Cutting Edge Newsletter
01 Nov 2023
by Multi-Institutional Trials Committee, Prevention Committee, Pediatric Trauma Surgery Committee, Military Liaison Committee, International Relations Committee, JTACS Editorial Board, Communications Committee

 

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Editor’s Letter

Written by: Shannon Marie Foster, MD, FACS

Friends and Colleagues – 

May the change of seasons be treating you kindly.  For those seen in Anaheim – a pleasure!  For those who missed – I hope you engaged/are engaging with the content remotely and on-demand!

Once again, the work of AAST committees cannot be overstated.   See our thought-leading authors and new work below. 

How to find the important work, reports, articles, white-papers, and additional contributions of these committees from previous issues and years past?  And truly understand the breadth and impact of committee participation?  At any time, after logging into the website, follow these steps to the archives and active links:  My AAST.  My Dashboard.  Scroll to bottom to find Cutting Edge Newsletter full edition links or Cutting Edge Blog to find specific features directly.  Additionally, if you are interested in exploring the mission, goals, and products of a particular committee, follow these steps to enter the committee pages:   After log in to the site, top right page headers include Donate - Committees - Member Directory.  The full list of all standing and ad-hoc AAST committees will populate after Committees selection.  Drop down carrot allows access to complete listing of active members of each and a red-boxed link to the committee page.  Here you will find the Mission, Activities, Research, Publications, Collaboratives, and Reports and key materials informing current work.   These pages are full of excellent resources and allow you to identify areas for involvement and volunteerism, individuals with whom you may hope to collaborate, and the most up to date situation facing each area of our practice and profession. 

Thank you for reading!  Please reach out to the highlighted authors and committees, amplify and partner this work, and share and distribute this important content to your colleagues, learners, and into your communities at large!

Teaser announcement:  Look for a special Cutting Edge edition next month highlighting the meetings and conferences of the last months with new interviews and behind the scenes content!

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

SMF 

 

Get to Know Your AAST Colleague

The Whole Surgeon

 

 

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Multi-Institutional Trials Committee 

AAST Multicenter Trials Committee Update

Written by: Joseph DuBose, MD
 

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.

Multicenter Study in Pelvic Fracture Hemorrhage (AAST HIPS)

 The AAST Hemorrhage Control Interventions in Pelvic Fracture study (aka "AAST HIPS") is an ongoing, prospective multi-center trial evaluating the effectiveness of various methods of hemorrhage control in reducing mortality from pelvic fractures. Inclusion criteria are restricted to hypotensive patients who receive early blood product resuscitation and/or undergo a hemorrhage control intervention. We know from prior research that mortality from bleeding pelvic fractures can be as high as 60%, and there has been little improvement in this dismal statistic over the past several decades. The aim of this study is to identify whether one or a combination of interventions (REBOA, angioembolization and/or pre-peritoneal packing) may make a difference.

The study is led by Dr. Melike Harfouche and Ms. Leslie Sult at the R Adams Cowley Shock Trauma Center and over 43 centers are actively contributing data. As of October, over 250 patients had been entered into the study's REDCap database, making it already the largest study thus far on hypotensive pelvic fractures. The researchers are eagerly awaiting the 500 patient milestone, when interim analyses will be conducted and potential results may be made available to the research community. There is much work left to be done on the topic of pelvic fractures, and through successful research collaborations we can move the needle forward and improve clinical outcomes.

 

Multicenter Study on Whole Blood Dosing for Trauma

How Much Whole Blood Should We Give to a Bleeding Patient? If you wonder this question, you should join our study! There remains a lot of variability across trauma centers regarding how much whole blood to transfuse to a bleeding patient. Many centers give one or two units of whole blood, perhaps based on old practice patterns of “transfusing two units”. Other centers base their decision on their supply whole blood and the need to parse it to as many patients as possible in between deliveries from their blood supplier. Still others give as much as they feel is needed. The point is that there is no standard and, to date, there are no studies evaluating a relationship between the amount of whole blood administered as part of a massive transfusion event and subsequent outcomes. Our study is a prospective, observational trial that seeks to answer these questions. Each center will continue to provide its own standard care and we will use the inherent variability in practice as a means to quasi-randomize patients to receiving various amounts of whole blood and then study outcomes. 

