March 2025

This study, featuring contributions from past and present Penn faculty, retrospectively compared outcomes of trauma patients with grade IV or V duodenal and/or pancreatic injuries who underwent pancreaticoduodenectomy (PD) versus non-PD surgical management. They found that patients who underwent the Whipple procedure experienced significantly higher complication rates and longer lengths of stay without a clear survival benefit.

Summary:
Severe pancreaticoduodenal trauma is rare, accounting for less than 5% of penetrating traumas, yet it carries high morbidity (up to 87%) and mortality (13%–50%) due to frequent concomitant injuries. Previous studies suggest that primary repair with drainage may reduce duodenal leak rates and shorten hospital stays compared to more complex surgical reconstructions. The authors hypothesized that PD does not improve outcomes compared to non-PD surgical approaches for grade IV–V pancreaticoduodenal injuries.

This study included trauma patients aged 15 years and older who were treated for grade IV–V duodenal injuries and/or grade IV–V pancreatic injuries requiring surgical intervention at 35 Level 1 trauma centers from 2010 to 2020. Patients were identified via trauma registries and retrospective chart review. The cohort was divided into two groups: those who underwent PD (either single- or multi-stage) and those who received non-PD surgical management, which included primary repair alone (PRA), wide extraluminal drainage without repair, or complex repair with adjunctive measures other than PD (CRAM). Logistic regression analysis was used to assess the study’s primary outcomes, which included GI complications, length of stay, readmission, and mortality.

A total of 95 patients were identified, with 32 undergoing PD and 63 receiving non-PD surgical interventions. The majority of patients were male (82%), with a mean age of 25.5 years and a mean BMI of 24.4 kg/m². Most patients presented with normal systolic blood pressure (SBP) (median 120 mmHg, IQR 102–140), a normal Glasgow Coma Scale (GCS) score (median 15, IQR 13–15), and a high Injury Severity Score (median 26, IQR 17–34). Patients in the PD group had significantly higher rates of grade V duodenal injuries (50% vs. 19%, p=0.004) and grade V pancreatic injuries (66% vs. 22%, p<0.001) compared to those in the non-PD group.

Although duodenal leak rates (23%) and anastomotic leak rates (10%) were similar between both groups (p>0.05), PD patients experienced significantly higher rates of GI-related complications (69% vs. 44%, p=0.031), including intra-abdominal abscess, GI bleed, ileus, and enterocutaneous fistula. PD was also associated with significantly longer ICU stays (16.5 vs. 6 days, p=0.012) and hospital stays (33.5 vs. 24.5 days, p=0.017) compared to non-PD. However, there were no significant differences in mortality (12.5% PD vs. 23.8% non-PD, p=0.279) or 30-day readmission rates (31.3% PD vs. 27% non-PD, p=0.810).

Subgroup analysis of patients without ampullary injuries (n=60) showed that PD was more frequently performed in those with grade V pancreatic injuries, pancreatic head injuries, and concomitant pancreatic and duodenal injuries. However, these patients had significantly higher anastomotic leak rates compared to those managed with non-PD interventions (30% vs. 4%, p=0.028).

While this study is limited by its retrospective nature and lack of granularity in the setting of multi-institutional chart review, it is a large cohort study for a rare event. The retrospective nature of the study also limits the ability to control for all confounding variables that may have influenced surgical decision-making. Variability in practice patterns across different trauma centers, along with differences in surgeon experience and subspecialty training, could have contributed to disparities in patient outcomes. Lastly, despite using standardized AAST grading criteria, intraoperative interpretations of injury severity—particularly regarding "massive disruption of the pancreatic head"—may have varied among surgeons, introducing further variability into the study findings. 

Bottom Line:
Grade IV and V duodenal and pancreatic traumatic injuries can be managed with either PD or alternative surgical interventions, though trauma PD is associated with high morbidity, prolonged hospital stays, and increased GI-related complications without a clear survival benefit. These findings suggest that non-PD surgical approaches should be strongly considered in patients without ampullary involvement or with less severe injuries to minimize postoperative complications and improve recovery outcomes.

This retrospective database study evaluates the effectiveness of pre-hospital tourniquet application in pediatric trauma patients, comparing outcomes based on the provider type—Emergency Medical Services (EMS), first responders (FR), or bystanders. The findings demonstrate that tourniquet placement by all provider groups is highly effective, with early application before EMS arrival associated with improved patient acuity, low failure rates, and no significant differences in outcomes based on the provider.

