The educational foundation for acute care surgery: Evolution of the specialty

The Journal of Trauma: Injury, Infection, and Critical Care · 2025-08-21 · 3 citations

ABSTRACT: Acute care surgery (ACS) was conceived in the early 2000s in response to a growing crisis in access to emergency general surgical care. The ACS fellowship was created to train general surgeons in this subspecialty. The purpose of this review is to discuss the origin of ACS and its evolution over the last 20 years and to survey the subspecialty's current status and future directions. Since the first programs were certified in 2008, the fellowship curriculum has undergone many changes. There is now more emphasis on emergency general surgery and a movement toward competency-based evaluations. Additionally, pediatrics and burn subtracks have been developed, and other programs emphasizing robotic surgery are being created. The didactic curriculum has been updated, and new programs highlighting community and networking, such as the Meet the Mentors discussions, fellow journal club, and boot camp, have also been formed. Acute care surgery has effectively leveraged the knowledge base of trauma surgery and surgical critical care to meet the changing needs of the healthcare system. Acute care surgery surgeons are well positioned for leadership roles both locally and nationally. Future challenges include building a more robust research base and further highlighting the scope and brand of ACS. ACS as a subspecialty has matured over the last two decades. In the coming years, ACS will continue to adapt to meet the needs of patients suffering from acute surgical illness or injury.

Morbidity prediction in conservatively managed rib fracture patients

European Journal of Trauma and Emergency Surgery · 2025-04-29

PURPOSE: Rib fractures, common in blunt chest trauma, affect 10% of trauma patients and are linked to increased pulmonary morbidity and mortality. This study applies machine learning to identify predictors of complications in conservatively managed rib fracture patients. METHODS: Data from the 2013-2021 American College of Surgeons' Trauma Quality Improvement Program included adults (≥ 18 years) with isolated thoracic injury from blunt trauma and conservatively managed rib fractures. Variables included demographics, comorbidities, injury severity, injury patterns, admission vitals, and complications. The permutation importance method identified top predictors of in-hospital complications. RESULTS: Of 321,355 rib fracture patients, 183,303 (57.0%) had isolated rib fractures. The five primary predictors of complications in all rib fracture patients were age, Glasgow Coma Scale (GCS) on admission, Revised Cardiac Risk Index (RCRI), chronic obstructive pulmonary disease (COPD), and alcohol use disorder. For isolated rib fracture patients, the same predictors applied but in the order: age, RCRI, GCS, COPD, and alcohol use disorder. A logistic regression model using these predictors showed acceptable discriminative capacity for complications in the full cohort [AUC (95% CI): 0.72 (0.71-0.72)] and isolated rib fracture patients [AUC (95% CI): 0.72 (0.71-0.73)]. CONCLUSION: Cardiovascular risk, age, and level of consciousness on admission are key predictors of complications in conservatively managed rib fracture patients. Though complication rates remain low overall, elderly patients with multiple cardiovascular risk factors face a heightened risk of deterioration.

Chest wall injury surgeon, know thyself

The Journal of Trauma: Injury, Infection, and Critical Care · 2025-07-17 · 1 citations

ABSTRACT: The use of surgical stabilization of rib fractures (SSRF) for non-flail fracture patterns continues to rise. However, multiple, recent randomized controlled trials in this patient population have failed to show a clear benefit to surgery. Rather than widening the gap between research and practice, we must embrace these trials, learn from them, and continue to refine the indications for surgery. Approaching SSRF with an awareness of our own cognitive biases, as well as scientific rigor, will advance the discipline of chest wall injury surgery.

Damage control does not offer a survival advantage and increases the risk of serious complications compared with early total care in severely injured patients with femoral shaft fractures

The Journal of Trauma: Injury, Infection, and Critical Care · 2025-03-20 · 5 citations

BACKGROUND: Damage control orthopedics (DCO) was proposed to minimize the second hit of extensive surgical procedures in severely injured patients when treated with early fracture fixation (early total care [ETC]). The impact of DCO and ETC on the outcomes of severely injured patients sustaining femoral shaft fractures (FSFs) is unclear. We hypothesized that DCO is associated with lower mortality and decreased incidence of complications compared with ETC. METHODS: The Trauma Quality Improvement Project database was queried from 2007 to 2021. Adult patients 14 years or older with FSF and Injury Severity Score of >15 were included. Patients were divided into ETC and DCO groups and stratified according to fracture type: open or closed. The primary outcomes included acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), severe sepsis, deep venous thrombosis (DVT), and mortality. Inverse probability treatment of weighting was used to balance the two cohorts of interest. A binomial logistic regression analysis was performed after inverse probability treatment of weighting to identify potential associations between the type of fixation procedure and the outcomes of interest. RESULTS: A total of 44,577 FSF patients were included. Mortality was 2.1%. No survival advantage was observed in the DCO group (odds ratio [OR], 0.92). However, significant associations between DCO and the risk of ARDS (OR, 1.64), AKI (OR, 1.57), severe sepsis (OR, 1.64), and DVT (OR, 1.64) were identified. Damage control orthopedics was not associated with decreased mortality after stratifying patients according to the fracture type and the type of operation. CONCLUSION: Damage control orthopedics is not associated with improved survival of severely injured patients with FSF. Damage control orthopedics is associated with an increased risk of ARDS, AKI, severe sepsis, and DVT compared with ETC. These findings persisted after analyzing the type of fracture. These results are significant for clinical practice, as more patients could be treated by ETC when compensated physiologically, independent of the fracture type. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Prediction of Amputation Following Severe Pediatric Lower Extremity Injury: Application of the Mangled Lower Extremity (MangLE) Score in a Pediatric Population

