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En la industria en general se requiere controlar variables físicas como temperatura y presión para elaborar productos, por ello se requiere especialistas en el tema de Instrumentación; consecuencia de esto se incrementa el precio final del producto elaborado. El objetivo de este trabajo es la adquisición de las variables físicas en LOGO! Soft V8.3 mediante el generador de señales y PT100 como parte del proyecto general de investigación. Mediante el generador de señales reemplazamos a un transductor de corriente y voltaje para simular las señales analógicas que son enviadas al Controlador Lógico Programable. Esta investigación se fragmentó en tres fases, la primera etapa se estudia sobre la generación de señales analógicas de corriente y voltaje basado en normas ISA, la segunda etapa es las conexiones físicas del generador de señales con el Logo Soft V8.3, y la última etapa se realizó la programación en LOGO! Soft Comfort V8.3 de la marca SIEMENS para utilizar las señales analógicas. Este artículo, nos permite tener una herramienta para temas de instrumentación y adquisición de datos que posteriormente será enviado por medio del IoT 2040 a la nube.

Objetivo: Mediante la prueba CareVPH (prueba para detección del ADN de VPH oncogénico) determinar la frecuencia de infección por VPH oncogénico en mujeres de 30-64 años que acuden al Centro Integral de Salud San Benito de Honduras, entre enero y diciembre del año 2017. Metodología: Estudio no experimental, descriptivo, longitudinal, retrospectivo realizado en el Centro Integral de Salud San Benito, con una población de 2,249 mujeres en edades entre los 30 y 64 años. Se aplicó estadística descriptiva y se utilizó el programa EPI INFO V7 para el análisis de datos. Resultados: Se confirmaron 332 casos positivos (14.76%) del total de las mujeres en el estudio. La mayoría de los casos positivos de VPH fueron detectados por el método de muestra autoaplicada 2120 (94.28%). El grupo etario con más casos positivos de VPH es el de 30 a 39 años, con 184 casos (55.42%), seguido del grupo de 40 a 49 años con 83 casos (25%). Conclusiones: El estudio reveló una alta prevalencia de infección por VPH oncogénico en mujeres de 30-64 años en el Centro Integral de Salud San Benito, con una tasa de infección del 14.76%. El grupo etario con el mayor número de casos positivos fue el de 30 a 39 años. La prueba CareVPH resultó ser una herramienta eficaz para la detección de VPH oncogénico en mujeres de 30-64 años.

RESUMEN Objetivo: Determinar los efectos de la exposición a vapores de gasolina sobre la función pulmonar en vendedores informales. Material y métodos: Estudio descriptivo de corte transversal realizado en expendedores informales de gasolina expuestos a sus vapores en el municipio de Maicao, Colombia. Se registraron datos sociodemográficos, se evaluó la función pulmonar por medio de espirometría, oximetría de pulso y, evaluación de la exposición a biomasa. Resultados: Se evaluaron 74 pacientes. El 87,8% eran de sexo masculino, encontrándose principalmente entre los 18 - 40 años (71,6%). El 21,6% (n=16) de la población reportó tener afecciones respiratorias, el 59,4% obtuvo un VEF1

Background The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years.

Arthroplasty; Internet-based intervention; Telehealth Artroplàstia; Intervenció basada en Internet; Telesalut Artroplastia; Intervención basada en Internet; Telesalud Purpose: The study aimed to demonstrate the reduction in postoperative follow-up visit time for patients receiving total knee arthroplasty (TKA) or reverse total shoulder arthroplasty (RTSA) by implementing a novel asynchronous telemedicine system compared to face-to-face visits. The range of motion interobserver agreement and patient satisfaction were evaluated in the telemedicine group. Methods: A randomized controlled trial was conducted with a total of 28 patients with a mean age of 71 years (range 13.3). Patients were distributed into two study groups, TKA (n = 14) and RTSA (n = 14), and each group was randomly allocated into a face-to-face or virtual follow-up visit group. For the virtual group, software was designed including patient-specific model items (X-ray, range of motion and functional scores) for each arthroplasty. Functional assessment was conducted using the International Knee Documentation Committee (IKDC) score for TKA and American Shoulder and Elbow score (ASES) and Simple Shoulder Test (SST) for RTSA. The range of motion interobserver concordance was conducted in the virtual follow-up groups via an intraclass correlation coefficient. Finally, a satisfaction survey was performed in the virtual follow-up groups. Mann-Whitney U test was used for statistical analysis. Results: Mean time differences between face-to-face and virtual follow-ups were 502.5 s (95% CI 387.8-617.1; p < 0.002) in the RTSA group and 710 s (95% CI 597.91-822; p < 0. 002) in the TKA group. The range of motion interobserver concordance in the virtual group was 0.974 for TKA and 0.804 for RTSA. Finally, virtual follow-up satisfaction using the telematic method was 8.9 out of 10. Conclusion: The results of this study showed that a virtual follow-up using asynchronous telemedicine systems could reduce visit times, allow a correct articular range of motion evaluation and maintain satisfaction perception for patients. Asynchronous telemedicine could be an efficient method to conduct postoperative follow-up after knee and shoulder arthroplasty.

