Objective: The objective of this guideline is to create a framework and recommendations for best practice management of traumatic liver injuries in trauma patients cared for by surgeons in the Americas. The guidelines presented are based on an extensive literature review including international studies and data as well as in-depth consensus discussions at the 2018 Panamerican Trauma Society Liver Trauma Consensus session. Materials and methods: A PubMed literature review was performed including all relevant prospective, retrospective, meta-analysis studies, and guideline manuscripts between 1995 and 2018. Expert presentations, literature review, and guideline proposal discussions were completed at the liver trauma consensus session at the annual Panamerican Trauma Society meeting in Cartagena, Colombia 2018. Results: The literature search revealed 32 relevant studies and manuscript as a foundation for the Panamerican Trauma Society Liver Trauma Management Guidelines. Expert discussions at the liver trauma consensus sessions added important aspects unique to clinical practice in rural and urban trauma centers in Latin American countries. The developed guidelines may contribute to a more standardized and evidence-based approach to the management of patients with liver trauma in the Americas. Conclusion: Liver trauma consensus sessions and detailed literature review were effective in completing a Panamerican Trauma Society consensus guidelines manuscript for the management of patients with liver trauma. The guidelines may assist physicians in the provision of a standard and effective approach to the management of patients with liver trauma across the Americas with the intent to improve outcomes and outcomes measurement.

Introduction: Optimal cuff pressure for intubated patients is 20–30 cm H₂O as routinely measured by manometry. This methodology is associated with elevated costs due to equipment requirements. The objective of this study was to evaluate another methodology, i.e., the minimal leak testing (MLT). Materials and methods: Initial cuff pressures were measured by manometry for all mechanically ventilated patients in a surgical intensive care unit (ICU). Two critical care physicians separately performed an MLT for each subject and cuff pressure was then remeasured by manometry. The rate of ventilator-associated pneumonia (VAP) was determined. Results: Thirty subjects with 100 patient events were evaluated. The post-MLT measured cuff pressures were highly consistent between physicians, with a Pearson correlation coefficient of 0.770 (p = 0.01). Average initial cuff pressures were not significantly different between manometry and MLT (25 cm H₂O vs 14 cm H₂O, p = 0.1894). Manometry had a higher incidence of elevated cuff pressures (n = 13/50 vs 2/100, p < 0.0001), while MLT had higher incidences low cuff pressures (n = 72/100 vs 17/50, p < 0.0001). No difference was observed in the VAP rate (2.8 vs 3.0 per 1,000 ventilator days, p = 0.96). Conclusion: Minimal leak testing is a known method of cuff pressure monitoring that was demonstrated in this study to provide a reproducible technique.

Background: Assembling an effective medical response for an overwhelming number of casualties has become a priority worldwide. Terrorist attacks have been part of the Colombian contemporaneous history. On February 7, 2003, a terrorist car bomb explosion occurred inside a private club in Bogotá, causing the largest number of casualties of all terrorist attacks for over 15 years. The present study analyses the hospital and prehospital responses to this mass casualty event by characterizing the patterns of injury, resource allocation, and outcome in a tertiary-level hospital where most of the casualties were treated. Materials and methods: This is a retrospective chart review of the patients brought to a single hospital (La Clínica del Country), which was the nearest to the terrorist attack. Demographics, severity of injury, patterns of injury, prehospital care, and outcomes were determined from the hospital medical records and government registries. Results: Of the 240 victims, 35 died at the explosion site (immediate mortality 17%). The 205 survivors were dispersed throughout the city, of whom 63 patients came to La Clínica del Country hospital. Most of these patients were evaluated only clinically and deemed not serious. The main mechanism of trauma was blunt (81.4%). The mean injury severity score (ISS) was 5.6 ± 8.3. Ten patients required emergent surgical intervention and 14 patients were admitted. The in-hospital mortality was 20%. Conclusion: This mass casualty event was a true test for the Colombian emergency medical system and disaster preparedness. The medical response and resource optimization resulted in an overall mortality rate similar to those observed in the recent European and North American bombings. Despite the limited resources, the continuous challenge of terrorist's attacks in Colombia made the country feel the need for training and preparing the healthcare professionals, allowing effective delivery of medical care.

