Annals of Surgery 2015


1. Ann Surg. 2015 Jun 15. [Epub ahead of print]

It's All About Location, Location, Location: A New Perspective on Trauma

Shaw JJ(1), Psoinos CM, Santry HP.

Author information: 
(1)*Department of Surgery; and †Department of Quantitative Health Sciences,
University of Massachusetts Medical School, Worcester, MA.

OBJECTIVE: To determine the effect of aeromedical transport on trauma mortality
when accounting for geographic factors.
BACKGROUND: The existing literature on the mortality benefit of aeromedical
transport on trauma mortality is controversial. Studies examining patient and
injury characteristics find higher mortality, whereas studies measuring injury
severity find a protective effect. Previous studies have not adjusted for the
time and distance that would have been traveled had a helicopter not been used.
METHODS: Retrospective analysis of an institutional trauma registry. We compared
mortality among adult patients (≥15 years) transported from the scene of injury
to our level I trauma center by air or ground (January 1, 2000-December 31, 2010)
using univariate comparisons and multivariable logistic regression. Regression
models were constructed to incrementally account for patient demographics and
injury mechanism, followed by injury severity, and, finally, by network bands for
drive time and roadway distance as predicted by geographic information systems.
RESULTS: Of 4522 eligible patients, 1583 (35%) were transported by air. Patients
transported by air had higher unadjusted mortality (4.1% vs 1.9%, P < 0.05). In
multivariable modeling, including patient demographics and type of injury,
helicopter transport predicted higher mortality than ground transport (odds ratio
[OR] 2.4, 95% confidence interval [CI] 1.2-4.0). After adding validated injury
severity measures to the model, helicopter transport predicted lower mortality
(OR 0.7, 95% CI 0.3-0.9). Finally, including geographic covariates found that
helicopter transport was not associated with mortality (OR 1.1, 95% CI 0.6-2.3).
CONCLUSIONS: Helicopter transport does not impart a survival benefit for trauma
patients when geographic considerations are taken into account.

PMID: 26079917  [PubMed - as supplied by publisher]

2. Ann Surg. 2015 Feb;261(2):390-4. doi: 10.1097/SLA.0000000000000717.

Tranexamic acid use in severely injured civilian patients and the effects on
outcomes: a prospective cohort study.

Cole E(1), Davenport R, Willett K, Brohi K.

Author information: 
(1)*Centre for Trauma Sciences, Blizard Institute, Queen Mary University of
London, London, United Kingdom; and †Nuffield Department of Orthopaedics,
Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United

OBJECTIVE: To characterize the relationship between tranexamic acid (TXA) use and
patient outcomes in a severely injured civilian cohort, and to determine any
differential effect between patients who presented with and without shock.
BACKGROUND: TXA has demonstrated survival benefits in trauma patients in an
international randomized control trial and the military setting. The uptake of
TXA into civilian major hemorrhage protocols (MHPs) has been variable. The
evidence gap in mature civilian trauma systems is limiting the widespread use of
TXA and its potential benefits on survival.
METHODS: Prospective cohort study of severely injured adult patients (Injury
severity score > 15) admitted to a civilian trauma system during the adoption
phase of TXA into the hospital's MHP. Outcomes measured were mortality, multiple
organ failure (MOF), venous thromboembolism, infection, stroke, ventilator-free
days (VFD), and length of stay.
RESULTS: Patients receiving TXA (n = 160, 42%) were more severely injured,
shocked, and coagulopathic on arrival. TXA was not independently associated with
any change in outcome for either the overall or nonshocked cohorts. In
multivariate analysis, TXA was independently associated with a reduction in MOF
[odds ratio (OR) = 0.27, confidence interval (CI): 0.10-0.73, P = 0.01] and was
protective for adjusted all-cause mortality (OR = 0.16 CI: 0.03-0.86, P = 0.03)
in shocked patients.
CONCLUSIONS: TXA as part of a major hemorrhage protocol within a mature civilian
trauma system provides outcome benefits specifically for severely injured shocked

PMID: 25412319  [PubMed - indexed for MEDLINE]

3. Ann Surg. 2015 Apr;261(4):760-4. doi: 10.1097/SLA.0000000000000879.

Selective nonoperative management in 1106 patients with abdominal gunshot wounds:
conclusions on safety, efficacy, and the role of selective CT imaging in a
prospective single-center study.

Navsaria PH(1), Nicol AJ, Edu S, Gandhi R, Ball CG.

Author information: 
(1)*Trauma Center, Groote Schuur Hospital, and Faculty of Health Sciences,
University of Cape Town and Medical Research Council of South Africa, Cape Town, 
South Africa †Department of Surgery, University of Calgary, Calgary, Canada.

