Journal of Trauma and Acute Care Surgery最新文献

Introduction: Timely access to emergency surgical care is a key metric for health system development and performance. To mitigate the risks of rural hospital closures in the United States, the 2021 Consolidated Appropriations Act introduced the rural emergency hospital (REH) designation, which promotes closure of inpatient units in small hospitals in favor of emergency and outpatient services via supplemental funding and reimbursement. We investigated trauma and emergency general surgery volumes at REH-eligible hospitals to evaluate the potential impact of REH designation on trauma and emergency general surgery care.

Methods: We used the 2021 Healthcare Cost and Utilization Project from five geographically diverse states (California, Florida, Iowa, Maryland, and Wisconsin) to select encounters where adult patients were treated for acute injuries or emergency general surgery conditions. We then identified REH-eligible hospitals (critical access hospitals or rural hospitals with <50 inpatient beds), comparing case volumes and patient populations at REH-eligible and -ineligible hospitals.

Results: We analyzed 2.1 million encounters. Trauma and emergency general surgery encounters at REH-eligible hospitals demonstrated substantial interstate variation, comprising 2% to 37% of statewide hospitalizations and up to 17% of statewide inpatient days, with rural states showing the highest proportions. Compared with ineligible hospitals, REH-eligible hospitals treated a higher proportion of patients who were White (85% vs. 55%), were living in rural areas (79% vs. 8%), and had lower incomes; treated fewer patients operatively (2% vs. 11%); and transferred more patients (5% vs. 3%) (all p < 0.001).

Conclusion: Hospitals eligible for REH designation contribute substantially to the care of injured and emergency general surgery patients, although this is variable across states. While this policy may preserve emergency services in rural areas, the substantial variation in REH-eligible hospital utilization and the vulnerable populations served necessitate systematic evaluation of impacts on surgical access, transfer protocols, and regional care capacity given the irreversible structural changes inherent in this designation.

Level of evidence: Epidemiological; Level III.

Introduction: Rehabilitation at inpatient rehabilitation facilities (IRFs) has been shown to improve seriously injured patients' long-term functional independence. However, not all patients with severe injuries are discharged to an IRF. The aim of this study is to examine differences in the proportion of severely injured patients discharged to IRFs across US states and assess the association between the regional supply of IRFs and the likelihood of IRF discharge.

Methods: We performed a retrospective analysis of 2021 Healthcare Cost and Utilization Project State Inpatient Databases across 13 states. We included severely injured (ISS >15) adult patients who survived to hospital discharge. We calculated the marginal probability of discharge to IRF, skilled nursing facility, home health agency, or home without services across states using a multinomial logistic regression model to control for patient demographics, insurance type, injury severity, medical comorbidities, and trauma center level. We also performed a mixed-effects logistic regression to evaluate the association between the supply of IRFs within individual states with the likelihood of discharge to IRF.

Results: We identified 104,017 severely injured patients. Across all 13 included states, 13% of patients were discharged to IRFs. There was considerable variation in the adjusted probability of discharge to an IRF across states, ranging from 6.4% in Oregon (95% confidence interval [CI], 5.6-7.1%) to 22.1% in Kentucky (95% CI, 20.8-23.4%), after controlling for potential confounders. The state-level supply of IRFs ranged from 0.49 to 8.63 per 1,000,000 population in Maryland and Arkansas, respectively. Each additional IRF per 1,000,000 population was associated with 11% increased odds of discharge to IRF (95% CI, 1.01-1.21; p = 0.024).

Conclusion: Severely injured patients face substantial differences in accessing high-level rehabilitation care at an IRF depending on their state of residence. Increasing the availability of IRFs within underserved states may improve access to specialized rehabilitation care for trauma patients.

Level of evidence: Therapeutic/Care Management; Level III.

Background: Geographic disparities in access to trauma care may contribute to excess firearm-related mortality. Trauma system expansion has progressed unevenly across the United States, and national-level assessments of its implications for patient outcomes are lacking.

Study design: We conducted a nationwide, county-level cross-sectional epidemiological study of 446,584 firearm-related injuries from January 1, 2014, to December 31, 2023, using data from the Gun Violence Archive and the US Census Bureau. Each county's optimal transport time (ground or air) to the nearest Level I/II trauma center was calculated using geospatial modeling. The primary outcome was case fatality rate (CFR), defined as the proportion of deaths among all reported firearm injuries. Multivariable Poisson regression was used to evaluate the relationship between transport time and CFR, adjusting for county-level sociodemographic characteristics, urbanicity, and US Census region.

Results: Of the 446,584 firearm injuries analyzed, 142,555 resulted in death (CFR, 31.9%). The population-weighted median optimal transport time was 30.9 minutes (interquartile range, 26.0-43.2). Case fatality rate increased significantly across transport time quartiles. After adjustment, each additional minute of transport time was independently associated with a 6.3% relative increase in CFR (incidence rate ratio 1.063; 95% confidence interval, 1.003-1.128; p = 0.04).

