Introduction: More than half of all trauma deaths occur in the prehospital setting with low- and middle-income countries assuming the greatest burden. Coordinated prehospital responses to trauma, including layperson first responders, can reduce the mortality. Trauma first responder courses (TFRCs) in Bolivia have improved participant knowledge and confidence levels. This study aims to analyze participant baseline characteristics and postworkshop evaluations to inform future course promotion and development. Materials and methods: Trauma responders unify to empower (TRUE)-Bolivia is a 4-hour didactic and practical TFRC covering scene safety, basic airway management, bleeding control, and pelvic binding. Participants, recruited from Santa Cruz, Bolivia, completing all pre- and post-course assessments were included. Quantitative data were aggregated and analyzed in SAS v9.4 with Chi-square analyses, and qualitative data were analyzed for thematic content in Microsoft Excel. Results: A total of 269 people, with an average age of 35.4 years, participated in 18 courses. Most participants were male (n = 211/269, 78.4%) with n = 149/253 (58.9%) working in public transportation, n = 64/253 (25.3%) in medical training, and n = 40/253 (15.8%) working in other fields. Of the 246 and 205 participants who responded to the safety behavior questions, respectively, 55.7% (n = 137/246) of participants wore seat belts less than 50% of the time and 60.5% (n = 124/205) wore helmets less than half the time while on a motorcycle. On post-course evaluation, n = 118/250 (47.2%) quoted skill acquisition to be the greatest benefit of the course, n = 37/250 (14.8%) quoted helping others, and n = 64/250 (25.6%) stated a combination of the two. Suggestions for improvement included adding content on burns, head injuries, and cardiopulmonary resuscitation. Conclusion: Understanding participants’ background and incorporating feedback allowed us to tailor the course to participants’ interests while maintaining the focus on trauma prevention and initial management. To maximize course impact, a local partnership has been formed with the municipal government to provide the courses to public transportation drivers who are likely to arrive first at a scene of trauma. Clinical significance: The didactic and practical content of TRUE-Bolivia empowers participants to save lives in the prehospital setting where ambulances can take over an hour to arrive.

Aim: To discuss important interventions and techniques to control hemorrhage in trauma patients. Background: Although there have been dramatic advances in trauma care over the last two decades, there are still a significant number of patients each year who succumb to death from hemorrhagic shock. Hemorrhage due to trauma is the leading preventable cause of death in the military setting, accounting for up to 90% of potentially preventable deaths; in the civilian setting, hemorrhage is second only to neurologic injuries as a cause of death due to trauma. In April 2013, the American College of Surgeons released the Hartford Consensus, with recommendations to enhance survivability from mass casualty incidents and active shooter scenarios. One of the four reports recommended an improvement in the implementation of bleeding control to prevent death from hemorrhage in patients with traumatic injuries. Review results: Advances in hemostatic resuscitation, antifibrinolytic medications, and more rapid transport times have all decreased mortality from hemorrhage. There has also been better bystander training through the more recent “Stop the Bleed” campaign, with its emphasis on early extremity hemorrhage control, including tourniquet use in the field. While previous studies have shown a decreased mortality in patients who were transported to the hospital quicker, decreasing the time to hemorrhage control remains one of the greatest barriers to improving patient mortality. Conclusion: In this consensus, the methods of hemorrhage control are discussed for use in the prehospital setting and the emergency department. Additionally, surgical procedures are described that may enhance hemostatic control in the operating room and lead to better outcomes during and after damage control surgeries.

