Trauma Surgery & Acute Care Open最新文献

Background: Non-operative management (NOM) of blunt splenic injury (BSI) is the target for pediatric trauma care. Yet, the rates of splenectomy have historically been higher at non-pediatric trauma centers (PTCs). We sought to determine if this difference improved contemporaneously.

Methods: Using the National Trauma Data Bank, 26 707 pediatric patients (age ≤18 years, 2013 to 2021) with BSI were identified and analyzed based on care at adult trauma centers (ATCs), dual trauma centers (DTCs), or pediatric trauma centers (PTCs) using descriptive statistics and logistic regressions. The primary outcome was splenectomy rate.

Results: Of the 26 707 pediatric patients with BSI, 5569 (20.9%) were treated at PTCs, 11 904 (44.6%) at ATCs, and 9234 (34.6%) at DTCs. In a multivariable logistic regression model, pediatric patients had significantly higher odds of splenectomy at ATCs (OR 4.89; 95% CI 3.82 to 6.45) and DTCs (OR 3.31; 95% CI 2.57 to 4.31) versus PTCs. In a subanalysis, older patients (15 years to 18 years) also had a significantly higher odds of splenectomy at ATCs (OR 7.27; 95% CI 4.58 to 12.1) and DTCs (OR 5.10; 95% CI 3.18 to 8.57) versus PTCs. Of patients aged 15 years to 18 years the majority were treated at ATCs (58.6%) or DTCs (32.1%) compared with PTCs (9.3%), whereas 32.6% of patients aged <15 years were treated at PTCs. These differences persisted across the study period.

Conclusion: Pediatric patients with BSI continue to have higher splenectomy rates when they are treated at ATCs and DTCs compared with PTCs. To improve these rates, healthcare systems should expand access to PTCs and investigate causality to improve pediatric trauma care rendered at ATCs and DTCs.

Level of evidence: Level II.

Effective leadership during trauma resuscitation is a determinant of team performance and patient outcomes, yet existing training curricula remain procedure-centric and do not explicitly address the leadership domain. A structured, competency-based framework tailored to the resuscitation context may support more consistent training, evaluation, and entrustment of emerging trauma leaders. A narrative review of the literature was conducted across MEDLINE, Embase and Scopus using terms related to trauma, leadership, non-technical skills and competency frameworks. Relevant publications were categorized into: (1) leadership theory and styles; (2) non-technical skills frameworks; (3) trauma resuscitation education and assessment and (4) high-reliability team training from allied domains. Concepts were synthesized to derive a set of core competencies for trauma resuscitation leadership. Five interdependent competencies were identified: (1) adaptive leadership style matched to clinical context; (2) time-bound decision-making under uncertainty; (3) communication strategies that balance clarity with brevity; (4) fostering psychological safety and team coordination and (5) ongoing self-reflection with coached feedback. A continuum of leadership styles, spanning directive to facilitative, was adapted to the acute resuscitation environment. Educational modalities proposed include high-fidelity simulation, structured video review, in-situ coaching and behavioral checklists linked to entrustable professional activities. The framework delineates leadership training as distinct from, but complementary to, established technical protocols such as Advanced Trauma Life Support. This competency-based framework provides a structured approach to developing trauma resuscitation leadership skills. By defining observable behaviors, mapping them to multimodal training methods and proposing evaluation strategies, it offers a basis for systematic integration into trauma education. The framework may enhance reproducibility of training, strengthen team performance and improve patient care in high-acuity environments. Level of evidence: Narrative review.

Background: Traumatic abdominal wall hernias (TAWHs) are uncommon but serious injuries resulting from blunt abdominal trauma. Despite their low incidence, the associated morbidity and mortality rates necessitate effective management strategies. This study aims to assess the incidence, injury patterns, and optimal management strategies for TAWHs.

Method: This retrospective cohort study was conducted at a level-1 trauma center in Melbourne, Australia, spanning 20 years. Patients diagnosed with TAWHs between October 2002 and October 2023 were identified through trauma and radiological databases.

