To leave or not to leave: American Association for the Surgery of Trauma (AAST) panel discussion on personal, parental, and family leave.

Navigating planned and emergent leave during medical practice is very confusing to most physicians. This is especially challenging to the trauma and acute care surgeon, whose practice is unique due to overnight in-hospital call, alternating coverage of different services, and trauma center's staffing challenges. This is further compounded by a surgical culture that promotes the image of a 'tough' surgeon and forgoing one's personal needs on behalf of patients and colleagues. Frequently, surgeons find themselves having to make a choice at the crossroads of personal and family needs with work obligations: to leave or not to leave. Often, surgeons prioritize their professional commitment over personal wellness and family support. Extensive research has been conducted on the topic of maternity leave and inequality towards female surgeons, primarily focused on trainees. The value of paternity leave has been increasingly recognized recently. Consequently, significant policy changes have been implemented to support trainees. Practicing surgeon, however, often lack such policy support, and thus may default to local culture or contractual agreement. A panel session at the American Association for the Surgery of Trauma 2022 annual meeting was held to discuss the current status of planned or unanticipated leave for practicing surgeons. Experiences, perspectives, and propositions for change were discussed, and are presented here.

Outcomes after Child Physical Abuse and Association with Community-Level Social Determinants of Health.

BACKGROUND: Child physical abuse is a significant cause of pediatric injury and death. Previous studies have described disparities in outcomes for physically abused children according to insurance status. We hypothesized that children treated for physical abuse would be more likely to live in neighborhoods with increased socioeconomic deprivation. STUDY DESIGN: We performed a retrospective review of children who were admitted with suspected physical abuse from 2011 to 2021. Home addresses at the time of admission were used to assign an Area Deprivation Index (ADI) of the neighborhood. Clinicopathologic and outcome variables were compared between children from neighborhoods in the top 10th and bottom 90th national neighborhood ADI percentile. Univariate and multivariate logistic models were constructed. RESULTS: One hundred eighty-four children were included for analysis. Children from the top 10th (more impoverished) ADI percentile presented with more severe injuries, had higher area injury scores in the abdomen and extremities, and required admission to the intensive care unit more often, compared with children from the bottom 90th ADI percentile (all p Values <0.05). Children from high ADI neighborhoods were more likely to be discharged to a different caretaker than children from low ADI neighborhoods (71% caretaker change vs 49% caretaker change, p = 0.005). Univariate and multivariate logistic regression demonstrated statistically significant association between the ADI score and the need for caretaker change at the time of discharge (p = 0.004). CONCLUSIONS: Community-level social determinants of health are closely associated with child physical abuse. Child abuse reduction strategies might consider increased support for families with fewer resources and social support systems.

Artificial neural networks can predict trauma volume and acuity regardless of center size and geography: A multicenter study.

BACKGROUND: Trauma has long been considered unpredictable. Artificial neural networks (ANN) have recently shown the ability to predict admission volume, acuity, and operative needs at a single trauma center with very high reliability. This model has not been tested in a multicenter model with differing climate and geography. We hypothesize that an ANN can accurately predict trauma admission volume, penetrating trauma admissions, and mean Injury Severity Score (ISS) with a high degree of reliability across multiple trauma centers. METHODS: Three years of admission data were collected from five geographically distinct US Level I trauma centers. Patients with incomplete data, pediatric patients, and primary thermal injuries were excluded. Daily number of traumas, number of penetrating cases, and mean ISS were tabulated from each center along with National Oceanic and Atmospheric Administration data from local airports. We trained a single two-layer feed-forward ANN on a random majority (70%) partitioning of data from all centers using Bayesian Regularization and minimizing mean squared error. Pearson's product-moment correlation coefficient was calculated for each partition, each trauma center, and for high- and low-volume days (>1 standard deviation above or below mean total number of traumas). RESULTS: There were 5,410 days included. There were 43,380 traumas, including 4,982 penetrating traumas. The mean ISS was 11.78 (SD = 6.12). On the training partition, we achieved R = 0.8733. On the testing partition (new data to the model), we achieved R = 0.8732, with a combined R = 0.8732. For high- and low-volume days, we achieved R = 0.8934 and R = 0.7963, respectively. CONCLUSION: An ANN successfully predicted trauma volumes and acuity across multiple trauma centers with very high levels of reliability. The correlation was highest during periods of peak volume. This can potentially provide a framework for determining resource allocation at both the trauma system level and the individual hospital level. LEVEL OF EVIDENCE: Care Management, level IV.

