AAST Annual Meeting 2016

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WAIKOLOA, HAWAII – Among a group of anticoagulated trauma patients, those on aspirin had the highest rate and risk of intracranial hemorrhage (ICH), while those on novel oral anticoagulants were not at higher risk for ICH, ICH progression, or death, a multicenter study found.

“The number of patients on warfarin and antiplatelet agents has significantly increased over time,” Leslie Kobayashi, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “These oral antithrombotic agents have been associated with poor outcomes following traumatic injury, including increased rates of intracranial hemorrhage, increased progression of intracranial hemorrhage, and increased mortality.”

Dr. Kobayashi, a surgeon with the University of California, San Diego’s Division of Trauma, Surgical Critical Care, and Burns, noted that in the past 5 years, several novel oral anticoagulants (NOAs) have been approved by the Food and Drug Administration for the treatment of venous thromboembolism as well as for stroke prevention among patients with atrial fibrillation. In general, the safety profile and efficacy of NOAs favorably compares with warfarin in most large randomized controlled trials. “Because of this, NOAs are now recommended as the first-line therapy for non-malignancy–related venous thromboembolism by the American College of Chest Physicians in their 2016 guideline updates,” she said. “However, we don’t have any idea what the effects of the NOAs are following traumatic injury. Several case reports exist in the literature describing catastrophic hemorrhage in patients on these NOAs following traumatic injury. Because of these case reports, several lawsuits have been brought against the makers of these medications, including one that settled against the makers of Pradaxa for $650 million in 2014.”

In a prospective, multicenter observational study conducted by the AAST’s Multi-institutional Trials Committee, Dr. Kobayashi and her associates set out identify injury patterns and outcomes in trauma patients taking the NOAs, and to test their hypothesis that patients taking NOAs would have higher rates of ICH, ICH progression, and death, compared with patients taking traditional oral anticoagulant therapies (OATs). Patients were included if they were admitted to the trauma service on warfarin, aspirin, clopidogrel, dabigatran, apixaban, or rivaroxaban. Pregnant patients, prisoners, and minors were excluded from the study. Data collected included demographics, mechanism of injury, vitals on admission, injuries/injury severity scores, labs, interventions, and reversal agents used such as vitamin K, prothrombin complexes, dialysis, and transfusion of fresh frozen plasma (FFP). Outcomes studied included ICH, ICH progression, and death.

In all, 16 Level 1 trauma centers enrolled 1,847 patients over a 2-year period. Their average age was 75 years, 46% were female, 77% were white, their median Injury Severity Score (ISS) was 9, and 99% sustained a blunt mechanism of trauma. The top two causes of injury were falls (71%) and motor vehicle crashes (15%). One-third of patients (33%) were on warfarin, while the remainder were on aspirin (26%), clopidogrel (24%), NOAs (10%), and 7% took multiple or other agents.

The mechanism of injury pattern was similar between patients taking NOAs and those taking OATs, with the exception of patients on aspirin being significantly less likely to have sustained a fall. Patients on aspirin also had a significantly higher median ISS. “Patients on NOAs presented more frequently in shock as defined by a systolic blood pressure of less than 90 mmHg, but this was not associated with increased need for packed red blood cell transfusion, bleeding requiring an intervention, need for surgical procedure, hospital LOS, complications, or death,” Dr. Kobayashi said.

About 30% of all patients studied underwent an attempt at reversal. The types of agents used to reverse the patients differed depending on drug agent, with antiplatelet patients more frequently getting platelets, and patients on warfarin more frequently receiving FFP, vitamin K, and prothrombin complex. “Interestingly, patients on the anti-Xa inhibitors more frequently received prothrombin complex as well,” she said. “This likely reflects some of the recent literature which suggests that there may be a therapeutic benefit to using prothrombin complex in patients taking the oral anti-Xa inhibitors but not in patients on dabigatran.”

Overall, bleeding, need for surgical procedure, need for neurosurgical procedure, complications, length of stay, and death were similar between those on NOAs and those on OATs. However, the rate of ICH was significantly higher in patients on aspirin. “What is even more surprising is that 89% of the patients in the aspirin-only group were on an 81-mg baby aspirin rather than the larger 325-mg dose,” Dr. Kobayashi said. This difference was significant on univariate analysis and was retained after multivariate logistic regression adjusted for differences between populations, with an OR for aspirin of 1.7 and a P value of .024. “This is not to suggest that patients on aspirin are doing markedly worse, compared to their counterparts, but I think most of us would have assumed that aspirin patients would have done better,” she commented. “I think we’ve definitively shown that is not the case.” Other independent predictors of ICH were advanced age (OR, 1.02), Asian race (OR, 3.1), ISS of 10 or greater (OR, 2.2), and a Glasgow coma score (GCS) of 8 or less (OR, 5.6).

Despite their increased risk for ICH, patients on aspirin were significantly less likely to undergo an attempt at reversal with any type of agent, at 16% with a P value of less than .001, on univariate analysis. “This was significantly lower than all other medications and was retained after multivariate logistic regression, with an OR of 0.3 and a P value of less than .001,” she said.

Progression of ICH did not differ by medication group. Other independent predictors included intraparenchymal location of hemorrhage (OR, 2.2), need for a neurosurgical procedure (OR, 5.1), an attempt at reversal (OR, 2.3) and a GCS of 8 or lower at admission (OR, 4.3). Similarly, multivariate analysis of death showed no significant differences between the different medication groups. Independent predictors included advanced age (OR, 1.06), GCS of 8 or less (OR, 13), progression of head injury (OR, 10), bleeding (OR, 2.3), and complications (OR, 2.1).

Dr. Kobayashi acknowledged that the study’s observational design is a limitation, as well as the fact that it lacked a control group of age-matched patients who were not taking anticoagulants. “Additionally, we had a relatively low number of patients on NOAs, at only 10% of the study population,” she said. “Lastly, there is potential for enrollment bias as all sites involved in this study were level one trauma centers.” She reported having no financial disclosures.

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Study finds nonoperative management of blunt splenic injuries in elderly safe

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WAIKOLOA, HAWAII – Nonoperative management of blunt splenic injuries in the geriatric population is safe, based on results from a study of national data.

Although the efficacy and safety of nonoperative management of blunt splenic injuries in adults is well established, “early recommendations stated that advanced age was a contraindication to nonoperative management of blunt splenic injuries due to high reported failure rates,” researchers led by Marc Trust, MD, wrote in an abstract presented at the annual meeting of the American Association for the Surgery of Trauma. “Although more recent literature has shown lower and acceptable failure rates, this population continues to fail more often compared to younger patients. Published data suffers from low patient numbers and is conflicting regarding future rate and safety.”

