Caracterización de lesiones causadas por accidentes de tránsito en dos instituciones de nivel I en Cali entre 2012-2014 y su relación con la aplicación de un plan de seguridad vial
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:6] [Pages No:83 - 88]
Keywords: Accidentalidad, Accidente de transito, Transito, Trauma
DOI: 10.5005/jp-journals-10030-1209 | Open Access | How to cite |
ANTECEDENTES En la actualidad los accidentes de tránsito son una de las principales causas de muerte en el mundo y la primera causa entre los 15 y 29 años, dicha mortalidad es el doble en países de bajos ingresos al compararla con los de altos ingresos. En su mayoría los accidentes tienen como víctimas a motociclistas y peatones. En Colombia producen cerca de 7000 muertes al año. Dado el impacto de esta problemática Colombia creo el Plan Nacional de Seguridad Vial que busca mitigar la accidentalidad. Métodos: Estudio observacional descriptivo, transversal. Se utilizó el Registro Internacional de Trauma del Hospital Universitario del Valle y la Fundación Valle de Lili en Cali, se incluyeron todos los casos consecutivos que presentaron lesiones por accidentes de tránsito en el periodo 2012–2014. Se realizó un análisis descriptivo según variables demográficas, clínicas y mortalidad p significativa < 0.05. Resultados: Un total de 38.313 registros, 9592 asociados a accidentes de tránsito de los cuales el 68% son hombres y 30, 4% mujeres, edad más prevalente entre 18–35 años (51, 4%), el 50.7% fueron politraumatismos, el 91% leves (ISS < 9). Se presentan con más frecuencia entre las 16:00– 22:00 hrs, el mayor número de casos se presentan el domingo (18, 9%). La mortalidad general fue del 2%, de la cual el 62% involucraban motocicletas. En el análisis por año se encontró una disminución en la tasa de mortalidad de 2, 33% en 2012 a un 1.51% en 2014 con p < 0.0001. Se estimaron 11.571 AVPP, el 83% aportados por hombres. Conclusiones: Los accidentes de tránsito continúan siendo una importante causa de trauma en el mundo, la mayor parte de los casos se presentan los fines de semana y en horario nocturno. El grupo etario con mayor frecuencia esta entre los 18–35 años los que a su vez presentan mayor riesgo y mayor aporte a los AVPP generando enormes pérdidas sociales. A su vez se observa que con la implementación del plan de seguridad vial desde el 2011 la mortalidad disminuye de manera significativa (p < 0.0001), parece ser que el mencionado plan se correlaciona con esta tendencia.
The Positive Impact on Emergency Department Length of Stay of a Clinical Practice Guideline-Directed Process for Direct Admission from the Emergency Department Computed Tomography Scan Suite to the Intensive Care Unit of Highest Level Trauma Activation Patients
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:8] [Pages No:89 - 96]
Keywords: ED-LOS, ED overcrowding, Direct from ED to ICU, ICU, Trauma
DOI: 10.5005/jp-journals-10030-1210 | Open Access | How to cite |
Introduction: Patients presenting to the emergency department (ED) as the highest level trauma activation (T1) are characteristically severely injured, having met physiologic or anatomic derangement criteria as defined by the American College of Surgeons’ (ACS) committee on trauma (COT) guidelines for field triage. ED overcapacity is a significant issue for the vast majority of hospitals in the United States. Multiple published reports show that ED overcapacity leads to delays in patient care and increased morbidity and mortality. Such negative impacts include those on trauma patients’ specifically. Based on literature-reported improved outcomes for decreased ED length of stay (LOS) in critically ill patients, we aimed for the expeditious transport from the ED computed tomography (CT) scanner suite to the intensive care unit (ICU), of T1 patients who were ultimately deemed to need ICU level of care. More, we hypothesized that a well-delineated, well-integrated multidisciplinary “direct to ICU” clinical practice guideline (CPG) would enable our stated aim to be achieved in a consistent manner. Methods: This was a retrospective evaluation of patients admitted to a Level II trauma center over a 12 month period. The cohorts were patients who were highest level (T1) and whose immediate post-ED destination was the ICU. ED LOS of stay (LOS) was assessed for both pre-CPG (January–April, 2016) and post-CPG (May to December 2016) groups. Patients going directly to the operating room (OR), interventional radiology (IR), ED deaths or medical-surgical unit (MedSurg), i.e., ward/ floor admissions were excluded. Results: The average ED LOS preimplementation of the CPG was 159 minutes (SD ± 8.8). The post-CPG implementation ED LOS average was 49 minutes (SD ± 8.87). Thus the ED LOS was 110 minutes less, post-CPG implementation. As a noteworthy comparative benchmark, the 2016 “one-way-street” article from the Massachusetts General Hospital reported an 82 minute median ED LOS for trauma patients admitted directly from the ED CT to the ICU. Conclusion: Implementation of a multidisciplinary “direct to ICU” CPG enabled the very expeditious, reproducible and process-oriented transport of critically ill trauma patients from the ED CT suite to the ICU. In support of contemporary, evidence-based efforts to enhance trauma patient outcomes while also addressing ED overcapacity concerns, We propose this “direct to ICU” CPG model for use by other trauma centers.
