January 2025 Cutting Edge Newsletter

Editor’s Note

Written by: Shannon Marie Foster, MD, FACS

Educational Development Committee​

Bridging the Gap: A New Initiative to Empower Patients in Trauma and Emergency Surgery

Written by: Joshua Dilday, DO and Kimberly Hendershot, MD FACS

Understanding complex medical conditions during a crisis can be overwhelming for patients and their families. Recognizing this challenge, Trauma Surgery & Acute Care Open (TSACO), in collaboration with the American Association for the Surgery of Trauma (AAST) and the American Trauma Society (ATS), has launched an innovative Patient Education Series.

This groundbreaking initiative aims to create accessible, patient-centered resources for individuals facing trauma and emergency general surgery conditions. With input from healthcare professionals, trauma survivors, and patient advocates, the series addresses a critical gap in patient education. The goal? To demystify complex medical issues and empower patients and their loved ones with knowledge about their conditions and care.

What Sets the Patient Education Series Apart?

• Collaborative Development: Articles are crafted with feedback from trauma survivors, families, and healthcare providers to ensure they are both accurate and relatable.
• Clear, Patient-Friendly Language: Each article explains common conditions, treatment options, and frequently asked questions in plain, understandable terms.
• Free and Open Access: Published in TSACO, the series is available online at no cost, ensuring patients and families worldwide can access these resources.
• Broad Coverage: Topics span the three pillars of acute care surgery—trauma, emergency general surgery, and surgical critical care.

A Vision for the Future

The Patient Education Series not only educates but also fosters trust and understanding between patients and providers. Hospitals, trauma centers, and clinicians are encouraged to share these resources through online links or printed handouts, integrating them into their patient care strategies.

Why It Matters

In moments of uncertainty, access to reliable information can alleviate anxiety and improve patient outcomes. By equipping patients and their families with clear, accessible knowledge, the series enhances their ability to make informed decisions and navigate their care journey with confidence.

This initiative underscores the commitment of TSACO, AAST, and ATS to improving patient-centered care and ensuring that no question goes unanswered during the most critical moments of need.

For more details, visit TSACO’s website. To help write an article, contact one of the three pillar leads:

Trauma: Tarek Kheirbek ([email protected])

Emergency General Surgery: Shannon Foster ([email protected])

Surgical Critical Care: Tejal Bhrambhatt ([email protected])

Empower patients. Improve care. Start here.
 

Palliative Care Committee

Cutting Edge: Goals of Care One-Pagers

Written by: Christine Toevs, MD, FACS, FCCM

The AAST Palliative Care Committee has spent the past year creating these helpful guides for you to use. We have covered six topics to date:

1. Goals of Care - A Primer for Surgeons
2. Goals of Care - Malignant Bowel Obstruction
3. Goals of Care – Withdrawal of Life-Sustaining Treatment and Care of the Imminently Dying Patient
4. Goals of Care – Capacity, Consent and Medical-Decision Making
5. Goals of Care – Difficult Issues Surrounding the Neuro-Devastated Patient
6. Goals of Care – The Family Meeting

They are designed to be helpful to the practicing surgeon, fellows, residents and medical students. They can be hung in the ICU, the resident workroom, and used for education. They can be downloaded and printed from the AAST website.

Goals of Care One-Pagers

The committee plans on adding more topics over the next year. If you have any suggestions or requests for topics that you would like included, please let me know. [email protected]
 

Critical Care Committee

Entrustable Professional Activities for Surgical Critical Care ​

Written by: Krista L. Kaups, MD, MSc, FACS

EPA development continues. EPAs have been adopted by essentially all general surgery programs in the evaluation of general surgery residents. (From the ABS: All general surgery programs plan to participate in EPAs. 97% of programs have chosen to use the ABS EPA App (SIMPL). 3% of programs are using other products including Firefly, SEPA, MyEvaluations, or institutionally developed tools).   EPAs for Surgical Critical Care will be implemented beginning with the new fellows next summer (August 1, 2025). The 9 core EPAs and 4 additional EPAs have been developed by the Scope Council, vetted by the reactor group and are currently being written. SIMPL agreements will be coming out in the Fall of 2024. Along with Amy Hildreth and Deb Stein, I’ve had the privilege of being part of this work. Ongoing kudos and thanks to those of you participating in the writing process and for the commitment of time, effort and energy involved.