Pancreatic trauma has a low incidence in both closed and penetrating injuries. The risk for morbidity and mortality is associated with injury severity of multiple organ injuries.To describe the characteristics of patients with penetrating pancreatic trauma treated at Foundation Valle del Lili (FVL), analyze the treatment performed and possible variables associated with the occurrence of complications related to injury to the pancreas and its treatment.A retrospective review was made. The medical records of patients with abdominal trauma penetrating with pancreatic injury seen in FVL between 2000 and 2013, and who survived more than 48 hours. We analyzed demographic variables, severity of trauma and management related to the development of pancreatic fistula.Twenty-eight patients were identified with median age 30 years (21-38). Eight (28%) were admitted in shock (SBP90 mm Hg). The anatomical severity measured by the PATI had median 50 (34.5-67.5). The number of organs injured: a median of 5 (5-6). Twenty-one patients (75%) had major vascular injuries, 19 (68%) gastric injury, 14 (50%) colon, 12 (43%) liver, small intestine 12 and 11 (39%) duodenal. The severity of pancreatic injury was a median of 3 (2-4). Treatment of pancreatic lesion consisted of suture in 12 cases (42.8%), distal resection in 8 (28.6%) and packing in 8. Local complications occurred in 23 patients (83%), abdominal sepsis in 19 (68%), pancreatic fistula in eight (29%) and intestinal fistula in six (21%). Four patients (14%) died, two from sepsis and two from multiorgan failure. No association was found between severity of trauma or damaged organs and the risk of fistula. Only pancreatic suture was associated with lower risk of complication.We present a series of patients with penetrating pancreatic trauma with a high prevalence of serious injuries and associated morbidity, despite which mortality was reduced. Simple suture of the pancreatic injury was associated with lower risk of fistula.El trauma de páncreas, tiene una baja incidencia tanto en heridas penetrantes como cerradas y se asocia a múltiples lesiones de órganos que determinan la severidad del trauma y el riesgo de morbilidad y mortalidad.Describir las características de los pacientes con trauma pancreático penetrante atendidos en a Fundación Valle del Lili (FVL), analizar el tratamiento realizado y las posibles variables asociadas a la ocurrencia de complicaciones relacionadas con la lesión del páncreas y dicho tratamiento.Se hizo una revisión retrospectiva de las historias clínicas de los pacientes con trauma abdominal penetrante con lesión de páncreas, manejados completamente en la FVL entre 2000 y 2013, que sobrevivieron más de 48 horas. Se analizaron variables demográficas, de la severidad del trauma y del manejo, relacionadas con el desarrollo de fístula pancreática.Se identificaron 28 pacientes con mediana de edad 30 años, (RIQ 21–38). Ocho, (28%) ingresaron en shock (TAS90 mm Hg).La severidad anatómica medida por el PATI tuvo una mediana de 50 (RIQ 34,5–67,5). El número de órganos lesionados una mediana de 5 (RIQ 5–6).21 pacientes (75%) tuvieron lesiones vasculares mayores o menores, 19 (68%) compromiso gástrico, 14 (50%) colónico, 12 (43%) hepático, 12 de intestino delgado, 12 vascular mayor y 11 (39%) duodenal. La severidad de la lesión pancreática tuvo una mediana de 3 con RIQ de 2 a 4.El tratamiento de la lesión pancreática consistió en sutura en 12 casos (42.8%), resección distal en 8 (28.6%) o empaquetamiento en 8.Se presentaron complicaciones locales en 23 pacientes (83%). Sepsis abdominal en 19 (68%), fístula pancreática en 8 (29%) y fístula intestinal en 6 (21%).Cuatro pacientes (14%) murieron. Dos por sepsis y dos por falla multiorgánica. No se encontró asociación entre la severidad del trauma o los órganos lesionados y el riesgo de fístula. Solamente la sutura del páncreas se asoció con menor riesgo de la complicación.Presentamos una serie de pacientes con trauma pancreático penetrante con una alta prevalencia de lesiones asociadas graves que determinaron una morbilidad considerable, a pesar de lo cual la mortalidad fue reducida. La sutura de la lesión pancreática se asoció con menor riesgo de fístula.