Conservative Treatment of Pancreatic Trauma–An Experience from a Brazilian Trauma Center
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:5] [Pages No:97 - 101]
Keywords: Abdominal trauma, Blunt trauma, Pancreas, Trauma
DOI: 10.5005/jp-journals-10030-1211 | Open Access | How to cite |
Introduction: This study wants to demonstrate that it is safe to treat pancreatic trauma conservatively in a developing country where resources are challenging. Materials and Methods: The study analyzed data from a Brazilian trauma center. Results: Thirteen patients from 2006 to 2017 had pancreatic trauma from low (I and II) and high grade (III) lesions and were treated conservatively. There was no mortality. Four patients had complications, but only one required laparotomy. In the study, a relationship was found with the degree of injury and time of hospitalization (p < 0.011), in addition to the presence of complications with the degree of complication (p < 0.021). Conclusion: Conservative treatment of pancreatic trauma has been performed in low and high grade lesions. It is believed that as long as there is a 24-hour surgical team, such as computed tomography (CT), the treatment of pancreatic trauma can be well-conducted. Clinical Significance: The study can decrease the number of unnecessary laparotomies. Objetivo: Este estudo quer demonstrar que é seguro tratar o trauma pancreático de forma conservadora em um país em desenvolvimento onde os recursos são desafiadores. Materiais e Métodos: O estudo analisou dados de um centro de trauma brasileiro. Resultados: Treze pacientes de 2006 a 2017 apresentaram trauma pancreático de baixo (I e II) e de alto grau (III), sendo tratados de forma conservadora. Não houve mortalidade. Quatro pacientes apresentaram complicações, mas apenas em um caso foi necessária laparotomia. No estudo, encontrou-se um relacionamento com o grau de lesão e tempo de internação (p 0,011), além da presença de complicações com o grau de complicação (p 0,021). Conclusão: o tratamento conservador do trauma pancreático é factível em lesões de baixo e alto grau. Acredita-se que, se houver uma equipe cirúrgica de 24 horas, com TC, o tratamento do trauma pancreático pode ser bem conduzido. Significância clínica: o estudo pode a diminuir o número de laparotomias desnecessárias.