In an effort to obtain well powered, nationwide data to evaluate the recent failure rates and effect on morality among geriatric patients, Dr. Trust of the University of Texas at Austin and his associates retrospectively reviewed the 2014 National Trauma Databank to identify patients with blunt splenic injury. Those who did not receive splenectomy within 6 hours of admission were considered to have undergone nonoperative management. Failure of nonoperative management was defined as requiring splenectomy during the same hospitalization. The primary endpoints were failure of nonoperative management and mortality.

Of the 18,917 total patients identified with a blunt splenic injury 2,240 (12%) were aged 65 years and older. Geriatric patients failed nonoperative management more often than did younger patients (6% vs. 4%; P less than .0001). Having an Injury Severity Score of 16 or greater was the only independent risk factor associated with failure of nonoperative management in geriatric patients (odds ratio, 2.8; P less than .0001). No difference in mortality was observed in geriatric patients who had successful versus failed nonoperative management (11% vs. 15%; P = .22). Independent risk factors for mortality in geriatric patients who underwent nonoperative management included admission hypotension (OR, 1.5; P = .048), high ISS (OR, 3.8; P less than .0001), low Glasgow Coma Scale (OR, 5.0; P less than .0001), and preexisting cardiac disease (OR, 3.6; P less than .0001). However, failure of nonoperative management was not independently associated with mortality (OR, 1.4; P = .3).

In their abstract, the researchers characterized the increased failure rates of nonoperative blunt splenic injuries in geriatric patients, compared with their counterparts as “acceptable” and noted that they were lower than previously reported in published literature. They reported having no financial disclosures.

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WAIKOLOA, HAWAII – Nonoperative management of blunt splenic injuries in the geriatric population is safe, based on results from a study of national data.

WAIKOLOA, HAWAII – Nonoperative management of blunt splenic injuries in the geriatric population is safe, based on results from a study of national data.

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LMWH best for preventing PE in patients with major trauma

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WAIKOLOA, HAWAII – Venous thromboembolism prophylaxis with low molecular weight heparin (LMWH), instead of unfractionated heparin (UH), is associated with lower risk of pulmonary embolism (PE) in patients with major trauma, results from a large study have shown.

The results of the study, based on data from the American College of Surgeons (ACS) Trauma Quality Improvement Program, suggest that LMWH-based strategies for thromboprophylaxis should be preferred after major trauma.

“Patients with major injury are at high risk for developing venous thromboembolism,” James Byrne, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “Deep vein thrombosis frequently complicates the clinical course, and pulmonary embolism remains a leading cause of delayed mortality. We know that pharmacologic prophylaxis reduces the risk of DVT. For this reason, timely initiation of either low molecular weight or unfractionated heparin is indicated for all patients.”

Dr. Byrne, a general surgery resident at Sunnybrook Health Science Center, Toronto, Ontario, Canada, went on to note that LMWH is often favored because of a randomized controlled trial which showed that LMWH was associated with fewer deep vein thromboses (N Engl. J. Med. 1996;335[10]:701-7). However, significant practice variability continues to exist.

“Practitioners might favor the shorter half-life of unfractionated heparin in patients where they perceive the risk for hemorrhagic complications is high,” he said. “There’s also recent evidence to suggest that dosing may be all important and that unfractionated heparin dosed three times daily may be equivalent to low molecular weight heparin. If this is true, it might suggest that the historically higher cost of low molecular weight heparin could favor the use of unfractionated heparin.”

Furthermore, there is a is a lack of evidence comparing either agent to prevent PE, he added. “This is an important gap in our knowledge, because PE frequently occurs in the absence of an identified DVT and carries a significant risk of death. At present, it is not known how practice patterns with respect to choice of prophylaxis type influence risk of PE at the patient or hospital levels.”

Due to a lack of evidence comparing agents to prevent PE, the researchers set out to compare the effectiveness of LMWH versus UH to prevent PE in patients with major trauma who were treated at trauma centers participating in the ACS Trauma Quality Improvement Program from 2012 to 2015. They included all adults with severe injury who received LMWH or UH and excluded those who died or were discharged within five days, and those with a bleeding disorder or chronic anticoagulation. The exposure was defined as thromboprophylaxis with LMWH versus UH, and the primary outcome was PE confirmed on radiologic imaging. Potential confounders were considered, including patient baseline characteristics, anatomic and global injury severity, presenting characteristics in the emergency department, acute intracranial injuries, orthopedic injuries, early surgical interventions, and timing of prophylaxis initiation.

Dr. Byrne and his associates then used three analytic approaches in the study: a propensity score matching methodology, a multivariable logistic regression model for PE, and a center-level analysis examining the influence of LMWH utilization on hospital rates of PE.

They identified 153,474 trauma patients from 217 trauma centers. Their median age was 50 years and 67% were male. Blunt trauma was most common (89%), with a mean Injury Severity Score score of 20. LMWH was the most common type of thromboprophylaxis used (74%), and PE was diagnosed in 2,722 patients (1.8%).

Compared with patients who received LMWH, those who received UH were older and were significantly more likely to have been injured by falling (42% vs. 28%), with higher rates of severe head injuries (43% vs. 24%) and intracranial hemorrhage (38% vs. 19%). Conversely, LMWH was most favored in patients with orthopedic injuries.

After propensity score matching, patients on LMWH suffered significantly fewer PEs (1.4% vs. 2.4%; odds ratio, 0.56). This result was consistent within propensity-matched subgroups, including for patients with blunt multisystem injuries (OR, 0.60), penetrating truncal injuries (OR, 0.65), shock in the ED (OR, 0.68), isolated severe traumatic brain injury (OR, 0.49), and isolated orthopedic injuries (OR, 0.28).

Results of a sensitivity analysis in which each propensity-matched pair was matched within the same trauma center yielded similar results. Specifically, patients who received LMWH were at significantly lower risk for developing PE (OR, 0.64). “Importantly, this analysis minimized residual confounding due to differences in hospital-level processes of care, such as prophylaxis dosing or frequency, mechanical prophylaxis use, and thromboembolism screening practices,” Dr. Byrne noted.

