Trauma Surgery & Acute Care Open最新文献

Early-career surgeons must be exposed to a sufficient number of surgical cases of varying complexity in a mentored environment to allow them to solidify, sustain and build on the skills gained in training. Decreased operative volumes at military treatment facilities and assignments that do not include strong mentoring environments can place military surgeons at a disadvantage relative to their civilian counterparts during this critical time following training. The challenge of lower operative volumes in the current interwar lull has been exacerbated by the decline in beneficiary care conducted within the Military Healthcare System. These challenges must be addressed by ensuring early-career surgeons maintain exposure to a large volume of complex surgical procedures and deliberate mentoring from senior surgeons. The purpose of this position statement is to provide actionable methods to support early-career military surgeons to effectively transition from training to independent practice.

Background: Since current fascial traction methods involve invasive procedures, they are generally employed late in the management of the open abdomen (OA). This study aimed to evaluate early versus late placement of a non-invasive, pressure-regulated device for fascial reapproximation and gap reduction in OA patients.

Methods: The study included all patients who had the abdominal fascia intentionally left open after damage control operation for trauma and emergency general surgery and were managed with the device in an academic hospital between January 1, 2020, and December 31, 2023. Time of device placement in relation to the end of index laparotomy was defined as early (≤24 hours) versus late (>24 hours). Time-related mid-incisional width reduction of the fascial gap and fascial closure were assessed using descriptive and linear regression analysis.

Results: There was a significantly higher percent reduction in the fascial gap at the midpoint of the laparotomies in the early (≤24 hours) AbClo placement group compared with the late (>24 hours) AbClo placement group, respectively, median 76% versus 43%, p<0.001. Linear regression adjusting for body mass index and the number of takebacks indicated that fascial approximation was 22% higher for early placement (β=0.22; CI 0.12, 0.33, p<0.001). Primary myofascial closure rate with early (≤24 hours) application of the device was 98% versus 85% with late application.

Conclusion: Early non-invasive application of the device (≤24 hours) after the initial laparotomy resulted in greater reduction of the fascial gap and higher primary fascial closure rate compared with late placement (>24 hours). Early non-invasive intervention could prevent abdominal wall myofascial retraction in OA patients.

Level of evidence: IV.

I had the privilege to learn from Dr Sharon Henry, the American Association for the Surgery of Trauma (AAST) vice president, over the past year as the AAST Associate Membership Mentoring Scholarship recipient. This essay serves as a reflection on my year and was presented at the 2024 AAST Annual Meeting. Mentorship breaks down into two stages: finding a mentor and keeping a mentor. Finding a mentor can occur through a formal mentorship process or relationships formed organically. It takes a connection between two people and time for a relationship to form. Keeping a mentor takes effort and intentionality. Mentorship doesn't end when the scholarship does. It is fluid, without direction, without a timeline, and it will evolve. It will take effort and intention to keep a mentor, but the reward is so great for all that effort put in. Often, what we receive out of mentorship cannot be quantified but the impact is profound.

In 1966, the National Academy of Sciences and National Research Council published 'Accidental Death and Disability: the Neglected Disease of Modern Society' which served as a national call to action to address the apparent public apathy towards the devastating and unnecessary toll that injury was taking on America. This white paper recommended the establishment of a National Trauma Association to drive public demand for injury prevention and mitigation. The American Association for the Surgery of Trauma heeding that call, founded the American Trauma Society (ATS) in 1968. Since its founding and with a mission of 'Save Lives. Improve Care. Empowering Survivors', the ATS has had a 56-year legacy of service to improve trauma care by providing professional and public education, advocacy for injury and violence prevention, and attending to the unique needs of trauma survivors and their families. As a focus of the ATS's advocacy efforts, the ATS's Legislative and Policy Committee (LPC) formulates the organization's legislative goals and strategy by reviewing proposed legislation and regulations that may favorably or adversely affect trauma professionals, and disseminating key information as position statements to the membership and public for edification and/or action. In accordance with this effort, the ATS has partnered with the Trauma Surgery and Acute Care Open to publish these important collaborative endeavors. For this inaugural publication of an ATS position statement, the topic we chose is workplace violence (WPV) in trauma centers. A work group of the ATS's LPC reviewed current literature gathered from a variety of organizational and agency sources addressing safety and protection of healthcare providers from WPV including federal and state legislative and regulatory initiatives. Based on the work groups review, we provide eight recommendations regarding the prevention, mitigation, or handling of WPV. We also review and discuss best practices and risk mitigation strategies, providing a listing of them in an accompanying appendix.

Since its inception, the specialty of acute care surgery has evolved and now represents a field with a broad clinical scope and large variations in implementation and practice. These variations produce unique challenges and there is no consistent definition of the scope, intensity or value of the work performed by acute care surgeons. This lack of clarity regarding expectations extends to surgeons and non-surgeons outside of our specialty, compounding difficulties in advocacy at the local, regional and national levels. Coupled with a lack of clarity surrounding the definition of full-time employment, these challenges have prompted surgeons to develop initiatives within acute care surgery in collaboration with the American Association for the Surgery of Trauma (AAST). A panel session at the AAST 2023 annual meeting was held to discuss the need to define a full-time equivalent for an acute care surgeon and how to consider and incorporate non-clinical responsibilities. Experiences, perspectives and propositions for change were discussed and are presented here.

