To Örebro University

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.

BACKGROUND: Atlantoaxial rotatory subluxation (AARS) is an important differential diagnosis in pediatric patients presenting with torticollis, which is caused by the subluxation of the C1 vertebra relative to the C2 vertebra. Because of the uncommon nature of this condition, there is a paucity in sufficiently sized studies describing AARS. The aim of the current investigation was therefore to characterize current clinical characteristics and management of AARS.

METHODS: The American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2021 was queried for pediatric (17 years old or younger) patients who were diagnosed with AARS following blunt trauma. Patients were grouped by age in order to describe and compare demographics, clinical characteristics, and in-hospital outcomes. A subgroup analysis was also performed on patients with isolated AARS, defined as AARS without the presence of a cervical fracture and an Abbreviated Injury Scale score of ≤1 in all regions besides the spine.

RESULTS: A total of 469 cases of AARS were identified, 211 (45.0%) were isolated AARS. Of these patients, 56.3% of AARS patients and 64.5% of isolated AARS patients were 8 years old or younger. Atlantoaxial rotatory subluxation in adolescents was due to a motor vehicle collision in 60.0% of cases, while 52.5% of infants/toddlers were injured in falls. Of all patients with AARS, 87.4% were managed conservatively, with or without a brace/other immobilizing device, while surgery was only indicated in 9.3% of patients. In cases of isolated AARS, conservative treatment was even more prevalent, with 92.4% of patients managed conservatively and only 4.7% requiring surgical intervention.

CONCLUSION: Atlantoaxial rotatory subluxation is most common in children 8 years old and younger, with the majority of cases resulting from falls or motor vehicle accidents. In the Trauma Quality Improvement Program database, most cases were able to be managed conservatively without the need for surgical intervention.

LEVEL OF EVIDENCE: Care Management; Level III.

INTRODUCTION: Hemorrhage is the leading cause of preventable deaths in trauma patients, resulting in 1.5 million deaths annually worldwide. Traditional trauma assessment follows the ABC (airway, breathing, circulation) sequence; evidence suggests the CAB (circulation, airway, breathing) approach to maintain perfusion and prevent hypotension. Damage Control Resuscitation (DCR), derived from military protocols, focuses on early hemorrhage control and volume replacement to combat the "diamond of death" (hypothermia, hypocalcemia, acidosis, coagulopathy). This study evaluates the implementation of DCR protocols in Brazilian trauma centers, hypothesizing sub-optimal resuscitation due to high costs of necessary materials and equipment.

METHODS: In 2024, an electronic survey was conducted among Brazilian Trauma Society members to assess DCR practices. The survey, completed by 121 participants, included demographic data and expertise in DCR.

RESULTS: All 27 Brazilian states were represented in the study. Of the respondents, 47.9% reported the availability of Massive Transfusion Protocol (MTP) at their hospitals, and only 18.2% utilized whole blood. Permissive hypotension was practiced by 84.3%, except in traumatic brain injury cases. The use of tranexamic acid was high (96.7%), but TEG/ROTEM was used by only 5%. For hemorrhage control, tourniquets and resuscitative thoracotomy were commonly available, but REBOA was rarely accessible (0.8%).

CONCLUSION: Among the centers represented herein, the results highlight several inconsistencies in DCR and MTP implementation across Brazilian trauma centers, primarily due to resource constraints. The findings suggest a need for improved infrastructure and adherence to updated protocols to enhance trauma care and patient outcomes.

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.

Background: Trauma systems are multifaceted frameworks that optimize patient care and outcomes. The development of trauma systems has been a regional priority in the Gulf Cooperation Council (GCC), yet implementation varies across countries. These variations contribute to measurable differences in system performance and patient outcomes. A systematic mapping of these disparities can guide efforts to harmonize standards and enhance trauma-care delivery throughout the region.

