Journal of Trauma and Acute Care Surgery最新文献

Background: Current tools to review focused abdominal sonography for trauma (FAST) images for quality have poorly defined grading criteria or are developed to grade the skills of the sonographer and not the examination. The purpose of this study is to establish a grading system with substantial agreement among coders, thereby enabling the development of an automated assessment tool for FAST examinations using artificial intelligence (AI).

Methods: Five coders labeled a set of FAST clips. Each coder was responsible for a different subset of clips (10% of the clips were labeled in triplicate to evaluate intercoder reliability). The clips were labeled with a quality score from 1 (lowest quality) to 5 (highest quality). Clips of 3 or greater were considered passing. An AI training model was developed to score the quality of the FAST examination. The clips were split into a training set, a validation set, and a test set. The predicted scores were rounded to the nearest quality level to distinguish passing from failing clips.

Results: A total of 1,514 qualified clips (1,399 passing and 115 failing clips) were evaluated in the final data set. This final data set had a 94% agreement between pairs of coders on the pass/fail prediction, and the set had a Krippendorff α of 66%. The decision threshold can be tuned to achieve the desired tradeoff between precision and sensitivity. Without using the AI model, a reviewer would, on average, examine roughly 25 clips for every 1 failing clip identified. In contrast, using our model with a decision threshold of 0.015, a reviewer would examine roughly five clips for every one failing clip - a fivefold reduction in clips reviewed while still correctly identifying 85% of passing clips.

Conclusion: Integration of AI holds significant promise in improving the accurate evaluation of FAST images while simultaneously alleviating the workload burden on expert physicians.

Level of evidence: Diagnostic Test/Criteria; Level II.

Background: There are no validated and sensitive models that can guide the decision regarding amputation in patients with mangled lower extremities. We sought to describe a simple scoring model, the Mangled Lower Extremity (MangLE) score, which can predict those who are highly unlikely to need an amputation as a means to direct resources to this cohort.

Methods: This is a retrospective study using the 2013-2021 American College of Surgeons Trauma Quality Improvement Program data set. Adult patients with a mangled lower extremity, defined as a crush injury or a fracture of the femur or tibia combined with severe soft tissue injury, arterial injury, or nerve injury, were included. Patients who suffered a traumatic lower extremity amputation, underwent amputation within 24 hours of admission, or who died within 24 hours of admission were excluded. Patients were divided into those who did/did not undergo amputation during their hospital stay. Demographics, injury mechanism, Injury Severity Score, and Abbreviated Injury Scale score, initial vital signs, and comorbid conditions were abstracted. A logistic regression model was constructed and the top five most important variables were used to create the score.

Results: The study includes 107,620 patients, of whom 2,711 (2.5%) underwent amputation. The five variables with the highest predictive value for amputation were arterial injury, lower-extremity Abbreviated Injury Scale score of ≥3, crush injury, blunt mechanism, and shock index. The lowest possible MangLE score was 0, and the highest was 15. The model demonstrated an excellent predictive ability for lower extremity amputation in both the development and validation data set with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.80-0.82) and 0.82 (95% confidence interval, 0.81-0.84), respectively. The negative predictive value for a score of <8 is 99%.

Conclusion: The MangLE score is able to identify patients who are unlikely to require amputation. Resources for limb salvage can be directed to this cohort.

Level of evidence: Prognostic and Epidemiological; Level IV.

Background: One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without.

Methods: This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation.

Results: A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation.

Conclusion: There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients.

Level of evidence: Prognostic and Epidemiological; Level II.

Background: Whole blood (WB) transfusion, compared with blood component therapy (CT), has been shown to have superior outcomes in the military population. However, whether this translates to the civilian population remains understudied. This study sought to determine the effect of WB on short-term in-hospital outcomes.

Methods: This retrospective cohort study included trauma patients at a Level I trauma center who received either WB or CT upon massive transfusion protocol activation between January 2021 and June 2023. The primary outcome was in-hospital mortality, and secondary outcomes included 24-hour mortality, 7-day mortality, 30-day mortality, trauma-induced coagulopathy, and the number of transfusion events required. The effect of transfusion type on patient outcomes was evaluated using a propensity-weighted modified Poisson regression.

Results: Of 1,027 massive transfusion protocol-activated patients, 480 (46.8%) received any WB. The propensity score weighting balanced the covariate distribution between the transfusion groups. Significant effect modification ( p < 0.05) by injury type (blunt vs. penetrating) on mortality outcomes was observed. Compared with CT recipients, penetrating trauma patients who received WB had a significantly lower adjusted risk of in-hospital (risk ratio [RR], 0.36; 95% confidence interval [CI], 0.15-0.89), 7-day (RR, 0.37; 95% CI, 0.15-0.94), and 30-day (RR, 0.36; 95% CI, 0.15-0.89) mortality but not significantly different 24-hour mortality (RR, 0.39; 95% CI, 0.15-1.00; p = 0.05). An elevated risk of trauma-induced coagulopathy was observed among WB recipients than CT recipients with blunt trauma (RR, 1.59; 95% CI, 1.07-2.36) but not among patients with penetrating injury (RR, 0.65; 95% CI, 0.30-1.40). Compared with CT recipients, WB recipients had reduced transfusion rates for both penetrating (RR, 0.59; 95% CI, 0.36-0.95) and blunt-related injuries (RR, 0.73; 95% CI, 0.58-0.91).