Results: Out of 220 patients identified, 71 were confirmed to have TAWHs. The mean age was 45.2 years. High-speed motor vehicle collisions were the most common injury mechanism. About 54% of patients required intensive care unit admission, and 53.5% underwent trauma laparoscopy/laparotomy. Key factors necessitating immediate operation included CT findings of free gas, perforation, degloving injury, hypoattenuation suggestive of bowel ischemia, and traumatic bowel injury. Additional CT findings significantly associated with intra-abdominal injury were free fluid, hematoma, contrast extravasation to suggest active hemorrhage, and bowel herniation through the hernia defect. The majority of patients without these CT findings were successfully managed conservatively, with the option of elective mesh repair.

Conclusion: Our study highlights the need for clinical vigilance in high-energy trauma cases and the use of CT in diagnosis. Although trauma laparotomy is essential for suspected intra-abdominal injury, select hemodynamically stable patients may be safely managed non-operatively.

Level of evidence: III, diagnostic test/criteria.

Background: The trauma triad of death, consisting of hypothermia, acidosis, and coagulopathy, has long been recognized as a major cause of mortality in trauma patients. Recently, hypocalcemia has emerged as a fourth component that plays a critical role in the prognosis of these patients. The objective of this meta-analysis is to evaluate the association between hypocalcemia and mortality among trauma patients.

Methods: The authors systematically reviewed studies published in English from OVID, EMBASE, and Cochrane databases between January 1, 2000 and October 31, 2024. Randomized controlled trials and cohort studies reporting mortality rates among trauma patients with hypocalcemia were included. A meta-analysis was conducted using random effects models. The methodological quality of the studies was assessed using the Cochrane risk of bias tool.

Results: Of the 4,209 studies identified, 20 were included in the meta-analysis. Trauma patients with hypocalcemia had a statistically significant increase in mortality (OR 2.79; 95% CI 2.01 to 3.89). This increase in mortality was also observed in subgroup analysis based on the timing of calcium level measurement: before blood transfusion (OR 2.45; 95% CI 1.75 to 3.43; I2=59%), before or after blood transfusion (OR 1.61; 95% CI 1.26 to 2.05; I2=0%), and no available data on the timing of calcium level measurement (OR 3.97; 95% CI 2.24 to 7.02; I2=78%). Notably, hypocalcemia was associated with increased mortality regardless of whether calcium levels were measured before or after blood transfusion. In terms of hypocalcemia severity, we found that more severe hypocalcemia was associated with higher mortality.

Conclusions: Hypocalcemia in trauma patients is associated with increased mortality. We suggest that hypocalcemia should be closely monitored regardless of the transfusion history.

Trial registration number: INPLASY number, 202330116.

Background: To evaluate the short-term clinical performance of Symvess (acellular tissue engineered vessel-tyod), formerly known as human acellular vessel, or HAV, compared with autologous vein for the treatment of extremity arterial injury.

Methods: Subjects treated with acellular tissue engineered vessel (ATEV) from two clinical trials were propensity score-matched on a 1:2 basis to PROspective Observational Vascular Injury Trial (PROOVIT) registry subjects with the same injured artery and treated with autologous vein. Matching characteristics included age, sex, trauma type (penetrating vs blunt), injury severity score, mangled extremity severity score, concomitant fracture, shunt use, and ischemia duration>6 hours. Incidence of outcomes (primary/secondary patency, amputation, conduit infection, reintervention for thrombosis/stenosis, pseudoaneurysm, and death) was assessed by a generalized linear model. Outcomes were assessed at Day 30 (ATEV group) or during initial hospitalization (autologous group).

Results: ATEV subjects lacking suitable autologous vein (n=67) and PROOVIT subjects treated with autologous vein (n=134) suffered injuries to axillary, brachial, femoral, popliteal, and posterior tibial arteries. Subgroups were clinically similar; Injury Severity Score, Mangled Extremity Severity Score, and duration of follow-up (16 vs 30 days) were higher for the ATEV subgroup.Primary patency for the ATEV versus autologous group was 86.6% versus 91.8%, secondary patency: 91.0% versus 97.7%; amputation: 7.5% versus 8.2%; conduit infection: 1.5% versus 0%; reintervention for thrombosis or stenosis: 6.0% versus 8.2%; and death 4.5% versus 4.5%, respectively. No cases of pseudoaneurysm, true aneurysm, or significant differences between the ATEV and autologous groups for any outcome were observed.