Multivariable logistic regression also showed that patients who received LMWH had lower odds of PE (OR, 0.59). Other significant predictors of PE included obesity (OR, 1.54), severe chest injury (OR, 1.31), femoral shaft fracture (OR, 1.60), and spinal cord injury (OR, 1.60). Delays in prophylaxis initiation beyond the first day in the hospital were associated with significantly higher rates of PE, with an 80% increased risk of PE for patients who had their prophylaxis initiated after the fourth day.

The researchers conducted a center-level analysis in an effort to answer the question whether practice patterns with respect to choice of prophylaxis type influence hospital rates of PE. Across all 217 trauma centers in the study, the median rate of LMWH use was 80%, while the mean rate of PE was 1.6%. When trauma centers were grouped into quartiles based on their unique rate of LMWH use, trauma centers in the highest quartile (median LMWH use: 95%) were 50 times more likely to use LMWH, compared to those in the lowest quartile (median LMWH use: 39%) after adjusting for patient case mix. Compared with the lowest quartile, trauma centers that used the greatest proportion of LMWH had significantly lower rates of PE (1.2% vs. 2.0%). After adjusting for patient baseline and injury characteristics, patients who were treated at trauma centers in the highest quartile had significantly lower odds of PE (OR, 0.59).

Dr. Byrne acknowledged certain limitations of the study, including the potential for residual confounding and the inability to account for the dosing and frequency of prophylaxis that was given. “We were only able to measure the type and timing of prophylaxis initiation. We don’t know what doses of prophylaxis were used, and it is possible that the trauma centers included in this study favored use of UH twice daily,” he said.

Therefore, it is possible that the results might have been different if they had been able to directly compare LMWH to UH administered three times a day. “We also couldn’t measure interruptions in dosing due to surgery or patient refusal,” he said. “However, if it the case that UH is more likely to be refused based on the need for more frequent dosing, perhaps that is another feather in the cap of low molecular weight heparin-based thromboprophylaxis strategies. Larger prospective studies are needed, that take into account prophylaxis type and dosing, and are powered to detect a difference with respect to PE.”

Dr. Byrne reported having no financial disclosures.

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Key clinical point: LMWH-based strategies for thromboprophylaxis should be preferred after major trauma.

Major finding: After propensity score matching, patients on LMWH had significantly fewer PEs, compared with those on unfractionated heparin (1.4% vs. 2.4%; odds ratio, 0.56). Data source: A multicenter analysis of 2,722 trauma patients who were diagnosed with pulmonary embolism.

Disclosures: Dr. Byrne reported having no financial disclosures.

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Pelvic fracture pattern predicts the need for hemorrhage control

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WAIKOLOA, HAWAII – Blunt trauma patients admitted in shock with anterior posterior compression III or vertical shear fracture patterns, or patients with open pelvic fracture are at greatest risk of severe bleeding requiring pelvic hemorrhage control intervention, results from a multicenter trial demonstrated.

Thirty years ago, researchers defined a classification of pelvic fracture based on a pattern of force applied to the pelvis, Todd W. Costantini, MD, said at the annual meeting of the American Association for the Surgery of Trauma. They identified three main force patterns, including lateral compression, anterior posterior compression, and vertical shear (Radiology. 1986 Aug;160 [2]:445-51).

“They were able to show that certain pelvic fractures were associated with soft tissue injury and pelvic hemorrhage,” said Dr. Costantini, of the division of trauma, surgical critical care, burns and acute care surgery at the University of California, San Diego. “Since then, several single center studies have been conducted in an attempt to correlate fracture pattern with the risk of pelvic hemorrhage. A majority of these studies evaluated angiogram as the endpoint for hemorrhage control. Modern trauma care has evolved to include multiple modalities to control hemorrhage, which include pelvic external fixator placement, pelvic angiography and embolization, preperitoneal pelvic packing, and the use of the REBOA [Resuscitative Endovascular Balloon Occlusion of the Aorta] catheter as an adjunct to hemorrhage control.”

In a recently published study, Dr. Costantini and his associates found wide variability in the use of various pelvic hemorrhage control methods (J Trauma Acute Care Surg. 2016 May;80 [5]:717-25). “While angioembolization alone and external fixator placement alone were the most common methods used, there were various combinations of these methods used at different times by different institutions,” he said.

These results prompted the researchers to prospectively evaluate the correlation between pelvic fracture pattern and modern care of pelvic hemorrhage control at 11 Level I trauma centers over a two year period. Inclusion criteria for the study, which was sponsored by the AAST Multi-institutional Trials Committee, were patients over the age of 18, blunt mechanism of injury, and shock on admission, which was defined as an admission systolic blood pressure of less than 90 mm Hg, or heart rate greater than 120, or base deficit greater than 5. Exclusion criteria included isolated hip fracture, pregnancy, and lack of pelvic imaging.

The researchers evaluated the pelvic fracture pattern for each patient in the study. “Each pelvic image was evaluated by a trauma surgeon, orthopedic surgeon, or radiologist and classified using the Young-Burgess Classification system,” Dr. Costantini said. Next, they used univariate and multivariate logistic regression analysis to analyze predictors for hemorrhage control intervention and mortality. The objective was to determine whether pelvic fracture pattern would predict the need for a hemorrhage control intervention.

Of the 46,716 trauma patients admitted over the two year period, 1,339 sustained a pelvic fracture. Of these, 178 met criteria for shock. The researchers excluded 15 patients due to lack of pelvic imaging, which left 163 patients in the final analysis. Their mean age was 44 years and 58% were male. On admission, their mean systolic blood pressure was 93 mm Hg, their mean heart rate was 117 beats per minute, and their median Injury Severity Score was 28. The mean hospital length of stay was 12 days and the mortality rate was 30%. The three most common mechanisms of injury were motor vehicle crash (42%), followed by pedestrian versus auto (23%), and falls (18%).

Compared with patients who did not require hemorrhage control intervention, those who did received more transfusion of packed red blood cells (13 vs. 7 units, respectively; P less than .01) and fresh frozen plasma (10 vs. 5 units; P = .01). In addition, 67% of patients with open pelvic fracture required a hemorrhage control intervention. The rate of mortality was similar between the patients who required a pelvic hemorrhage control intervention and those who did not (34% vs. 28%; P = .47).

The three most common types of pelvic fracture patterns were lateral compression I (36%) and II (23%), followed by vertical shear (13%). Patients with lateral compression I and II fractures were least likely to require hemorrhage control intervention (22% and 19%, respectively). However, on univariate analysis, patients with anterior posterior compression III fractures and those with vertical shear fractures were more likely to require a pelvic hemorrhage control intervention, compared with those who sustained other types of pelvic fractures (83% and 55%, respectively).

