J Trauma Acute Care Surg [JOURNAL]
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200 papers
Response to a Letter to the Editor "interpreting prophylactic antibiotic use in closed basilar skull fractures: Caution in claims-based evidence".
Kim E, Sunwoo W
J Trauma Acute Care Surg · 2026 Jul · PMID 42397755 · Publisher ↗
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The impact of fathers and male role models on recovery and resilience in pediatric victims of violent trauma.
Lang KJ, Seewer EC, Williams RF … +1 more , Lin S
J Trauma Acute Care Surg · 2026 Jul · PMID 42390557 · Publisher ↗
BACKGROUND: Despite the growing awareness of social determinants of health in pediatric trauma care, the influence of fathers and male caregivers on recovery following violent injury remains underexplored. Understanding...
BACKGROUND: Despite the growing awareness of social determinants of health in pediatric trauma care, the influence of fathers and male caregivers on recovery following violent injury remains underexplored. Understanding this potential protective factor is essential to developing wraparound service models and resilience-building strategies for high-risk youth. METHODS: We conducted a retrospective cohort analysis of a prospectively maintained database of patients aged 0 to 17 enrolled in a hospital-based violence intervention program at an ACS-verified Level I pediatric trauma center. Eligible patients sustained violent injuries, including gunshot wounds, assaults, or stabbings, and received longitudinal case management over 6 to 12 months. Demographic, household, and social data were collected, with specific attention to caregiver composition. Outcomes included school enrollment, violent reinjury, juvenile court involvement, safety assessments, and resilience scores from Coping Orientation to Problems Experienced (COPE). Comparative analyses were performed based on the presence or absence of a father or male caregiver in the home. RESULTS: Among 227 patients enrolled over 3 years, only 31 (14%) had a father present, and 36 (16%) had any male caregiver. Mothers were present in 89% of households. Mean age was 15 years (IQR: 11-16); 67% were male, and 65% were gunshot wound victims. No significant differences were found in baseline social determinants or postdischarge safety concerns. Children with fathers demonstrated higher Coping Orientation to Problems Experienced resilience scores and showed a greater likelihood of accepting emotional support, engaging in prayer or meditation, and finding comfort in spiritual beliefs (all p<0.05). School enrollment postprogram was higher among those with fathers (100% vs. 82%, p=0.016) and was associated with fewer juvenile adjudications (p=0.002). CONCLUSIONS: Few violently injured children have a father or male caregiver present. The presence of male caregivers was associated with improved school engagement and psychological resilience following violent trauma, emphasizing the importance of male involvement in recovery and possibly prevention efforts. (J Trauma Acute Care Surg. 2026;101: 233-240. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.
Peptidyl arginine deiminase 2 (PAD2) inhibition is associated with acute and long-term benefits in a murine model of traumatic brain injury.
Dawood ZS, Jang A, Mei H … +10 more , Liggett MR, Wang B, Barasa L, Thompson PR, Couchenour DC, Anand A, Chtraklin K, Liu B, Li Y, Alam HB
J Trauma Acute Care Surg · 2026 Jul · PMID 42390438 · Publisher ↗
BACKGROUND: Traumatic brain injury (TBI) is a major contributor to trauma-related deaths and disability worldwide. Management of TBI is currently limited to supportive care. We have previously shown that global knockout...
BACKGROUND: Traumatic brain injury (TBI) is a major contributor to trauma-related deaths and disability worldwide. Management of TBI is currently limited to supportive care. We have previously shown that global knockout of PAD2 confers neuroprotection, but its therapeutic potential was unclear. This study was designed to test the hypothesis that selective inhibition of PAD2 following TBI would improve neurological outcomes. METHODS: Male mice (c57bl6/j, 11-14 wk) were subjected to controlled cortical impact-induced TBI, and 5 to 10 minutes later, randomly given either PAD2 inhibitor ("loading dose" 60 mg/kg AFM41a dissolved in dimethyl sulfoxide (DMSO) or vehicle (DMSO), (n=6/group). One day post-TBI, frozen brain sections were Nissl-stained to determine lesion size. In a separate experiment, the long-term impact of AFM41a treatment on motor, sensory, and cognitive recovery after TBI was evaluated. In addition to the loading dose, animals received a "maintenance dose" of 30 mg/kg of AFM41a or vehicle on postinjury days (PIDs) 2 to 5. Neurologic Severity Scores (NSS on PIDs 1-8) and visuospatial learning via Morris water maze test (MWM on PIDs 21-30) were assessed. RESULTS: Mice treated with AFM41a had significantly smaller lesion sizes compared with the control group (p<0.05). Treatment with AFM41a also increased the rate of sensory and motor recovery, as evidenced by reduced NSS on PIDs 1 to 5 (p<0.05), and improved visuospatial learning and memory as shown by MWM (p<0.05). CONCLUSIONS: PAD 2 is a promising therapeutic target in TBI, and its inhibition with AFM41a, a first-in-class PAD2-selective inhibitor, confers early neuroprotection as well as sustained cognitive benefits.
