Panamerican Journal of Trauma, Critical Care & Emergency Surgery

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2020 | May-August | Volume 9 | Issue 2

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Manuel Lorenzo


[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:1] [Pages No:00 - 00]

   DOI: 10.5005/pajt-9-2-vi  |  Open Access |  How to cite  | 



Dr. Felipe Vega Rivera

PTS Statement on Virtual Congress 2020

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:1] [Pages No:00 - 00]

   DOI: 10.5005/pajt-9-2-v  |  Open Access |  How to cite  | 


Original Article

Milena Alcázar, Maria Del Pilar Gutierrez, Santiago Rojas, Tatiana Suarez, Carlos Morales

Performance of Noncontrast Multidetector Computed Tomography Compared with a Reference Standard (Surgery/Pathology or Clinical Follow-up) in Diagnosing Acute, Nontraumatic Abdominal Pain

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:6] [Pages No:91 - 96]

   DOI: 10.5005/jp-journals-10030-1287  |  Open Access |  How to cite  | 


Introduction: Computed tomography (CT) with intravenous (IV) contrast is the method of choice for diagnosing and selecting treatments for surgical pathologies in patients visiting the emergency room (ER) for acute, nontraumatic abdominal pain. However, there are risks, high costs, and delays in medical attention associated with this modality. Studies have suggested performance of CT without venous contrast for diagnosing appendicitis. Nevertheless, no methodologically rigorous studies have evaluated CT without IV contrast performance when used as the main diagnostic tool for patients with acute abdominal pain. Objective: This study aims to evaluate the diagnostic performance of noncontrast abdominal CT and compare it with a reference standard (surgery/pathology or clinical follow-up) to detect surgical diseases in patients with acute abdominal pain. Design: This is a cross-sectional, diagnostic test study. Place: Hospital Universitario San Vicente Foundation (Medellín, Colombia). Materials and methods: This is a cross-sectional convenience sample diagnostic test study of consecutively selected patients who underwent noncontrast CT of the abdomen. All patients were those who presented to the ER with abdominal complaints. All patients who consented underwent a noncontrast and IV contrast CT scans. Two radiologists with different levels of expertise independently evaluated the noncontrast tomography images to specify the diagnostic findings. Final diagnoses were collected independently from the patients’ clinical histories. Patients who did not undergo surgery, their clinical histories were reviewed during hospitalization. Those who were not hospitalized had their clinical course obtained by telephone 2 weeks after being discharged. Results: Of the 157 included patients, 19.1% underwent surgery because of an acute pathology. For noncontrast abdominal contrast tomography, values of 93.3% sensitivity (95% CI 82.7–100), 96.8% specificity (95% CI 93.4–100), 87.5% PPV (95% CI 74.4–100), 98.4% NPV (95% CI 95.8–100), 29.6 LR+ (95% CI 11.24–78.1), 0.07 LR− (95% CI 0.02–0.26), and 97.4% diagnostic accuracy were obtained. The interobserver concordance had a kappa value of 0.88. Conclusion: Noncontrast abdominal CT performs well in differentiating medical vs surgical diseases in patients with acute abdominal pain.


Original Article

Juan F Figueroa, Christian Loyola, Fray Martínez, Juan C Salamea

Efficacy of the Basic Trauma Course in Family Medicine Resident Physicians in Southern Ecuador: It is Time to Innovate Education in Trauma

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:4] [Pages No:97 - 100]