The American Surgeon · 2025-09-25

BackgroundSevere lower extremity injuries in pediatric patients present significant challenges for surgeons deciding between repair and amputation. A novel scoring system, the MangLE score, has been developed to identify adult patients who are unlikely to require amputation after severe lower extremity injury. This study sought to evaluate the predictive ability of the MangLE score in pediatric patients.MethodsA retrospective analysis was conducted using the 2013-2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Pediatric patients (≤17 years) with mangled lower extremities were included. Patients were stratified into age groups (0-3, 4-9, 10-13, and 14-17 years), and the predictive ability of the MangLE score for lower extremity amputation was assessed based on the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity.ResultsA total of 7959 patients met the inclusion criteria. The MangLE score demonstrated an excellent predictive capability in patients aged 10-13 (AUC (95% CI): 0.87 (0.79-0.94)) and 14-17 (AUC (95% CI): 0.83 (0.79-0.86)). At the cutoff of ≥8, this resulted in an NPV of 99.7% for 10-13-year-olds and 99.4% for 14-17-year-olds. However, the MangLE score was ineffective in discriminating between those who did and did not require a lower extremity amputation in patients between 0 and 9 years old.DiscussionThe MangLE score maintains an excellent predictive ability for identifying those unlikely to require lower extremity amputation in pediatric mangled extremity patients aged 10-17; however, it fails to accurately predict this outcome in younger patients.Level of EvidenceLevel IV.

Research priorities in chest wall injury: Secondary analysis of the National Trauma Research Action Plan

The Journal of Trauma: Injury, Infection, and Critical Care · 2025-12-17

INTRODUCTION: Chest wall injury (CWI) occurs in 10% to 15% of trauma admissions and is associated with significant short- and long-term morbidity. Despite recent advances in management, critical knowledge gaps remain. This study sought to identify consensus-based research priorities for CWI established by the National Trauma Research Action Plan (NTRAP). METHODS: This study is a secondary analysis of consensus-based research priorities collected using an online Delphi survey methodology by 11 NTRAP panels, each focused on different domains across the entire spectrum of trauma care. The database of research questions or gaps was queried for the key words "Chest Wall/Rib," "Rib Fracture/Pain Management," and "Rib Fracture/Pulmonary Management." RESULTS: Fifty-seven CWI-related research questions were identified across seven NTRAP panels. Of these, 15 (26%) were rated as high priority and 42 (74%) as medium priority. Most CWI-related research questions appeared in the following topics: Chest Wall/Ribs (n = 22), followed by Blocks/Regional Anesthesia: Effects on Pain (acute/chronic, hemodynamics, inflammation) (n = 5) and Special Populations: Long-term Outcomes after Trauma in Older Adults; Functional Recovery and Mortality (n = 3). Eighteen questions specifically addressed surgical rib fixation. CONCLUSION: National Trauma Research Action Plan identified 57 consensus-driven research priorities in CWI. These findings should inform extramural funding efforts, focusing on studies that evaluate short-term clinical metrics, comparative effectiveness research between surgical and nonsurgical management, and the long-term impact of CWI on patient recovery and quality of life. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level V.

Does pediatric trauma center designation matter for children in shock from gunshot wounds? A Trauma Quality Improvement Program analysis

The Journal of Trauma: Injury, Infection, and Critical Care · 2025-06-10 · 1 citations