CT-first resuscitation for severe blunt trauma: A propensity score-matched cohort study.
Matsumoto S, Senoo S, Aoki M … +2 more , Funabiki T, Shimizu M
J Trauma Acute Care Surg · 2026 Jul · PMID 42385208 · Publisher ↗
BACKGROUND: In unstable blunt trauma, whole-body computed tomography (WBCT) is often deferred because the bleeding source is uncertain, potentially delaying definitive hemorrhage control. This retrospective cohort study...
BACKGROUND: In unstable blunt trauma, whole-body computed tomography (WBCT) is often deferred because the bleeding source is uncertain, potentially delaying definitive hemorrhage control. This retrospective cohort study assessed whether CT-first resuscitation (CTFR)-immediate WBCT in a CT-equipped trauma resuscitation room with prespecified triggers for hemorrhage control-is associated with transfusion, time to hemostatic intervention, and mortality after blunt trauma. METHODS: We conducted a retrospective cohort study (2019-2023) comparing adults managed with CTFR at a single center with patients in the Japan Trauma Data Bank, a national trauma registry. We performed 1:1 propensity score matching (n = 248 per group). The primary outcome was 24-hour red blood cell (RBC) units; secondary outcomes were time to CT initiation, time to first hemostatic intervention (surgical or endovascular), and in-hospital mortality. Sensitivity analyses used multiple imputation. RESULTS: CTFR shortened the time to CT initiation (median, 0.4 vs. 29.0 min; p<0.001) and time to first hemostatic intervention (median, 53.7 vs. 134.0 min; p<0.001). Any RBC transfusion within 24 hours was similar (29.4% vs. 30.6%; p = 0.845). Adjusted 24-hour RBC units were lower with CTFR (mean difference, -0.84 units; 95% CI: -1.65 to -0.03; p = 0.043). In-hospital mortality was similar (9.7% vs. 8.9%; p=0.877). In an exploratory subgroup of patients presenting with shock, CTFR was associated with a larger reduction in 24-hour RBC units (adjusted mean difference, -3.76 units; 95% CI: -6.44 to -1.09; p = 0.006). CONCLUSIONS: In a matched comparison with a national registry cohort, CTFR was associated with earlier WBCT, shorter time to hemostatic intervention, and modestly lower adjusted 24-hour RBC transfusion requirements, while mortality was similar. These associations appeared more pronounced among patients presenting with shock in exploratory subgroup analyses. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
The intravenous targeted nanopeptide, CAQK, is neuroprotective and improves motor function after spinal cord injury in rats.
Castillo JA, Uppuluri J, Le M … +13 more , Tran T, Pivetti C, Huang KW, Vatoofy S, Ratcliff A, Dangan A, Bannerman S, Lee M, Shahin M, Loll E, Clark K, Wang A, Russo R
J Trauma Acute Care Surg · 2026 Jun · PMID 42378652 · Publisher ↗
BACKGROUND: CAQK is a homing peptide that targets sites of central nervous system injury and has previously demonstrated functional benefits in traumatic brain injury models. We recently demonstrated its localization to...
