BACKGROUND:Traumatic coagulopathy is a major contributor to mortality after severe hemorrhage. Tranexamic acid (TXA) reduces fibrinolysis, and N-acetylcysteine (NAC) has antioxidant and anti-inflammatory properties. Both agents have shown benefit individually, but their combined effect has not been previously investigated in trauma. We hypothesized that early administration of NAC with TXA during resuscitation could attenuate acidosis and fibrinolysis in an experimental study with a hemorrhagic shock and polytrauma swine model. METHODS:Thirty-six male Landrace pigs (28.3 ± 3.0 kg) were randomized into five groups: Sham (n = 5), Ringer lactate (n = 5), NAC (n = 6), TXA (n = 6), and NAC+TXA (n = 6). Animals underwent experimental standardized polytrauma (femur fracture, controlled hemorrhage of 60% blood volume), followed by immediate resuscitation and a grade IV liver injury. Standard physiological parameters, blood gases, lactate, coagulation tests, fibrinogen, and thromboelastometry (ROTEM parameters) were assessed at baseline, post-shock, post-resuscitation, post-liver injury, and final. RESULTS:All trauma groups developed profound shock physiology compared with Sham. The NAC+TXA group demonstrated the most complete correction of acid-base status, achieving the highest final pH (7.5 ± 0.03), significantly greater than Ringer lactate (7.3 ± 0.09), NAC (7.3 ± 0.06), and TXA (7.3±0.11) ( p = 0.001). Lactate and base deficit showed directionally similar improvements.Thromboelastometry showed attenuated fibrinolysis with combined therapy. The NAC+TXA group exhibited lower maximum lysis after liver injury compared with NAC (10 ± 3% vs 16 ± 4%, p = .008). Other ROTEM parameters displayed directionally similar trends toward improved clot formation. CONCLUSIONS:In this swine polytrauma model, the combined administration of NAC and TXA was associated with improved in acid-base status and attenuation of fibrinolysis. While these physiological effects are preliminary, they support additional experimental investigations to clarify mechanisms, reproducibility, and potential translational relevance of NAC+TXA as an adjunct in damage control resuscitation. ( J Trauma Acute Care Surg . 2026;101: 297-305. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.

INTRODUCTION:Burn injuries are a significant global health concern, with an estimated 8.4 million cases annually. Although specific cost data from Brazil are limited, international reports estimate an average burn-related hospitalization cost of USD 88,218. Educational tools for populations are desirable to prevent burn injury. Thus, the authors designed a gamified model to promote burn education and prevention among Brazilian students. METHODS:The intervention was conducted in four public schools, three High Schools (HS) and one Vocational School (VS). Students first completed a 21-question online pre-test assessing their baseline knowledge. A 20-minute lecture followed, covering burn classification and prevention. Students then participated in an interactive online trivia game (Burn Game) designed to reinforce learning. Finally, they completed the same test as a post-intervention assessment. RESULTS:A total of 134 students participated (73 from VS, 61 from HS), with a mean age of 18.6 ± 4.9 years; 73.13% were female. Post-test scores improved significantly across the participants, with 132 students showing higher scores. The overall mean score difference was 7.16-points (95% CI: 6.47-7.86; p < 0.001). Subgroup analysis revealed gains in both VS (MD = 6.08; 95% CI: 5.33-6.83) and HS students (MD = 8.46; 95% CI: 7.41-9.51), with HS students showing the greatest improvement. CONCLUSION:The present study suggests that gamified teaching indeed contributed to significantly increasing students' knowledge about burn prevention and classification.