   DOI: 10.5005/jp-journals-10030-1286  |  Open Access |  How to cite  | 


Introduction: In Ecuador, as in other Latin American countries, trauma has become one of the main reasons to seek medical care in the country. According to data obtained from the National Institute of Statistics and Censuses (INEC), the rate of homicides, car accidents, suicides, and burns, grouped together, represent the main cause of morbidity and mortality in people aged between 18 years and 40 years, surpassing mortality due to cardiovascular causes or diabetes. Additionally, one study on geolocation of calls made to the emergency services (SIS-ECU 9-1-1) indicated that trauma in the country is becoming more and more frequent in marginal urban and rural areas, where health services are scarce. Due to this emerging situation, it is necessary to evaluate the short- and long-term effectiveness of the Basic Trauma Course (BTC), a course designed to educate students, general practitioners, prehospital staff and primary healthcare physicians. Objective: To evaluate the effect of the BTC in family medicine residents who work in Health Centers in marginalurban and rural areas of the Azuay, Cañar, and Morona Santiago provinces in southern Ecuador. Materials and methods: Quasi-experimental study in which knowledge is evaluated at three stages in time (before the course, at the end of the course and one year later) in 39 family medicine residents. Comparison of means of the test scores was made using formulas in SPSS of analysis of variance (ANOVA) and Tukey HSD. Results: ANOVA brought significant differences between measurements (F = 8.38, p value < 0.0005). The increase in the score between the pretest and the immediate posttest was significant (p value < 0.01). The difference between pretest and late posttest was not significant. The comparison of the immediate and late posttest results showed a decrease in the mean, being statistically significant (p value < 0.01). Conclusion: The BTC, as a unique training course, does not guarantee the permanence of long-term knowledge in participants who do not regularly attend to the trauma patient, requiring constant training using spaced repetition methods, for adequate consolidation.



İbrahim Eker, Soner Yilmaz, Rıza A Çetinkaya, Aytekin Ünlü, Aysel Pekel, Rahşan I Sağkan, Zerrin Ertaş, Orhan Gürsel, Hacı U Muşabak, Ertuğrul Yazici, Sebahattin Yilmaz, Cengizhan Açikel, İsmail Y Avci, Ferit Avcu, Emin Kürekçi, Patrizio Petrone

A Cycle of Freezing and Thawing as a Modified Method for Activating Platelets in Platelet-rich Plasma to Use in Regenerative Medicine

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:4] [Pages No:101 - 104]

   DOI: 10.5005/jp-journals-10030-1285  |  Open Access |  How to cite  | 


Background: Platelet-rich plasma (PRP) has been widely used to improve wound healing and tissue repair. The objective of this study was to assess a cycle of freezing/thawing and its effect in the amount of growth factors in PRP. Materials and methods: After the preparation of PRP using standard methods, the samples were equally divided into two groups: The first group was activated by adding 10% calcium gluconate, while the second group was cryopreserved at −80°C for 24 hours. Enzyme-linked immunosorbent assay was used for aliquots of PRP to measure concentrations of insulin-like growth factor-1, platelet-derived growth factor, and basic fibroblast growth factor. Results: 15 mL of whole blood was obtained from 20 volunteers and collected into citrated tubes. The mean platelet count of the donors and the autologous PRP were 238.5 ± 44.7 × 103/μL and 544.7 ± 161.5 × 103/μL, respectively. There were no significant differences between the growth factor levels of freeze-thawed and calcium-activated PRP. A cycle of freezing/thawing was the only independent factor associated with the growth factor yield in the multivariate model. Conclusion: With its features of being simple, inexpensive, and easy for standardization, a cycle of freezing/thawing may be the method of choice for PRP activation procedure, without inducing fibrin matrix. This study was performed in a laboratory setting; therefore, future clinical trials are recommended.



Alexander Rodríguez, Eliana Cervera, Gigliola Macchia, Xilene Mendoza, Walter Martínez, Osmar Pérez, Homero Sanjuán, Pedro Villalba

Utility of S-100B as a Potential Tool for Neuromonitoring and Prediction of Neuroworsening in Acute Phase of Traumatic Brain Injury

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:9] [Pages No:105 - 113]