On multivariate analysis, the three main independent predictors of need for a hemorrhagic control intervention were anterior posterior compression III fracture (odds ratio, 109.43; P less than .001), open pelvic fracture (OR, 7.36; P = .014), and vertical shear fracture (OR, 6.99; P = .002). Pelvic fracture pattern did not predict mortality on multivariate analysis.

The invited discussant, Joseph M. Galante, MD, trauma medical director for the University of California, Davis Health System, characterized the study as important, “because it examines all forms of hemorrhage control, not just arterioembolism in the treatment of pelvic fractures,” he said. “The ability to predict who will need hemorrhage control allows for earlier mobilization to resources, both in the operating room or interventional suite and in the resuscitation bay.”

Dr. Costantini reported having no financial disclosures.

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Key clinical point: Patients with anterior posterior compression III pelvic fractures face an especially high risk of severe bleeding that requires a hemorrhage control intervention.

Major finding: On multivariate analysis, the three main independent predictors of need for a hemorrhagic control intervention were anterior posterior compression III fracture (odds ratio, 109.43; P less than .001), open pelvic fracture (OR, 7.36; P = .014), and vertical shear fracture (OR, 6.99; P = .002). Data source: A prospective evaluation of 163 patients with pelvic fracture who were admitted to 11 Level I trauma centers over a two-year period.

Disclosures: Dr. Costantini reported having no financial disclosures.

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Novel device provides real-time glucose monitoring of critically ill

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WAIKOLOA, HAWAII – Use of an automated bedside blood monitoring platform was safe and effective in measuring glucose in critically ill patients, results from a pivotal, prospective multicenter trial demonstrated.

“The hypermetabolic stress response to injury is a well-known entity following injury,” Grant V. Bochicchio, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. “Hyperglycemia has been shown to be intimately associated with this response. Numerous studies have reported that hyperglycemia has been associated with increased infection and worse outcome in critically injured trauma patients.” In addition, several studies have demonstrated that the glucose meters used for trauma patients are inaccurate, whether in relation to anemia or other factors, said Dr. Bochicchio, chief of acute and critical care surgery at Washington University, St. Louis.

He presented results from a trial that evaluated the safety and accuracy of a continuous inline glucose monitor in 200 critically ill and trauma patients. The OptiScanner, an investigational device manufactured by OptiScan Biomedical, automatically measures plasma-based glucose levels to enable early detection of hypoglycemia, hyperglycemia, or glucose variability. The OptiScanner has yet to be cleared by the Food and Drug Administration, but Dr. Bochicchio said that he expects a decision from the agency in the next several months.

The system includes the device itself as well as a single-use, disposable cartridge, which is the only point of contact with the patient’s blood. A proprietary zero-depth space connector seamlessly attaches a disposable cartridge to the patient’s IV line, to ensure that blood flows smoothly without the need for heparin. “The OptiScanner automatically draws blood and the spectrometer measures blood glucose directly from the plasma sample without the need of calibration,” Dr. Bochicchio said. “Plasma glucose results are then displayed on the screen along with a trending graph of the glucose values. If the glucose values move outside of the desired range, the OptiScanner alerts the clinician by displaying the glucose value against a red background. We’re actually measuring [blood glucose] at the time of the patient in the ICU without having to send it to a lab, without having to wait 4 hours for a turnaround. This is where we have to go with ICU medicine.”

The purpose of the current trial was to evaluate the safety and accuracy of the OptiScanner in patients admitted to one of four ICUs who had an expected length of stay of 18 hours and required glucose monitoring. To be eligible they had to have a central line in place and could not have hematocrit level of less than 15% or greater than 60% on enrollment, and they had to be able to connect to the proximal port of the central venous catheter. Enrollment was defined as time of connection to the OptiScanner. Patients could remain connected for up to 72 hours. Blood draws were performed every 15 minutes, and a comparative sample was drawn within a 2-minute window at a minimum of 1-hour interval. The paired blood samples were then spun down for plasma within 15 minutes by the study team and analyzed twice by the Yellow Springs Instrument STAT Plus Glucose and Lactate Analyzer, which is the gold standard for measuring blood glucose levels remotely.

The primary endpoint was a mean absolute relative deviation (MARD) of 10% or less, while the secondary endpoint was a population coefficient of variance (PCV) of 13% or less. The mean age of the 200 patients was 62 years, 69% were male, 83% were white, and their mean Apache II score was 15.1. An analysis of 3,735 paired readings revealed that the mean MARD was 7.6%, “which is better than what we set our objective for,” Dr. Bochicchio said. The mean PCV was 9.8%, “which was the ideal,” he said. “So we achieved our primary and secondary objectives.” More than half of patients (52%) exhibited at least one form of dysglycemia, while 25% of patients exhibited at least one episode of hypoglycemia, severe hyperglycemia, or glycemic variability.

The invited discussant, Dennis Y. Kim, MD, FACS, noted that glucose control remains a key tenet of modern-day critical care. “It’s difficult to ignore the numerous technical and logistical challenges involved in obtaining a rapid and accurate glucose measurement upon which protocolized management decisions can be instituted,” said Dr. Kim, a surgeon at Harbor-UCLA Medical Center, Los Angeles. “Reliability of point of care devices, the ever-increasing work demands on our ICU nurses, and lack of sufficient data points to permit analysis of trends are but a few of the issues surrounding glycemic control. Dr. Bochicchio and his colleagues are to be congratulated on the present study, which proposes a potential solution to the aforementioned problems in managing hyperglycemia in the ICU.”

The study was funded by OptiScan Biomedical. Dr. Bochicchio reported having no financial disclosures.

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Key clinical point: The first inline continuous glucose monitor is safe and accurate for use in critically ill surgical patients.

Major finding: An analysis of 3,735 paired readings revealed that the mean absolute relative deviation (MARD) was 7.6%, which achieved the primary endpoint for accuracy.

Data source: A trial which set out to evaluate the safety and accuracy of the OptiScanner in 200 patients admitted to one of four ICUs who had an expected length of stay of 18 hours and required glucose monitoring.

Disclosures: The study was funded by OptiScan Biomedical. Dr. Bochicchio reported having no financial disclosures.