Introduction: In recent years, the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) has become popular to prevent or treat massive bleeding due to placenta accreta spectrum (PAS). Objective: There are multiple variations in REBOA use in this context and although the experience of vascular surgeons is extensive with aortic balloons, there are particularities in the management of these devices in the obstetric population that deserve to be discussed. Methods: We discuss some technical considerations or “lessons learned” in our center that may be useful for other groups starting to use REBOA in PAS Conclusion: Although REBOA is a useful strategy to prevent or treat massive bleeding due to PAS, its incorporation into management protocols must be carried out in a programmed and supervised manner.

Background Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients. Methods A systematic review of the literature was conducted. Results Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed. Conclusion Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population.

Background: Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of Posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center.Methods: This is a retrospective review of the patients who survived more than 48 hours. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors.Results: We included 192 patients treated from 2011 to 2020. There were 169 (88.0) male. The mean interquartile range, (IQR) of age was 27 (22 - 35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18 - 44) and 17 (10 - 27), respectively. Thoracic AIS was >3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%). Stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%).Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with Video Assisted Thoracoscopy Surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple Logistic Regression identified thoracic AIS >3 (OR 6.4, 95% CI 1.77 – 23. 43), and visible contamination (OR 5.13, 95% IC 1.26 – 20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema.Conclusion: The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors of empyema after penetrating diaphragmatic trauma.

Introducción. La mayoría de las lesiones de carótida cervical en nuestra institución se manejan por vía endovascular. El objetivo de este estudio fue describir los desenlaces del manejo de las lesiones de carótida cervical en un hospital de cuarto nivel en la ciudad de Cali, Colombia. Métodos. Estudio de series de casos, retrospectivo, descriptivo, en pacientes con trauma de carótida (penetrante y cerrado), admitidos en un centro de alta complejidad de la ciudad de Cali, en el periodo comprendido desde enero de 2018 hasta enero de 2020. Resultados. Se evaluaron 20 pacientes con lesión de carótida, de los cuales 90 % tenía trauma penetrante, en su mayoría por proyectil de arma de fuego. La zona más frecuentemente afectada fue la carótida interna (65 %) y el 40 % de los pacientes presentaban síntomas neurológicos al ingreso. Se realizó manejo endovascular en 13 pacientes, con un 75 % de éxito en el manejo endovascular al ingreso. La mortalidad general fue del 20 %, que en su mayoría estuvo relacionada con traumatismo en otros órganos. El 69 % de los pacientes quedaron sin secuelas neurológicas al alta y el 25 % con secuelas mínimas. Discusión. Se muestra una serie de casos con lesión de carótida donde, teniendo en cuenta las variables de mal pronóstico para hacer una selección adecuada de los pacientes candidatos a este tipo de terapia, el resultado del manejo endovascular fue exitoso.

Background Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. Methods Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1. Results Twelve components of preoperative care were considered. Consensus was reached after three rounds. Conclusions These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.

The effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling pelvic bleeding has been reported with increasing frequency during surgical management of placenta accreta spectrum (PAS). The deployment of REBOA may lead to significant variations in vital signs requiring special care by anesthesiology during surgery. These modifications of blood pressure by REBOA in PAS patients have not been accurately documented. We report the changes in blood pressure that occur when the aorta is occluded and then released in patients with PAS. This prospective, observational study includes 10 patients with preoperative PAS suspicion who underwent prophylactic REBOA device insertion between April 2018 and October 2019. REBOA procedural-related data and blood pressure fluctuations under invasive monitoring before and after inflation and deflation were recorded in the operating room. After prophylactic REBOA deployment in zone 3 of the aorta in PAS patients, we observed a transitory increase in blood pressure (median increase of 22.5 mmHg in SBP and 9.5 mmHg in DBP), which reached severe hypertension (SBP >160 mmHg) in 50% of patients. All patients presented a decrease in blood pressure after the removal of the aortic occlusion (median decrease of 23 mmHg in SBP and 10.5 mmHg in DBP), and 50% (five patients) required the administration of vasopressor drugs. Immediately after aortic occlusion is applied in zone 3 in PAS patients and after the occlusion is removed, significant hemodynamic changes occur, which often lead to therapeutic interventions.

Introduction The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion techniques have been incorporated into the management of this pathology. Our aim was to examine the endovascular practice patterns among PAS patients treated during a 9-year period in a low-middle income country in which an interdisciplinary group's technical skills were improved with the creation of a PAS team. Methodology A retrospective cohort study including all PAS patients treated from December 2011 to November 2020 was performed. We compared the clinical results obtained according to the type of endovascular device used (group 1, internal iliac artery occlusion balloons; group 2, resuscitative endovascular balloons of the aorta; group 3, no arterial balloons due to low risk of bleeding) and according to the year in which they were attended (reflects the PAS team level of experience). A fourth group of comparisons included the woman diagnosed during a cesarean delivery and treated in a nonprotocolized way. Results A total of 113 patients were included. The amount of blood loss decreased annually, with a median of 2,500 mL in 2014 (when endovascular occlusion balloons were used in all patients) and 1,394 mL in 2020 (when only 38.5% of the patients required arterial balloons). Group 3 patients (n = 16) had the lowest bleeding volume (1,245 mL) and operative time (173 minutes) of the entire population studied. Group 2 patients (n = 46) had a bleeding volume (mean, 1,700 mL) and transfusions frequency (34.8%) slightly lower than group 1 patients (n = 30) (mean of 2,000 mL and 50%, respectively). They also had lower hysterectomy frequency (63% vs. 76.7% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS and S2 compromise. Conclusion Endovascular techniques used for bleeding control in PAS patients are less necessary as interdisciplinary groups improve their surgical and teamwork skills. Level of evidence Therapeutic care management, level III.

Introduction: Exsanguination remains a leading cause of preventable death in traumatically injured patients. To better treat hemorrhagic shock, hospitals have adopted massive transfusion protocols (MTPs) which accelerate the delivery of blood products to patients. There has been an increase in mass casualty events (MCE) worldwide over the past two decades. These events can overwhelm a responding hospitals supply of blood products. Using a computerized model, this study investigated the ability of US trauma centers (TCs) to meet the blood product requirements of MCEs. Methods: Cross-sectional survey data of on-hand blood products were collected from 16 US level-1 TCs. A discrete event simulation model of a TC was developed based on historic data of blood product consumption during MCEs. Each hospitals blood bank was evaluated across increasingly more demanding MCEs using modern MTPs to guide resuscitation efforts in massive transfusion (MT) patients. Results: A total of 9,000 simulations were performed on each TCs data. Under the least demanding MCE scenario, the median size MCE in which TCs failed to adequately meet blood product demand was 50 patients (IQR 20-90), considering platelets. Ten TCs exhaust their supply of platelets prior to red blood cells (RBCs) or plasma. Disregarding platelets, five TCs exhausted their supply of O- packed RBCs, six exhausted their AB plasma supply, and five had a mixed exhaustion picture. Conclusion: Assuming a TCs ability to treat patients is limited only by their supply of blood products, US level-1 TCs lack the on-hand blood products required to adequately treat patients following a MCE. Use of non-traditional blood products, which have a longer shelf life, may allow TCs to better meet the blood product requirement needs of patients following larger MCEs. Funding Agencies|Center for Translational Injury Research; John B Holmes Professorship in Clinical Sciences

