Jump to The Whole Surgeon
Jump to The Gun Violence Awareness Campaign
Jump to Multi-Institutional Committee
Jump to Acute Care Surgery Committee
Jump to DEI Committee
Jump to Prevention Committee
Jump to Pediatric Trauma Committee
Jump to Patient Assessment Committee
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Editor’s Letter

Written by: Shannon Marie Foster, MD, FACS

Friends and Colleagues –

I hope to find you well and safe.  Whatever weather mess you have regionally found – fire, flash floods, drought - the hot summer is upon us.  Hiding in air conditioning has never been so relevant as we dodge abysmal air quality and record-breaking heat.  How does that affect your life and practice?  Does it change patient presentations?  We would very much welcome feedback and comments related to seasonal/weather-induced variations in both trauma and emergency general surgery presentations (email below) that further highlight locoregional or geographic considerations.

Thank you for the warm and positive feedback regarding the changes to our formatting, layout, and imagery, particularly the inclusion of The Whole Surgeon:  Get to Know Your AAST section.  The images in this issue are breathtaking and risk-taking!  Ironic and wonderful for trauma surgeons.  Thanks to those who have answered the ask.  Interested in sharing?  Reach out to me!  Another reminder to ensure your My AAST profile and picture are up-to-date as all authors and contributors are being featured.

Speaking of imaging, the participation and responses to the inaugural AAST Gun Violence Awareness Month Campaign cannot be overstated.  The summary and images included here represent only a sample of the national action, reenforcing that advocacy can start at home with something as simple as a T-shirt.   Please read the materials and look for additional reports and resources from the campaign.

Committee work cannot be exaggerated in its scope and contribution.  In this issue, the Prevention Committee adds a new element in Wildlife Awareness, Dr. Dumas highlights the true performance improvement of video review, Dr. Notrica and the Pediatric Trauma Committee update the algorithms for solid organ injury, and the DEI Committee via Dr. Quintana asks us to look beyond definitions alone to understand the depth and intersectionality of Diversity, Equity, and Inclusion as living, evolving, interconnected ideas rather than strict constructs. 

As the summer educational transition of medical students, residents, fellows, and first practices nears its conclusions, the season of meetings commences.   Not only our 82^nd Annual in Anaheim, but in August both the World Trauma Congress in Tokyo and the Summit on the Advancement of Focused Equity Research in Trauma (SAFER-Trauma) in Chicago.   I hope you are participating as able in these amazing conferences, but as time and money constrain us all – look to these pages in the editions ahead for coverage and highlights. 

Feedback, comments, questions, and participation always welcome…
[email protected] or [email protected]

 SMF

Get to Know Your AAST Colleague

The Whole Surgeon

AAST Associate Member Council

AAST Gun Violence Awareness Campaign

Written by: Ryan Dumas, MD

Written by: Navpreet Dhillon, MD

Shock Trauma fully embraced the AAST Gun Violence Awareness Month Campaign, taking the message to heart. Spearheaded by Dr. Tom Scalea, former AAST President and Physician in Chief of the R Adams Cowley Shock Trauma Center at the University of Maryland, the center purchased one hundred t-shirts, the largest order of the campaign. Faculty, staff, and trainees aligned with the AAST wearing orange, spelling out "STC" for "Shock Trauma Center." This was highlighted by the Baltimore Sun, the largest newspaper in Maryland. Thanks to the AAST, Shock Trauma was able to send a strong message to the community. Dr. Tom Scalea states, “Given the amount of violence we see, especially the recent mass shooting in Baltimore, Shock Trauma wanted to publicly support the AAST’s campaign. Quoting two former AAST presidents, we look forward to a day where there are fewer holes in a smaller number of people.”

Multi-Institutional Trials Committee 

AAST Multicenter Trials Committee Update

Written by: Joseph DuBose, MD

AAST Multicenter Trials Committee Update

The AAST MCT continues to review and support the implementation of high-quality multicenter research efforts designed and led by our membership.  Several great efforts are being developed that are open to enrollment and support from fellow AAST members.  Below we highlight ongoing activities of your Multicenter Trials Committee and highlight studies for involvement.

Revised Survey Process Implemented

The MCT was recently tasked with a revision of our Survey process for membership.  As such, a subcommittee for Surveys was established, led by a Drs. Galinos Bamparas, James Byrne, Anaar Siletz and Paul Albini.  The new process will involve a quarterly proposal deadline with rolling quarterly release of approved surveys.  Further information on how to submit a survey for consideration and details of the process are available on the AAST website.

The ultimate objective of this industrious group is to create a process for survey distribution that is not cumbersome to membership and optimizes the survey results for subsequent reporting and publication.  We continue to work with the editors of our industry journals in these discussions and explore novel methodologies that will result in the highest quality of membership survey products.