Aim: Few studies examine the relationship of language and surgical outcomes. Language is not included as a variable in many databases. The aim of this study was to examine the association of language and outcomes in trauma. Materials and methods: A 5-year retrospective review was performed at a level I trauma center. All adult trauma patients with a non-English primary language were matched to an English-speaking cohort by age, gender, injury mechanism, initial Glasgow coma scale (GCS), and injury severity score (ISS). Analysis included an unpaired two-tailed Student's t test for continuous variables and a Fisher's exact test for categorical variables. Results: Three hundred ninety-five non-English-speaking patients were identified. There was no difference in mortality, intubation rate, number of ventilator days, average hospital length of stay, readmission rates, or rates of nine complications, even when stratified for high (≥15) vs low (≤14) ISS. Non-English-speaking patients had a shorter average length of intensive care unit (ICU) stay (5.4 vs 6.9 days, p = 0.03), were mostly self-pay (236, 59.7% vs 127, 32.2%, p < 0.01), and were more likely to be discharged home (340, 86.1% vs 309, 78.2%, p = 0.01). Conclusion: Despite similar outcomes, non-English-speaking trauma patients left the ICU more quickly, were more likely self-pay, and more likely to be discharged home. Clinical significance: These findings raise concerns about possible disparities in trauma care for non-English speaking patients and highlight the importance of inclusion of language as a variable in patient registries and national databases. Future studies should investigate additional potentially significant socioeconomic factors.

Aim: Whole-body computed tomography (WBCT) has been used as a high-yield diagnostic tool in trauma. However, increased exposure to radiation and delay in treatment have been cited as challenges to its widespread use. We hypothesized that WBCT has at least the same radiation exposure compared to organ-selective CT (OSCT), and it does not inflict further delays in diagnosis. Materials and methods: We retrospectively review all trauma patients in whom CT scans were performed on arrival at a level I trauma center, from January 2016 to December 2017. Results: A total of 123 patients were included: 53 in the OSCT group and 70 in the WBCT group. In the OSCT group, 64.1% of the patients had penetrating trauma, and chest injuries were the most common injured body cavity (79.3%). In the WBCT group, 65.7% had blunt trauma, and head injuries were the most common (71.9%). The OSCT group required subsequent follow-up studies to rule out other injuries, which in turn did not occur in the WBCT group (47.2% vs 0%, p < 0.001). The total radiation exposure dose was higher in the OSCT group [22 mSv (IQR 6–31) vs 15.1 mSv (IQR 9.9–24.8) p < 0.001]. The median CT scan-to-diagnosis time was lower in the WBCT group [22 minutes (14–32) vs 32 minutes (21–65); p < 0.001]. Conclusion: The OSCT has the potential of missing potentially life-threatening injuries that require subsequent follow-up scans. This, in turn, would increase the patient's overall radiation exposure and potentially delay definitive surgical treatment. Trauma patients undergoing WBCT had lower total radiation exposure with no delay in diagnosis. Level of evidence: V, therapeutic.

Background: Injury in the prehospital setting is a leading cause of death worldwide, and noncommunicable diseases (NCDs) and injuries substantially burden low- and middle-income countries (LMICs). Timely and effective prehospital emergency care improves outcomes, and these systems of care have been recommended by the World Health Organization (WHO). However, there is a gap in the literature on strategies to support effective prehospital care in LMICs. Through our collaboration with Service d\'Aide Medicale d\'Urgence (SAMU), the prehospital emergency medical service (EMS) in Kigali, Rwanda, we aimed to develop and implement standardized checklists and protocols for commonly encountered emergencies and assess the initial implementation. Study design: The eight most common conditions treated by SAMU were identified through a previously established electronic registry. Protocols and checklists were drafted using established and publicly available resources from a regional EMS body in Virginia and customized using stakeholder analysis to fit the resources and setting in Rwanda. The metrics for each condition were incorporated into a single ambulance run sheet, and a 1-month pilot trial tracked checklist use and metric adherence. Results: We aimed to create eight protocols and checklists. We focused on the eight most common conditions including extremity injury, traumatic brain injury (TBI), altered mental status (AMS), hyperglycemia, hypoglycemia, postpartum hemorrhage, adult acute respiratory distress, and pediatric acute respiratory distress. Initial results showed variability in prehospital care across the different complaints and highlighted the benefits of using checklists. Subsequently, the Rwanda Ministry of Health (MOH) approved the checklists as the national standard for prehospital care. Implementation is in its initial stages with additional data to come in a later publication. Conclusion: Standardization of prehospital care is important in order to ensure patients receive optimal, evidence-based care. The program described in this study demonstrates how protocols and checklists can be implemented in the prehospital setting.

