The trauma and acute care surgeon in the COVID-19 pandemic era

The World Health Organization recognized in March 2020 the existence of a pandemic for the new coronavirus that appeared in China, in late 2019, and whose disease was named COVID-19. In this context, the SBAIT (Brazilian Society of Integrated Care for Traumatized Patients) conducted a survey with 219 trauma and emergency surgeons regarding the availability of personal protective equipment (PPE) and the role of the surgeon in this pandemic by means of an electronic survey. It was observed that surgeons have been acting under inadequate conditions, with a lack of basic supplies as well as more specific equipment such as N95 masks and facial shields for the care of potential victims who may be contaminated. The latter increases the risk of contamination of professionals, resulting in potential losses in the working teams. Immediate measures must be taken to guarantee access to safety equipment throughout the country, since all trauma victims and/or patients with emergency surgical conditions must be treated as potential carriers of COVID-19

A review of ureteral injuries after external trauma

<p>Abstract</p> <p>Introduction</p> <p>Ureteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management.</p> <p>Literature review</p> <p>Eighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%.</p> <p>Conclusion</p> <p>The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.</p

O cirurgião de trauma e emergência na era da pandemia de COVID-19

A Organização Mundial de Saúde reconheceu a partir de março de 2020 a existência de uma pandemia do novo coronavírus que surgiu na China no final de 2019, e cuja doença foi denominada COVID-19. Neste contexto, a SBAIT (Sociedade Brasileira de Atendimento Integrado ao Traumatizado) realizou pesquisa com 219 cirurgiões de Trauma e de Urgências e Emergências a respeito de disponibilidade de equipamentos de proteção individual (EPI) e do papel do cirurgião nesta pandemia, por meio de formulário eletrônico. Observou-se que os cirurgiões vêm atuando em condições inadequadas, com falta de insumos básicos assim como equipamentos mais específicos, como máscaras N95 e protetores faciais, para a atenção de potenciais vítimas que estejam contaminadas. Isso eleva o risco de contaminação dos profissionais e causa decorrentes baixas na força de trabalho. Medidas imediatas devem ser adotadas para garantir o acesso aos equipamentos de segurança em todo país uma vez que, todos os pacientes vítimas de trauma e/ou portadores de doenças cirúrgicas de urgência devem ser tratados como potenciais portadores do COVID-19

Umbilical cord mesenchymal stem cells for COVID-19 acute respiratory distress syndrome: A double-blind, phase 1/2a, randomized controlled trial

Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with high mortality. Mesenchymal stem cells are known to exert immunomodulatory and anti-inflammatory effects and could yield beneficial effects in COVID-19 ARDS. The objective of this study was to determine safety and explore efficacy of umbilical cord mesenchymal stem cell (UC-MSC) infusions in subjects with COVID-19 ARDS. A double-blind, phase 1/2a, randomized, controlled trial was performed. Randomization and stratification by ARDS severity was used to foster balance among groups. All subjects were analyzed under intention to treat design. Twenty-four subjects were randomized 1:1 to either UC-MSC treatment (n = 12) or the control group (n = 12). Subjects in the UC-MSC treatment group received two intravenous infusions (at day 0 and 3) of 100 ± 20 × 106 UC-MSCs; controls received two infusions of vehicle solution. Both groups received best standard of care. Primary endpoint was safety (adverse events [AEs]) within 6 hours; cardiac arrest or death within 24 hours postinfusion). Secondary endpoints included patient survival at 31 days after the first infusion and time to recovery. No difference was observed between groups in infusion-associated AEs. No serious adverse events (SAEs) were observed related to UC-MSC infusions. UC-MSC infusions in COVID-19 ARDS were found to be safe. Inflammatory cytokines were significantly decreased in UC-MSC-treated subjects at day 6. Treatment was associated with significantly improved patient survival (91% vs 42%, P =.015), SAE-free survival (P =.008), and time to recovery (P =.03). UC-MSC infusions are safe and could be beneficial in treating subjects with COVID-19 ARDS

Perioperative Radiologic Evaluation of Patients with Difficult Abdominal Wall Defects