Methods: A scoping review was conducted per PRISMA-ScR guidelines. PubMed, Scopus, and the Cochrane Library databases were searched for English-language publications (2000-2024) on prehospital emergency care, hospital-based trauma management, or post-hospital rehabilitation in GCC countries. Two reviewers independently screened and charted eligible studies; articles addressing only clinical outcomes without system-level discussion were excluded. Gray literature sources included Ministry of Health (MOH) websites, local news reports, and expert opinion.

Results: Of 1758 studies, 51 were fully screened, and 43 met the inclusion criteria. All GCC countries, except for UAE, operate a single centralized EMS system via a uniform national emergency number. Fleet sizes range from 36 ambulances in Bahrain to over 1379 in Saudi Arabia, with mean response times ranging from 5.3 min in Qatar to 15 min nationally in Kuwait. Formal trauma centers are limited in the region: Bahrain has no formal trauma centers, Qatar and Kuwait each have one dedicated trauma center (level 1 and 2 equivalent, respectively), Oman has two (level 2 and level 3 equivalent), Saudi Arabia has two (level 1 equivalent), and the UAE has nine (levels 1-3 equivalent). Local trauma registries exist in all countries, with a national trauma registry only in Qatar. Posthospital rehabilitation, although variable in resources, is delivered through MOH networks in all countries and supplemented by private providers.

Conclusion: Despite progress, gaps persist in trauma center accreditations, national registry development, and formation of integrated rehabilitation networks. Concerted improvements could further enhance trauma care delivery in the region with a desired improvement in overall outcomes.

Background: Enhanced recovery after surgery (ERAS) protocols reduce length of stay, complications, and costs for elective surgical procedures. It remains challenging to implement ERAS concepts in the acute trauma patient due to deranged physiological reserve from the penetrating or blunt trauma producing altered physiology. However, systems of care improve access to early intervention and potentially reduce mortality. These consensus guidelines examine optimal prehospital, resuscitation-room, intraoperative and postoperative treatment, systems of ethical management, and overall care for trauma patients in the postresuscitation phase of care. The guideline is presented in three parts, this being Part 2.

Methods: Experts in aspects of management of trauma surgical patients and intensive care were invited to contribute by the International ERAS Society and IATSIC. PubMed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements using the patient, intervention, comparator outcome (PICO) consensus questions created by the expert group. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies; reviewed and summarized recommendations were graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. These recommendations based on current best evidence, with extrapolation from elective patient studies, where appropriate, were followed by a modified two-round Delphi method to validate final recommendations. Several ERAS components are already standard of care within national and society guidelines and are endorsed. The bulk of the text focuses on key areas pertaining specifically to trauma care of major trauma and polytrauma in the ICU-requiring group.

Results: Overall, 37 aspects of trauma care were considered, with multiple PICO questions and subpoints. Consensus was reached after two rounds of a modified Delphi process involving all authors, with minor adjustments to some phrasing required, but with 87% overall agreement on all statements (100% agreement on 31 of the main statement sets, prior to minor edits to address the points of difference for the rest, with 100% total agreement thereafter). None were rejected outright. The recommendations and level of evidence for each aspect of trauma care that may impact on improved recovery and reduced length of hospital stay are presented with grade of recommendation.

Conclusions: This paper presents the results of the postoperative care and ICU aspects. The guidelines are based on current best evidence for an ERAS approach to patients who have had major injuries and polytrauma. These guidelines are not exhaustive but collate the best available evidence on important components of care for this patient population. As some of the evidence is extrapolated from elective surgery and nontrauma emergency surgery, some of the components need further evaluation in future studies.

Background: Enhanced recovery after surgery (ERAS) protocols reduce length of stay, complications, and costs for elective surgical procedures. It remains challenging to implement ERAS concepts in the acute trauma patient due to deranged physiological reserve from the penetrating or blunt trauma producing altered physiology. However, systems of care improve access to early intervention and potentially reduce mortality. These consensus guidelines examine optimal pre-hospital, resuscitation-room, intra- and post-operative treatment, systems of ethical management, and overall care for trauma patients in the post-resuscitation phase of care. The guideline is presented in three parts, this being part 3.