Conclusions: Short-term outcomes were similar between ATEV subjects without feasible autologous vein, and propensity score-matched autologous vein recipients from the PROOVIT registry. The ATEV may provide effective and safe revascularization in subjects with extremity arterial injury without feasible autologous vein.

Level of evidence: Level 3, Therapeutic/Care Management.

Background: Exsanguinating hemorrhage is the leading cause of death in combat casualty care. With improvement in body armor, risk for extremity injuries is increasingly making surgical control of vessels and extremity fasciotomies critically important for saving life and/or limb. Yet, surgeon hands-on experience with major trauma has decreased. In military settings, with limited surgical resources, surgeons could be required to work independently and outside their scope of expertise. We explored whether just-in-time skill refreshment with video review improves performance of selected procedures.

Methods: Surgeons (n=44) performed upper and lower extremity fasciotomies and axillary and femoral artery exposures on anatomic donors. They were divided into two groups: one group received Surgical Technical Assistance Tool (STAT) video procedure assistance and the other received no assistance (control group). Performance was evaluated using a five-component (anatomy, pathophysiology, patient management, technical skills, and procedural) Individual Procedure Score (IPS). The total number of compartment decompressions/constriction releases (maximum 10, combined fasciotomy procedures) and number of vessels controlled (maximum of four, combined vascular procedures) were measured. Each compartment decompression/constriction release and each vessel controlled are also single data points within the IPS.

Results: In combined fasciotomies, STAT significantly improved the number of successful compartment decompressions/constriction releases as well as procedural, anatomy, and technical IPS components. In combined vascular procedures, STAT improved anatomy IPS, but not the number of vessels successfully controlled. For successful compartment decompression/constriction release, there was a significant linear correlation with procedural, anatomy, and technical IPS components. For successful vascular control, there was a significant linear correlation with procedural and technical IPS components. There was no correlation between success and pathophysiology or patient management scores.

Conclusion: A video-based, just-in-time refresher tool can dramatically improve procedural success and performance scores in procedural, anatomy, and technical components during trauma-related extremity procedures.

Level of evidence: Level II, Original Research, Therapeutic/Care Management.

Background: Burnout is increasingly recognized as a critical occupational issue impacting physician well-being and patient care. Although surgeons are known to experience high burnout rates, the specific burden among trauma surgeons remains poorly researched. This systematic review and meta-analysis focuses on burnout exclusively among trauma surgeons. We aim to analyze the prevalence of burnout among trauma surgeons and identify associated factors by analyzing their alleviating and exacerbating influences through systematic review, meta-analysis, and meta-regression.

Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines, we used a combination of searching databases, individual journals and cross-referencing. Two independent reviewers screened studies measuring burnout in trauma surgeons. A random-effects meta-analysis was performed using logit-transformed proportions. Heterogeneity was assessed using I² statistics and meta-regression examined the impact of measurement tools.

Results: Analysis of 19 studies (n=4,634) revealed a pooled burnout prevalence of 60.0% (95% CI 46.9% to 74.4%) with substantial heterogeneity (I²=97.9%, p<0.0001). Studies using the Maslach Burnout Inventory (n=13) showed high emotional exhaustion (35.2%) and depersonalization (45.6%), but maintained strong personal accomplishment (75.3%). Key burnout-exacerbating factors included younger age, long working hours, and administrative burden, whereas protective factors included mentorship and protected non-clinical time.

Conclusions: Trauma surgeons experience among the highest burnout rates reported among surgical specialties, warranting systemic physician-centric interventions, with a shift in focus from diagnosis to prevention. Despite significant occupational stressors, persistently high personal accomplishment levels suggest specialty-specific resilience factors, meriting further investigation. Evidence-based strategies, including formal mentorship programs, psychological risk management models, and protected non-clinical time have the potential to mitigate burnout.