As lesões traqueobrônquicas são eventos raros, porém potencialmente fatais, geralmente associadas a traumas torácicos de alta energia e frequentemente diagnosticadas tardiamente. O manejo adequado das vias aéreas é essencial para a sobrevida nesses casos. Relata-se aqui o caso de um homem de 34 anos, vítima de esmagamento torácico por queda de empilhadeira, que apresentou ferimento penetrante em hemitórax direito, enfisema subcutâneo e insuficiência respiratória grave. Foi intubado em ambiente pré-hospitalar e transferido por via aérea a um centro de referência. Na admissão, apresentava instabilidade hemodinâmica e hipoxemia refratária, sendo encaminhado diretamente ao centro cirúrgico. Durante o procedimento, identificou-se transecção completa da traqueia cerca de 3 cm acima da carina, associada à laceração extensa do brônquio fonte direito. Observou-se que o paciente estava intubado seletivamente no brônquio esquerdo, o que, de forma não intencional, permitiu ventilação eficaz do pulmão esquerdo, garantindo oxigenação mínima até a reparação cirúrgica. Realizou-se anastomose traqueobrônquica e posterior avaliação vascular, que revelou dissecção de artéria vertebral. O paciente evoluiu com estabilidade respiratória, porém apresentou sequelas, incluindo AVC isquêmico de circulação posterior, déficit visual parcial, estenose traqueal e comprometimento motor e sensitivo do membro superior direito. Este caso destaca a importância do reconhecimento precoce das lesões traqueobrônquicas, do manejo adequado das vias aéreas e da transferência a centros especializados. A intubação seletiva à esquerda, embora acidental, teve papel crucial na sobrevida, funcionando como estratégia ventilatória temporariamente protetora diante da ruptura completa da traqueia.

Traumatic lumbar hernia (TLH) is a rare and challenging abdominal wall defect. In these patients, treatment success is usually assessed by recurrence, although persistent postoperative bulging or asymmetry may remain clinically relevant even without true failure of repair. This study evaluated the abdominal symmetry index (ASI), defined as a CT-based side-to-side ratio of lateral abdominal wall distance, as an objective morphologic parameter after TLH reconstruction with dual polypropylene mesh. A single-center retrospective comparative study was performed at a tertiary academic referral center from 2006 to 2025. The study included 25 consecutive eligible patients with TLH who underwent elective open abdominal wall reconstruction with dual polypropylene mesh and 25 controls without abdominal wall disease. In the TLH group, ASI was assessed on CT before and after surgery; controls underwent a single CT-based assessment. The operative repair consisted of deep preperitoneal/retroperitoneal reinforcement whenever feasible, muscle reapproximation when possible, and preaponeurotic/onlay reinforcement. Sex distribution did not differ significantly between groups. Mean age was 42 +/- 13 years in the hernia group and 37 +/- 13 years in controls, while mean body mass index was 31 +/- 4 and 28 +/- 5 kg/m2, respectively (p = 0.023). Hernia volume was estimated using the ellipsoid formula and had a median value of 443 cm3 (range, 244–1013 cm3). Clinical follow-up was 62 +/- 47 months, and the interval between surgical repair and the latest postoperative CT scan was 687.3 +/- 712.6 days. No recurrence was observed. Before surgery, the measurement on the hernia side was significantly greater than on the contralateral side (185 +/- 24 mm vs. 144 +/- 12 mm; p < 0.0001). After reconstruction, this difference was no longer statistically significant (154 +/- 15 mm vs. 149 +/- 13 mm; p = 0.1022). Mean ASI was 1.29 +/- 0.18 preoperatively, 1.03 +/- 0.07 postoperatively, and 0.99 +/- 0.03 in controls (overall p < 0.0001). Holm-Sidak adjusted pairwise comparisons showed significant differences between preoperative TLH and controls (p = 1.14 × 10^-13) and between preoperative and postoperative TLH (p = 1.64 × 10^-11), whereas postoperative TLH did not differ significantly from controls (p = 0.2142). ASI was feasible as an exploratory CT-based morphologic index for postoperative evaluation of TLH repair. Reconstruction with dual polypropylene mesh was associated with substantial improvement in abdominal wall symmetry, with postoperative values approaching those of controls. Further validation, including interobserver reproducibility and correlation with patient-reported outcomes, is required before broader adoption.