Aim: To assess the impact of international surgical observership, the level of satisfaction of past participants and obtain their feedback on their experience. Since 2011, the international observership program (IOP) is offered in partnership with the Panamerican Trauma Society (PTS) and the Virginia Commonwealth University (VCU), Division of Acute Care Surgery Services. The IOP has facilitated knowledge exchange opportunities on trauma care and emergency medical systems (EMSs) for physicians in training from Latin America countries. Materials and methods: An online survey using REDCap was conducted among past participants (n = 36). The 14-question survey had a combination of dichotomous, multiple-choice, open-ended, and Likert scale questions. To keep the survey anonymous, participant identifiers were not used. Descriptive analysis was carried out. Results: The response rate was 53% (n = 19). The overall effect of IOP should be considered as positive, as 17 (89%) respondent alumni consider the IOP exceeded or met their expectations and 18 (95%) would recommend it to a friend and colleague. Similarly, 89% of the IOP's alumni believe that the observership helped them with their career growth. Most of the observers commented that the experience was inspiring, opened their minds, and broadened their horizons. Conclusion: The present survey adds further evidence of the positive impact that international observerships offer to physicians in training coming from low- and middle-income countries. The IOP introduces students to new knowledge for comprehensive care of trauma patients that would be advantageous to their future professional roles.

Introduction: Residual pneumothorax (rPTX) after tube thoracostomy (TT) is not an uncommon occurrence (10–20%) in any active trauma center. Many different practice patterns exist on how to deal with this clinical conundrum. These differing strategies can include more invasive procedures and increased length of stay (LOS). We hypothesize that the vast majority of these patients can be safely managed with observation and most can be discharged home without complete resolution. Materials and methods: A retrospective study was conducted on trauma patients managed in a level I center over a 2-year period. A “post-pull” chest X-ray was obtained on all TT patients after removal. All patient with rPTX were included for analysis. Results: A total of 412 patients required chest tubes. Since 98 patients were deceased, we excluded them from the study. A total of 314 patients were studied. Forty-two percent of the patients were male, with median age 40. Sixty-one percent of the patients were blunt trauma victims and 39% were penetrating trauma victims. The indications for chest TT were pneumothorax, hemothorax, and hemopneumothorax. A total of 163 had post-pull pneumo and discharged home with residual pathology prior to discharge. Five of these patients were readmitted (3%), and only one required repeat TT, roughly 0.6%. Conclusion: The vast majority of “post-pull” rPTX patients can be managed conservatively and can be safely discharged even without complete resolution.

Introduction: Motorcycles have become a popular choice of transport in Tanzania, hence there is an increase in motorcycle crashes. Considering the high rate of motorcycle crashes, magnitude and seriousness of the injuries in the head and neck region, studying the pattern of maxillofacial injuries in motorcycle crash victims (MCV) is inevitable. The aim of the study was to investigate the occurrence, types, and treatment of maxillofacial fractures in MCV at Muhimbili, a tertiary national hospital in Tanzania. Materials and methods: This was a descriptive, cross-sectional, and hospital-based study that included all MCV. These were received, interviewed (including the use or nonuse of helmets and alcohol intake), physically examined, and investigated for maxillofacial injuries. Maxillofacial fractures were categorized as mandibular, midface, and upper third of face (frontal) fractures. Management of the injuries included supportive, medical, and surgical treatment. The data were analyzed using Statistical Package for Social Sciences (SPSS) Version 20. Results: A total of 116 MCV predominantly (113, 97.4%) men were included in this study with a male-to-female ratio of 37.7:1. The crash victims were aged between 14 years and 66 years (mean of 29.43 ± 8.88), and the 20 years and 39 years age group was the most affected. More than half (53.4%) of the victims had not put on helmets and only 18.1% of the victims were under the influence of alcohol during the crashes. The majority (89.7%) of MCV sustained maxillofacial fractures whereby 71.2% had mandibular fractures, 66.3% had midface fractures, and 9.6% had frontal bone fractures. The severity of injuries significantly correlated with the speed of motorbikes during crashes. Maxillomandibular fixation (MMF) was the commonest treatment modality of the fractures employed. Conclusion: The findings of this study revealed that young men (14–39 years) were more prone to motorcycle crashes. The majority of MCV did not wear helmets and only a few were under the influence of alcohol during the crashes. The mandible and zygoma were the frequently fractured bones and the odds of multiple fractures increased with increased speed of motorbikes. Clinical significance: The results of this study cast light on the pattern and burden of oral and maxillofacial injuries in Tanzania, thus serving as the basis for future interventions to improve the injured patient outcomes, and reduce morbidity and mortality. The information obtained from this study can be used by public health researchers to improve health policies on road traffic crash prevention.