Surgical Management of Solid Organ Injuries.

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Paying it forward: Four-year analysis of the Eastern Association for the Surgery of Trauma Mentoring Program.

BACKGROUND: Mentorship programs in surgery are used to overcome barriers to clinical and academic productivity, research success, and work-life balance. We sought to determine if the Eastern Association for the Surgery of Trauma (EAST) Mentoring Program has met its goals of fostering academic and personal growth in young acute care surgeons. METHODS: We conducted a systematic program evaluation of EAST Mentoring Program's first 4 years. Demographic information was collected from EAST records, mentorship program applications, and mentee-mentor career development plans. We reviewed the career development plans for thematic commonalities and results of a structured, online questionnaire distributed since program inception. A mixed methods approach was used to better understand the program goals from both mentee and mentor perspectives, as well as attitudes and barriers regarding the perceived success of this career development program. RESULTS: During 2012 to 2015, 65 mentoring dyads were paired and 60 completed the program. Of 184 surveys distributed, 108 were returned (57% response rate). Respondents were evenly distributed between mentees and mentors (53 vs. 55, p = 0.768). In participant surveys, mentoring relationships were viewed to focus on research (45%), "sticky situations" (e.g., communication, work-life balance) (27%), education (18%), or administrative issues (10%). Mentees were more focused on research and education versus mentors (74% vs. 50%; p = 0.040). Mentees felt that goals were "always" or "usually" met versus mentors (89% vs. 77%; p = 0.096). Two barriers to successful mentorship included time and communication, with most pairs communicating by email. Most respondents (91%) planned to continue the relationship beyond the EAST Mentoring Program and recommended the experience to colleagues. CONCLUSION: Mentee satisfaction with the EAST Mentoring Program was high. Mentoring is a beneficial tool to promote success among EAST's young members, but differences exist between mentee and mentor perceptions. Revising communication expectations and time commitment to improve career development may help our young acute care surgeons.

External validation of the Air Medical Prehospital Triage score for identifying trauma patients likely to benefit from scene helicopter transport.

BACKGROUND: The Air Medical Prehospital Triage (AMPT) score was developed to identify injured patients who may benefit from scene helicopter emergency medical services (HEMS) transport. External validation using a different data set is essential to ensure reliable performance. The study objective was to validate the effectiveness of the AMPT score to identify patients with a survival benefit from HEMS using the Pennsylvania Trauma Outcomes Study registry. METHODS: Patients 16 years or older undergoing scene HEMS or ground EMS (GEMS) transport in the Pennsylvania Trauma Outcomes Study registry 2000-2013 were included. Patients with 2 or higher AMPT score points were triaged to HEMS, while those with less than 2 points were triaged to GEMS. Multilevel Poisson regression determined the association of survival with actual transport mode across AMPT score triage assignments, adjusting for demographics, mechanism, vital signs, interventions, and injury severity. Successful validation was defined as no survival benefit for actual HEMS transport in patients triaged to GEMS by the AMPT score, with a survival benefit for actual HEMS transport in patients triaged to HEMS by the AMPT score. Subgroup analyses were performed in patients treated by advanced life support providers and patients with transport times longer than 10 minutes. RESULTS: There were 222,827 patients included. For patients triaged to GEMS by the AMPT score, actual transport mode was not associated with survival (adjusted relative risk, 1.004; 95% confidence interval, 0.999-1.009; p = 0.08). For patients triaged to HEMS by the AMPT score, actual HEMS transport was associated with a 6.7% increase in the relative probability of survival (adjusted relative risk, 1.067; 95% confidence interval, 1.040-1.083, p < 0.001). Similar results were seen in all subgroups. CONCLUSIONS: This study is the first to externally validate the AMPT score, demonstrating the ability of this tool to reliably identify trauma patients most likely to benefit from HEMS transport. The AMPT score should be considered when protocols for HEMS scene transport are developed and reviewed. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III; therapeutic/care management study, level IV.

Development and Validation of the Air Medical Prehospital Triage Score for Helicopter Transport of Trauma Patients.

