A low-cost, DIY tourniquet simulator with built-in self-assessment for prehospital providers in Guatemala city.

BACKGROUND: Hemorrhage is the leading cause of preventable death after trauma. In high-income countries first responders are trained in hemorrhage control techniques but this is not the case for developing countries like Guatemala. We present a low-cost training model for tourniquet application using a combination of virtual and physical components. METHODS: The training program includes a mobile application with didactic materials, videos and a gamified virtual reality environment for learning. Additionally, a physical training model of a bleeding lower extremity is developed allowing learners to practice tourniquet application using inexpensive and accessible materials. Validation of the simulator occurred through content and construct validation. Content validation involved subjective assessments by novices and experts, construct validation compared pre-training novices with experts. Training validation compared pre and post training novices for improvement. RESULTS: Our findings indicate that users found the simulator useful, realistic, and satisfactory. We found significant differences in tourniquet application skills between pre-training novices and experts. When comparing pre- and post-training novices, we found a significantly lower bleeding control time between the groups. CONCLUSION: This study suggests that this training approach can enhance access to life-saving skills for prehospital personnel. The inclusion of self-assessment components enables self-regulated learning and reduces the need for continuous instructor presence. Future improvements involve refining the tourniquet model, validating it with first-responder end users, and expanding the training program to include other skills.

A new approach for the acquisition of trauma surgical skills: an OSCE type of simulation training program.

BACKGROUND: Worldwide, trauma-related deaths are one of the main causes of mortality. Appropriate surgical treatment is crucial to prevent mortality, however, in the past decade, general surgery residents' exposure to trauma cases has decreased, particularly since the COVID-19 pandemic. In this context, accessible simulation-based training scenarios are essential. METHODS: A low-cost, previously tested OSCE scenario for the evaluation of surgical skills in trauma was implemented as part of a short training boot camp for residents and recently graduated surgeons. The following stations were included bowel anastomosis, vascular anastomosis, penetrating lung injury, penetrating cardiac injury, and gastric perforation (laparoscopic suturing). A total of 75 participants from 15 different programs were recruited. Each station was videotaped in high definition and assessed in a remote and asynchronous manner. The level of competency was assessed through global and specific rating scales alongside procedural times. Self-confidence to perform the procedure as the leading surgeon was evaluated before and after training. RESULTS: Statistically significant differences were found in pre-training scores between groups for all stations. The lowest scores were obtained in the cardiac and lung injury stations. After training, participants significantly increased their level of competence in both grading systems. Procedural times for the pulmonary tractotomy, bowel anastomosis, and vascular anastomosis stations increased after training. A significant improvement in self-confidence was shown in all stations. CONCLUSION: An OSCE scenario for training surgical skills in trauma was effective in improving proficiency level and self-confidence. Low pre-training scores and level of confidence in the cardiac and lung injury stations represent a deficit in residency programs that should be addressed. The incorporation of simulation-based teaching tools at early stages in residency would be beneficial when future surgeons face extremely severe trauma scenarios.

Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions.

There is a critical shortage of blood available for transfusion in many low- and middle-income countries. The consequences of this scarcity are dire, resulting in uncounted morbidity and mortality from trauma, obstetric hemorrhage, and pediatric anemias, among numerous other conditions. The process of collecting blood from a donor to administering it to a patient involves many facets from donor availability to blood processing to blood delivery. Each step faces particular challenges in low- and middle-income countries. Optimizing existing strategies and introducing new approaches will be imperative to ensure a safe and sufficient blood supply worldwide.

Transgastric repair of transfixing gastroesophageal junction gunshot wound: video case report.

Managing traumatic injuries of the gastroesophageal junction (GEJ) is infrequent due to associated lesions of adjacent highly vascularized organs. Its anatomical localization in the upper abdomen makes the repair challenging to perform. A stable 23-year-old male was presented at the emergency department with two thorax gunshot wounds. Computed tomography revealed air in the periesophageal space and right hemopneumothorax with no injury of the major vessels. A chest tube was placed and the patient was transferred hemodynamically stable to the operating. Abdominal exploration identified injuries to the left diaphragm; liver lateral segment; 1-cm transfixing perforation of the GEJ and right diaphragmatic pillar. Primary repair of the GEJ was performed and patched with a partial fundoplication. The diaphragm was repaired and the liver bleeding controlled. Finally, drains and a feeding jejunostomy were placed. The patient had an uneventful early postoperative course and was discharged home on the 12th postoperative day.

Tourniquet use for civilian extremity hemorrhage: systematic review of the literature.

