J Trauma Acute Care Surg [JOURNAL]
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200 papers
Microvesicles in stored human whole blood increase thrombin generation via phosphatidylserine.
Wattley LJ, Chae R, Schuster RH … +2 more , Goodman MD, Pritts TA
J Trauma Acute Care Surg · 2026 Mar · PMID 41728877 · Publisher ↗
INTRODUCTION: Microvesicles are submicron blebs shed from aging cells during storage. Some microvesicles have been shown to be procoagulant; however, the influence of microvesicles on coagulability of stored whole blood...
INTRODUCTION: Microvesicles are submicron blebs shed from aging cells during storage. Some microvesicles have been shown to be procoagulant; however, the influence of microvesicles on coagulability of stored whole blood has not been elucidated. Additionally, the mechanism of microvesicle influence on coagulation in human blood is unknown. We hypothesized that microvesicles produced during storage express phosphatidylserine on their outer leaflet, which causes an increase in thrombin generation. METHODS: Whole blood was collected into citrate phosphate double dextrose from 14 healthy donors (6 male, 8 female) aged 20 to 30 years and stored for 21 days. Baseline and end of storage hemostasis was measured with rotational thromboelastometry (Non-Activated ROTEM [NATEM] and Extrinsically Activated ROTEM [EXTEM]). Thrombin generation was measured after stimulation with tissue factor (TF) and phospholipids as well as TF alone. Microvesicles were measured using flow cytometry on day 1 and day 21 of storage. Microvesicle effects were determined by adding microvesicles to platelet-poor plasma (PPP) with and without lactadherin and assaying for changes in thrombin generation. RESULTS: Whole blood did not demonstrate differences in NATEM after storage. However, on EXTEM analysis, whole blood demonstrated decreased coagulability. When PPP was stimulated with TF and phospholipids, or TF alone, thrombin generation increased with storage duration. Microvesicle concentrations also increased with storage duration. When microvesicles were added to PPP and then stimulated with TF and phospholipids or TF alone, thrombin generation was increased, and this effect was mitigated by blocking phosphatidylserine on microvesicles with lactadherin. CONCLUSION: Whole blood storage results in increased thrombin generation potential over time. This has previously been viewed as beneficial but could be detrimental when unchecked. These data suggest that changes in thrombin generation are due in part to phosphatidylserine expression on microvesicles produced during storage. These data highlight the need for further studies investigating the use of stored whole blood.
The current state of acute care surgery workforce and practice models: A joint statement by the American Association for the Surgery of Trauma, the American College of Surgeons Committee on Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association.
Staudenmayer KL, Barmparas G, Barnes SL … +15 more , Biffl WL, Cohen MJ, Davis KA, de Moya M, Goldberg AJ, Joseph B, Martin RS, Murphy PB, Rizzo AG, Rotondo M, Savage SA, Smith JW, Todd SR, Zarzaur BL, Bulger E
J Trauma Acute Care Surg · 2026 Mar · PMID 41728876 · Full text
Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue func...
Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue functions, disaster response, and other important services. Despite its key role in patient care and hospital operations, ACS faces challenges to its sustainability. This overview targets readers who wish to understand the structure and scope of ACS and who work with or manage these practices. The goal is to provide an overview of ACS, its current challenges, and suggestions for developing the specialty. This consensus statement was created by the Acute Care Surgery Workforce Workgroup, which includes representatives from various national surgical organizations. The article combines current ACS models, staffing and compensation practices, and institutional value. It relies on expert agreements and national trends. Several key themes are examined. The value of ACS is shown through better patient outcomes, efficiency, cost savings, and support for institutional missions like disaster preparedness and education. Current ACS programs differ significantly in structure, but two main staffing models exist: traditional (historic) and time delineated. Each model has its own advantages and challenges regarding workload, sustainability, and academic involvement. Regardless of the staffing model, most physician compensation often depends on the measurement of work relative value units. However, these do not fully capture the extent and intensity of ACS work. Additional challenges for the specialty include inconsistencies in terminologies, the absence of board certification, and varying compensation standards. Acute care surgery is a crucial specialty that provides significant value to patients, hospitals, and health care systems. To maintain sustainability and quality, health care leaders need to consider the complexities of ACS practice discussed in this article as well as local demands. Staffing and compensation models should be sustainable and optimize for patient care. Recognizing both clinical and nonclinical contributions of ACS surgeons is essential for resilience and further development of the specialty.