BACKGROUND: CAQK is a homing peptide that targets sites of central nervous system injury and has previously demonstrated functional benefits in traumatic brain injury models. We recently demonstrated its localization to spinal cord injury (SCI) after intravenous administration and hypothesized that it could enhance motor recovery after SCI. METHODS: Twelve female Sprague-Dawley rats underwent C5 right-sided spinal cord hemicontusion. Animals were randomized to receive intravenous CAQK (2.5 mg/kg) or saline daily for 7 days, beginning 1 hour postinjury. Motor performance was assessed using the Irvine, Beatties, and Bresnahan (IBB) Forelimb Recovery Scale, a scale from 0 to 9, with 9 being normal function. IBB score was assessed at five time points over 8 weeks, followed by histological analysis. An in vitro neuroprotection assay was also conducted to evaluate the neuroprotective effects of CAQK at various doses. RESULTS: All animals exhibited motor deficits immediately after injury. Compared with saline controls, CAQK-treated rats demonstrated significantly improved motor recovery at 1, 2, 5, and 8 weeks postinjury (week 8: IBB = 7 vs. 3; p = 0.01). Histologic analysis showed significantly reduced astroglial activation in the CAQK group (GFAP: treated = 0.1±0.01 vs. untreated = 0.7±0.2; p = 0.002) and increased axonal preservation (NFM: treated = 0.3±0.06 vs. untreated = 0.1±0.06; p = 0.03). In vitro, CAQK significantly enhanced neuronal network complexity compared with saline (p < 0.05). CONCLUSIONS: CAQK treatment significantly improved motor outcomes compared with saline-only treatment. Ex vivo analysis of spinal cord tissue showed enhanced tissue recovery in CAQK-treated rats. In vitro, neuroprotection was evident in cells treated with CAQK. Overall, these findings support CAQK's potential as a targeted therapeutic candidate for SCI. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). STUDY TYPE: Basic Science.
Authors' reply to the Letter to the Editor on "Use of extracorporeal membrane oxygenation in traumatic injuries with acute respiratory distress syndrome: A systematic review and meta-analysis".
Akbarpoor F, da Nobrega Oliveira REN
J Trauma Acute Care Surg · 2026 Jun · PMID 42371736 · Publisher ↗
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Characteristics and time course of postconcussive symptoms in children and adolescents with moderate to severe extracranial trauma with and without mild traumatic brain injury.
Biffl SE, Biffl WL, Ignacio RC … +12 more , Castelo MR, Burch A, Gorra A, Schoonover B, Cohen P, Rivera N, Hightower T, Wattsman TA, Wilkes W, Fox N, Goldsmith A, Askegard J
J Trauma Acute Care Surg · 2026 Jun · PMID 42371732 · Publisher ↗
BACKGROUND: Mild traumatic brain injury (mTBI), including concussion, is common and has received a great deal of attention, but terminology and diagnosis can be confusing. Postconcussive symptoms (PCS) are well-described...
BACKGROUND: Mild traumatic brain injury (mTBI), including concussion, is common and has received a great deal of attention, but terminology and diagnosis can be confusing. Postconcussive symptoms (PCS) are well-described in the setting of concussion and isolated mTBI, but the individual symptoms are nonspecific and may be present in patients with extracranial injuries without TBI. The time course of PCS has not been well-characterized in patients with extracranial trauma, either with or without concomitant mTBI. We hypothesized that patients with mTBI with moderate/severe extracranial trauma would experience a unique, more severe and longer-lasting pattern of PCS with more negative impact on quality of life (QOL) when compared with similar trauma patients without mTBI. METHODS: Prospective multicenter study (2018-2024) of patients aged 5 to 17 with extracranial Injury Severity Score >8, excluding moderate/severe TBI. Patients with and without mTBI (GCS 13-15, alteration of mental status or other signs/symptoms of TBI) were included. Patients were assessed at 1 week, 3 weeks, and 3 months with the Rivermead PCS Inventory and PedsQL QOL assessments. RESULTS: One hundred thirty-four patients were included: 53 (40%) had mTBI. Adolescent mTBI patients had significantly higher PCS Inventory scores than non-mTBI adolescents at T1 and T2. Symptoms persisted in >25% of both groups at T3. The QOL was impacted by the PCS burden. CONCLUSIONS: Although attrition compromised the statistical power of the study, many patients with moderate/severe extracranial trauma have a significant PCS burden at 3 months postinjury. Those with mTBI have a greater symptom burden and unique symptomatology compared with those without mTBI. Attention to diagnosis and treatment of mTBI and support and anticipatory guidance for all pediatric moderate/severe trauma patients is warranted. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
CONVERT: Civilian outcomes of emergency department tourniquet conversion.
Fox AL, Stuart M, Clemens M … +1 more , Callaway DW
J Trauma Acute Care Surg · 2026 Jun · PMID 42371668 · Publisher ↗
BACKGROUND: Tourniquet conversion (TC) involves the removal of a tourniquet with the achievement of hemostasis using wound packing, hemostatic dressings, and/or pressure bandages as a less invasive method of hemorrhage c...