INTRODUCTION: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. METHODS: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. RESULTS: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. CONCLUSIONS: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

Tourniquet use for civilian extremity hemorrhage: systematic review of the literature / Uso de torniquete nas hemorragias de extremidades na população civil: revisão sistemática da literatura

ABSTRACT Introduction: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. Methods: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. Results: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. Conclusions: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

RESUMO Introdução: o uso de torniquete em extremidades (TQ) aumentou no ambiente civil; os resultados benéficos observados nas forças armadas influenciaram a aceitação por equipes de pré-hospitalar (PH) assim como pela população leiga. Esta revisão teve como objetivo analisar os tipos de TQ de extremidades usados em ambiente civil, local da lesão, indicações e complicações. Métodos: revisão sistemática foi conduzida com base em artigos originais publicados no PubMed, Embase e Cochrane seguindo as diretrizes do PRISMA de 2010 a 2019. Extração de dados focada no uso de TQ de extremidade para controle de hemorragia em ambiente civil, dados demográficos, tipo de estudo e duração, mecanismo de lesão, indicações de uso, local da lesão, tipo de TQ, tempo de TQ e complicações. Resultados: dos 1.384 artigos identificados, 14 foram selecionados para revisão com total de 3.912 vítimas civis com hemorragia nas extremidades e 3.522 colocações de extremidades TQ analisadas. A maioria foi aplicado em pacientes do sexo masculino (79%), com trauma contuso ou penetrante. Entre as indicações estavam choque hemorrágico, suspeita de lesões vasculares, sangramento contínuo e amputações traumáticas parciais ou completas. A aplicação na extremidade superior foi o local de aplicação mais comum (56%), quase todos aplicados a uma única extremidade (99%), e apenas 0,6% requereram aplicações nas extremidades superior e inferior. 80% dos TQs aplicados eram dispositivos comerciais e 20% improvisados. Conclusões: o uso de TQ em ambientes civis está associado a traumas. Os TQs comerciais são mais utilizados, com tempo menor que uma hora de uso e poucas complicações.

Impact of Personal Protective Equipment on Surgical Performance During the COVID-19 Pandemic.

BACKGROUND: The Severe Acute Respiratory Syndrome Coronavirus 2 pandemic has exposed surgeons to hazardous working conditions, imposing the need for personal protective equipment (PPE) use during surgery. The use of such equipment may affect their non-technical skills, augment fatigue, and affect performance. This study aimed to assess the surgeons' perceptions of the impact of wearing PPE during emergency surgery throughout the pandemic. METHODS: An international cooperation group conducted an anonymous online survey among surgeons from over 30 countries, to assess perceptions about the impact of PPE use on non-technical skills, overall comfort, decision making, and surgical performance during emergency surgery on COVID-19 patients. RESULTS: Responses to the survey (134) were received from surgeons based on 26 countries. The vast majority (72%) were males. More than half of the respondents (54%) felt that their surgical performance was hampered with PPE. Visual impairment was reported by 63%, whereas 54% had communication impediments. Less than half (48%) felt protected with the use of PPE, and the same proportion perceived that the use of such equipment influenced their decision making. Decreased overall comfort was cited by 66%, and 82% experienced increased surgical fatigue. CONCLUSIONS: Surgeons perceived impediment for both visibility and communication, and other non-technical skills while using PPE on emergency surgery in COVID-19 patients. Their perceived lack of protection and comfort and increased fatigue may have inhibited their optimal surgical performance. More attention should be placed in the design of more user-friendly equipment, given the possibility of a second wave of the pandemic.

Epidemiología y definiciones en infecciones quirúrgicas / Epidemiology and definitions in surgical infections

El presente trabajo forma parte de una serie de artículos de revisión cuyo objetivo es repasar conceptos fundamentales en el ejercicio quirúrgico a fin de estimular y reforzar el uso racional de los antibióticos, mediante la adquisición de herramientas relacionados con la importancia, prevención y el manejo de las infecciones quirúrgicas. En este artículo en particular se aborda la epidemiología local, regional y mundial de las infecciones quirúrgicas, su diagnóstico y su impacto social(AU)

This work is part of a series of review articles whose objective is to reassess fundamental concepts in surgical practice in order to stimulate and reinforce the rational use of antibiotics, through the acquisition of tools related to the importance, prevention and management of surgical infections. This particular article addresses the local, regional and global epidemiology of surgical infections, their diagnosis and their social impact(AU)

Manejo laparoscópico del trauma abdominal por arma blanca / Laparoscopic management of abdominal stab trauma