Closed (Blunt) Compared to Open (Penetrating) Pulmonary Contusion–A National Trauma Data Bank Review
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:6] [Pages No:102 - 107]
Keywords: Chest trauma, ICU, Lung, Mortality, Penetrating, Pulmonary contusion (blunt, closed, open)
DOI: 10.5005/jp-journals-10030-1212 | Open Access | How to cite |
Introduction: Pulmonary contusion is a common injury and may occur in blunt or penetrating trauma patients. These injury mechanisms may have a distinct pathophysiology, differ in the out come and may require individualized treatment. The purpose of this study is to compare these two mechanisms of pulmonary contusion in respect to outcome and clinical management. Methods of Research: The 2012 National Trauma Data Bank (NTDB) was queried for open and closed pulmonary contusion utilizing ICD-9 codes 861.31 and 861.21. Data for both groups were analyzed with t-test for numerical data and chi-square for categorical data utilizing SPSSTM and Vassar StatsTM. Results: A total of 12,884 patients with pulmonary contusions were identified. The closed pulmonary contusion was present in 12,329 patients, open pulmonary contusion in 555 patients. Patients with closed pulmonary contusions were older with a mean age of 38.00 ± 22.23 versus 30.58 ± 12.88. Patients with closed pulmonary contusion had a higher injury severity score (ISS) 21.60 ± 0.22 versus 18.64 ± 1.08, p = 0.001. Closed pulmonary contusion was associated with increased ventilator days 3.09 ± 0.13, p = 0.052, intensive care unit (ICU) days 5.11 ± 0.15 versus 4.01 ± 0.69, p = 0.003 and hospital length of stay 0.65 ± 0.25 versus 9.37 ± 0.99, p = 0.032. Conclusion: Blunt (closed) pulmonary contusion is more prevalent than open (penetrating) pulmonary contusion and is associated with a higher injury severity score (ISS). Closed pulmonary contusion shows a tendency towards more extended mechanical ventilation time and is associated with a longer ICU stay, hospital length of stay and mortality. These findings might be secondary to associated chest wall trauma and other organ system injuries or secondary to the volume size of involved lung parenchyma. A pulmonary contusion may be a different entity compared to penetrating pulmonary contusion with different patient demographics, care requirements and outcome. Additional research is required to better understand contributing factors, differences in pathophysiology and clinical management of these two different disease processes.
Guiding Observers in Trauma Simulation Education: The Effect of Directed Simulation Observation on Achieving Educational Objectives
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:6] [Pages No:108 - 113]
Keywords: Checklist, High fidelity simulation training, Patient simulation, Simulation, Simulation training, Trauma
DOI: 10.5005/jp-journals-10030-1213 | Open Access | How to cite |
Introduction: It is known that medical education can be augmented by simulation, that active participant, and observers demonstrate educational benefit. What is not well researched are strategies for maximizing observer benefit. Human patient simulation is of growing importance in the era of restricted duty hours, but remains a limited resource, restricting the number of learners that can be trained at one time. We hypothesized that a strategy could be employed to increase capacity through structured engagement of observers. The purpose of this study is to assess the effects of structured observation tools on observers’ confidence in content knowledge, task, and procedural skills, and team-based learning. Materials and Methods: A scenario-based simulation course was created and implemented for third-year medical students during their trauma clerkship. Students participated in simulations and observed classmates via a live video stream. One treatment group of observers used a checklist listing critical actions to guide their observation while the control group had no observational aid. Confidence in ability was measured via pre and post-course self-assessments to identify disparities between the groups. The difference in the reported confidence prior to and following the course was analyzed, primarily using t-tests. Results: Overall, students had a significant increase in self-reported competence following the simulation course (p-value < 0.001). Students using the checklist had a greater increase in confidence in competencies involving medical content knowledge and procedural skills (p < 0.05), whereas their counterparts who did not have an observation tool had greater confidence increases in team-based competencies (p < 0.05). Specifically, learners’ confidence in their ability to “communicate clearly with team members” increased more in the group without a checklist (p < 0.05). Conclusion: These findings suggest structured tools directed to the observer impact learning. Checklist observation tools enhanced content knowledge and procedural skill educational objectives, while unaided observation was superior for communication and interpersonal team-based competencies.