If you are interested, please contact Dr. Babak Sarani – [email protected]. To date, there are 5 hospitals in this study and we have enrolled approximately 50 patients. We seek to enroll 200 patients total in this pilot study.

 

Multicenter Study of Pre-Hospital Intubation 

Prehospital intubation is highly controversial. While there is scant research suggesting that prehospital intubation may be associated with improved neurologic outcomes in the presence of traumatic brain injury, there is growing evidence that prehospital intubation is associated deleterious outcomes in the setting of trauma; especially for those patients experiencing exsanguination. However, secondary to variable study design, prehospital staffing, and other confounding factors, there is currently no consensus amongst the trauma community regarding prehospital airway management for the acutely injured. Therefore, our study seeks to provide a contemporary, national assessment of prehospital airway management so leaders in the trauma community can provide firm recommendations, and ultimately, patients will benefit from receiving best practice.

To date, 17 sites around the United States have submitted data on over 700 patients! Our study will be enrolling patients through the end of October 2024 as we plan to submit our research to the 2025 AAST Annual Meeting. That said, given the robust nature of our dataset, our group is planning numerous publications for years to come exploring airway management in the setting of acute injury! Should your trauma center have any interest in exploring this important research topic, you can reach out directly to the University of Colorado Hospital’s Trauma Research Program Manager, Shane Urban, at [email protected]. 

 

Multi-center Study of Trauma Video Review on Impact of Care

This mixed-methods multicenter study aims to evaluate the impact of an institutional trauma video review (TVR) program on timely control of traumatic hemorrhagic shock. We will use multivariable modeling to compare outcomes derived from retrospective TQIP data between hospitals pre-TVR and post-TVR implementation, with each hospital serving as its own control. To compare data from both the pre-TVR and post-TVR time periods, we are specifically recruiting level 1 and 2 trauma centers that implemented a TVR program between January 2018 and December 2021. 

Any trauma centers meeting the above criteria and interested in participating are encouraged to contact us at [email protected] – we will begin enrolling centers soon.

  

Negative Splenic Angiogram- Is Embolization Needed?

Angioembolization in the management of splenic trauma is an established strategy to maximize the likelihood of splenic preservation.  Recent studies have advocated liberal embolization regardless of angiographic findings, especially in the setting of a high-grade splenic injury or contrast extravasation on CT.    While the decision to perform embolization is not controversial when angiography demonstrates focal bleeding or a vascular abnormality, it is more debatable when the angiogram is “negative.” whether embolization should be performed.   It is also unclear what exactly is meant by a “negative” angiogram in the published literature.

This study proposes to evaluate the outcomes of embolization vs no embolization based on angiographic findings.  We are seeking to enroll patients retrospectively who underwent splenic angiography over a 5- year period.  Although the focus of the study is on outcomes of negative splenic angiography, in order to perform a comprehensive assessment of embolization practices, we propose the inclusion of all subjects who received splenic angiography (whether positive or negative) during the study period.  For more information, please contact Adrian Ong, MD ([email protected]). 

 

Prevention Committee

Preventable Auto VS. Wildlife Collisions

Written by: Alexis Moren, MD, MPH; Stephanie Bonne, MD; Christine Castater, MD, MBA; Thomas K. Duncan, DO, FACS, FICS;�Ronald Gross, MD, FACS; Sharven Taghavi MD, MPH, MS, FACS, FCCP; Jeffry Nahmias, MD, MHPE

Our recent review on wildlife awareness sparked additional discussion of issues that naturally arise with cohabitation with wildlife. This manuscript aims to highlight the importance of wildlife awareness while driving and provide recommendations to help prevent future collisions. These collisions appear to be increasing as our population increases and communities extend further into the wilderness, thus allowing fewer opportunities for wildlife to evade human civilization. The information may be helpful for both surgeons as well as other medical providers and the community at large.

