Background Operative mortality for high-grade liver injury (HGLI) remains 42% to 66%, with near-universal mortality after retrohepatic caval injury. The objective of this study was to evaluate mortality and complications of operative and nonoperative management (OM and NOM) of HGLI at our institution, characterized by a trauma surgery–liver surgery collaborative approach to trauma care.Methods This was an observational cohort study of adult patients (age ≥16) with HGLI (The American Association for Surgery of Trauma (AAST) grades IV and V) admitted to an urban level I trauma center from January 2010 to November 2021. Data were obtained from the electronic medical record and state trauma registry. Patients were categorized by management strategy: immediate OM or planned NOM. The primary outcome was 30-day mortality.Results Our institution treated 179 patients with HGLI (78% blunt, 22% penetrating); 122 grade IV (68%) and 57 grade V (32%) injuries. All abdominal gunshot wounds and 49% of blunt injuries underwent initial OM; 51% of blunt injuries were managed initially by NOM. Procedures at the initial operation included hepatorrhaphy±packing (66.4%), nonanatomic resection (5.6%), segmentectomy (9.3%), and hepatic lobectomy (7.5%). Thirty-day mortality in the OM group was substantially lower than prior reports (23.4%). Operative mortality attributable to the liver injury was 15.7%. 19.4% of patients failed NOM with one death (1.4%).Conclusion We report an operative mortality of 23.4% for HGLI in a trauma care system characterized by a collaborative approach by trauma surgeons and liver surgeons.Level of evidence III

An 18-year-old male presented via Emergency Medical Services as a level 1 trauma following a gunshot wound to the right flank. Initial vital signs were a heart rate of 135/ minute, blood pressure of 127/77 mm Hg, and a respiratory rate of 25/minute. He was awake and appropriate complaining only of severe abdominal pain. On primary survey, his airway was patent, and there were equal bilateral breath sounds. Intravenous fluid resuscitation was initiated using normal saline. Examination revealed peritonitis and a right flank wound only. Trauma bay imaging was limited to chest and abdominal radiographs which demonstrated a metal projectile consistent with a bullet lodged at the left inferior sternal border in the epigastrium. Focused Assessment with Sonography in Trauma examination was positive in the right upper quadrant (negative pericardial view). The patient was taken emergently to the operating room for exploratory laparotomy. Upon entering the abdomen, a large volume of hemoperitoneum was encountered, and the abdomen was packed in the standard fashion. Marked hepatic injury was immediately apparent, and there was audible bleeding in the region of the portal triad which was temporarily controlled with a manual Pringle maneuver. Further dissection revealed this to be bleeding from the left branch of the portal vein, and a concomitant bile duct injury was also noted. Left lateral segment resection was performed. Operative findings revealed that the bullet entered in the right flank, traversed the diaphragm then through the right lobe of the liver just superior to the gallbladder fossa (leaving the gallbladder attached to remaining liver by only a few peritoneal strands), passing just posterior to the hilar structures, and finally through the left lateral segment, lodging just below the sternum. In addition to the left lateral segment resection, a segment VI six resection, cholecystectomy, diaphragm repair, and intraoperative cholangiogram were also performed. The abdomen was packed, temporarily closed, and he was taken to the ICU for recovery and ongoing resuscitation. On post-trauma day 1, the patient returned to the operating room for second look laparotomy. There was some continued oozing from the liver which was treated with electrocautery, but no bile staining was noted (Figure 1). To assure continued hemostasis and to try to avoid a bile leak, Peitzman paste was mixed using 20 mL of fresh frozen plasma, 5 packets of Avitene, and 10 000 units of thrombin (Figure 2). This was mixed to a thick, viscous paste consistency and was then applied to the raw surfaces of the hepatic parenchyma (Figure 3). Closedsuction drains were placed, the abdomen was closed, and the patient returned to the ICU. His postoperative course was complicated only by a central line-related venous thrombosis, which was treated with therapeutic anticoagulation. There was no bleeding or bile leakage, and the patient was discharged to home on therapeutic anticoagulation. He was lost to follow-up from our trauma clinic, but review of the patient’s electronic medical record reveals that he was seen in the emergency department approximately 3 months after injury for an unrelated complaint and at that time was having no apparent complications.

Background: Limited exposure to surgical subspecialties during medical school may be responsible for decreasing medical student interest in surgery. Although most medical schools have surgery interest groups to increase exposure, our aim was to evaluate the impact of a focused surgical subspecialty roundtable on preclerkship students' perceptions of surgical careers. Methods: Faculty members from each surgical subspecialty shared their experiences and led roundtable discussions with five to seven first- and second-year medical students at a time (total n = 59). Pre-event and post-event surveys were administered to assess students' interest in surgery, knowledge of training paths, values related to specialty selection, and perception of surgeons. Results: Forty students completed pre-event and post-event surveys. The number of students who were extremely or very interested in surgery increased after this event (65% versus 72.5%, P < 0.001). The greatest number of students indicated an interest in orthopedic surgery, and the fewest indicated an interest in neurosurgery. After the event, thirteen (32.5%) students changed their preferences for the subspecialty in which they were most interested. Students demonstrated improved knowledge of training length and integrated residencies (83.8% versus 96.3%, P = 0.003). The perceived importance of intellectual challenge, research opportunities, and training length decreased, whereas the importance of compensation, work/life balance, long-term patient follow-up, and the job market increased. Students' perceptions of surgeons' work/life balance (10% versus 25%, P < 0.001) and ability to be team players (82.5% versus 85%, P = 0.01) improved significantly after the roundtable. Conclusions: The surgical specialty roundtable increased students' interest in surgery, improved knowledge of training paths, and altered perceptions related to career decision-making. (C) 2020 Elsevier Inc. All rights reserved.

