Although the P-GCS score is related to functional outcome as measured by the FIM score and mortality in head injury, current mortality prediction models may need to be modified to account for the nonlinear relationship between P-GCS score and mortality. The P-GCS score is not a good clinical tool for outcome prediction in individual head-injured patients, given the variability in mortality rates and functional outcomes at all scores.

BACKGROUND:Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS:An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014)(2015)(2016)(2017)(2018)(2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS:The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, −9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION:Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication.

INTRODUCTION:Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS:Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS:Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intraabdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION:The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma.

No abstract

Therapeutic study, level IV; prognostic study, level III.

No abstract

As surgeons, we know trauma. We easily bring to mind commonly accepted examples: the 2-car pileup with multiple fatalities, the fall off a ladder, and the gunshot wound to the abdomen. We see people bloody, bruised, and broken every day and we come to believe that trauma surgeons care for patients only on those patients' most dramatic and clearly life-threatening days. Unfortunately, for many patients, this does not tell the whole story.Exposure to multiple traumatic events across the life span is regrettably common. Approximately 2 in 3 children experience trauma or chronic stress, and almost 90% of adults experience at least 1 traumatic exposure, as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5), in their lifetime. 1 These negative experiences collectively elevate a patient's risk for long-term health conditions and subsequent trauma recidivism. [2][3][4] These data highlight 2 central questions. Do we who provide medical care truly understand how various types of trauma may affect a patient? And if not, can we genuinely deliver optimal care?Part of this discrepancy is, arguably, how we define trauma. Among Merriam-Webster's definitions of trauma is "an injury to living tissue…caused by an extrinsic agent," which certainly captures the essence of the physical injury one observes in the trauma bay. However, the Substance Abuse and Mental Health Services Administration (SAMHSA) expands the definition of trauma to include any event or circumstance that an individual (or group) experiences that can increase the risk for physical or psychological harm. 5 The SAMHSA definition of trauma is compelling and pulls us away from our concrete logic. Trauma is not only physical injury but also emotional and psychological harm. More important, trauma does not have to be a discrete event but can include a state of being-such as homelessness, neglect, or poverty-that has the potential for future harm. Primary care, psychiatry, and pediatrics have begun to incorporate this broadened definition of trauma into the care of patients, but surgery too must shift toward trauma-informed care for maximum benefit to patients.Although the concept of trauma-informed care may be novel to surgeons, it evolved out of a public health approach that considers antecedents of disease and behavior. Taken from the socioecological framework, a patient has individual, community, and societal factors that collectively increase or decrease the risk for poor health and injury.

Flail chest is used as one of the indicators for rib fixation, which is being performed more frequently. Radiologic and clinical flail chest are not clearly differentiated in published studies and the relationship between radiologic flail chest (RFC) and outcomes are not clearly established. Our study was designed to evaluate the relationship of RFC to outcomes in patients with severe blunt chest injury. Adult patients with severe blunt chest injury admitted between January 1, 2014, and June 30, 2016, were identified retrospectively. Three hundred and eighty-three patients were studied and mortality rate was not significantly different in patients with an RFC diagnosis (5.88%) compared with patients without RFC (3.83%), P = 0.50. Length of stay (LOS) in patients with and without RFC were compared and patients with RFC were found to have a statistically significant increase in both hospital and intensive care unit LOS (P = 0.0178, P < 0.0017). Multivariate analysis confirmed RFC as an independent predictor of increased LOS when compared with the number of rib fractures and displacements. Our study suggests that RFC may drive inappropriate use of rib fixation. This questions the justification of liberal rib fixation based on the perceived high mortality rate of modern flail chest diagnoses.