Objetivo: Utilizar la laparoscopia como alternativa terapéutica en pacientes con traumatismo abdominal por arma blanca. Métodos: Estudio prospectivo, la muestra estuvo representada por 30 pacientes que ingresaron por traumatismo abdominal por arma blanca, durante el periodo diciembre 2010 ­ agosto 2011. Resultados:Fueron evaluados 30 pacientes, 87% masculinos. El 64% tenían una edad comprendida entre 20 y 40 años. El tiempo de evolución fue menor a 5 horas. El 100% de los pacientes presentaban estabilidad hemodinámica. Se realizaron 30 laparoscopias sin necesidad de conversión a cirugía abierta. Conclusión: En el trauma abdominal penetrante por arma blanca, se demostró que es viable la utilización de la laparoscopia como método diagnóstico seguro y terapéutico(AU)

Objective: To use laparoscopic procedure like a therapeutic technique in patients with stab wounds abdominal trauma. Methods: Prospective study, the sample was represented by 30 patients who were admitted with stab wounds abdominal trauma, since December 2010 ­ August 2011. Results:Were evaluated 30 patients, 87% males. The 64%had an age range between 20-40 years old. The evolution time was less than 5 hours. The 100% presented hemodynamic stability.It was made 30 laparoscopic procedures, without needs to conversión to laparotomy. Conclusion: It proved that in stab wounds abdominal trauma is reliable to use laparoscopic procedures like a safe diagnostic and therapeutic method(AU)

Trauma torácico severo (TTS): experiencia en el Hospital Domingo Luciani: Caracas / Severe thoracic trauma (TTS): experience in the Hospital Domingo Luciani: Caracas

Describir la incidencia y manejo del trauma torácico severo en los Servicios de Cirugía del Hospital "Dr. Domingo Luciani" durante el período 2008-2009. Estudio retrospectivo, descriptivo, transversal. Se seleccionaron pacientes diagnósticados como traumatismo torácico en el centro, que presentaron fracturas del primer, segundo o tercer arco costal, fractura escapular, fractura esternal, ó la combinación de cualquiera de estas, desde enero de 2008 hasta diciembre 2009. Se evaluo edad, sexo, evento traumático, radiología, días hospitalización, toracotomía mínima, valores de laboratorio e ingreso a UTI. El grupo mayormente afectado fue 41 a 50 años con 31,1% y el sexo masculino (68,8%) 44% Accidentes en vehículos 50,9% de los casos evidenciaron fracturas del 2do-3er arco costal, 86,6% de los casos ameritaron drenaje torácico y 11% requirieron manejo en UTI. El TTS es una entidad seria, comprende fracturas de los 3 primeros arcos costales y/o fracturas de esternón y/o fracturas de escapula. Englobamos todas estas como TTS pues hay relación probada entre estas fracturas y traumas de alto impacto, causando lesiones potencialmente fatales. Consideramos la necesidad de redefinir el término de TTS, crear un protocolo de atención y estandarización para optimizar la atención del paciente lesionado.

To describe the incidence and management of severe thoracic trauma (STT) in General Surgery Service of Hospital "Dr. Domingo Luciani" during 2008-2009 period. A retrospective study descriptive, trasnversal. Patients diagnosed with severe thoracic trauma, (first, second or third rib fracture, sternal or scapular fracture or a combination of any), during January 2008 to December 2009. We reviewed, age, sex, traumatic event, radiologic images, hospitalization time, chest tube drainage, laboratory values and ICU admission. Group most affected was 41 to 50 years (31,1%) and males (68,8%). Traffic accidents caused 44% of trauma. In 50,9%, 2nd and 3rd rib fractures was present. 86,6% Needed chest tube dranage and 11% required ICU admission. The STT is a serious entity. It is defined by fracture of any of the 3 first ribs and/or sternal or scapular fracture. We included all these injuries as STT because there is a relationship between these fractures and high energy trauma, leading to potentially fatal consequences. We consider the need of redefining the STT term, creating an approach protocol and setting it up for optimizing the injured patient attention.