OBJECTIVE: The aim of this study was to develop and internally validate a triage score that can identify trauma patients at the scene who would potentially benefit from helicopter emergency medical services (HEMS). SUMMARY BACKGROUND DATA: Although survival benefits have been shown at the population level, identification of patients most likely to benefit from HEMS transport is imperative to justify the risks and cost of this intervention. METHODS: Retrospective cohort study of subjects undergoing scene HEMS or ground emergency medical services (GEMS) in the National Trauma Databank (2007-2012). Data were split into training and validation sets. Subjects were grouped by triage criteria in the training set and regression used to determine which criteria had a survival benefit associated with HEMS. Points were assigned to these criteria to develop the Air Medical Prehospital Triage (AMPT) score. The score was applied in the validation set to determine whether subjects triaged to HEMS had a survival benefit when actually transported by helicopter. RESULTS: There were 2,086,137 subjects included. Criteria identified for inclusion in the AMPT score included GCS <14, respiratory rate <10 or >29, flail chest, hemo/pneumothorax, paralysis, and multisystem trauma. The optimal cutoff for triage to HEMS was ≥2 points. In subjects triaged to HEMS, actual transport by HEMS was associated with an increased odds of survival (AOR 1.28; 95% confidence interval [CI] 1.21-1.36, P < 0.01). In subjects triaged to GEMS, actual transport mode was not associated with survival (AOR 1.04; 95% CI 0.97-1.11, P = 0.20). CONCLUSIONS: The AMPT score identifies patients with improved survival following HEMS transport and should be considered in air medical triage protocols.

Helicopter transport improves survival following injury in the absence of a time-saving advantage.

BACKGROUND: Although survival benefits have been shown at the population level, it remains unclear what drives the outcome benefits for helicopter emergency medical services (HEMS) in trauma. Although speed is often cited as the vital factor of HEMS, we hypothesized a survival benefit would exist in the absence of a time savings over ground emergency medical services (GEMS). The objective was to examine the association of survival with HEMS compared with GEMS transport across similar prehospital transport times. METHODS: We used a retrospective cohort of scene HEMS and GEMS transports in the National Trauma Databank (2007-2012). Propensity score matching was used to match HEMS and GEMS subjects on the likelihood of HEMS transport. Subjects were stratified by prehospital transport times in 5-minute increments. Conditional logistic regression determined the association of HEMS with survival across prehospital transport times strata controlling for confounders. Transport distance was estimated from prehospital transport times and average HEMS/GEMS transport speeds. RESULTS: There were 155,691 HEMS/GEMS pairs matched. HEMS had a survival benefit over GEMS for prehospital transport times between 6 and 30 minutes. This benefit ranged from a 46% increase in odds of survival between 26 and 30 minutes (adjusted odds ratio [AOR], 1.46; 95% CI, 1.11-1.93; P < .01) to an 80% increase in odds of survival between 16 and 20 minutes (AOR, 1.80; 95% CI, 1.51-2.14; P < .01). This prehospital transport times window corresponds to estimated transport distance between 14.3 and 71.3 miles for HEMS and 3.3 and 16.6 miles for GEMS. CONCLUSION: When stratified by prehospital transport times, HEMS had a survival benefit concentrated in a window between 6 and 30 minutes. Because there was no time-savings advantage for HEMS, these findings may reflect care delivered by HEMS providers.

Geographic Variation in Outcome Benefits of Helicopter Transport for Trauma in the United States: A Retrospective Cohort Study.

OBJECTIVE: Evaluate the effect of US geographic region on outcomes of helicopter transport (HT) for trauma. BACKGROUND: HT is an integral component of trauma systems. Evidence suggests that HT is associated with improved outcomes; however, no studies examine the impact of geographic variation on outcomes for HT. METHODS: Retrospective cohort study of patients undergoing scene HT or ground transport in the National Trauma Databank (2009-2012). Subjects were divided by US census region. HT and ground transport subjects were propensity-score matched based on prehospital physiology and injury severity. Conditional logistic regression was used to evaluate the effect of HT on survival and discharge to home in each region. Region-level characteristics were assessed as potential explanatory factors. RESULTS: A total of 193,629 pairs were matched. HT was associated with increased odds of survival and discharge to home; however, the magnitude of these effects varied significantly across regions (P < 0.01). The South had the greatest survival benefit (odds ratio: 1.44; 95% confidence interval: 1.39-1.49, P < 0.01) and the Northeast had the greatest discharge to home benefit (odds ratio: 1.29; 95% confidence interval: 1.18-1.41, P < 0.01). A subset of region-level characteristics influenced the effect of HT on each outcome, including helicopter utilization, injury severity, trauma center and helicopter distribution, trauma center access, traffic congestion, and urbanicity (P < 0.05). CONCLUSIONS: Geographic region impacts the benefits of HT in trauma. Variations in resource allocation partially account for outcome differences. Policy makers should consider regional factors to better assess and allocate resources within trauma systems to optimize the role of HT.

