Summary: The scope of this special issue covers recent trends in Acute Biliary Disease. Systematic reviews and meta-analyses are also welcome in order to present the most current evidence based management options for acute biliary disease. Acute biliary disease is one of the most common emergency general surgical diseases treated by the acute care surgeon and this special issue is meant to provide practical guidance and a review of the cutting edge. Objectives: Provide a practical review of the most common acute biliary disease clinical questions and provide evidence based recommendations.

Summary: The scope of this special issue covers recent trends in Acute Biliary Disease. Systematic reviews and meta-analyses are also welcome in order to present the most current evidence based management options for acute biliary disease. Acute biliary disease is one of the most common emergency general surgical diseases treated by the acute care surgeon and this special issue is meant to provide practical guidance and a review of the cutting edge. Objectives: Provide a practical review of the most common acute biliary disease clinical questions and provide evidence based recommendations.

Background: Here, we investigate the incidence of traumatic injuries during the COVID-19 pandemic over a year-long period which includes the first documented COVID-19 case in the US as well as rollout of vaccines. The study period includes the months of strictest lockdowns which early reports have focused on, as well as reopening. Methods: This retrospective analysis was performed with all records of trauma patients from our level 1 trauma center's trauma registry. Mean weekly and total yearly patient counts from 2017–2019 and 2020 were compared using independent samples t-test or Mann-Whitney U test. Shapiro-Wilk and Levene's tests were used to assess normality and variances, respectively. Results: There were more trauma patients in 2020 than the 2017–2019 average. In 2020, there were significantly higher weekly counts of penetrating injuries vs the 2017–2019 average [mean (SD)] [22.5 (7.2) vs 17.5 (3.1), p < 0.000], specifically gunshot wounds (GSWs) [15.8 (6.0) vs 11.3 (2.7), p < 0.0000] and more assaults [23.3 (6.7) vs 19.4 (3.2), p < 0.0003]. In 2020, fewer falls [11.9 (4.3) vs 13.4 (2.6), p < 0.03], pedestrian/bicycle accidents [5.5 (3.1) vs 7.5 (2.1), p < 0.0002], and accidents in general [45.9 (17.1) vs 50.9 (5.6), p < 0.05] presented to our hospital compared to previous years. Overall, weekly totals were higher than average in 2020, but were lower than average during the strictest shutdowns from March 18 to May 15. Conclusion: During the first 3 months and strictest lockdown of the pandemic, the number of traumatic injuries was significantly lower than average. Once restaurants reopened at 50% capacity, bars reopened, and gatherings of <50 people were allowed, weekly counts of trauma patients were above average in most (26/32, 81%) weeks through the end of the year. Increased GSWs and assaults this year may suggest increased interpersonal conflict. Increased violent and traumatic injury necessitating medical care is concerning for emergency departments and hospitals already overloaded with patient volume and facing staffing shortages due to the COVID-19 pandemic.

Aim: To describe an institution's experience with the implementation of a chest computed tomography (CT) protocol to screen suspected cases of COVID-19 among trauma patients. Materials and methods: This is a longitudinal observational study, which was carried during 67 days of the COVID-19 pandemic. We included all adult trauma patients, who underwent chest CT at admission. According to the screening protocol, all patients with moderate/severe trauma requiring hospitalization and/or surgery underwent chest CT. Imaging suggestive of COVID-19 led to activation of infection control protocols in the operating room and during hospitalization. We performed univariate analysis to compare patients according to indication of chest CT (trauma mechanism or COVID-19 protocol). Results: We included 352 patients. Mean age was 44.95 years, 74.64% were male. Most patients (72.16%) underwent chest CT due to mechanism of trauma. Nine (2.35%) patients had CT scans suggestive of COVID-19, seven of which were performed based on the screening protocol. Among these nine patients, three were symptomatic for COVID-19 and one had laboratory confirmation of SARS-CoV-2 infection. With respect to the patient subgroups according to CT scan indication, difference was observed regarding body injury location (p = 0.000), presence of COVID-19 symptoms (p = 0.014) and prevalence of altered imaging findings (p = 0.000). Conclusion: Although further validation for this purpose is needed, chest CT has shown to be an important tool for screening suspected cases of COVID-19 in the context of trauma surgery. Clinical significance: Improvement of COVID-19 screening in trauma settings can allow better allocation of resources and minimize viral transmission.