Evidence-based, cost-effective management of nontraumatic esophageal perforations: An algorithm of the Journal of Trauma and Acute Care Surgery Emergency General Surgery Algorithms Work Group.
Hasson RM, Salim A, Castillo-Angeles M … +8 more , Biffl WL, Costantini TW, Diaz J, Inaba K, Livingston DH, Winchell R, Napolitano LM, Coimbra R
J Trauma Acute Care Surg · 2026 Mar · PMID 41728875 · Full text
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Western Trauma Association critical decisions in trauma: Significant blunt cardiac injury.
Kopelman TR, Biffl WL, Coimbra R … +16 more , Bower KL, Croft CA, Fox CJ, Hartwell JL, Hynes AM, Inaba K, Keric N, Kerwin AJ, Lorenzo M, Magee GA, Privette AR, Schellenberg M, Schuster KM, Tesoriero R, Watters JM, Stein DM
J Trauma Acute Care Surg · 2026 May · PMID 41718613 · Publisher ↗
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An American College of Surgeons Committee on Trauma Stop the Bleed guideline on the use of improvised tourniquets for trauma patients with life-threatening extremity hemorrhage 2025.
Tran A, Dodd J, Dawson EG … +23 more , Campion EM, Browder TD, Rochwerg B, Bank MA, Bankhead BK, Berry SD, Brown C, Edwards SB, Goodyear S, Griepentrog JE, Hill D, Kelliher S, Liao L, McGonagill PW, Oley WB, Schaefer GP, Simonson B, Trankiem CT, Vella MA, Wilson S, Zito TR, Inaba K, on behalf of the Improvised Tourniquet Working Group for the American College of Surgeons Committee on Trauma Stop the Bleed Program, Los Angeles, California
J Trauma Acute Care Surg · 2026 Jun · PMID 41718598 · Publisher ↗
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Veno-venous extracorporeal membrane oxygenation and damage-control laparotomy in acute care surgery patients: A safe and successful option for patient rescue.
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 Jul · PMID 41705911 · Publisher ↗
INTRODUCTION: The combined use of Veno-venous extracorporeal membrane oxygenation (VV-ECMO) and damage-control laparotomy/open abdomen (DCL/OA) is not well described in the literature. We hypothesized that the mortality...
INTRODUCTION: The combined use of Veno-venous extracorporeal membrane oxygenation (VV-ECMO) and damage-control laparotomy/open abdomen (DCL/OA) is not well described in the literature. We hypothesized that the mortality with concurrent VV-ECMO and DCL/OA would not be statistically different from that reported for either intervention alone. METHODS: Patients managed with a DCL/OA and VV-ECMO from March 2014 through March 2022 were retrospectively reviewed from a prospectively collected database at a single quaternary care center. The primary outcome was in-hospital mortality. Survivor and nonsurvivor cohorts were compared using univariate and bivariate analyses with a priori significance at p ≤ 0.05. A multivariable regression analyses was performed to identify independent predictors of mortality. RESULTS: Fifty-two patients were managed with VV-ECMO and concurrent DCL/OA. The majority of patients were male (58%), with a mean (SD) age of 41 (14) years. The primary indication for VV-ECMO was acute respiratory distress syndrome/pneumonia (83%). The primary indications for DCL/OA were abdominal compartment syndrome (37%) and trauma (19%). Sixty percent of the patients underwent VV-ECMO cannulation after DCL/OA. Survival at hospital discharge was 58%. Survivors had a lower mean Sequential Organ Failure Assessment score (12 vs. 14, p = 0.02), higher mean Respiratory ECMO Survival Prediction score (3.5 vs. 1.1, p = 0.004), lower mean preoperative lactic acid level (4 vs. 7, p = 0.04) and were more likely to receive anticoagulation while on VV-ECMO (70% vs. 30%, p = 0.012) than nonsurvivors. Postdischarge, survival rates at 3, 6, 9, and 12 months were 90%, 72%, 69%, and 62%, respectively. After adjusting for confounders, the use of anticoagulation (odds ratio, 0.08; 95% confidence interval, 0.01-0.42) and a higher Respiratory ECMO Survival Prediction score (odds ratio, 0.71; 95% confidence interval, 0.53-0.95) were associated with decreased mortality. CONCLUSION: Relatively favorable outcomes are often achieved in acute care surgery patients treated with concomitant VV-ECMO and DCL/OA. Veno-venous extracorporeal membrane oxygenation should not be considered a contraindication to DCL/OA and vice versa. ( J Trauma Acute Care Surg . 2026;101: 136-144. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Retrospective Cohort Study; Level III.