Measuring satisfaction: factors that drive hospital consumer assessment of healthcare providers and systems survey responses in a trauma and acute care surgery population.

Hospital quality metrics now reflect patient satisfaction and are measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Understanding these metrics and drivers will be integral in providing quality care as this process evolves. This study identifies factors associated with patient satisfaction as determined by HCAHPS survey responses in trauma and acute care surgery patients. HCAHPS survey responses from acute care surgery and trauma patients at a single institution between 3/11 and 10/12 were analyzed. Logistic regression determined which responses to individual HCAHPS questions predicted highest hospital score (a rating of 9-10/10). Demographic and clinical variables were also analyzed as predictors of satisfaction. Subgroup analysis for trauma patients was performed. In 70.3 per cent of 182 total survey responses, a 9-10/10 score was given. The strongest predictors of highest hospital ranking were respect from doctors (odds ratio [OR] = 24.5, confidence interval [CI]: 5.44-110.4), doctors listening (OR: 9.33, CI: 3.7-23.5), nurses' listening (OR = 8.65, CI: 3.62-20.64), doctors' explanations (OR = 8.21, CI: 3.5-19.2), and attempts to control pain (OR = 7.71, CI: 3.22-18.46). Clinical factors and outcomes (complications, intensive care unit/hospital length of stay, mechanism of injury, and having an operation) were nonsignificant variables. For trauma patients, Injury Severity Score was inversely related to score (OR = 0.93, CI: 0.87-0.98). Insurance, education, and disposition were also tied to satisfaction, whereas age, gender, and ethnicity were nonsignificant. In conclusion, patient perception of interactions with the healthcare team was most strongly associated with satisfaction. Complications did not negatively influence satisfaction. Insurance status might potentially identify patients at risk of dissatisfaction. Listening to patients, treating them with respect, and explaining the care plan are integral to a positive perception of hospital stay.

Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90.

BACKGROUND: Undertriage is a concern in geriatric patients. The National Trauma Triage Protocol (NTTP) recognized that systolic blood pressure (SBP) less than 110 mm Hg may represent shock in those older than 65 years. The objective was to evaluate the impact of substituting an SBP of less than 110 mm Hg for the current SBP of less than 90 mm Hg criterion within the NTTP on triage performance and mortality. METHODS: Subjects undergoing scene transport in the National Trauma Data Bank (2010-2012) were included. The outcome of trauma center need was defined as Injury Severity Score (ISS) greater than 15, intensive care unit admission, urgent operation, or emergency department death. Geriatric (age > 65 years) and adult (age, 16-65 years) cohorts were compared. Triage characteristics and area under the curve (AUC) were compared between SBP of less than 110 mm Hg and SBP of less than 90 mm Hg. Hierarchical logistic regression was used to determine whether geriatric patients newly triaged positive under this change (SBP, 90-109 mm Hg) have a risk of mortality similar to those triaged positive with SBP of less than 90 mm Hg. RESULTS: There were 1,555,944 subjects included. SBP of less than 110 mm Hg had higher sensitivity but lower specificity in geriatric (13% vs. 5%, 93% vs. 99%) and adult (23% vs. 10%, 90% vs. 98%) cohorts. AUC was higher for SBP of less than 110 mm Hg individually in both geriatric and adult (p < 0.01) cohorts. Within the NTTP, the AUC was similar for SBP of less than 110 mm Hg and SBP of less than 90 mm Hg in geriatric subjects but was higher for SBP of less than 90 mm Hg in adult subjects (p < 0.01). Substituting SBP of less than 110 mm Hg resulted in an undertriage reduction of 4.4% with overtriage increase of 4.3% in the geriatric cohort. Geriatric subjects with SBP of 90 mm Hg to 109 mm Hg had an odds of mortality similar to those of geriatric patients with SBP of less than 90 mm Hg (adjusted odds ratio, 1.03; 95% confidence interval, 0.88-1.20; p = 0.71). CONCLUSION: SBP of less than 110 mm Hg increases sensitivity. SBP of less than 110 mm Hg has discrimination as good as that of SBP of less than 90 mm Hg, with superior improvements in undertriage relative to overtriage in geriatric patients. Geriatric patients newly triaged to be positive under this change have a risk of mortality similar to those under the current SBP criterion. This change in SBP criteria may be merited in geriatric patients, warranting further study to consider elevation to a Step 1 criterion in the NTTP. LEVEL OF EVIDENCE: Diagnostic study, level IV.