 For those not familiar with them (or who were quietly hoping they would go away!): “Entrustable Professional Activities (EPAs) are units of work a physician performs that can be directly observed - things people do, such as evaluating and managing a patient experiencing a specific medical concern. A suite of EPAs for a specialty can define the core clinical activities that a trainee should exhibit to be deemed competent and worthy of autonomy and entrustment in patient care.”  Each one can be completed in less than a minute – and are linked to Milestones. Further education about EPAS is available on the ABS website, a webinar is scheduled for December 18th on the AAST website and a session with the Program Coordinators is also planned. Additional education material will also be forthcoming.

Entrustable Professional Activities (EPAs) were developed to provide the opportunity for frequent, time-efficient, feedback-oriented and workplace-based assessment in the course of daily clinical workflow. EPAs are an important clinical assessment component of competency-based resident education (CBRE). They offer the opportunity to operationalize competency evaluation and related entrustment decisions in the course of regular patient care, and address some of the challenges educators and trainees have faced in bridging core competency theory into clinical practice and performance assessment. 

(From ABS website)  It is important to note that EPAs are NOT competencies, but rather a complement to competencies, and serve as a way to translate the broad concept of competency into everyday practice.

EPAs are units of work a physician performs that can be directly observed - things people do, such as evaluating and managing a patient experiencing a specific medical concern.

Competencies are broad and foundational domains of ability, such as medical knowledge or interpersonal skills.

Milestones are capabilities that describe progress at advancing levels of competence along the sequence from novice to expertise.

A suite of EPAs for a specialty can define the core clinical activities that a resident should exhibit to be deemed competent and worthy of autonomy and entrustment in patient care. Because EPAs are anchored in clinical practice, they allow a way to capture the in-the-moment decisions that attending physicians are already making about how much supervision or autonomy they will give a trainee in a real-world setting and can inform the trainee’s progress towards entrustment for a patient’s care.

The EPA Scope Councils use a variety of inputs including existing definitions of the specialty as well as trainee and practicing surgeon case logs to define the final set EPAs for their specialty area. The goal of the scoping process is to define the foundation of the specialty that can be expected of all trainees in all programs, as framed by current training requirements, practice data, and demographic need, including those domains that are common enough to be meaningfully and reliably assessed in all training environments.
 

AAST Associate Member Council

Associate Member Council Update

Written By: Brittany K. Bankhead, MD, MS, FACS

As the newly appointed Chair of the AAST Associate Member Council, I am thrilled to step into this role at such an exciting time in our organization's journey. Reflecting on the past "lucky 7" years of Associate Membership, our team is filled with pride at how far we have come. I recently had the opportunity to present our progress at the Board of Managers meeting, showcasing the incredible growth and development that has taken place. I couldn’t help but smile when I contrasted photos of the inaugural class—a modest group of a few dozen who resembled wallflowers at a middle school dance—with images from just a few years later, featuring hundreds of members actively working, collaborating, networking, and mentoring one another in the vision set for by the AAST at its inception of this group. 

When we first launched at that meeting in 2019, our Associate Membership stood at just 96 individuals. Today, that number in 2024 has soared to 839. Our leadership infrastructure has evolved from a small core of 4 executive members and 3 committees, to a robust framework consisting of 5 committees, each led by a councilor and committee chair, supported by 6 vice-chairs and 2 formal liaisons to the AAST.

