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The use of vasopressors during the acute resuscitation of severely injured patients with trauma has long been controversial. Building on the concept of permissive hypotension, damage control resuscitation focuses on hemostatic transfusion of blood products to maintain perfusion pressures. However, targeting lower perfusion pressures while awaiting definitive hemorrhage control is contraindicated in some patient subpopulations and may be detrimental. Coupled with the shift towards a circulation-first approach to resuscitation, there is increasing interest in the use of vasopressors in the trauma bay. This narrative review aims to summarize the evidence behind trauma bay vasopressors and identify the potential role of vasoactive medications in the early phases of trauma care.

When we think about leadership in trauma and acute care surgery, we are often reminded of the direct impact we can have beyond immediate patient care. Leadership is not just about making decisions; it’s about fostering growth within our institutions, among our colleagues and beyond the four walls of our centers. Importantly, leadership and its influence extend throughout the hospital and impact our trainees, mentees, colleagues, and peers alike. As guest speakers at the 2024 American Association for the Surgery of Trauma Annual Meeting Lunch Session entitled “Directorships, Leadership Roles, and Taking the Lead: Everything I Wish I Knew”, KB, JWS and DMS all shared their journeys and thoughts on the complexities, hardships, and rewards of leadership in their roles as clinicians, educators, researchers, and surgeon administrators. This work represents a summary of the lunch panel and provides insights for surgeons seeking to navigate similar paths in academic surgical leadership.

BackgroundThe majority of preventable adverse event (AEs) in trauma care occur during the initial phase of resuscitation, often within the trauma bay. However, there is significant heterogeneity in reporting these AEs that limits performance comparisons between hospitals and trauma systems. The objective of this study was to create a taxonomy of AEs that occur during trauma resuscitation and a corresponding classification system to assign a degree of harm.MethodsThis study used a modified RAND Delphi methodology to establish a taxonomy of AEs in trauma and a degree of harm classification system. A systematic review informed the preliminary list of AEs. An interdisciplinary panel of 22 trauma experts rated these AEs through two rounds of online surveys and a final consensus meeting. Consensus was defined as 80% for each AE and the final checklist.ResultsThe Delphi panel consisted of 22 multidisciplinary trauma experts. A list of 57 evidence-informed AEs was revised and expanded during the modified Delphi process into a finalized list of 67 AEs. Each AE was classified based on degree of harm on a scale from I (no harm) to V (death).DiscussionThis study developed a taxonomy of 67 AEs that occur during the initial phases of a trauma resuscitation with a corresponding degree of harm classification. This taxonomy serves to support a standardized evaluation of trauma care between centers and regions.Level of evidenceLevel 5.

BackgroundVideo-based review is paramount for operative performance assessment but can be laborious when performed manually. Hierarchical Task Analysis (HTA) is a well-known method that divides any procedure into phases, steps, and tasks. HTA requires large datasets of videos with consistent definitions at each level. Our aim was to develop an AI model for automated segmentation of phases, steps, and tasks for laparoscopic cholecystectomy videos using a standardized HTA.MethodsA total of 160 laparoscopic cholecystectomy videos were collected from a publicly available dataset known as cholec80 and from our own institution. All videos were annotated for the beginning and ending of a predefined set of phases, steps, and tasks. Deep learning models were then separately developed and trained for the three levels using a 3D Convolutional Neural Network architecture.ResultsFour phases, eight steps, and nineteen tasks were defined through expert consensus. The training set for our deep learning models contained 100 videos with an additional 20 videos for hyperparameter optimization and tuning. The remaining 40 videos were used for testing the performance. The overall accuracy for phases, steps, and tasks were 0.90, 0.81, and 0.65 with the average F1 score of 0.86, 0.76 and 0.48 respectively. Control of bleeding and bile spillage tasks were most variable in definition, operative management, and clinical relevance.ConclusionThe use of hierarchical task analysis for surgical video analysis has numerous applications in AI-based automated systems. Our results show that our tiered method of task analysis can successfully be used to train a DL model.

ObjectiveTo quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial.Summary background dataTreatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined.MethodsA simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage.ResultsA total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001).ConclusionThis simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted.Level of evidenceNA.

The novel SARS-CoV-2 (COVID-19) disrupted many facets of the healthcare industry throughout the pandemic and has likely permanently altered modern healthcare delivery. It has been shown that existing healthcare infrastructure influenced national responses to COVID-19, but the current implications and resultant sequelae of the pandemic on the organizational framework of healthcare remains largely unknown. This paper aims to review how aspects of contemporary medical systems – the physical environment of care delivery, global healthcare supply chains, workforce structures, information and communication systems, scientific collaboration, as well as policy frameworks – evolved in the initial response to the COVID-19 pandemic.