Three Sequential Balloon Catheters for Vascular Exclusion of the Liver and Aortic Control (one REBOA and two REBOVCs): A Hemorrhage Control Strategy in Suprahepatic Vena Cava Injuries
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:9] [Pages No:114 - 122]
Keywords: Endovascular balloon, Hemorrhage control, Suprahepatic, Vena cava injury
DOI: 10.5005/jp-journals-10030-1214 | Open Access | How to cite |
Introduction: We hypothesized that sequential deployment of a resuscitative endovascular balloon occlusion in the aorta REBOA, Pringle maneuver, and two Resuscitative balloon occlusion of the inferior vena cava (REBOVC) would provide hepatic vascular exclusion and hemorrhage control. Materials and Methods: Hemodynamic monitoring and splenectomy were performed in seven swine. One REBOA device and two REBOVCs were positioned under fluoroscopy in the thoracic aorta, suprahepatic and infrahepatic inferior vena cava (IVC); 35% of the total blood volume was removed. Hepatic vascular exclusion was performed for 15 minutes during shock through sequential deployment of the REBOA in the thoracic aorta, Pringle maneuver, the REBOVC in the infrahepatic IVC, and the REBOVC in the suprahepatic IVC. Hepatic vascular exclusion was reversed in the following sequence: Deflation of the REBOVC in the suprahepatic IVC, followed by the infrahepatic IVC REBOVC, release of the Pringle, and deflation of the REBOA. Subsequently, a 1.5 cm injury was performed in the suprahepatic IVC. Immediately thereafter, hepatic vascular exclusion was performed for 15 minutes followed by reversal of exclusion; suture repair of the injury was performed in two animals. Results: Hepatic vascular exclusion effectively stopped the bleeding from the suprahepatic IVC injury, significantly increased MAP. The procedure did not aggravate shock assessed by pH, lactate and base excess, and hemodynamics. Reversal of the exclusion led to immediate exsanguination from the suprahepatic IVC injury except after suture repair of the injury. Conclusion: Sequential deployment of REBOA, Pringle maneuver and two REBOVCs provided vascular exclusion of the liver and effectively temporized the hemorrhage from the suprahepatic IVC. Clinical Significance: Vascular exclusion of the liver during operative repair is difficult in the setting of massive bleeding. The procedure described herein is less invasive and effectively controls the bleeding.
Trauma Surveillance and Epidemiology in Haiti: A Pilot Study
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:10] [Pages No:123 - 132]
Keywords: Haiti, Pilot, Registry, Surveillance, Trauma
DOI: 10.5005/jp-journals-10030-1215 | Open Access | How to cite |
Introduction: Trauma remains a leading cause of mortality worldwide, with eighty-nine percent of deaths occurring in lowto- middle-income countries (LMIC). In Haiti, the mortality rate due to injuries is estimated to be twice the rate of the United States. Currently, no standardization of reporting trauma statistics exists in Haiti. The purpose of this project was to pilot a trauma surveillance logbook at four hospitals in four different regions of the country. Methods: A 17-item registry logbook was developed. Training for emergency department (ED) staff was performed on an iPad for 8-10 minutes. Data collection took place prospectively over four weeks. After this period, the logbook was compared to ED registries, and data was collected retrospectively for unrecorded, qualifying patients. Results: Eleven to sixty-nine patients were included in data analysis. The average age of patients was 27.3 years (range 0.25–87) and 68.1% were male. The majority of injuries were seen in patients ages 15–29. The highest number of patients presented on Fridays, and the highest volume of patients per hour occurred in the afternoon nursing shift (1 to 7 pm or 2 to 8 pm). The majority of patients arrived alert (94.7%), within four hours of their injury (77.9%), and by motorcycle (35%). The three most common mechanisms of injury were traffic accident (37.7%), fall (17.0%) or knife/cut wound (12.6%). The upper extremity (33.6%), lower extremity (30.8%) and the head/neck (26.7%) were the most commonly injured body regions. Treatments received in the ED are presented for 90.1% patients with the majority receiving minor and medical treatment (46.9%), and discharge status was recorded for 1009 (86.3%) patients, with 54.9% simply being treated and discharged. Discussion: Trauma and injury surveillance has become a national priority in Haiti. This study represents an initial attempt to qualify the burden of trauma-related disease in the country to make data-informed decisions regarding resource allocation and injury prevention programs.