La Enfermedad de Chagas es una parasitosis crónica y sistémica causada por el protozoario hemoflagelado Trypanosoma cruzi y transmitida, fundamentalmente, por insectos de la subfamilia Triatominae. Actualmente, se reconocen al menos 151 especies de Triatominae, con especies de los géneros, Triatoma, Rhodnius y Panstrongylus, con un importante papel epidemiológico en la transmisión de la enfermedad. En Ecuador es difícil conocer la verdadera situación epidemiológica de esta enfermedad, sus implicaciones y la situación sobre su gestión de prevención y control. Se realizó una revisión de los datos epidemiológicos de la enfermedad de Chagas, publicadas en el Subsistema de Vigilancia Epidemiológica del Ministerio de Salud Pública desde el 2013 al 2019. La revisión sistemática de las especies de triatominos fue realizada a partir de investigaciones originales publicadas en base de datos de acceso público. La revisión realizada reportó 439 casos confirmados de Chagas con una alta incidencia en los últimos dos años. La prevalencia se ha observado ligeramente en mujeres con un grupo etario prevalente de 20 a 49 años. En el Ecuador se registra 17 especies de triatominos. Las especies Triatoma dimidiata y Rhodnius ecuadoriensis son los principales vectores de la enfermedad, con una alta densidad en las provincias de Loja y Manabí debido a su alta capacidad de adaptación y la colonización de nuevos hábitats.

Background: Most remote areas have restricted access to healthcare services and are too small andremote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. Methods: The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. Results: The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. Conclusions: The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections. (c) 2020 Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.

Background This study aimed to determine the critical threshold of systolic blood pressure (SBP) for aortic occlusion (AO) in severely injured patients with profound hemorrhagic shock. Methods All adult patients (>15 years) undergoing AO via resuscitative endovascular balloon occlusion of the aorta (REBOA) or thoracotomy with aortic cross clamping (TACC) between 2014 and 2018 at level I trauma center were included. Patients who required cardiopulmonary resuscitation in the prehospital setting were excluded. A logistic regression analysis based on mechanism of injury, age, Injury Severity Score, REBOA/TACC, and SBP on admission was done. Results A total of 107 patients underwent AO. In 57, TACC was performed, and in 50, REBOA was performed. Sixty patients who underwent AO developed traumatic cardiac arrest (TCA), and 47 did not (no TCA). Penetrating trauma was more prevalent in the TCA group (TCA, 90% vs. no TCA, 74%; p Conclusion Systolic blood pressure of 60 mm Hg appears to be the optimal value upon which AO must be performed immediately to prevent the probability of death (>50%). However, values of SBP less than 70 mm Hg also increase the probability of cardiac arrest. Level of evidence Therapeutic study, level IV.

