Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department.

OBJECTIVES: Blunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period. METHODS: We performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death. RESULTS: We included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01-1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported. CONCLUSION: The incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.

Prophylactic platelet transfusion and risk of bleeding associated with ultrasound-guided central venous access in patients with severe thrombocytopenia.

BACKGROUND: Reported risk of bleeding complications after central catheter access in patients with thrombocytopenia is highly variable. Current guidelines recommend routine prophylactic platelet (PLT) transfusion before central venous catheter placement in patients with severe thrombocytopenia. Nevertheless, the strength of such recommendations is weak and supported by observational studies including few patients with very low PLT counts (<20 × 109 /L). This study aims to assess the risk of bleeding complications related to using or not using prophylactic PLT transfusion before ultrasound-guided central venous access in patients with very low PLT counts. METHODS: This was a retrospective cohort study of patients with very low PLT counts (<20 × 109 /L) subjected to ultrasound-guided central venous catheterization between January 2011 and November 2019 in a university hospital. Bleeding complications were graded according to the Common Terminology Criteria for Adverse Events. A multivariate logistic regression was conducted to assess the risk of major and minor bleeding complications comparing patients who did or did not receive prophylactic PLT transfusion for the procedure. Multiple imputation by chained equations was used to handle missing data. A two-tailed p < 0.05 was considered statistically significant. RESULTS: Among 221 patients with very low PLT counts, 72 received prophylactic PLT transfusions while 149 did not. Baseline characteristics were similar between transfused and nontransfused patients. No major bleeding events were identified, while minor bleeding events were recognized in 35.7% of patients. Multivariate logistic regression analysis showed no significant differences in bleeding complications between patients who received prophylactic PLT transfusions and those who did not (odds ratio 0.83, 95% confidence interval 0.45-1.55, p = 0.567). Additional complete case and sensitivity analyses yielded results similar to those of the main analysis. CONCLUSIONS: In this single-center retrospective cohort study of ultrasound-guided central venous access in patients with very low PLT counts, no major bleeding was identified, and prophylactic PLT transfusions did not significantly decrease minor bleeding events.

Hypertonic saline infusion does not improve the chance of primary fascial closure after damage control laparotomy: a randomized controlled trial.

BACKGROUND: Previous observational studies showed higher rates of abdominal wall closure with the use of hypertonic saline in trauma patients with abdominal injuries. However, no randomized controlled trials have been performed on this matter. This double-blind randomized clinical trial assessed the effect of 3% hypertonic saline (HS) solution on primary fascial closure and the timing of abdominal wall closure among patients who underwent damage control laparotomy for bleeding control. METHODS: Double-blind randomized clinical trial. Patients with abdominal injuries requiring damage control laparotomy (DCL) were randomly allocated to receive a 72-h infusion (rate: 50 mL/h) of 3% HS or 0.9 N isotonic saline (NS) after the index DCL. The primary endpoint was the proportion of patients with abdominal wall closure in the first seven days after the index DCL. RESULTS: The study was suspended in the first interim analysis because of futility. A total of 52 patients were included. Of these, 27 and 25 were randomly allocated to NS and HS, respectively. There were no significant differences in the rates of abdominal wall closure between groups (HS: 19 [79.2%] vs. NS: 17 [70.8%]; p = 0.71). In contrast, significantly higher hypernatremia rates were observed in the HS group (HS: 11 [44%] vs. NS: 1 [3.7%]; p < 0.001). CONCLUSION: This double-blind randomized clinical trial showed no benefit of HS solution in primary fascial closure rates. Patients randomized to HS had higher sodium concentrations after the first day and were more likely to present hypernatremia. We do not recommend using HS in patients undergoing damage control laparotomy. Trial registration The trial protocol was registered in clinicaltrials.gov (identifier: NCT02542241).

Association of resuscitative endovascular balloon occlusion of the aorta (REBOA) and mortality in penetrating trauma patients.

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.

Drugs, Violence and Trauma in the Colombian Context: A Health Care Point of View of a Human Rights Challenge.

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.

Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients.