Methods: Experts in aspects of management of trauma surgical patients and intensive care were invited to contribute by the International ERAS Society and IATSIC. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements using the patient intervention comparator outcome (PICO) consensus questions created by the expert group. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies; reviewed; and summarized recommendations were graded using the grading of recommendations, assessment, development and evaluation (GRADE) system. These recommendations based on current best evidence, with extrapolation from elective patient studies where appropriate, were followed by a modified two-round Delphi method to validate final recommendations. Several ERAS components are already standard of care within national and society guidelines and are endorsed. The bulk of the text focuses on key areas pertaining specifically to trauma care of major trauma and polytrauma in the ICU-requiring group.

Results: Overall 37 aspects of trauma care were considered with multiple PICO questions and sub-points. Consensus was reached after two rounds of a modified Delphi process involving all authors, with minor adjustments to some phrasing required but with 87% overall agreement on all statements (100% agreement on 31 of the main statement sets, prior to minor edits to address the points of difference for the rest with 100% total agreement thereafter). None were rejected outright. The recommendations and level of evidence for each aspect of trauma care that may impact on improved recovery and reduced length of hospital stay are presented with grade of recommendation.

Conclusions: Four main areas of relevance to ethics and systems are presented as part 3. The guidelines are based on current best evidence for an ERAS approach to patients who have had major injuries and polytrauma. These guidelines are not exhaustive but collate the best available evidence on important components of care for this patient population. As some of the evidence is extrapolated from elective surgery and non-trauma emergency surgery, some of the components need further evaluation in future studies.

Background: Enhanced recovery after surgery (ERAS) protocols reduce length of stay, complications, and costs for elective surgical procedures. It remains challenging to implement ERAS concepts in the acute trauma patient due to deranged physiological reserve from the penetrating or blunt trauma producing altered physiology. However, systems of care improve access to early intervention and potentially reduce mortality. These consensus guidelines examine optimal pre-hospital, resuscitation-room, intra-, and post-operative treatment, systems of ethical management, and overall care for trauma patients in the post-resuscitation phase of care. The guideline is presented in three parts, this being part 1.

Methods: Experts in aspects of management of trauma surgical patients and intensive care were invited to contribute by the International ERAS Society and IATSIC. PubMed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements using the patient intervention comparator outcome (PICO) consensus questions created by the expert group. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies, reviewed, and summarized recommendations were graded using the grading of recommendations, assessment, development and evaluation (GRADE) system. These recommendations based on current best evidence, with extrapolation from elective patient studies, where appropriate, were followed by a modified two-round Delphi method to validate final recommendations. Several ERAS components are already standard of care within national and society guidelines and are endorsed. The bulk of the text focuses on key areas pertaining specifically to trauma care of major trauma and polytrauma in the ICU-requiring group.

Results: Overall 37 aspects of trauma care were considered with multiple PICO questions and sub-points. Consensus was reached after two rounds of a modified Delphi process involving all authors, with minor adjustments to some phrasing required, but with 87% overall agreement on all statements (100% agreement on 31 of the main statement sets, prior to minor edits to address the points of difference for the rest with 100% total agreement thereafter). None were rejected outright. The recommendations and level of evidence for each aspect of trauma care that may impact on improved recovery and reduced length of hospital stay are presented with grade of recommendation.

Conclusions: The guidelines relating to initial care and decision-making are presented in part 1 of the Guidelines. These guidelines are based on current best evidence for an ERAS approach to patients who have had major injuries and polytrauma. The guidelines are not exhaustive but collate the best available evidence on important components of care for this patient population. As some of the evidence is extrapolated from elective surgery and non-trauma emergency surgery, some of the components need further evaluation in future studies.