Conclusion: Prolonged transport time to trauma centers is significantly associated with increased firearm injury mortality across the United States, independent of sociodemographic factors. These findings support the use of geospatial information systems tools to guide trauma system planning, particularly in rural and underserved communities where geographic barriers remain a persistent threat to equitable outcomes.

Level of evidence: Epidemiologic Study; Level III.

Introduction: Platelet transfusion is a scarce resource in many trauma centers that is not without its own complications. Controversy exists in the literature regarding platelet transfusion in the setting of traumatic brain injury in patients on antiplatelet agents.

Methods: A search of the MEDLINE and Cochrane Reviews databases was used to identify all studies examining platelet transfusion and antiplatelet agents related to traumatic brain injury published from inception to March 2024. Study selection, data extraction, and bias assessment were conducted independently by two reviewers. Heterogeneity was assessed via I2 statistic, and publication bias was evaluated using Newcastle Ottawa Scale for cohort studies. A meta-analysis was performed to estimate pooled treatment effects with 95% confidence intervals (CIs).

Results: Of the 131 studies initially identified, 11 studies met the inclusion criteria comprising 1,326 patients who received platelet transfusion and 5,391 patients who did not. Across studies, patients receiving platelets were more severity injured than those who did not (mean Glasgow Coma Scale, 13.4 ± 0.44 vs. 14.2 ± 0.26; mean Injury Severity Score, 20.7 ± 0.9 vs. 18 ± 3.4). Pooled analysis found that receiving platelet transfusion did not significantly change the likelihood of mortality or hemorrhage progression (odds ratio, 1.40; 95% CI, 0.72-2.71; odds ratio, 1.09; 95% CI, 0.37-3.20, respectively). Both length of stay (LOS) and intensive care unit LOS were found to be significantly longer with platelet transfusion (2.2 days longer: 95% CI, 2.07-2.32; 3.06 days longer: 95% CI, 2.0-4.13).

Conclusion: The results currently available in the literature do not support the routine reversal of preinjury antiplatelet agents for reducing mortality or hemorrhage progression. Furthermore, the use of platelet transfusion in these patients may unnecessarily prolong intensive care unit and hospital LOS. This meta-analysis provides justification for randomized-controlled trials investigating the effects of platelet transfusion in head-injured patients on preinjury antiplatelet agents. Obtaining higher level of evidence will expedite the creation of high-quality evidence-based guidelines for the management of these complex patients.

Level of evidence: Systematic Review/Meta-analysis; Level IV.

Background: Trauma induces a "genomic storm" of gene expression in circulating leukocytes. We hypothesized that the neutrophil contribution to this response after blunt trauma varies with the magnitude of physiologic insult.

Methods: Blunt trauma patients had blood samples taken at 0 hour, 8 hours, 24 hours, and 72 hours postinjury. Clinical data on injury pattern, treatment, and outcomes were collected. Circulating neutrophils were isolated for whole transcriptome RNAseq. Over the 72-hour study period, differentially expressed genes were compared in trauma patients with and without admission lactate levels ≥3 mmol/L. Clinical outcomes and plasma effectors of neutrophil function were correlated with transcriptomic signatures.

Results: Nineteen patients were enrolled (median Injury Severity Score, 25; interquartile range, 14-36) with 14,517 genes analyzed. Admission serum lactate correlated with Injury Severity Score, organ failure at 72 hours postinjury, and distinct transcriptional changes, with 108 genes differentially expressed in neutrophils of high vs. low admission serum lactate patients. Top biological processes associated with high admission lactate included cAMP response element binding protein, rat sarcoma viral oncogene homolog/mitogen-activated protein kinase and nitric oxide pathways. Differentially expressed genes were clustered by dynamic expression. The largest cluster of differentially expressed genes in high vs. low admission lactate patients was associated with multiple pathways involved in neutrophil migration and extravasation. Similar to septic shock, the expression of a proinvasive transcriptional transcriptome was identified following injury and was most pronounced in patients with high admission serum lactate.

Conclusion: Cell type-specific analysis teases out the time- and insult-dependent neutrophil signal from the circulating leukocyte "storm." Neutrophil activation by severe trauma induces a proinvasive transcriptome signal, a potential link between the circulating and tissue phenotypes associated with poor clinical outcomes.

Level of evidence: Translational Prospective Cohort Study; Level IV.

Introduction: Mortality from pelvic ring fractures (PRFs) complicated by hemorrhagic shock remains high, and there are limited high-quality data to guide care. We compared two primary hemorrhage control interventions: pelvic angiography +/- embolization (PAE) and preperitoneal pelvic packing (PPP), hypothesizing similar odds of death.