Background: Traumatic brain injury (TBI) patients are commonly faced with excessive muscle wasting and severe malnutrition, despite adequate calories. Malnutrition in TBI patients is associated with adverse outcomes, but the specific factors contributing to this are unknown. Certain factors are associated with a higher risk of malnutrition. Factors looked at in this study are age, sex, race, body mass index (BMI), preexisting comorbidities, surgical intervention, when feeds were started, and what feeds were given. Methods: Data of the TBI patients were collected prospectively from 2nd June 2019 to 8th November 2019 at the Chris Hani Baragwanath Academic Hospital in Soweto, Gauteng. Results: A total of 32 patients were included in the study; two were left out due to lack of consent. About 96.88% of the patients were male, with most patients falling into the age categories of 18–40 years. A minority of patients were mild TBI, with a GCS of 13–15, 4.17%. Of the patients included, the majority was severe TBI, GCS 3–8, 62.5%. Treatment options for the TBI were split evenly for conservative treatment and surgery. Unfortunately, 25% of the patients were demised during this study. The mechanism of injury varied among patients. Fourteen patients were allegedly assaulted, four were involved in pedestrian vehicle accidents (PVA), and eight patients had unknown mechanisms of injury. The prevalence of malnutrition on day 10 of the mid-upper arm circumference (MUAC) measurement was 31.25%, and on day 21, it was 56.25%. The only two factors we found to have a risk for malnutrition in TBI was a longer length of hospital stay, p-value <0.001, and the later feeds were started on the TBI patients, p-value 0.014. Conclusion: TBI is associated with malnutrition at day 10 postinjury as indicated by a reducing MUAC. Delay to initiation of feeding and shorter hospital stay appear to be independent risk factors for malnutrition post-TBI. Further studies are needed to validate this finding.

Background: Obtaining an efficient vascular access in a short-time is fundamental for the patient with hypovolemic shock in the emergency room. In case of peripheral venous access failure, the second option is not yet well defined. Objective: Critically appraise the literature on the use of intraosseous access and central venous access comparing these two interventions with respect to time to complete each of them, rate of success, and complications. Methods: The electronic databases used were MEDLINE / PubMed, PubMed Central, CAPES Platform, The Cochrane Library, EuroPMC, and Virtual Health Library (VHL). Literature reviews, conference proceedings, case reports, case series, comments, and correspondence were excluded, as were studies with children under 18 and a small sample. For the meta-analysis which estimated success in the first attempt, the odds ratios for success, the Mantel-Haenszel method was used for fixed effects. For the analysis of the execution time between procedures, the inverse variation method for fixed results was used. Meta-analysis calculations were performed using the Reviewer Manager 5.3 software. Results: A total of 144 studies were found, four of which were selected for the review, totaling 167 patients. There was superiority of intraosseous access in relation to central venous access with respect to the success rate in the first attempt (9.93; 95% CI 5.08–19.40; 0.00,001) and duration of the procedure (1.94; 95% CI 2.02–1.13; 0.00,001). All four studies comparing access found better performance and less time to perform intraosseous access compared to the central venous catheter. Conclusion: It is possible to determine that intraosseous vascular access is a safe, reliable, and a faster option in trauma patients in shock in the emergency room with inaccessible peripheral veins.

Aim and objective: Pay homage to the Founding Father of Neurosurgery. Materials and methods: Literature review. Background: Walter Dandy was a neurosurgeon from Johns Hopkins Hospital in Baltimore, USA. Trained by Harvey Cushing, another founding father of the specialty, Dandy excelled in his technical ability and became the leading neurosurgeon at Hopkins till death at 60 in 1946. His contributions to the field of neurosurgery include 160 articles and five books, among them a classic text on neurosurgery, “Surgery of the Brain” (1935) and many original operative procedures. Clinical significance: Surgical heritage review.

