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Background Minimal aortic injury (MAI), a subtype of acute traumatic aortic injury, is being increasingly recognized with better imaging techniques. Given conservative management, the role of follow-up imaging albeit important yet has to be defined. Methods All trauma chest computed tomography angiographies (CTAs) at our center between January 2012 and January 2019 were retrospectively reviewed for presence of MAI. MAIs were generally reimaged at 24 to 72 hours and then at a 7- and 30-day interval. Follow-up CTAs were reviewed for stability, progression, or resolution of MAI, along with assessment of injury severity scores (ISS) and concomitant injuries, respectively. Results A total of 17,569 chest CTAs were performed over this period. Incidence of MAI on the initial chest CTA was 113 (0.65%), with 105 patients receiving follow-up CTAs. The first, second, third, and fourth follow-up CTAs were performed at a median of 2, 10, 28, and 261 days, respectively. Forty five (42.9%), 22 (21%), 5 (4.8%), and 1 (1%) of the MAIs were resolved by first, second, third, and fourth follow-up CTAs. Altogether, 21 patients showed stability (mean ISS of 16.6), and 11 demonstrated improvement (mean ISS 25.8) of MAIs. Eight patients had no follow-up CTA (mean ISS 21). No progression to higher-grade injury was observed. Advancing age decreased the odds of MAI resolution on follow-up. A possible trend (p-value 0.22) between increasing ISS and time to resolution of MAIs was noted. Conclusion In our series of acute traumatic MAIs diagnosed on CTA imaging, there was no progression of injuries with conservative management, questioning the necessity of sequential follow-up imaging.

COVID-19 has impacted how we deliver care to patients, and much remains unknown regarding optimal management of respiratory failure in this patient population. There are significant controversies regarding tracheostomy in patients with COVID-19 related to timing, location of procedure, and technique. In this narrative review, we explore the recent literature, publicly available guidelines, protocols from different institutions, and clinical reports to provide critical insights on how to deliver the most benefit to our patients while safeguarding the health care force. Consensus can be reached that patients with COVID-19 should be managed in a negative-pressure environment with proper personal protective equipment, and that performing tracheostomy is a complex decision that should be made through multidisciplinary discussions considering patient prognosis, institutional resources, staff experience, and risks to essential health care workers. A broad range of practices exist because there is no conclusive guidance regarding the optimal timing or technique for tracheostomy.

Objective To compare early outcomes and 24-hour survival after LVR with the novel polyethylene glycol-20k-based crystalloid (PEG-20k), WB, or hextend in a preclinical model of lethal HS. Background Posttraumatic HS is a major cause of preventable death. Current resuscitation strategies focus on restoring oxygen-carrying capacity (OCC) and coagulation with blood products. Our lab shows that PEG-20k is an effective non-sanguineous, LVR solution in acute models of HS through mechanisms targeting cell swelling-induced microcirculatory failure. Methods Male pigs underwent splenectomy followed by controlled hemorrhage until lactate reached 7.5-8.5 mmol/L. They were randomized to receive LVR with PEG-20k, WB, or Hextend. Surviving animals were recovered 4 hours post-LVR. Outcomes included 24-hour survival rates, mean arterial pressure, lactate, hemoglobin, and estimated intravascular volume changes. Results Twenty-four-hour survival rates were 100%, 16.7%, and 0% in the PEG-20k, WB, and Hextend groups, respectively (P = 0.001). PEG-20k significantly restored mean arterial press, intravascular volume, and capillary perfusion to baseline, compared to other groups. This caused complete lactate clearance despite decreased OCC. Neurological function was normal after next-day recovery in PEG-20k resuscitated pigs. Conclusion Superior early and 24-hour outcomes were observed with PEG-20k LVR compared to WB and Hextend in a preclinical porcine model of lethal HS, despite decreased OCC from substantial volume-expansion. These findings demonstrate the importance of enhancing microcirculatory perfusion in early resuscitation strategies.

The Joint Commission has established medication reconciliation as a National Patient Safety Goal, but it has not been studied much in trauma even though it is integral to safe patient care. This article reviews the existing medication reconciliation strategies and their applicability to the trauma setting. To perform medication reconciliation, hospitals use a variety of strategies including pharmacists or pharmacy technicians, electronic medical record tools, and patient-centered strategies. All of these strategies are limited in trauma. Subpopulations such as injured children, the elderly, and those with brain trauma are particularly challenging and are at risk for suboptimal care from inaccurate medication reconciliation. Further research is necessary to create a safe and efficient system for trauma patients.

Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes.We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing.Over 12 months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities.Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.

The extended focused assessment with sonography for trauma (eFAST) ultrasound examination is an essential step in the initial assessment of trauma patients. Its accuracy depends on the ability to acquire high-quality ultrasound images, and we hypothesized that increasing BMI was associated with increased odds for incorrect eFAST. All adult blunt trauma activations at a high-volume urban trauma center in 2016 that underwent eFAST and CT chest, abdomen, and pelvis were included (n = 446). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the eFAST were calculated with CT results as reference. The association of BMI and eFAST accuracy was determined using univariate analyses. Sensitivity and specificity of the eFASTexamination were 27.1 per cent and 91.7 per cent, respectively, with an overall 76.2 per cent accuracy. At BMI 36 kg/m2, the odds of having incorrect eFAST results increased to odds ratio (OR) = 1.85 (95% confidence interval, 1.03–3.32; P = 0.05). For those with BMI > 40 kg/m2, the OR increased to OR = 3.12 (95% confidence interval, 1.45–6.69; P = 0.01). One-third of patients in this study were obese or morbidly obese. The latter was associated with increased odds for incorrect eFAST results, particularly the abdominal examination component.