Over the years, we have taken great strides in providing educational opportunities and resources to our members. We have hosted 23 webinars, produced 2 handbooks, organized 4 town halls and 5 grand rounds, and delivered 13 professional development series. Our contributions extend to the broader academic community as well, with 2 surgical critical care podcast episodes and 2 patient education articles now published. Social media has played a significant role in amplifying our impact, with 4 "Forks & Things" segments and 18 "Turnover Times" promoting the scientific achievements of both associate and fellow members. At the Annual Meeting, we have organized 2 research courses and facilitated 19 lunch and pre-sessions, providing even more platforms for trainees and early career faculty to learn. Our formal collaboration with TSACO, the TSACO-Associate Member Scholarship Award, has also now led to the award and publication of 7 new articles by Associate Members. The launch of the Associate Member Academic Series, aimed at highlighting the academic endeavors of our members, has held 4 quarterly programs thus far-  Drs. Julia Coleman, Elinore Kaufman, Melike Harfouche, and John Hwabejire have led the way in promoting this exciting new opportunity (open to any of our members to showcase their scientific work!).

It is particularly gratifying to note that of the 49 new fellows elected to full AAST membership in 2024, nearly 40% were former associate members. This is a powerful indicator of the role associate membership plays in fostering growth and leadership within our field. Looking ahead, I am excited about the opportunities that await us in the coming year. I am deeply grateful for the privilege of serving as Chair for the next two years, and I eagerly anticipate the continued dedication of our members towards advancing patient care, advancing the science of trauma surgery, and uplifting one another in our shared mission.

Diversity, Equity, and Inclusion Committee

“Everyone is Healing…” 

Written By: Helena Bugacov, Ph.D. 

As healthcare providers and trainees, there are times when we must put our personal beliefs aside to do our job. Sometimes, we’re required to find creative, practical solutions to prevent wider disparities within healthcare. As a trainee transitioning to the role of provider and healer, I recently had a powerful experience that will forever change the way I perceive painful triggers and those responsible for them.  

Tattoo removal is often thought of as a cosmetic procedure, but for many, it can serve a paramount role in preventing future trauma. Gang members and victims of human trafficking often have tattoos associated with the life they’re trying to put behind them. These unmistakable tattoos can put our patients at risk of further violent victimization, preventing their integration into crime-free society. The dilemma this creates commonly manifests in physical trauma, of which I’ve encountered much in the LA General Medical Center (LAGMC) emergency department.  

Recognizing this problematic pattern, LAGMC trauma surgeon Dr. Damon Clark founded Disposable Ink in 2016, a tattoo-removal program for those wishing to escape cycles of crime, violence, and victimization. As Dr. Clark’s mentee, I have had the privilege of working with Disposable Ink via the Soledad Enrichment Action group and LA City's Gang Reduction and Youth Development organization (GRYD). This experience exemplifies the ability of an academic medical institution to address the needs of its local community to save lives. Dr. Clark has trained dozens of surgical residents and medical trainees to remove tattoos, myself included. Dr. Damon Clark and his team have removed over 400 clients’ tattoos to date, resulting in some truly inspirational success stories for patients escaping difficult pasts. Dr. Clark continues to expand the program, addressing the needs of the most vulnerable.  

At Disposable Ink, Dr. Clark repeatedly reminds us volunteers not to ask about the history of tattoos during their removal. He reminds us that our job is to assist with the removal process in a respectful and considerate manner, without further inducing any trauma or triggering. Recently, I was assisting Dr. Clark in removing a large gang tattoo that took up the patient’s entire chest and abdomen. The patient, a large white male, had “WAR on [N-word]” tattooed across his chest. Underneath was a giant swastika covering his entire abdomen. Dr. Clark asked him what he wanted to remove, and the patient said just the letters on top. He would keep the large symbol “cuz F&*% them Jews”.   I have experienced antisemitism before, along with being called a “beaner” by peers in school, referring to my Jewish and Hispanic background. However, this was the first time I was put in a position of needing to support, care for, and comfort a person who had just made offensive remarks towards me.    