Analysis of a National Trauma Registry in Cameroon: Implications for Prehospital Care Strengthening
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:10] [Pages No:133 - 142]
Keywords: Cameroon, Emergency medical services, Global surgery, Injury epidemiology, Low income countries, Prehospital care, Public health, Sub-Saharan Africa, Trauma registry
DOI: 10.5005/jp-journals-10030-1216 | Open Access | How to cite |
Introduction: About 54% of all injury deaths in developing counties are attributable to lack of prehospital care. The study aims to ascertain the current state, determinants, and opportunities for strengthening prehospital care delivery in Cameroon Methods: From July 2015 to January 2017, Cameroon Trauma Registry was implemented simultaneously at Laquintinie Hospital of Doula, Limbe Regional Hospital, and Catholic Hospital Pouma. Data was subjected to descriptive and inferential analysis. A multiple logistic regression models was built to predict getting prehospital care. Results: The 7879 patients were mostly male (72.6%), urban dwellers (94%), self-employed (39%) averaging 31.4 years (SD = 15.5). The commonest causes of injury were road traffic crashes (53%), blunt force (15%) and falls (15%). About 669 (9%) patients got prehospital care such as hemostasis (55.3%), fracture immobilization (24%), repositioning (10%), and giving fluid infusions (8%). Friends (35.8%), medical personnel (30.4%), or passersby (20.2%) provided prehospital care. Transport was via taxis (56%), motorcycles (18%), and private vehicles (16%). Predictors of getting prehospital care were injuries at school (perfect predictor), home (OR = 3.10, p < 0.0001), public places (OR = 3.79, p < 0.0001), or distance. 5 km from the hospital (OR = 4.06, p < 0.0001), and rural residence (OR = 4.43, p < 0.0001). Discussion: Prehospital care is typically provided by untrained laypersons in rural and distant areas, and schools. Formal lay provider training may improve prehospital care capacity and access and can drive health system growth. Conclusion: Formal prehospital trauma systems are limited in Cameroon. Prehospital care development can drive health system growth. Study findings and literature suggest that prehospital trauma care delivery can be improved by leveraging and training lay first-responders to provide prehospital care.
A Comparative Analysis of Functional Fibrinogen Assays using TEG and ROTEM in Trauma Patients Enrolled in the FiiRST Trial
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:15] [Pages No:143 - 157]
Keywords: Coagulation tests, Fibrinogen concentrate, Functional fibrinogen, Thrombelastography, Thromboelastometry, Trauma
DOI: 10.5005/jp-journals-10030-1217 | Open Access | How to cite |
Introduction: Given the growing use of both thrombelastography (TEG) and rotational thromboelastometry (ROTEM) in trauma and surgery, it is important to determine whether the two are interchangeable, and how comparable they are to Clauss fibrinogen assay and for clinical use. We recently completed a randomized control trial on early fibrinogen in trauma (the Fii RST trial). The object of this analysis was to evaluate the interchangeability and correlations between TEG and ROTEM functional fibrinogen assays in injured trauma patients. Also, we evaluated their correlation with Clauss fibrinogen and compared their potentials for diagnosis of coagulopathy and use in guided fibrinogen administration. Materials and Methods: The Post-hoc analysis of the coagulation data collected as part of the FiiRST trial. It was a comparative analysis of functional fibrinogen assays using TEG and ROTEM in trauma patients screened for hypotension and need for blood transfusion. TEG and ROTEM tests were also compared with Clauss fibrinogen assay and INR as additional analyses of their clinical use. Results: TEG and ROTEM parameter values were correlated but were significantly different, and their agreement fell outside acceptable limits and thus were not interchangeable. TEG maximum amplitude (MA) and ROTEM maximum clot firmness (MCF) showed closest correlations with Clauss fibrinogen concentration, particularly with ROTEM FIBTEM MCF (r = 0.84; p < 0.001). There were discrepancies between TEG and ROTEM in their detection of coagulation abnormalities, hypofibrinogenemia, and hyperfibrinolysis. Conclusion: TEG and ROTEM fibrinogen assay parameters were associated, especially between TEG MA and ROTEM MCF, showing the strongest correlation, but the parameters were not interchangeable. TEG and ROTEM showed varying extents of correlations with Clauss fibrinogen. Overall, ROTEM parameters exhibited better correlations with Clauss fibrinogen than TEG. Different algorithms for TEG and ROTEM need to be developed for diagnosis of coagulopathy and guided fibrinogen administration in trauma.