Aim and objective: To report the case and the clinical-surgical evolution of a patient after blunt cervical-thoracic trauma that resulted in fracture of the clavicle, injury to the subclavian artery and vein and almost total avulsion of the brachial plexus, as well as perform a literature review. Background: Vascular injury to the subclavian artery and vein through blunt trauma is rare. In blunt trauma, you run into an accident of high enough energy to injure the various structures that protect these vessels. Detailed anamnesis and physical examination are essential for elucidating the case, and imaging exams are excellent adjuvants in the decision-making process in these cases. Case description: A 33-year-old woman, victim of a collision of a motorcycle and a light pole, is referred to a secondary health service, where she develops ischemia of the left upper limb, associated with a fractured clavicle and brachial plexus injury. Patient underwent vascular and orthopedic surgery, respectively. The patient evolved with good general condition, good left upper limb perfusion and lack of sensitivity and movement of the limb. Conclusion: The evaluation of the case and the studies surveyed showed the complexity of the condition, making an assertive diagnosis and early approach to vascular lesions of the subclavian vessels essential, in order to obtain satisfactory results. Clinical significance: The rarity associated with the high complexity of subclavian vessel injury, as well as its high mortality when not detected quickly and correctly, makes this case report relevant to the scientific community, since its exposure is related to the literature review allows sharing important knowledge about the subject.

Antecedentes: La toracotomía resucitativa es una maniobra realizada en los pacientes con traumatismos que se presentan “in extremis,” especialmente en lesiones penetrantes del torso. Existen numerosos reportes en literatura sobre toracotomía en adultos, algunos en pediatría, pero no hay reportes de casos en recién nacidos debido a lo inusual del trauma en esta etapa de la vida. Objetivo: El presente reporte tiene como objetivo documentar un caso inusual de un recién nacido con traumatismo penetrante por bala en el tórax, nacido por una cesárea de urgencia debido al estado agonal de su madre por las múltiples lesiones que sufrió. Al encontrarse en estado fatal se intenta resucitarlo por medio de una toracotomía anterolateral izquierda, no se logra obtener la sobrevida debido a lo irreparable de la lesión y las consecuencias de la exanguinación. Resultados: El presente caso documenta el ingreso al servicio de Emergencia de adultos de una paciente embarazada, clínicamente a término con múltiples perforaciones por arma de fuego en tórax y abdomen, en estado agónal debido a las pérdidas hemáticas masivas. Se logra auscultar un adecuado foco fetal, por lo que el equipo de emergencia decide llevar a cesárea de emergencia, obteniendo un producto sin signos de vida al momento de extraerlo del útero (estado fatal). Se realiza toracotomía de resucitación en el recién nacido evidenciando una lesión irreparable del ventrículo izquierdo y hemorragia exanguinante. Conclusiones: La toracotomía resucitativa en trauma tiene estrictas indicaciones y los mejores resultados se obtienen en el paciente con lesiones penetrantes en tórax, con paro presencial o de reciente evolución. Este caso evidencia una clara indicación del procedimiento: estado fatal, paro cardiaco potencialmente rescatable, traumatismo penetrante en el tórax; es poco frecuente en pediatría y no hay reportes de la literatura en recién nacidos. La decisión de realizar toracotomía no es discutible si la indicación es clara como el presente caso, y la edad no es un factor a considerar. Palabras clave: Toracotomía de reanimación, trauma cardiaco, reporte de un caso, toracotomía de emergencia, lesiones por arma de fuego, herida precordial, trauma pediátrico, lesión cardiaca penetrante.