Study highlight: A multi-institutional, retrospective review for validation of the cirrhosis outcomes score in trauma (COST):

Liver disease affects one out of every 10 people in the United States. This number is likely underestimated as many cases of liver disease, particularly compensated cirrhosis, go undiagnosed. In 1990, cirrhosis was identified as an independent predictor of poor outcomes in trauma patients. However, current trauma injury grading systems, such as injury severity scores (ISS) and trauma injury severity score (TRISS), do not take into account liver dysfunction as a risk factor. A score that includes the degree of liver dysfunction would enhance the ability of ISS or TRISS to predict mortality in trauma patients with cirrhosis. While the Child-Pugh (CTP) classification system was historically used to quantify the severity of liver dysfunction, the model for end-stage liver disease (MELD – Tbili, Cr, INR, Na) score is now widely used as an index of liver disease severity, for survival prediction, for surgical risk stratification, and for prioritization of organ allocation. The MELD score is more readily available than the CTP score for the prediction of mortality in trauma patients. Several prior studies have investigated combining trauma injury grading systems with known liver dysfunction scales. Corneille et al found ISS + MELD and ISS + CTP were stronger predictors of mortality than ISS alone for both. Inaba et al found each unit increase in the MELD score was associated with an 18% increase in the odds of mortality, adjusted odds ratio 1.18.

In our pilot study, a total of 318 cirrhotic trauma patients were analyzed of which the majority were males who suffered blunt trauma. The primary outcome of mortality in-patient, 30-days, 60-days, 90-days, and 1-year was evaluated. COST which was defined as the simple sum of Age, ISS, and MELD was associated mortality on regression analysis, in increasing intervals. A regression analysis of the three individual variables did not demonstrate a need to weigh the components of the score. Adding the individual variables in a weighted fashion did not significantly improve the AUROC and it would add significant complexity to the score calculation. The primary aim of this MIT is to review the risk factors and outcomes of cirrhotic trauma patients to validate the proposed COST mortality prediction model created at Atrium Health Wake Forest Baptist. Secondary goals include elucidating the impact of cirrhosis on morbidities, hospital/ICU LOS, and ultimate patient disposition. Achieving the specific goals of this proposed trial will further our understanding for the prognosis of cirrhotic trauma patients and improve goals of care discussions with patients and their families.

Acute Care Surgery Committee

It Is Time to Rethinking Performance Improvement in Trauma

Written by: Ryan P. Dumas MD, FACS

 Think about Performance Improvement and Patient Safety (PIPS) programs at your trauma center. Consider the last time you sought additional clinical information about how a critically injured trauma patient presented and was resuscitated in your trauma bay. You likely accessed the electronic medical record (EMR), opened a patient’s chart, and started to sift through the notes, imaging, and labs to recreate a timeline of events, understand patient physiology, and hopefully determine the plan of care. In reality, you likely walked away with an incomplete picture and maybe even more questions than answers.

Traditional chart review of the medical record is woefully inadequate for trauma performance review. It is a system that relies on human recollection, it is fraught with missing data[1], bias[2], and in the case of trauma resuscitation, it is a tool that tries to bring order to something that is inherently chaotic. Additionally, while the principles of ATLS teach trauma resuscitation in a vertical ‘A-B-C-D-E’ fashion ATLS often unfolds in a horizontal manner and patient assessment occurs simultaneously making accurate documentation challenging even in the most experienced of hands.      

There is another option. A high-definition audiovisual recording of a patient’s entire resuscitation. From pre-arrival timeout to the CT scanner or operating room, as if you are there, in real-time with the team. Like a fly on the wall. Immediately, questions unable to be answered by the EMR become clearer. What was the tone of the resuscitation? How loud was the room? Was the team leader readily identifiable? How quickly did patient physiology evolve? Did the team communicate effectively?  Were procedures done expeditiously? Did blood arrive promptly? Was equipment well positioned and readily available? Suddenly, questions from an incomplete EMR unable to be answered are now able available and a patient’s most critical minutes are brought to light.  

It may not yet be in the Grey Book[3] but Trauma Video Review (TVR) is the gold standard for performance improvement in trauma. There is no better tool for PI and every trauma center that wants to practice at the proverbial “tip of the spear” and provide the highest quality care should have a TVR program. A well-established TVR program allows not only for identification of opportunities for improvement, but also can highlight strengths of a program and measure programmatic change.

First described in the late 1980s[4] trauma video review has enjoyed a resurgence in utilization over the past decade due the ubiquitous nature of audiovisual data, readily available hardware with cloud-based storage, and an improved understanding of medicolegal implications, the Health Insurance Portability and Accountability Act and the consent process[5]. Not only are more Level 1 and Level 2 trauma centers utilizing TVR, but many plan to start in the future[6]. Perhaps most importantly, the technology is universally well received by its users[6].      

The care of critically injured patients is high stakes, high-pressure, and often characterized by high-impact, low-frequency procedures. In an unforgiving environment, teams must function and communicate effectively to save lives. In an effort to focus on performance improvement in trauma and highlight critical skills and decision making, trauma programs need to put themselves under the lens and maximizes their “reps”. Much like an eleven player NFL team watches film together and players study their performance, it is imperative trauma teams to the same. Why would they not?

• “Proper film study is vital for any NFL team to win. Players that can take what they see on the screen and transfer that knowledge to the field will always have their ‘eyes on the prize’”[7].