   DOI: 10.5005/jp-journals-10030-1288  |  Open Access |  How to cite  | 


Aim: In this review, we summarize the evidence on the use of S-100B in traumatic brain injury (TBI) of all severities, its clinical significance, and its prognostic value in the different posttrauma phases. Background: Most of the published studies report the serum determination of S-100B in the context of mild TBI as a predictor of positive CT scan, which represents a valuable tool when establishing a criterion to indicate the performance of the CT and decide the medical discharge. Likewise, we have reported several studies that correlate S-100B with the clinical evolution of the patient with severe TBI, showing an excellent indicator of intracranial hypertension. However, there are few studies that report on the impact of S-100B as a predictor of neuroworsening in the acute phase in moderate TBI. Review results: Traumatic brain injury comprises a heterogeneous group of traumatic injuries that can evolve progressively. Almost 90% of head injuries that reach the hospital are mild head injuries or mild TBI, which is defined by a score of more than 12 on the Glasgow Coma Scale (GCS). Of this, a few can be accompanied by a hemorrhagic lesion that can be detected by further imaging techniques. Still, utilizing these techniques in every single patient that comes to the ER does not only take a toll on the finances of the hospital but, more importantly, also exposes the patients to unnecessary radiation. There are still difficulties to correlate the findings on imaging with secondary injury, and to predict the clinical evolution in the acute phase and in the long-term. Serum S-100B levels have shown high sensibility and negative predictive value (NPV) for intracranial complications after mild head injury. Most of the published studies report that measurement in serum of S-100B in the context of mild TBI, as a predictor of CT findings, represents a valuable tool when establishing a criterion for indication of CT and to decide medical discharge. However, there are few studies that report the impact of S-100B as a predictor of neuroworsening in the acute phase of moderate TBI, which is defined by a score between 9 and 12 on the GCS. Conclusion: Serum S-100B is a useful marker of brain damage in TBI. Its usefulness has been studied mainly as a support to evaluate the need to perform a CT scan in mild TBI, and to monitor patients with moderate-to-severe TBI, in order to predict the outcome and validate the response to treatment. This review highlights S-100B as a versatile marker whose clinical utility depends on the severity of the head trauma. In this way, S-100B would be a potential predictor of neuroworsening in the acute phase in moderate TBI. Clinical significance: Despite its valuable utility as a predictor of positive CT in mild TBI, and as a tool for neuromonitoring in established severe TBI, the greater utility of S-100B could be as a predictor of neuroworsening in the acute phase in the moderate TBI.



Evelyn M Serrano, George Molina, Geoffrey A Anderson, Sara J Singer, William R Berry, Alex B Haynes, Martha E Larrea Fabra, Marc A de Moya

Evaluation of the Perceptions of Safety of Surgical Practice at a Tertiary Academic Trauma Hospital in Havana, Cuba

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:6] [Pages No:114 - 119]

   DOI: 10.5005/jp-journals-10030-1289  |  Open Access |  How to cite  | 


Aim: The aim of this study was to demonstrate the feasibility of measuring the perceptions of safety of surgical practice in a tertiary hospital in Havana, Cuba. Materials and methods: A validated survey used to measure the perceptions of safety of surgical practice among operating room (OR) personnel was translated into Spanish. The survey was administered to all OR personnel who worked at the General Calixto García Hospital between June 15, 2015, and October 30, 2017. The survey consisted of two demographic questions and 16 items that respondents could answer using a seven-point Likert scale. Responses were dichotomized and evaluated between surgeons and trainees and between participants with ≤5 years and ≥6 years of experience. Results: There were 200 respondents (response rate of 46.5%, 200/430), which included 55 (27%) surgeons, 116 (58%) trainees, 10 (5%) anesthesiologists, and 19 (9.5%) nurses. The majority of respondents reported having ≤5 years of experience (71.4%, n = 142). Surgeons and participants with ≥6 years of experience more often had a significantly more favorable perception of surgical safety than trainees and participants with ≤5 years of experience, respectively. Conclusion: The perceptions of safety of surgical practice were successfully measured at a tertiary hospital in Havana, Cuba. The perception of surgical safety differed according to professional role and years of experience. Clinical significance: Making surgery safer includes fostering a favorable culture of surgical safety in the OR so that all personnel feel empowered to speak up and act on behalf of patient's safety.