Tattoo removal can be a painful experience. This patient was having a very difficult time with his procedure because it was large and it was done “on the inside,” meaning that it was made in prison without the use of professional ink. At first, I found it challenging to comfort him, pre-cool the area for local anesthesia, hold his hand per his request, and talk him soothingly through the procedure. I normally feel very excited to be of assistance and comfort patients. But I recognized that it was hard to remain respectful and comforting as he had just chosen to have a symbol on his chest that to my culture reflects hatred and the persecution of millions of people.  

This patient had no idea that I was Jewish. I realized he was in a vulnerable position and that this tattoo removal had nothing to do with me. At that moment, it was my job to accept his choices and support him as a patient, regardless of his background or beliefs. Supporting him in this moment meant to provide him with the best quality of care and ensure he felt comfortable, heard and cared for. Respecting him also meant understanding where he was in his life journey, having empathy for his current situation and trusting that he, too, was doing his best.  

After this session, Dr. Damon Clark, an African American physician from Detroit, mentioned that he has heard countless offensive remarks by patients whom he was treating. He said that he always tries to remember that “everyone is healing from something,” and he continually tries to remain respectful even when it is difficult. My life as a future physician is rooted in my belief that every human is entitled to quality care. As I continue my education, learning and absorbing everything that can make me a better doctor, I will hold this experience in high regard as a lesson you can’t read in a book or test for on an exam. 

Pediatric Trauma Committee

Pediatric Vascular Trauma: Who will be responsible for these injuries?

Written by: Matthew T. Harting, MD, MS, Natalie Drucker, MD, Charles S. Cox, Jr, MD

Take Away Messages:

• Pediatric vascular trauma (PVT) demands a timely, expert, and unique response, including specialized development and maintenance of an advanced skillset, in order to optimize outcomes.
• While variable, the structure of a vascular response team must include continual and immediate availability of trauma, pediatric, and vascular expertise.
• Open repair remains the mainstay for managing most injuries with a very narrow indications for endovascular repairs.

Pediatric vascular trauma is not exactly vascular surgery, trauma surgery or pediatric surgery. Over time, with changing paradigms of surgical training, a gap has developed in many institutions in terms of who is principally responsible for children with major vascular injuries. To that end, we sought to examine our approach/results to integrated trauma vascular care and what models could exist in different types of facilities. Finally, the issue of endovascular care comes up in dealing with older children and is worthy of discussion. A review of all of the components of individual injuries is beyond the scope of this communication.

As of 2020, penetrating injuries became the leading cause of death among children and adolescents age 1-19 in the United States. Among these patients who survive to reach advanced medical care, vascular injuries are associated with significant morbidity, along with challenges around patient ownership and expertise. These injuries can lead to life-threatening hemorrhage and/or limb-threatening ischemia if not addressed in a timely manner. Vascular injury management demands unique expertise, which is particularly nuanced for the pediatric patient. An integrated team may provide the best approach to rapid hemorrhage control and revascularization, though the structure of vascular response teams in children’s hospitals is highly variable. Herein, we will highlight the scope of the epidemic of traumatic vascular injuries in pediatric patients, provide an overview of current evidence and outcomes, discuss the variability of team structure, identify training opportunities for maintenance of expertise, and provide overarching team structure strategies. Finally, we provide a high-level look at initial resuscitation and address endovascular approaches and limitations germane to pediatric vascular trauma (PVT).

Outcomes and experience

Frequency and outcomes in PVT vary by injury mechanism, location, severity of injury, and a myriad of other factors. Vascular injuries are infrequent in the pediatric trauma patient, comprising 0.6-2% of all injured patients¹. Despite this low incidence, extremity vascular injuries in children are associated with limb loss rates between 2% and 11%, along with an overall mortality range of 0-15%.^2-4 (Table)^1,2,5-7 Vascular injuries in younger pediatric patients are more likely the result of a blunt injury⁴, though this transitions to penetrating injuries in the mid-teens. While thoracic and abdominal vascular injuries occur, the upper and lower extremities are the first and second most common vessel injury locations, respectively,^4,6 Vascular injuries increase in frequency with increasing age and are twice as likely in boys⁴. Increasing frequency of pediatric vascular trauma (PVT) seems to be occurring over time; fortunately, mortality is likely improving.³