Much like video review in sports, the benefits of TVR to a trauma program do not stop at performance improvement. Almost every aspect of a trauma program can be impacted by trauma video review[8]. The educational benefits within a multi-disciplinary team-based environment allows emergency medicine, and nursing providers watch a team’s resuscitative efforts highlighting effective performances as well as identify opportunities. High-impact, low-frequency procedures such as resuscitative thoracotomy can be reviewed, and those not having been immediately involved in the procedure now have an opportunity to see, hear, and watch as a thoracotomy unfolds and most importantly watch the evolution of patient physiology. As a research tool, the data obtained from TVR is unmatched. The time-dilation of a resuscitation is unmasked and second-to-second benchmarks can be calculated, team performance scores measured and high-stakes procedures analyzed. In its current iterations, TVR is so accurate, it has been shown to outperform in-person, real time data collection[9]. The ability to pause, rewind, zoom-in, and replay affords the viewer an unparalleled perspective on a resuscitation.        

Video based education will continue to expand and impact surgical education throughout the entire surgical field[10]. Its utilization will only increase as robotic, laparoscopic and open surgery videographic data becomes increasingly available. The American Board of Surgery started piloting video-based assessment in 2021[11] and it will not be long until videographic technical assessment is part of the certification process.

Since the American College of Surgeons Committee on Trauma first published its standards for the optimal care of the trauma patient in 1976 and subsequently began verification and designation in 1987 the committee has been at the forefront of the care of the injured patient. The only remaining question is when, not if, the ACS COT consider trauma video review an integral part of trauma performance improvement.

1. Dumas, R.P., et al., Benchmarking emergency department thoracotomy: Using trauma video review to generate procedural norms. Injury, 2018. 49(9): p. 1687-1692.
2. Sun, M., et al., Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record. Health Aff (Millwood), 2022. 41(2): p. 203-211.
3. Surgeons, A.C.o., The Verification, Review, and Consultation (VRC) Program: Resources for Optimal Care of the Injured Patient. Vol. Seventh. 2022.
4. Hoyt, D.B., et al., Video recording trauma resuscitations: an effective teaching technique. J Trauma, 1988. 28(4): p. 435-40.
5. Dumas, R.P., et al., Roll the Tape: Implementing and Harnessing the Power of Trauma Video Review. J Surg Educ, 2022. 79(6): p. e248-e256.
6. Dumas, R.P., et al., Trauma video review utilization: A survey of practice in the United States. Am J Surg, 2020. 219(1): p. 49-53.
7. Lillibridge, M. A Former Player's Perspective on Film Study and Preparing for an NFL Game. 2012 [cited 2023 4/20/23]; Available from: https://bleacherreport.com/articles/1427449.
8. Vella, M.A., R.P. Dumas, and D.N. Holena, Supporting the Educational, Research, and Clinical Care Goals of the Academic Trauma Center: Video Review for Trauma Resuscitation. JAMA Surg, 2019. 154(3): p. 257-258.
9. Rees, J.R., et al., Trauma video review outperforms prospective real-time data collection for study of resuscitative thoracotomy. Surgery, 2022. 172(5): p. 1563-1568.
10. Ahmet, A., et al., Is Video-Based Education an Effective Method in Surgical Education? A Systematic Review. Journal of Surgical Education, 2018. 75(5): p. 1150-1158.
11. Maloney, A. ABS to Explore Video-Based Assessment in Pilot Program Launching June 2021. 2021 [cited 2023; Available from: https://www.absurgery.org/default.jsp?news_vba04.21.

Diversity, Equity, and Inclusion Committee

A Reflection on Definitions and Meaning

Written by: Megan Quintana, MD

Definitions may not seem to have dynamic properties. When we think back to looking up a word in the dictionary, it may have held several listed meanings, but we were not expecting that each year, a new dictionary with updated definitions would be unveiled. However, three commonly used words, with even greater meaning, need to be continually defined and allowed to evolve over time. The words “diversity,” “equity,” and “inclusion” should not be left in a static position but need to be flexible and malleable, ever striving to mean more and do more for our entire community. It is also difficult to consider these individual words alone, as each word and meaning is inextricably interconnected.

Diversity has long been seen as “increasing representation including of people from various  backgrounds, perspectives, orientations, and experiences.” Diversity is “the range of human differences, including but not limited to race, ethnicity, gender identity, sexual orientation, age, social class, physical ability or attributes, religious or ethical values system, national origin, and political beliefs.” Although lists of diverse characteristics in different descriptions can vary, these definitions are only a fraction of the equation as many individuals have intersecting and overlapping social identities. Diversity in and of itself can often point out significant disparities and imbalances. Goals of enhancing diversity are valuable, but cannot be accomplished without then also addressing equity.

Equity refers to “fair and just practices that ensure access, resources, and opportunities are provided for all to succeed and grow.” It touches on the act of providing resources to obtain equal outcomes. Imbalances inherent to our social systems provoke the need for processes that promote equity. Organizations such as hospitals try to focus on ‘equity’ by providing both employees and patients with equal access to opportunities and resources. National protests over injustices have helped motivate reflection on biases, stereotypes, and gaps in accountability and how these factors have hindered equity. And while race and ethnicity are often at the forefront of our characterization of equity, true justice needs to account for the intersection of all identities.