Resumen Introduccion: estudios recientes han reportado la ocurrencia de fenomenos tromboticos o coagulopatia en pacientes con COVID-19 Hay posiciones divergentes en cuanto a la prevencion, el diagnostico y el tratamiento de estos fenomenos, y la practica clinica actual esta basada unicamente en deducciones por extension a partir de estudios retrospectivos, series de casos, estudios observacionales y guias internacionales desarrolladas previas a la pandemia Objetivo: establecer un grupo de recomendaciones sobre prevencion, diagnostico y manejo de las complicaciones tromboticas asociadas a COVID-19 Metodos: se desarrollo una guia rapida en la que se aplico el marco de la evidencia a la decision (EtD) de GRADE y un sistema de participacion iterativo, con analisis estadisticos y cualitativos de sus resultados Resultados: se generaron 31 recomendaciones clinicas enfocadas a: a) Pruebas de coagulacion en adultos sintomaticos con sospecha de infeccion o infeccion confirmada por SARS-CoV-2;b) Tromboprofilaxis en personas adultas con diagnostico de COVID-19 (escalas de riesgo, tromboprofilaxis de manejo ambulatorio, intrahospitalario y duracion de tromboprofilaxis despues del egreso de hospitalizacion), c) Diagnostico y tratamiento de las complicaciones tromboticas y d) Manejo de personas con indicacion previa a usar agentes anticoagulantes Conclusiones: las recomendaciones clinicas de este consenso orientan la toma de decisiones clinicas respecto a prevencion, diagnostico y tratamiento de fenomenos tromboticos en pacientes con COVID-19, y representan un acuerdo que ayudara a disminuir la dispersion en las practicas clinicas acorde con el desafio que nos impone la pandemia Introduction: recent studies have reported the occurrence of thrombotic phenomena or coagulopathy in patients with COVID-19 There are divergent positions regarding the prevention, diagnosis, and treatment of these phenomena, and current clinical practice is based solely on deductions by extension from retrospective studies, case series, observational studies, and international guidelines developed prior to the pandemic Objective: to generate a group of recommendations on the prevention, diagnosis and management of thrombotic complications associated with COVID-19 Methods: a rapid guidance was carried out applying the GRADE Evidence to Decision (EtD) frameworks and an iterative participation system, with statistical and qualitative analysis Results: 31 clinical recommendations were generated focused on: a) Coagulation tests in symptomatic adults with suspected infection or confirmed SARS CoV-2 infection;b) Thromboprophylaxis in adults diagnosed with COVID-19 (Risk scales, thromboprophylaxis for outpatient, in-hospital management, and duration of thromboprophylaxis after discharge from hospitalization), c) Diagnosis and treatment of thrombotic complications, and d) Management of people with previous indication of anticoagulant agents Conclusions: recommendations of this consensus guide clinical decision-making regarding the prevention, diagnosis, and treatment of thrombotic phenomena in patients with COVID-19, and represent an agreement that will help decrease the dispersion in clinical practices according to the challenge imposed by the pandemic

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging option for hemorrhage control, but its use is limited in scenarios such as penetrating chest trauma. The aim of this study was to describe the use of REBOA as a resuscitative adjunct in these cases with major hemorrhage and to propose a new clinical management algorithm. Methods This was a prospective, observational study conducted at a single Level I trauma center in Colombia. We included all patients older than 14 years with severe trauma who underwent REBOA from January 2015 to December 2019. Patients received REBOA if they were in hemorrhagic shock and were unresponsive to resuscitation. Results A total of 56 patients underwent REBOA placement of which 37 had penetrating trauma and 23 had chest trauma. All patients were hemodynamically unstable upon arrival to the emergency department, with a median systolic blood pressure of 69 mm Hg (interquartile range [IQR], 57-90 mm Hg) and median Injury Severity Score was 25 (IQR, 25-41). All REBOAs were deployed and inflated in zone 1, median inflation time was 40 minutes (IQR, 26-55 minutes), and no adverse neurologic outcomes were observed. Fifteen patients had REBOA and a median sternotomy. Eleven patients had concomitant abdominal wounds. Overall mortality was 28.6%, and there was no significant difference between penetrating versus blunt trauma patients (21.6% vs. 42.1%, p = 0.11). The survival rate of thoracic injured patients was similar to the predicted survival (65.2% vs. 63.3%). Conclusion Resuscitative endovascular balloon occlusion of the aorta can be used safely in penetrating chest trauma, and the implementation of a REBOA management algorithm is feasible with a well-trained multidisciplinary team. Level of evidence Therapeutic, level V.

