaining the effectiveness of current and future antibiotics.

Se informa sobre 1 caso de infusión intracardíaca de cristaloides como medida inicial de reanimación. El procedimiento está indicado en toracotomía de resucitación por desangramiento. Se revisa la literatura disponible y se discuten las alternativas de manejo. La infusión intracardíaca de cristaloides y sangre es uno de los objetivos terapéuticos de la toracotomía de resucitación.

La sepsis intraabdominal presenta una mortalidad entre el 30 y el 80% con el tratamiento tradicional de laparotomía y drenaje del foco séptico. En la literatura se han descrito varios métodos para prevenir la reacumulación de la colección purulenta. Se muestra la experiencia del tratamiento de individuos con sepsis abdominal refractaria a las medidas usuales de manejo, tratados en el Hospital Universitario del Valle de Cali, Colombia, en un período de 4 años. Se trataron 200 pacientes con sepsis abdominal mediante el método de abdomen abierto y malla de plástico, inicialmente, y luego con malla de nailon con cremallera. Se describe la técnica para la colocación de la malla y el manejo de los lavados abdominales cada 24 horas en la cama del paciente bajo sedación o anestesia general. A los pacientes se les agrupó según la clasificación anatómica, se les midió el APACHE II, el ATl en los sujetos traumatizados y se los correlacionó con la mortalidad. La principal indicación para la colocación de la malla fue la peritonitis generalizada difusa. Se realizaron 8 lavados en promedio para los pacientes que sobrevivieron. El promedio de días con malla fue 15. La mortalidad para los pacientes tratados con malla y lavados fue de 33.5%.

Trauma toracoabdominal significa ruptura del diafragma y no solamente herida del tórax inferior. Este tipo de trauma no tiene signos ni síntomas específicos, lo cual hace difícil el diagnóstico. El lavado peritoneal y las pruebas de Rayos X tienen falsos positivos y falsos negativos. La laparoscopia y la toracoscopia parecen las mejores modalidades diagnósticas. Por otra parte, la demora en el tratamiento puede resultar en hernia diafragmática, la cual presenta alta morbilidad y mortalidad.

Se realizó una revisión del tema de las quemaduras y de su terrible complicación, la infección, utilizando un enfoque práctico, con el propósito de actualizar los conceptos relevantes del mismo y de prevenir las indeseables consecuencias de esta patología, tanto más graves cuanto menos 'adecuada sea su terapéutica. Una larga experiencia personal y una extensa consulta bibliográfica, sirvieron de base al trabajo realizado, cuya conclusión es la de que al tema debe dársele mayor importancia y difusión en los medios científicos y académicos, en defensa y beneficio de un gran número de pacientes que en nuestro medio son víctimas de esta grave enfermedad.

Las pérdidas de volumen en el paciente quirúrgico pueden ser a expensas del espacio intravascular como ocurre en el caso de la hemorragia o a expensas del espacio intersticial como ocurre en el caso de la peritonitis o las quemaduras (1-5). Las pérdidas de líquidos corporales por deshidratación son relativamente bien toleradas, al menos en la etapa inicial, como se puede observar en los pacientes quemados o con procesos de deshidratación pura. Se requiere una pérdida importante de líquidos para que aparezcan alteraciones de los signos vitales, como se puede deducir de la Tabla 1, que especifica las cifras en mL para un adulto de 70 kg (6,7). En cambio, las pérdidas por hemorragia son muy mal toleradas, como se deduce de la tabla 2 en la que se hicieron cálculos para el mismo paciente (2, 3, 8).

Abstract Background Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population. Materials and methods We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms “trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements.” Results The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis. Conclusions Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.

Non-compressible torso hemorrhage (NCTH) (i.e. bleeding from anatomical locations not amenable to control by direct pressure or tourniquet application) is a leading cause of potentially preventable death after injury. In select trauma patients with infra-diaphragmatic NCTH-related hemorrhagic shock or traumatic circulatory arrest, occlusion of the aorta proximal to the site of hemorrhage may sustain or restore spontaneous circulation. While the traditional method of achieving proximal aortic occlusion included Emergency Department thoracotomy (EDT) with descending thoracic aortic cross-clamping, resuscitative endovascular balloon occlusion of the aorta (REBOA) affords a less invasive option when thoracotomy is not required for other indications. In this article, we review the innovation, pathophysiologic effects, indications for, and technique of EDT and partial, intermittent, and complete REBOA in injured patients, including recommended methods for reversing aortic occlusion. We also discuss advantages and disadvantages of each of these methods of proximal aortic occlusion and review studies comparing their effectiveness and safety for managing post-injury NCTH. We conclude by providing recommendations as to when each of these methods may be best, when indicated, to manage injured patients with NCTH.