The complexity of abdominal defects necessitating operative repair has increased exponentially in recent years. In addition, there has been increasing adoption of advanced operative techniques, such as a variety of component separation techniques. Finally, there has been an explosion in the available prosthetic materials, both synthetic and biologic, to augment the repair. As a consequence of these factors, surgeons are currently taking on increasingly challenging abdominal wall defects than ever before. Careful preoperative imaging is crucial to every aspect of the management of these patients. Imaging aids in establishing the diagnosis, especially in patients with a large body habitus or in whom the presence of tenderness precludes an adequate clinical examination. Ultrasonography, in both the supine and standing positions and with and without the Valsalva maneuver, and computed tomography are most useful here. In the rare instance of concern for a hernia in the pregnant patient, magnetic resonance imaging might be required. Computed tomography is critical for operative planning. It can detect the presence of domain loss, necessitating a preoperative pneumoperitoneum. It also allows precise assessment of the size of the defect, relative size of the rectus abdominus muscle, and the size and state of the lateral abdominal wall musculature. This is a key step in determining the component separation technique that is ideal for the particular defect. Ultrasonography can be used intraoperatively to determine the location of the linea semilunaris for accurate placement of the initial incision in performing an endoscopic component separation. Ultrasonography and computed tomography are also critical in the detection of postoperative complications, including seromas, abscesses, and inflammatory reactions to the mesh used. Finally, ultrasonography and computed tomography are valuable in the detection of recurrence

Trauma Systems, Trauma Registries, and Prehospital Triage

Trauma systems are an integrated, hierarchical, and regionalized network of agencies, institutions, and resources aimed at full collaboration, trained, and dedicated to control, treat, and prevent deaths and permanent disability in a population, directly or indirectly related to trauma disease. The main objective of trauma systems is to maximize the effort and effectiveness of all human, material, and financial resources available. The main objective of trauma registries is to provide information for trauma systems, and that includes accurate and reliable information of the causes, circumstances, and type of injuries of the population. Access to trauma victims depends on various aspects. It will be defined by the existence of medical or paramedical services for emergency transport, type of transportation, hospital resources, and the number of victims. The flow plans and protocols will determine the referral of these patients to the definitive care. In multiple-casualty disasters, prehospital and field staff can use a simplified version of “simple triage and rapid treatment” (START). Using the “START,” patients will be classified into four groups of colors and priorities: red, yellow, green, and black. The great benefit of START is the accurate identification of severe patients who will benefit from efficient and expeditious transportation to the Specialized Trauma Centers, where victims would be assured of resources and better treatment care

Using Telemedicine in Mass Casualty Disasters

The goal of this study is to test an implementation and examine users' perceptions about the usefulness of telemedicine in mass casualty and disaster settings and to provide recommendations for using telemedicine in these settings. Ninety-two US Army Forward Surgical Team (FST) members participated in a high-fidelity mass casualty simulation at the Army Trauma Training Center (ATTC). Telemedicine was implemented into this simulation. Only 10.9% of participants chose to use telemedicine. The most common users were surgeons and nurses. Participants believed it somewhat improved patient care, attainment of expert resources, decision-making, and adaptation, but not the timeliness of patient care. Participants reported several barriers to using telemedicine in the mass casualty setting, including (1) confusion around team roles, (2) time constraints, and (3) difficultly using in the mass casualty setting (eg, due to noise and other conditions). There appear to be barriers to the use and usefulness of telemedicine in mass casualty and disaster contexts. Recommendations include designating a member to lead the use of telemedicine, providing telemedical resources whose benefits outweigh the perceived cost in lost time, and ensuring telemedicine systems are designed for the conditions inherent to mass casualty and disaster settings

Enhancing trauma education worldwide through telemedicine

Abstract Advances in information and communication technologies are changing the delivery of trauma care and education. Telemedicine is a tool that can be used to deliver expert trauma care and education anywhere in the world. Trauma is a rapidly-evolving field requiring access to readily available sources of information. Through videoconferencing, physicians can participate in continuing education activities such as Grand Rounds, seminars, conferences and journal clubs. Exemplary programs have shown promising outcomes of teleconferences such as enhanced learning, professional collaborations, and networking. This review introduces the concept of telemedicine for trauma education, and highlights efforts of programs that are utilizing telemedicine to unite institutions across the world.</p

Enhancing trauma education worldwide through telemedicine

Advances in information and communication technologies are changing the delivery of trauma care and education. Telemedicine is a tool that can be used to deliver expert trauma care and education anywhere in the world. Trauma is a rapidly-evolving field requiring access to readily available sources of information. Through videoconferencing, physicians can participate in continuing education activities such as Grand Rounds, seminars, conferences and journal clubs. Exemplary programs have shown promising outcomes of teleconferences such as enhanced learning, professional collaborations, and networking. This review introduces the concept of telemedicine for trauma education, and highlights efforts of programs that are utilizing telemedicine to unite institutions across the world