The roads we travel were once a vast tapestry of nature for animals to freely roam but over time humans have encroached upon most wild habitats, trading dirt trails for ribbons of asphalt.  In fact, there are over 4 million miles of roads in the United States alone.1 This carves habitats into pieces within which wildlife must navigate. Furthermore, this makes the convergence of wildlife and road traffic unavoidable. Habitat fragmentation disrupts natural migration patterns, forcing animals to cross roads to search for food, water, and shelter.1 These forays frequently end in collisions between humans and wildlife and can seriously impact both parties.

Each year there are more than 260,000 crashes involving animals.1 The damage from road traffic incidents are felt by both animals and humans. Annually, these events are associated with approximately 12,000 human injuries and 200 human fatalities and animals are often left with severe injuries, including fractures, and death.1,2 In addition, humans may face psychological trauma as a result of the crash. These collisions are also costly and account for more than 4 billion US dollars annually.1
 

Incidence and Effects
The most common wildlife culprit involved in motor vehicle collisions are deer. In rural states such as Wyoming, wildlife-vehicle trauma represent almost 20% of reported collisions.2,3  A 2019 study by Conover et al. showed that in a single year, 58,622 deer-vehicle collisions were reported, followed by 640 moose-vehicle collisions.4 Other animals involved in auto vs wildlife incidents include squirrels, birds, and domesticated animals such as dogs and/or cats. With only half of all encounters reported to insurance companies and police, these numbers likely underestimate the incidence.4

Of the nearly 60,000 collisions, 27,000 people visit the Emergency Department annually.4-6 When involving larger animals such as moose, these collisions are more likely to result in human fatalities.4,5 Although an unknown number of collisions with moose occur across the United States, Pelletier et al. found that there were about 3,400 moose collisions in Maine during a 5-year period (2000–2004).5 Over this 5-year period, these collisions resulted in a total of 1,600 injuries and 17 fatalities, equaling 320 injuries and 3 fatalities annually.4,5  

According to the Insurance Institute for Highway Safety and Highway Loss Data Institute, 6,000 human deaths have occurred over a 40-year period related to animal-vehicle collisions. In 2021, the highest number of human deaths from wildlife-vehicle crashes occurred between October and December, which coincided with deer mating season when there is increased movement of the deer population. A survey querying 1,000 people in the United States about their experiences with wildlife on roads resulted in 80% of drivers noting a “near-miss” moment with an animal defined by 45% as swerving, 24% as hitting brakes to avoid a collision with the animal, and 2% as swerving off the road.1
 

Awareness and Take-Home Points
The number of wildlife-vehicle collisions can be reduced by raising awareness of this important topic. Improvements in transportation infrastructure is one public health-based engineering solution to this problem. The Department of Transportation produced the last major report on this topic in 2008 and proposed updates which included funding for wildlife crossings to help relieve states, tribes, and localities from some of the costs of constructing and rehabilitating structures such as bridges and tunnels to enable wildlife to avoid vehicular traffic and increase safety to both humans and animals.6  Fifteen years have passed and significant changes in our landscape since then, prompt the need for another such report.2 Additionally, education for the public is needed to instill good driving practices. These can be summarized into five critical things to remember when driving:

  1. Be aware of wildlife warning signs including wildlife migration and breeding patterns in the areas you may be visiting.
  2. Watch your speed, and be especially aware in the early morning and at dusk when animals are most active.
  3. Drive defensively, not offensively
  4. Consider whether it is safe to swerve
  5. Plan ahead, “what if” an animal ran into the road; what would your tactic be to avoid it?

Many campaigns exist to develop and implement mitigation strategies to wildlife-vehicular trauma, such as investing in wildlife crossings, fences, and reflective signage to reduce frequency of collisions and safeguard both wildlife and motorists.2,6 However, this problem will undoubtedly require a multifaceted solution as the foreseeable future only includes closer wildlife-human living spaces. Thus, it is incumbent on trauma surgeons and the community at-large to educate on best driving practices and support primary prevention efforts such as those discussed in this manuscript.

