Trauma is the oldest surgical subspecialty. Prehistoric evidence demonstrates early techniques for suturing lacerations, performing amputations, and setting fractures. Trephined skulls hint at early surgical attempts to relieve intracranial pressure after traumatic brain injury. The oldest known treatise on trauma care, the Edwin Smith Papyrus, dates back to 1600 BC and consists of 48 case descriptions of injuries. Such archaeological evidence reveals that ancient civilizations, from the Egyptians, to the Babylonyians, to the Mayans, treated wounds sustained from hand-to-hand and projectile-based combat.
Advancements in trauma care have closely paralleled technological advances on the battlefield. Ambulances were first introduced during the Siege of Malaga in 1487. Ambroise Paré first described the use of ligatures for hemostasis during his term as a military surgeon in 16th-century France. The practice of triage was developed during the Napoleonic Wars in the early 19th century, and the association of aggressive fluid resuscitation with pulmonary failure was described during the Vietnam Conflict. The Gulf Wars enhanced our understanding of massive transfusion ratios, management of traumatic brain injury, and tourniquet use. As weapons evolved with the invention of gunpowder and mechanized transportation, so evolved the understanding of blast injury and polysystem trauma.
In the civilian sector, research has historically consisted of expert opinion and single-center case series. High-quality studies on injured patients are extremely difficult to conduct, due to barriers to informed consent in the emergent setting, poor patient follow-up, and other methodological issues. However, in the past few decades, professional organizations such as the American Association for the Surgery of Trauma (AAST), the Eastern Association for the Surgery of Trauma (EAST), and the Western Trauma Association (WTA) have made great strides in organizing multicenter trials to enrich the quality of the trauma literature. This expanding evidence has steadily invalidated prior surgical dogma. In this chapter, we present several benchmark trials that have dramatically contributed to the trauma surgery literature. As the field of trauma surgery encompasses not only traumatology but also emergency surgery and surgical critical care, the importance of these trials spans multiple disciplines, and should influence the practices of trauma surgeons, general surgeons, and surgical intensivists alike.
Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI, National Emergency X-Radiography Utilization Study Group
NEJM 2000 Jul;343(2):94–99.Takeaway Point: A decision instrument based on a set of five clinical criteria can help identify a subset of patients who, after blunt trauma, are at extremely low risk for cervical injury and can safely forego cervical spine (c-spine) imaging.
Commentary: The authors present the results of a large, multicenter observational study on imaging of the cervical spine after blunt trauma. The decision instrument identifies five criteria that patients must meet following blunt trauma that, if met, identifies them as “low risk” for cervical spine injury. These five criteria are straightforward, and based on the results of this study, highly sensitive for diagnosing cervical spine injury. Utilizing this clinical decision instrument may significantly decrease costs and exposure to ionizing radiation by avoiding cervical spine imaging in low-risk blunt trauma patients. The Canadian c-spine rule1 is another decision instrument that attempts to limit the amount of radiographs of the c-spine obtained after blunt trauma, which has a potentially lower sensitivity but higher specificity. American trauma centers tend to use the NEXUS criteria preferentially.
Introduction: Clinicians fear missing a cervical spine injury in a blunt trauma patient. For this reason, radiographs of the cervical spine are obtained for nearly every patient who presents after blunt trauma. A decision instrument based on five clinical criteria has been proposed to identify patients with a low probability of injury who therefore do not require radiographs of the cervical spine following blunt trauma. Sample size limitations have previously prevented widespread adoption of this decision instrument.
Objective: The National Emergency X-Radiography Utilization Study (NEXUS) was designed to validate this decision instrument and to test the hypothesis that patients with blunt trauma who meet all five criteria have a very low probability of clinically significant injury to the cervical spine.
Trial Design: Prospective observational study.
Inclusion Criteria: All patients with blunt trauma who underwent radiography of the cervical spine in the emergency department.
Exclusion Criteria: Patients with penetrating trauma and those who underwent cervical spine imaging for any reason unrelated to trauma, or patients without imaging.
Intervention: Observational study; a physician completed a data form to document presence or absence of the five clinical criteria: (1) absence of tenderness at the posterior midline of the cervical spine, (2) normal level of alertness, (3) no focal neurologic deficits, (4) no evidence of intoxication, and (5) no distracting injuries. Decision to proceed with radiography was made entirely at the discretion of the clinician.
Endpoints: To determine, within a confidence interval of 0.5%, the sensitivity of the decision instrument.
Sample Size: 34,069 patients were included in the study from 21 centers across the United States.