Patient physiology and crash characteristics are essential components of field triage for motor vehicle crashes. We aimed to identify prehospital information that predicted high injury severity or critical patient condition on hospital arrival. The association of demographics, shock index (SI), Glasgow Coma Scale, and 10 crash characteristics of trauma activations for motor vehicle crashes with injury severity score (ISS) ≥ 16 and a composite of hypotension, need for blood transfusions, or immediate operation was determined using univariate and multivariate analyses. A total of 133 of 498 patients (27%) had ISS ≥ 16; SI ≥ 0.9, Glasgow Coma Scale ≤, 8, speed ≥ 55 mph, seatbelt use, airbag deployment, ambulatory patient, severe vehicle damage, ejection, and extrication were associated with ISS ≥ 16. Only abnormal SI and high speed remained independent predictors for ISS ≥ 16 with Odds Ratio (OR) = 10.76 (95% confidence interval (CI), 1.14-101, P = 0.04) and OR = 10.37 (95% CI, 1.48–72.93, P = 0.02), respectively. SI ≥ 0.9 predicted the composite outcome with OR = 5.92 (95% CI, 2.32–15.08, P < 0.01). Many commonly reported crash characteristics did not predict clinically important outcomes. Improvements in road and vehicle safety may be resulting in lower injury severity despite major crash mechanisms.

Prison violence is a complex and multifaceted phenomenon. While a great deal of research has been conducted in male samples, very few studies are dedicated to understanding violence committed by female offenders. Two constructs that have emerged as important predictors of violence are psychopathy and impulsivity. These constructs may be an important line of inquiry due to the close association between psychopathy, impulsivity, and violence. In a sample of 166 female offenders, we used the 3-facet model of psychopathy and 3-factor model of trait impulsivity with the goal to statistically explain two types of prison violence: official reports of violent misconducts over a 12-month period, and self-report of deliberately instigating a violent altercation. We conducted three separate regression models to test the independent contribution of psychopathy and impulsivity, as well as accounting for the overlap between psychopathy and impulsivity. When impulsivity and psychopathy were not competing within the same model, affective and behavioral psychopathic traits, and nonplanning impulsiveness predicted violent misconducts. However, when accounting for impulsivity and psychopathy within the same model, only affective psychopathic traits remained significant. When predicting if an offender deliberately started a violent altercation, separate statistical models showed affective and interpersonal psychopathic traits, and nonplanning impulsiveness were significant. When competing for variance within the same statistical model, only affective and interpersonal psychopathic traits remained as significant predictors. This suggests an overlap between psychopathic traits and nonplanning impulsivity when understanding violent misconducts in female offenders, while affective psychopathic explains female prison violence, regardless of impulsivity.

The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study.Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study.Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively.This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Research on sex differences in the association of psychopathy with fluid intelligence is limited, and it remains unknown if fluid intelligence plays a meaningful role in explaining the psychopathy–aggression link for men and women. The present study aimed to test for sex differences in the relation between the four-facet model of psychopathy and intelligence, and to assess whether fluid intelligence moderates the link between psychopathy and aggression. In a community sample of men ( n = 356) and women ( n = 196), we assessed psychopathy using the Psychopathy Checklist: Screening Version (PCL:SV), fluid intelligence using the Raven’s Progressive Matrices, and types of aggression using the Aggression Questionnaire (AQ). Hierarchical regressions showed that the psychopathy lifestyle facet was negatively associated with intelligence and there were no sex differences. Our analyses for types of aggression revealed sex differences and similarities. For both men and women, total AQ scores were predicted by higher antisocial facet scores. Lower intelligence moderated the link between higher antisocial facet scores and aggression in men, but not for women. Physical aggression in women was associated with higher interpersonal, affective, and antisocial facet scores, whereas for men, it was only associated with higher antisocial facet scores. Verbal and indirect aggression were associated with higher intelligence in both men and women. For men only, higher antisocial facet scores were associated with verbal and indirect aggression. Higher intelligence moderated the link between the lifestyle facet and indirect aggression for women, whereas for men, it moderated the link between the affective facet and indirect aggression. This study further highlights sex differences in mechanisms of psychopathy-related aggression, which need to be considered in the development of violence interventions and risk assessment.

The Walker Dip refers to the cycle of the improvement of care for the battle injured soldier over the course of a conflict, followed by the decline in the skills needed to provide this care during peacetime, and the requisite need to relearn those skills during the next conflict. As the operational tempo of the conflicts in Afghanistan and Iraq has declined, concerns have arisen regarding whether US military surgeons are prepared to meet the demands of future conflicts. This problem is not unique to the US military, and allied nations have taken creative steps to address the Walker Dip in their own surgical communities. A panel entitled "Military and Civilian Trauma System Integration: Where Have We Come; Where Are We Going and What Can We Learn from Our International Partners" at the 2018 American Association for the Surgery of Trauma meeting brought together a cadre of civilian and military surgeons with experience in this area. The efforts described involved the creation of a new trauma training program in Doha, Qatar, the military civilian partnership in the Netherlands, and the steps taken to address the deficit of penetrating trauma in Sweden. This article focuses on the lessons that can be learned from our allied partners to assure readiness for deployment among military surgeons. LEVEL OF EVIDENCE: Economic and Value Based Evaluations, level V.