Pediatric vascular team variability and maintenance of expertise

The specific design, structure, and function of the team that responds to and manages PVT is highly variable by center.⁸ Classic models have the injured patient cared for by the trauma service, consulting vascular surgery, interventional/neurointerventional radiologists. This adult model translates poorly into children’s hospitals and has led to variable outcomes in PVT. The forces that have led to this variability are numerous. First, the increase in the application of endovascular approaches (with a concomitant decrease in open vascular procedures),^9,10 the rise of the integrated vascular surgery training paradigm,¹¹ and the increasing forces of sub-specialization,¹² are generating trauma surgeons, general surgeons, and vascular surgeons with an overall decreased collective open vascular experience and comfort,^13,14 given training that leaves these surgeons less equipped to handle emergent exposure, decision-making, and reconstruction.⁸ Second, the infrequency of PVT requires those with vascular trauma expertise to also practice within a specialty which provides alternative volume; a practice isolated to vascular trauma does not exist. Third, shifts in call coverage and infrequency of exposure render maintenance of expertise and availability increasingly challenging. Fourth, the pediatric population is a highly individualized population, where patient size, growth, and unique physiology, along with infrequency of exposure, and overall comfort for adult¹⁵ and pediatric¹⁶ providers are challenges which are difficult to overcome. Fifth, the urgency of the intervention limits the opportunity for centralization of highly expert care, increasing the dilution of the experience, while requiring numerous centers to develop an often-imperfect solution to this clinical need. Delay in intervention, secondary to untimely diagnosis or transport, prolongs ischemic times and worsens outcomes.¹⁷ Sixth, centers have highly variable personnel constructs, historical cultures, and volumes. Free-standing children’s hospitals and children’s hospitals within adult centers have unique resource availability.¹⁶ American College of Surgeons (ACS)-verified pediatric and adult trauma centers are different than non-ACS-verified centers,⁴ with notable variability in availability of expertise specific to PVT. Further, trauma volume is variable by center.¹⁸ Seventh, prehospital care and emergency department expertise is highly variable. Prompt recognition and early, appropriate diagnostics with efficient, early resuscitation are key to the function of a high-level trauma center.

There are a number of training options for the pediatric surgeon or trauma surgeon to gain and maintain expertise within a team caring for the PVT patient. The role and scope of responsibility ranges from total pre, intra and post-operative care to coordination of management of the multiply injured patient. There are specific courses related to vascular exposures in trauma (ASSET Course: Advanced Surgical Skills for Exposure in Trauma as one example).^19,20 There are various components of pediatric surgical practice that can include vascular surgical procedures such as extracorporeal life support (ECLS or ECMO) vascular reconstruction, vascular ring management, tumor resection with vascular reconstruction, along with vascular trauma. The ASSET course includes both cognitive didactic and technical hands-on cadaver dissection opportunities. Evidence suggests that ASSET training improves exposure techniques, procedure competency/efficiency, and rate of successful vascular control.²¹ Moreover, although the course enables surgical residents to reach an expert competency level, interval experience affected skill retention at 18 months.²² Clearly, baseline education combined with consistent experience establishes and maintains an expert level of competency. Therefore, even if the pediatric surgeon isn’t ultimately tasked with the repair of the injured vessel, the exposure, vascular control, potential for shunting, and need for fasciotomy can be performed concomitantly or pre-emptively with a consultant who performs the revascularization.

As another example, resuscitative endovascular balloon occlusion of the aorta (REBOA) is being employed with increasing frequency, given evidence of its efficacy and improvements in the devices available.²³ It can serve as a resuscitative adjunct in patients in hemorrhagic shock, including adolescent and pediatric patients.²⁴  Due to size limitations, this effort is focused on adolescents, although there are published guidelines on balloon inflation volumes for smaller patients²⁵ and the newer device (COBRA-OS, Front Line Medical) uses a 4 French arterial sheath. 