Campwala, Insiyah BS; Aranda-Michel, Edgar BS; Watson, Gregory A. MD, FACS; Hamad, Giselle G. MD, FACS, FASMBS; Losee, Joseph E. MD, FACS, FAAP; Sultan, Ibrahim MD, FACS, FACC Author Information

Blunt cerebrovascular injuries (BCVI) are generally associated with high-energy injury mechanisms. Less is known regarding lower-energy injuries in elderly patients. We sought to determine the incidence of BCVI and characterize current BCVI screening practices and associated complications in elderly ground-level fall patients (EGLF, ≥ 65 years). We hypothesized that BCVI in EGLF patients would be clinically significant and screening would be less common.

BACKGROUND:The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of "surgical rescue" in the practice of ACS.METHODS:A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index.RESULTS:Of 2,410 ACS patients, 320 (13%) required "surgical rescue": most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients ("local"), whereas 38% were referred from another surgical service ("institutional") and 26% referred from another institution ("regional"). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between "local" and "institutional" patients, but hospital length of stay and discharge to home were significantly worse in "institutional" referrals.CONCLUSION:We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the "surgical rescue" of surgical and procedural complications.LEVEL OF EVIDENCE:Epidemiological study, level III; therapeutic/care management study, level IV.

BACKGROUND Older adult trauma patients are at increased risk of poor outcome, both immediately after injury and beyond hospital discharge. Identifying patients early in the hospital stay who are at increased risk of death after discharge can be challenging. METHODS Retrospective analysis was performed using our trauma registry linked with the social security death index from 2010 to 2014. Age was categorized as 18 to 64 and 65 years or older. We calculated mortality rates by age category then selected elderly patients with mechanism of injury being a fall for further analysis. Computed Tomography Abbreviated Assessment of Sarcopenia for Trauma (CAAST) was obtained by measuring psoas muscle cross-sectional area adjusted for height and weight. Kaplan-Meier survival analysis was performed, and proportional hazards regression modeling was used to determine independent risk factors for in-hospital and out-of-hospital mortality. RESULTS A total of 23,622 patients were analyzed (16,748, aged 18–64 years; and 6,874, aged 65 or older). In-hospital mortality was 1.96% for ages 18 to 64 and 7.19% for age 65 or older (p < 0.001); postdischarge 6-month mortality was 1.1% for ages 18 to 64 and 12.86% for age 65 or older (p < 0.001). Predictors of in-hospital and postdischarge mortality for ages 18 to 64 and in-hospital mortality for ages 65 or older group included injury characteristics such as ISS, admission vitals, and head injury. Predictors of postdischarge mortality for age 65or older included skilled nursing before admission, disposition, and mechanism of injury being a fall. A total of 57.5% (n = 256) of older patients who sustained a fall met criteria for sarcopenia. Sarcopenia was the strongest predictor of out-of-hospital mortality in this cohort with a hazard ratio of 4.77 (95% confidence interval, 2.71–8.40; p < 0.001). CONCLUSION Out of hospital does not assure out of danger for the elderly. Sarcopenia is a strong predictor of 6-month postdischarge mortality for older adults. The CAAST measurement is an efficient and inexpensive measure that can allow clinicians to target older trauma patients at risk of poor outcome for early intervention and/or palliative care services. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

A care surgery (ACS) was initially proposed by the American Association for the Surgery of Trauma as a specialty composed of trauma, surgical critical care, and emergency surgery. In addition, we and others have always considered elective general surgery as a vital component of our ACS service. The promulgation of ACS has filled the public need for surgeons who provide care to the critically ill and injured patients in our hospitals. During the past several years, it has become apparent to us that a crucial service that we provide to both our hospital and the region is that of surgical rescue. Surgical rescue is essentially pulling the patient from the fire after they have developed a complication from surgical or medical care. In reviewing national hospital discharge data, ‘‘complication of medical or surgical care’’ is a more frequent diagnosis than bowel obstruction, cholecystitis, and appendicitis combined. Thus, this is a common clinical diagnosis in a group of patients who are often desperately ill after a medical or surgical complication. In reviewing data from our institution, 10% of our general surgery (nontrauma) admissions/consults are for surgical rescue from a major complication. On average, we see a patient per day requiring surgical rescueVmore than 80% require an operation, and more than half require multiple procedures to be rescued from their complication. Importantly, 50% of these patients are from other services (the majority surgical) within our hospital, 25% from the region, and 25% on our own service. Provision of this immediate care to extricate a patient from a major complication is mandatory for the successful care of the complex patients in our regions and on the thoracic, vascular, cardiac, medical, and other services within our hospitals. Recent reports have shown that the incidence of complications at high-performing versus low-performing hospitals is not as different as one would intuitively suspect. The difference is in the ability to save the patient who has developed a major complication. A high-performing hospital rescues the patient from the complication; the low-performing hospital does not. Our hospital administrators will certainly be familiar with the term failure to rescue but may not understand the vital role of the ACS surgeon in providing surgical rescue. As ACS matures and evolves, it is clear that an essential component of ACS is the immediate care that we provide in surgical rescue of the patient who has developed a complication of his or her medical or surgical care. Moving forward, the essential components of ACS should be redefined as trauma, surgical critical care, emergency and elective surgery, and surgical rescue.