Background Most triage guidelines for blunt chest wall trauma focus on advanced age and multiple fractured ribs to indicate a high-risk patient population that should be admitted to an intensive care unit (ICU). Overly sensitive ICU admission criteria, however, may result in overutilization of resources. We revised our rib fracture triage guideline to de-emphasize age and number of rib fractures, hypothesizing that we could lower ICU admission rates without compromising outcomes. Methods Patients admitted to our level 1 trauma center over 9 months after the institution of the revised guideline (N = 248) were compared with those admitted over 6 months following the original guideline (N = 207) using Fisher’s exact and Wilcoxon-Mann-Whitney tests, as appropriate. Univariate followed by multivariate analyses were performed to determine risk factors for complications. Results The ICU admission rate significantly decreased from 73% to 63% ( P = .02) after the institution of the revised guideline, despite an increase in the patient’s age and injury acuity of the cohort. There was no significant difference in respiratory complications, unplanned ICU admission rates, and overall mortality. Poor incentive spirometer effort (750 mL or less) and dyspnea in the trauma bay were the strongest predictors of an adverse composite outcome and prolonged hospital length of stay. Discussion A revised rib fracture triage guideline with less emphasis on the patient’s age and the number of fractured ribs safely lowered ICU admission rates. Poor functional status rather than age and anatomy was the strongest predictor of complications and prolonged hospital stay.

Background Current evidence-based screening algorithms for blunt cerebrovascular injury (BCVI) may miss more than 30% of carotid or vertebral artery injuries. We implemented universal screening for BCVI with computed tomography angiography of the neck at our level 1 trauma center, hypothesizing that only universal screening would identify all clinically relevant BCVIs. Methods Adult blunt trauma activations from July 2017 to August 2019 underwent full-body computed tomography scan including computed tomography angiography neck with a 128-slice computed tomography scanner. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of common screening criteria. We determined independent risk factors for BCVI using multivariate analyses. Results A total of 4,659 patients fulfilled the inclusion criteria, 2.7% (n = 126) of which had 158 BCVIs. For the criteria outlined in the American College of Surgeons Trauma Quality Improvement Program Best Practices Guidelines, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 72.2%, 64.9%, 6.8%, 98.5%, and 65.2%, respectively; for the risk factors suggested in the more extensive expanded Denver criteria, they were 82.5%, 50.4%, 5.3%, 98.9%, and 51.4%, respectively. Twenty-three percent (n = 14) of patients with BCVI grade 3 or higher would not have been captured by any screening criteria. Cervical spine, facial, and skull base fractures were the strongest predictors of BCVI with odds ratios and 95% confidence intervals of 8.1 (5.4-12.1), 5.7 (2.2-15.1), and 2.7 (1.5-4.7), respectively. Eighty-three percent (n = 105) of patients with BCVI received antiplatelet agents or therapeutic anticoagulation, with 4% (n = 5) experiencing a bleeding complication, 3% (n = 4) a BCVI progression, and 8% (n = 10) a stroke. Conclusion Almost 20% of patients with BCVI, including a quarter of those with BCVI grade 3 or higher, would have gone undiagnosed by even the most extensive and sensitive BCVI screening criteria. Implementation of universal screening should strongly be considered to ensure the detection of all clinically relevant BCVIs. Level of evidence Diagnostic study, level III.

Trauma is a major problem in the United States. Mortality from trauma is the number one cause of death under the age of 45 in the United States and is the third leading cause of death for all age groups. There are approximately 200,000 deaths per year due to trauma in the United States at a cost of over $671 billion in combined healthcare costs and lost productivity. Unsurprisingly, trauma accounts for approximately 30% of all life-years lost in the United States. Due to immense development of trauma systems, a large majority of trauma patients survive the injury, but then go on to die from complications arising from the injury. These complications are marked by early and significant metabolic changes accompanied by inflammatory responses that lead to progressive organ failure and, ultimately, death. Early resuscitative and surgical interventions followed by close monitoring to identify and rescue treatment failures are key to successful outcomes. Currently, the adequacy of resuscitation is measured using vital signs, noninvasive methods such as bedside echocardiography or stroke volume variation, and other laboratory endpoints of resuscitation, such as lactate and base deficit. However, these methods may be too crude to understand cellular and subcellular changes that may be occurring in trauma patients. Better diagnostic and therapeutic markers are needed to assess the adequacy of interventions and monitor responses at a cellular and subcellular level and inform clinical decision-making before complications are clinically apparent. The developing field of metabolomics holds great promise in the identification and application of biochemical markers toward the clinical decision-making process.

This review focuses on pitfalls and lessons learned during the development, implementation, and sustainability of hospital community-based youth violence prevention program. In the USA, homicide is the third leading cause of death among youth aged 10–24. The re-injury rate seen at Virginia Commonwealth University Trauma center (VCU-TR) is comparable to the nationally observed rate of 10 to 50%. VCU-TR, along with several other Trauma Centers, has taken an active role in the development of hospital community-based youth violence prevention programs. The efforts have been effective in reducing recidivism and the risks of violence. Significant pitfalls can be avoided in the development and sustainability of an evidence-based, collaborative, hospital community-based youth violence prevention programs. This review highlights the effectiveness of hospital community-based violence prevention programs in reducing the risks of re-injury. There are significant pitfalls to avoid both internal within the institution as well as external with the community partners.

Panamerican Trauma Society was born 30 years ago with the mission of improving trauma care in the Americas by exchange of ideas and concepts and expanding knowledge of trauma and acute illness. The authors, immediate-past leaders of the organization, review the evolution of this assembly of diverse cultures and nationalities. How to cite this article Ivatury RR, Aboutanos M. Panamerican Trauma Society: The First Three Decades. Panam J Trauma Crit Care Emerg Surg 2017;6(2):90-123.

BackgroundAccurate medication reconciliation in trauma patients is essential but difficult. Currently there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS) based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.MethodsPlasma samples were collected from 356 patients who provided informed consent including-10 healthy controls, 19 known positive or negative controls and 327 trauma patients over 65 years of age who were evaluated at our large, urban Level 1 Trauma Center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage was compared with LCMS results to determine overall accuracy, sensitivity, specificity and positive and negative predictive values (PPV, NPV) of the assay.ResultsOf 356 patients, 39 were on DOACs (10.96%): 21 were on Apixaban, 14 on rivaroxaban and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.06%, (PPV 92.50% and NPV 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.11% (PPV 86.36% and NPV 99.40%). There were three false positive results and two false negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.ConclusionsThis LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.Study type: diagnostic testBasic Science paper: therefore does not require a level of evidence.