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Brief screen helps identify patients with PTSD, depression

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WAIKOLOA, HAWAII – A new nine-item tool known as the Injured Trauma Survivor Screen demonstrated strong sensitivity and specificity for predicting posttraumatic stress disorder and depression in trauma patients.

At the annual meeting of the American Association for the Surgery of Trauma, Terri deRoon-Cassini, PhD, said that the rates of PTSD among trauma patients range from 10% to 42%, depending on the type of injury sustained. “There is significant life impairment, including an increased risk for suicide and an increased risk for morbidity and mortality,” said Dr. deRoon-Cassini, a clinical psychologist and associate professor with the division of trauma and critical care at the Medical College of Wisconsin, Milwaukee.

The ACS Committee on Trauma currently recommends PTSD screening by trauma centers, including the 20-item PTSD Checklist and the nine-item PHD-9 for depression. However, these symptom-based screens were not validated in hospitalized trauma patients. “This becomes important, because according to the symptom trajectory of PTSD after trauma, about 22% of people experience chronic disease and about 16%-18% of people who have symptoms at baseline do not translate to symptoms by 6 months, so screening with a symptom-based measure isn’t always the best route,” she said.

In an effort to create a brief screening tool to identify those at risk for PTSD and depression following traumatic injury, Dr. deRoon-Cassini and her associates scoured existing medical literature on the topic to review risk factors and created an item pool of questions based on those risk factors. They came up with 47 items and statistically “funneled out the items to create the most parsimonious model predicting who goes on to develop PTSD and depression separately,” she explained. They then created the Injured Trauma Survivor Screen (ITSS), a nine-item list of yes/no questions that takes about 5 minutes to administer: five items for PTSD and five items for depression, with one item that overlaps. The five ITSS PTSD questions are:

• Did you think you were going to die? (risk factor being perceived life threat; odds ratio 6.32).

• Do you think this was done to you intentionally? (risk factor being intentionality; OR, 4.24).

• Have you felt more restless, tense, or jumpy than usual? (risk factor being assessment of arousal; OR, 5.31).

• Have you found yourself unable to stop worrying? (risk factor being worry/rumination; OR, 4.49).

• Do you find yourself thinking that the world is unsafe and that people are not to be trusted? (risk factor being negative alterations in cognition; OR, 5.52).

The five ITSS depression questions are:

• Have you ever taken medication for, or been given a mental health diagnosis? (risk factor being preexisting psychopathology; OR, 10.58).

• Has there ever been a time in your life you have been bothered by feeling down or hopeless or lost all interest in things you usually enjoyed for more than 2 weeks? (risk factor being premorbid depression; OR, 3.78).

• Did you think you were going to die? (risk factor being perceived life threat; OR, 9.69).

• Have you felt emotionally detached from your loved ones? (risk factor being negative alteration in mood; OR, 8.03).

• Do you find yourself crying and are unsure why? (risk factor being mood/depression; OR, 9.18).

The researchers administered the survey to 139 patients at two trauma centers. More than half (69%) were male, 48% were white, 40% were African American, and the remainder were from other ethnic backgrounds. The three most common mechanisms of injury were motor vehicle crashes (29%), motorcycle/all-terrain vehicle crashes (19%), and falls (13%). Dr. deRoon-Cassini reported that administration of the ITSS within 4 days of injury demonstrated a 75% sensitivity for identifying the risk for PTSD and depression, a 94% specificity for PTSD, and a 96% specificity for depression, with a cutoff score of 2 out of 5 for both subscales based on a receiver operating characteristic (ROC) curve analysis.

One month following administration of the ITSS, 20% of patients were diagnosed with depression and 29% were diagnosed with PTSD. Of those diagnosed with PTSD, 55% met criteria for concomitant depression “so we are seeing a high comorbidity between PTSD and depression, which is consistent with the medical literature,” she said.

“The ITSS represents a brief way that we can screen for PTSD and depression within a trauma system,” Dr. deRoon-Cassini said. “At our institution, social workers administer the tool. They have a flow sheet in our EMR system where they enter the responses. If someone screens positive, a best practice recommendation is put into the patient’s chart, which gets funneled to a trauma psychology consult. On the treatment side we try to intervene by triaging the severity of the current distress the person is experiencing, past comorbidities, and past trauma histories. From there we decide whether to do a brief intervention or more intensive evidence-based interventions for PTSD or depression together or separately.”

The study was funded by a grant from the Medical College of Wisconsin. Coauthors included Joshua Hunt, PhD, of the Medical College of Wisconsin, Milwaukee; Ann Marie Warren, PhD, of Baylor Medical Center, Dallas; and Karen Brasel, MD, FACS, of Oregon Health & Science University, Portland. Dr. deRoon-Cassini reported having no financial disclosures.

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Key clinical point: A brief screening tool effectively predicted PTSD and depression when administered during hospitalization following injury.

Major finding: Administration of the Injured Trauma Survivor Screen (ITSS) within 4 days of injury demonstrated a 75% sensitivity for identifying the risk for PTSD and depression, a 94% specificity for PTSD, and a 96% specificity for depression.

Data source: An analysis of 139 patients from two trauma centers who completed the ITSS.

Disclosures: The study was funded by a grant from the Medical College of Wisconsin. Dr. deRoon-Cassini reported having no financial disclosures.

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Preperitoneal pelvic packing benefits subset of pelvic fracture patients

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WAIKOLOA, HAWAII – Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage caused by unstable pelvic fractures, results from a long-term single-center study showed.

“Despite advances in care of the critically injured patient, mortality rates for patients with hemodynamic instability due to pelvic fractures remains greater than 30%,” Clay Cothren Burlew, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “The majority of trauma centers in the United States use angioembolization for hemorrhage control. While angioembolization is effective in controlling arterial sources of hemorrhage, which constitutes about 15% of pelvic bleeding, it does not address the venous or bony sources of hemorrhage within the pelvis. Additionally, time to arterial hemorrhage control using angioembolization usually takes several hours to accomplish, even at the most advanced level I trauma centers.”

Preperitoneal pelvic packing in combination with external fixation has been advocated to rapidly arrest hemorrhage, facilitate other emergent operative procedures, and provide efficient use of angioembolization, said Dr. Burlew of the department of surgery at Denver Health Medical Center. However, a 2015 AAST multicenter trial reported a 32% mortality rate for complex pelvic fracture patients who present in shock. The time to intervention for these patients was 3-5 hours (J Trauma Acute Care Surg. 2016;80:717-25).