Conclusion: The effect of WB on in-hospital mortality is modified by injury type, suggesting the need to consider penetrating injury as an important indication for WB resuscitation. In addition, WB reduces transfusion requirements across both injury types, decreasing patient exposure to transfusion events.

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

Background: Unplanned return to the operating room (uROR) is associated with worse outcomes and increased mortality. Little is known regarding intraoperative factors associated with uROR after emergent surgery in trauma patients. The objective of this study was to identify intraoperative factors associated with uROR after emergent hemorrhage control procedures in bleeding trauma patients.

Methods: We used anesthetic record of intraoperative management to perform a retrospective study (2017-2022) of bleeding trauma patients who were taken for an emergent hemorrhage control operation.

Results: A total of 225 patients met the inclusion criteria, 46 (20%) had uROR, and 181 (80%) did not. While there was no difference in demographics, mechanism, admission physiology, or time from emergency department to operating room, the uROR patients had a higher Injury Severity Score (30 vs. 25, p = 0.007). While there was no difference in volume of crystalloid infused (3,552 ± 2,279 mL vs. 2,977 ± 2,817 mL, p = 0.20), whole blood (2.2 ± 0.9 vs. 2.0 ± 0.5, p = 0.20), or platelets (11.6 ± 8.6 vs. 9.2 ± 9.0, p = 0.14), the uROR group received more packed red blood cells (11.5 ± 10.6 vs. 7.8 ± 7.5, p = 0.006) and plasma (9.6 ± 8.3 vs. 6.5 ± 6.6, p = 0.01), and more uROR patients received ≥10 U of packed red blood cells (48% vs. 27%, p = 0.006). Damage-control surgery (DCS) was more common in uROR patients (78% vs. 45%, p < 0.0001). After logistic regression, ≥10 U of packed cells in the operating room (4.3 [1.5-12.8], p = 0.009), crystalloid (1.0 [1.0-1.001], p = 0.009), International Normalized Ratio (INR) (7.6 [1.3-45.7], p = 0.03), and DCS (5.7 [1.7-19.1], p = 0.005) were independently associated with uROR.

Conclusion: Massive transfusion, crystalloid resuscitation, persistent coagulopathy, and DCS are the most significant risk factors for uROR. During hemorrhage control surgery in bleeding trauma patients who receive ≥10 U of blood, providers must maintain a keen focus on minimizing crystalloid and ongoing balanced resuscitation, particularly during damage-control procedures.

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

Background: Vascular surgery board eligibility may be secured through 5+0 integrated programs (IV) as well as 5+2 general surgery/vascular fellowship pathway (VF). We hypothesized that IV graduates accrue less experience relevant to vascular trauma than VF graduates. We assessed the first decade of IV graduate experience and compared it to contemporaneous VF graduates.

Methods: The 2013-2022 Accreditation Council for Graduate Medical Education case log data were collected for IV and VF graduates. Vascular fellows' data were combined with synchronousgeneral surgery residency data. Open vascular cases were classed as cerebrovascular, upper extremity, thoracic, abdominopelvic, infrainguinal, and infrapopliteal. Nonvascular open cases were categorized as neck, thoracic, and abdominopelvic. Nonoperative trauma and critical care data were recorded.

Results: There were 1,224 VF and 397 IV graduates. In 2012, 8.3% of graduating vascular surgeons trained in IV programs. By 2022, this proportion was 32.6%. The number of IV programs increased by 4.4 programs per year over the study period ( p < 0.05), whereas VF programs remained unchanged. Integrated vascular chiefs logged significantly more lower extremity cases, and VFs logged more upper extremity cases ( p < 0.05). IV graduates reported a fraction of the VF open nonvascular cases. Integrated vascular graduates logged 5% of the abdominopelvic, 18% of the thoracic, and 3% of the neck cases of VFs ( p < 0.05). Vascular fellows' critical care and nonoperative trauma were each higher than those of IV fellows ( p < 0.05). Integrated vascular graduates logged six vascular repairs for every vascular exposure.

Conclusion: The proportion of vascular surgeons trained through IV programs has nearly quadrupled. Integrated vascular graduates have a fraction of the experience in critical care, trauma, and nonvascular surgery compared with VF graduates. Relative inexperience with open surgical anatomy and with critically ill patients may limit IV graduates' ability to care for the patient with vascular trauma.

Level of evidence: Diagnostic Test/Criteria; Level IV.