Introduction: The Bologna guideline outlines three small bowel obstruction (SBO) management pathways. It remains unclear how pathway selection influences post-operative infections.

Methods: A multi-national, prospective, observational, audit of SBO management (November 1, 2023-May 31, 2024) captured demographics, care, and outcomes. Patients were grouped by pathway (successful non-operative management [NOM], NOM followed by surgery [NOM-T], direct to surgery [DTS]). Intergroup comparisons by chi-square or Fisher exact test, significance for p < 0.05.

Results: A total of 1,737 patients were assessed across 21 countries (850 NOM, 379 NOM-T, 508 DTS). Operative cohorts demonstrated similar age (NOM-T 65.2 ± 17.3 vs. DTS 65.5 ± 18.4 y; p = 0.834) and gender (NOM-T 53.6% vs. DTS, 52% female; p = 0.688). Comorbidities were more frequent in patients undergoing NOM-T (77.8%) versus DTS (69.7%; p < 0.001). DTS demonstrated more intestinal ischemia (NOM-T 22.8% vs. DTS 33%; p = 0.002). Time to OR was longer in NOM-T (43.8 ± 30.6 vs. DTS 12.4 ± 15.2 h; p < 0.001). Hospital length of stay (LOS) (NOM-T 12.4 ± 15.2 vs. DTS 7.7 ± 8.0 d; p < 0.001) and LOS (NOM-T 10.1 ± 10.4 vs. DTS 6.6 ± 9.1 d; p < 0.001) were longer in NOM-T. Superficial wound dehiscence (3.9%) and fascial dehiscence (2.6%) were uncommon. Overall surgical site infection (SSI) incidence was similar (NOM-T 8.7% vs. DTS 7.7%; p = 0.578). Deep SSI overall frequency was low (3.9%) but increased in NOM-T (5.5%) versus DTS (2.8%, p = 0.035).

Conclusions: An NOM trial before operation for adhesive SBO seems to increase deep SSI risk and likely reflects time to OR as well as hospital and surgeon factors-elements that merit specific evaluation.

BACKGROUND: Trauma is the leading cause of death in pediatric patients, with major vascular injuries significantly worsening outcomes. This study aimed to evaluate the mortality and complication profile of pediatric trauma patients suffering from major vascular injuries as a result of gunshot wounds (GSWs) compared with blunt mechanisms.

METHODS: We queried the American College of Surgeons Trauma Quality Improvement Program database from 2013 to 2021 for pediatric (≤12 years old) trauma patients who suffered a major vascular injury as a result of either blunt trauma or a GSW. Patients were excluded if they had a head or face Abbreviated Injury Scale ≥2 or an Abbreviated Injury Scale of 6 in any other region. These groups were examined regarding demographics, clinical characteristics, and in-hospital outcomes. In order to adjust for confounding, Poisson regression models with robust standard errors were employed.

RESULTS: After applying the inclusion and exclusion criteria 1,605 patients remained for further analysis. Of these, 18.1% patients (n = 292) suffered a GSW. GSW patients were significantly more injured than blunt trauma patients (Injury Severity Score ≥ 16: 59.6% vs. 33.6%, p < 0.001). GSW patients had significantly higher rates of major intrathoracic as well as femoral vascular injuries, whereas intraabdominal aortic and renal vascular injuries were more common in blunt trauma patients. GSW patients accordingly demonstrated significantly higher rates of in-hospital mortality (21.2% vs. 5.3%, p < 0.001) and overall complications (13.7% vs. 8.4%, p = 0.007). After adjusting for potential confounding, suffering a major vascular injury due to a GSW was associated with an 80% higher rate of mortality (p = 0.013).

CONCLUSION: The overall lethality and complication rate for major vascular injury is greater after GSWs than blunt trauma. These findings underscore the importance of firearm injury prevention and provide further insight into the new leading cause of death in children.

LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.