BACKGROUND: Tourniquet conversion (TC) involves the removal of a tourniquet with the achievement of hemostasis using wound packing, hemostatic dressings, and/or pressure bandages as a less invasive method of hemorrhage control. TC is routinely performed in emergency departments to reduce ischemic complications associated with prolonged tourniquet use. Despite increasing civilian prehospital tourniquet application, empirical data guiding TC remain limited, and existing protocols rely largely on expert opinion. METHODS: We conducted a retrospective cohort study of trauma patients presenting with prehospital-applied extremity tourniquets to a Level I trauma center between March 2021 and December 2024. TC was defined as the removal of a tourniquet with replacement by wound packing, hemostatic dressings, and/or pressure bandages. Outcomes were categorized as successful conversion, procedural intervention, or operative intervention. Secondary outcomes included injury-related complications, attribution of complications to tourniquet use, and factors associated with delayed or failed conversion. Multivariable logistic regression was used to identify predictors of successful conversion. RESULTS: Among 647 patients, 543 (83.9%) underwent successful TC in the emergency department without procedural or operative intervention. Median tourniquet duration was 40 minutes (interquartile range, 30-59). Sixty patients (9.3%) experienced injury-related complications, with none attributed to tourniquet use. Complications were more common in patients requiring operative intervention compared with those successfully converted (44.4% vs. 4.6%). Increasing tourniquet duration was independently associated with decreased odds of successful conversion per 30-minute interval [odds ratio (OR), 0.41; 95% CI, 0.32-0.53]. Upper extremity tourniquets were less likely to be successfully converted than lower extremity tourniquets (OR, 0.61; 95% CI, 0.38-0.97). CONCLUSIONS: TC in the emergency department is successful for most patients with prehospital-applied tourniquets. Complications appear primarily related to the inciting injury rather than tourniquet use, particularly when the duration is under 2 hours. These findings support existing conversion protocols and highlight the importance of timely reassessment to minimize duration-associated complications. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.
Relative Superiority: A framework for military and civilian trauma care based on special operations warfare.
Singh K, Dion PM, Tulloch V … +1 more , Beckett A
J Trauma Acute Care Surg · 2026 Jun · PMID 42371409 · Publisher ↗
The foundational principles in trauma care align with the operational strategies of Special Forces. Here we present a novel perspective on trauma care drawn from the book "Spec Ops-Case Studies in Special Operations Warf...
The foundational principles in trauma care align with the operational strategies of Special Forces. Here we present a novel perspective on trauma care drawn from the book "Spec Ops-Case Studies in Special Operations Warfare: Theory and Practice" (1995) by Admiral (Ret'd) William H. McRaven. The book introduces the concept of Relative Superiority (RS), defined as a point in time when a smaller, well-trained, and well-prepared force gains a decisive advantage over a larger adversary. Achieving and maintaining RS requires precise timing and coordinated action. As time progresses, the opportunity to gain or retain this advantage diminishes. In trauma care, RS can be compared with the critical window for achieving hemorrhage control, timely resuscitation, and rapid transition to damage control surgery. Delays in these interventions decrease survival probability. If hemorrhage control is achieved but not sustained, re-establishing it becomes increasingly difficult and often fatal. This framework is illustrated through two trauma case studies. In Case Study I, timely interventions result in sustained control and survival. In Case Study II, delays led to only temporary control, which is subsequently lost, contributing to patient death. Within the RS framework, rapid surgical access can shift the advantage by attenuating hemorrhage and mitigating shock; however, speed alone does not guarantee survival. Achieving and maintaining RS requires sustained hemostasis, access to resources, and delivery of high-quality care. Applying the RS framework to trauma care offers a structured approach to evaluating the timing and effectiveness of interventions during critical phases of care. Its integration into Morbidity and Mortality discussions may help identify missed opportunities, guide performance improvement, and inform system-level changes. This conceptual model may support trauma teams in understanding how small gains at key moments influence overall outcomes in high-acuity clinical scenarios.
A novel approach to blood supply in the era of large-scale combat operations.
Hazen BJ, Staak BP, Holcomb JB
J Trauma Acute Care Surg · 2026 Jun · PMID 42360887 · Publisher ↗
Future large-scale combat operations (LSCOs) against a near-peer adversary are projected to generate casualty volumes far exceeding those experienced during the Global War on Terror. Estimates range from 800 to 3,600 US...