Drugs, Violence and Trauma in the Colombian Context: A Health Care Point of View of a Human Rights Challenge
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:6] [Pages No:158 - 163]
Keywords: Colombia, Drug Trafficking, Injury, Trauma, Violence
DOI: 10.5005/jp-journals-10030-1218 | Open Access | How to cite |
The impact of violence due to illicit drugs markets varies tremendously in magnitude and characteristics depending on several factors. In Colombia, drugs and trauma are related in multiple ways. From interpersonal violence at the street level to the criminal actions of various armed groups whose violent campaigns are financed through the vast profits associated with the illicit drug market. The objective of this review is to analyze the association of the illicit drugs trade and its impact on violence in Colombia from the viewpoint of healthcare providers who care for trauma patients. Injuries related to drug traffic violence are high in Colombia, and only a small reduction was obtained after severe crime enforcement policies. The societal cost of the war on drugs policy is high on trauma deaths and related disabilities according to several reports from non-government agencies and the Colombian National Institute of Legal Medicine and Forensic Sciences. A health care initiative in order to understand the drug phenomena as a health care problem shifting the actual criminal-justice based on the approach can minimize the human rights crisis that is evolving being faced every day at health care facilities in Colombia. This new approach in the actual post-conflict environment deserves to be analyzed.
Disseminated Abdominal Actinomycosis: An Unusual Cause of Obstruction
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:3] [Pages No:164 - 166]
Keywords: Abdominal presentation, Actinomycosis, Bowel obstruction
DOI: 10.5005/jp-journals-10030-1219 | Open Access | How to cite |
Introduction: Actinomycosis is an uncommon diagnosis, involving the abdominal cavity in around 20% of cases. It is characterized by its tendency to form masses and abscesses that, added to its subacute onset, can be difficult to differentiate from other conditions. Obstruction is rare but is mainly associated with the presence of an abnormal growth of tissue as mimicking a malignancy. Pelvic forms are usually related to prolonged use of intrauterine devices, although other causes within mucosal disruption have been described. Case report: A 36-year-old woman with type 1 diabetes mellitus and diabetic nephropathy who underwent pancreas-kidney transplantation, with no incidences during the surgical procedure. She developed fever, which did not disappear despite drainage of abdominal fluid collections. Subsequently, she developed abdominal obstructive symptoms requiring urgent surgery. During the exploratory laparotomy, numerous small white formations were identified scattered throughout the entire abdominal cavity, causing firm adhesions between bowels. During the procedure, biopsies were taken and adhesiolysis was performed. Conclusion: Abdominal actinomycosis must be considered not just in the presence of fever and weight loss but also must be rule out in unusual onsets such as small bowel obstruction. To our knowledge this presentation as disseminated lesions has not been described in the literature.
Colonic Obstruction in an Immunosuppressed Patient with Gastrointestinal Histoplasmosis
[Year:2018] [Month:May-August] [Volume:7] [Number:2] [Pages:3] [Pages No:167 - 169]
Keywords: Histoplasmosis, Abdominal location, Intestinal obstruction
DOI: 10.5005/jp-journals-10030-1220 | Open Access | How to cite |
Introduction: Histoplasmosis is a systemic disease that usually affects immunosuppressed patients. Isolated intestinal manifestation is rare, and sometimes can be confused with other entities. A patient with acquired immunodeficienc syndrome (AIDS) delete hyphen associated with colonic obstruction due to intestinal histoplasmosis resolved with medical treatment is presented. Case report: A 35-year-old man arrived in the emergency room due to the intestinal occlusive syndrome. At a physical examination, a painful mass was detected at the right hypochondrium. He had been treated in another hospital for 11 months, but without recollection of his diagnosis. The Abdominal X-ray was compatible with intestinal occlusion, and the abdominal computed tomography (CT) showed a collapsed and stenotic lesion at the hepatic angle of the colon, with fistulous trajectories. A diagnosis of HIV was confirmed after contacting the previous hospital. The results of a recent colonoscopy described an ulcerated mass and a concentric stenosis in the transverse colon with a suspicious of malignancy. The biopsy confirmed Histoplasma capsulatum (H. capsulatum) by PCR. Because of these findings, medical treatment with antifungal and digestive exclusion was initiated, presenting good response without the need for more aggressive procedures. Conclusion: When immunodeficiency is diagnosed, especially HIV, and is associated with a not life-threating intestinal manifestation, a differential diagnosis must include opportunistic infections. Adequate medical treatment is usually sufficed to avoid unnecessary emergency surgical procedures.