Trauma Surgery—Controversies and Shifting Management Paradigms

Trauma remains a major public health, financial, and societal liability. To address this burden in both the civilian and military arenas, continuous efforts are made to improve the care provided to trauma victims. Indeed, recent advances in the investigation and treatment of traumatic injuries have increased the choices in clinical management available to the surgeon. This special issue of the Scandinavian Journal of Surgery aims to explore selected areas in trauma surgery where recent advances and shifting clinical paradigms have been made or where there is often contention regarding the most efficacious mode of therapy. To that end, a group of renowned trauma experts, who have spent their careers investigating and treating patients with injuries, was assembled. Each of these specialists has taken the challenge to present an up-to-date review of his or her respective topic and to introduce a forthright view on controversial topics.

In the first article, Dr Enrique Ginzburg and Dr Jeremy Grushka from Miami, United States, discuss the use of minimally invasive surgery (MIS) in trauma patients. Although MIS is increasingly used in emergent and elective surgical conditions, its role in diagnosing and treating injuries is not well defined. Furthermore, safety concerns, as well as lack of clarity regarding clinical indications for minimally invasive procedures, continue to hamper the popularization of laparoscopy and thoracoscopy in trauma patients. The authors compile the most recent evidence in support of or against the use of these procedures in modern trauma surgery. They outline the advantages and limitations of laparoscopy or thoracoscopy compared to traditional open surgery, and conclude that MIS can be used in hemodynamically stable patients as a diagnostic or therapeutic tool.

Endovascular stenting technology has dramatically changed the management of vascular trauma. Dr Elias Degiannis and Dr Reuven Jacks from Johannesburg, South Africa, critically present the state-of-the-art management and controversies in endovascular therapy of vascular injuries. They review the utilization of this technique in blunt aortic injury as well as central (subclavian, carotid, and vertebral artery) and peripheral (popliteal artery) vascular trauma. In addition, the authors discuss general endovascular topics, including technical aspects and limitations of endovascular stenting. The lack of information on long-term complications and outcomes, especially regarding central and peripheral vessel injuries, is emphasized.

Resuscitative thoracotomy (RT) is a dramatic procedure that may provide the only hope for a selected group of patients presenting in extremis. RT has been the subject of much debate, and no consensus exists regarding many aspects of this bold maneuver. The review of RT, written by Dr Reuven Rabinovici and Dr Nikolay Bugaev from Boston, United States, discusses the most current agreements and disagreements surrounding the indications and long-term outcomes of RT. It also highlights some less discussed facets of RT, including the biochemical profile of patients undergoing this operation, the potential for organ donation, and the prospects of pre-hospital RT and RT in military settings. Last, these authors focus on international differences in performing RT, potential future adjuncts such as endovascular aortic balloon occlusion and suspended animation, and the cost and occupational exposure during RT. To complement this review chapter, Dr Rabinovici presents his own experience with 67 consecutive RT.

Recent conflicts such as those in Afghanistan and Iraq resulted in many combat casualties. Thus, it is not surprising that military trauma care has evolved and generated new military medicine concepts. Dr Kluger and his colleagues from Haifa, Israel, describe several distinct features of combat zone injuries and review the practices developed to address them. The authors focus on the causes of preventable death, including bleeding control, resuscitation paradigms, and rapid and safe evacuation. Specifically, they discuss the use of tourniquets, hemostatic dressings, tranexamic acid, and blood products, including fresh whole blood and freeze-dried plasma. They also describe advances in medical evacuation and forward surgical capabilities. The importance of data collection and international collaboration to enable improved understanding of combat injuries is highlighted.

Dr Eugene Moore and his group from Denver, United States, summarize the most recent concepts in trauma-induced coagulopathy (TIC). These authors focus primarily on controversial topics such as pathophysiology, blood component and factor therapy, and goal-directed evaluation and treatment. Specifically, they describe a contemporary cell-based model for hemostasis, which challenges the traditional “cascade” model. The role of the endothelium, protein C, and platelet dysfunction is emphasized and the availability of thromboelastography (TEG), as a point-of-care methodology, which allows for prompt TIC pattern recognition and blood component therapy, is stressed. There is also a discussion on the various available hemostatic products (packed red blood cells (RBC), whole blood, platelets, fresh frozen plasma, fibrinogen concentrate, recombinant activated factor VII (rFVIIa), prothrombin complex concentrate, desmopressin, tranexamic acid, aminocaproic acid, and aprotinin) and their optimal use.

