March 2025 Cutting Edge Newsletter

March 2025 Cutting Edge

Jump to Editor’s Note
Jump to World War III? What to know and how can Trauma Centers get ready?
Jump to Prioritizing Health Equity and Inclusive Excellence within Trauma
Jump to The AAST Associate Membership Update
Jump to The Journal of Trauma and Acute Care Surgery News
Jump to A Collaboration between the Pediatric Committee and the Palliative Care Committee
Jump to Summary of Updated APSA Guidelines for the Management of Blunt and Spleen Injuries

Editor’s Note

Written by: Shannon Marie Foster, MD, FACS

Disaster Committee

World War III? What to know and how can Trauma Centers get ready?

Written by: Jeannette Capella, MD, Med, FACS, Vice Chair AAST Disaster Committee and Adam D Fox, DO, FACS, Chair AAST Disaster Committee 

Even a brief amount of time spent watching the news can become worrisome for an increasing number of conflicts around the world. Although most are far away and can be considered “local” problems or you do not want to think about hypotheticals, it has always been the job of the trauma surgeon to prepare for all eventualities. There are multiple real threats, and understanding how the trauma system may be involved is valuable for all those reading this.

There are currently several departments and agencies within the US government trying to maximize readiness in the face of a Large-Scale Combat Operation (LSCO) with countries that might be considered military peers or near-peers. The Department of Defense (DOD), Administration for Strategic Preparedness and Response (ASPR) and the National Disaster Medical System (NDMS), to name a few, are working to produce solutions to questions such as: How can the civilian health care system aid our military and absorb thousands of injured war fighters? How would these patients be distributed once back in the continental United States? Who would be the coordinating agencies for these patients? All verified trauma centers might be involved in caring for war casualties and therefore need to be prepared. This begins with an understanding of how your center works within a federal, regional, and local response system. Do you participate in a Regional Medical Operations Coordination Center (RMOCC)? Does your hospital disaster committee have this topic on their agenda? How often do trauma surgeons participate in local and regional exercises?

The trauma community needs to take heed of the planning going on at the Federal level for possibilities such as massive numbers of war fighters. Now is the time to begin asking the questions and preparing for what may become a reality. Early involvement at both the local and regional level allows the trauma system to help develop, plan, and execute in a situation that may otherwise present as overwhelming.

 Diversity, Equity, and Inclusion Committee

Prioritizing Health Equity and Inclusive Excellence within Trauma

Written By: Cherisse Berry, MD, FACS

Health equity is the sixth domain of quality but often the forgotten domain of quality. The Joint Commission now mandates strategies for reducing health disparities, screening patients for structural determinants of health, and developing an action plan to address identified health disparities within patient populations.  By 2026, Centers for Medicare and Medicaid Services (CMS) will require that payment determination be tied to the mandatory reporting of structural determinants of health. Thus, prioritizing the elimination of inequities and disparities in trauma care is vital not only from a regulatory, social justice, and equity standpoint, but also for improving the overall health and economic prosperity of our patients.  As defined by CMS, health equity is defined as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.” Yet people of color and other underserved and historically marginalized groups, experience higher rates of morbidity and mortality after injury.

Carr et al found that nearly 30 million Americans lacked access to trauma care in 2010. Factors associated with less access to trauma care included the uninsured, Medicaid and Medicare eligible patients, and rurality. Haider et al found that minoritized patients have worse outcomes after trauma when compared to Caucasian patients and patients treated in hospitals with higher percentages of minoritized patients had significantly increased odds of mortality when compared with hospitals treating primarily Caucasian patients. While disparities in trauma care across every link in the trauma care chain of survival are known, a data-driven strategic approach to eliminating these inequities are unknown.

However, before developing strategies and solutions to eliminating inequities among the injured, it is important to have a fundamental understanding of the historical policies rooted in structural racism that have contributed to the disparities in trauma care that we see today. Structural racism operates through laws and policies (e.g. redlining) that allocated resources in ways that disempower and devalue members of racial and ethnic minoritized groups resulting in disparities in access to high quality care and to inequities in the structural determinants of health that are seen today: poor access to health care, poor housing conditions and physical environments, poorly funded schools, and poor access to capital. These structural determinants of health rooted in structural racism become the drivers of health and lead to poor health outcomes: increased mortality, readmissions, and hospital acquired conditions.

