Article 1
Prospective derivation and validation of a NECROtizing Soft tissue InfectionS (NECROSIS) score: An EAST multicenter trial. Kim DY, Iavasile A, Kaji AH, Nahmias J. et al. J trauma Acute Care Surg. 2024 May 9.
Necrotizing soft tissue infections (NSTIs) is a rare, albeit likely significantly under diagnosed, but devastating condition requiring prompt diagnosis and treatment. In this EAST multicenter trial, conducted across 16 U.S. medical centers over 2.5 years, the study aimed to address the limitations of existing diagnostic tools, such as the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, by developing a new clinical risk index: NECROSIS. The authors felt that the LRINEC score is an underperforming tool often criticized for its low sensitivity and reliance on laboratory data that may not be immediately available.
Among 362 patients evaluated, 297 (82%) were confirmed to have NSTIs, highlighting the high burden of these aggressive infections in the study population. The researchers identified three independent clinical predictors—systolic blood pressure ≤120 mmHg, violaceous skin discoloration, and a white blood cell count ≥15×10³/μL—that formed the basis of the NECROSIS score. This simple, three-point scale demonstrated strong predictive power, with each additional point increasing the likelihood of NSTI. For example, a score of 1 had a sensitivity of 92%, capturing most cases, while a score of 3 offered 100% specificity, confirming the diagnosis with little room for false positives. The NECROSIS score outperformed the widely used LRINEC score. In the validation cohort, NECROSIS achieved significantly higher sensitivity (92% compared to LRINEC’s 35%) and demonstrated consistent test characteristics, with an area under the ROC curve of 0.75, indicating robust predictive accuracy. Importantly, NECROSIS relies solely on clinical findings available at the bedside, reducing diagnostic delays and facilitating early surgical intervention, which is critical for these rapidly progressive infections.
By integrating simple yet highly predictive clinical markers, the NECROSIS score addresses the limitations of prior diagnostic tools and offers a practical solution for emergency general surgeons. This study not only validates its effectiveness but also highlights its potential to improve outcomes through early recognition and timely treatment of NSTIs. Future research will focus on external validation across diverse settings and exploring its integration with microbiologic and therapeutic data to refine its use further.
Article 2
Stop the Bleed-Wait for the Ambulance or Get in the Car and Drive? A Post Hoc Analysis of an EAST Multicenter Trial. Simpson JT, Nordham KD, Tatar A, et al. Am Surg. 2024 Sep 30:31348241265135.
The following study offers a thought-provoking analysis of prehospital transport methods for penetrating trauma in urban environments, challenging traditional reliance on emergency medical services (EMS). Using data from a prior EAST multicenter study, the authors evaluated outcomes for 1,999 patients with penetrating torso or proximal extremity trauma, comparing private vehicle transport (PVT) to EMS, including both basic life support (BLS) and advanced life support (ALS) modes. The findings suggest that PVT, a "scoop-and-run" approach, does not result in worse outcomes and may offer advantages, particularly in scenarios where rapid transport is critical.
Propensity-matched analyses revealed that PVT had comparable in-hospital mortality rates to EMS transport, despite the lack of prehospital interventions. Notably, ALS transport was associated with higher emergency department mortality compared to PVT (3.9% vs. 1.9%), emphasizing potential delays or unintended consequences of prehospital procedures. Secondary outcomes, including hospital length of stay, ICU-free days, and complications, were similar between PVT and EMS groups. Furthermore, logistic regression analysis suggested that PVT was associated with decreased odds of mortality compared to BLS transport, strengthening the case for its consideration in urban trauma systems.
The study underscores the potential of PVT to save time and conserve EMS resources, aligning with evolving practices such as police transport in some cities. Extending the role of bystanders to include transport, akin to their role in the Stop the Bleed campaign, may improve outcomes for urban penetrating trauma patients. However, logistical and ethical challenges, such as ensuring safe arrival at trauma centers, require careful planning. The findings challenge prehospital paradigms and advocate for integrating PVT into urban trauma care strategies, calling for further research to refine implementation and assess broader applicability.