Training, experience, trauma system processes, and expertise are associated with increased rates of successful use of both open and endovascular techniques.^26,27 Especially in lower volume centers, high-fidelity simulation, anatomically accurate modeling, and human tissue-like physical models all allow development and maintenance of skills in a risk-free environment. Virtual reality simulation has been used to effectively teach REBOA skills.²⁸ Objective structured clinical examination (OSCE) training for surgical skills is effective in improving proficiency and self-confidence.²⁹ Vascular anastomosis-specific training has been employed for the development of the basic technical skills required for vascular surgery.³⁰

Optimizing pediatric vascular team structure

How are we to reconcile these challenges and forces to maintain timely and expert care of PVT? Fortunately, there are likely multiple solutions, as optimal outcomes in PVT are likely achievable through several unique structures and with the involvement of various specialties. Outcomes in vascular trauma have repeatedly been shown to be specialty independent,^10,31,32 therefore the composition of an effective team may take on many forms, depending on the specific institution.  Several overarching construct options include the following:

Option 1: Comprehensive surgical management via centralized expertise. A pediatric and/or adult trauma-trained surgeon who has experience and expertise in pediatric trauma, vascular control and definitive repair leads a team. This individual (or, ideally, a team of individuals) are consistently available, along with operating room (OR) team availability and expertise. A separate microvascular team (often hand or plastic surgeons) is available. Further, all necessary imaging and operative equipment are available. The risk of Option 1 is the lack of depth of expertise for complex repairs and the need for an “Option 1.5” in terms of occasional vascular surgical consultation.

Option 2: Trauma surgeon leadership with focused consultation. A pediatric and/or adult trauma-trained surgeon leads initial stabilization, diagnosis, resuscitation, exposure, control +/- shunting. A vascular surgeon with significant experience in open repair and trauma consults for intraoperative technical expertise. A separate microvascular team is available. OR team availability and expertise exist, and all necessary imaging and operative equipment are available. The risk of Option 2 is a niche vascular surgical specialist may not be a useful consultant (specialist in endovascular aortic disease or practice limited to venous disease). Avoidance of this requires frank discussions before forming the team.

Option 3: Trauma surgeon stabilization with broad consultation. A pediatric and/or adult trauma-trained surgeon leads initial stabilization, diagnosis, and resuscitation. Consultation with appropriate expertise* occurs for exposure, control, and definitive repair. OR team availability and expertise exist, and all necessary imaging and operative equipment are available. The risk of Option 3 is management by committee and loss of patient trauma physiology prioritization.

*open vascular surgery, endovascular, transplant, pediatric cardiovascular, and/or hand (microvascular)

Initial resuscitation, evaluation, and imaging in PVT

An initial focused physical examination should follow thorough, fundamental trauma primary and secondary surveys. Pediatric trauma resuscitation and massive transfusion protocols have been widely adapted from initial work in adults.³³ Three evolving elements of resuscitation practice in children are (1) use of low titer O negative, whole blood resuscitation vs. balanced ratios of PRBC:FFP;PLT,³⁴ (2) thromboelastography (TEG) driven component replacement,³⁵ and (3) tranexamic acid, or TXA as an adjunct to hemorrhage control, either prophylactically or in setting of fibrinolysis³⁶ on TEG.^37,38 

A threatened limb or other potential vascular injury should identify hard and/or soft signs of vascular injury and a subsequent arterial pressure index, for a possible vascular injury. This is accomplished with a doppler probe, a blood pressure cuff, and the following formula: Arterial pressure index (API)=doppler systolic pressure distal to injury/doppler systolic pressure of an uninjured upper extremity. An API<0.9 is both highly sensitive (>95%) and specific (>97%) for arterial injury, even for the pediatric patient.^39,40 If the doppler signal interrogation or API support the concern for vascular injury, one of three common modalities should be used to further characterize the injury: digital subtraction angiography (DSA), duplex ultrasonography, or computed tomography arteriography (CTA). CTA has become the most utilized approach, particularly for the pediatric patient, due to its availability, excellent image quality, high sensitivity and specificity, and these patients often require this imaging anyway for associated injuries.