Methods: A prospective, multicenter, observational study was conducted for individuals with blunt trauma-associated PRF with a systolic blood pressure of <90 mm Hg who received ≥4 U of packed red blood cells within 24 hours and/or used a hemorrhage control intervention (2022-2024). Bivariate comparisons, multivariable regression controlling for several clinical factors, and inverse probability treatment weighting analysis were performed. Primary outcomes were 3- and 6-hour mortality.

Results: Of 948 patients, 524 underwent either PPP (n = 68, 13.0%), PAE (n = 390, 74.4%), or both (n = 66, 12.6%) and comprise the study cohort. Compared with PAE, PPP patients had higher Injury Severity Scores (41 vs. 34, p < 0.001) and worse physiology (lowest systolic blood pressure, 62 vs. 74 mm Hg; lactate, 6.4 vs. 4.3; p < 0.001) and more frequently underwent laparotomy (67.6% vs. 23.6%, p < 0.001). In-hospital (47.1% vs. 18.5%, p < 0.001) and 24-hour (38.2% vs. 4.1%, p < 0.001) mortality were higher in PPP versus PAE with more earlier deaths (27.9% vs. 0.5% within 3 hours, p < 0.001). Preperitoneal pelvic packing was associated with higher odds of death at 3 hours (odds ratio, 64.0; confidence interval, 8.8-465.1) and 6 hours (odds ratio, 15.1; confidence interval, 4.4-51.7) compared with PAE. Inverse probability treatment weighting analysis demonstrated 19.4% higher probability of death at 6 hours for PPP versus PAE ( p < 0.001).

Conclusion: Whereas hypotensive patients with PRFs are more likely to undergo PAE, PPP is reserved for patients with more severe hemorrhagic shock, which may account for the observed higher mortality. Findings from this study suggest that PAE is an appropriate first-line therapy for most patients with bleeding pelvic fractures at trauma centers with rapid access to endovascular therapy.

Level of evidence: Therapeutic/Care Management; Level III.

Background: This systematic review and meta-analysis evaluated the efficacy and safety of ketamine for pain management in acute bone fractures, assessing pain intensity, additional analgesia needs, hospital stay, patient satisfaction, and adverse events.

Methods: A systematic search of PubMed, Cochrane, and Embase databases was conducted up to July 2025, identifying randomized controlled trials involving adult patients with acute bone fractures. Studies comparing ketamine (monotherapy or adjuvant) against placebo, standard care, or alternative pain management were included. Data extraction and risk of bias assessment were performed independently by two reviewers. Meta-analyses used random-effects models, with continuous outcomes analyzed via mean differences and standardized mean differences, and dichotomous outcomes via risk ratios.

Results: Fourteen randomized controlled trials, encompassing 1,453 patients, were included. No statistically significant differences in pain intensity were found between ketamine and control groups at 15, 30, or 60 minutes (p>0.05). Similarly, no significant differences were observed in additional analgesia requirements, hospital length of stay, or patient satisfaction (p>0.05). While overall adverse events were comparable, ketamine was associated with increased rates of nervous system (48% vs 16%) and psychiatric (14,6% vs 4%) adverse events. Sensitivity analysis, excluding high-risk bias studies, suggested a trend toward improved ketamine efficacy at 15 minutes (SMD -1.24; 95% CI -2.72, 0.24; p=0.10) and significant improvement at 30 minutes (SMD -0.43; 95% CI -0.12, 0.75; p=0.007).

Conclusion: Ketamine for acute bone fractures shows minimal to no difference in pain management compared with conventional approaches. However, a trend toward reduced additional analgesia, including opioid consumption, was noted. The increased incidence of nervous system and psychiatric adverse events with ketamine necessitates strict medical monitoring.

Level of evidence: Systematic Review and Meta-analysis; Level II.

Abstract: In 2023, the Trauma Burns and Surgical Critical Care Board (TBSCCB) embarked on the process of developing Entrustable Professional Activities (EPAs) for Surgical Critical Care (SCC) fellowships. This was accomplished in pre-planned stages, modeled after the general surgery EPA creation process, namely selection of EPAs by the TBSCCB members, recruitment of Reactor Panel and Writing Groups, drafting of EPA descriptions with inclusion/exclusion and scope by TBSCCB, engagement of the Reactor Panel, identification of phases of care, drafting of learner functions, development of cognitive frameworks, mapping to American College of Graduate Medical Education SCC 2.0 milestones, writing of expected behaviors, harmonization of behaviors and final editing and publication. There are several considerations that are unique to the specialty that presented particular challenges in the development and execution of SCC EPAs This article described the process that was utilized to create the suite of SCC EPAs and these unique challenges with which the Scope Council, Writing Group, and Reactor Panel were faced.