BACKGROUND: Dynamic and efficient resuscitation strategies are now being implemented in severely injured hemodynamically unstable (HU) patients as blood products become readily and more immediately available in the trauma room. Our ability to maintain aggressive resuscitation schemes in HU patients allows us to complete diagnostic imaging studies before rushing patients to the operating room (OR). As the criteria for performing computed tomography (CT) scans in HU patients continue to evolve, we decided to compare the outcomes of immediate CT versus direct admission to the OR and/or angio suite in a retrospective study at a government-designated regional Level I trauma center in Cali, Colombia. METHODS: During a 2-year period (2012-2013), blunt and penetrating trauma patients (≥ 15 years) with an Injury Severity Score (ISS) greater than 15 who met criteria of hemodynamic instability (systolic blood pressure [SBP] <100 mm Hg and/or heart rate >100 beats/min and/or ≥ 4 U of packed red blood cells transfused in the trauma bay) were included. Isolated head trauma and patients who experienced a prehospital cardiac arrest were excluded. The main study outcome was mortality. RESULTS: We reviewed 171 patients. CT scans were performed in 80 HU patients (47%) immediately upon arrival (CT group); the remaining 91 patients (53%) went directly to the OR (63 laparotomies, 20 thoracotomies) and/or 8 (9%) to the angio suite (OA group). Of the CT group, 43 (54%) were managed nonoperatively, 37 (46%) underwent surgery (15 laparotomies, 3 thoracotomies), and 2 (5%) underwent angiography (CT OA subgroup). None of the mortalities in the CT group occurred in the CT suite or during their intrahospital transfers. CONCLUSION: There was no difference in mortality between the CT and OA groups in HU patients. CT scan was attainable in 47% of HU patients and avoided surgery in 54% of the cases. Furthermore, CT scan was helpful in deciding definitive/specific surgical management in 46% scanned HU patients who necessitated surgery after CT. LEVEL OF EVIDENCE: Therapy/care management study, level IV.

Predictors of Positive Subxiphoid Pericardial Window in Stable Patients with Penetrating Injuries to the Precordial Region.

Background: Subxiphoid pericardial window (SPW) remains a valuable diagnostic tool for patients at risk of occult cardiac injuries. However, how to select patients that could benefit from this procedure remains unclear. We aimed to identify clinical predictors of positive SPW in patients with penetrating precordial injuries. Materials and methods: Prospective data collection of 183 patients who underwent SPW for the exclusion of penetrating cardiac injuries during 2002 - 2004 at a level I trauma centre in Cali, Colombia. Patient's demographics, clinical characteristics, and injury information were obtained. Independent predictors of positive SPW were assessed using stepwise logistic regressions. Results: There were 41 positive SPW (22.4%). Unadjusted analyses demonstrated that stab/knife wounds (OR 2.48, 95% CI 1.17-5.25, p = 0.017), single wound (OR 14.61, 95% CI 1.9-110, p = 0.009), and clinical signs of pericardiac tamponade (OR 8.52, 95% CI 3.92-18.4, p < 0.001) were associated with increased odds of positive SPW. Conversely, systolic blood pressure (0.98, 95% CI 0.96-0.99) and stable physiological index (OR 0.31, 95% CI 0.14-0.65, p = 0.002) were associated with decreased odds. In multivariable analyses, signs of pericardiac tamponade (OR 6.37, 95% CI 2.78-14.6, p < 0.001), and single injuries (OR 12.99, 95% CI 1.6-102.7, p = 0.015) remained as independent predictors of positive SPW. Conclusion: Emphasis on early recognition of the clinical signs of pericardiac tamponade could be the most important factor for the identification of occult cardiac injuries. Patients with multiple wounds to the precordial region who reached the hospital may not benefit from a SPW. However, high level of awareness is important because the incidence of occult cardiac injuries is not negligible.