Evaluating the impact of artificial intelligence tools on the detection of chest injuries from medical imaging: A systematic review and meta-analysis.
Lai JTF, Cheng KJ, Eliahoo J … +4 more , Gibb I, Frith D, Masouros S, Hettiaratchy S
J Trauma Acute Care Surg · 2026 Apr · PMID 41705907 · Publisher ↗
BACKGROUND: There has been a growing interest in the clinical application of artificial intelligence (AI) tools in medical imaging to aid diagnosis. This study conducts a systematic review of existing literature and perf...
BACKGROUND: There has been a growing interest in the clinical application of artificial intelligence (AI) tools in medical imaging to aid diagnosis. This study conducts a systematic review of existing literature and performs a meta-analysis to compare the diagnostic performance of unassisted clinicians (CU) with clinicians assisted with AI (CA) in detecting traumatic chest injuries on diagnostic imaging. METHODS: This systematic review was registered on the international Prospective Register of Systematic Reviews (CRD42024568478). A literature search was conducted on Ovid Medline, Ovid Embase, and the IEEE Xplore digital library, which included all studies evaluating the diagnostic performance of AI compared with a clinician for the detection of traumatic chest injuries on imaging in adults. The risk of bias was assessed using the quality assessment tool for diagnostic accuracy studies (QUADAS-2). Comparison between CA and CU groups was performed using meta-analysis for the primary outcome of diagnostic sensitivity and diagnostic time (DT) as a secondary outcome, with mean difference used as the effect measure. RESULTS: The search strategy identified 6,013 records. Following a full-text review, 20 studies were included, with 12 suitable for meta-analysis for rib fracture detection. The use of AI was associated with an improvement in sensitivity (CA, 0.88; CU, 0.76; mean difference, 0.12) and a reduction in DT (DT CA, 115 seconds; DT CU, 214 seconds; mean difference, -99 seconds). CONCLUSION: Artificial intelligence assistance can improve the diagnostic performance of clinicians. Clinicians assisted with AI were associated with an increase in the diagnostic sensitivity with a reduction in the DT to detect rib fractures on clinical imaging compared with CU. However, the overall quality of the evidence is poor, and further research into clinically useful models is required. LEVEL OF EVIDENCE: Systematic Review and Meta-analysis; Level IV.
Diverting loop ileostomy with antegrade colonic lavage compared with colectomy in Clostridioides difficile colitis: A decade-long propensity score-matched analysis.
Zangbar B, Mehta R, Kirsch J … +6 more , Jose A, Froula G, Bronstein M, Carlson A, Shnaydman I, Prabhakaran K
J Trauma Acute Care Surg · 2026 Mar · PMID 41705902 · Publisher ↗
BACKGROUND: Fulminant Clostridioides difficile colitis (CDC) carries high morbidity and mortality, often necessitating emergent surgical intervention. While total abdominal colectomy (TAC) remains the standard of care, d...
BACKGROUND: Fulminant Clostridioides difficile colitis (CDC) carries high morbidity and mortality, often necessitating emergent surgical intervention. While total abdominal colectomy (TAC) remains the standard of care, diverting loop ileostomy with antegrade colonic lavage (DLI) has emerged as a colon-preserving alternative. This study aimed to compare outcomes between DLI and TAC and evaluate the safety of a DLI first approach, including cases that ultimately failed DLI. METHODS: We performed a retrospective analysis of adult patients with CDC undergoing TAC or DLI between 2012 and 2021 using the National Inpatient Sample. Patients with abdominal compartment syndrome, colonic perforation, or alternative surgical indications were excluded. Patients who required TAC because of failed DLI trial were included in the DLI group. Propensity score matching was performed 1:1 to adjust for demographics, illness severity, and comorbidities. Outcomes assessed included mortality, discharge disposition, hospital length of stay, complications, and costs. A subgroup analysis compared patients with failed DLI with primary TAC. RESULTS: Of 6,618 patients undergoing surgery for CDC, 10.7% received DLI and 89.3% underwent TAC. After matching, 668 patients remained in each group. No significant difference was observed in mortality (24.4% DLI vs. 26.0% TAC, p = 0.600), although DLI patients had longer hospital stays and higher costs ( p < 0.05). Postoperative wound disruption and infection were significantly less common in the DLI group ( p < 0.05). Among patients with failed DLI (n = 116), outcomes including mortality, length of stay, and complications were comparable with primary TAC postmatching. CONCLUSION: Diverting loop ileostomy with antegrade colonic lavage appears to be a safe alternative to colectomy in select patients with fulminant CDC. Although it does not confer a survival benefit, it is associated with lower wound morbidity and does not worsen outcomes even when conversion to colectomy is required. These findings support the selective use of DLI as a colon-preserving surgical strategy. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Comparative analysis of outcomes in pediatric traumatic brain injury at urban teaching versus nonteaching hospitals across the United States.