Endovascular approach for pediatric extremity injury?

There is a very limited role for endovascular treatment for prepubertal upper extremity trauma due to a combination small vessels, easy open exposure for the mid and distal arm, and poor durability in the long-term.⁴¹ Therefore, we believe, and evidence supports, the only reason for endovascular intervention in the pediatric population is to treat sites in which proximal control cannot be easily obtained or is associated with significant morbidity such as axillosubclavian injuries.^42-45 In these situations, if the patient is unstable or has multiple sites of concomitant injury, it may be beneficial to temporize the patient with a stent-graft to rapidly re-establish distal perfusion and deal with the repercussions in a more elective manner as they materialize. Commercially available self-expandible peripheral stents span from 5-13 mm (Viabahn Endoprosthesis, W.L. Gore and Associates) and should be sized 5-10% over the target vessel diameter.⁴⁶ In a catastrophic limb injury, embolization of branch points with evidence of extravasation can be considered in very select patients but not recommended, once again, due to general ease of surgical access without the need to leave foreign materials. Postoperatively, dual antiplatelet pharmacologic treatment with a baby aspirin and clopidogrel is preferred for at least three months while aspirin is continued indefinitely to maintain graft patency.⁴⁷

Open surgical reconstruction remains the pillar of lower extremity vascular trauma in the pediatric patient. The same principles for pre- and post-pubertal patients described in other vascular beds remain true for the lower extremity. However, we have found several instances where endovascular intervention may be potentially useful; these cases are universally situations where the open exposure of an arterial bed will cause significant morbidity. For example, the patient with distal profunda femoral artery injury in which exposure will lead to significant bleeding and need for transection of thigh musculature or the patient with a proximal anterior tibial artery injury in which there is no easy way to expose the interosseus portion without potential injury to the bridging anterior tibial vein while maintaining proximal and distal control. ⁶  These cases may be better suited with coil embolization, particularly if concomitant injuries or challenging anatomy complicate the situation, given the presence of excellent collaterals in these locations.

Do I need a Hybrid Room?

The short answer to this question is YES.  There are growing indications for use of the Hybrid Room in which advanced imaging can be done upon completion of a vascular repair.⁴² Importantly, there is the ability to expand the management of complex truncal injuries using balloon catheters, ECMO cannulation with imaging, and other contingency equipment and/or the use for embolization of solid organ injuries or pelvic injuries.^43,44

Conclusions

The time to formulate the optimal approach to PVT is prior to the appearance of the patient with a critical injury. Critical review of your institutional resources and personnel allows the optimal integration of the team for the uncommon (but increasing in frequency) patient with these injuries.

References

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Pediatric Trauma Committee

Pediatric Pancreatic Trauma: Kids are Not Just Little Adults

Written By: Bindi Naik-Mathuria, MD, MPH

Blunt pancreatic injuries in children are rare, accounting for only 0.3% of admissions for blunt trauma and 0.6% of abdominal injuries, with high-grade injuries with duct involvement representing only 15% of all pancreatic injuries [1]. Most trauma surgeons have limited experience with managing these patients, as even high-volume pediatric trauma centers manage only 0-3 of these patients per year [2]. These injuries most commonly occur in the pancreatic body or neck overlying the spine. Since pancreatic duct leakage can lead to pseudocyst formation and other comorbidities, the standard of care in the adult population for AAST grade III injury (duct transection at body/tail) is distal pancreatectomy according to the practice management guideline from the Eastern Association for the Surgery of Trauma (EAST) due to the adverse consequences of pancreatic duct leak in the adult population [3].