As we endeavor to enhance diversity and promote equity, an inclusive environment is essential.  Inclusion is “involvement and empowerment, where the inherent worth and dignity of all people are recognized.” Inclusion requires tolerance and acceptance. Some of the best definitions of inclusion point to the active and intentional aspects of the word. To truly foster inclusivity, there is an ongoing engagement with diversity.

“DEI isn’t a thing we do, it’s how we do all things.” Internal DEI strategies must align with external community engagement efforts. Given the unexpected events of the past few years, we can forecast with certainty that a focus on equity, continued and deeper integration of DEI into all hospital and acute care surgery practices, and the need for DEI education and training should only continue to evolve and expand. DEI is not a topic to define but diversity, equity and inclusion need to be words that define how we live and practice. These words and their meanings provide a common language for us to put forward, a charge with which to guide our community.

Bibliography

“Diversity.” Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/diversity. Accessed 14 Jul. 2023.

Servaes S, Choudhury P, Parikh AK. What is diversity? Pediatr Radiol. 2022 Aug;52(9):1708-1710. doi: 10.1007/s00247-022-05356-0. Epub 2022 Mar 29. PMID: 35348810; PMCID: PMC8962281.         

https://everfi.com/blog/workplace-training/dei-topics-orgnaizations-will-consider-2021-beyond/

https://diversity.gwu.edu/diversity-and-inclusion-defined

Prevention Committee

Wildlife Awareness

Written by: Alexis Moren MD,MPH,FACS, Deborah A. Kuhls, MD FACS FCCM FRCST (Hon), Thomas K. Duncan, DO, FACS, FICS , Shelbie Kirkendoll DO,MS, Christine Castater MD MBA, Ronald Gross, MD, FACS, Sharven Taghavi MD, MPH, MS, FACS, FCCP, Sigrid Burruss, MD 

“Mountain lions killed after string of Arizona pet deaths”, “Bear gets revenge on man who shot it”, “Polar bear in fatal Alaska attack was in poor health”, “Alligator kills 85-yeard old Florida woman as she walked dog”, and “Sharks bite two fishermen in Florida Keys in separate incidents”, are a few of the headlines from May 2023 that highlighted wildlife attacks on humans. These are rare but significant events. Interactions between species present opportunities for appreciation, recreation, and potential challenges. To coexist, humans must learn from these contacts and promote safety.

The Wilderness Act passed in 1964 has allowed conservation of 112 million acres across 46 states.¹ Preservation of this vast wilderness allows individuals to explore untouched nature and appreciate wildlife in natural settings. Over 310 million people visit national parks annually with a notable increase June through September.² July has been designated Wildlife Awareness month, to address the challenges we face as co-inhibitors.³ While the benefits of wildlife observation, photography and ecotourism are important, one must be aware of wildlife safety as the threat of injury remains.

Despite preventive efforts, wildlife attacks still occur. Over the past 50 years, the world has lost two-thirds of its wildlife, 77% of uninhabited land and 87% of uncultivated oceans.^4,5,6 The loss of domain has resulted in increasing human–wildlife interactions and therefore escalating  attacks on humans.⁷ Further explanations for the rise in human-wildlife attacks include the rise in the human population resulting in human encroachment into natural habitats, hunting and killing bans leading to increased wildlife populations, humans moving into less populated areas resulting in forcible co-habitation, and the movement of large predators such as coyotes, cougars and black bears back into urban areas in search of prey.^8,9 Inexpert personnel who explore backcountry areas are up to 84 times more likely to be injured by a bear than a normal tourist in Yellowstone National Park and Glacier National Park.^10,11  This naivety increases the frequency of injuries as people approach wildlife with the intention to pet, feed, and/or photograph. Contrary to people moving into remote areas, segregation between humans and wildlife has resulted in a lack of fear and awareness of potential dangerous threats.

Smaller wildlife pose the greatest risk to humans. Nearly 47,000 people seek medical attention annually due to bites.⁸ The most common culprits are rodents (27,000), bats (1,300), birds (1,500), and raccoons (1,300).⁸ Snake bites, both venomous and nonvenomous account for approximately 13,000 emergency department visits annually. ¹³

Large predator attacks occur less frequently, however, they tend to receive significantly more media attention. Conover et al. found that attacks by alligators, cougars, polar bears, grizzly bears, black bears, and coyotes have been increasing in North America in recent decades.⁸ On average, 30 bear attacks are reported yearly, with Alaska representing the state with the most attacks.^8,10,14 Alaska reports an average of 7.6 attacks per year during the last decade with 88% involving grizzly bears, 11% black bears and 1% polar bears.¹⁵ Other large animals including hooved wild-life also pose a threat. Deer, moose, elk and bison, often considered docile species, are known to attack when feeling threatened.⁸ Annually, wildlife–vehicle collisions result in >59,000 human injuries and >440 deaths.⁸ Approximately 58,000 of the motor vehicle collisions involve deer.⁸ Other animals involved in  numerous human injuries each year include alligators, cougars, foxes, and coyotes.⁸