Agyekum R, Chidiac C, Layoun CJ … +6 more , Ntow S, Siddiqui Z, El-Bassiri M, Slidell MB, Haut ER, Nasr IW
J Trauma Acute Care Surg · 2026 Feb · PMID 41705899 · Publisher ↗
BACKGROUND: Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children, and timely access to trauma centers is crucial for improving outcomes. Scarce research compares pediatric TBI outcomes...
BACKGROUND: Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children, and timely access to trauma centers is crucial for improving outcomes. Scarce research compares pediatric TBI outcomes between urban teaching and nonteaching hospitals. This study addresses this gap. METHODS: We conducted a cross-sectional analysis of patients aged 0 to 17 years with TBI admitted to US urban hospitals from 2016 to 2021 using data from National Inpatient Sample database. Outcomes were in-hospital mortality, length of stay (LOS), and complications. RESULTS: Of 28,674 TBI patients, 27,586 (96.2%) were admitted to teaching hospitals. These patients were younger (8.3 vs. 10.4 years, p < 0.001), more likely to be Black (16.7% vs. 9.0%, p < 0.001), and Medicaid insured (49.5% vs. 42.6%, p < 0.001). Teaching hospitals had more referrals (29.2% vs. 13.1%, p < 0.001) and more severely injured patients (Injury Severity Score, ≥25: 29.6% vs. 21.9%; p < 0.001). Mortality was comparable across both settings as were most medical complications. Length of stay was longer (mean [SD], 5.9 [11.6] days vs. 4.3 [8.1] days; p < 0.001), and deep venous thrombosis was marginally higher in teaching hospitals (1.0% vs. 0.3%, p < 0.02). Adjusted models showed similar odds in mortality (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.69-1.61) and complications (OR, 0.96; 95% CI, 0.69-1.35) but longer LOS (β coefficient, 0.85; 95% CI, 0.13-1.57) in teaching hospitals. Black and uninsured children had higher odds of death than Whites (OR, 1.41; 95% CI, 1.18-1.69) and Medicaid patients (OR, 1.70; 95% CI, 1.28-2.26) within teaching hospitals. CONCLUSION: Teaching hospitals admitted more ill patients, had higher referrals, and higher patient volumes than nonteaching hospitals. While mortality and complications did not differ, LOS was longer in teaching hospitals. Notably, within teaching hospitals, Black and uninsured children had higher mortality. These findings highlight appropriate triaging in pediatric TBI care while also drawing attention to potential structural inequities that warrant urgent intervention. LEVEL OF EVIDENCE: Retrospective Cross-sectional Study; Level III.
Intrathoracic surgical stabilization of rib fractures: What you need to know.
Schubl SD, Greig CJ, Doben A
J Trauma Acute Care Surg · 2026 Mar · PMID 41701566 · Publisher ↗
Rib fractures remain among the most common injuries in trauma patients. The past two decades have seen a sharp increase in the scientific study of chest wall injury and the development of multiple dedicated rib stabiliza...
Rib fractures remain among the most common injuries in trauma patients. The past two decades have seen a sharp increase in the scientific study of chest wall injury and the development of multiple dedicated rib stabilization systems, including some that are deployable intrathoracically. Beyond repair of fractured ribs, chest wall injury also includes management of other intrathoracic pathologies that can make the addition of video-assisted thoracoscopy to chest wall surgery prudent. Indications for rib fracture surgery have been published by numerous surgical societies despite ongoing debate though none recommend one repair system or approach over another. Early and complete clearance of the chest space at the time of surgery, when surgical stabilization is indicated, has shown benefit in patients with severe chest wall trauma. The recent availability of a second-generation intrathoracic system with novel suture and knot-based fixation increases the options for chest wall surgeons when considering surgical repair. This review summarizes the understanding of intrathoracic surgical stabilization to date and the scenarios where surgical clearance of the chest space is potentially worthwhile. Additional considerations, timing, limitations, and infectious concerns are reviewed in the hopes of providing the reader with what they need to know on the topic.