Introduction: Emergency pancreatoduodenectomy is a procedure that is indicated for the management of severe pancreaticoduodenal trauma after damage control surgery. Objectives: To present our experience of pancreaticoduodenal trauma management with emergency pancreatoduodenectomy and damage control surgery. Materials and methods: Retrospectively recorded data of patients with severe pancreaticoduodenal trauma who underwent a pancreatoduodenectomy and damage control for trauma at a high-volume trauma center. Results: In a period of 6 years, four patients (three men and one woman, median age 17.5 years, range: 16–21 years) with severe pancreaticoduodenal trauma underwent a pancreatoduodenectomy and damage control procedure (gunshot n = 4), and in a second surgical procedure underwent gastrointestinal tract reconstruction. In total, 75% incidence of surgical site infection (SSI) was reported, 25% health-care-associated pneumonia, and 50% postoperative pancreatic fistula (POPF). Intensive care unit (ICU) of 12.25 and hospital stay of 29.5 days mean and no mortality. Conclusion: An emergency pancreatoduodenectomy can be a lifesaving procedure in patients with non-reconstructable duodenopancreatic injuries. Damage control surgery in pancreaticoduodenal trauma is an alternative for management although with high risk of morbidity.

Introduction: The Yellow May Movement was created in Brazil in 2014, with only one objective, i.e., to bring society's attention to the high rates of deaths and injuries in traffic all around the world. The aim is to raise awareness toward the issue of road safety and mobilize the whole society, involving the most diverse segments. Aim: This manuscript aims to introduce the “Yellow May” Movement and provide an update of its current status and suggest future directions it should follow. Materials and methods: Between the years 2014 and 2019, data were collected using citations from the Yellow May Campaign. Results: The movement started in seven countries and has been growing every year. By 2019, the movement had more than 3,000 campaign actions in 28 countries. The campaign's reach on social media has risen exponentially over the last 5 years, reaching more than 444,000 website views in 2019. The number of partners around the world has also risen. Conclusion: The movement has increased every year changing our consciousness and the way we perceive mobility and may be an embryo for public policy in countries with little tradition of trauma prevention.

Introduction: Traumatic degloving injuries consist of detachment of skin and subcutaneous tissue from the underlying fascia and muscles due to high-energy shearing forces. Open degloving injuries of the torso are poorly described, have many different presentations, and their full extension is difficult to assess. This article aims to describe this patient population (soft tissue injuries, associated trauma, treatment particularities, morbidity, and mortality), alerting emergency surgeons to this entity. Materials and methods: This study is a case series of blunt trauma patients presenting open degloving injuries of the torso. After institutional research and ethics board approval, data were collected through electronic medical records at the Hospital Universitário do Oeste do Paraná, Cascavel–Paraná, Brazil. The degloving injuries were classified according to the involved torso segment. The treatment of the degloved area was divided as contamination control, infection and ischemia control, and reconstruction techniques. The data were organized and displayed in tables and text. Results: Six patients were identified, with age of 36.5 ± 7.5 years, and injury severity score (ISS) of 31.3 ± 16.7. All presented hypovolemic shock on admission and shearing forces as trauma mechanism. In four patients, degloved area involved pelvis/perineum, one patient injured the anterior wall of the abdomen, and one the back of thoracolumbar area. All patients had associated injuries. The number of surgeries for treatment of soft tissue injuries was 5.1 ± 2.6. Hospital stay was an average of 40.2 days. Two patients died. Conclusion: Patients with open degloving injury of the torso have high ISS. Morbidity and mortality may occur due to the associated lesions or soft tissue lesions. Surgery requirements, the high number of procedures, and long hospital length of stay reinforce the complexity of the treatment and the need for adequate therapeutic planning.