Prevention of hypophosphatemia after burn injury with a protocol for continuous, preemptive repletion.

Severe burn injury has been shown to result in hypophosphatemia. Hypophosphatemia can cause cardiac, hematologic, immunologic, and neuromuscular dysfunction. This study compares serum phosphate levels and outcomes in patients who were administered a continuous, preemptive phosphate repletion protocol vs those who only received phosphate supplementation after they developed hypophosphatemia. Records of patients with greater than 19% TBSA burn admitted to the intensive care unit from 2006 to 2010 were reviewed. Patients were divided into two groups: historical controls who received responsive repletion when serum phosphate levels were less than 2.5 mg/dl (2006-2008) and the experimental group that received 30 mmol intravenous every 6 hours starting at approximately 24 hours after injury as long as serum phosphate levels were less than 4 mg/dl (2008-2010). Patients with chronic kidney disease or acute kidney injury were excluded. Data collected included age, weight, burn size, age, all serum phosphate levels, and total amount of phosphate administered. Differences in groups were compared with Mann-Whitney U test and Fisher's exact test. A total of 30 patients were included in the study, 20 in the responsive repletion group and 10 in the continuous repletion group. No significant difference was detected in age, sex, burn size, or full thickness burn size between groups. The continuous group had a statistically lower percentage of hypophosphatemic lab values compared with the responsive group, 13 ± 14% vs 45 ± 21% (P < .0001). No difference was found in percent of observations reflecting hyperphosphatemia (median of 2% in each group, P = .7). Four patients in the continuous group suffered cardiac and/or infectious complications compared with 16 in the responsive group (P = .04). Continuous, pre-emptive repletion of phosphate prevents hypophosphatemia after severe burn injury when compared with responsive repletion in historical controls. The protocol resulted in less hypophosphatemia without increasing the risk of hyperphosphatemia. This study also suggests that continuous repletion may result in fewer complications, but this needs to be confirmed in larger, prospective studies.

Evidence-based improvement of the National Trauma Triage Protocol: The Glasgow Coma Scale versus Glasgow Coma Scale motor subscale.

BACKGROUND: Ideal triage uses simple criteria to identify severely injured patients. Glasgow Coma Scale motor (GCSm) may be easier for field use and was considered for the National Trauma Triage Protocol (NTTP). This study evaluated performance of the NTTP if GCSm is substituted for the current GCS score ≤ 13 criterion. METHODS: Subjects in the National Trauma Data Bank undergoing scene transport were included. Presence of NTTP physiologic (Step 1) and anatomic (Step 2) criteria was determined. GCSm score ≤ 5 was defined as a positive criterion. Trauma center need (TCN) was defined as Injury Severity Score (ISS) > 15, intensive care unit admission, urgent operation, or emergency department death. Test characteristics were calculated to predict TCN. Area under the curve was compared between GCSm and GCS scores, individually and within the NTTP. Logistic regression was used to determine the association of GCSm score ≤ 5 and GCS score ≤ 13 with TCN after adjusting for other triage criteria. Predicted versus actual TCN was compared. RESULTS: There were 811,143 subjects. Sensitivity was lower (26.7% vs. 30.3%), specificity was higher (95.1% vs. 93.1%), and accuracy was similar (66.1% vs. 66.3%) for GCSm score ≤ 5 compared with GCS score ≤ 13. Incorporated into the NTTP Steps 1 + 2, GCSm score ≤ 5 traded sensitivity (60.4% vs. 62.1%) for specificity (67.1% vs. 65.7%) with similar accuracy (64.2% vs. 64.2%) to GCS score ≤ 13. There was no difference in the area under the curve between GCSm score ≤ 5 and GCS score ≤ 13 when incorporated into the NTTP Steps 1 + 2 (p = 0.10). GCSm score ≤ 5 had a stronger association with TCN (odds ratio, 3.37; 95% confidence interval, 3.27-3.48; p < 0.01) than GCS score ≤ 13 (odds ratio, 3.03; 95% confidence interval, 2.94-3.13; p < 0.01). GCSm had a better fit of predicted versus actual TCN than GCS at the lower end of the scales. CONCLUSION: GCSm score ≤ 5 increases specificity at the expense of sensitivity compared with GCS score ≤ 13. When applied within the NTTP, there is no difference in discrimination between GCSm and GCS. GCSm score ≤ 5 is more strongly associated with TCN and better calibrated to predict TCN. Further study is warranted to explore replacing GCS score ≤ 13 with GCSm score ≤ 5 in the NTTP. LEVEL OF EVIDENCE: Prognostic study, level III.