For the current study, the researchers hypothesized that pelvic packing would result in a shorter time to intervention and lower mortality, compared with other pelvic fracture management strategies.

Since September 2004 all patients at the Denver Health Medical Center with persistent hemodynamic instability and a pelvic fracture underwent pelvic packing. Indication for packing is a persistent systolic blood pressure of less than 90 mm Hg in the initial resuscitation period despite the transfusion of two units of red blood cells. “Initial stabilization of the pelvis is performed in the emergency department with a pelvic sheet or a binder,” Dr. Burlew explained. “Skeletal fixation of the pelvis with an external fixator or a pelvic C clamp is done concurrently with preperitoneal pelvic packing in the operating room. Angiography is performed for ongoing pelvic bleeding, defined as greater than four units of red blood cells after the patients’ coagulopathy is corrected; immediate postpacking angiography is performed for ongoing hemodynamic instability despite packing and external fixation.”

Over a period of 11 years, 2,293 patients were admitted to Denver Health Medical Center with pelvic fractures. Of these, 128 patients in refractory shock underwent pelvic packing. More than half of the patients (70%) were men, their mean age was 44 years, and their mean Injury Severity Score was 48. The most common mechanism of injury was motor vehicle collision, followed by auto/pedestrian accidents and motorcycle collision. Pelvic fracture patterns included every classification, with anterior posterior compression (APC) III and lateral compression (LC) II patterns predominating. Of these, 18 patients had open pelvic fractures. More than half of patients (70%) had an extremity injury, 65% had a thoracic injury, 63% had an abdominal injury, 43% had a traumatic brain injury, and 38% had a spine injury.

The mean systolic blood pressure of patients was 74 mm Hg and their mean heart rate was 120 beats per minute in the emergency department. Their mean base deficit was 12. However, 32% of patients did not have an arterial blood gas reported during this time frame. When the researchers compared 13% of patients who underwent postpacking angioembolization with those who did not require angioembolization after pelvic packing, they observed no significant differences in age, injury severity score, presenting systolic BP, presenting systolic BP/base deficit, or ED transfusions. The only difference that reached statistical significance was a lower heart rate in the ED in the postpacking angioembolization group, compared with the preperitoneal pelvic packing alone group (110 vs. 121 beats per minute). “We also realized that the angioembolization group received more red blood cells and fresh frozen plasma prior to ICU admission, as well as in the subsequent 24 hours,” Dr. Burlew said.

The majority of patients (84%) had a single packing of the preperitoneal space, while 20 patients underwent repacking when returned to the operating room; all occurred prior to July 2011. “At this time point we determined that there was an increased infection rate with repacking of the pelvis,” Dr. Burlew said. “There were 15 pelvic space infections. Four occurred in those with open fractures or perineal degloving, four developed in those with associated bladder injuries, and seven pelvic space infections occurred in patients without an open fracture.” The infection rate was 6% among patients with a single packing of the pelvis, compared with an infection rate of 45% among those who underwent repacking. “This emphasizes the need for local control of small bleeders when the pelvis in unpacked, using electrocautery and topical hemostatic agents,” she said.

Dr. Burlew went on to note that comparison of two prospective observational study groups with differing management schema may provide salient information. “The AAST multicenter study was an evaluation of the modern-day care of pelvic fracture patients from 11 different centers,” she said. “In that study, the mortality rate among patients presenting in shock who did not undergo pelvic packing was 32%. The mortality rate in our series was 21%, with a relative risk reduction that was statistically significant.” She concluded that pelvic packing “has a faster time to intervention for pelvic fracture–related hemorrhage. Arterial bleed was only present in 13% of patients, rendering angiography of limited utility. Pelvic packing should be utilized for pelvic fracture–related bleeding in the patient who remains hemodynamically unstable despite red blood cell transfusion.”

One of the study authors, Ernest E. Moore, MD, disclosed that he has received research funding from Haemonetics, TEM, and Prytime Medical Devices, and Charles J. Fox, MD, is on the clinical advisory board for Prytime Medical Devices. Dr. Burlew reported having no financial disclosures.

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Key clinical point: Preperitoneal pelvic packing should be used for pelvic fracture–related bleeding in patient who remain hemodynamically unstable.

Major finding: Of the 128 patients who underwent preperitoneal pelvic packing for life-threatening hemorrhage caused by unstable pelvic fractures, 27 died, for a mortality rate of 21%, which is significantly lower than other analyses in the medical literature.

Data source: An 11-year study of 2,293 patients who were admitted to Denver Health Medical Center with pelvic fractures.

Disclosures: One of the study authors, Ernest E. Moore, MD, disclosed that he has received research funding from Haemonetics, TEM, and Prytime Medical Devices, and Charles J. Fox, MD, is on the clinical advisory board for Prytime Medical Devices. Dr. Burlew reported having no financial disclosures.

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Sarcopenia an effective measure of frailty in elderly patients

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WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.

“Setting expectations about operative outcomes is an important part of the preoperative counseling process, Erika L. Rangel, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. In a previous study that she and her associates conducted at Brigham and Women’s Hospital, Boston, the risk for mortality was found to continue long after hospital discharge in older patients who undergo emergency surgery: 16% at 30 days, 22% at 3 months, 28% at 6 months, and 32% 1 year after surgery (J Trauma and Acute Care Surg. 2015 Sep;79[3]:349-58).

“Knowing the risk of mortality increases significantly over the first year after surgery for elderly patients, identification of high-risk patients preoperatively gives surgeons an opportunity to tailor their care to best suit their patients,” said Dr. Rangel, who is a surgeon at Brigham and Women’s. “For example, for some elderly patients with limited life expectancy, an extended hospital stay or loss of independence could be more important than mortality as an outcome measure. For them, palliative or less-invasive treatments with lower immediate morbidity and mortality might be preferable to a high-risk operation. Helping patients to understand their long-term outcomes helps make the decision to operate based on their personal values.”

Traditionally, surgeons use subjective opinion or basic scoring systems such as the American Society of Anesthesiologists (ASA) classification to stratify risk for surgery in elderly patients. “However, the ASA score can be subjective, and there’s inconsistency between evaluators,” Dr. Rangel said. “The Charlson Comorbidity [Index] rates a patient based on the presence or absence of 19 comorbidities, but it doesn’t tell the surgeon anything about the patient’s functional status.” Frailty is a good measure of an elderly patient’s physiologic reserve to withstand an operation, she continued, but is difficult to measure in the acute care setting. One solution is to measure sarcopenia, which predicts postoperative complications, disability, and mortality in elderly elective surgery patients. “The problem is that very few studies have looked at the impact of sarcopenia in the emergency surgery populations, and the ones that exist only look at short-term outcomes, which don’t completely capture the mortality risk,” she said.