Psychopathy has been long associated with aggression. However, few studies have looked at differences between men and women. Studies that do exist demonstrate that psychopathy differentially relates to aggression in men and women, and indicate that environmental factors may play a significant role in influencing these associations. A key environmental factor is a history of lifetime physical abuse (LPA), which has been linked to aggressive behavior in both men and women. The aim of the present study was to test if psychopathy differentially predicted physical, verbal, and indirect aggression in men and women, and if these associations were moderated by LPA. In a large community sample of men (n=369) and women (n=204) we assessed the 4-facet model of psychopathy (Interpersonal, Affective, Lifestyle, Antisocial) with the Psychopathy Checklist: Screening Version (Hart et al., 1995), LPA with the Addiction Severity Index (First et al., 1996), and self-report aggression with the Aggression Questionnaire (Buss & Warren, 2000). Results revealed sex differences and similarities. Physical aggression was associated with the affective facet of psychopathy in both men and women, though in different directions based on the moderating effects of LPA. Verbal aggression was associated with higher antisocial facet scores and LPA for men and not women. Lastly, indirect aggression was associated with the antisocial facet of psychopathy for men, and the interpersonal facet for women, and these associations were not moderated by LPA. In women, low antisocial facet scores and no LPA were found to be protective for indirect aggression. These results show that LPA and psychopathy generally increase the risk of aggression, but the interaction between LPA and psychopathy differentiates the risk of aggression forms for men and women. These sex differences highlight the need for female-responsive interventions to target sex-specific risk factors for aggressive behavior.

Fifty percent of women killed in intimate partner violence (IPV) were seen by a health care provider within a year of their death. As guest speaker to Virginia Commonwealth University Trauma Center (VCU-TC), Dr. James Davis (Western Trauma Association past president) challenged VCU-TC to develop a hospital-based IPV program. This research examines the development and impact of an integrated hospital/VCU-TC-based IPV program.The IPV survey was carried out to determine need for training and screening. Hospital forensic nurse examiners case logs were evaluated to determine IPV prevalence. An integrated IPV program-Project Empower was developed, consisting of staff education, patient screening, victim crisis fund, and interdisciplinary sexual assault/domestic violence intervention team. Between 2014 and 2018, patients admitted with an IPV consult to Project Empower were entered into a secure database capturing demographics, mechanisms, income data, and social determinants of risk. Program feasibility was evaluated on patient engagement via screening and case management. Program impact was evaluated on crisis intervention, safety planning, and community referral.Forensic nurse examiner data and IPV survey evaluation noted 20% IPV prevalence and lack of IPV screening and training. The IPV patients (N = 799) were women (90%), unmarried (79%) and African-American (60%). Primary mechanisms were firearm (44%) or stabbing (34%). Survivors were perpetrated by a cohabiting (42%) or dating partner (18%). Monthly income averaged US $622. Forty percent had no health insurance. Advocates provided 62% case management. Survivors received victim crisis funds (16%), safety planning (68%), crisis intervention (78%), sexual and domestic violence education (83%), and community referral (83%). Within 5 years, 35 (4%) were reinjured and seen in the emergency department. Thirty-one (4%) were readmitted for IPV-related injuries. Two deaths were attributed to IPV.Critical call for hospital-based IPV intervention programs as a priority for trauma centers to adopt cannot be underestimated but can be answered in a comprehensive integrated model.Therapeutic, level I.

BACKGROUND Previous ex vivo studies have shown that polyethylene glycol-20,000 Da (PEG-20k), a novel synthetic polymer that is highly effective for resuscitation, has a hypocoagulable effect on human blood. This study's objective was to determine the in vivo effects of PEG-20k-based resuscitation solutions on coagulation and platelet function in a porcine model of hemorrhagic shock. METHODS Anesthetized pigs underwent controlled hemorrhage until the lactate reached 7 mmol/L or 50% to 55% of their estimated blood volume was removed. A laparotomy was performed to simulate tissue injury. Low volume resuscitation (LVR) was given with fluorescein isothiocyanate-labeled 10% PEG-20k solution (100 mg/mL) or Lactated Ringers, both delivered at volumes equal to 10% of the estimated blood volume (n = 5). Thromboelastography was performed after surgery (baseline), after hemorrhage, and 15 minutes, 120 minutes, and 240 minutes postresuscitation. Hemoglobin was measured to determine changes in plasma volume. Plasma PEG-20k concentration was measured by indicator dilution. RESULTS Pigs given PEG-20k survived 2.6-fold longer than controls (p < 0.001) and had a significant increase in plasma volume demonstrated by the sustained drop in hemoglobin, relative to controls. Pigs resuscitated with LR died from hypotension an average of 90 minutes after resuscitation compared to the PEG-20k pigs, which all survived 240 minutes and were then euthanized with normal blood pressure and lactate. Administration of PEG-20k primarily decreased the thromboelastograph maximum amplitude, however this began to return toward baseline by 240 minutes. Peak plasma concentration of PEG-20k after LVR were 40% lower than predicted, based on simple dilution (5.7 mg/mL vs. 10 mg/mL) and the half-life was 59.6 minutes. CONCLUSION These data demonstrate that acute resuscitation with PEG-20k significantly improves tolerance to hypovolemia but also decreases platelet function in the coagulation cascade, which was due, in part, to its volume expanding effects.