Reducing occurrences is the key to preventing wildlife attacks. By recognizing the complexity of these relationships and the continued coexistence, implementing effective management strategies, and fostering responsible behavior, we can ensure harmonious interactions that benefit both humans and wildlife. As attacks are bound to increase over the next decades our goal should be education in order to mitigate attacks. Some common rules to minimize attacks include:⁹

1. Respectful viewing
2. Properly dispose of waste
3. Store food in containers
4. Go in groups
5. Keep domesticated animals on leash
6. Carry an air horn and/or animal repellant spray
7. No sudden movements: stay calm, back away, don’t turn your back
8. Give the animal a way to escape – don’t run, avoid eye contact, appear large by raising arms
9. Hold small children and don’t bend over
10. Make noise: shout, yell, whistle, clap-hands  

References

1. The Wilderness Act. Public Law 88-577 (16 U.S.C. 1131-1136)
   88th Congress, Second Session. September 3, 1964. Access 5/18/23 https://wilderness.net/learn-about-wilderness/key-laws/wilderness-act/default.php

2. National Parks Service (NPS). 2022. Annual Visitation Highlights. USA. Accessed May 15, 2023. https://www.nps.gov/subjects/socialscience/annual-visitation-highlights.htm
3. National Today. Wild About Wildlife Month. Accessed May 25, 2023. https://nationaltoday.com/wild-about-wildlife-month/
4. Renewable Energy and Environmental Sustainability in India. 2019. Global Study Shows Worlds Shrinking Wilderness. Accessed May 8, 2023. https://www.iamrenew.com/environment/global-study-shows-worlds-shrinking-wilderness/
5. World Wildlife Fund. 2020. Living Planet Report 2020. Accessed May 9, 2023. (https://f.hubspotusercontent20.net/hubfs/4783129/LPR/PDFs/ENGLISH-FULL.pdf)
6. The Guardian. Losing the wilderness: a 10th has gone since 1992 – and gone for good. December 21, 2017. Accessed May 25, 2023. https://www.theguardian.com/environment/2017/dec/21/losing-the-wilderness-a-tenth-has-gone-since-1992-and-gone-for-good
7. com. Carnivores' attacks on humans are becoming more common, and climate change isn't helping. February 07, 2023. Accessed May 25, 2023. https://www.nbcnews.com/science/environment/carnivores-attacks-humans-are-becoming-common-climate-change-isnt-help-rcna68998
8. Conover, M. R. 2019. Numbers of human fatalities, injuries, and illnesses in the United States due to wildlife. Human–Wildlife Interactions 13(2):264–276, Fall 2019.
9. Black bear spotted 3 times in Portland's Forest Park. May 21, 2023. Accessed May 25, 2023.
   https://www.oregonlive.com/news/2023/05/black-bear-spotted-3-times-in-portlands-forest-park.html
10. Conover, M. R. 2008. Why are so many people attacked by predators? Human–Wildlife Interactions 2:139–140
11. Herrero, S., and S. Fleck. 1989. Injury to people inflicted by black, grizzly or polar bears: recent trends and new insights. International Conference on Bear Research and Management 8:25–32.
12. Conover, M. R., W. C. Pitt, K. K. Kessler, T. J. DuBow, and W. A. Sanborn. 1995. Review of human injuries, illnesses, and economic losses caused by wildlife in the United States. Wildlife Society Bulletin 23:407–414.
13. Centers for Disease Control and Prevention (CDC). 2016. Venomous snakes. Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Accessed May 8, 2023.
14. Conover, M. R., W. C. Pitt, K. K. Kessler, T. J. DuBow, and W. A. Sanborn. 1995. Review of human injuries, illnesses, and economic losses caused by wildlife in the United States. Wildlife Society Bulletin 23:407–414.
15. Smith, T. S., and S. Herrero. 2018. Human–bear conflict in Alaska: 1880–2015. Wildlife Society Bulletin 42:254–263

Pediatric Trauma Committee

Top 21 take-aways after a decade of pediatric trauma progress

Written by: David M Notrica, MD FACS FAAP

Trauma Medical Director
Phoenix Children’s Hospital Level 1 Pediatric Trauma Center
Fellowship Program Director
Mayo Clinic/Phoenix Children’s Hospital Pediatric Surgery Fellowship
Professor of Child Health and Surgery
University of Arizona College of Medicine Phoenix
Associate Professor of SurgeryMayo Clinic College of Medicine and Science
Associate Editor
Trauma Surgery & Acute Care Open

1 in every 10,000 children in the US sustains an abdominal trauma each year, with 8000 children hospitalized with blunt liver and/or spleen injury (BLSI).  Renal and pancreatic injury result in 600 and 200 admissions, respectively.