OBJECTIVE: The primary aim of this study was to delineate the role of computed
tomography (CT) in patients undergoing NOM for AGSW.
BACKGROUND: Nonoperative management (NOM) of abdominal gunshot wounds (AGSWs)
remains controversial.
METHODS: This prospective study included all patients with abdominal gunshot
injuries admitted to our trauma center from April 1, 2004 to September 30, 2009. 
Exclusion criteria included patients with peritonitis, hemodynamic instability,
unreliable physical examination, head and spinal cord injury with an AGSW
underwent immediate laparotomy. The remaining patients were selected for NOM.
Nonperitonitic stable patients with right-sided thoracoabdominal/right upper
quadrant gunshots and/or hematuria underwent mandatory CT with intravenous
contrast. CT to detect missile trajectory was optional. The primary outcome
measure was failure of NOM. Secondary outcomes were unnecessary laparotomy rates
and mortality.
RESULTS: A total of 1106 patients with abdominal gunshot injuries were admitted. 
Of these, 834 (75.4%) underwent immediate laparotomy, whereas 272 (24.6%) were
selected for NOM. In the former group, there were 56 (6.7%) deaths and 29 (3.5%) 
unnecessary laparotomies, whereas in the latter NOM group, 82 (30.1%) patients
were managed by serial clinical examination alone, whereas 190 (69.9%) patients
underwent abdominal CT scanning, in addition to serial clinical examination. The
overall NOM success rate was 95.2%. Of the 13 patients undergoing delayed
laparotomy, there were 10 therapeutic, 2 nontherapeutic, and 1 negative
CONCLUSIONS: The NOM of appropriately selected patients with AGSW with selective
use of CT scanning is feasible, safe, and effective, but largely based on
findings from serial clinical examinations.

PMID: 25185470  [PubMed - indexed for MEDLINE


1. Ann Surg. 2015 Sep;262(3):512-8; discussion 516-8. doi:

FAST ultrasound examination as a predictor of outcomes after resuscitative
thoracotomy: a prospective evaluation.

Inaba K(1), Chouliaras K, Zakaluzny S, Swadron S, Mailhot T, Seif D, Teixeira P, 
Sivrikoz E, Ives C, Barmparas G, Koronakis N, Demetriades D.

Author information: 
(1)*Division of Trauma Surgery and Surgical Critical Care, Department of Surgery,
University of Southern California, Los Angeles, CA †Department of Emergency
Medicine, University of Southern California, Los Angeles, CA.

OBJECTIVE: The objective of this study was to examine the ability of Focused
Assessment Using Sonography for Trauma (FAST) to discriminate between survivors
and nonsurvivors undergoing resuscitative thoracotomy (RT).
BACKGROUND: RT is a high-risk, low-salvage procedure performed in arresting
trauma patients with poorly defined indications.
METHODS: Patients undergoing RT from 10/2010 to 05/2014 were prospectively
enrolled. A FAST examination including parasternal/subxiphoid cardiac views was
performed before or concurrent with RT. The result was captured as adequate or
inadequate with presence or absence of pericardial fluid and/or cardiac motion. A
sensitivity analysis utilizing the primary outcome measure of survival to
discharge or organ donation was performed.
RESULTS: Overall, 187 patients arrived in traumatic arrest and underwent FAST.
Median age 31 (1-84), 84.5% male, 51.3% penetrating. Loss of vital signs occurred
at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. Emergent left
thoracotomy was performed in 77.5% and clamshell thoracotomy in 22.5%. Sustained
cardiac activity was regained in 48.1%. However, overall survival was only 3.2%. 
An additional 1.6% progressed to organ donation. FAST was inadequate in 3.7%,
28.9% demonstrated cardiac motion and 8.6% pericardial fluid. Cardiac motion on
FAST was 100% sensitive and 73.7% specific for the identification of survivors
and organ donors.
CONCLUSIONS: With a high degree of sensitivity for the detection of potential
survivors after traumatic arrest, FAST represents an effective method of
separating those that do not warrant the risk and resource burden of RT from
those who may survive. The likelihood of survival if pericardial fluid and
cardiac motion were both absent was zero.

PMID: 26258320



Clinical Prediction Rules

1. Ann Surg. 2015 Oct 22. [Epub ahead of print]

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

Brown JB(1), Gestring ML, Guyette FX, Rosengart MR, Stassen NA, Forsythe RM,
Billiar TR, Peitzman AB, Sperry JL.

Author information: 
(1)*Division of General Surgery and Trauma, Department of Surgery, University of
Pittsburgh Medical Center, Pittsburgh, PA †Division of Acute Care Surgery,
Department of Surgery, University of Rochester Medical Center, Rochester, NY
‡Department of Emergency Medicine, University of Pittsburgh Medical Center,
Pittsburgh, PA.

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

PMID: 26501703  [PubMed - as supplied by publisher]