Future large-scale combat operations (LSCOs) against a near-peer adversary are projected to generate casualty volumes far exceeding those experienced during the Global War on Terror. Estimates range from 800 to 3,600 US casualties per day, potentially overwhelming a military medical system optimized for counterinsurgency warfare with rapid evacuation and limited daily losses. Hemorrhage remains the leading cause of preventable battlefield death, and blood is the cornerstone of combat casualty care. Although the military blood system advanced significantly during the Iraq and Afghanistan conflicts, it was not designed for sustained, high-volume attrition warfare. The Global War on Terror data provides critical insight. Of ∼53,000 wounded service members over two decades, roughly 20% received blood transfusions, leaving nearly 42,500 wounded who did not require transfusions. Extrapolated to a projected 72,000-casualty LSCO scenario, ∼57,500 individuals would constitute a "walking wounded" population-hemodynamically stable casualties who could represent a substantial, immediately available donor pool. We propose institutionalizing a structured "Walking Wounded Blood Bank," in which eligible, stable casualties donate blood before evacuation. In addition, integrating blood donation into routine redeployment processing could further augment supply during protracted conflict. In contrast, harvesting blood from the deceased is biologically unsound, ethically problematic, and mathematically negligible as a scalable solution. Preparation for LSCO requires confronting the arithmetic of mass casualties. Leveraging the walking wounded and redeploying forces as structured donor populations offers a pragmatic, ethical, and operationally feasible strategy to expand transfusion capacity before demand exceeds supply.
The role of shock index, pediatric age-adjusted, in early identification and management of hemorrhagic shock in pediatric trauma.
Adejumo FF, Ledford C, Cook N … +3 more , Schauer S, Greenwald E, Piehl M
J Trauma Acute Care Surg · 2026 Jun · PMID 42360868 · Publisher ↗
BACKGROUND: Hemorrhagic shock is a leading cause of preventable pediatric trauma death, with hypotension representing a late, decompensated stage associated with high mortality. This study evaluates the shock index, pedi...
BACKGROUND: Hemorrhagic shock is a leading cause of preventable pediatric trauma death, with hypotension representing a late, decompensated stage associated with high mortality. This study evaluates the shock index, pediatric age-adjusted (SIPA), as an early marker of compensated shock and a potential trigger for timely transfusion in pediatric trauma. METHODS: Retrospective cohort study in a large community hospital system (310,000 annual emergency visits) of all pediatric (age <18 y) Level 1 trauma activations admitted from January 2017 through December 2023. Generalized linear models assessed the adjusted relationship between the initial vital signs and hospital outcomes. The Cox proportional hazard model assessed the effect of SIPA on time to blood transfusion. RESULTS: Among 601 pediatric trauma patients, the median age was 12.2 years; 68.7% were male, 41.3% black, and 35.1% white. Over half of all deaths (50.7%) occurred in the emergency department (ED). Mortality was significantly higher among patients with hypotension on ED arrival (54.4% vs. 1.5%, p < 0.01). ED hypotension [adjusted odds ratio (aOR), 3.93; 95% CI, 1.05-14.73] and ED transfusion (aOR, 5.51; 95% CI, 2.11-14.36) independently predicted mortality. Although patients with initial ED hypotension had a shorter time to blood transfusion [3.3 vs. 15.5 h; hazard ratio, 1.53 (95% CI, 0.87-2.72); p = 0.14], hypotension in the ED remained a strong predictor of death. On the contrary, patients with an elevated SIPA experienced an 82% increase in time to blood transfusion initiation {4.5 vs. 17.8 h; p = 0.04; [hazard ratio, 1.82 (95% CI, 1.14-2.90), p = 0.01]} and a reduction in hospital mortality [aOR, 0.42 (95% CI, 0.22-0.81), p = 0.01]. CONCLUSIONS: This finding supports the integration of SIPA into pediatric trauma resuscitation protocols to enhance early recognition and treatment of hemorrhagic shock. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III. STUDY TYPE: Observational Cohort Study.
To pack or plug: AAST multicenter evaluation of hemorrhage control interventions in pelvic fracture management: Erratum.
J Trauma Acute Care Surg · 2026 Jul · PMID 42335394 · Publisher ↗
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Polyphosphate-based hemostatic gauze preserves distal perfusion compared with QuikClot Combat Gauze in a porcine extremity trauma model with hemorrhagic shock.
Wippel D, Heidler J, Gratl A … +8 more , Lobenwein D, Gaeth C, Hinck D, Kluckner M, Abram J, Spraider P, Martini J, Wipper S
J Trauma Acute Care Surg · 2026 Jul · PMID 42335393 · Publisher ↗
BACKGROUND: Uncontrolled hemorrhage remains the leading preventable cause of death after trauma. Current prehospital strategies emphasize rapid bleeding control, yet benchmark kaolin-based dressings may impair distal per...