Utility of transversus abdominis plane block in trauma and emergency general surgery laparotomy: A quality improvement project.
Forman S, Park S, Hom B … +9 more , Greenlee S, Nekooei N, Mano Y, Tan M, Lewis M, Siletz A, Martin M, Inaba K, Matsushima K
J Trauma Acute Care Surg · 2026 Mar · PMID 41701565 · Publisher ↗
BACKGROUND: Transversus abdominis plane (TAP) blocks reduce opioid use and improve outcomes in elective surgeries, but their benefit in acute care surgery has not been demonstrated. Our program recently developed a quali...
BACKGROUND: Transversus abdominis plane (TAP) blocks reduce opioid use and improve outcomes in elective surgeries, but their benefit in acute care surgery has not been demonstrated. Our program recently developed a quality improvement project to implement a pain management protocol including TAP blocks for emergency laparotomy. The purpose of this study is to evaluate the impact of TAP blocks on opioid use and hospital outcomes. METHODS: As part of a hospital quality improvement initiative, we conducted a retrospective cohort study (2022-2024) including patients (18 years or older) who underwent an emergency laparotomy. Patients were divided into TAP block and no TAP block cohorts. Univariate and multivariate analyses were performed to assess the association between the use of TAP blocks and study outcomes including postoperative morphine milligram equivalents (MME), hospital length of stay, and postoperative complications. RESULTS: Among 219 patients (TAP block, 110; no TAP block, 109), those receiving TAP blocks required significantly less total MME (64 vs. 118, p = 0.009) and daily MME (9 vs. 15, p < 0.001) and were less likely to require ≥20 MME/day (22.7% vs. 45.9%, p < 0.001). No significant differences were observed in postoperative complications or hospital length of stay. Multivariate analysis showed the use of TAP blocks was associated with decreased odds of requiring ≥20 MME/day (adjusted odds ratio, 0.363; 95% confidence interval, 0.195-0.675; p = 0.001), and less MME per day ( β = -14.52; 95% confidence interval, -27.50 to -1.53; p = 0.029). CONCLUSION: Our results suggest that the use of TAP blocks was significantly associated with reduced opioid use in trauma and emergency general surgery patients. While further research is warranted, TAP blocks should be considered for postoperative pain management in acute care surgery patients undergoing emergency laparotomy. LEVEL OF EVIDENCE: Therapeutic/Care Management Study; Level III.
Transfusion in transit: A decade of prehospital blood transfusion in pediatric trauma.
Sutyak KM, Chen EC, Mock L … +8 more , Cabrera R, Joly JM, Tsao K, Cotton BA, Meyer DE, Cox CS, Lally KP, Drucker NA
J Trauma Acute Care Surg · 2026 Apr · PMID 41701564 · Publisher ↗
BACKGROUND: Prehospital blood transfusion improves mortality in adults, with limited evidence in children. This study describes prehospital blood transfusion in pediatric trauma patients and the impact on shock index, pe...
BACKGROUND: Prehospital blood transfusion improves mortality in adults, with limited evidence in children. This study describes prehospital blood transfusion in pediatric trauma patients and the impact on shock index, pediatric adjusted (SIPA). METHODS: This study is a retrospective cohort study of trauma patients younger than 18 years who received blood transfusions during helicopter transport to a Level 1 pediatric trauma center from 2011 to 2023. Primary outcome was change in SIPA at time of emergency department (ED) arrival with prehospital transfusion. Secondary subgroup analysis was performed based on transport origin. RESULTS: Of 137 patients, 58% (80 of 137 patients) were male (median age, 9.3 years [interquartile range (IQR), 4.3-14.5 years]) with a median Injury Severity Score of 26 (IQR, 17-38); 57% (77 of 137 patients) were transported from the scene, and 43% (60 of 137 patients) from another hospital. The median blood volume administered was 300 mL (IQR, 200-535 mL) or 10 mL/kg (IQR, 7-16 mL/kg). Patients were more physiologically imbalanced prior to transfusion (median heart rate, 124 beats per minute [bpm; IQR, 102-150 bpm]; systolic blood pressure, 80 mm Hg [IQR, 63-99 mm Hg]) than at ED arrival (median heart rate, 112 bpm [IQR, 97-133 bpm]; systolic blood pressure, 102 mm Hg [IQR, 84-120 mm Hg]). Shock index, pediatric adjusted, was decreased at ED arrival (median SIPA preblood, 1.52 [IQR, 1.11-2.16]; median SIPA ED arrival, 1.10 [IQR, 0.89-1.38]). The SIPA transitioned from abnormal to normal at ED arrival in 24% (32 of 131 patients); hemodynamic improvement was more pronounced in patients from the scene. Death in the first 24 hours occurred in 43 patients; 25 presented in cardiac arrest and died on ED arrival. Most deaths (81%, 47 of 58 patients) were associated with traumatic brain injury. CONCLUSION: After receiving prehospital transfusion, 35% of children arrived with a normal shock index, and 24% converted from abnormal to normal SIPA by ED arrival, with significant hemodynamic improvement in patients transported from both the scene and other hospitals. These results support prehospital transfusion as critical for the treatment of hemorrhagic shock in children. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Executive summary of the Brain Trauma Foundation Guidelines for the Management of Penetrating Traumatic Brain Injury, Second Edition.