BACKGROUND: Recent studies have demonstrated improved outcomes for severely injured pediatric trauma patients treated at pediatric trauma centers (PTCs). Nonetheless, specific injury patterns requiring immediate lifesaving intervention may offset the recognized benefits of PTC over adult trauma centers (ATCs). This study aims to compare the clinical outcomes of hypotensive pediatric trauma patients with gunshot wounds (GSWs), based on trauma center type. We hypothesize that outcomes are equivalent for this clinical scenario. METHODS: The 2013-2021 Trauma Quality Improvement Program data set was used to identify all hypotensive pediatric patients (15 years or younger) with GSWs. Hypotension was defined per Pediatric Advanced Life Support Guidelines. Patients with an Abbreviated Injury Scale score of 6 in any region and transferred patients were excluded. In order to identify the association between PTC verification status and outcomes, Poisson regression models with robust standard errors were used. RESULTS: A total of 687 patients met the criteria for analysis, and 236 (34%) cases were treated at PTCs. Pediatric trauma center patients were slightly younger (lower quartile, 10 vs. 12 years old; p = 0.037). There was no significant difference in Injury Severity Score or crude mortality rates (68.1% vs. 70.8%, p = 0.524). After adjusting for confounders, Poisson regression showed no reduction in in-hospital mortality, complications, failure to rescue, intensive care unit admission, or mechanical ventilation rates at PTCs compared with ATCs. CONCLUSION: Gunshot wounds in children pose unique clinical challenges. Majority of cases are cared for at ATCs. Analysis of best available data did not demonstrate a benefit to managing these patients at a PTC. Conversely, ATCs were not superior, despite managing this scenario in both adults and children more often. These findings underscore the importance of ATCs in the care of this particular injury pattern and call attention to the recent pediatric readiness requirements for American College of Surgeons (ACS)-verified trauma centers to treat pediatric firearm injuries at both PTCs and ATC. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Surgical Stabilization of Rib Fractures: Relative Importance of Risk Factors for Complications

The American Surgeon · 2025-07-31

Background Surgical stabilization of rib fractures (SSRF) remains controversial as studies search for the patient population who would benefit most from SSRF. This study aimed to identify the predictive risk factors in patients with chest wall injuries who underwent SSRF and sustained in-hospital complications. Methods This study is a retrospective review of the 2016-2019 Trauma Quality Improvement Program database. Data included age, sex, comorbidities, Abbreviated Injury Score (AIS), injury pattern, interventions, and complications. All adult patients who suffered ≥1 rib fracture following an isolated thoracic injury (AIS ≥2 but < 6 and AIS ≤ 1 in all other regions) and underwent SSRF were eligible for inclusion. Results A total of 1823 patients were included in this study of whom 4.8% ( N = 87) of patients suffered an in-hospital complication. Patients who suffered a complication were generally older, male, had a higher cardiac risk, were more severely injured, and tended to have a longer time to SSRF (3.8 vs 2.5 days, P < 0.001). The top 5 predictors of in-hospital complications were RCRI, thorax AIS, time to SSRF, age, and sex. These variables were sufficient for achieving an acceptable discriminative ability for complications (AUC (95% CI): 0.78 (0.73-0.83)). Discussion Cardiovascular risk, thoracic injury severity, and delayed SSRF were correlated with elevated risk of complications. As time to surgery constitutes the sole changeable factor, prompt intervention may substantially diminish postoperative morbidity. These findings can enhance risk classification and assist therapeutic decision making for SSRF.

In reply: Survival advantages of damage-control orthopedics in military and counter-terrorism settings

The Journal of Trauma: Injury, Infection, and Critical Care · 2025-08-13

Association between whole blood versus balanced component therapy and survival in isolated severe traumatic brain injury

Trauma Surgery & Acute Care Open · 2025-05-01

Background: Whole blood transfusion (WBT) is associated with improved hemostasis and possibly mortality in patients with hemorrhagic shock after injury but there are no studies in patients with isolated severe traumatic brain injury (TBI). The objective of this investigation was to compare outcomes of balanced component therapy (BCT) versus WBT in patients with an isolated severe TBI. Methods: Adult patients (≥18 years) registered in the Trauma Quality Improvement Program (2016-2019) who suffered a blunt isolated severe TBI (head Abbreviated Injury Score ≥3 in the head and ≤1 in the remaining body regions) and who received a BCT (1-2:1 packed red blood cell (PRBC):fresh frozen plasma and 1-2:1 PRBC:platelets) or WBT were eligible for inclusion. Patients were matched, based on the transfusion received, using propensity score matching. The primary outcome of interest was in-hospital mortality. Results: A total of 217 patients received either WBT (n=82) or BCT (n=135). After propensity score matching, 50 matched pairs were analyzed. The rate of in-hospital mortality was significantly lower in the WBT compared with BCT group (43.1% vs 66.7%, p=0.025) corresponding to a relative risk (RR) reduction of 35% in in-hospital mortality (RR (CI 95%): 0.65 (0.43 to 0.97)). However, in subgroup analyses comparing those who were managed surgically and conservatively, this association only remained significant among patients who underwent neurosurgical intervention. Conclusions: WBT in patients with severe isolated TBI is associated with better survival compared with BCT in patients who require neurosurgical intervention. Further investigation into this finding using an appropriately powered, prospective study design is warranted. Level of evidence: Level III, therapeutic.