BACKGROUND: Uncontrolled hemorrhage remains the leading preventable cause of death after trauma. Current prehospital strategies emphasize rapid bleeding control, yet benchmark kaolin-based dressings may impair distal perfusion through intraluminal thrombosis. Polyphosphate (PolyP)-based dressings could offer effective hemostasis while maintaining arterial flow. METHODS: In a prospective, randomized, controlled large-animal extremity trauma model with hemorrhagic shock, PolyP gauze was compared with kaolin-based Combat Gauze (CG) under a standardized compression and resuscitation protocol. Primary endpoints were survival time and survival proportion; secondary endpoints included distal femoral flow, blood loss, hemodynamics, metabolic status, and coagulation. Outcome assessment was investigator blinded. RESULTS: Baseline characteristics were comparable between groups (n = 11 per group). Survival at 120 minutes (PolyP 90.9% vs. CG 81.8%) and total blood loss (1,780 ± 219 vs. 1,847 ± 484 mL, p = 0.72) did not differ significantly. First-pass hemostasis was achieved in 63.6% of PolyP- and 81.8% of CG-treated animals (p = 0.64). In contrast, distal pulsatile femoral flow was restored in 90.9% of PolyP-treated animals compared with 27.3% after CG (p = 0.0075). Hemodynamics, metabolic markers (lactate, base excess, pH, hemoglobin), and systemic coagulation assays (prothrombin time, fibrinogen, activated partial thromboplastin time) evolved similarly across groups. CONCLUSION: In this swine extremity trauma model with shock, PolyP gauze provided hemostasis equivalent to the current benchmark while significantly improving distal arterial perfusion. These findings support expanding performance benchmarks for prehospital hemostatic dressings to include downstream perfusion and justify further translational and field evaluation. (J Trauma Acute Care Surg. 2026;101: 129-135. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
Antibiotic use in emergency general surgery: What you need to know.
Krebs ED, Sawyer RG
J Trauma Acute Care Surg · 2026 Jul · PMID 42335392 · Publisher ↗
Antimicrobials are among the classes of pharmaceuticals most used by acute care surgeons, with many emergency general surgery conditions either related to infections or at high risk of infectious complications. As such,...
Antimicrobials are among the classes of pharmaceuticals most used by acute care surgeons, with many emergency general surgery conditions either related to infections or at high risk of infectious complications. As such, knowledge of proper use of antimicrobial agents, especially in this era of increasing antimicrobial resistance, is imperative for optimal outcomes. This review focuses on the advanced infectious diseases and antimicrobial utilization knowledge required to treat complicated and critically ill surgical patients. Overall concepts pertaining to antibiotics are discussed, followed by a more in-depth discussion of conditions common in emergency general surgery. Key themes include the importance of source control and accurate culture data, the frequent need for broad-spectrum, empiric antimicrobial therapy, subsequent careful de-escalation of antibiotics, and minimizing treatment duration. (J Trauma Acute Care Surg. 2026;101: 13-27. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).
Invited commentary: Reconciling the academic mission with workforce reality in acute care surgery.
Rotondo MF
J Trauma Acute Care Surg · 2026 Jun · PMID 42335315 · Publisher ↗
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Association between the fresh frozen plasma-to-red blood cell ratio and mortality in pediatric severe trauma.
Utsumi S, Ohki S, Ishii J … +1 more , Shime N
J Trauma Acute Care Surg · 2026 Jun · PMID 42335301 · Publisher ↗
BACKGROUND: The optimal fresh frozen plasma (FFP)-to-red blood cell (RBC) ratio in pediatric severe trauma has not yet been established. We investigated the association between the FFP-to-RBC transfusion ratio and clinic...
BACKGROUND: The optimal fresh frozen plasma (FFP)-to-red blood cell (RBC) ratio in pediatric severe trauma has not yet been established. We investigated the association between the FFP-to-RBC transfusion ratio and clinical outcomes in pediatric severe trauma, aiming to identify an optimal threshold. METHODS: This multicenter, retrospective, observational study uses data from the Japan Trauma Data Bank from 2019 to 2023. The study included pediatric patients aged below 18 years with severe trauma (injury severity score >15). Patients were categorized into a high-FFP group (FFP-to-RBC ratio ≥1) and a low-FFP group (ratio of <1). The primary outcome was in-hospital mortality. Inverse probability of treatment weighting based on propensity scores was used to balance patient characteristics. Restricted cubic spline analysis was applied to evaluate the linearity and dose-response effects of the FFP-to-RBC ratio on in-hospital mortality. A weighted mixed-effects logistic regression model accounting for intrahospital clustering was used as a sensitivity analysis. RESULTS: A total of 336 patients were included, with 284 assigned to the high-FFP group. Weighted logistic regression analysis using inverse probability of treatment weighting demonstrated significantly lower in-hospital mortality in the high-FFP group (adjusted odds ratio, 0.47; 95% confidence interval, 0.28-0.78). The restricted cubic spline curve indicated a nonsignificant trend in which in-hospital mortality decreased progressively as the FFP-to-RBC ratio increased. Sensitivity analysis attenuated the association to nonsignificance (adjusted odds ratio, 0.67; 95% confidence interval, 0.29-1.53). CONCLUSIONS: A higher FFP-to-RBC ratio was associated with significantly lower in-hospital mortality. However, these findings should be interpreted cautiously, given the retrospective design and sensitivity analysis suggesting potential hospital-level confounding. ( J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/care management; Level III.