The rate of splenectomy for children with blunt splenic injury has gone down.  In the year 2000, more than 18% of children with splenic injuries underwent splenectomy.  The most recent data from KIDS presented recently at the 2023 Western Pediatric Trauma Conference by Eldredge, et al shows that that number is now down to <6%, but now holding steady.

ATOMAC+  updated their recommendations last year into a new and simpler algorithm, (figure 4), and The American Pediatric Surgery Association (APSA) Trauma Committee published a new, simple-to-follow grid guide (figure 5). APSA now uses the acronym APSA -- A=Admission; P=Procedures: S=Set Free; and A=Aftercare as shown in the figure below.

Figure 4.  ATOMAC guideline v12.0 for management of blunt liver or spleen injury.  LR=lactated ringers; NS=normal saline; PRBCs=packed red blood cells; CT = computed tomography; ICU= Intensive Care Unit; Hb=hemoglobin; NPO=nothing by mouth; q6h=every 6 hours; NOM=nonoperative management; ICU=intensive care unit; q2h=every 2 hours.  PECARN=Pediatric Emergency Care Applied Research Network; PedSRC = Pediatric Surgery Research Consortium; Algorithm used by permission of ATOMAC. 

ATOMAC simplified their original guideline by removing the ‘crossover pathway’ and eliminating mandatory admission for some low-grade injuries (figure 5) and clarifying the appropriate timing for CT.   They also eliminated all mandatory hemoglobin levels after the initial one.  The two primary tenants of the ATOMAC guideline (no more than 20mL/kg of crystalloid, and no patient failure until after blood transfusion) remain in the current iteration of the guideline.  The APSA guidelines and the ATOMAC guidelines present similar messages in different ways:  ICU admission only for bleeding patients, transfusion threshold of 7.0 g/dL, angiography is limited to patients with clinical signs of shock (not for contrast extravasation alone), rely on vital signs (not labs), discharge when clinically stable.  The ATOMAC guideline also adds a NOM failure endpoint of 40mL/kg of blood.

The original APSA recommendations brought attention to the need to decrease the number of splenectomies done for children with blunt trauma.  These recommendations went a long way in accomplishing this goal.  In 2013, the ATOMAC guidelines provided a more algorithmic approach to management and incorporated the newly available research at that time and was based on hemodynamic status.  The use of hemodynamic status  rather than imaging has proven safe and effective.  The updated APSA nomogram provide guidance for management of children with blunt abdominal injury with an easier to use format..

Patient Assessment Committee

What is the Patient Assessment Committee?

Written by: Gail T. Tominaga, MD

What is the Patient Assessment Committee? The focus of the Patient Assessment Committee is on developing systems to measure disease severity and patient outcomes for research and quality improvement encompassing Acute Care Surgery (Trauma, Emergency General Surgery and Surgical Critical Care). Previous completed work defined the scope and burden of Emergency General Surgery (EGS) and created anatomic grading and data dictionaries for common inflammatory/infectious EGS diseases and hemorrhagic EGS diseases.

Two major endeavors of the committee over the past few years are the Trauma Protocol Project in conjunction with the American College of Surgeons (ACS) -Committee on Trauma (COT) and revision and validation of the AAST Organ Injury Scores.

Clinical trauma protocols that we have completed and published include the inpatient venous thromboembolism prophylaxis after trauma protocol¹, management of Acute Respiratory Distress Syndrome (ARDS) and severe hypoxemia protocol², and adult damage control resuscitation protocol³. Clinical trauma protocols near completion are post-discharge venous thromboembolism prophylaxis after trauma protocol and glucose management for the ICU adult trauma patient. The clinical protocols now underway include mechanical ventilation and weaning protocol, sedation and analgesia during mechanical ventilation protocol, nutritional support in the critically ill trauma patient and management of severe chest injuries. Our committee is now looking for ideas for the next trauma protocols to work on and would like input from the AAST membership.

Organ Injury Scale (OIS) revisions we have completed are the OIS update for spleen, liver and kidney⁴, OIS for bowel injury⁵, and the new OIS for bowel mesenteric injury⁵. In the pipeline are revision of the Renal OIS based on recent MITC data and revision of the Pancreatic OIS based on recent published studies.

We have completed validation studies on skin and soft tissue scoring⁶, acute cholecystitis scoring⁷, and penetrating colon OIS⁸. We have completed additional studies on acute cholecystitis (revision of scoring⁸ and diagnostic studies⁹) that were presented at the AAST annual meeting.

Our committee welcomes any input from the membership for future projects and papers. I would like to thank all the hard-working members of the Patient Assessment Committee and volunteers from the membership. We also could not get all this work done without the support and guidance from Ms. Sharon Gautschy, Ms. Rachel Sass, and Ms. Brea Sanders.

AAST PAC Publications:

1. Yorkgitis BK, Berndtson AE, Cross A, Kennedy R, Kochuba MP, Tignanelli C, Tominaga GT, Jacobs DG, Marx WH, Ashley SW, Ley EJ, Napolitano L, Costantini TW. American Association for the Surgery of Trauma / American College of Surgeons-Committee on Trauma Clinical Protocol for Inpatient Venous Thromboembolism Prophylaxis after Trauma. J Trauma Acute Care Surg 2022; 92(3):507-604. PMID: 34797813.