Statistical Analysis: Sample size calculation, sensitivity and specificity, negative and positive predictive value.
Baseline Data: Patients ranged in age from <1 year to 101; 2.5% were under 8 years of age. Demographics were otherwise not reported.
Outcomes: 34,069 patients who sustained blunt trauma underwent cervical spine radiography. Of these patients, 818 (2.4%) had radiographically demonstrated cervical spine injury. The decision instrument yielded a false negative for 8 of the 818 patients with radiographically documented c-spine injury. 576 patients met predetermined criteria for a clinically significant c-spine injury, and of these two were cleared as “low risk” by the instrument. One patient who was judged low risk did require operative intervention for a laminal fracture. For all injuries, the sensitivity of the clinical criteria is 99% and negative predictive value (NPV) is 99.8%; for clinically significant injuries, the sensitivity is 99.6% and the NPV 99.9%. With the decision instrument criteria, 4309 patients (12.6%) could have been spared radiographic evaluation.
Conclusion: This prospective, multicenter study confirms the validity and utility of a decision instrument based on five clinical criteria for identifying patients who, after blunt trauma, have a low probability of having sustained an injury to the cervical spine.
Limitations: This study included all patients with blunt trauma who were evaluated in the emergency department. Most of these patients were of low acuity and would not have triggered trauma activation. The documented rate of cervical spine injury is 2–3 times greater, or nearly 6%, in patients with higher acuity. Additionally, the study is observational, so it is possible that some patients who met the decision instrument criteria did not have cervical radiographs obtained and were therefore not included in the study. The study included all ages and did not control for any demographic information.
Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study.
Demetriades D, Murray JA, Chan L, Ordoñez C, Bowley D, Nagy KK, Cornwell EE III, Velmahos GC, Muñoz N, Hatzitheofilou C, Schwab CW, Rodriguez A, Cornejo C, Davis KA, Namias N, Wisner DH, Ivatury RR, Moore EE, Acosta JA, Maull KI, Thomason MH, Spain DA, Committee on Multicenter Clinical Trials
J Trauma. 2001 May;50(5):765–775.Takeaway Point: The surgical management of penetrating colon injury (primary anastomosis vs. diversion) does not affect the incidence of abdominal complications.
Commentary: The authors prospectively studied management and subsequent outcomes of patients with penetrating colon injury requiring resection from 19 trauma centers in an observational cohort. They compared patients who received primary anastomosis with those who were diverted, and identified risk factors for colon-related abdominal complications. They found that abdominal complications after penetrating colon injury are unrelated to surgical management (primary anastomosis vs. diversion). This is an observational trial, and the groups were not balanced; sicker patients were more likely to receive a diversion. Despite the authors’ recommendations to attempt primary repair for all traumatic colon injuries, the conclusive data to support this recommendation are not yet available. This trial does provide compelling rationale for a potential randomized trial in the future.
Introduction: The optimal management of patients who have penetrating colonic injuries requiring resection is poorly defined because of the fairly small number of patients at any one center who require resection.
Objective: To evaluate the safety of primary anastomosis or diversion and identify independent risk factors for the development of colon related abdominal complications.
Trial Design: Observational multicenter prospective study.
Inclusion Criteria: Penetrating colon injuries requiring resection.
Exclusion Criteria: Patients with rectal injuries and all deaths occurring within 3 days of admission.
Intervention: Observational trial; surgical methods and antibiotic prophylaxis were surgeon’s preference.
Endpoints: Colon-related mortality, colon-related abdominal complications (anastomotic leak, intra-abdominal abscess or peritonitis, fascial dehiscence, and colon obstruction or necrosis), ICU and hospital stay.
Sample Size: 297 patients from 19 institutions between December 1998 and July 2000.
Statistical Analysis: χ2 test or two-tailed Fisher exact test, Wilcoxon rank sum test, Kruskal–Wallis test.
Baseline Data: Mean age was 28.6 years, 93% of patients were men; 97% of injuries from gunshot wounds. Overall, 197 patients were managed with primary repair and anastomosis and 100 with diversion. There was a significantly higher incidence of delayed operation (>6 hours), shock at admission, left colon injury, small-bowel and liver injuries, blood transfusion requirements, and severe fecal contamination in the diversion group. The diversion group received significantly longer duration of antibiotics.