In an effort to better understand how sarcopenia affects long-term outcomes after emergency surgery in the elderly, the researchers retrospectively reviewed patients aged 70 years or older who underwent urgent or emergent abdominal surgery at Brigham and Women’s between 2006 and 2011. Patients were stratified by operative severity using the POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) score. Operations considered major included any laparotomy, open cholecystectomy, and bowel resection, while those considered moderate were laparoscopic cholecystectomy, appendectomy, and hernia repairs without bowel compromise. To measure sarcopenia, the researchers used preoperative CT images to calculate the average bilateral psoas muscle cross-sectional area at the L3 level, normalized for height. Primary outcome was 1-year mortality. Secondary outcomes were mortality at 30 days, 90 days, and 180 days.

Dr. Rangel reported results from 297 patients that were evaluated: 222 with no sarcopenia and 75 with sarcopenia. Their mean age was 78 years, 57% were female, and 84% were white. Compared with nonsarcopenic patients, sarcopenic patients did not differ in terms of age, sex, or race. Comorbidities were high in both groups, with 75% of patients having an ASA score of 3 or greater and 31% having a Charlson score of 4 or greater. More than 40% had some sort of underlying malignancy, yet there were no significant differences between the two groups in terms of ASA scores, Charlson scores, or the prevalence of malignancy.

Compared with nonsarcopenic patients, sarcopenic patients had longer hospital length of stay (14 vs. 11 days, respectively; P = .012), were more likely to require ICU care (67% vs. 50%; P = .012), and had higher in-hospital mortality (27% vs. 9%; P less than .01). In addition, sarcopenic patients had higher hazard ratios of mortality, compared with their nonsarcopenic counterparts, at 30 days (hazard ratio, 3.5; P = .01), 90 days (HR, 3.5; P less than .001), 180 days (HR, 2.6; P = .001), and at 1 year (HR, 2.5; P = .001).

“The measurement of sarcopenia is a practical tool that can be used at the bedside,” Dr. Rangel concluded. “It just takes 3 or 4 minutes using a single axial slice of a preoperative CT scan. Since it uses CT imaging that’s obtained for initial diagnostic purposes, it incurs no additional cost. The identification of sarcopenia has immediate applications for care of the geriatric patient. It should trigger the surgeon to set realistic goals of care and frame expectations about survival [and] should prompt processes of care that improve patient outcomes. High-risk patients might benefit from geriatric consultation or specialized geriatric pathways, early palliative care evaluation, and advance care planning.” She reported having no financial disclosures.

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WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.

WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.

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Key clinical point: Sarcopenia is an objective measure of frailty that can be calculated before surgery to identify potentially vulnerable elderly patients.

Major finding: Sarcopenic patients had higher hazard ratios of mortality, compared with their nonsarcopenic counterparts, at 30 days (HR, 3.5), 90 days (HR, 3.5), 180 days (HR, 2.6), and at 1 year (HR, 2.5).

Data source: A retrospective review of 297 patients aged 70 years or older who underwent urgent or emergent abdominal surgery at Brigham and Women’s between 2006 and 2011.

Disclosures: Dr. Rangel reported having no financial disclosures.

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ACS should make firearm injury prevention a priority, COT member survey says

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WAIKOLOA, HAWAII – Nearly 90% of American College of Surgeons Committee on Trauma members believe that the ACS should give the highest or a high priority to reducing firearm-related injuries, according to results from a national survey.

“In the United States, we value personal liberty and personal safety highly,” Deborah A. Kuhls, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. “However, that sometimes leads to a polarized view on firearms. Some view it as a freedom in personal safety. Others view it as a limitation of freedom and [as promotion of] violence.”

According to National Trauma Data Bank/Trauma Quality Improvement Program data from 2014, falls rank as the leading mechanism of injury sustained by patients treated at trauma centers in the United States (44%), followed by motor vehicle crashes (34%), and firearms (4%). However, because firearm injuries are so lethal, death by falls, motor vehicle crashes, and firearms are roughly equivalent, in the range of 10.4 per 100,000 to 10.6 per 100,000, with the societal cost of firearms injury estimated to have been $174 billion in 2010 (Surgery 2014;155[5]:894-8). “This is roughly double the Department of Education budget and triple the Department of Homeland Security budget,” said Dr. Kuhls, professor of surgery and chief of critical care at the University of Nevada, Las Vegas, and chair of the ACS Committee on Trauma (COT) Injury Prevention and Control Committee.

In an effort to evaluate ACS COT member attitudes about firearm ownership, freedom, responsibility, physician/patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development, Dr. Kuhls and the COT Injury Prevention and Control Committee developed a 32-item anonymous survey that was sent to 254 COT members between December 2015 and February 2016. Results were extracted by ACS staff.

Of 254 COT members who received the survey, 237 completed the survey, for a response rate of 93%. Their mean age was 52 years, and 88% were male, 88% were married, 85% were white, and 58% had children in the home. More than one-quarter (29%) had military experience, 88% practiced acute care, trauma, general surgery, or pediatric surgery; 43% had firearms in the home, and 33% had personal experience with a family or friend injured or killed from firearm injury. A significantly higher proportion of respondents with military experience had firearms in the home, compared with those who had no military experience (56% vs. 37%, respectively; P less than .01). By Centers for Disease Control and Prevention demographic region, the percentage of members who have firearms in their home was lowest in the Northeast (14%), followed by the West (38%), the Midwest (48%), and the South (56%).

Dr. Kuhls also reported that 88% of respondents indicated that they think the ACS should give a high or the highest level of priority to firearm injury prevention. When asked about private ownership of firearms, about 53% thought that gun ownership is generally beneficial/an important personal liberty, while 30% believed that gun ownership is generally harmful and limits personal liberty. The remaining 17% had no opinion on the issue.

The majority of respondents (95%) said that health care professionals should be allowed to counsel patients (or parents of patients) about how to prevent gun-related injuries, while 96% felt that the CDC and other federal agencies should fund research on the epidemiology and prevention of gun-related injuries.