Antecedentes: La ventana pericárdica subxifoidea (SPW) sigue siendo una valiosa herramienta de diagnóstico para los pacientes con riesgo de lesiones cardíacas ocultas. Sin embargo, la forma de seleccionar a los pacientes que podrían beneficiarse de este procedimiento sigue siendo poco clara. El objetivo fue identificar predictores clínicos de SPW positivos en pacientes con lesiones penetrantes precordiales. Materiales y métodos: Recolección de datos prospectivos de 183 pacientes a los que se le realizo SPW para la exclusión de lesiones cardiacas penetrantes durante el 2002 hasta 2004 en un centro de trauma de nivel I en Cali, Colombia. Se obtuvo datos demográficos del paciente, características clínicas y la lesión. Los predictores independientes de SPW positivo se evaluaron mediante regresión logística paso a paso. Resultados: Hubo 41 positivos para SPW (22,4%). Análisis no ajustados demostraron que las heridas de arma blanca/cuchillo (OR 2.48, IC 95%: 1,17 a 5,25; p = 0,017), sola herida (OR 14,61; IC del 95%: 1,9 a 110, p = 0,009), y los signos clínicos de taponamiento pericárdico (OR 8,52, IC 95% 3,92 a 18,4, p < 0,001) se asociaron con mayores probabilidades de un SPW positivo. Por el contrario, la presión arterial sistólica (CI 0,98, 95%: 0,96 a 0,99) y el índice fisiológico estable (OR 0,31; IC del 95%: 0,14 a 0,65; p = 0,002) se asociaron con una disminución de las probabilidades. En el análisis multivariable, los signos de taponamiento pericárdico (OR 6,37; IC del 95%: 2,78 a 14,6, p < 0,001), y lesiones individuales (OR 12,99, 95% CI 1,6 a 102,7, p = 0,015) permanecieron como predictores independientes del SPW positivo. Conclusión: El énfasis en el reconocimiento temprano de los signos clínicos de taponamiento pericárdico podría ser el factor más importante para la identificación de las lesiones cardíacas ocultas. Los pacientes con múltiples heridas en la región del pecho que llegaron al hospital no se pueden beneficiar de un SPW. Sin embargo, un alto nivel de conciencia es importante porque la incidencia de las lesiones cardíacas ocultas no es despreciable.

The effect of admission spontaneous hypothermia on patients with severe traumatic brain injury.

INTRODUCTION: Recent information has emerged regarding the harmful effects of spontaneous hypothermia at time of admission in trauma patients. However the volume of evidence regarding the role of spontaneous hypothermia in TBI patients is inadequate. METHODS: We performed secondary data analysis of 10 years of the Pennsylvania trauma outcome study (PTOS) database. Unadjusted comparisons of the association of admission spontaneous hypothermia with mortality were performed. In addition, full assessment of the association of hypothermia with mortality was conducted using multivariable logistic regressions reporting the odds ratios (OR) with the 95% confidence intervals (CI) and P-values. RESULTS: There were 11,033 patients identified from the PTOS with severe TBI. There were 4839 deaths (43.9%). The proportion of deaths in hypothermic patients was higher than the proportion of deaths in normothermic patients (53.9% vs. 37.4% respectively; P value<0.001). In a multivariable logistic regression model adjusted for demographics, injury characteristics, and information at admission to the trauma centre, the odds of death among patients with hypothermia were 1.70 times the odds of death among patients with normothermia (OR 1.70, 95% CI 1.50-1.93), indicating that the probability of death was significantly higher when patients arrived hypothermic at the trauma centre. CONCLUSION: The presence of spontaneous hypothermia at hospital admission is associated with a significant increase in the risk of mortality in patients with severe TBI. The benefit of maintaining normothermia in severe TBI patients, the impact of prolonged re-warming in patients with established hypothermia and the introduction of prophylactic measures to complications of hypothermia are key points that require further investigation.

Bayesian semi-parametric analysis of Poisson change-point regression models: application to policy making in Cali, Colombia.