OBJECTIVE:Early prognosis determination after traumatic brain injury remains challenging, yet reliable early markers remain limited. A Glasgow Coma Scale-Pupil (GCS-P) score of 1, combining a GCS of 3 and bilaterally nonreactive pupils, has been proposed as a marker of catastrophic injury, although some patients may recover. The authors hypothesized that persistence of a GCS-P score of 1 after 24 h could predict poor prognosis. METHODS:Descriptive study in a quaternary ICU in Brazil, including adult patients admitted between 2019 and 2025 with a pre-sedation GCS of 3 and bilaterally nonreactive pupils. Patients with unknown initial neurological status or a Marshall Computed Tomography Classification < 3 were excluded. Clinical characteristics, imaging findings, treatments, and outcomes were prospectively collected. The primary outcome was the Glasgow Outcome Scale-Extended (GOSE) at hospital discharge. RESULTS:Among 2645 ICU admissions, 868 were due to TBI, and 49 met the inclusion criteria. Patients were predominantly young (median age 38-years), male (79.6%), and had high illness severity (median SAPS3 of 68). Most suffered blunt trauma, and nearly half underwent hemicraniectomy. All patients who persisted with a GCS-P score of 1 after 24-hours died during hospitalization (n = 36, 95% CI 90.3%-100%). Among those who improved their GCS-P score within 24-hours (n = 13), mortality was 54% (95% CI 25.1%-80.8%), and 31% (95% CI 9.1%-61.4%) recovered consciousness (GOSE > 2). CONCLUSION:Persistence of a GCS-P score of 1 after 24-hours is a highly reliable marker of poor prognosis in patients with severe TBI. These findings warrant external validation.

ABSTRACT Background: The benefit of laparoscopy in blunt abdominal trauma (BAT) remains debated. This study analyzed patients with BAT treated by laparoscopy in a tertiary reference trauma service in Brazil. Methods: A retrospective clinical study of hemodynamically stable patients with BAT treated by laparoscopy over a 12-year period was conducted. Laparoscopies were classified as diagnostic (DL) or therapeutic (TL). Results: Over a 12-year period, 85 patients with BAT were treated laparoscopically. The median age was 30 years, and most patients were male (80%) and had an ASA of I (72%). Collision was the most frequent mechanism (46%). The main indications for laparoscopy were the presence of free fluid without parenchymal lesions on CT (59%) and abdominal pain/signs of peritoneal irritation (11.5%). The conversion rate was 26%, and these patients were included in the control group (n=22). Among the laparoscopies (n=63), 36% (n=31) were DL, and 38% (n=32) were TL. The seat belt sign was present in 12% of the patients in the total series. The most frequent therapeutic procedure is suturing of the bladder, colon, and diaphragm. There was correspondence between the CT and intraoperative findings, and there were no unnoticed injuries. The surgical time was longer in the CG (p<0.05). Conclusion: Laparoscopy can be safe and effective for the management of patients who are victims of blunt abdominal trauma, selected preoperatively and hemodynamically stable. Success in this type of approach depends on a tripod: adequate selection of patients, trained surgeons and full-time availability of materials and subsidiary tests.

Pancreatic portal vein fistula (PPVF) is a rare condition, often a complication of chronic pancreatitis, involving communication between a pancreatic collection and the portal vein. Early diagnosis is crucial to prevent severe complications, including portal vein thrombosis and hemorrhage. This case report presents a 62-year-old man with HIV and congestive heart failure who developed a PPVF following walled-off necrosis due to acute pancreatitis. Diagnosis of this complication resulted from abdominal pain secondary to splenic artery branch bleeding into the collection, which was treated by embolization. Despite systemic complications, the patient recovered without the need for walled off necrosis drainage. This case underscores the challenge and the importance of individualized treatment for PPVFs and its complications.