BACKGROUND Acute-care surgery (ACS), trauma, and surgical critical care (SCC) fellowships graduate fellows deemed qualified to perform complex cases immediately upon graduation. We hypothesize international fellow rotations can be a resource to supplement operative case exposure. METHODS A survey was sent to all program directors (PDs) of ACS and SCC fellowships via e-mail. Data were captured and analyzed using the REDCap (Research Electronic Data Capture) tool. RESULTS The survey was sent to 113 PDs, with a response rate of 42%. Most fellows performed less than 150 operative cases (59.5%). The majority of PDs thought the operative exposure either could be improved or was not enough to ensure expertise in trauma and emergent general surgery. Only a minority of the PDs found their case load exceptional (can be improved: 43%, not enough: 30% exceptional: 27%). Most PDs thought an international experience could supplement the breadth of cases, provide research opportunities, and improve understanding of trauma systems (70%). Ten sites offered international rotations (70%). Most fellowships would be willing to provide reciprocity to the host institution (90%). CONCLUSIONS The majority of PDs for ACS, trauma, and SCC programs perceive a need for increased quality and quantity of operative cases. The majority recognize international fellow rotations as a valuable tool to supplement fellows' education.

To determine the role of cell swelling in severe hemorrhagic shock and resuscitation injury.Circulatory shock induces the loss of energy-dependent volume control mechanisms. As water enters ischemic cells, they swell, die, and compress nearby vascular structures, which further aggravates ischemia by reducing local microcirculatory flow and oxygenation. Loading the interstitial space with cell impermeant molecules prevents water movement into the cell by passive biophysical osmotic effects, which prevents swelling injury and no-reflow.Adult rats were hemorrhaged to a pressure of 30 to 35 mm Hg, held there until the plasma lactate reached 10 mM, and given a low-volume resuscitation (LVR) (10%-20% blood volume) with saline or various cell impermeants (sorbitol, raffinose, trehalose, gluconate, and polyethylene glycol-20k (PEG-20k). When lactate again reached 10 mM after LVR, full resuscitation was started with crystalloid and red cells. One hour after full resuscitation, the rats were euthanized. Capillary blood flow was measured by the colored microsphere technique.Impermeants prevented ischemia-induced cell swelling in liver tissue and dramatically improved LVR outcomes in shocked rats. Small cell impermeants and PEG-20k in LVR solutions increased tolerance to the low flow state by two and fivefold, respectively, normalized arterial pressure during LVR, and lowered plasma lactate after full resuscitation, relative to saline. This was accompanied by higher capillary blood flow with cell impermeants.Ischemia-induced lethal cell swelling during hemorrhagic shock is a key mediator of resuscitation injury, which can be prevented by cell impermeants in low-volume resuscitation solutions.

BackgroundNovel crystalloid solutions containing polyethylene glycol polymers (PEG-20k) produce dramatic resuscitation effects but dose-dependently produce a hypocoagulative state. The objective of this study was to examine possible mechanisms of this effect. Based on previous thromboelastography data, we hypothesize the effect is largely due to platelet interactions with the polymers.MethodsWhole citrated blood from healthy volunteers was diluted ex-vivo 10% with crystalloids and tested for coagulation and platelet function. The specific tests included prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and von Willebrand factor (vWf) activity, thrombin generation, thromboelastography with and without platelet mapping, platelet flow cytometry, and erythrocyte sedimentation rate.FindingsFibrinogen and vWF activities, PT, and aPTT were not affected by PEG-20k dilutions. Thrombin activity was mildly suppressed with PEG-20k (TTP- 20%). Platelet mapping demonstrated significantly greater % inhibition of both ADP and arachidonic acid-induced platelet aggregation with PEG-20k, but direct ADP-activated gpIIa/IIIb (PAC1) and P-selectin (CD62P) binding site expression was not altered. Mild dose-dependent suppression of TEG-MA was seen with PEG-20k using platelet poor plasma. Erythrocyte Sedimentation Rates (ESR) were dramatically accelerated after dilution with 10% PEG-20k, which was competitively blocked by smaller PEG polymers, suggesting nonspecific PEG-20k cell binding effects.ConclusionsPEG-20k creates a mild hypocoagulative state in whole blood at concentrations ≥10%, which may be due to platelet-PEG interactions at the IIb/IIIa interface with lesser effects on fibrin polymerization. This interaction may cause a functional thrombasthenia induced by nonspecific platelet surface passivation by the PEG polymer.

Aim Five million annual global deaths are attributable to injuries. Yet, a lack of reliable data leaves the true magnitude of injuries unknown in many low- and middle-income countries (LMICs), like Bolivia. Trauma registries provide a means of acquiring these data. We sought to evaluate methodology, preliminary results, and lessons learned during the implementation of a pilot, hospital-based trauma registry at one facility in Santa Cruz de la Sierra, Bolivia. Materials and methods Data collection occurred from January to September 2015 at Clínica Foianini, a private, 50-bed, third-level facility in Santa Cruz. A paper trauma registry form based on the Panamerican Trauma Society's (ATS's) essential elements model was utilized. Trained nurses completed forms at a trauma patient's initial hospital presentation. Results were analyzed via descriptive statistics. Results The registry produced 91 forms over 8 months. An ICD-10 diagnosis code search of hospital visits showed 2,816 eligible patients, with a registry capture rate of 3.2%. Most were males (59.3%) in their mid-20s with head contusions (19.8%), penetrating/lacerating upper extremity (11.0%) or head (7.7%) wounds, or upper extremity fractures (6.6%). Many forms were missing critical data, with average omissions of 12.5 per form (26.0% of questions) and 23.7 per question (26.0% of subjects). Errors averaged 1.0 per form (2.1% of questions) and 2.0 per question (2.2% of subjects). Conclusion Early efforts to implement a paper-based trauma registry at one Bolivian hospital highlight areas for improvement, mainly within education, training, and oversight. Lessons learned will inform long-term objectives to make the registry a standard hospital program across the city, and eventually throughout Bolivia, arming decision-makers with data for targeted trauma initiatives that save lives. Clinical significance These results provide insight into trauma registry implementation in LMICs, which serves to further inform the Bolivian program and can be applied to comparable initiatives in similar settings. How to cite this article Boeck MA, Blair KJ, Foianini JE, Perry HB, Mata LV, Aboutanos MB, Haider AH, Swaroop M. Implementation of a Hospital-based Trauma Registry in Santa Cruz de la Sierra, Bolivia: Methodology, Preliminary Results, and Lessons learned. Panam J Trauma Crit Care Emerg Surg 2016;5(2):101-112.