Bartolomeu A Nascimento Jr, Lorena T de Melo Rolim, Gustavo P Fraga

Importance of the Epidemic Curve for Cross-country Comparison of COVID-19 Mortality: A Brief Analysis on Interpreting the Pandemic Numbers

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:2] [Pages No:120 - 121]

   DOI: 10.5005/jp-journals-10030-1276  |  Open Access |  How to cite  | 



Kristen Nordham, Danielle Tatum, Juan Duchesne

Effects of Social Distancing on the Incidence of Traumatic Injuries

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:4] [Pages No:122 - 125]

   DOI: 10.5005/jp-journals-10030-1277  |  Open Access |  How to cite  | 


Aim: To understand how social distancing orders impact the incidence of traumatic injuries. Background: In an attempt to blunt the spread of the novel coronavirus SARS-CoV-2, social distancing and stay home orders have been enforced. Here we analyze the effect that these public health measures have had on the rate of traumatic injury presenting to a level 1 trauma center. Materials and methods: This is a retrospective analysis of the number of trauma patients presenting to a level I trauma center from January 2019 through April 2020. Patients were identified using an institutional trauma registry and include trauma transfers, trauma activations, and admitted trauma patients. The independent samples t-test and the Mann–Whitney U test were used to assess differences between groups. Shapiro–Wilk and Levene's tests were used to assess normality and variances, respectively. Results: When comparing daily admissions in 2020 before and after social distancing orders, there was a significant reduction in the median daily number of trauma patients (12 vs 8.5; p < 0.0001) after the social distancing order was put into place. Additionally, there was a significant decrease in the mean number of weekly trauma patients presenting to our hospital in 2020 before and after social distancing orders (86.1 vs 60.3; p < 0.0001). When looking at weekly patient counts, there was a significant reduction in blunt trauma patients when comparing pre- and post-social distancing (56.6 vs 35.7; p < 0.01). However, there was no change in the number of weekly penetrating injuries (17.0 vs 17.1). Conclusion: Social distancing orders have significantly reduced the number of blunt trauma patients presenting to our level 1 trauma center. Further studies will be needed to determine long-term effects of these measures.



Andrés V Ayala, Sofía A Zárate, Andrés E Zabala, Luis Pacheco, Fernando I Narváez, María L Alvear, José R Negrete

Perspectives and Recommendations for Laparoscopic Surgery in the COVID-19 Era

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:7] [Pages No:126 - 132]

   DOI: 10.5005/jp-journals-10030-1279  |  Open Access |  How to cite  | 


A new human coronavirus called SARS-CoV-2 is currently causing a pandemic of the coronavirus disease 2019 (COVID-19). Healthcare institutions including surgical centers and their workers are in risk of contagion due to high exposure to SARS-CoV-2. The objective of the present manuscript is to review the available literature and elucidate the key points for maintaining safety in laparoscopic surgery during the pandemic. Currently, any patient who requires surgery and in whom the diagnosis of COVID-19 has not been ruled out should be treated as a positive patient and the correspondent safety measures should be taken. Surgical plume is a bioproduct that places healthcare workers who are exposed to it in a potential risk of acquiring different health conditions. There is no clear evidence to affirm that the exposure to surgical plume and pneumoperitoneum can cause COVID-19; nevertheless, as we do not know yet the real risk of transmission and infectivity of particles found in surgical smoke, it is recommended to take measures for a controlled evacuation of pneumoperitoneum and the use of a simple filtration system during laparoscopic surgery. We must understand that as our entire life changed with this pandemic, laparoscopic surgery should also change in particular aspects to give our patients the best treatment under the safest conditions as possible.