Dr George Velmahos and Dr Haytham Kafafarani from Boston, United States, describe the pathophysiology of the triad of traumatic death, which consists of acidosis, hypothermia, and coagulopathy. They present the novel concept of damage control resuscitation, designed to address this lethal combination of homeostatic derangements. Included in their review is a discussion on body rewarming, reversal of acidosis, permissive hypotension, restrictive fluid administration, and hemostatic resuscitation, including blood component therapy and hemostatic adjuncts. Last, the authors present a useful algorithm for damage control resuscitation and surgery.

Bleeding pelvic fractures have always been a challenge even for the most experienced trauma surgeons, and despite advances in management, their mortality remains high. Dr Ingo Marzi and Dr Thomas Lustenberger from Frankfurt, Germany, critically summarize the most up-to-date treatment options for this frequently catastrophic condition. They recommend angiographic embolization for stable patients with evidence of ongoing bleeding, and emergent pre-peritoneal packing and mechanical stabilization of the pelvis for hemodynamically unstable patients. Occasionally, post-op angioembolization may be required to control residual post-operative bleeding.

Open fractures pose a significant challenge to the trauma surgeon, as they carry higher rates of morbidity and mortality compared with closed boney injuries. Dr Scott Ryan from Boston, United States, provides the updated literature on this common injury type and critically analyzes the most debated controversies with regard to the initial management of open fractures, including timing of initial operative debridement, antibiotic coverage, and time to wound closure or coverage. Future directions such as the role of negative pressure wound therapy are discussed.

Recently, plating of rib fractures associated with flail chest has gained popularity, as it has been shown in some studies to reduce pulmonary complications, shorten ventilation days, and decrease mortality. However, the use of this procedure in patients with rib fractures in general has not received much attention. Dr Luke Leenen and his associates from Utrecht, The Netherlands, provide a systematic review of the current indications and operative techniques for rib fracture fixation. They emphasize that the level of evidence for rib plating in patients with rib fractures, with or without a flail segment, is limited, and encourage conducting future prospective randomized studies to standardize specific indications for this procedure. They also describe the history and technical aspects of rib fixation.

Trauma-related critical care has evolved to address the needs of both civilian and military casualties. This evolution is the result of several landmark multi-center randomized studies, which were concluded during the last decade. Dr Heidi Frankel and her co-authors from Los Angeles, United States, comprehensively describe recent changes in vent management paradigms, trauma sepsis, vasopressors use in hemorrhage, glucose control, nutrition, and hemodynamic monitoring. Highlights include new definitions of ventilator-associated events (VAEs) and of the adult respiratory distress syndrome (ARDS) as well as updates on sepsis guidelines by the Surviving Sepsis Campaign. In addition, several new potential markers of sepsis (interleukin-6 (IL-6), human leukocyte antigen DR (HLA-DR)) and anti-sepsis drugs (procalcitonin (PCT)) are introduced. The use of vasopressin in the treatment of hemorrhagic shock as well the importance of glucose control is also discussed. In addition, the authors present updates on nutritional support (total parenteral nutrition (TPN), glutamine supplementation, and omega-3 fatty acids) and non-invasive hemodynamic monitoring of the critically injured.

Last, I would like to thank the authors for their contribution and the Editor of the Scandinavian Journal of Surgery, Dr. Ari Leppäniemi, for providing this excellent platform for the dissemination of updated knowledge in the field of trauma.

Reuven Rabinovici, MD, FACSGuest editor for the special issue on traumaDivision of Trauma and Acute Care Surgery, Tufts Medical Center, 800 Washington Street, #4488, Boston, MA 02111, USAEmail: [e-mail]