Summary:
Tourniquet placement (TP) is a critical intervention for hemorrhage control, yet limited data exist on its use in pediatric patients. No prior studies have evaluated the outcomes of tourniquet application in a national pediatric cohort within the civilian setting. Using the National Emergency Medical Services Information System (NEMSIS) database from 2017 to 2020, this study analyzed 301 pediatric patients (ages 0–19) who received pre-hospital tourniquet application. The median patient age was 17 years, and 86.7% were male. Patients were categorized based on the timing of tourniquet application relative to EMS transport, with 187 tourniquets placed before EMS arrival and 105 after.

Tourniquet success rates were exceptionally high, with nearly all placements succeeding on the first attempt (100% pre-EMS vs. 98.7% post-EMS, p = 0.31). Patients who received a tourniquet before EMS arrival had significantly lower rates of critical acuity upon EMS arrival (18.1% vs. 36.6%, p = 0.002) and at emergency department (ED) arrival (21.0% vs. 35.2%, p < 0.0001). However, the degree of acuity improvement following tourniquet application did not significantly differ between groups (p = 0.22), with over half of all patients demonstrating improved acuity (52.1% pre-EMS vs. 62.8% post-EMS). Tourniquet failure rates were minimal, with only one patient in each group (0.7% vs. 1.28%) experiencing worsened acuity.

When stratified by provider type, no significant differences were observed in acuity improvement following tourniquet placement (p = 0.08), and all provider groups demonstrated high success rates, with nearly 100% of tourniquets successfully applied on the first attempt. Pre-EMS tourniquet application was associated with a decreased likelihood of presenting with critical acuity (OR 0.84, 95% CI 0.76–0.94, p = 0.003), whereas placement by bystanders or first responders after EMS arrival increased the odds of acuity improvement (OR 1.90, 95% CI 1.06–3.41, p = 0.03). Additionally, tourniquet failure was associated with decreased odds of acuity improvement (OR 0.62, 95% CI 0.44–0.86, p = 0.005).

Because the majority of patients in this study were older adolescents, future research should focus on younger children to refine best practices for tourniquet use in this population. Additionally, this study evaluates only pre-hospital and initial hospital arrival outcomes, and further prospective research is needed to assess the in-hospital and long-term effects of pre-hospital tourniquet application in pediatric trauma patients.

Bottom Line: These findings reinforce that pre-hospital tourniquet application in pediatric trauma patients is safe, effective, and associated with improved acuity at hospital arrival, particularly when applied before EMS transport. The significant improvement in patient condition with early application highlights the need for greater awareness and education on pediatric tourniquet use, especially among pre-hospital providers and caregivers. 

This retrospective study analyzes national transplant registry data to examine the prevalence and patterns of out-of-sequence (OOS) kidney allocation, assessing how frequently OOS allocations occur, which organ procurement organizations (OPOs) initiate them, which transplant centers receive them, and the characteristics of donors whose kidneys are placed OOS. The findings indicate that OOS allocation, originally intended to facilitate placement of hard-to-match kidneys, varies significantly among OPOs and disproportionately benefits certain transplant centers and patient demographics, raising concerns about potential disparities in access to transplantation.

Summary:
In March 2021, the Kidney Allocation System using a 250-nautical-mile radius between recovery and transplant hospitals (KAS250) was implemented as the new national, distance-based system for allocating deceased donor kidneys. Simultaneously, new OPO performance metrics were introduced, emphasizing the number of organs allocated and transplanted. Since then, placement times have increased, as has the number of centers OPOs must contact before a kidney is allocated. While organ allocation is typically determined by a combination of compatibility and waitlist time, OOS allocation occurs when a kidney is placed after bypassing higher-ranked candidates who were not offered the organ. Prior to KAS250, OOS allocation accounted for less than 3% of kidney placements, but by 2023, it had risen to nearly 20%. Despite this increase, the rate of kidney non-use has also risen.

This study utilized national Organ Procurement and Transplantation Network (OPTN) data from January 2022 to December 2023 to characterize the frequency and distribution of OOS allocations, the characteristics of donors and recipients, and the behaviors of the top five OPOs placing kidneys OOS, as well as the top five transplant centers receiving them.

During the study period, 4,977 OOS allocations occurred. Of these, 4.5% were placed immediately without any prior in-sequence offers. For 41.6% of OOS kidneys, between 11 and 100 in-sequence offers were declined before OOS placement, while 33% of OOS kidneys had more than 100 refusals before being placed. The study found that the top five OPOs each tended to allocate OOS kidneys to a distinct, small group of transplant centers. High-volume transplant centers were more likely to receive OOS kidneys, with the top 11 centers by volume performing 21.6% of their transplants using OOS kidneys, while small-volume centers (<50 transplants per year) used OOS kidneys only 4.3% of the time. The center performing the most OOS transplants conducted 297 OOS kidney transplants, comprising 43.5% of its total deceased donor kidney volume. Additionally, 92.3% of OOS kidney transplants occurred at centers that bypassed a median of 13 candidates from their own waitlist.

