Trauma, emergency and critical care sur geons play an important role during the pandemic. Although these surgeons are not particularly involved in COVID-19 care, their non-technical skills such as tea mwork, experience in the decision-making process, hospital management, preparedness and response to disasters and catastrophes, and, their leadership skills, are necessary to cope with this complex scenario.

COVID-19 is caused by a novel coronavirus, which belongs to a family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV).

SARS-CoV was discovered in November 2002, in Canton, China, and was SARS-CoV-2 was first repor ted by officials in Wuhan City, Hubei, China, on Decem ber 8, 2019; on March 11, 2020, the World Health Orga nization (WHO) described the situation as a pandemic. In Argentina, the first case was confirmed on March 3, 2020, in a 43-year-old man who arrived in the country from Milan, Italy.

The virus is highly contagious, and although most people recover without needing hospital treatment, about 1 out of 5 patients develop a serious condition. The disease is extremely aggressive in the elderly and in those with noncommunicable diseases; however, anyone can become infected and develop a serious form.

Thus, the high incidence of infection has tested the healthcare systems worldwide, challenging the hos pital capacity with high numbers of critically ill patients in short intervals of time and with a severity that has not been seen over the past 100 years, overloading the healthcare centers and particularly the intensive care units (ICU). Therefore, it was necessary to provide bio safety equipment to protect healthcare professionals, who are considered a highly vulnerable population. Indeed, several documents have demonstrated that many of them have become infected and died from the disease. In order to preserve the health and safety of the health care workers, "non-essential" activities were suspended or performed from home, due to the need for social distancing.

The COVID-19 pandemic is intertwined with the epidemic triggered by trauma (a condition clearly neglected in developing countries). Trauma is the lea ding cause of mortality worldwide among people < 45 years and it is estimated that approximately 10% of annual deaths worldwide are due to trauma. Between 2012 and 2020 the WHO set out actions to prevent violence; yet more than 90% of these deaths occur in low- and middle-income countries where preventive measures are often not sufficiently implemented and where the health systems are less prepared to meet the challenge. Trauma contributes to the vicious circle of poverty with economic and social consequences that affect individuals, communities and societies. In the trauma and emergency care departments, surgeons, clinicians and emergency physicians take care of the se patients who are admitted together with COVID-19 patients, following the protocols established in the "Advanced Trauma Life Support" Program © (ATLS). This program, which is working in Argentina since 1989, has standardized that the professionals who assist the victims must use the appropriate personal protection equipment.

Given the massive attendance of patients to the emergency rooms, the hospitals have implemen ted standards for the management of bed availability; therefore, they are operating under emergency triage algorithms. Elective surgeries were canceled based on the expected increase in the number of patients. The hospital wards were reorganized and divided into CO VID-19 and non-COVID-19 areas. Trauma cases and blood product supplies have decreased due to man datory social isolation. However, there is a permanent concern for the health situation due to the possibility of reducing the restrictions before the hospital resources return to normal and receive a great number of trauma patients superimposed on COVID-19(+) cases. This is a major challenge as the emergency surgical team was set up as a workforce available to serve in other roles because of the dynamic redistribution of the personnel required by social distancing and isolation due to infec tion. Thus, work became more difficult due to the need for prior training and use of personal protection measu res and isolation devices. For this reason, many emer gency surgeons took updating courses and modules for developing skills in the care of COVID-19 patients.

The shock room, the operating room and the critical care unit have been considered scenarios whe re health care workers are exposed to the greatest risk of infection since some procedures performed in these areas are potentially sources of aerosols. For this rea son, the number of professionals essential for patient care was limited, maintaining the concept that the lea der should have the greatest skills and experience to provide care. In addition, such procedures on patients with suspected or confirmed COVID-19 should ideally be performed in areas prepared with negative pressure.

The emergency operating room underwent other specific changes. Endotracheal intubation is an aerosol-generating procedure, and only the anesthe siologist and the minimum required staff should be in the operating room during the procedure, after which the surgical team can enter wearing level 3 personal protection equipment. Tracheotomy is another aero sol-generating procedure, so its indication is highly con troversial. Occasionally, excessive secretions in these patients cause airway tamponade that requires urgent bronchoscopy or tube replacement, with the resulting risk of viral spread. An elective procedure can minimize the risk and cannula replacement is more rapid, sim ple and safer. Some centers decided to perform these procedures in the ICU, thus limiting the interruption of closed-loop ventilation and preventing possible conta mination during in-hospital transport. In addition, open surgical or hybrid approaches have been described to limit aerosol generation, minimizing bleeding complica tions and bronchoscopy time. The steps are performed using a transparent device, ideally with negative pres sure since trachea is opened. Other aerosol-generating procedures include gastrointestinal endoscopies and la paroscopy. Several recommendations have been made for laparoscopy: use of smoke and gas evacuators, highly effective antibacterial/antiviral filtration systems (which are also used in endotracheal intubation and placement of pleural drains), and the use a closed sys tem connected to a container with sodium hypochlorite solution for suction and evacuation of gases.

Trauma and surgical emergencies are still inevi table even in the context of the pandemic; therefore, their management (conservative vs. surgical approach) and control (either in an outpatient or inpatient basis) must be approached with common sense and timing, avoiding delays, considering all the patients COVID-19 positive cases, optimizing resources and preserving the health of patients and healthcare workers.