Galvan Talamantes Yazmin, Vega Felipe, Mercedes N Lopez-Hernandez, Alvarez Reséndiz G Esteban

Considerations for the Emergency and Perioperative Management of Patients with COVID-19

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:9] [Pages No:133 - 141]

   DOI: 10.5005/jp-journals-10030-1280  |  Open Access |  How to cite  | 


The COVID-19 pandemic is a threat to global health, which is multiplying rapidly due to its high degree of contagiousness; some of these patients will require surgical services and anesthesia care for endotracheal intubation. Protecting staff members and preventing cross transmission of infection during airway approaches and surgical procedures for patients with known or suspected COVID-19 infection is paramount, preserving the capacity of health systems. Careful planning, consensual clinical decision-making, and rigorous personal protective equipment (PPE) will be required; avoid performing nonessential or urgent surgical procedures that generate greater viral exposure. The medical teams during the perioperative period will face unexpected inconveniences therefore, and due to the continuous management, that is evolving, this article aims to discuss the essential PPE, describe the modifications in the management of the airway, and cite the particular precautions consequent to the surgical act.



Shrey Modi, Bhuwan Giri

Acute Care Surgery in the Times of COVID-19 Pandemic: Our Experience at a Large Safety Net Hospital

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:5] [Pages No:142 - 146]

   DOI: 10.5005/jp-journals-10030-1284  |  Open Access |  How to cite  | 


Background: There is limited experience in managing confirmed or suspected coronavirus disease 2019 (COVID-19) patients who present for emergency general surgery. Differing presentations, diagnostic uncertainty, and lack of guidelines present challenges to surgeons taking care of these patients. Materials and methods: We present a retrospective case series of five patients (age: 20s–50s) with acute surgical emergencies, highly suspected or positive for COVID-19, providing an overview of diagnosis, management, and outcomes. Results: The first two cases were patients with acute cholecystitis and perforated duodenal ulcer with high suspicion for COVID-19 but negative reverse transcription polymerase chain reaction (RT-PCR) results. The third case was a COVID-19 confirmed patient with acute appendicitis managed nonoperatively. The last two cases were COVID-19 positive patients with lower extremity abscess and intussusception. Conclusion: Clinical decisions were made based on the urgency of each case while simultaneously navigating their COVID-19 infection status. Recognizing asymptomatic carriers, maintaining effective communication between different teams, and planning perioperative care were important aspects in achieving favorable outcomes.



Eman A Toraih, Danielle Tatum, Mohammad H Hussein

Development of an Inclusive Interhospital Resource Allocation to Mitigate States Hospital Capacity during COVID-19

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:8] [Pages No:147 - 154]

   DOI: 10.5005/jp-journals-10030-1281  |  Open Access |  How to cite  | 


The severe acute respiratory syndrome coronavirus (SARS-CoV-2), commonly known as COVID-19, has resulted in severe resource shortages in the areas that have become hot spots. A leading area of concern has been hospital bed and intensive care unit bed availability that would leave hospitals unable to treat the most severe cases and which would result in unnecessary additional loss of life. Here, we present a model based on prediction of cases by state to propose resource allocation to alleviate hospital bed shortages.



Tercio de Campos, Salomone Di Saverio, Carlos Y Benítez, Mohammad Azfar

Trauma and Acute-care Surgeons’ Perception of Personal Safety during the COVID-19 Pandemic

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:3] [Pages No:155 - 157]

   DOI: 10.5005/jp-journals-10030-1282  |  Open Access |  How to cite  | 


The World Health Organization recognized in March 2020 the existence of a pandemic of the new coronavirus that appeared in China in late 2019, which was named coronavirus disease 2019 (COVID-19). In this context, a survey was conducted with 125 trauma and emergency surgeons from across the world regarding the availability of personal protective equipment (PPE) and the role of the surgeon in the pandemic, using an electronic survey. The study findings suggest that many surgeons work under inadequate conditions, particularly in South America, without the necessary supplies and equipment such as N95 masks and facial shields when contacting potentially contaminated patients. The findings indicate an increased risk of contamination by healthcare workers, which may result in losses of working professionals. Immediate measures must be taken to guarantee access to safety equipment throughout the globe, since all patients with emergency surgical conditions must be managed as potentially carrying the COVID-19 virus..