Abstract Background Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups. Methods The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion. Recommendations Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO. Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention. Discussion This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.

Abstract Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a “planned second-look” laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

Abstract Background The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence. Methods This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes. Results From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death. Conclusion The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted. Trial registration IRB approval number: HM20006627. Retrospective trial not registered.

Abstract The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use of the Sepsis-3 definitions.

Abstract Background Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. Methods A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. Results The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4–6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p

Abstract Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Abstract Background The objective of this systematic review and meta-analysis was to determine the effect of REBOA, compared to resuscitative thoracotomy, on mortality and among non-compressible torso hemorrhage trauma patients. Methods Relevant articles were identified by a literature search in MEDLINE and EMBASE. We included studies involving trauma patients suffering non-compressible torso hemorrhage. Studies were eligible if they evaluated REBOA and compared it to resuscitative thoracotomy. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. We conducted meta-analysis using random effect models. Results We included three studies in our systematic review. These studies included a total of 1276 patients. An initial analysis found that although lower in REBOA-treated patients, the odds of mortality did not differ between the compared groups (OR 0.42; 95% CI 0.17–1.03). Sensitivity analysis showed that the risk of mortality was significantly lower among patients who underwent REBOA, compared to those who underwent resuscitative thoracotomy (RT) (RR 0.81; 95% CI 0.68–0.97). Conclusion Our meta-analysis, mainly from observational data, suggests a positive effect of REBOA on mortality among non-compressible torso hemorrhage patients. However, these results deserve further investigation.

Abstract Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Objetivo: describir el manejo operatorio del trauma cardíaco penetrante y cerrado. Fuentes de información: publicaciones en la literatura internacional y nacional con aportes relevantes respecto del manejo quirúrgico del trauma cardíaco. Resultados: en materia prehospitalaria, existe consenso que se obtienen mejores resultados mediante un transporte rápido a un quirófano. En cambio, el manejo en detalle del paciente en estado crítico con trauma cardíaco penetrante no está claro en la literatura. Por este motivo la presente revisión describe las técnicas utilizadas en el Hospital Universitario del Valle. En materia de trauma cardíaco complejo, así como de trauma cardíaco cerrado, se presentan las conclusiones de las guías de manejo publicadas en la literatura. Conclusiones: mediante un enfoque estandarizado de manejo operatorio es posible ofrecer mejores posibilidades de sobrevida. Este tipo de manejo es particularmente útil en los individuos que ingresan en estado agónico o choque profundo.

La demanda por atención de urgencias y en particular por trauma se ha incrementado en forma constante durante las últimas décadas en la mayoría de los hospitales. En efecto, en varios países del continente, en los hospitales de mayor tecnología, las consultas y admisiones por urgencias representan más del 50% de! total. En los hospitales universitarios de algunos países, esta proporción puede llegar a más del 80%. ¡En el Hospital Universitario del Valle de Cali, Colombia, por ejemplo, casi e! 90% de las admisiones de Cirugía tienen su origen en urgencias, es decir sólo e! 10% son pacientes de tipo electivo.

Se define el síndrome pospericardiotomía y se califica una entidad infrecuente. Se presenta 1 caso documentado de este estado patológico, diagnosticado en un hombre de 25 años de edad quien había sufrido una herida con arma cortopunzante en el área precordial. Se discuten aspectos históricos, etiológicos, fisiopatológicos, clínicos, paraclínicos, diagnósticos, terapéuticos y anatomopatológicos del síndrome pospericardiotomía. Por último, se transcriben 21 referencias bibliográficas nacionales e internacionales sobre el tema.

La superficie cruenta de una quemadura contiene microorganismos en cantidad variable a pesar del uso de agentes tópicos. En efecto, los agentes tópicos disponibles en la actualidad permiten un manejo exitoso del área quemada, pero no consiguen esterilizar 'completamente la superficie cruenta (1). Por este motivo el cultivo convencional de superficie se considera inadecuado para identificar el germen protector de la infección y en su lugar se recomienda el uso del cultivo biopsia

La mortalidad producida por trauma en cualquiera de sus formas, cronológicamente presenta tres picos de frecuencia, cuyas causas pueden ser: - Primeros minutos: Lesión severa del encéfalo, o ruptura de grandes vasos. - Primeras horas: Hematoma subdural o hemorragia intraabdominal. - Días o semanas: infección o falla múltiple. En gran parte de los servicios quirúrgicos se ha demostrado que la mayoría de las muertes tardías después del trauma se debe a esta última causa.

Abstract Emergency surgery is performed in every hospital with a A and E unit all around the world. However it is organized in different ways with different results. Aim of this paper is to present history, current scope, current training program and new politics for training national program of 3 countries of different continents. Brazil, Finland and US emergency surgery models are presented discussing all criticisms showed during the WSES Summer Meeting 2008.