Introduction: Screening, brief intervention, and referral to treatment (SBIRT) has demonstrated up to 50% reduction in alcohol-related traumatic injury and is mandated by the American College of Surgeons for trauma center accreditation. While SBIRT effectiveness has been previously investigated, optimal implementation in the trauma setting has not. We sought to improve SBIRT compliance through integration of screening into a performance improvement checklist (PIC) deployed during morning report. We hypothesized that PIC would establish a self-sustaining model for improved alcohol screening/intervention.

Methods: This was a retrospective study comparing trauma patients pre-PIC (January-May 2022) to post-PIC (January-May 2023) after PIC implementation in January 2023. The primary outcome was SBIRT performance. The PIC prompted alcohol intervention specialist consultation if blood alcohol content >80 mg/dL, <21 years old, or Alcohol Use Disorders Identification Test ≥8. Significance was determined if p<0.05.

Results: There were 705 pre-PIC and 840 post-PIC patients. Pre-PIC unscreened patients were more often uninsured (13% vs. 25%, p<0.01) and black (8% vs. 14%, p=0.02) compared with screened pre-PIC patients. There were no significant differences among screened versus unscreened patients after PIC with respect to age, sex, race, or ethnicity (p>0.05). Overall, screening improved pre-PIC to post-PIC (52% vs. 88%, p<0.01) and the percentage of patients who screened positively also increased after PIC (8% vs. 23%, p<0.01). Brief intervention was unchanged (83% vs. 81%, p=1).

Conclusion: The PIC is a novel tool that demonstrated improved alcohol screening and referral. It improved compliance with SBIRT and reduced implicit bias in the population screened. Utilization of a PIC is easily translatable to other centers and could become a national standard to advance performance improvement.

Level of evidence: IV.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly being used for temporary bleeding control in patients with trauma with non-compressible truncal hemorrhage (NCTH). In recent years, the technique is gaining popularity in postpartum hemorrhage and non-traumatic cardiac arrest, although still underutilized. In other surgical fields, however, there is not yet much awareness for the possible advantages of this technique. Consequently, for non-trauma indications, limited data are available.

Methods: Description of the use of REBOA in two patients with hemorrhagic shock due to exsanguinating non-traumatic NCTH.

Results: In the first case, REBOA was deployed at the emergency department in a patient in their 80s presenting with hemorrhagic shock due to a ruptured abdominal aortic aneurysm. Hemodynamic stability was obtained and a CT scan was subsequently performed for planning of endovascular aneurysm repair. After successful placement of the endograft, the REBOA catheter was deflated and removed. In the second case, REBOA was performed in a patient with shock due to iatrogenic epigastric artery bleeding after an umbilical hernia repair to prevent hemodynamic collapse and facilitate induction of anesthesia for definitive surgery. During laparotomy, blood pressure-guided intermittent aortic balloon occlusion was used to preserve perfusion of the abdominal organs. Patient made a full recovery.

Conclusion: REBOA deployment was successful in achieving temporary hemorrhage control and hemodynamic stability in patients with non-traumatic NCTH. REBOA facilitated diagnostic work-up, transportation to the operating room and prevented hemodynamic collapse during definitive surgical repair. In the right patient and skilled hands, this relatively simple endovascular procedure could buy precious time and prove lifesaving in a variety of non-compressible hemorrhage.

Unplanned intensive care unit (ICU) admission (UIA) is a Trauma Quality Improvement Program benchmark that is associated with increased morbidity, mortality, and length of stay (LOS). Elderly patients with multiple rib fractures are at increased risk of respiratory failure. The Integrated Pulmonary Index (IPI) assesses respiratory compromise by incorporating SpO₂, respiratory rate, pulse, and end-tidal CO₂ to yield an integer between 1 and 10 (worst and best). We hypothesized that IPI monitoring would decrease UIA for respiratory failure in elderly trauma patients with rib fractures.

Methods: Elderly (≥65 years old) trauma inpatients admitted to a level 1 trauma center from February 2020 to February 2023 were retrospectively studied during the introduction of IPI monitoring on the trauma floor. Patients with ≥4 rib fractures (or ≥2 with history of chronic obstructive pulmonary disease) were eligible for IPI monitoring and were compared with a group of chest Abbreviated Injury Scale score of 3 (≥3 rib fractures) patients who received usual care. Nurses contacted the surgeon for IPI ≤7. Patient intervention was left to the discretion of the provider. The primary endpoint was UIA for respiratory failure. Secondary endpoints were overall UIA, mortality, and LOS. Statistical analysis was performed using χ² test and Student's t-test, with p<0.05 considered significant.

Results: A total of 110 patients received IPI monitoring and were compared with 207 patients who did not. The IPI cohort was comparable to the non-IPI cohort in terms of gender, Injury Severity Score, Abbreviated Injury Scale, mortality, and LOS. There were 16 UIAs in the non-IPI cohort and two in the IPI cohort (p=0.039). There were no UIAs for respiratory failure in the IPI group compared with nine in the non-IPI group (p=0.03).

Conclusion: IPI monitoring is an easy-to-set up tool with minimal risk and was associated with a significant decrease in UIA in elderly patients with rib fracture.

Level of evidence: Level III, therapeutic/care management.