Kitagawa R, Dengler B, Hawryluk GWJ … +4 more , Bell R, Ghajar J, Mangat HS, Stein DM
J Trauma Acute Care Surg · 2026 Mar · PMID 41700745 · Publisher ↗
BACKGROUND: New literature and military conflicts inspired the second edition of the Guidelines for the Management of Penetrating Traumatic Brain Injury (pTBI). In an effort to make the evidence-based guidelines more imp...
BACKGROUND: New literature and military conflicts inspired the second edition of the Guidelines for the Management of Penetrating Traumatic Brain Injury (pTBI). In an effort to make the evidence-based guidelines more impactful to clinical practice, expert consensus and treatment algorithms were incorporated. METHODS: The published pTBI guidelines were reviewed, and an executive summary of the recommendations specifically relevant to trauma and critical care were created. These include resuscitation, imaging including screening for vascular injuries, critical care management (intracranial pressure, antibiotics, seizure prophylaxis, and thromboembolic prophylaxis), timing of surgery, surgical technique, management of vascular complications, and prognosis. RESULTS: A summary of the recommendations is provided including evidence-based guidelines (3 Level II, 10 Level III, and 15 Level IV) as well as expert consensus (Level C, 57 statements). Seven treatment algorithms are presented including a futility assessment tool. CONCLUSION: The pTBI guidelines are intended to be used to assist the clinical care of a patient with pTBI. The clinical questions are addressed with published evidence when available and supplemented with expert consensus to guide the clinician caring for a patient with pTBI from admission, including resuscitation and imaging, surgical intervention, postoperative care and monitoring, and future screening and follow-up.
Combined intracranial hemorrhage subtypes should not change modified Brain Injury Guidelines criteria.
Johnson EH, Lee JS, Cripps MW … +2 more , McIntyre RC, Schroeppel TJ
J Trauma Acute Care Surg · 2026 Mar · PMID 41670407 · Publisher ↗
BACKGROUND: The modified Brain Injury Guidelines (mBIG) are an established protocol to triage traumatic brain injury with intracranial hemorrhage (ICH) while reducing resource utilization. However, mBIG do not differenti...
BACKGROUND: The modified Brain Injury Guidelines (mBIG) are an established protocol to triage traumatic brain injury with intracranial hemorrhage (ICH) while reducing resource utilization. However, mBIG do not differentiate between isolated and combined intracranial hemorrhage (cICH). This study evaluated whether patients with multiple ICH subtypes require different triage. METHODS: We performed a retrospective study of adult patients classified as mBIG 1 or mBIG 2 at two Level I trauma centers January 1, 2017, to June 30, 2023. Patients with cICH (≥2 subtypes) were compared with isolated ICH. Primary outcome was clinical deterioration, defined as new focal neurologic findings, pupillary examination changes or Glasgow Coma Scale score of <13 as compared with initial presentation. Secondary outcomes included radiographic progression, neurosurgical consultation, neurosurgical intervention, number of head computed tomography, hospital and intensive care unit length of stay, and readmission. RESULTS: Among 844 patients, 251 (29.7%) had cICH. Compared with isolated, cICH patients had higher Injury Severity Score (14.3 vs. 11.8, p < 0.001), longer intensive care unit length of stay (1 vs. 0, p < 0.001), and greater radiographic progression (20.3% vs. 11.3%, p = 0.002). However, clinical deterioration (1.0% vs. 2.6%, p = 0.252), neurosurgical intervention (0.4% vs. 0.2% p = 0.507), and readmission (5.2% vs. 3.7%, p = 0.413) were rare and did not differ between groups. CONCLUSION: While cICH is associated with more radiographic progression and resource utilization compared with isolated ICH, it is not associated with higher occurrence of clinical deterioration or neurosurgical intervention. These findings support continued use of mBIG for isolated and cICH with escalation of care reserved for neurological deterioration or other high-risk features. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Female patients receiving massive transfusion are less likely to receive whole blood despite survival benefit.