Colecistectomía transvaginal asistida por minilaparoscopia: con uso de instrumental convencional: experiencia inicial / Transvaginal cholecystectomy assisted with minilaparoscopy: with conventional instruments: initial experience

Describir la técnica quirúrgica en la colecistectomía transvaginal sin cicatriz visible con el uso de instrumental laparoscópico convencional, en el Hospital “Dr. Domingo Luciani”. Caracas. Se presenta caso de paciente femenina de 52 años de edad, con litiasis vesicular sintomática a quien se le practica colecistectomía transvaginal. Se realizó colecistectomía transvaginal sin complicaciones intraoperatorias. No se administraron analgésicos orales ni parenterales, el alta hospitalaria se dio a las 12 horas del procedimiento. Evolución satisfactoria de la paciente con un seguimiento de 30 días. La cirugía asistida por minilaparoscopia puede considerarse intermedia entre el NOTES, y la cirugía laparoscópica. El siguiente caso demuestra la factibilidad y seguridad del procedimiento realizado por cirujanos generales con entrenamiento laparoscópico y con el uso de instrumental convencional.

Describe the surgical technique in the transvaginal cholecystectomy without a scar using conventional laparoscopic instruments, in the “Dr. Domingo Luciani” Hospital. Caracas. Presents female patient 52 years old, with sintomatic gallstones who is practicing transvaginal cholecystectomy. Was performed transvaginal cholecystectomy without intraoperative complications. No analgesics were administered oral or parenteral, was discharged at 12 hours of the procedure. There was a satisfactory progress of the patient with a follow upof 30 days. Minilaparoscopy assisted surgery can be considered intermediate between NOTES, and laparoscopic surgery. The following case demonstrates the feasibility and safety of the procedure performed by general surgeons with laparoscopic training and the use of conventional instruments.

Ulcus péptico perforado: revisión de 102 casos en el Hospital Dr. "Domingo Luciani" / Perforated peptic ulcer: a review of 102 cases at the Hospital Dr. Domingo Luciani

Determinar los aspectos epidemiológicos y el tratamiento quirúrgico en los pacientes con ulcus péptico perforado atendidos en el Departamento de Cirugía General del Hospital Domingo Luciani. IVSS, Caracas. Estudio retrospectivo, transversal, descriptivo y observacional, realizado en el período correspondiente de julio de 1989 a julio de 2007, mediante la revisión de historias clínicas de pacientes intervenidos quirúrgicamente por ulcus péptico perforado. Un total de 102 pacientes fueron intervenidos por ulcus péptico perforado, en su mayoría hombres (90 por ciento), con edad promedio de 40 años. El principal síntoma fue el dolor. Los pacientes acudieron en las primeras 24 horas del inicio de los síntomas. Los antecedentes más importantes fueron el hábito tabáquico y alcohólico (62 por ciento y 56 por ciento). La localización más frecuente de la úlcera fue prepilórica (64 por ciento). La técnica de reparación quirúrgica más empleada fue la rafia de la úlcera más parche de epiplón (44 por ciento). La morbilidad fue de 27.5 por ciento y la mortalidad de 5 por ciento. El ulcus péptico perforado se presenta con mayor frecuencia en hombres fumadores. La raparación quirúrgica con rafia y parche de epiplón es segura.

Las colangioyeyunoanastomosis centrales y periféricas en el tratamiento de las estenosis altas de las vías biliares: experiencia personal de 164 casos / The central and peripheral cholangiojejunoanastomoses in the treatment of high strictures of the bile ducts: personal experience of 164 cases

Se presenta la experiencia del autor en diferentes técnicas quirúrgicas de colangioyeyunostomías y resecciones hepáticas asociadas a nivel del tercio proximal de la convergencia biliar entre 1988 y el 2004. Análisis de datos obtenidos de la experiencia personal llevada prospectivamente por el autor, en colangioyeyunostomías realizadas a nivel del tercio proximal del hepático común y en la convergencia, entre 1988 y el 2004, referidos al mismo a cuatro diferentes Instituciones: Servicio de Cirugía II del Hospital Ildemaro Salas (IVSS), Servicio de Cirugía Digestiva del Hospital Oncológico "Padre Machado", Servicio de Cirugía III del Hospital "Domingo Luciani" (IVSS) y al Instituto de Clínicas y Urología Tamanaco. Se excluyeron pacientes con estenosis bajas. Se analizaron 164 casos. 64,4 por ciento de las cirugías se hicieron por lesiones intraoperatorias ocurridas durante colecistectomías. El 33,3 por ciento se debieron a enfermedad maligna. 154 (93.9 por ciento) fueron centrales o hiliares y 10 (6,09 por ciento) fueron periféricas. Se efectuaron 32 resecciones hépáticas, 23 (71,7 por ciento) fueron resecciones menores y 9 (28,13 por ciento) fueron mayores. Se realizaron 95 (57,9 por ciento) reintervenciones de las vías biliares: 90 (94.4 por ciento) por patología benigna y 5 (5.2 por ciento) por patología maligna. La morbilidad fue de 21,9 por ciento y la mortalidad fue de 7,9 por ciento (61,5 por ciento sepsis). 88.68 por ciento de los pacientes con lesión de la vía biliar, presentaron buena evolución. Los pacientes con estenosis biliares tratadas con las diferentes técnicas quirúrgicas descritas en el presente estudio mejoraron su calidad de vida en comparación con las condiciones preoperatorias de dichos pacientes.

