Prevalence and predictors of surgical intervention in trauma patients activated by the American College of Surgeons Committee on Trauma guidelines

Study objectives: We determine the frequency in which trauma activations were associated with operative management by a trauma surgeon and whether currently used American College of Surgeons Committee on Trauma (ACS-COT) guidelines of out-of-hospital variables could predict such findings to help better prioritize the urgency of trauma surgeon presence during trauma activations. Methods: This was a retrospective analysis of a prospectively recorded trauma registry of all trauma activations from January 1, 1997, to December 31, 2002. Univariate analyses of out-of-hospital variables recorded in the trauma registry were evaluated in a university-based Level I trauma center serving a region of approximately 3 million people, with an annual emergency department census of 53,000 patients. All trauma activations were analyzed to determine whether operative management was performed. Subjects were then subdivided into 3 groups, defined as emergency (operative management 1 to 4 hours). In all cases, the surgical specialist and disposition were noted. Out-of-hospital variables were evaluated to determine predictive values of emergency and urgent surgical intervention. Results: There were 5,001 trauma activations during the study period. Thirty percent went to the operating room, with 4% emergency, 8% urgent, and 18% semiurgent. Orthopedics performed operative management on 37% of all cases, followed by general surgery at 32%. For emergency cases, general surgery performed operative management on 69%, followed by neurosurgery on 11%. For urgent cases, general surgery performed operative management on 38% and neurosurgery on 25%. For semiurgent cases, orthopedics took 53%, and general surgery took 22%. Predictors of emergency operative management include systolic blood pressure less than 90 mm Hg (RR 3.00; 95% confidence interval [CI] 2.0 to 4.4 mm Hg); penetrating trauma (RR 8.0; 95% CI 6.1 to 10.6), and blunt trauma (RR 0.12; 95% CI 0.09 to 0.17). Predictors of urgent operative management include penetrating trauma (RR 2.30; 95% CI 1.88 to 2.82). Variables not correlated with operative management were pulse rate, respiratory rate, Glasgow Coma Scale score, blunt trauma, and age. Conclusion: Although eventual operative management of trauma activations is common, emergency operative management occurred in only 4% of patients. Predictors of emergency operative management were systolic blood pressure less than 90 mm Hg and penetrating trauma. Currently accepted ACS-COT trauma guidelines of out-of-hospital variables poorly predicted the need for emergency, urgent, and semiurgent operative management. Upcoming further multivariate and classification and regression tree analysis is necessary to better classify trauma patients into various risk categories for any urgent surgical intervention.