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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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.

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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.