Trauma abdominal fechado é uma causa frequente de internação em serviços de emergência, podendo afetar múltiplos órgãos e demandando avaliação rápida e manejo adequado para evitar complicações. O baço é o órgão mais comumente lesionado, e lesões pancreáticas associadas, embora menos frequentes, podem agravar o quadro clínico. A decisão entre tratamento conservador e intervenção cirúrgica depende da estabilidade clínica e da evolução do paciente. Relato de Caso Homem de 29 anos foi encontrado inconsciente em via pública e levado ao PS pelo SAMU. À admissão, apresentava vias aéreas pérvias, tórax com expansibilidade preservada. Estava hemodinamicamente estável, com pelve estável, abdome indolor e exame E-FAST negativo. A escala de coma de Glasgow era 14, com pupilas isocóricas. A tomografia computadorizada de corpo inteiro revelou trauma esplênico grau III, pequeno pneumotórax direito, fratura transversa do corpo do esterno e pneumomediastino. Optou-se inicialmente pelo tratamento conservador. No terceiro dia, o paciente desenvolveu sinais de irritação peritoneal e queda significativa da hemoglobina, de 14,4 g/dL para 9,7 g/dL. Nova tomografia evidenciou aumento do líquido livre abdominal, áreas heterogêneas no corpo do pâncreas e agravamento das lacerações esplênicas com hematoma subcapsular. Realizou-se videolaparoscopia diagnóstica, convertida para laparotomia exploradora, durante a qual foram feitas pancreatectomia corpo-caudal, esplenectomia e drenagem abdominal. Evoluiu sem intercorrências significativas. Recebeu alta da UTI no quinto dia, com retirada do dreno no 13º dia e alta hospitalar. Discussão Manejo do trauma esplênico é conservador em pacientes estáveis, com monitoramento rigoroso para detectar complicações. A presença de lesão pancreática associada e sinais de peritonite indica necessidade de intervenção cirúrgica. A pancreatectomia corpo-caudal e esplenectomia controlaram o sangramento e removeram tecido comprometido. A conversão da videolaparoscopia para laparotomia é comum em traumas complexos, permitindo melhor controle cirúrgico. A ausência de fístula pancreática e a evolução favorável indicam sucesso no tratamento.

OBJECTIVE:Medical education is undergoing a profound transformation due to technological advancements. Integrating cutting-edge tools like virtual environments and computer-based simulators heralds a new era in teaching methodologies. The objective of the study is to analyze the performance and satisfaction levels of residents undergoing basic surgical skills training using virtual reality. METHODS:The authors recruited residents from the first year in general surgery and allocated them randomly into three groups: a) Text; b) Practice and c) Virtual reality. Initially, the residents completed a pretest for an evaluation and then they were trained according to the group they were assigned to. All the residents performed a 30-minute training session. After that, they took a posttest. Both tests were composed of multiple-choice ten questions. At the end of this study, the authors determined the score by calculating the delta of the performance (Δ = posttest -pretest). After the training, all the participants filled in a five-question satisfaction questionnaire. RESULTS:Regarding the difference between the pretest and post-test, there was no difference between groups. Only one participant (1/8) showed nausea in the virtual groups. The recommendation and satisfaction after the task were higher in the Virtual reality group compared to the Text group. There was an association between satisfaction after the exercises (VR) and recommendation score. CONCLUSIONS:Virtual reality is safe and non-inferior to traditional surgical instrumentation training. This tool might be a practical and attractive alternative to the traditional instrumentation classes.

Abstract Objective To report a challenger case which surgical approach involves relevant strategies to prevent and treat complications of complex incisional hernias. In extraordinary circumstances, in this case report, it will be shown strategies to lead with chronic sinus and its postoperative complications. Methods This case report refers to a patient, masculine, 74 years old, with a history of complex perineal infection, needing a colostomy—which was realized in another hospital. During his hospitalization, he evolved with evisceration. In the surgical procedure to correct the evisceration, the team deemed it was necessary to put a pre aponeurotic mesh and a pre peritoneal mesh. In this hospital, the patient presented in the outpatient consult with an ostomy, a parastomal hernia and a chronic sinus. In this case report, we address possible preventions, better treatments and how to deal with complications. Conclusion Cases like this illustrate the abstruse related to the treatment of complex hernias associated with the presence of chronic sinus and its possible evolutions.