 

 References

  1. Wildlife On The Road: Collisions with Animals On the Road. 2022. Accessed July 1, 2023. https://www.havahart.com/wildlife-on-the-road#:~:text=In%20a%20given%20year%2C%20there,and%20over%20150%20human%20fatalities.
  2. The Pew Charitable Trusts. Wildlife-Vehicle Collisions Are a Big and Costly Problem and Congress Can Help. May 2021. Accessed July 3, 2021. https://www.pewtrusts.org/en/research-and-analysis/articles/2021/05/10/wildlife-vehicle-collisions-are-a-big-and-costly-problem-and-congress-can-help
  3. Mohanty CR, et al. A Study of the Pattern of Injuries Sustained from Road Traffic Accidents Caused by Impact with Stray Animals. J Emerg Trauma Shock. 2021 Jan-Mar;14(1):23-27
  4. 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.
  5. Pelletier, A. 2006. Injuries from motor-vehicle collisions with moose – Maine, 2000–2004. Morbidity and Mortality Weekly Report 55:1272–1274.
  6. Insurance Information Institute. Facts + Statistics: Deer vehicle collisions. 2022. Accessed July 1, 2023. https://www.iii.org/fact-statistic/facts-statistics-deer-vehicle-collisions
  7. Centers for Disease Control and Prevention. Nonfatal Motor-Vehicle Animal Crash—Related Injuries. 2004. Accessed July 3, 2023. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5330a1.htm

 

 
Pediatric Trauma Committee

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

Written by: Matthew T. Harting, MD, MS, Natalie Drucker, MD, MS, S. Keisin Wang 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 less of a role for endovascular repairs.

Pediatric vascular trauma represents a complex intersection between vascular surgery, trauma surgery, and pediatric surgery. With changing paradigms of surgical training, a gap has developed in many institutions in terms of who is principally responsible for children with vascular injuries. To that end, we sought to examine our approach to integrated trauma vascular care and what models may exist in other facilities. Finally, the issue of endovascular therapies 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 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 patients.1 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

Screenshot 2025-08-20 at 3.42.01 PM.png

 

1,2,5-7 Vascular injuries in younger pediatric patients are more likely the result of a blunt injury,4 though this transitions to penetrating injuries in the mid-teens. While thoracic and abdominal vascular injuries occur, the upper and lower extremities are the most and second most common vessel injury locations, respectively.4,6 Vascular injuries increase in frequency with increasing age and are twice as likely in boys.4 While still rare overall, frequency of pediatric vascular trauma (PVT) may be increasing 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 surgeons or interventional and neurointerventional radiologists as appropriate.. 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, there has been a shift in surgical training leading to less comfort with open vascular procedures.  This is due to 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 The result is trauma surgeons, general surgeons, and vascular surgeons with an overall decreased collective open vascular experience and comfort,13,14 leaving them 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 PVT could 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, potential for growth, and unique physiology lead to decreased overall comfort level for both adult15 and pediatric16 providers. 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 perioperative care to surgical procedure 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, composite vascular-tumor reconstructions, 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 ultimately isn’t tasked with the repair of the injured vessel, the exposure, vascular control, potential for shunting, and use of fasciotomy can be performed concomitantly 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.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 patients,25 and a newer 4-French device (COBRA–OS, Frontline Medical, Ontario) is now FDA approved and widely used.  Training, experience, trauma system processes, and expertise are associated with increased rates of successful use of this technique.26,27 Finally, 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 Additionally, 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 may be 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 hospital or institution. Several overarching construct options include: 

Option 1: Comprehensive surgical management via centralized expertise. A pediatric 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 reconstruction (often hand or plastics) team 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 consultation.

Option 2: Trauma surgeon leadership with focused consultation. A pediatric and/or adult trauma-trained surgeon leads initial stabilization, diagnosis, resuscitation, exposure, and control with possible shunting. A vascular surgeon with significant experience in open repair/trauma consults for intraoperative technical expertise. A separate microvascular reconstruction 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 (for example, a specialist in endovascular aortic disease or practice limited to venous disease). Avoidance of this requires frank discussions regarding call coverage 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 prioritization of patient physiology as a polytrauma patient..