Outcomes: Overall colon-related mortality was 1.3% (four deaths), all in the diversion group. Overall incidence of abdominal complication was 22% after primary repair and 27% after diversion (p 0.37). Multivariate analysis identified three independent risk factors for abdominal complications: severe peritoneal contamination, >4 units of blood in the first 24 hours, and single-agent antibiotic prophylaxis. Average ICU stay was longer in the diversion group (3.7 days vs. 7.4 days) but this did not reach statistical significance (p 0.08), and overall hospital stay was similar (p 0.13).
Conclusion: For penetrating colon injuries requiring resection, performing primary anastomosis versus diversion is not associated with the incidence of colon-related abdominal complications.
Limitations: As this is a prospective observational study with confounding variables, data presented are class II evidence and lack randomization. The clinical decision to perform a primary anastomosis versus diversion was likely related to patient factors, including the noted difference in baseline comorbidities between the two groups, with the diversion group being significantly sicker.
Management of patients with anterior abdominal wall stab wounds: A Western Trauma Association multicenter trial.
Biffl WL, Kaups KL, Cothren CC, Brasel KJ, Dicker RA, Bullard MK, Haan JM, Jurkovich GJ, Harrison P, Moore FO, Schreiber M, Knudson MM, Moore EE
J Trauma. 2009 May; 66(5):1294–1301.Takeaway Point: Stable, asymptomatic patients with anterior abdominal stab wounds can be safely observed for symptoms of bleeding or hollow viscus injury, rather than proceeding to immediate exploratory laparotomy.
Commentary: The authors present a large, prospective observational study evaluating multiple techniques for assessing the hemodynamically stable patient with an anterior abdominal stab wound. They conclude that unless peritonitis, shock, or evisceration is present, an immediate exploratory laparotomy is not indicated. A number of additional studies and observation modalities are detailed in order to assist in the management of these patients to minimize resource utilization and the prevalence of nontherapeutic exploratory laparotomy. A large, prospective multicenter trial detailing the resource utilization of this approach is warranted.
Introduction: Patients with penetrating abdominal stab wounds who present with shock, peritonitis, or evisceration require exploratory laparotomy as a lifesaving surgical intervention. Other patients presenting with anterior abdominal stab wounds are hemodynamically stable and asymptomatic. The care of these patients is less well defined, and management remains controversial.
Objective: The purpose of this multicenter study was to evaluate the clinical course of patients managed by the various strategies, to determine whether there are differences in associated non-therapeutic laparotomy, emergency department discharge, or complication rates.
Trial Design: Observational multicenter prospective cohort study.
Inclusion Criteria: Age ≥16 with anterior abdominal stab wound, defined as that area bordered by the costal margin superiorly, the groin creases inferiorly, and the anterior axillary lines laterally.
Exclusion Criteria: Patients with back, flank, or presumed thoracoabdominal wounds, pregnancy, incarceration.
Intervention: No aspect of management was dictated by the study.
Endpoints: Hospital discharge, emergency department discharge.
Sample Size: 359 patients from 11 institutions between 2006 and 2007.
Statistical Analysis: Sensitivity, specificity, NPV, PPV.
Baseline Data: 318 men and 41 women, mean age 33.4 years. 121 patients had two or more wounds.
Outcomes: 81 patients underwent immediate exploratory laparotomy, of which 68 (84%) were therapeutic. Of patients who were discharged from the emergency department, the decision was made by local wound exploration in 23%, CT scan in 21%, and diagnostic peritoneal lavage (DPL) in 18%. Exploratory laparotomy based on results from CT, local wound exploration, and DPL were nontherapeutic in 57%, 24%, and 31% of patients. 12% of patients who were admitted for serial clinical examinations underwent exploratory laparotomy, of which 33% were found to be nontherapeutic. There was no apparent morbidity due to delay in intervention. The authors compared CT scan, serial clinical assessments, focused assessment with sonography for trauma (FAST), DPL, and local wound exploration for predictive value. Local wound exploration and serial exams have 100% sensitivity, with 54% and 96% specificity, respectively. FAST has 21% sensitivity.
Conclusion: Shock, evisceration, and peritonitis require immediate exploratory laparotomy after anterior abdominal stab wound. Patients without these findings may be safely observed for signs and symptoms of bleeding or hollow viscous injury.
Limitation: Morbidity following observation for asymptomatic patients is not clearly defined. No safety or cost-effectiveness data are provided. This is a purely observational study.
Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David T, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R
Ann Surg. 2010 Dec; 252(6):959–965.Takeaway Point: Prehospital rapid-sequence intubation (RSI) is associated with favorable neurological outcomes at 6 months posttrauma when compared to intubation on arrival at the hospital.
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