Background: Due to the high number of women injured by gender violence, it is essential to consolidate an action plan that allows to prevent, reduce, and repair this type of violence. Our objective is to analyze the impact of the national strategy for the eradication of violence against women carried out in Spain in the years 2013 to 2016. Study design: This study presents a descriptive analysis of the data collected in the national registries on gender violence from January 2011 to December 2018 and the comparison of results before and after the implementation of the strategy. Results: The average number of annual victims in the years prior to the implementation of the program was 30,744 (DS 2259.91) and 30,147 (DS 1,610.79) after its application (p = 0.790) with an average annual deaths due to gender violence of 56.5 (DS 7.77) and 49.5 (DS 2.12), respectively (p = 0.344). The average number of complaints for gender violence in the initial period were 131,239.5 (DS 3906.77) with the average of complaints by third parties of 2,585 (DS 569.93). In the period after the plan, the average number of total complaints was 229,495 (DS 88436.43) (p = 0.257), with the average number of complaints by third parties being 7026.5 (DS 1265.01) (p = 0.45). The percentage of convictions for violence against women during the first period was 59.5 and 68.94% in the subsequent period (p = 0.028). Conclusion: Strategies against gender violence in Spain have obtained an ostensible increase in public awareness of the problem and an increase in the number of complaints and convictions. However, the number of victims and mortality due to gender violence has not achieved a statistically significant decrease. In view of these data, it is necessary to continue insisting on the application of new strategies to achieve a greater impact on this important social problem.

Introduction: Massive transfusion (MT) is defined as the administration of ≥10 U of packed red blood cells (PRBCs) in 24 hours. Alternative definitions have been proposed which have not been compared regarding mortality or multiorgan failure (MOF). The objective is to compare the discriminative ability of proposed definitions of MT concerning mortality and MOF. Materials and methods: Patients with trauma team activation in a level I trauma hospital of Cali, Colombia, between 2015 and 2017 were included. Demographics and trauma characteristics were evaluated. The following MT definitions were measured: ≥50 U of total blood products in 24 hours (MT50-24), ≥6 U of PRBCs in 6 hours (MT6-6), ≥10 U of PRBCs in 6 hours (MT10-6), a combination of MT10-24 plus MT6-6 (MTcombi), ≥5 U of PRBC in 4 hours (MT5-4), ≥4 U of PRBC in 1 hour (MT4-1), and the critical administration threshold (CAT) which is 3 U of PRBCs in 1 hour. The operative characteristics were calculated for each definition. Multiorgan failure was defined as a sequential organ failure assessment (SOFA) score of ≥6 points. Results: We included 394 subjects. A total of 266 (67%) received at least 1 unit of PRBCs in the first 24 hours, from which trauma mechanism was penetrating in 84.6%; 86.8% were male, with a median [interquartile range (IQR)] age of 29 (22–38) years and injury severity score (ISS) of 25 (25–29). A positive ABC score for massive transfusion score was positive in 87.2%. Sensitivity and specificity were as follows: multiorgan failure: MT10-24 18.6% and 98.2%, MT6-6 34.3% and 91.3%, MTcombi 38.2% and 91.3%, MT5-4 38.2% and 92.2%, and MT4-1 48% and 78.4%. Mortality: MT10-24 40.6% and 92.2%, MT6-6 62.7% and 82.6%, MTcombi 64.4% and 80.6%, MT5-4 61% and 81.1% and MT4-1 71.1% and 68.6%. Conclusion: All definitions showed an association with a higher risk of mortality and MOF, generally with low sensitivity but high specificity. The MT definition of ≥10 PRBCs in 24 hours should be revised.

Introduction and goal: The implementation of trauma quality improvement programs requires high-quality data to identify opportunities for improvement. The aim of this research is to evaluate the quality of data considered basic to identify opportunities for improvement in the care processes registered in the hospitals that are part of the Province of Buenos Aires Trauma Network, during the year 2018. Materials and methods: Retrospective observational study analyzing the quality of 48 fields pertaining to 4,489 cases with trauma medical history entered in the trauma registry (TR) of fundación trauma (FT) in 13 hospitals during 2018. The data were distributed and analyzed in 6 categories: trauma event; prehospital care; patient's data; hospital admission and care process; vital signs, comorbidities and injuries; and trauma indexes and scores. Results: When analyzing the 48 fields, an average of completeness of 64% was found. Of the 13 analyzed hospitals, the one with the best data quality had a completeness average of 92%; and the one with the lowest quality had an average of 58%. Considering the average of completeness, the categories are distributed in the following order: (1) patient's data, 97.5%; (2) indexes and scores, 71.2%; (3) trauma event, 68.6%; (4) vital signs, comorbidities and injuries, 66.5%; (5) hospital admission and care process, 60%; and (6) prehospital care, 38.6%. Conclusion: The distribution of complete data presents a wide variation between the analyzed categories, having at one end the patient's data and the injuries; and on the other hand, the procedures and complications. In general terms, we can say that, even though there is information available to work on the implementation and monitoring of quality improvement strategies, the quality of the information for the development of scores and improvement strategies presents as a challenge itself. In this sense, it is necessary to have specific strategies aimed at improving the quality of information in medical records.