Arcieri TR, Cobler-Lichter MD, Reyes AM … +6 more , Delamater JM, Namias N, Pizano LR, Carter NH, Proctor KG, Meizoso JP
J Trauma Acute Care Surg · 2026 Apr · PMID 41649416 · Publisher ↗
BACKGROUND: Female trauma patients may be less likely to receive whole blood (WB) because of clinician concern regarding RhD alloimmunization and physiologic differences despite evidence supporting the safety of WB use i...
BACKGROUND: Female trauma patients may be less likely to receive whole blood (WB) because of clinician concern regarding RhD alloimmunization and physiologic differences despite evidence supporting the safety of WB use in this population. We hypothesized that, in female patients requiring massive transfusion (MT), high proportions of WB are associated with decreased mortality but that females are less likely to receive WB than males. METHODS: Adults aged 18 to 64 years from the 2020-2023 Trauma Quality Improvement Program database who received MT (≥5 blood units within 4 hours of arrival) were retrospectively reviewed. Transfers, burns, deaths within 1 hour, and patients who received >100 U of any blood product were excluded. The proportion of MT given as WB was calculated as WB ratio (WB/total red blood cell-containing units). The median of nonzero WB ratios was used to divide patients who received WB into two cohorts, ultimately creating three groups (no WB, low WB, and high WB). Mixed-effect logistic regressions were performed to assess the effect of sex on receiving WB and the effect of WB proportions on mortality. RESULTS: Of 33,811 patients (19.2% female), 29.6% received WB. After controlling for confounders, both pre- and postmenopausal females were significantly less likely to receive WB than males (premenopausal: adjusted odds ratio [aOR], 0.403 [0.367-0.442]; postmenopausal: aOR, 0.655 [0.531-0.808]). On mixed-effect regression analysis, high WB ratios were associated with decreased 30-day mortality for both males (aOR, 0.808 [0.725-0.901]) and females (aOR, 0.776 [0.617-0.976]). On subanalysis, this effect persisted only for postmenopausal females (aOR, 0.589 [0.384-0.903]). CONCLUSION: Female trauma patients are less likely than males to receive WB during MT despite a survival benefit. These results underscore the need to address sex-based differences in transfusion practices. The root of this disparity should be investigated to optimize outcomes for all patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Early versus delayed appendectomy for acute uncomplicated appendicitis in adult and pediatric patients: A systematic review and meta-analysis.
Ahmed H, Trinh F, Jatana S … +6 more , Fujita K, Kung JY, Jogiat U, Karmali S, Switzer N, Mocanu V
J Trauma Acute Care Surg · 2026 May · PMID 41636758 · Publisher ↗
BACKGROUND: Appendicitis has traditionally been managed with urgent surgery. Because of operative room and logistic constraints, surgery may be delayed. Evidence on the impact of this delay remains equivocal. The aim of...