However, children tolerate pancreatic leak better than adults do, and thus this remains one of the few controversial management topics in pediatric trauma. In a review of 100 children managed with NOM, complications were rare and sepsis and mortality did not occur and the most frequent complication was pseudocyst, which resolved spontaneously or required drainage [4]. Over the past few decades, observation (non-operative management or NOM) has gained popularity, and pediatric surgeons remain divided about which strategy, operative management (distal pancreatectomy) or NOM, leads to faster recovery and better outcomes in children [5]. NOM offers the advantages of avoiding an operation and sparing pancreatic resection that may lead to future pancreatic insufficiency. However, the literature has controversial outcomes of whether or not outcomes are better with this approach [2].

A recent review of the TQIP database demonstrated an increased upward trend of NOM use for high-grade pancreatic injuries in children (AIS 3+), ranging from lowest utilization of NOM at 48% in 2013 to a peak of 67% in 2019 [5]. Additionally, in the majority of cases, NOM meant observation only, as only 23% of children managed with NOM had concomitant endoscopic retrograde cholangiopancreatography (ERCP) with stent placement [4]. Notably, in the whole NOM cohort, the incidence of sepsis was very low (0.4%) and pseudocyst formation and hospital length of stay were significantly lower than the late operative management group [5].

One issue with direct comparison of outcomes between NOM and Operative management (OM) is that NOM management can be highly variable regarding feeding practices, elective interventions, and discharge criteria [2], likely due to lack of standardized management and the rarity of these injuries leading to lack of experience at each center. In 2017, the Pediatric Trauma Society (PTS) pancreatic trauma study consortium published a standardized clinical pathway for NOM of pancreatic trauma [6]. The PTS NOM pathway was based on early oral feeding with feeding advance and discharge based on clinical symptoms alone, avoiding serial pancreatic enzymes to guide management (Figure 1), and avoiding repeat imaging unless still symptomatic at least one week after injury [6].  Prospective outcomes following the PTS standardized pathway for grade III injury cases were recently published [7]. Early, straightforward recovery was common (81%), and delayed recovery was due to early feeding intolerance related to symptomatic pseudocysts [7]. Pancreatic ascites at presentation predicted pseudocyst development; therefore, it may be prudent to consider early intervention (operation or endoscopic stent) for these cases, although further study is needed to confirm this finding [7].

A prospective trial directly comparing outcomes of NOM and OM of this rare injury in the pediatric trauma population is underway to determine which strategy should be the gold standard in children. Until then, we can recommend that NOM is an acceptable and safe strategy to manage acute and chronic pancreatic transection in children. ERCP with stent is not mandatory and observation alone can suffice, although at times recovery can be slow. Furthermore, the PTS NOM clinical pathway should be followed (Figure 2) as it has been shown to lead to good outcomes and improved resource utilization compared to non-standardized management [7].

References

[1] Englum B R, Gulack BC, Rice HE, Scarborough JE, Adibe OO. Management of blunt pancreatic injury in children: review of the National Trauma Data Bank. J Pediatr Surg. 2016 Sep;51:526-1531.

[2] Naik-Mathuria B. Practice variability exists in the management of high-grade pediatric pancreatic trauma. Ped Surg Int 2016 Aug; 32:789-94.

[3] Ho VP, Patel NJ, Bokhari F, et al. Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017 Jan;82:185-199.

[4] Rosenfeld EH, Vogel AM, Jafri M, Burd R et al. Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children. Pediatr Surg Int, 2019 Aug;35:861-7.

[5] Katsura M, Ikenoue T, Aoki M, et al.  Recent Changes in the Management of High-Grade Blunt Pancreatic Injury in Children: A Nationwide Trend Analysis. J Am Coll Surg. Published online February 7, 2024. doi:10.1097/XCS.0000000000001033

[6] Naik-Mathuria BJ, Rosenfeld EH, Gosain A, et al. Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative. J Trauma Acute Care Surg 2017 Oct;83:589-596.

[7] Naik-Mathuria B, Ehrlich PF, Escobar MA Jr, et al. Prospective Outcomes of Standardized Non-operative Management of Pancreatic Trauma With Ductal Injury in Children: Less is More. J Pediatr Surg. Published online October 10, 2024. doi:10.1016/j.jpedsurg.2024.161976.