Background: Telemedicine has been safely used across various surgical specialties at different stages of outpatient care, with effectiveness measured by clinical outcomes, cost savings, and user satisfaction. When employed for communication between physicians at a referral center and lower-complexity hospitals, it enables quick specialist evaluations for patients with relative emergencies. This study describes the experience of a tertiary care service in managing thoracic surgical conditions through telemedicine case discussions. Methods: This prospective study, from March 2022 to February 2023, focused on teleconsultations with hospitals in the referral area of a public academic hospital. Consultations were conducted synchronously and asynchronously via a proprietary platform. Data were collected on the originating hospital, patient demographics, admission date, diagnosis, and clinical summary. Cost savings were calculated by estimating avoided round-trip ambulance transportation. The analysis included data from the public health system's referral records. Results: Out of 4,386 evaluation requests, 341 (7.7%) were discussed with a thoracic surgery specialist. Of these, 181 (53%) were managed without patient transfer, and 53 required rediscussion to revisit the initial medical approach. Immediate transfer, outpatient evaluation, or surgery was recommended in 160 cases. Conclusion: The incorporation of telemedicine into interhospital regulation of thoracic surgical diseases effectively reduced unnecessary patient transfers while providing the originating service with valuable information for managing specialty-specific situations.

Transmediastinal traumatic injuries challenge trauma surgeons due to their potential to involve thoracic and abdominal cavities, requiring rapid assessment for timely interventions. This case report describes a 27-year-old male with a thoracoabdominal gunshot wound, emphasizing the potential role of ultrasound in emergency settings. The patient presented with diminished left-sided breath sounds and stable hemodynamics. Physical examination revealed an entry wound at the sixth intercostal space. With portable X-ray unavailable, ultrasound detected left hemothorax, pneumothorax, and pneumopericardium. The sonographic findings suggested the bullet's trajectory and helped further management. CT confirmed findings, with esophagoscopy and thoracoscopy identifying minor esophageal and pericardial injuries. Discharged three days post-injury, the patient highlights ultrasound's utility in resource-limited settings despite lower sensitivity compared to CT.

OBJECTIVES:To evaluate the impact of implementing a structured prioritization process on surgical waiting times and compliance with time-to-intervention targets for non-elective surgeries in a tertiary academic emergency hospital. METHODS:This observational retrospective single-center cohort study compared two periods before and after implementing a prioritization system. All non-elective surgeries performed from June to August 2022 (pre-intervention) and from November 2022 to January 2023 (post-intervention) were analyzed. The intervention included urgency classification, a real-time Kanban dashboard, and daily multidisciplinary scheduling meetings. The primary outcome was the median time from surgical indication until surgical procedure. The secondary outcome included adherence to predefined acceptable waiting time windows. Statistical comparisons were performed using Chi-Square, Fisher's exact, or Mann-Whitney U tests. A significance level of p < 0.05 was adopted. RESULTS:1851 surgeries were analyzed (967 pre-implementation and 884 post-implementation). The median waiting time was significantly reduced from 17h20min to 8h52min (p < 0.001). Compliance with acceptable waiting time windows increased from 60.5 % to 77.1 % (OR = 2.205; 95 % CI 1.799-2.701). CONCLUSIONS:Introducing a structured prioritization strategy significantly reduced waiting times and improved adherence to surgical timelines in a high-complexity emergency environment. The model proved feasible, effective, and well-accepted by multidisciplinary teams. The long-term impact of the implementation of the model could be further addressed in future studies.

In the emergency care of cancer patients, in addition to cancer -related factors, two aspects influence the outcome: (1) where the patient is treated and (2) who will perform the surgery. In Brazil, a significant proportion of patients with surgical oncological emergencies will be operated on in general hospitals by surgeons without training in oncological surgery. OBJECTIVE: The objective was to discuss quality indicators and propose the creation of an urgent oncological surgery advanced life support course. METHODS: Review of articles on the topic. RESULTS: Generally, nonelective resections are associated with higher rates of morbidity and mortality, as well as lower rates of cancer -specific survival. In comparison to elective procedures, the reduced number of harvested lymph nodes and the higher rate of positive margins suggest a compromised degree of radicality in the emergency scenario. CONCLUSION: Among modifiable factors is the training of the emergency surgeon. Enhancing the practice of oncological surgery in emergency settings constitutes a formidable undertaking that entails collaboration across various medical specialties and warrants endorsement and support from medical societies and educational institutions. It is time to establish a national registry encompassing oncological emergencies, develop quality indicators tailored to the national context, and foster the establishment of specialized training programs aimed at enhancing the proficiency of physicians serving in emergency services catering to cancer patients.