2. Fawley J, Tignanelli CJ, Werner N, Kasotakis G, Mandell SP, Glass NE, Dries DJ, Costantini TW, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma Clinical Protocol for Management of Acute Respiratory Distress Syndrome and Severe Hypoxemia. Journal of Trauma and Acute Care Surgery ():10.1097/TA.0000000000004046, June 12, 2023. | DOI: 10.1097/TA.0000000000004046.

3. LaGrone L, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma / American College of Surgeons Committee on Trauma Protocol for Damage Control Resuscitation of the Trauma Patient. Accepted for publication: J Trauma Acute Care Surgery, 2023.

4. Kozar RA, Crandall M, Shanmuganathan K, Zarzaur BL, Coburn M, Cribari C, Kaups K, Schuster K, Tominaga GT and the AAST Patient Assessment Committee. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg; 85(6):1119-1122, 2018.

5. Tominaga GT, Crandall M, Cribari C, Zarzaur B, Bernstein M, Kozar RA and AAST Patient Assessment Committee. Organ Injury Scaling 2020 Update: Bowel and Mesentery. J Trauma Acute Care Surg; 91(3):e73-e77, 2021. PMID: 34137742.

6. Savage S, Li SW, Utter GH, Cox JA, Wydo SM, Cahill K, Sarani B, Holzmacher J, Duane TM, Gandhi RR, Zielinski MD, Ray-Zack M, Tierney J, Chapin T, Murphy PB, Vogt KN, Schroeppel TJ, Callaghan E, Kobayashi L, Coimbra R, Schuster KM, Gillaspie D, Timsina L, Louis A, Crandall The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study. Journal of Trauma and Acute Care Surgery 86(4):p 601-608, April 2019. | DOI: 10.1097/TA.0000000000002175.

7. Schuster KM, O’Connor R, Cripps M, Kuhlenschmidt K, Taveras L, Kaafarani HM, El Hechi M, Puri R, Mull J, Schroeppel TJ, Rodriquez J, Cullinane DC, Cullinane LM, Enniss TM, Sensenig R, Zilberman B, Crandall M. Multicenter validation of the American Association for the Surgery of Trauma grading scale for acute cholecystitis. J Trauma Acute Care Surg 90(1):p 87-96, January 2021. | DOI: 10.1097/TA.0000000000002901.

8. Zeinneddin A, Tominaga GT, Crandall M, Almeida M, Schuster KM, Jawad G, Maqbool B, Sheffield A, Dhillon NK, Radow BS, Moorman ML, Martin ND, Jacovides CL, Lowry D, Kaups K, Horwood CR, Werner NL, Proano-Zamudio JA, Kaafarani HMA, Marshall W, Godat LN, Schaffer KB, Staudenmayer KL, Kozar RA. Contemporary Management and Outcomes of Penetrating Colon Injuries: Validation of the 2020 AAST Colon Organ Injury Scale. J Trauma Acute Care Surg. 2023 Apr 19. doi: 10.1097/TA.0000000000003969. Online ahead of print. PMID: 37072893.

9. Schuster KM, O’Connor R, Cripps M, Kuhlenschmidt K, Taveras L, Kaafarani HM, El Hechi M, Puri R, Schroeppel TJ, Enniss T, Puri R, Cullinane DC, Cullinane LM, Agrawal S Jr, Kaups K, Crandall M, Tominaga G. Revision of the AAST grading system for acute cholecystitis with comparison to physiologic measures of severity. J Trauma Acute Care Surg; 2022; 92(4):664-674. PMID: 34936593.

10. Schuster KM, O’Connor R, Cripps M, Kaafarani HM, Puri R, Schroeppel TJ, Enniss TM, Cullinane DC, Crandall M, Tominaga GT. Imaging Acute Cholecystitis, One Test is Enough. Am J Surg. 2023 Jul;226(1):99-103. doi: 10.1016/j.amjsurg.2023.02.018. Epub 2023 Feb 24. PMID: 36882336.

Journal of Trauma and Acute Care Surgery

JTACS Update

Written By: Raul Coimbra, MD, PhD

Editor in Chief, Journal of Trauma and Acute Care Surgery.

Dear members of the AAST, authors, and readers of the Journal of Trauma and Acute Care Surgery. 

Two important updates:

1. On July 1, we started collecting the new JTACS Conflict of Interest Disclosure Forms upon the initial submission of a manuscript in the Editorial Manager system. Everything is going smoothly and well. All you need to do is to download the form from jtrauma.com, complete it, save it on your computer, and use it every time you have a new submission. We hope that updating your form once per year will make the process easy for you. Do not forget to check the CMS Open Payments Database at https://openpaymentsdata.cms.gov every June, when it is updated, then update your form for another year.
2. The 2022 Impact Factor was released at the end of June. The 2022 Impact factor reflects citations in 2022 of manuscripts published in 2020 and 2021. JTACS IF held steady at 3.4 (a small drop of 0.3). This year the most highly reputable surgical journals had significant drops in their IF (of several points) due to a combination of changes in the methodology used to calculate IF and in the selection of citable articles, as well as an across-the-board decrease in the number of submissions. JTACS went UP in the Critical Care Journals rankings and in the Surgical Journals rankings. We thank all of you for your continued support of our flagship journal.