INTRODUCCION: La intoxicacion por distintas drogas es una importante causa de morbimortalidad en la edad pediatrica. No obstante, la intoxicacion por amlodipino, que es un farmaco dihidropiridinico del grupo de calcioantagonistas ampliamente usado, no se encuentra bien documentada en Ecuador. El tratamiento se basa en implementar medidas para el shock clasico, en conjunto con medidas especificas para este tipo de intoxicacion.CASOS CLINICOS: Presentamos dos reportes de casos clinicos de pacientes adolescentes ingresadas en unidad de cuidados intensivos pediatricos (UCIP), por intento autolitico mediante ingesta de amlodipino en conjunto con otros farmacos.EVOLUCION: Durante su estancia hospitalaria presentaron cuadros evolutivos distintos. En ambos casos se necesito manejo con drogas vasoactivas, modificando su dosis de acuerdo a respuesta clinica. En los dos casos se administro gluconato de calcio por horario y otras medidas de soporte descritas en el presente manuscrito. Finalmente, las dos pacientes presentaron buena evolucion y fueron dadas de alta, con previa valoracion y seguimiento de psicologia y psiquiatria.CONCLUSION: La intoxicacion por amlodipino ha sido descrita escasamente debido a su baja frecuencia, a esto se anade el poco conocimiento basado en evidencia; motivos que la constituyen como un reto diagnostico y terapeutico. Destacamos, en base a nuestra experiencia, la importancia de un alto indice de sospecha y de priorizar el inicio de vasopresores sobre la reanimacion hidrica. Adicionalmente, recomendamos documentar la dosis exacta de ingesta e indagar sobre el consumo de otros farmacos para clasificar adecuadamente la gravedad de la intoxicacion y establecer un plan de tratamiento. Finalmente, la monitorizacion y evaluacion clinica constante y el apoyo de examenes de laboratorio guiaran la conducta. ABSTRACT CASE SERIES: AMLODIPINE INTOXICATION BACKGROUND: Drug poisoning is an important cause of morbidity and mortality in pediatric patients. However, amlodipine poisoning, a widely used dihydropyridine calcium chanel blocker, is not fully documented in Ecuador. Treatment consists of classic measures for shock management and specific measures for this type of intoxication.CASE REPORTS: We present two case reports, both of teenage patients admitted into the pediatric intensive care unit for suicide attempt by taking amlodipine and some other drugs.EVOLUTION: During hospital stay, they presented a different evolutionary course. In both cases vasoactive drugs were needed, dosage was modified according to clinical course. Also in both patients, calcium gluconate was administered along with other support measures described in this paper. Finally, both patients presented a good outcome and were discharged after psychological and psychiatric assessment and follow up.CONCLUSION: The low frequency of amlodipine poisoning and the lack of evidence-based knowledge, constitute it as a diagnostic and therapeutic challenge. Based on our experience, we highlight the importance of early suspicion and prioritizing the use of vasopressors over fluid resuscitation. Additionally, we recommend documenting the exact dose of intake and inquiring about consumption of other drugs to properly classify the severity of the poisoning and stablish the treatment plan. Finally, constant clinical monitoring and support of laboratory tests will guide the conduct.

Generalidades. Desde diciembre de 2019 se detectó una nueva infección respiratoria, causada por el virus denominado SARS-CoV-2, decretada posteriormente como pandemia, lo cual ha exigido al personal de salud replantear la forma de prestar sus servicios en salud y garantizar la auto-protección con recursos que han sido insuficientes incluso en los países más desarrollados. Dado que la transmisión del SARS-CoV-2 ocurre a través de aerosoles expulsados de la vía aérea, que pueden ser inhalados o llevados a las mucosas por contacto con las manos contaminadas, se requiere minimizar la posibilidad de contagio para los equipos de atención en salud. Objetivos. Brindar herramientas a los cirujanos que les permitan elegir la técnica con menor probabilidad de exposición a aerosoles. Describir el paso a paso de la técnica quirúrgica de la traqueostomía percutánea, enfatizando en el control sobre la generación de aerosoles en pasos críticos. Aspectos técnicos. La técnica completamente percutánea con kit de traqueostomía permite un mejor sello entre tejidos y dispositivos. Los escenarios más frecuentes para realizar una traqueostomía son: el paciente intubado con ventilación mecánica y el paciente con falla en la intubación que requiere una intervención de emergencia. Conclusión. El alto contagio del COVID-19 al practicar intervenciones en la vía aérea nos obliga a hacer énfasis en las estrategias que reduzcan la formación de aerosoles y permitan la contención de los mismos durante la realización de traqueostomías.