Introduction and objectives Injuries and noncommunicable diseases account for greater than 73% deaths and 76% disability adjusted life years (DALYs) in Latin America, where trauma care is challenging especially when resources are scarce. Education and training is a basic step in trauma systems development, which was shown to improve survival. Except for urban areas, trauma courses are unavailable and unaffordable in the Latin region. The aim of this study is to evaluate the feasibility of implementation of a basic trauma education course (BTC) for resource-limited areas adopted and promulgated by the Panamerican Trauma Society (PTS) since 2011. Materials and methods Basic trauma education course was administered in Paraguay, Medellin, Chile, and Panama during the PTS congresses (2011-2013). The two-day course was based on the patient's pathway system, addressing the management of the patient through various echelon of care from rural health centers to local provincial hospital and tertiary treatment facilities. It contained 20 hours of didactic lectures and hands on skill labs on basic trauma resuscitation, stabilization, and transport, as well as trauma system-oriented teaching (triage, EMS, kinematics, trauma registries). Panamerican Trauma Society international and national instructors administered the courses. Course logistics and coordination were carried out by international and local coordinators and by trauma league medical students. Pre and post (30 multiple-choice questions) tests were used to assess participants. Paired t-test was used to compare scores. Results Fifty-four students (rural physicians, EMS providers, students, nurses, and administrators) participated. Pre and posttest score comparison showed significant improvement 74% vs 85% respectively, p-value < 0.0001. Conclusion A tailored trauma course and evaluation can be feasible in educating local providers. The PTS can promulgate the application of BTCs that may serve as a model for continuing trauma care education in developing countries. Course follow-up evaluation is pending. How to cite this article Mata LV, Mora FE, Quiodettis M, Fischer J, Machain GM, Salamea JC, Rodas EB, Aboutanos MB. Panamerican Trauma Society Basic Trauma Education Course Administration in Resource-limited Areas. Panam J Trauma Crit Care Emerg Surg 2016;5(2):83-87.

Hypovolemic shock reduces oxygen delivery and compromises energy-dependent cell volume control. Consequent cell swelling compromises microcirculatory flow, which reduces oxygen exchange further. The importance of this mechanism is highlighted by the effectiveness of cell impermeants in low-volume resuscitation (LVR) solutions in acute studies. The objectives of this study were to assess impermeants in survival models and to compare them with commonly used crystalloid solutions.Adult rats were hemorrhaged to a pressure of 30 mm Hg to 35 mm Hg, held there until the plasma lactate reached 10 mM, and given an LVR solution (5-10% blood volume) with saline alone (control) and saline with various concentrations of polyethylene glycol-20k (PEG-20k), Hextend, or albumin. When lactate again reached 10 mM following LVR, full resuscitation was started with crystalloid and red blood cells. Rats were either euthanized (acute) or allowed to recover (survival). The LVR time, which is the time from the start of the LVR solution until the start of full resuscitation, was measured as was survival and diagnostic laboratory values. In some studies, the capillary oncotic reflection coefficient was determined for PEG-20k to determine its relative impermeant and oncotic effects.PEG-20k (10%) significantly increased LVR times relative to saline (eightfold), Hextend, and albumin. Lower amounts of PEG-20k (5%) were also effective but less so than 10% doses. PEG-20k maintained normal arterial pressure during the low-volume state. Survival of a 180-minute LVR time challenge was 0% in saline controls and 100% in rats given PEG-20k as the LVR solution. Surviving rats had normal laboratory values 24 hours later. PEG-20k had an oncotic reflection coefficient of 0.65, which indicates that the molecule is a hybrid cell impermeant with significant oncotic properties.PEG-20k-based LVR solutions are highly effective for inducing tolerance to the low-volume state and for improving survival.