*open vascular surgery, endovascular, transplant, pediatric cardiovascular, and/or microvascular reconstruction

 

Initial resuscitation, evaluation, and imaging in PVT

After a fundamental trauma assessment with thorough primary and secondary surveys, a focused vascular physical examination should be performed.  . 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 be identified on examination with hard or soft signs of vascular injury and a subsequent arterial pressure index. This is accomplished with a doppler probe, a blood pressure cuff, and the following formula: 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 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 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 presentation of the patient with a critical injury. Critical review of institutional resources and available personnel allows the optimal integration of the team for the uncommon (but increasing in frequency) patient with these injuries.

 

References

  1. Barmparas G, Inaba K, Talving P, et al. Pediatric vs adult vascular trauma: a National Trauma Databank review. Journal of Pediatric Surgery. 2010;45(7):1404-1412.
  2. Corneille MG, Gallup TM, Villa C, et al. Pediatric vascular injuries: acute management and early outcomes. The Journal of Trauma. 2011;70(4):823-828.
  3. Eslami MH, Saadeddin ZM, Rybin DV, et al. Trends and Outcomes of Pediatric Vascular Injuries in the United States: An Analysis of the National Trauma Data Bank. Annals of Vascular Surgery. 2019;56:52-61.
  4. Prieto JM, Van Gent JM, Calvo RY, et al. Pediatric extremity vascular trauma: It matters where it is treated. The Journal of Trauma and Acute Care Surgery. 2020;88(4):469-476.
  5. Klinkner DB, Arca MJ, Lewis BD, Oldham KT, Sato TT. Pediatric vascular injuries: patterns of injury, morbidity, and mortality. Journal of pediatric surgery. 2007;42(1):178-182; discussion 182-173.
  6. Wahlgren CM, Kragsterman B. Management and outcome of pediatric vascular injuries. The Journal of Trauma and Acute Care Surgery. 2015;79(4):563-567.
  7. Prieto JM, Van Gent JM, Calvo RY, et al. Evaluating surgical outcomes in pediatric extremity vascular trauma. Journal of Pediatric Surgery. 2020;55(2):319-323.
  8. DuBose JJ, Morrison JJ, Scalea TM, Rasmussen TE, Feliciano DV, Moore EE. Beyond the Crossroads: Who Will be the Caretakers of Vascular Injury Management? Annals of Surgery. 2020;272(2):236-237.
  9. Forrester JD, Weiser TG, Maggio P, et al. Trends in open vascular surgery for trauma: implications for the future of acute care surgery. The Journal of Surgical Research. 2016;205(1):208-212.
  10. Scalea TM. Caring for vascular injuries: Training more vascular specialists may not be the answer. The Journal of Trauma and Acute Care Surgery. 2022;92(4):760-761.
  11. Shannon AH, Robinson WP, 3rd, Hanks JB, Potts JR, 3rd. Impact of New Vascular Fellowship Programs on Vascular Surgery Operative Volume of Residents in Associated General Surgery Programs. Journal of the American College of Surgeons. 2019;228(4):525-532.
  12. Joels CS, Langan EM, 3rd, Cull DL, Kalbaugh CA, Taylor SM. Effects of increased vascular surgical specialization on general surgery trainees, practicing surgeons, and the provision of vascular surgical care. Journal of the American College of Surgeons. 2009;208(5):692-697, quiz 697 e691; discussion reply 697-699.
  13. Eckert M, Cuadrado D, Steele S, Brown T, Beekley A, Martin M. The changing face of the general surgeon: national and local trends in resident operative experience. American Journal of Surgery. 2010;199(5):652-656.