Aim and objective: This manuscript reports a case of severe traumatic brain injury in a patient complicated by Falciparum malaria with review of the literature and discussion of possible underlying mechanism aggravating the secondary brain injury. Background: Plasmodium falciparum (P. falciparum) malaria accounts for more than 90% of deaths caused by malaria in the world. Parasitized red blood cells sequester and cause capillary occlusion, endothelial damage, cytokine activation, and dysregulation of coagulation leading to exacerbation of secondary injury after traumatic brain injury. Case description: The case reports highlight a rare case of 38-year-old patient admitted after traumatic brain injury with rapid deterioration. Patient was found to have P. falciparum malaria with 3.9% parasitised RBC. CT head revealed a large right sided subdural haemato-hygroma, midline shift and ischemia in the right posterior cerebral artery territory. Despite timely intervention and evacuation of subdural haematoma, patient had a poor outcome with multiple infarcts, hemorrhagic transformation, and early hydrocephalus. Patient remains in a vegetative state in a long-term unit. Conclusion: Combined effect of endothelial, microcirculatory, inflammatory, and clotting dysfunction caused by traumatic brain injury and parasitaemia leading to aggravation of secondary brain injury. Clinical significance: This case report highlights the intricate relationship between endothelial, inflammatory, and coagulation cascade triggered after brain injury. The nature of coagulopathy in such patients is complex with state of hypo-coagulation early followed by a hyper-coagulatory state in the late phase.

The recently described coronavirus (SARS-CoV-2) has produced a series of pathological changes after infection of the human body. A significant percentage of infected critically ill patients with COVID-19 will require multiple intensive care strategies to give appropriate support to increase the possibility of favorable evolution. The new coronavirus could invade using the respiratory mucosa and to infect various cell types successively creating a severe inflammatory response. Patients with cerebral neurotrauma have elements associated with the primary and secondary lesions. Lung injury impact brain with hypoxia, hypercapnia, hypocapnia, mediators release, presence of neurotoxic factors, and endothelial activation. On the other hand, brain injury impacts lungs due to increase in intracranial pressure (ICP). There is development of neuroinflammatory phenomena, the activation of sympathetic nervous system, and the presence of intense dopaminergic activity through the hypothalamic-pituitary-adrenal axis. Studies have demonstrated injury at the ultrastructural level in type II pneumocytes after traumatic brain injury.

Large vessel occlusion with acute embolic stroke (AES) is usually undergo embolectomy attempt within 24 hours on last known normal. Embolectomy leads to clots extraction and improvement of distal flow to minimize or complete reversal of AES. The size of clot extracted is usually in different fragments. One complete extraction of full occlusive clot is rare. The chance of extraction does down with extend of occlusion, duration, type of clot, and location. Here we describe a single pass extraction of over 10 cm clot which improved the distal flow with marked reduction is neurological weakness.

Blood flow to the brain is mainly through anterior circulation via bilateral internal carotid arteries and through posterior circulation via bilateral vertebral arteries. The anterior circulation is for the respective side with the communication with the anterior communicating artery. The posterior flow is with the single basilar artery formed from vertebral arteries. There are collaterals present but the main vasculature determines most of the flow. This dynamic is normally balanced except in pathological conditions where flow is compensated from other vessels through the circle of Willis. It is rare to see a competing flow on each side and further, it is more complex when one region has a restricted flow and while another region has hyperdynamic

Medical products transportation has become an important research topic requiring multidisciplinary collaboration among experts in surgery, public health, and health economics. Drones can be a promising tool to increase access to stabilizing neurotrauma care following a pediatric traumatic brain injury in the Caribbean. This commentary describes how the use of drones and neurotrauma education can increase health outcomes of neurosurgical emergencies on remote islands of low-and middle-income nations in the developing world.

Neurocritical care monitoring is prudent for the close neurological evaluation and adjustment of the treatment. Neuromonitoring allows the identification and evaluation of various physiological variables that can be modified after the primary injury. In severe TBI management, the use of intracranial probe is part of the advanced management of the neurocritical patient. Decompressive craniectomy, focal brain surgery, fracture skull, and previous prothesis makes it extremely tricky to achieve cerebral parenchymal probe placement (PPP).