NJURIES TO THE HEART and great vessels can occur by almost any mechanism in patients who have sustained trauma. These injuries can be categorized into injuries that are so devastating that patients die at the scene and injuries that are stable enough for patients to arrive at the hospital. In the hospital setting, several factors affect the management of patients who sustain cardiac or great vessel injuries, including the mechanism of injury (penetrating v blunt), patient stability (unstable v stable), and injury location (cardiac v great vessels). When a patient presents with an obvious cardiac injury, the anesthesiology team should be prepared to initiate several key interventions immediately. These interventions include airway management, obtaining intravenous access, and determining which patients are candidates for extreme lifesaving maneuvers. The anesthetic management in the operating room (OR) includes supporting the circulation, providing maneuvers that aid surgical repair, and identifying the extent of cardiac injury. Postoperatively, it is important to ensure adequate resuscitation and continue close monitoring. The following case highlights various issues that need to be considered when managing a patient who presents with a significant cardiac injury. CASE REPORT A 31-year-old man (height 175 cm, weight 77 kg) was brought to the trauma center after sustaining stab wounds with a machete. One wound was to the left shoulder, and a second wound was to the left anterior chest. He arrived without vital signs and receiving cardiopulmonary resuscitation (CPR). The total time without vital signs was reported by prehospital personnel to be o10 minutes. The patient underwent immediate tracheal intubation, intravenous access was obtained, and an anterolateral resuscitative thoracotomy was performed in the emergency department (ED). Because of cardiac tamponade, a decision was made to open the pericardium. A large amount of blood clot was evacuated from the pericardial space. Two large lacerations were identified involving both left and right ventricles. These lacerations were closed emergently with staples. After continued CPR and administration of crystalloids and blood, the heart began exhibiting unorganized electrical activity. The heart was defibrillated with internal paddles, and organized cardiac activity was obtained. The patient was rushed to the OR. In the OR, the patient was placed in the supine position. A 9F central venous catheter was inserted in the right internal jugular vein. A right radial arterial catheter also was placed. The trauma center’s massive transfusion protocol was initiated, and the patient’s intravenous access was connected to a rapid infusion device. Scopolamine, 0.4 mg, rocuronium, 80 mg, fentanyl, 250 μg (in divided doses), and cefazolin, 2 g, were administered. Sevoflurane was used for anesthetic maintenance as tolerated by the patient’s blood pressure. Careful attention was given to avoid large fluctuations in blood pressure because of concern that severe hypertension would increase bleeding or disrupt the initial repair. The goal was to maintain the patient’s systolic blood pressure (SBP) at 80 to 90 mmHg. An initial dose of epinephrine, 100 μg, was administered owing to severe hypotension. After incision, a median sternotomy was performed, and the pericardium was reopened. The laceration at the apex of the right ventricle, which had been closed temporarily with staples, was oversewn with a 3-0 polypropylene (Prolene) suture and pledgets in a running fashion. The injury to the left ventricle was repaired in a similar fashion via the anterolateral thoracotomy wound. When the cardiac injuries were closed, a left lung injury was sutured, and bleeding was controlled. Two left-sided chest tubes, one right-sided chest tube, and a mediastinal chest tube were placed, and the sternotomy was closed with sternal wires. Skin incisions were closed with staples. The patient’s initial pH and base excess in the OR were 6.8 and � 16.5, respectively. Fluid totals for the case were 8 L of crystalloid, 17 units of packed red blood cells, 7 units of fresh frozen plasma, and 10 units of platelets. The estimated blood loss was 8,500 mL, and urine output was 405 mL. On leaving the OR, the pH was 7.3, and base excess was � 5.9. The patient was transported intubated to the trauma intensive care unit

The American Association for the Surgery of Trauma (AAST) recently established a grading system for uniform reporting of anatomic severity of several emergency general surgery (EGS) diseases. There are five grades of severity for each disease, ranging from I (lowest severity) to V (highest severity). However, the grading process requires manual chart review. We sought to evaluate whether International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9-CM, ICD-10-CM) codes might allow estimation of AAST grades for EGS diseases. The Patient Assessment and Outcomes Committee of the AAST reviewed all available ICD-9-CM and ICD-10-CM diagnosis codes relevant to 16 EGS diseases with available AAST grades. We then matched grades for each EGS disease with one or more ICD codes. We used the Official Coding Guidelines for ICD-9-CM and ICD-10-CM and the American Hospital Association's "Coding Clinic for ICD-9-CM" for coding guidance. The ICD codes did not allow for matching all five AAST grades of severity for each of the 16 diseases. With ICD-9-CM, six diseases mapped into four categories of severity (instead of five), another six diseases into three categories of severity, and four diseases into only two categories of severity. With ICD-10-CM, five diseases mapped into four categories of severity, seven diseases into three categories, and four diseases into two categories. Two diseases mapped into discontinuous categories of grades (two in ICD-9-CM and one in ICD-10-CM). Although resolution is limited, ICD-9-CM and ICD-10-CM diagnosis codes might have some utility in roughly approximating the severity of the AAST grades in the absence of more precise information. These ICD mappings should be validated and refined before widespread use to characterize EGS disease severity. In the long-term, it may be desirable to develop alternatives to ICD-9-CM and ICD-10-CM codes for routine collection of disease severity characteristics.

Background Post-traumatic stress disorder (PTSD) has become a recognized healthcare crisis. Urban trauma centers (UTC) treat a high rate of violently injured patients, a known risk factor for PTSD. A quality improvement (QI) project related to PTSD was implemented to assess the prevalence of PTSD symptomology post-discharge and the need for inpatient screening and referral. Study design In 2013, 3,525 patients were admitted to a UTC, of which 560 suffered a violent injury. One hundred and twentysix (23%) were provided PTSD education and offered resources for mental health treatment (MHT). Patients in police custody, with self-inflicted injuries, with injuries related to domestic violence, or who were non-English speaking were not included in the QI analysis (37%). At 4 to 6 weeks post-discharge, patients were contacted and administered a four item PTSD screening tool. Referral to MHT was offered and provided if requested. Results One hundred and twenty-six patients were evaluated. Sixty-four (51%) patients were reached at 4 to 6 weeks postdischarge and 60 (48%) completed the full 4-item tool. Fifty (78%) had GSW, 7 (11%) had stab wounds, and 7 (11%) had assault. Sixty-two percent reported experiencing at least one major symptom of PTSD, and 52% experienced >2 major symptoms. Eighty-seven percent of patients who developed symptoms of PTSD refused referrals pre-discharge. Post-discharge, patients with at least one PTSD symptom (37) requested MHT at a significantly higher rate than those without symptoms (23; p = < 0.0001). Patients with 3 to 4 symptoms requested referral information at a higher rate than those with 0 to 2 symptoms (p ≤0.0001). Conclusion Violently injured patients are at risk for the development of PTSD symptoms post-discharge. Trauma centers have a unique opportunity to implement PTSD screening, referral and post-discharge follow-up to effect change for this at-risk population. How to cite this article Jordan A, Goldberg S, Bivins J, Hogue B, Wolfe L, Aboutanos MB. Post-traumatic Stress Symptoms in a Violently Injured Civilian Population: A Need for Hospital Identification and Resources. Panam J Trauma Crit Care Emerg Surg 2015;4(2):54-58.

