Damage control resuscitation should be initiated as soon as possible after a traumatic event to avoid metabolic decompensation and high mortality rates. This article aims to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the “Stop the Bleed” initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the “Stop the Bleed” initiative. We identified that prehospital personnel has a better perception of hemostatic techniques such as tourniquet use than hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally, 250cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be managed using warmed blankets or the administration of intravenous fluids warmed before infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase the survival rate of severe trauma patients.

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% of these die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. The aim of this article is to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with Zone I resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.

Patients with hemodynamic instability have a sustained systolic blood pressure less or equal to 90 mmHg, a heart rate greater or equal to 120 beats per minute and an acute compromise of the ventilation/oxygenation ratio and/or an altered state of consciousness upon admission. These patients have higher mortality rates due to massive hemorrhage, airway injury and/or impaired ventilation. Damage control resuscitation is a systematic approach that aims to limit physiologic deterioration through a group of strategies that address the physiologic debt of trauma. This article aims to describe the experience earned by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia in the management of the severely injured trauma patient in the emergency department following the basic principles of damage control surgery. Since bleeding is the main cause of death, the management of the severely injured trauma patient in the emergency department requires a multidisciplinary team, which should perform damage control maneuvers aimed at rapidly control bleeding, hemostatic resuscitation and/or prompt transfer to the operating room, if required.

Jenny M Vidal et al RESUMENAntecedentes: La incidencia de trauma abdominal penetrante (TAP) ha aumentado en las últimas décadas como consecuencia de la violencia; convirtiéndose en un principal motivo de consulta en urgencias; su evaluación y manejo son desafiantes y evolutivos. Objetivo ratificar la seguridad del manejo no operatorio (MNO) de TAP y describir los resultados clínicos y las características de los pacientes con trauma abdominal penetrante a quienes se les ofreció MNO en un hospital nivel I. Diseño del estudio:Entre febrero y mayo 2016 se realizó un estudio cohorte prospectiva, incluye todos los pacientes con TAP ingresados a un hospital público nivel I. Se estableció protocolo MNO en pacientes hemodinámicamente estables, consistió en monitoreo hemodinámico y examen físico cada 4horas, tomografía según caso; estudio aprobado por comité ética institucional. Análisis estadístico: test chi-cuadrado o Wilcoxon según variable, significancia 0.05.Resultados: Se registró 46 pacientes, 91.30% (n = 42) hombres, mediana edad 25.6 ± 8.6años; 50% proyectil arma fuego (PAF) y 50% arma corto-punzante (ACP); laparotomía exploratoria 52.2% (n = 24), laparotomía innecesaria 2.2% (n = 1). El 47.82% (n = 22) MNO; de éstos, 77.27% (n = 17) por ACP y 22.72% (n = 5) por PAF. Mediana de TAS 90 (90-91), FC 83 (73-88), FR 19 (18-20); lugar lesión: toracoabdominal 50% (n = 11), 36.36% (n = 8) abdomen anterior, 13.64% (n = 3) abdomen posterior y flancos; 22.72% (n = 5) requirieron tomografía abdominal; 50% (n = 11) presentaron lesiones acompañantes; mediana estancia hospitalaria 2días (2-3); mortalidad y complicaciones a 1mes post-trauma 0% (n = 0). Conclusiones:El MNO del TAP es seguro respetando un protocolo estricto de selección y seguimiento; pacientes con TAP y sin compromiso hemodinámico fueron sometidos exitosamente a MNO y sin ninguna complicación a 30 días, independientemente de la región abdominal lesionada; la TAC contrastada abdominal no debe ser rutinaria. El hecho de evitar una cirugía innecesaria disminuye la morbi-mortalidad, costos hospitalarios; siempre y cuando sea hospital nivel I y cuente con cirujano de trauma y quirófano disponible.Palabras Claves: Cirugía innecesaria, Hemodinámicamente estables, Laparotomía exploratoria, Manejo no operatorio, Trauma penetrante de abdomen. ABSTRACTBackground: The incidence of penetrating abdominal trauma (PAT) has increased in recent decades as a consequence of the violence, becoming a main reason for consultations in emergency services. Its evaluation and management are defiant and evolve over time. The objective is to ratify the safety of the nonoperative management (NOM) of PAT, describe the clinical results and characteristics of patients with PAT who were offered NOM in a first-level hospital. Study design:This is a prospective cohort study conducted during February and May 2016. It includes all patients with PAT admitted to first-level public hospital. A NOM protocol was established in hemodynamically stable patients; hemodynamic monitoring and physical examin...

Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.