Is the rate of chest computed tomography different between adult and pediatric Level 1 trauma centers?
Hess T, Wang M, Chappell C … +4 more , Healy J, Ciullo S, Moront M, Lindholm EB
J Trauma Acute Care Surg · 2026 Jun · PMID 42335298 · Publisher ↗
BACKGROUND: Injured children receive trauma care at both children's hospitals and adult trauma centers. The established risk that radiation poses to children mandates minimizing exposure whenever possible. Several studie...
BACKGROUND: Injured children receive trauma care at both children's hospitals and adult trauma centers. The established risk that radiation poses to children mandates minimizing exposure whenever possible. Several studies show chest computed tomography (CCT) rarely alters management of children with suspected thoracic trauma when the chest radiograph (CXR) is normal. We hypothesize that adult trauma centers overutilize CCT for children with suspected blunt thoracic trauma. METHODS: We conducted a retrospective review of the Pennsylvania Trauma System Foundation database for all children below 15 years old sustaining blunt trauma between 2019 and 2023. Patients who presented to Level 1 pediatric regional trauma centers (PTC) (n=3) were compared with adult Level 1 trauma centers (ATC) (n=10); transfers were excluded. ICD-10 procedure codes were used to identify patients with any interventions on the chest. RESULTS: The query identified 1,241 qualified patients, 850 treated at PTCs and 391 at ATCs. PTC patients were younger with a higher injury severity score (ISS). There was a decreased rate of CCT at PTCs (10.94% vs. 19.18%, p<0.0001). Subgroup analysis revealed a difference in CCT rate for ages 10-14 (18.33% vs. 35.97%, p<0.0001). PTCs also had a higher rate of thoracostomy tube placement (10.75% vs. 1.48%, p=0.002), but there were no differences in intubation, cardiopulmonary arrest, thoracotomy, or sternotomy. Subgroup analysis of patients with a length of stay <3 days showed no differences in age, ISS, or interventions; however, the rate of CCT was higher at ATCs (6.58% vs. 25.77%, p<0.0001). CONCLUSIONS: CCT rates were lower across all age groups in the PTC cohort despite PTCs having a higher ISS score. Interestingly, there continued to be decreased CCT use at PTCs for children who were admitted for less than 3 days. Our findings support the hypothesis that adult trauma centers overutilize CCT in children suspected of blunt thoracic trauma. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level III.
Iodine-based spectral CT can quantify transient kidney injury in hemorrhagic shock: Results from a translational large-animal model.
Hübner CT, Kalbas Y, Klingebiel FK … +8 more , Ricklin J, Hinkelmann MA, Stoeck CT, Sawauchi K, Weisskopf M, Cinelli P, Pape HC, Pfeifer R
J Trauma Acute Care Surg · 2026 Jun · PMID 42330360 · Publisher ↗
BACKGROUND: After severe hemorrhage and polytrauma, late complications such as multi-organ failure (MOF) remain major contributors to morbidity and mortality. Especially after hemorrhagic shock the kidney is known to be...