A Poisson regression model with an offset assumes a constant baseline rate after accounting for measured covariates, which may lead to biased estimates of coefficients in an inhomogeneous Poisson process. To correctly estimate the effect of time-dependent covariates, we propose a Poisson change-point regression model with an offset that allows a time-varying baseline rate. When the nonconstant pattern of a log baseline rate is modeled with a nonparametric step function, the resulting semi-parametric model involves a model component of varying dimension and thus requires a sophisticated varying-dimensional inference to obtain correct estimates of model parameters of fixed dimension. To fit the proposed varying-dimensional model, we devise a state-of-the-art MCMC-type algorithm based on partial collapse. The proposed model and methods are used to investigate an association between daily homicide rates in Cali, Colombia and policies that restrict the hours during which the legal sale of alcoholic beverages is permitted. While simultaneously identifying the latent changes in the baseline homicide rate which correspond to the incidence of sociopolitical events, we explore the effect of policies governing the sale of alcohol on homicide rates and seek a policy that balances the economic and cultural dependencies on alcohol sales to the health of the public.

Safety of performing a delayed anastomosis during damage control laparotomy in patients with destructive colon injuries.

BACKGROUND: Recent studies report the safety and feasibility of performing delayed anastomosis (DA) in patients undergoing damage control laparotomy (DCL) for destructive colon injuries (DCIs). Despite accumulating experience in both civilian and military trauma, questions regarding how to best identify high-risk patients and minimize the number of anastomosis-associated complications remain. Our current practice is to perform a definitive closure of the colon during DCL, unless there is persistent acidosis, bowel wall edema, or evidence of intra-abdominal abscess. In this study, we evaluated the safety of this approach by comparing outcomes of patients with DCI who underwent definitive closure of the colon during DCL versus patients managed with colostomy with or without DCL. METHODS: We performed a retrospective chart review of patients with penetrating DCI during 2003 to 2009. Severity of injury, surgical management, and clinical outcome were assessed. RESULTS: Sixty patients with severe gunshot wounds and three patients with stab wounds were included in the analysis. DCL was required in 30 patients, all with gunshot wounds. Three patients died within the first 48 hours, three underwent colostomy, and 24 were managed with DA. Thirty-three patients were managed with standard laparotomy: 26 patients with primary anastomosis and 7 with colostomy. Overall mortality rate was 9.5%. Three late deaths occurred in the DCL group, and only one death was associated with an anastomotic leak. CONCLUSIONS: Performing a DA in DCI during DCL is a reliable and feasible approach as long as severe acidosis, bowel wall edema, and/or persistent intra-abdominal infections are not present.

Improving mortality predictions in trauma patients undergoing damage control strategies.

The increased use of damage control surgery in complex trauma patients requires accurate prognostic indicators. We compared the discriminatory capacity of commonly used trauma and intensive care unit (ICU) scores, including revised trauma score, injury severity scores, trauma score-injury severity scores, acute physiology and chronic health evaluations II, and clinical and laboratory parameters, on 83 consecutive trauma patients admitted to the ICU, undergoing damage control. Logistic regressions were built for mortality prediction within 30 days. Performances of the models were assessed in terms of discrimination and calibration. Areas under the receiver operating characteristic curve from the models were compared. Overall mortality was 38.5 per cent. A "clinical" model was constructed including ICU admission pH and hypothermia (≤ 35 C °) and the number of packed red blood cells during the first 24 hours. This model was adjusted for age and demonstrated better discrimination for mortality prediction (areas under the receiver operating characteristic curve = 0.8054) than injury severity score (P value = 0.049), abdominal trauma index (P value = 0.049), and acute physiology and chronic health evaluations II (P value = 0.001). There was no statistically significant difference in discrimination for mortality prediction between the "clinical" model and revised trauma score (P value = 0.4) and trauma score-injury severity score (P value = 0.4). We concluded that the combination of ICU admission pH and hypothermia and blood transfusions during 24 hours provided an excellent discriminatory capacity for mortality prediction in this complex patient population.

Policies for alcohol restriction and their association with interpersonal violence: a time-series analysis of homicides in Cali, Colombia.