OBJECTIVES Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest. METHODS Approval by the Institutional Review Board was obtained. All nonsurviving patients with traumatic cardiac arrest who reached the trauma bay were evaluated retrospectively for 1 year. Comparisons between groups of patients in whom LTTE was performed as part of the resuscitation effort and those in whom it was not performed were conducted. RESULTS From January 2012 to January 2013, 37 patients did not survive traumatic cardiac arrest while in the trauma bay: 14 in the LTTE group and 23 in the non-LTTE group. When comparing the LTTE and non-LTTE groups, both were similar in sex distribution (LTTE, 86% male; non-LTTE, 74% male; P = .68), age (34.8 versus 24.1 years; P= .55), Injury Severity Score (41.0 versus 38.2; P= .48), and percentage of penetrating trauma (21.6% versus 21.7%; P = .29). Compared with the non-LTTE group, the LTTE group spent significantly less time in the trauma bay (13.7 versus 37.9 minutes; P = .01), received fewer blood products (7.1% versus 31.2%; P = .789), and were less likely to undergo nontherapeutic thoracotomy in the emergency department (7.14% versus 39.1%; P < .05). The non-LTTE group had a mean of $3040.50 in hospital costs, compared with the mean for the LTTE group of $1871.60 (P = .0054). CONCLUSIONS In this study, image-guided resuscitation with LTTE decreased the time in the trauma bay and avoided nontherapeutic thoracotomy in nonsurviving trauma patients. Limited TTE could improve the use of health care resources in patients with traumatic cardiac arrest.

Currently, there is no established system for assessing disease severity in emergency general surgery (EGS) patients. The purpose of this project was to develop a uniform grading system for measuring anatomic severity of disease in this patient population.The Committee on Patient Assessment and Outcomes of the American Association for the Surgery of Trauma developed a proposal by consensus of experts for grading severity of EGS diseases. It was then reviewed and approved by the Board of Managers of the American Association for the Surgery of Trauma.A uniform grading system for measuring anatomic severity of disease in EGS is described, with specific grades for eight commonly encountered gastrointestinal conditions. These grades range from Grade I through Grade V, reflecting an escalating clinical progression from mild disease limited within the organ itself to severe disease that is widespread.This article provides a unified grading system for measuring anatomic severity of disease that is essential to advance the science of EGS. Once validated, a description of disease grade should be included in the emerging EGS registries and in research studies involving EGS patients.

We hypothesize that limited transthoracic echocardiogram (LTTE) is a useful tool to guide therapy during the initial phase of resuscitation in trauma patients.All highest-level alert patients with at least one measurement of systolic blood pressure less than 100 mm Hg, a mean arterial pressure less than 60 mm Hg, and/or a heart rate greater than 120 beats per minute who arrived to the trauma bay (TB) were randomized to have either LTTE performed (LTTEp) or not performed (non-LTTE) as part of their initial evaluation. Images were stored, and results were reported regarding contractility (good vs. poor), fluid status (empty inferior vena cava [hypovolemic] vs. full inferior vena cava [not hypovolemic]), and pericardial effusion (present vs. absent). Time from TB to operating room, intravenous fluid administration, blood product requirement, intensive care unit admission, and mortality were examined in both groups.A total of 240 patients were randomized. Twenty-five patients were excluded since they died upon arrival to the TB, leaving 215 patients in the study. Ninety-two patients were in the LTTEp group with 123 patients in the non-LTTE group. The LTTEp and non-LTTE groups were similar in age (38 years vs. 38.8 years, p = 0.75), Injury Severity Score (ISS) (19.2 vs. 19.0, p = 0.94), Revised Trauma Score (RTS) (5.5 vs. 6.0, p = 0.09), lactate (4.2 vs. 3.6, p = 0.14), and mechanism of injury (p = 0.44). Strikingly, LTTEp had significantly less intravenous fluid than non-LTTE patients (1.5 L vs. 2.5 L, p0.0001), less time from TB to operating room (35.6 minutes vs. 79.1 min, p = 0.0006), higher rate of intensive care unit admission (80.4% vs. 67.2%, p = 0.04), and a lower mortality rate (11% vs. 19.5%, p = 0.09). Mortality differences were particularly evident in the traumatic brain injury patients (14.7% in LTTEp vs. 39.5% in non-LTTE, p = 0.03).LTTE is a useful guide for therapy in hypotensive trauma patients during the early phase of resuscitation.Therapeutic study, level II.

Endovascular technology during the past decade has introduced innovative strategies to manage vascular trauma. The purpose of this study was to evaluate the current use catheter-based endovascular damage-control techniques (CDET) in North, Central, and South America. A survey was sent to the presidents of local societies in Latin America, members of the board, and past presidents of the Pan-American Trauma Society. The survey was sent using the Research Electronic Data Capture collection tool. A total of 67 surveys were sent with an 85 % response rate. Surgeons from 15 countries participated in the survey. All of the centers in North America had capabilities to perform these procedures. In none of these centers, however, were they performed by trauma and acute care surgeons. In Central and South America, 64 % of the surgeons responded that they have an interventional radiology service, and in 56 % of the cases, trauma and acute care surgeons were already performing CDET. Eight-eight percent of those surveyed thought that the addition of CDET to trauma would improve patient care; 86 % would be interested in further training in this technique if such programs were available. Finally, 68 % thought that the addition of CDET would help the field of acute care surgery and trauma financially. CDET is being performed already by trauma and acute care surgeons in Latin American countries. More research is necessary to evaluate the role of the trauma surgeon in the endovascular suite as well as training requirements.