BACKGROUND: After severe hemorrhage and polytrauma, late complications such as multi-organ failure (MOF) remain major contributors to morbidity and mortality. Especially after hemorrhagic shock the kidney is known to be at high risk. As laboratory parameters, like creatinine, provide only delayed and indirect information about kidney function, our study evaluated whether iodine-based spectral computed tomography (SDCT) can quantify renal perfusion in a large-animal polytrauma model. METHODS: Thirty-two Landrace pigs (70±5 kg) were used, randomized into four groups (n=8). Tissue trauma group (TTFx) received a blunt chest injury and bilateral femur shaft fractures. In the shock (HS) group, hemorrhagic shock was induced by controlled blood withdrawal. The polytrauma (PT) group underwent tissue trauma and hemorrhagic shock. Eight uninjured pigs served as controls. Whole-body SDCT with iodine mapping was performed after trauma and after 24 hours. Serum creatinine was measured in parallel. Urine was sampled at baseline, after resuscitation, and after 24 hours. RESULTS: Significant differences in renal perfusion measured by iodine uptake were found during shock and after polytrauma: groups with hemorrhagic shock showed reduced renal perfusion compared with controls (P<0.001). Decreased iodine uptake correlated strongly with increased creatinine levels (ρ=-0.505, P=0.009). Hemorrhagic shock caused pronounced intrarenal functional impairment, reflected by elevated fractional sodium excretion (FENa 2.49% vs. 0.35%, P<0.001), reduced urine osmolality (P<0.001), and decreased urinary urea concentrations (P<0.001). Fractional calcium excretion (FECa), a novel parameter, was strongly increased in the shock group (6.18% vs. 0.19%, P<0.001). After 24-hour resuscitation, no significant differences between the groups were observed in either iodine uptake, creatinine levels, or urinary parameters. CONCLUSIONS: Spectral iodine imaging seems to reflect renal perfusion impairment after hemorrhagic shock. The observed correlations with creatinine and urinary parameters suggest that spectral CT may provide a rapid, imaging-based assessment of kidney dysfunction. The renal perfusion normalizes with resuscitation along with renal function parameters. (J Trauma Acute Care Surg. 2026;101: 121-128. c 2026 The Author (s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE: Not applicable.
State gun policies affect veteran and civilian suicide rates differently.
Hiraldo L, Wolansky RL, Sujka J … +3 more , Luchette FA, Kuo PC, Kendall M
J Trauma Acute Care Surg · 2026 Jun · PMID 42329101 · Publisher ↗
BACKGROUND: Veterans die by suicide with firearms at 1.5 times the rate of civilians. State firearm policies show variable effectiveness, but their differential impact on veteran populations remains unclear. Understandin...
BACKGROUND: Veterans die by suicide with firearms at 1.5 times the rate of civilians. State firearm policies show variable effectiveness, but their differential impact on veteran populations remains unclear. Understanding differential associations is critical given veterans' unique firearm relationships. METHODS: Analysis used state-level data from 2003 to 2022 examining 12 firearm policies across 49 states. Data sources included CDC WISQARS, National Veteran Suicide Prevention Annual Report, and RAND State Firearm Law Database. Mixed-effects models with state random effects and time trends assessed policy impacts on suicide rates. Interaction analyses (Policy × Population) tested differential associations. State-level analysis examined relationships between policy comprehensiveness and veteran-civilian mortality gaps. Bonferroni correction was applied (α=0.00417). RESULTS: The analysis included 821 state-year observations from 49 states (2003-2022). Veterans demonstrated higher suicide rates (36.3 per 100,000) compared with the general population (20.1 per 100,000) and greater firearm involvement (67.6% vs. 53.0%). Interaction analysis revealed limited differential policy associations between populations. Only 2 of 12 policies demonstrated differential associations after Bonferroni correction (α=0.00417): local selective preemption showed harmful associations among veterans (+10.11 percentage points, p<0.001), while firearm tracing requirements demonstrated protective associations in the general population (+4.39 percentage points, p=0.001). Geographic disparities in veteran-civilian suicide gaps ranged from 14% (Hawaii) to 162% (Rhode Island). However, no significant correlation was observed between state-level policy comprehensiveness and veteran-civilian gaps (r=.08, 95% CI, -.21 to .35, p=0.583). CONCLUSIONS: Most state firearm policies demonstrated similar associations with suicide rates in both populations, and only 2 of 12 policies showed differential associations. The absence of correlation between policy comprehensiveness and veteran-civilian gaps indicates that policy quality and contextual factors matter more than aggregate policy counts. While evidence-based firearm policies benefit both populations, elevated veteran suicide rates persist across all policy environments, indicating that effective prevention requires integration of policy-level interventions with veteran-specific clinical approaches. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic/epidemiological; Level III.
Response to: Veno-venous ECMO and damage control laparotomy: Important questions remain.
Ghneim MH, Deshwar AB, Zhang AL … +7 more , O'meara L, Vesselinov R, Efron DT, Stein DM, Powell E, Rabin J, Scalea TM
J Trauma Acute Care Surg · 2026 Jun · PMID 42319843 · Publisher ↗
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