Introduction: The kidney is an organ frequently affected in children with abdominal trauma. Approximately 1 of 10 patients will have an injury of the renal parenchyma, vascular hilar or collecting systems. Materials and method: The objective of this work was to analyze a series of pediatric patients with renal trauma, evaluate their clinical evolution and the result of the treatment through a retrospective and descriptive study. Patients under 15 years of age admitted with suspicion or diagnosis of renal trauma between January 2013 and March 2019 at the San Vicente Foundation University Hospital in the city of Medellín, Colombia were included. The exclusion criteria were all those patients with incomplete medical history, older than 15 years, iatrogenic lesions and known renal malformation. Results: One hundred and forty four patients with a diagnosis of abdominal trauma and suspected renal involvement were identified; in 29.9% the diagnosis could be confirmed. Of the 43 patients, 65.1% were men and the average age was 9.4 years. Closed trauma corresponded to 93%, with the main etiology being falls (27.9%) followed by blunt trauma (20.9%). The main symptoms were low back pain, abdominal pain and hematuria. Grade III trauma was the most frequent (40.2%) followed by IV (30.2%). Conclusion: The most frequent treatment was clinical observation (76.7%) with 100% effectiveness. 16.3% required surgery and 7% angioembolization as initial management with an effectiveness of 100% and 66% respectively. The complication rate was 7% and there were no deaths in the present study.

Background: While extensive research has been conducted on healthcare utilization after severe penetrating trauma events, there is a dearth of information on healthcare utilization prior to these events. This study examined the emergency department (ED) utilization patterns to determine if prior ED visits for injury were a risk factor for severe penetrating trauma. Materials and methods: This retrospective cohort study examined the ED visit records of 215,800 patients with 489,800 ED visits and 3,322 trauma registry patients from November 2010 to February 2015 at Grady Memorial Hospital, a large, urban hospital with a level I trauma center. Data analysis was conducted using logistic regression and Cox proportional hazard models. Results: Among 215,800 ED patients, 224 patients with prior ED visits experienced severe penetrating trauma (as reported to the trauma registry). After adjustment for age, sex, employment, insurance, high utilization, and admission status, prior ED visits for injury were associated with severe penetrating trauma (OR 1.60, CI 1.21–2.10, p = 0.001). Cox proportional hazard models were used to estimate hazard ratios (HR) for factors associated with time to a penetrating trauma event following a patient's last ED visit. After adjusting for age, sex, employment status, admission status, high utilization, and insurance status, patients with an injury diagnosis at their last ED visit had a HR of 1.43 (CI 1.07–1.93, p = 0.016). Conclusion: After adjusting for confounders, a previous ED visit for injury remained a significant risk factor for severe penetrating trauma and an elevated rate of time to penetrating trauma. These findings suggest a need for targeted violence intervention programs and improved ED injury surveillance.

Duodenal and pancreatic trauma are rare injuries difficult to recognize and, when severe, difficult to treat. The present article talks about the clinical presentation and surgical options for this type of trauma.

Introduction: Explosive blast is defined as the violent energy release that is transferred to the environment; being able to push columns of air, particulate material and hot gases that when encountering the human body can cause potentially mortal injuries. Materials and methods: A narrative review about blast trauma is presented. Articles not related to blast trauma published in languages other than Spanish and English and those whose central theme was different from that is treated by general surgery and its subspecialties were excluded. Discussion: Each of the 5 injury mechanisms described for this type of trauma is described, and a summary is made of the diagnosis and management of the most frequent thoracic, abdominal and peripheral vascular injuries associated to blast injury. Conclusion: It is essential to know the mechanisms of injury to give the appropriate management to the victims of this type of injuries in a organised and global manner.

Perforating pancreatic injury (PPI) is an uncommon event in trauma centers. In rare cases, it can complicate with pancreatic fluid collections (PFC). Although it is well known in cases of acute pancreatitis, there are few described cases in trauma patients. Another feared complication is the disconnection of the major pancreatic duct (MPD), which most authors recommend to be treated immediately. We hereby report a successful case of PPI that was initially approached by videolaparoscopy, coursed with an infected PFC formation and a MPD disconnection. This case analysis suggests that videolaparoscopy may be feasible in patients with PPI and that minimally invasive approaches in the acute phase might postpone more aggressive procedures to an elective and well-planned approach.