Article 1
Beyond Glasgow Coma Scale: Prehospital prediction of traumatic brain injury. Schuchut JE, Rakhit S, Smith MC, Han JH, Brown JB, Grigorian A, Gondek SP, Smith JW, Patel MB, Maiga AW. Surgery. 2025 Mar:179:108893.
The authors’ primary objective was to understand the limitations of prehospital identification of traumatic brain injury (TBI). Utilizing retrospective data from the Trauma Quality Improvement Program, they identified 1,687,336 adult trauma patients with a blunt mechanism of injury and requisite prehospital data. Out of the overall population, 35% had a mild TBI and 3.7% had a moderate or severe TBI. Using a prehospital GCS score of ≤12 to predict TBI resulted in a positive predictive value (PPV) of 75.6% and negative predictive value of (NPV) 64.7%. However, when limited to moderate or severe TBI these values changed to a PPV of 33.7% and NPV of 99.3%. Adjusting the prehospital prediction criteria to require a GCS ≤12, heart rate <65 bpm, and systolic blood pressure >150 mmHg improved the PPV for moderate or severe TBI to 55.3% and modestly decreased the NPV to 96.4%. The authors conclude that adding physiologic variables to the prehospital GCS allows for improved identification of TBI patients by filtering out those with an altered mental status due to shock.
On a larger scale, the study points to the difficulty of applying a tool outside of its intended use. While the GCS is a ubiquitous piece of neurologic assessments, it was developed in the intensive care unit to harmonize the communication between both the physicians and nurses. As such, one may presume that when Teasdale and Jennett did their seminal study, the patients had already undergone surgery to achieve hemorrhage control and had been resuscitated, thus obviating any effects of hemorrhagic shock on their GCS. The present study demonstrates that using the GCS score in the prehospital environment introduces additional confounding variables that need to be considered. Although the general trend of these results was likely already understood by most members of the trauma team, this serves as an important lesson as we consider what pre-hospital interventions to provide traumatically injured patients. If patients are entered into prehospital treatment protocols by GCS alone, we will be overtreating a significant portion of the patients. For low-risk interventions this may be acceptable, but as the risk of an intervention increases its use needs to be balanced against the low PPV of a prehospital GCS.
Article 2
Integrated vascular training may not prepare graduates to care for vascular trauma patients. Kundi R, Dhillon NK, Ley EJ, Scalea TM. J Trauma Acute Care Surg. 2025 Jan 1;98(1):42-47.
This is a review of 10 years’ worth (2013-2022) of ACGME case log data from integrated vascular (IV) and vascular fellowship (VF) program graduates. In it, the authors find that there was an unsurprising sharp increase in the proportion of IV graduates over the study period – 8.2% to 32.6%. IV chiefs logged more lower extremity cases and fewer upper extremity cases in their final year of training than VF, though the absolute numbers did not differ by much. More notably, despite a requirement for 18 months of “core surgical educational experience,” IV chiefs logged significantly more lower extremity cases and considerably fewer nonvascular open abdominal (5%), thoracic (18%), and neck (3%) cases than VF graduates. They also lacked critical care and nonoperative trauma experience as compared with general surgery-trained graduates. The authors conclude that this leaves IV graduates ill-prepared to care for injured patients.
This paper is certainly thought-provoking and brings up an issue familiar to many in trauma and general surgery. Its strengths include its use of a large longitudinal data set to assess trends over 10 years. The reliance on data from only the final year of training may skew the results – the authors mention the required 18 months of “core” surgical training for IV, but those 18 months likely do not overlap with the final year, thus we should not be surprised by the lack of nonvascular cases in that year. By the same token, it is curious that VFs are doing this many NONvascular cases in their final year. For example, they report an average of 59 nonvascular cases in this year, which seems high for a vascular fellow. Perhaps there is some difference in the way cases are being reported – potentially including the explanation proposed by the authors in another part of the paper, which is that IVs are only performing vascular repairs after exposure by another surgeon. An interesting follow up to this paper would be one that examines the differences between IV (+/- VFs) and general surgery (+/- trauma fellowship) graduates over time. One has to imagine, and it anecdotally seems to be the case, that there has been a commensurate decrease in vascular experience for general and trauma surgeons. This is briefly alluded to in the Discussion of the paper (another work is cited in which the proportion of vascular cases among general surgery chief residents declined from 30% to 12% over 20 years), but this might be the most urgent element of the issue for our trauma community.
Article 3
Geography of the Underserved: The Contribution of Rural Non-Trauma Hospitals to Trauma Care. Kaufman EJ, Prentice C, Williams D, Song J, Haddad DN, Brown JB, Chen X, Colling K, Chatterjee P. Ann Surg. 2024 Sep 18.
This is a cross-sectional study of 5 years’ worth (2016-2020) of the National Emergency Department Sample (NEDS) looking at the distribution of care for injured rural residents (n=748,587) among rural vs urban centers and trauma centers (TCs) vs non-trauma centers (NTCs). The authors found that about half of these patients were cared for in rural NTCs, 31% went to an urban TC, 16% an urban NTC, and 2% a rural TC. Notably, only 23 of the 3,601 hospitals in the study were rural TCs. While the majority of injuries treated at rural NTCs were moderate in severity (ISS 9-15), 15.7% were severe (ISS>15). Rural NTCs definitively managed the majority of the injuries they saw, transferring only 21.9%. Over 60,000 patients had an ISS>15, were seen at a rural NTC, and were NOT transferred.
The authors list several limitations, but these are minor and in general the results are striking – as the authors say, we may be underappreciating the role that rural NTCs play in the broader trauma system. We know that these hospitals are the most immediately available ones to a large portion of the US population, and while there has long been a priority placed on how to increase easy access to TCs, perhaps these rural NTCs are sufficient for the majority of injuries. Beyond this paper, it will be interesting to learn more about who stays at rural NTCs, who gets transferred to urban TCs, and what their outcomes are. Of the severely injured patients who remained at a rural NTC in this study, 35% were head-injured. Did they stay because there were capable neurosurgeons at the NTC? (The authors note that Kaufman et al have previously demonstrated a benefit to a TC even in this scenario). Did the patients that got transferred need interventions only available at a TC? Are their outcomes similar to patients with injuries of similar severity, that travel further to get to a TC in the first place? This paper appropriately suggests that rural NTCs have more value than we might have previously appreciated; it also generates further interesting questions on how best to manage patients who are injured in rural areas.