C Rodrigo Olvera, Rishi Rattan

COVID-19 Pandemic Acute-care Surgery Practice Survey Results from the Panamerican Trauma Society International Trauma Tele-Grand Rounds

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:4] [Pages No:158 - 161]

   DOI: 10.5005/jp-journals-10030-1283  |  Open Access |  How to cite  | 


Objective: As of June 9, 2020, the coronavirus disease 2019 (COVID-19) pandemic has affected more than 7 million people worldwide, causing more than 400,000 deaths. Acute-care surgery approaches in times of the COVID-19 pandemic were discussed during the Panamerican Trauma Society International Trauma Tele-Grand Rounds meeting in April 27, 2020. The purpose of this study is to identity practice patterns among surgeons treating acute surgical diseases during the pandemic. Materials and methods: COVID-19 epidemiology, prevalence in surgical patients, and treatment options of patients with acute surgical diseases in the presence of SARS-CoV-2-positive status were discussed. An electronic audience response system was used to assess opinions and practice patterns of the participating surgeons. Deidentified data collection was performed, stored, and subsequently analyzed using Excel software 2018. Results: The conference was attended by 91 participants from 20 countries. Forty-six surgeons participated in the survey, with 36% practising at a hospital with >80 active COVID-19 inpatients. Forty-eight percent of the participating surgeons had provided surgical care for SARS-CoV-2-positive (CoV+) patients. At the time of provider–patient interaction, 58% of surgeons were not aware of the CoV+ status. Surgeons reported changing practice patterns during the pandemic. They would treat CoV+ patients with acute cholecystitis with antibiotics only (64%), IR drain (12%), laparoscopic-(5%), open cholecystectomy (12%), and no opinion (7%). For acute appendicitis, 57% of surgeons favor antibiotics only vs open-(29%), laparoscopic appendicectomy (10%), and no opinion (4%). Gas/smoke-filtering systems for laparoscopy were available only to 14% of respondents. SARS-CoV-2 screening protocols utilize one RNA real-time polymerase chain reaction (RT-PCR) (29%), two RNA-RT-PCR 72 hours apart (7%), and IgG/IgM plus RNA RT-PCR (17%); 17% have no screening capacities. Conclusion: Standard acute-care surgery practice patterns changed favoring nonoperative treatment. Testing protocols vary among healthcare systems. Further studies are needed to understand the impact of the COVID-19 pandemic on outcomes in acute-care surgery patients.



Maria Tudela, Maria Fernandez

Massive Pneumoperitoneum after Bronchoscopy and Noninvasive Ventilation in a COVID-19 Patient, without Associated Pneumomediastinum or Pneumothorax

[Year:2020] [Month:May-August] [Volume:9] [Number:2] [Pages:3] [Pages No:162 - 164]

   DOI: 10.5005/jp-journals-10030-1278  |  Open Access |  How to cite  | 


The most common cause of pneumoperitoneum is a perforated hollow viscus. However, there are other causes that have been termed nonsurgical, asymptomatic, benign, or idiopathic pneumoperitoneum, most of them of thoracic origin; these are due to complications caused by invasive mechanical ventilation or interventional procedures such as fiberoptic bronchoscopy and are accompanied by pneumomediastinum, pneumothorax, or both. We present a case of isolated massive pneumoperitoneum, without accompanying pneumothorax or pneumomediastinum, in a patient with bilateral bronchopneumonia due to coronavirus disease 2019 (COVID-19) already cured and who underwent urgent bronchoscopy due to hemoptysis. This is a rather exceptional case due to barotrauma after noninvasive ventilation, and in whose pathophysiological mechanism both bronchoscopy and possible pulmonary fibrosis resulting from bilateral COVID-19 pneumonia may also have played a role.


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