  14. Potts JR, 3rd, Valentine RJ. Declining Resident Experience in Open Vascular Operations Threatens the Status of Vascular Surgery as an Essential Content Area of General Surgery Training. Annals of Surgery. 2018;268(4):665-673.
  15. Bonasso PC, Dassinger MS, Smeds MR, Moursi MM. Pediatric Vascular Surgical Practice Patterns. Annals of Vascular Surgery. 2019;54:103-109 e108.
  16. Bonasso PC, Gurien LA, Smith SD, Gowen ME, Dassinger MS. Pediatric vascular trauma practice patterns and resource availability: A survey of American College of Surgeon-designated pediatric trauma centers. The Journal of Trauma and Acute Care Surgery. 2018;84(5):758-761.
  17. Oller DW, Rutledge R, Clancy T, et al. Vascular injuries in a rural state: a review of 978 patients from a state trauma registry. The Journal of Trauma. 1992;32(6):740-745; discussion 745-746.
  18. Taghavi S, Jones G, Duchesne J, et al. Impact of trauma center volume on major vascular injury: An analysis of the National Trauma Data Bank (NTDB). American Journal of Surgery. 2020;220(3):787-792.
  19. Bowyer MW, Kuhls DA, Haskin D, et al. Advanced Surgical Skills for Exposure in Trauma (ASSET): the first 25 courses. The Journal of Surgical Research. 2013;183(2):553-558.
  20. Kuhls DA, Risucci DA, Bowyer MW, Luchette FA. Advanced surgical skills for exposure in trauma: a new surgical skills cadaver course for surgery residents and fellows. The Journal of Trauma and Acute Care Surgery. 2013;74(2):664-670.
  21. Mackenzie CF, Garofalo E, Shackelford S, et al. Using an Individual Procedure Score Before and After the Advanced Surgical Skills Exposure for Trauma Course Training to Benchmark a Hemorrhage-Control Performance Metric. J Surg Educ. 2015;72(6):1278-1289.
  22. Mackenzie CF, Garofalo E, Puche A, et al. Performance of Vascular Exposure and Fasciotomy Among Surgical Residents Before and After Training Compared With Experts. JAMA Surg. 2017;152(6):581-588.
  23. Bini JK, Hardman C, Morrison J, et al. Survival benefit for pelvic trauma patients undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta: Results of the AAST Aortic Occlusion for Resuscitation in Trauma Acute Care Surgery (AORTA) Registry. Injury. 2022;53(6):2126-2132.
  24. Theodorou CM, Brenner M, Morrison JJ, et al. Nationwide use of REBOA in adolescent trauma patients: An analysis of the AAST AORTA registry. Injury. 2020;51(11):2512-2516.
  25. Carrillo L, Skibber M, Kumar A, et al. Morphometric and Physiologic Modeling Study for Endovascular Occlusion in Pediatric Trauma Patients. ASAIO Journal. 2020;66(1):97-104.
  26. Theodorou CM, Anderson JE, Brenner M, et al. Practice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry. The Journal of Surgical Research. 2020;253:18-25.
  27. Theodorou CM, Salcedo ES, DuBose JJ, Galante JM. Hate to Burst Your Balloon: Successful REBOA Use Takes More Than a Course. J Endovasc Resusc Trauma Manag. 2020;4(1):21-29.
  28. Brenner M, Hoehn M, Pasley J, Dubose J, Stein D, Scalea T. Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon. The Journal of Trauma and Acute Care Surgery. 2014;77(2):286-291.
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  34. Anand T, Obaid O, Nelson A, et al. Whole blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-matched analysis. The Journal of Trauma and Acute Care Surgery. 2021;91(4):573-578.
  35. Vogel AM, Radwan ZA, Cox CS, Jr., Cotton BA. Admission rapid thrombelastography delivers real-time "actionable" data in pediatric trauma. Journal of Pediatric Surgery. 2013;48(6):1371-1376.
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Military Liaison Committee Update