Survey respondents were then asked to rate their opinion on the ACS initiating efforts to advocate for or support legislation on 15 possible initiatives to prevent firearm violence, ranging from “improve mental health screening and treatment to reduce suicides and gun violence” to increase penalties when guns [are] provided to others illegally including dealers” to “require safety features, including child-proof locks and ‘smart gun’ technology,” and “identify and implement evidence-based injury prevention programs.”

The greatest consensus was reached in the advocacy area titled “improve mental health screening and treatment to reduce suicides and gun violence” (ranging from 89% to 93%), while the least consensus was in the advocacy area titled “require firearms owners to be 21 years of age or older” (ranging from 41% to 71%).

The most common themes that emerged on qualitative analysis were concern that the topic is too political, as well as calls to improve existing data “to understand what role we can play in injury prevention,” and that “surgeons should be involved in solving the problem,” Dr. Kuhls said. “There were also a lot of comments on responsible ownership.” She noted that more than 90% of respondents support 7 out of 15 proposed initiatives, 80%-90% support an additional 3 initiatives, and 70%-80% support an additional 4 proposed initiatives.

The invited discussant, Ernest E. Moore, MD, FACS, a surgeon in Denver, described the effort to develop firearm injury prevention policy as laudable. However, “this process carries a risk of merely supporting the bandwagons already in motion,” Dr. Moore said. “In that light I would like to focus on the conspicuous areas of disagreement, specifically civilian access to assault rifles. The fundamental issue is the magazine capacity of rifles – housing 30 or more bullets, enabling rapid shooting. Mass shootings, defined as greater than or equal to five victims, are currently an epidemic in our country. The volatile issues are eliminating assault rifles to reduce mass shootings [and] the interpretation of the Second Amendment to keep and bear arms. I do not believe a randomized prospective trial is necessary to establish the fact that mass shootings are only feasible because irresponsible individuals have access to these weapons. The urgency in this issue is heightened by the reality that mass shootings are increasingly inspired by terrorist activity, beyond individuals traditionally considered mentally ill.”

Dr. Kuhls described the current survey as “the initial step” in an effort to develop firearm injury prevention policy. “We are just about to receive results from a survey of the Board of Governors for the ACS,” she said. “We plan to develop short- and long-term plans to address this public health challenge that leverages survey consensus findings in four ACS pillars: advocacy, quality, systems, and education. We need to continue this conversation.” She expressed gratitude to the COT Executive Committee and liaison members from the ACS Board of Regents in addition to members of the COT Injury Prevention and Control Committee. She reported having no financial disclosures.

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Key clinical point: American College of Surgeons Committee on Trauma members support ACS making firearm injury prevention a priority.

Major finding: A majority of respondents (88%) indicated that they think the ACS should give a high or the highest level of priority to firearm injury prevention.

Data source: Responses to 32-item anonymous survey that was completed by 237 members of the ACS COT between December 2015 and February 2016.

Disclosures: Dr. Kuhls reported having no financial disclosures.

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Trauma operative training declining for general surgery residents

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WAIKOLOA, HAWAII – Trauma training for general surgery residents has significantly declined in recent years, results from an analysis of the Accreditation Council for Graduate Medical Education data registry on surgical education showed.

Aaron Strumwasser, MD, an attending trauma surgeon and surgical intensivist at the Los Angeles County/University of Southern California Medical Center, characterized the decline in trauma training as “sobering.” In an effort to test their hypothesis that trauma training for general surgery residents is on the decline since the inception of the 80-hour workweek, Dr. Strumwasser and his associates set out to compare the operative caseloads before and after the inception of the 80-hour workweek; to note trends in specific operative domains and determine if deficiencies exist and to determine whether subspecialty training (specifically, vascular fellowship and integrated vascular surgery residency) has altered general surgery resident operative volume. They extracted data from the ACGME database on resident trauma volume for trauma cases by category and by resident training year for the years 1999-2015. Only those cases logged as primary surgery were included. The researchers subdivided trauma cases into five domains: head and neck, thoracic, abdomen, solid organ, and extremity. Resident trauma experience (operative caseload) was compared, based on before the inception of the 80-hour workweek (1999-2002) and after (2003-present).

A trend toward decreased operative trauma for general surgery residents was observed in the time periods before and after implementation of the 80-hour workweek (a mean of 39,252 vs. 36,065 cases, respectively; P = .07). At the same time, the number of trauma laparotomies increased from 4,708 to 11,234 cases, the number of vascular trauma cases dropped sharply, from 4,926 to 799 cases, while the number of neck explorations and thoracotomies remained relatively stable. The researchers also found that as open vascular operative caseload by general surgery trainees decreased (from a mean of 4,599 to a mean of 2,755; P less than .01), there was a relative increase in the open vascular operative caseload of vascular fellows and integrated vascular surgery residents (from a mean of mean 845 to a mean of 1,465; P less than .01). When individual graduating resident caseloads were analyzed before and after implementation of the 80-hour workweek, decreased operative volumes were prevalent across multiple domains including decreased operative caseloads in thoracic, abdominal, solid organ, and extremity vascular trauma (P less than .01 for all).

Solutions to the current situation seem to fall into one of three categories, Dr. Strumwasser said: advanced simulation training such as Advanced Surgical Skills Exposure in Trauma and Advanced Trauma Operative Management; extending or changing the structure of general surgery training and promoting trauma and Acute Care Surgery fellowships.

The invited discussant, Mark A. Malangoni, MD, FACS, associate director of the American Board of Surgery, said that other factors have affected the exposure of general surgery residents to trauma care, including a decrease in violent crime and motor vehicle crash rates over the past 3 decades. In addition, “nonoperative management has become the standard of care for many injuries that were previously operated,” Dr. Malangoni said.

“Subspecialization has clearly narrowed the scope of general surgery and trauma surgery practice. As a result, we now treat many complex injuries with a team-based approach. So unless societal trends reverse, it is highly unlikely that we will do more open operations in the future, since many nonoperative and noninvasive options work just as well or even better, said Dr. Malangoni. “It’s easy to blame these changes on duty hours requirements and the corresponding reduction in call, and decreasing exposure to trauma and emergent conditions. However, it’s important to recognize that there are 10% more residencies as well as 15% more resident graduates in 2015, compared to 15 years ago, which further magnifies the effect of the overall decline in trauma operative volume. So how do we meet the challenge of teaching residents to perform operations uncommonly done not only during but also after residency, while maintaining quality care for our patients? This is a challenge shared by nearly every surgical specialty due to a general decline in open operations overall.”

Dr. Strumwasser reported having no financial disclosures.

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