Trauma Surgery & Acute Care Open (TSACO)

The TSACO Touchpoint

Written By: Elliott R. Haut, MD, PhD, FACS

Editor in Chief, Trauma Surgery & Acute Care Open (TSACO)

TSACO’s Inaugural Impact Factor (2.0)

There was no better email to get as the TSACO Editor in Chief than the one which read “I am pleased to inform you that Trauma Surgery & Acute Care Open’s inaugural Impact Factor is 2.0.” Wow. This is a spectacular start for a relatively new journal. The credit for the score really goes to my predecessor, Dr. Timothy Fabian. He started our journal from nothing and deserves the credit for this first impact factor. While we are excited at our 2.0, we know that we have to keep the momentum going. Impact factor is just one measure of the influence a journal has. We also need to consider other metrics including website visits, social media engagement, and global readership. Along with the Impact Factor, we are required to supply other key journal metrics (all of which can be found on the website at https://tsaco.bmj.com/pages/about/ ). The journal’s median time to first decision with is 31 days and the median time from acceptance to publication is 21 days. Our Citescore is 3.7.

AAST Associate Membership TSACO Scholarship

The AAST Associate Membership has teamed up with the journal and are excited to announce a new scholarship opportunity, available exclusively for AAST associate members. To promote our membership and underscore one of the core missions of the AAST, this collaboration seeks to highlight and promote research led by Associate Members in our trauma community. Applicants can submit a manuscript which will be reviewed by an Associate Member Peer Review Committee and subsequently TSACO. Winning manuscripts will have their article publication charges paid by the AAST. We anticipate a monthly winner. To find out more information about this unique opportunity for associate members (who are required to be the first or senior author), visit the website at https://www.aast.org/associate-member-journal-opportunities .

TSACO is the official journal of The World Trauma Congress

The World Trauma Congress will take place at the Keio Plaza Hotel in Tokyo, Japan on August 9-12^th, 2023. Representatives from over 30 international trauma societies will gather in Tokyo for 4-days dedicated to sharing knowledge and research on trauma from speakers and attendees from around the globe with diverse perspectives. TSACO will be front and center as the official journal. We have multiple editorial board members speaking, moderating, and in attendance. We anticipate a number of high-quality educational, review and original research papers to be published after the meeting. For more information about how to join us in person, check out the meeting’s website at https://www.wtc2022tokyo.org .

TSACO is the official journal of the Summit on the Advancement of Focused Equity Research in Trauma (SAFER-Trauma)

TSACO has recently partnered with the Coalition for National Trauma Research (CNTR) (https://www.nattrauma.org ) as the official journal of the upcoming Summit on the Advancement of Focused Equity Research in Trauma (SAFER-Trauma) conference. https://www.nattrauma.org/safer-trauma-new/ This hybrid (in-person/virtual) meeting is being held in Chicago on August 2-3, 2023 and still has space available for attendance. It will be led by Vanessa Ho, MD, PhD and features speakers including Cherisse Berry MD, Zara Cooper, MD, Joseph Sakran, MD, MPH, MPA and Michaela West MD PhD, one of the TSACO Associate Editors for Diversity, Equity, and Inclusion. The goal of the summit is to help the trauma research community identify and characterize current gaps in trauma health disparities research, define funding mechanisms and pathways for collaboration, and outline a research agenda targeted at reducing and eliminating health disparities in trauma care. Funding for this conference is made possible [in part] by a grant from the Agency for Healthcare Research and Quality (AHRQ).

Call for Papers for “Combating Disparities in Trauma and Acute Care Surgery” Topic Collection

The timing for the SAFER conference could not be better as it aligns nicely with the journal’s upcoming Topic Collection titled “Combating Disparities in Trauma and Acute Care Surgery.” https://tsaco.bmj.com/pages/topic-collection We anticipate a series of original research on interventions that have resulted in a reduction of traumatic injury or general surgery emergencies, improvements in access to timely and high-quality care, and better outcomes among the most vulnerable populations in need of trauma and acute care. Papers have a submission deadline of December 13, 2023. The collection’s guest editors are Heena Santry MD, D’Andrea Joseph MD (TSACO’s other Associate Editor for Diversity, Equity, and Inclusion), and Michaela West, MD PhD.

How can we do better? What are your suggestions?

The journal’s vision is “to provide the global trauma & acute care surgery community with free access to top-notch scientific information.” We have grown our editorial board (https://tsaco.bmj.com/pages/editorial-board/ ) and I am honored to have a great team working to enhance the mission of TSACO. But we also realize we can continually improve. We are always open to your suggestions. Do you have a new idea for a Topic Collection? A pitch for a novel article type? A conference or organization that we should partner with? Email me anytime ([email protected]) or tweet at me @elliotthaut (https://twitter.com/elliotthaut ).