Background Limited data are available regarding the natural history of patients undergoing primary surveillance for intraductal papillary mucinous neoplasm (IPMN). We hypothesize that symptoms, radiologic characteristics, and cytopathology will predict cancer risk during surveillance. Methods Between March 2002 and March 2010, 522 patients were diagnosed with IPMN at a single, high-volume institution. Low versus high oncologic risk was stratified prospectively. Patients with under 3 months of surveillance were excluded. Results Two hundred ninety-two patients underwent primary surveillance for IPMN. Two hundred forty-four (84%) were classified as low-risk IPMN. Mean surveillance duration was 35 (4–99) months. Thirty (12%) patients initially stratified as low-risk developed a new indication for pancreatic resection. Only 28 underwent resection, and pathologic tissue analysis revealed 27 (96%) low-grade IPMN and one (4%) high-grade dysplastic IPMN. Overall, two (1%) patients initially determined to be low-risk developed invasive cancer. Forty-eight (16%) patients stratified as high-risk IPMN were initially managed nonoperatively. Of the 13 (27%) high-risk patients that died during follow-up, two (15%) died from pancreatic cancer. Conclusions Progression to pancreatic cancer during surveillance for low-risk IPMN was rare. Current indications for resection did not forecast malignancy. Poor operative candidates with high-risk IPMN progressed to invasive cancer more commonly, though a substantial portion succumbed to non-IPMN-related death.

Trauma team performance, measured by the non-technical skills scale T-NOTECHS, has been shown to impact patient outcomes. We assess how personnel movements affect non-technical skills and time of resuscitation(TOR) using trauma video review. A prospective study of blunt and/or penetrating trauma activations recorded between May and November 2023 ​at a Level-I trauma center. Regressions controlling for confounders were used to measure the association between foot traffic and the outcomes of interest1: TOR2 T-NOTECHS score(Smith et al., 2015; Mackenzie et al., 2007; Maiga et al., 2024; Vella et al., 2024; Pucher et al., 2014; Dumas et al., 2020; Succar et al., 2024; Steinemann et al., 2012; Andersson et al., 2012; Conrad et al., 2010; Lies and Zhang, 2015) .5-155-15 We identified 77 trauma activations, with 40 ​%(n ​= ​32/77) penetrating injuries. There was a median of 17[14–18] individuals at the start of trauma activations. During resuscitations, individuals entered the room a median of 12[8–18] times and exited the room 17[11–22] times. The median TOR was 8[6–10] min and the median T-NOTECHS was 7[6–8]. Regression analysis showed foot traffic was independently associated with increased TOR(β 0.34, p-value <0.01) and worse total T-NOTECHS score(β 0.06, p ​< ​0.01). Higher foot traffic is associated with poorer team performance and delays in resuscitation. Future directions should further explore environmental and personal factors that may impede performance metrics. •Current impact of environmental factors on trauma activations is unknown.•The platform allows the assessment of environmental factors such as foot traffic.•Delays in resuscitation were seen with higher foot traffic in and out of the room.•Higher foot traffic was also linked with worse T-NOTECHS score.

PurposeAdverse events (AEs) during trauma resuscitation are common and heterogeneity in reporting limits comparisons between hospitals and systems. A recent modified Delphi study established a taxonomy of AEs that occur during trauma resuscitation. This tool was further refined to yield the Safety Threats and Adverse events in Trauma (STAT) taxonomy. The objective of this study was to evaluate the inter-rater reliability of the STAT taxonomy using in-situ simulation resuscitations.MethodsTwo reviewers utilized the STAT taxonomy to score 12 in-situ simulated trauma resuscitations. AEs were reported for each simulation and timestamped in the case of multiple occurrences of a single AE. Inter-rater reliability was assessed using Gwet’s AC1.ResultsThe agreement on all AEs between reviewers was 90.1% (973/1080). The Gwet’s AC1 across AE categories were: EMS handover (median 0.72, IQR [0.54, 0.82]), airway and breathing (median 0.91, IQR [0.60, 1.0]), circulation (median 0.91, IQR [0.72, 1.0]), assessment of injuries (median 0.80, IQR [0.24, 0.91]), management of injuries (median 1.00, IQR [1.00, 1.00]), procedure related (median 1.00, IQR [81, 1.00]), patient monitoring and IV access (median 1.00, IQR [1.00, 1.00]), disposition (median 1.00, IQR [1.00, 1.00]), team communication and dynamics (median 0.80, IQR [0.62, 1.00]).ConclusionsThe STAT taxonomy yielded 90.1% agreement and demonstrated excellent inter-rater reliability between reviewers in the in-situ simulation scenario. The STAT taxonomy may serve as a standardized evaluation tool of latent safety threats and adverse events in the trauma bay. Future work should focus on applying this tool to live trauma patients.