The majority of splenic injuries are currently managed nonoperatively. The primary indication for operative management of blunt splenic injury is hemodynamic instability. Findings which correlate with failure of nonoperative management include grade IV or V splenic injury, high Injury Severity Scores, or active extravasation. The role of angiograph/embolization is becoming better defined, appropriate in the patient with pseudoaneurysm or active extravasation or the stable patient with grade IV or V splenic injury.

From the Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania. This lecture was presented at the 73rd annual meeting of the American Association for the Surgery of Trauma, September 11, 2014, in Philadelphia, Pennsylvania. Address for reprints: Andrew B. Peitzman, MD, Department of Surgery, F-1281, UPMC-Presbyterian, Pittsburgh, PA 15213; email: [email protected]; [email protected].

BACKGROUND Single-center experience has shown that American College of Surgeons (ACS) trauma verification can improve outcomes. The current objective was to compare mortality between ACS-verified and state-designated centers in a national sample. METHODS Subjects 16 years or older from ACS-verified or state-designated Level I and II centers were identified in the National Trauma Databank 2007 to 2008. A predictive mortality model was constructed using Trauma Quality Improvement Project methodology. Imputation was used for missing data. Probability of mortality in the model determined expected deaths. Observed-to-expected (O/E) mortality ratios with 90% confidence interval (CI) and outliers (90% CI more than or less than 1.0) were compared across ACS and state Level I and II centers. The mortality model was repeated with ACS versus state included. RESULTS There were 900,274 subjects. The model had an area under the curve of 0.92 to predict death. Level I ACS centers had a lower median O/E ratio compared with state centers (0.95 [interquartile range, 0.82–1.05] vs. 1.02 [interquartile range, 0.87–1.15]; p < 0.01), with no difference in Level II centers. Level II state centers had more high O/E outliers. ACS verification was an independent predictor of survival in Level II centers (odds ratio, 1.26; 95% CI, 1.20–1.32; p < 0.01) but not in Level I centers (p = 0.84). CONCLUSION Level II centers have a disproportionate number of high mortality outliers, and ACS verification is a predictor of survival. Level I ACS centers have lower O/E ratios overall, but no difference in outliers. ACS verification seems beneficial. These data suggest that Level II centers benefit most, and promoting Level II ACS verification may be an opportunity for improved outcomes. LEVEL OF EVIDENCE Prognostic study, level III.

Although, historically, shock associated with traumatic injury has been evaluated through knowledge of the 4 recognized shock patterns—cardiogenic, obstructive, distributive, and hypovolemic—many trauma practitioners view traumatic shock as a unique fifth shock pattern. Although secondary to a systemic inflammatory response syndrome triggered by endogenous danger signals, traumatic shock represents a unique pathological condition that begins with multiple, usually blunt, trauma and may conclude with multiple organ dysfunction syndrome and death. While varying mechanisms of injury may lead to different presentations of shock and cardiovascular decompensation, a unifying theme of traumatic shock is an overwhelming inflammatory response driven by proinflammatory cytokines, and the downstream results of this cytokine storm including, but not limited to, acute respiratory distress syndrome, coagulopathy, sepsis, and multiple organ dysfunction syndrome. Treatment is primarily supportive; however, research into novel therapeutics for traumatic shock is ongoing and promises some direction for future care.

Although, historically, shock associated with traumatic injury has been evaluated through knowledge of the 4 recognized shock patterns--cardiogenic, obstructive, distributive, and hypovolemic--many trauma practitioners view traumatic shock as a unique fifth shock pattern. Although secondary to a systemic inflammatory response syndrome triggered by endogenous danger signals, traumatic shock represents a unique pathological condition that begins with multiple, usually blunt, trauma and may conclude with multiple organ dysfunction syndrome and death. While varying mechanisms of injury may lead to different presentations of shock and cardiovascular decompensation, a unifying theme of traumatic shock is an overwhelming inflammatory response driven by proinflammatory cytokines, and the downstream results of this cytokine storm including, but not limited to, acute respiratory distress syndrome, coagulopathy, sepsis, and multiple organ dysfunction syndrome. Treatment is primarily supportive; however, research into novel therapeutics for traumatic shock is ongoing and promises some direction for future care.