Written by: Colonel Jennifer Gurney, MD, FACS, MC, USA

The Military Liaison Committee held the Inaugural Fallen Surgeons Educational Symposium the day before the AAST Annual Meeting in Anaheim, California, and it was a huge success! The event was attended by nearly 100 military and civilian surgeons and physicians including residents and fellows.

The symposium began with remarks from AAST President Eileen Bulger, followed by the presentation of colors by the Blue Eagles Honor Guard. The conference honored fallen surgeons and nurses from the Global War on Terrorism. The honored were Dr. Mark Taylor, US Army; Dr. John Pryor, US Army; Dr. Brian Allgood, US Army; Maria Ortiz, RN US Army; and Jennifer Moreno, RN, US Army.

The ACS-COT Region 13 State Level Resident Paper Competition was conducted for the Army, Navy, and Air Force. Nineteen papers, including clinical and basic science research, were presented (more than in the last five years combined!). The symposium will be the enduring home of the COT Region 13 State Resident Paper Competition.

A highlight of the symposium was the Keynote address by CAPT (Ret) Jim Wetherbee, an astronaut with six space missions and former Navy test pilot who spoke directly to the engaged audience on tactics to achieve operational excellence. Wetherbee targeted surgeons and leaders by discussing risk, planning, and leadership.

There were also two engaging panel sessions: The first, entitled Good Surgery in Bad Places, where military and civilian surgeons discussed low-resource surgical care in military, rural, and global health engagement environments and gave tips and tricks. The second panel was on difficult ethical decisions in the deployed environment with staff from the Uniformed Services University of the Health Sciences, Defense Medical Ethics Center. This provocative and engaging presentation led to a lively discussion with robust audience involvement.

The Inaugural FSES had an engrossed audience until the end of the day. The AAST Military Liaison Committeeexpresses gratitude to the AAST Board of Managers for supporting this enduring effort, the Military Health System Strategic Partnership with the American College of Surgeons for financial support, and unrelenting assistance from Rachel and Sharon. We look forward to continuing this new tradition of the Military Liaison Committee.

 

AAST International Academic Mentorship Program Report (2021-2023)

Written By: Eduarda Sá Marta 

Being part of the American Association for the Surgery of Trauma’s International Academic Mentorship (IAM) Program has provided me with invaluable experience in collaborative research with an academic surgeon from the United States.  

Besides the added value of being mentored by an experienced academic in the field of surgery, Prof. W. Alan Guo, the research project that our team is currently finalizing also adds to the body of research done in Portugal regarding traumatic brain injury. Indeed, a reduced number of papers have been published with Portuguese data on this topic, and Portugal is a country with no current trauma-specific database. I hope to bring some attention to the importance of creating a national trauma database in Portugal to improve future research in trauma in this country. 

The IAM program has also allowed me to attend and present some of the results of our research project comparing traumatic brain injury outcomes between Portugal and the United States at the 82nd Annual Meeting of the American Association for the Surgery of Trauma in Anaheim. This was not only a significant achievement for me, but also an opportunity to network with surgeons from the United States and from other parts of the world. 

In summary, I thank the AAST and my mentor, Prof. W. Alan Guo, for giving me the unique opportunity to further develop my academic career. I hope that my participation in this program will also serve as a stepping stone to further continue collaborative research with US surgeons and academics. 

 

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.

2023 has been a very exciting year for JTACS. We have been implementing several new processes to improve the Journal for our members. Additionally, we have created a new article series and a new supplement of J Trauma. See below:

 

NEW ARTICLE SERIES: “…WHAT YOU NEED TO KNOW”

These are concise but comprehensive review articles written by experts on “hot topics” covering clinical and translational topics of the three domains of Acute Care Surgery: Trauma, Emergency General Surgery, and Surgical Critical Care. We will be publishing 2-3 articles/month for the next 4-5 years. We hope the articles will be useful for those looking for cutting-edge yet practical information to guide clinical care and research.

The first three articles were published in the October issue of the Journal and are titled: 1) Injury-Induced Endotheliopathy: What You Need to Know; 2) Damage Control Resuscitation in Adult Trauma Patients: What You Need to Know; and 3) Damage Control Resuscitation in Pediatric Trauma: What You Need to Know.

In the November issue of the Journal we will be publishing 2 articles: 1) Damage Control Surgery in Emergency General Surgery: What You Need to Know and 2) Management of Traumatic Brain Injury in Older Adults: What You Need to Know.

 

NEW J TRAUMA ARTICLE COLLECTION:

Similar to last year’s J Trauma article collection (Organ Injury Scale Manuscripts), this year, in collaboration with the AAST Patient Assessment Committee, we created a new article collection with the most important manuscripts on “Trauma Scoring Systems”. We invited Dr. Howard Champion to write the preface of the collection recognizing his extremely relevant contributions to the development of scoring systems over the years. This document is a “must-have” for all of us. The document can be found at www.jtrauma.org, and it is free to download for AAST members.

I hope you enjoy both publication types described above. Please let us know if you have comments or suggestions for our Journal.

 

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