Risk factors associated with venous thromboembolism in isolated blunt chest trauma.

Isolated chest trauma is not historically considered to be a major risk factor for venous thromboembolism (VTE). After blunt chest trauma, VTE may be underappreciated because pain, immobility, and inadequate prophylaxis as a result of hemorrhage risk may all increase the risk of VTE. This investigation determines the predictors and rate of VTE after isolated blunt chest trauma. A review of patients admitted to a Level I trauma center with chest trauma between 2007 and 2009 was performed. Demographics, injuries, VTE occurrence, prophylaxis, comorbidities, Injury Severity Score, intensive care unit/hospital length of stay, chest tube, and mechanical ventilation use were recorded. VTE rate was compared between those with isolated chest injury and those with chest injury plus extrathoracic injury. Predictors of VTE were determined with regression analysis. Three hundred seventy patients had isolated chest trauma. The incidence of VTE was 5.4 per cent (n = 20). The VTE rate in those with chest injury plus extrathoracic injury was not significantly different, 4.8 per cent (n = 56 of 1140, P = 0.58). Independent risk factors for VTE after isolated chest trauma were aortic injury (P < 0.01, odds ratio [OR], 47.7), mechanical ventilation (P < 0.01; OR, 6.8), more than seven rib fractures (P < 0.01; OR, 6.1), hemothorax (P < 0.05; OR, 3.9), hypercoagulable state (P < 0.05; OR, 6.3), and age older than 65 years (P < 0.05; OR, 1.03). Patients with the risk factors mentioned are at risk for VTE despite only having thoracic injury and might benefit from more aggressive surveillance and prophylaxis.

Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. METHODS: The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (http://www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. CONCLUSION: Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS: The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION: There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

The National Trauma Triage Protocol: can this tool predict which patients with trauma will benefit from helicopter transport?

BACKGROUND: Helicopter transport (HT) is an important component of American trauma care, but prospectively identifying patients that would benefit from this resource remains difficult. The objective of this study was to assess the role of the National Trauma Triage Protocol (NTTP) in selecting patients that would benefit from HT. METHODS: Subjects transported by HT or ground transport from the scene of injury in 2007 were identified using the National Trauma Databank version 8. Criteria from the stepwise NTTP available in the data set were collected including physiologic data, anatomic injuries identified by DRG International Classification of Diseases-9th Rev. codes, and age. Subgroups of patients who met specific triage criteria were evaluated using logistic regression to determine if transport modality was an independent predictor of survival after controlling for demographics, injury severity, prehospital time, and presence of other NTTP triage criteria. Standard test characteristics were calculated for each criterion to predict trauma center need (TCN). The performance of triage criteria to predict TCN was compared between the groups using independent receiver operating characteristic area under the curve analysis. RESULTS: There were 258,387 subjects transported either by helicopter (16%) or by ground (84%). HT subjects were more severely injured (mean [SD], Injury Severity Score, 15.9 [12] vs. 10.2 [10], p < 0.01). Logistic regression identified HT as an independent predictor of survival in subjects with a subset of triage criteria, including penetrating injury, GCS<14, RR<10 or >29 breaths per minute, and age>55 years. Each criterion previously mentioned was significantly more predictive of TCN in the HT group than in the ground transport group (p < 0.01). CONCLUSION: Patients who meet certain triage criteria in the field seem to have an independent survival benefit if transported to a trauma center by helicopter. Furthermore, these criteria are highly specific and more reliably predict TCN in the HT group. The specific triage criteria listed previously should be carefully considered when developing policies for scene helicopter use in the trauma setting.