Comparing kidneys allocated in sequence versus those placed OOS, OOS kidney donors were older, more likely to be classified as donation after circulatory death (DCD), and more likely to have hypertension and diabetes. They also had higher terminal creatinine levels and were more frequently classified as high-risk (Kidney Donor Profile Index >85%). Recipients of OOS kidneys had shorter waiting times compared to standard allocation recipients (258 days vs. 411 days), were older (median age 61 vs. 55 years), and were less likely to be female (34.1% vs. 40.8%). OOS kidneys were also less frequently transplanted into Black and Hispanic recipients compared to standard allocation kidneys. The odds of receiving an OOS kidney rather than being bypassed were higher for females and significantly higher for Hispanic (OR 1.3) and Asian (OR 1.78) candidates compared to White candidates.

This study is not without limitations. The available data do not consistently record whether OOS allocation was attempted for kidneys that were ultimately not transplanted, making it difficult to assess whether OOS placement reduces kidney non-use. Furthermore, the study cannot fully account for the clinical decision-making processes that lead to OOS placements, such as the urgency of transplant need, logistical considerations, or center-specific practices.

Bottom Line:
OOS allocation has increased from less than 3% before KAS250 to nearly 20% and is now widely utilized by OPOs. This shift may reflect OPO efforts to meet new Center for Medicare and Medicaid Services (CMS) performance metrics, but it may also be a response to the logistical complexities introduced by KAS250. While OOS allocation may serve a practical role in placing hard-to-match kidneys, concerns have been raised by professional societies and media reports regarding its potential to introduce inequities in transplant access. The lack of standardized oversight and regulation in OOS allocation has created opportunities for disparities, highlighting the need for a more transparent and equitable allocation framework.

This single-center cohort analysis examined healthcare utilization and revenue generation among trauma patients before and after implementing a multidisciplinary, coordinated post-trauma care program—the Center for Trauma Survivorship (CTS). The study argues that such programs improve patient follow-up and continuity of care while increasing hospital revenue and profitability.

Summary:
Significant advancements in acute trauma care have led to improved survival rates, resulting in a growing number of patients living with long-term, life-altering injuries. As a result, there is increasing recognition of the importance of post-acute care for trauma patients, particularly through multidisciplinary care teams that address both medical and psychosocial recovery.

This study conducted a cohort analysis comparing healthcare utilization and financial outcomes before and after the implementation of the CTS program. The CTS team included a nurse practitioner, nurse liaison, social worker, and patient navigator, with access to a psychiatrist and trauma surgeon as needed. The study focused on adult trauma patients with severe injuries, defined as those with an Injury Severity Score (ISS) of 16 or greater or requiring an ICU stay of at least two days. Financial data were obtained from the hospital’s billing and accounting system. The analysis included 176 patients treated in the year before CTS implementation (PRE cohort) and 256 patients treated in the year after CTS implementation (CTS cohort).

The findings revealed a significant increase in post-discharge care for patients in the CTS cohort. Outpatient visits more than doubled, with 1,623 visits in the CTS group compared to 748 in the pre-CTS group. Follow-up surgeries increased nearly fourfold (98 vs. 26 procedures), with the largest increases seen in surgical clinic visits (+404%) and rehabilitation services (+291%). Additionally, the proportion of patients discharged to acute rehabilitation rose from 32% in the pre-CTS group to 50% in the CTS cohort, suggesting improved continuity of care. From a financial perspective, CTS patients generated an additional $7,752 in net revenue per patient and $4,558 more in contribution margin compared to those in the pre-CTS cohort.

Despite its compelling findings, the study has several limitations. Without a randomized controlled trial, it is difficult to establish a direct causal relationship between CTS implementation and improved outcomes. The study lacks methodological rigor in that it does not control for confounding variables or include a time-series analysis, which limits the reliability of the conclusions. Additionally, patient-reported outcomes and quality-of-life measures were not assessed beyond clinic visits and follow-up surgeries, providing an incomplete picture of the program’s overall impact. While increased outpatient visits suggest improved access to care, it remains unclear whether these additional services directly translated to better long-term recovery.

Bottom line:
This study adds to the growing body of evidence supporting post-discharge care as a priority for trauma centers and hospital systems. Coordinated care models not only enhance patient access to essential follow-up services but also improve hospital financial performance. These findings highlight the potential benefits of multidisciplinary trauma recovery programs for both patients and healthcare institutions.