Understanding that health disparities among the injured is rooted in structural racism, the AAST DEI Committee sought to prioritize a strategic approach to identifying solutions. During the 2022 AAST Annual Meeting, we held a lunch session entitled “Quality Care is Equitable Care: A Call to Action to Link Quality to Achieving Health Equity within Trauma and Acute Care Surgery” which was subsequently published in TSACO. During the 2023 AAST Annual Meeting, we held a lunch session entitled “Solutions to achieving health equity and eliminating health care disparities within Acute Care Surgery” which was subsequently published in TSACO.  We then sought to convene a Delphi consensus panel of stakeholders to identify health equity standards within trauma that CMS would pay for and develop a plan to integrate those standards within our databases, practice management guidelines, research designs, and trauma verification standards. The American College of Surgeons (ACS) Office of Inclusive Excellent had already been leading in this space with an initiative to integrate equity standards within the standard quality domains that preceded this idea. Thus, we came together and collaborated to develop the ACS Trauma Equity Taskforce and hosted the first health equity in trauma virtual summit on February 12^th, 2025, entitled “Achieving Better Outcomes in Trauma Care”. With over 90 participants, subject matter experts, and leaders in health equity in trauma care representing nine trauma societies, we have identified health equity leading practices that may inform trauma verification standards by embedding evidence-based trauma specific equity principles into the standard quality domains. As we work to finalize these recommendations, the identified equity principles represent an evidence-based, data-driven strategic approach to eliminating disparities and inequities among the injured.

Cherisse Berry, MD FACS
Immediate Past Chair, AAST DEI Committee
Chair, American College of Surgeons Trauma Equity Taskforce
Professor of Surgery and Vice Chair of Academic Affairs
Director of Research, Eric Munoz Trauma Center, University Hospital- Newark, NJ
Rutgers Health, New Jersey Medical School

The Journal of Trauma and Acute Care Surgery News

Written By: Raul Coimbra, MD, PhD, FACS; Editor-in-Chief 

What You Need to Know Article Series
This very well-received and popular article series has reached a milestone. From October 2023 to February 2025, 39 manuscripts have been published on trauma, surgical critical care, and emergency general surgery topics. We hope you read and use these articles in your research and in your clinical practice. There is always an article covering a topic of your interest. Check them out and share them with your clinical and research teams. They are free to download for one year from the publication date.

 Here is the lineup from January – March 2025.

January 2025:
Diagnosis and Management of Blunt Cerebrovascular Injuries: What You Need to Know
Damage Control Thoracic Surgery: What You Need to Know
Fluid Resuscitation in Trauma: What You Need to Know 

February 2025:
Current Management of Acute Appendicitis in Adults: Want You Need To Know
Pregnancy and Trauma: What you need to know 

March 2025
Tips and Tricks in the Operative Management of Esophageal, Trachea and Bronchial Injuries: What You Need to Know
The Always Evolving Diagnosis and Management of C. difficile Colitis: What You Need to Know

JTACS EGS Algorithms
The first two EGS algorithms have been published and the feedback from the readership is great. We hope you are reading and using them in your clinical practice. Remember that these are published OPEN ACCESS and are free to download immediately.

January 2025
Evidence-Based, Cost-Effective Management of Acute Cholecystitis: An Algorithm of the Journal of Trauma and Acute Care Surgery Emergency General Surgery Algorithms Working Group

March 2025
Evidence-Based, Cost-Effective Management of Acute Appendicitis. An Algorithm of the Journal of Trauma and Acute Care Surgery Emergency General Surgery Algorithms Work Group

JTACS Biostatistical Reviews
We will publish the first mini-article on Biostatistics, as part of the JTACS Biostatistical Reviews to help authors to report  their analysis using the most accurate statistical methodology.