BACKGROUND: Cali, Colombia, has a high incidence of interpersonal violence deaths. Various alcohol control policies have been implemented to reduce alcohol-related problems. The objective of this study was to determine whether different alcohol control policies were associated with changes in the incidence rate of homicides. METHODS: Ecologic study conducted during 2004-08 using a time-series design. Policies were implemented with variations in hours of restriction of sales and consumption of alcohol. Most restrictive policies prohibited alcohol between 2 a.m. and 10 a.m. for 446 non-consecutive days. Moderately restrictive policies prohibited alcohol between 3 a.m. and 10 a.m. for 1277 non-consecutive days. Lax policies prohibited alcohol between 4 a.m. and 10 a.m. for 104 non-consecutive days. In conditional autoregressive negative binomial regressions, rates of homicides and unintentional injury deaths (excluding traffic events) were compared between different periods of days when different policies were in effect. RESULTS: There was an increased risk of homicides in periods when the moderately restrictive policies were in effect compared with periods when the most restrictive policies were in effect [incidence rate ratio (IRR) 1.15, 90% confidence interval (CI) 1.05-1.26, P = 0.012], and there was an even higher risk of homicides in periods when the lax policies were in effect compared with periods when the most restrictive policies were in effect (IRR 1.42, 90% CI 1.26-1.61, P < 0.001). Less restrictive policies were not associated with increased risk of unintentional injury deaths. CONCLUSION: Extended hours of sales and consumption of alcohol were associated with increased risk of homicides. Strong restrictions on alcohol availability could reduce the incidence of interpersonal violence events in communities where homicides are high.

Trauma care training for National Police nurses in Colombia.

INTRODUCTION: In response to a requirement for advanced trauma care nurses to provide combat tactical medical support, the antinarcotics arm of the Colombian National Police (CNP) requested the Colombian National Prehospital Care Association to develop a Combat Tactical Medicine Course (MEDTAC course). OBJECTIVE: To evaluate the effectiveness of this course in imparting knowledge and skills to the students. METHODS: We trained 374 combat nurses using the novel MEDTAC course. We evaluated students using pre- and postcourse performance with a 45-question examination. Field simulations and live tissue exercises were evaluated by instructors using a Likert scale with possible choices of 1 to 4. Interval estimation of proportions was calculated with a 95% confidence interval (95% CI). Differences in didactic test scores were assessed using a t-test at 0.05 level of statistical significance. RESULTS: Between March 2006 and July 2007, 374 combat nursing students of the CNP were trained. The difference between examination scores before and after the didactic part of the course was statistically significant (p < 0.01). After the practical session of the course, all participants (100%) demonstrated competency on final evaluation. CONCLUSIONS: The MEDTAC course is an effective option improving the knowledge and skills of combat nurses serving in the CNP. MEDTAC represents a customized approach for military trauma care training in Colombia. This course is an example of specialized training available for groups that operate in austere environments with limited resources.

Deferred primary anastomosis versus diversion in patients with severe secondary peritonitis managed with staged laparotomies.

BACKGROUND: There is inconclusive data on whether critically ill individuals with severe secondary peritonitis requiring multiple staged laparotomies may became eligible candidates for deferred primary anastomoses (DPA). We sought to compare a protocol for DPA against a protocol for diversion in severely ill critical patients with intra-abdominal sepsis. METHODS: A retrospective cohort study was performed examining 112 patients admitted through an ICU between 2002 and 2006, with diagnosis of secondary peritonitis and managed with staged laparotomies whom required small- or large-bowel segment resections. Patients were categorized and compared according to the surgical treatment necessitated to resolve the secondary peritonitis (DPA versus diversion). Outcome measures were days on mechanical ventilation, days required in ICU, days required in hospital, incidence of fistulas/leakages, acute respiratory distress syndrome (ARDS), and mortality. RESULTS: There were 34 patients subjected to DPA and 78 to diversion. Fistulas/leakages developed in three patients (8.8%) with DPA and four patients (5.1%) with diversion (p = 0.359). ARDS was present in 6 patients (17.6%) with DPA and 24 patients (30.8%) with diversion (p = 0.149). There were 30 patients (88.2%) with DPA and 65 patients (83.3%) with diversion discharged alive (p = 0.51). There were not statistical significant differences between groups among survivors regarding hospital length of stay, ICU length of stay, and days on mechanical ventilation. CONCLUSIONS: We did not find significant differences in morbidity or mortality when we compared DPA versus diversion surgical treatment. It is feasible to perform a primary anastomosis in critically ill patients with severe secondary peritonitis managed with staged laparotomies.