Purpose The purpose of this study was to examine the association of REBOA and mortality in a group of patients with penetrating trauma to the torso, treated in a level-I trauma center from Colombia. Methods In a retrospective cohort study, patients with penetrating trauma, requiring emergency surgery, and treated between 2014 and 2018, were included. The decision to use or not use REBOA during emergent surgery was based on individual surgeon's opinion. A propensity score (PS) was calculated after adjusting for age, clinical signs on admission (systolic blood pressure, cardiac rate, Glasgow coma scale), severe trauma in thorax and abdomen, and the presence of non-compressive torso hemorrhage. Subsequently, logistic regression for mortality was adjusted for the number of red blood cells (RBC) transfused within the first six hours after admission, injury severity score (ISS), and quintiles of PS. Results We included 345 patients; 28 of them (8.1%) were treated with REBOA. Crude mortality rates were 17.9% (5 patients) in REBOA group and 15.3% (48 patients) in control group (p = 0.7). After controlling for RBC transfused, ISS, and the PS, the odds of death in REBOA group was 78% lower than that in the control group (odds ratio [OR] 0.20, 95% confidence interval [95%CI] 0.05-0.77, p = 0.01). Conclusion We found that, when compared to no REBOA use, patients treated with REBOA had lower risk-adjusted odds of mortality. These findings should be interpreted with caution and confirmed in future comparative studies, if possible.

Introducción. La tomografía corporal (TC) total en la evaluación de pacientes con trauma grave, puede ser una herramienta eficaz y segura para decidir entre un tratamiento quirúrgico y uno no quirúrgico, pero aún no son claras las implicaciones diagnósticas y los riesgos asociados con esta técnica. Métodos. Se incluyeron pacientes mayores de 15 años con trauma grave que fueron sometidos a TC total. Se evaluaron la seguridad, la efectividad y la eficiencia por medio de los parámetros de incidencia de nefropatía inducida por los medios de contraste, dosis total de radiación por paciente, proporción de casos en los que la TC total cambió el manejo, y el retraso en el diagnóstico. Resultados. Se incluyeron 263 pacientes, 83 % sufrieron trauma cerrado y 17 % sufrieron trauma penetrante. La gravedad de la lesión fue mayor en estos últimos y, sin embargo, el trauma cerrado con inestabilidad hemodinámica se presentó con mayores grados de choque. El 65 % de los pacientes recibió tratamiento selectivo no operatorio. Entre los subgrupos, no hubo diferencias significativas en el tiempo entre el ingreso a la sala de urgencias y la toma de la TC total (p=0,96) y, en la mayoría de los casos, el tiempo entre la práctica de la TC total y el diagnóstico de presencia o ausencia de heridas fue menor de 25 minutos. La mediana de radiación total estuvo por debajo de 20 mSv en todos los grupos. No hubo diferencias significativas en la mortalidad (p=0,17). Conclusión. La TC total es una herramienta segura y eficiente para decidir entre un tratamiento quirúrgico y uno no quirúrgico en los casos de trauma grave, independientemente del mecanismo de la lesión o la estabilidad hemodinámica al ingreso.

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

BACKGROUND: The goal of our study was to evaluate the differences in care and clinical outcomes of patients with chest trauma between two hospitals, including one public trauma center (Pu-TC) and one private trauma center (Pri-TC). METHODS: Patients with thoracic trauma admitted from January 2012 to December 2018 at two level I trauma centers (Pu-TC: Hospital Universitario del Valle, Pri-TC: Fundación Valle del Lili) in Cali, Colombia, were included. Multivariable logistic regression was used to assess for differences in in-hospital mortality, adjusting for relevant demographic and clinical characteristics. RESULTS: A total of 482 patients were identified; 300 (62.2%) at the Pri-TC and 182 (37.8%) at the Pu-TC. Median age was 27 years (IQR 21–36) and median Injury Severity Score was 25 (IQR 16–26). 456 patients (94.6%) were male, and the majority had penetrating trauma [total 465 (96.5%); Pri-TC 287 (95.7%), Pu-TC 179 (98.4%), p 0.08]. All patients arrived at the emergency room with unstable hemodynamics. There were no statistically significant differences in post-operative complications, including retained hemothorax [Pri-TC 19 vs. Pu-TC 18], pneumonia [Pri-TC 14 vs. Pu-TC 14], empyema [Pri-TC 13 vs. Pu-TC 13] and mediastinitis [Pri-TC 6 vs. Pu-TC 2]. Logistic regression did, however, show a higher odds of mortality when patients were treated at the Pu-TC [OR 2.27 (95% CI 1.34–3.87, p < 0.001]. CONCLUSIONS: Our study found significant statistical differences in clinical outcomes between patients treated at a Pu-TC and Pri-TC. The results are intended to stimulate discussions to better understand reasons for outcome variability and ways to reduce it.