Aim: Minimally invasive surgery (MIS) is becoming widely accepted as a useful diagnostic and therapeutic modality in acute trauma management. This study aims to describe the experience of a Brazilian trauma center with laparoscopic procedures for the management of abdominal trauma over a two-decade period. Materials and methods: A retrospective analysis was conducted on all patients undergoing laparoscopy following blunt and penetrating abdominal trauma and admitted to a single trauma center from October 1997 to January 2019. Data on subjects’ demographics, baseline presentations, diagnostic and therapeutic laparoscopic procedures performed, and outcomes were reported. Results: Laparoscopic surgical exploration was performed on 225 patients presenting with abdominal trauma during the study period, including 28 (12.4%) patients sustaining blunt and 197 (87.6%) penetrating injuries, primarily stab wounds (68%; n = 153). The mean age was 30.2 ± 12.9 years (range 7–81) and the majority accounted for males (84%; n = 189). Negative laparoscopy and nontherapeutic procedures were recorded in 71 (31.5%) and 34 (15%) cases, respectively. After positive findings in diagnostic laparoscopic, 55 (24.4%) patients underwent exclusive minimally invasive repair and the remaining 65 cases (28.8%) required conversion to open surgery, thus avoiding 160 unnecessary laparotomies. No missed injuries were reported. The overall morbidity rate was 8.4%, with only 1.7% of complications being classified as severe, including two demises. Conclusion: Diagnostic and therapeutic laparoscopy are an appropriate management in selected patients sustaining both blunt or penetrating abdominal trauma, with potentially improved outcomes compared with traditional approaches. Further research shall provide quality evidence for the establishment of standardized protocols to guide indications and limits of this technique in trauma practice.

Introduction: Trauma is the leading cause of death in children globally. Approximately, 10% of admissions to pediatric intensive care units (PICUs) are trauma related. Establishing a common method of evaluating outcomes in PICUs is a critical factor in improving the quality of patient care. In the pediatric population, there is no certainty whether critical illness scores or trauma scores are the best predictors of mortality. Materials and methods: Retrospective review of the trauma registry of the PICU of eliminar Ricardo Gutiérrez Children's Hospital, which includes deidentified data from all admissions to the PICU between 2005 and 2017. The scores evaluated were pediatric trauma score (PTS), injury severity score (ISS), new injury severity score (NISS), revised trauma score (RTS), trauma injury severity score (TRISS), and pediatric index of mortality (PIM2). Results: In total, 360 patients (56% male) with an average age of 60 months, 30 to 116 (median, interquartile range) were included. In total, 73% suffered traumatic brain injury, 26% had injuries to the extremities, 19% to the chest, 14% to the abdomen, 6% to the pelvis, and 5% to the spine or spinal cord. In total, 43% had injuries in one body region, 29% in two regions, and 28% in more than two. The most frequent combination was a brain injury with an injury to the extremities (16%). The main causes of trauma were falls (42%), followed by vehicular collision against pedestrians (20%) and injuries to motor passengers (7%). The overall mortality was 6.0%. We evaluated the discriminative ability of each score using receiver operating characteristic curve (ROC) with mortality as the outcome of interest (area under the curve and 95% CI): NISS 0.749 (0.63–0.86), ISS 0.788 (0.69–0.89), PTS 0.899 (0.84–0.96), RTS 0.912 (0.84–0.98), TRISS 0.933 (0.86–0.99), and PIM2 0.973 (0.93–1.0). Conclusion: In this sample from a single institution, the PIM2 score had a superior discrimination ability than trauma scores using mortality as the outcome variable. These results need to be tested in a study with a larger population sample.

This report is a personal reflection on four decades of trauma, remembering legends of the past, focusing on the metamorphosis of trauma surgery, and speculating on its future.