ABSTRACT The role of wound protectors in laparoscopic surgeries is highly controversial in the literature. Some studies demonstrate their benefit in reducing the rate of surgical site infections; however, these results are not reproducible across all procedures. In addition to protecting the operative wound, these devices can be used at sites of surgical specimen extraction in laparoscopic procedures. Several commercially available devices serve this purpose but are scarcely available in resource-limited settings. One of the reasons for this limitation is the cost of the device. In this technical note, we aim to provide a cost-effective option utilizing materials readily available in the operating room and with a simple fabrication process.

Background: Systemic in flammatory responses mimicking infectious complications are often present in surgical patients. Methods: The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24 h of the suspicion of infection was de fined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24 h of suspicion or not prescribed was de fined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion.

Background: It is not known whether anatomical scores perform better than general critical care scores for trauma patients admitted to the intensive care unit (ICU). We compare the predictive performance for hospital mortality of general critical care scores (SAPS 3 and SOFA) with anatomical injury-based scores (Injury Severity Score [ISS] and New ISS [NISS]). Methods: Retrospective cohort study of patients admitted to a specialized trauma ICU from a tertiary hospital in São Paulo, Brazil between May, 2012 and January, 2016. We retrieved data from the ICU database for critical care scores and calculated ISS and NISS from chart data and whole body computed tomography results. We compared the predictive performance for hospital mortality of each model through discrimination, calibration, and decision-curve analysis. Results: The sample comprised 1053 victims of trauma admitted to the ICU, with 84.2% male patients and mean age of 40 (±18) years. Main injury mechanism was blunt trauma (90.7%). Traumatic brain injury was present in 67.8% of patients; 43.3% with severe TBI. At the time of ICU admission, 846 patients (80.3%) were on mechanical ventilation and 644 (64.3%) on vasoactive drugs. Hospital mortality was 23.8% (251). Median SAPS 3 was 41; median maximum SOFA within 24 h of admission, 7; ISS, 29; and NISS, 41. AUROCs (95% CI) were: SAPS 3 = 0.786 (0.756-0.817), SOFA = 0.807 (0.778-0.837), ISS = 0.616 (0.577-0.656), and NISS = 0.689 (0.649-0.729). In pairwise comparisons, SAPS 3 and SOFA did not differ, while both outperformed the anatomical scores (p < .001). Maximum SOFA within 24 h of admission presented the best calibration and net benefit in decision-curve analysis. Conclusions: Trauma-specific anatomical scores have fair performance in critically ill trauma patients and are outperformed by SAPS 3 and SOFA. Illness severity is best characterized by organ dysfunction and physiological variables than anatomical injuries.

This study aimed to analyze the prognostic value of the SOFA, APACHE II, and MPI (Mannheim Peritonitis Index) scores in the indication for Damage Control Surgery (DCS) in non-trauma. Retrospective analysis of patients undergoing DCS between 2014 and 2019. SOFA and APACHE II scores were calculated using parameters preceding DCS, while MPI was based on surgical descriptions. Statistical analysis: Qualitative variables were compared using the Chi-square test or Fisher's exact test, and quantitative variables using Pearson's correlation coefficient. The Student's T test was employed for mean comparisons. The sample comprised 104 patients (59 males), with a median age of 63.5 years, of whom 52 (50

Postoperative intestinal fistulae is one of the most feared complications. Despite its downsides, computerized tomography is the most widely used radiological exam to evaluate postoperative intestinal complications. Point of Care Ultrasound (POCUS) is a bedside tool that can sometimes expedite diagnosis and treatment, avoiding the potential downsides of a CT scan. We describe a case in which the use of POCUS yielded prompt identification of relevant signs in a patient suspected of having an intestinal fistula. We discuss the sonographic findings and the benefit of expediting definitive treatment, thus potentially lowering the morbidity of the patient.