March 2025
An Introduction to Propensity Score Analysis in Acute Care Surgery Research: Methodology and Pitfalls

Pediatric and Palliative Care Committee​s

Pediatric Palliative Care

Written By: Dr. Lillian Liao, MD;
Special thanks to Christine Toevs, MD, Stephanie Lueckel, MD, and Bindi Naik-Mathuria, MD

Pediatric Palliative Care – Injured children are a unique group within the trauma population as they are still developing as human beings both mentally and physically. Thus, palliative care in this age group looks different compared to the adult population. While the primary focus of adult palliative care is on end-of-life care, the focus in children is serious injuries children with life altering disabilities. The goal of pediatric palliative care is to optimize the quality of life for both the child and the family as they navigate life altering diseases and injuries including  the end of the complex care process or the end of life.

There is a paucity of literature regarding injured patients in the arena of pediatric palliative care, as most are focused on chronic diseases of childhood. The subspecialty of pediatric palliative care is relatively young as it was endorsed by the American Academy of Pediatrics (AAP) in 2000. This article will provide general information on each type of palliative care in children and resources to further educate the trauma team regarding pediatric palliative care. In particular, those adult trauma centers caring for children aged 16-17 years of age should consider collaboration with pediatric palliative care teams.

AAP supports an "integrated model of palliative care" in which palliative care is offered to a patient and the family at the time of diagnosis and the care is carried out throughout the illness whether it ends in cure or death. Palliative medicine should not only be offered to those children who are imminently dying or have a terminal condition as many needy children who may benefit may be missed. The goal is to provide patients, and their families support with curative, life-prolonging, and palliative care. Pediatric palliative care is a multi-disciplinary approach much like trauma care. The pediatric palliative care involves specialty boarded physicians, advance practice providers, nurses, physical/occupational therapists, nutritionists, social workers, psychologists, pharmacists, child development specialists, case managers, chaplains, bereavement counselors, child-life specialists, music therapy, and the ethics team when appropriate.  Most broadly, pediatric palliative care can be divided into two categories: Supportive Palliative Care and End of life Palliative Care.

Supportive Pediatric Palliative Care – Children who sustain life altering injuries which include severe traumatic brain injury, spinal cord injuries, polytrauma with physical and mental limitations are patients who will benefit from Palliative Care consultation.

• The main goal is to allow children to grow and develop through childhood after surviving a developmentally altering injury, either physical or mental. For example, a child with sustained severe traumatic brain injury, pelvic fracture, and small bowel injury who requires ventilator support and tube feeding with a grim prognosis will alter the child’s ability to have a “normal” childhood. Communication of these life-changing events and coordination of treatment for the family is challenging. The palliative care team can assist by helping the family understand the prognosis, addressing conflicting goals and values, allowing time to ask questions, and coordinating consistent communication between various disciplines (trauma, neurosurgery, orthopedics, pediatric critical care, and others) for both inpatient and outpatient treatment.
• The care team helps the child and family create a new “normal”, as disabilities are not a normal part of childhood development.
• Medical decisions are mostly made by the family compared with adult patients who can make their own decisions. Supportive pediatric palliative care helps parents with questions, such as:
  • Should we prolong treatment? When should we stop treatment and transition to comfort care?
  • Should I have a conversation with my child (in cases when there is understanding. Ex: femur fracture, acute amputations, scarring from injury)?
  • How much do I tell him/her?
  • Will the conversation upset or frighten my child?
  • Will talking about dying make it come true?

End of life Pediatric Palliative Care – Injuries, unintentional and intentional,  are the leading cause of death among children, ages 0-18. Children generally are not proactive in end-of-life planning. Development of a partnership between the patient, family, and the palliative care team is crucial to optimizing treatment plans for both the child and the family. As the family and child have come to the decision that the disease (traumatic injuries) cannot be overcome, based on their believes and goals, end of life care should proceed with the help of the palliative care team. This process of end-of-life care in children is very similar to the adult palliative team process. Communication needs for families with children and adolescents with life-threatening conditions should include:

• Straight forward information regarding medical conditions. Prediction of outcomes in devastating yet non-fatal injuries is difficult in children due to a lack of case volume and the resilience of a child’s physiology with normal functioning organ systems to survive. A new “normal” and what each family wants/can tolerate should be respected in the discussion.
• Coordinated team communication should be aligned so all clinicians are sharing the same information regarding prognosis and outcomes.
• Providing recommendations and resources (chaplain, child-life, music therapy, psychologists for parents/child) to address conflicting goals and values. Respecting the faith and hope of the family as they have family goals and unique understanding of their child.
• Providing time for parents to make difficult decisions when time allows.
• Helping families understand common signs and symptoms that occur such as appetite, alertness, breathing patterns, cardiac insufficiency, loss of bowel/bladder control, and skin changes.
• Providing options for memory making whether it is handprints, locks of hair, bereavement photos, printed heart rhythm strips, fingerprint charms, etc.
• Hospital ethics may be involved with decision making in specific occasions when a child has no available family or if a family needs more guidance with end-of-life choices.

Shared Decision Making – When an injury is so severe the trauma team anticipates life altering changes for a child, the pediatric palliative care team should be involved. Life altering changes can include physical limitations (i.e. traumatic amputations or complex pelvic fractures) to mentally alternating injuries (i.e. moderate to severe traumatic brain injury) or where there is an anticipated developmental halt or delays compared to the uninjured child. Early involvement of the pediatric palliative care team can assist the family with trust building to develop family driven value-based care throughout an uncertain future for the child, which may or may not include death. Discussions with older children who will likely participate in care decisions requires special training. Shared decision making with the palliative care team can help the family unit reduce the burden of guilt as well as uncertainty.

References:

• Guidance for Pediatric End-of-Life Care | Pediatrics | American Academy of Pediatrics
• (2000). Palliative care for children. Pediatrics, 106 (2), 351-357.
• Feudtner, C. (2007), Collaborative communication in pediatric palliative care:
• A foundation for problem-solving and decision making. Pediatric clinics of
• North America. 54, 583-607.
• Davies, B., Sehring, J. C., Cooper, B. A., Hughes, A., Philp, J. C., Amidi-Nouri, A., et al (2008). Barriers to palliative care for children: Perceptions of pediatric health care providers. Pediatrics, 121, 282-288.
• pdf
• NIH resources to help families navigate pediatric palliative care | National Institutes of Health (NIH)

Pediatric Committee

Summary of Updated APSA Guidelines for the Management of Blunt and Spleen Injuries

Written By: Heather Ots, MD and John K. Petty, MD

Brenner Children’s Hospital
Wake Forest University School of Medicine
Winston-Salem, NC

The original American Pediatric Surgical Association (APSA) guidelines for management of blunt liver and spleen injuries (BLSI) established a standard of care for management of these injuries in children. The recently published update reflects the continued evolution of this care. The updated guidelines, built upon a thorough literature review and expert consensus, prioritize hemodynamics over imaging, delineate indications for intervention, and expand the scope of associated care.  The guidelines are structured around four sections: Admission, Procedures, Set Free, and Aftercare (“APSA”.)

1. Admission: The updated guidelines significantly modify the prior approach to hospital admission and intensive care unit (ICU) utilization. Instead of relying solely on the AAST grade of injury to determine admission location and level of care, the primary determinant is now the patient's hemodynamic status after initial resuscitation. Patients with abnormal vital signs after resuscitation, regardless of injury grade, should be admitted to the ICU. Those with normal vital signs should be admitted to the ward. For ICU patients, bed rest is continued until vital signs are normal. Ward patients do not require activity restrictions. The frequency of blood draws is reduced to a complete blood count (CBC) on admission and 6 hours after injury. Additional laboratory studies are appropriate when clinically indicated based on vital signs, physical examination or concerning laboratory results. The risk of bleeding from BLSI peaks at around 4 hours in children. Diet restrictions are also tailored to the patient's status; ICU patients remain NPO until hemodynamic stability is achieved, while ward patients may receive a regular diet on admission.
2. Procedures: The approach to procedures is similarly refined. The decision to transfuse is based on the presence of unstable vital signs after fluid resuscitation, hemoglobin levels below 7 mg/dL, or clear evidence of ongoing or recent bleeding. Angioembolization is reserved for patients with persistent bleeding despite transfusion, and it is not recommended solely based on the presence of contrast blush on CT scan in the absence of hemodynamic instability. Operative exploration is reserved for situations where continued hemorrhage is present despite transfusions or when other critical information is needed. This selective approach to procedures aims to reduce unnecessary interventions.
3. Set Free (Discharge): Discharge from the hospital is determined by the patient's clinical condition rather than injury grade. Criteria for discharge include toleration of a regular diet, minimal abdominal pain, and normal vital signs. The risk of bleeding from BLSI plateaus at around 36 hours after injury.
4. Aftercare: The guidelines recommend activity restriction for a period of “injury grade plus two” weeks. Routine follow-up imaging is not necessary for asymptomatic patients with low-grade injuries, although imaging might be considered in cases of persistent symptoms following high-grade injuries. This reduced reliance on routine imaging reflects the low incidence of delayed complications in well-managed patients.