Uso intracorporal de zeolite (Quick Clot®) en paciente con trauma toracoambominal penetrante: reporte de primer caso en Venezuela / Intracorporal use of zeolite (Quick Clot®) in a patient with a penetrating thoracic and abdominal trauma: report of the first case in Venezuela

Presentar la primera experiencia del uso de zeolite como agente hemostático, en un paciente severamente lesionado. Paciente masculino de 28 años de edad quien ingresa a la Unidad de Politraumatizados del Hospital Domingo Luciani, 30 minutos posteriores a herida por arma de fuego de proyectiles múltiples (escopeta) en región torácica y abdominal. Ingresa hemodinámicamente inestable. Es llevado a quirófano realizándole Fase I de cirugía de control de daños. Por persistencia de sangrado se decide utilizar zeolite como agente hemostático. Control satisfactorio del sangrado, con posterior evolución favorable y egreso a los 10 días del postoperatorio. La utilización de estrategias para el control de la hemorragia como lo es el zeolite (Quick Clot®), representa una alternativa efectiva y segura para el control de la hemorragia en el paciente severamente lesionado.

Estudio comparativo entre hemorroidectomía cerrada y la técnica de Milligan-Morgan / Closed hemorroidectomy and the Milligan-Morgan technique: a comparative study

El objetivo es demostrar la eficacia y seguridad de la hemorroidectomía cerrada utilizando clamp de Buie en comparación con la hemorroidectomía abierta (Milligan-Morgan) mediante evaluación de los síntomas a las 24 horas, 1era, 4ta, y 8va semana postoperatoria en pacientes que axudieron al Hospital General del Este "Dr. Domingo Luciani". Agosto 2003-octubre 2004. Como método, estudio prospectivo, explicativo, experimental, aleatorio, simple ciego con muestra de 27 pacientes por grupos. Motivo de consulta más frecuente: dolor ano-rectal, 48 pacientes (88,89 por ciento); la enfermedad hemorroidal predominante: trombosadas 50 pacientes (93 por ciento). En el sangrado postoperatorio a las 24 horas p=0,002 (C.B:4, MM: 16 pac.); el prurito para la cuarta semana P= 0,001 (C.B: 6, M.M: 19). El el dolor fue mayor en la evolución del paciente al que se le aplicó la M.M hasta la cuarta semana (p=0,02; p<0,001; p=0,001). Las complicaciones, sangrado a las 24 horas en ambas técnicas (C.B: 3,7 por ciento y M.M: 7,4 por ciento). La media de la estancia hospitalaria: 1,18 días (P=0,21). Tiempo de cicatrización en C.B tuvo una media: 15,44 y en M.M: 27,55 días (p<0,001). Aplicando la técnica CB, la media de reintegro a sus actividades: 13,70, mientras que en M.M: 21,81 días (p<0.001). La hemorroidectomía cerrada utilizando clamp de Buie es fácil de realizar y se obtienen mejores resultados: menor dolor postoperatorio, sangrado, prurito, cicatrización y reintegro a sus actividades, aportándole mejores beneficios al paciente

Control de daños plus: reporte del primer caso en Venezuela / Damage control plus: a first case report in Venezuela

El objetivo es presentar caso clínico de control de daños, el cual se complementó con angioembolización, lo que ha sido denominado Control de Daños Plus. Paciente masculino de 27 años de edad, quien ingresó a la Unidad de Cirugía de Emergencia del Hospital Universitario de Caracas posterior a arrollamiento, inestable, con un trauma pélvico severo. Es llevado a quirófano donde se le realizó cirugía de control de daños. Por persistencia del sangrado pélvico, se le realizó arteriografía y embolización selectiva de vasos sangrantes. Evolución satisfactoria, decidiéndose su alta médica a los 45 días de postoperatorio y remitido a plan de rehabilitación. La combinación de la cirugía de control de daños y angioembolización es una estrategia factible para el control del sangrado pélvico de pacientes en Fase II, representando una alternativa poco invasiva, que debe ser tomada en cuenta