Additional Considerations: The updated guidelines address several important considerations:

• Delayed Complications: The low incidence of delayed complications, including delayed hemorrhage and pseudoaneurysms, in properly managed patients is highlighted, further justifying the less intensive approach.
• Hemodynamic Monitoring:  Scoring systems, such as the Shock Index-Pediatric Adjusted (SIPA) may be helpful to identify children who are at higher risk of failure of nonoperative management.
• Therapeutic Angioembolization: Angioembolization should be considered for hemorrhage control when there is ongoing bleeding despite blood transfusion. Preemptive angioembolization in children is not supported.
• Operative Intervention: Operative intervention should be pursued when hemodynamic instability persists despite resuscitation and transfusion. The use of massive transfusion and damage control operative strategies are appropriate in children with severe hemorrhage.  Nonoperative management fails in 5-7% of children with BLSI.

In conclusion, the updated APSA guidelines represent a significant shift towards a more individualized and less intervention-heavy approach to managing pediatric BLSI. The focus is on hemodynamic stability, early identification of ongoing bleeding, and timely intervention only when necessary. This approach aims to improve patient outcomes while minimizing unnecessary resource utilization and potential risks associated with extensive interventions.

From Williams RF, Grewal H, Jamshidi R, Naik-Mathuria B, Price M, Russell RT, Vogel A, Notrica DM, Stylianos S, Petty J. Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries. J Pediatr Surg. 2023 Aug;58(8):1411-1418.

AAST NEW SURVEY METHODOLOGY

Dear Valued AAST Member,

We are writing to inform you about an exciting initiative from the Multi-Institutional Trials Committee (MITC).

As the premier professional organization for Trauma and Acute Care surgeons, the AAST is well-positioned to provide insight into matters important to our specialty.  High-quality surveys of AAST Members can answer important questions about current practice patterns, opinions, and concerns within our community.  Historically, however, many surveys haven’t met the standards for rigorous scientific analysis and publication.  As a result, most surveys do not achieve their stated goals.  Furthermore, survey respondents may never see return on their invested time in the form of high-quality study results. 

We believe this to be a missed opportunity.

In 2025, the MITC will trial a novel “Representative Sample” Methodology to form the Current Practice in Trauma and Acute Care Surgery Consensus Group.

WHAT YOU NEED TO KNOW

How the “Representative Sample” Methodology Works:

• A small number of AAST Members will be invited to participate by random selection

• The “Representative Sample” will be validated against the broader AAST Membership

• A small number of high-quality, peer-reviewed surveys will be circulated to this group

Advantages of the “Representative Sample” Approach to Surveys:

• Same scientifically rigorous approach used by the Pew Research Center

• High response rates to surveys of interest to all AAST Members

• Improved scientific yield, hypothesis generation, publication in scientific journals

WHAT HAPPENS NEXT

• A small number of AAST Members will be invited at random to participate in the inaugural cohort of the Trauma and Acute Care Surgery Current Practice Consensus Group (CPCG).

• Invitations will be sent by email between February 17 – 28.  We ask that you look out for an invitation in your inbox and, if you are invited, agree to participate.  The CPCG cohort will be finalized by March 1. 

• Participants in the CPCG will receive personalized recognition from the AAST President and leadership for their service.

Please feel free to direct questions about this initiative to the AAST Surveys Subcommittee of the MITC at:  [email protected]

Thank you for your valued time!