BACKGROUND: Appendicitis has traditionally been managed with urgent surgery. Because of operative room and logistic constraints, surgery may be delayed. Evidence on the impact of this delay remains equivocal. The aim of this systematic review and meta-analysis is to assess postoperative outcomes of delayed appendectomy amongst both pediatric and adult populations. METHODS: A systematic review with meta-analysis was performed including studies comparing cohorts of urgent versus delayed appendectomy, excluding those with interval appendectomy. Studies were included as long as one relevant postoperative complication was mentioned; for adults, only prospective studies were included. A comprehensive search of six databases was performed including studies from January 1, 2000, to January 15, 2024. A meta-analysis with a random effects model and restricted maximum likelihood was used. RESULTS: Of 11,227 citations, 20 pediatric and 5 adult studies were included, with 827,019 and 4250 patients, respectively. Definitions of early surgery cohorts were usually surgery within 4 to 12 hours or overnight, and delayed surgery >4 to 12 hours or next day. The pediatric meta-analysis revealed no increased risk of intraoperative perforation in delayed versus emergent cohorts (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.78-1.72), length of stay (mean difference, 1.2 days; 95% CI, -0.3 to -2.8), abscess (OR, 0.80; 95% CI, 0.29-2.25), surgical site infection (OR, 1.11; 95% CI, 0.93-1.30), or readmission (OR, 0.82; 95% CI, 0.55-1.21). The adult meta-analysis results revealed no difference between the delayed and emergent appendectomy groups for intraoperative perforation (OR, 1.29; 95% CI, 1.00-1.67), abscess (OR, 1.54; 95% CI, 0.58-4.10), surgical site infection (OR, 1.35; 95% CI, 0.71-2.56), or conversion to open (OR, 0.81; 95% CI, 0.64-1.03). Subgroup analyses showed increased length of stay in pediatric population (mean difference, 0.42 days; 95% CI, 0.10-0.74). CONCLUSION: These findings suggest that a modest delay in appendectomy may be permissible in pediatric and adult settings and adult patients presenting with acute appendicitis. While this does not replace surgeon clinical acumen, it may help guide decision making in resource-constrained settings. ( J Trauma Acute Care Surg . 2026;100: 822-830. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Systematic Review and Meta-analysis; Level III.
Effects of partial versus complete aortic occlusion on macro and microcirculatory flows in swine hemorrhagic shock.
Ospina Tascón GA, Aldana Diaz JL, Orozco N … +12 more , Palacios H, Rengifo M, Peña CA, Ordóñez CA, Marulanda AM, Velasco MI, Rios E, Betancourt M, García-Gallardo G, Pérez-Téllez C, Gómez H, García AF
J Trauma Acute Care Surg · 2026 Apr · PMID 41636753 · Publisher ↗
INTRODUCTION: REBOA is a recognized rescue strategy in exsanguinating shock. Nevertheless, effects of partial- versus total-REBOA inflation on both macrocirculatory and microcirculatory splanchnic flows are not fully und...
INTRODUCTION: REBOA is a recognized rescue strategy in exsanguinating shock. Nevertheless, effects of partial- versus total-REBOA inflation on both macrocirculatory and microcirculatory splanchnic flows are not fully understood. METHODS: Controlled hemorrhagic shock was induced in 18 landrace pigs. After 30 minutes of shock, animals were randomly allocated to receiving partial-REBOA (n = 6), total-REBOA (n = 6), or no-REBOA (n = 6). Resuscitation with whole blood was initiated 25 minutes after balloon inflation (in both REBOA groups) or attaining shock (in no-REBOA group). Thereafter, the balloon was progressively deflated according to hemodynamic tolerance. Aortic root, femoral, and end-diastolic left ventricular pressures were monitored throughout the experiment. Simultaneous carotid, supra-celiac abdominal aorta and superior mesenteric artery flows were recorded, while microvascular flows at jejunal-serosa and mucosa were assessed by laser Doppler flowmetry (LDF) and sidestream dark-field video-microscopy. Mesenteric-venous blood samples were drawn to measure blood gases and lactate levels. All macrohemodynamic and microhemodynamic parameters were followed up to 4 hours of completing REBOA deflation (or its equivalent-time in no-REBOA group). RESULTS: Total-REBOA group showed the highest increase in aortic-root and coronary perfusion pressures during inflation, but these decreased significantly during reperfusion period, compared with partial- and no-REBOA ( p < 0.001). Partial- and total-REBOA groups showed significant decreases in superior mesenteric artery flow during reperfusion period compared with no-REBOA ( p < 0.001). However, partial-REBOA allowed some flow during inflation while enabling significantly better jejunal-microvascular flow assessed by LDF during reperfusion period, when compared with total-REBOA ( p = 0.048). The proportion of jejunal-villi with predominant continuous flow was significantly higher in partial- than total- or no-REBOA groups ( p < 0.01). The total-REBOA group had higher arterial and mesenteric-venous lactate levels both during occlusion and reperfusion periods ( p = <0.001; p = <0.001, respectively) when compared with partial-REBOA and no-REBOA groups. CONCLUSION: Partial-REBOA preserved regional-mesenteric and intestinal microcirculatory blood flow during both balloon occlusion and the early reperfusion period compared with total-REBOA. Partial-REBOA was also related with more favorable mesenteric venous pH and lactate values during balloon occlusion and reperfusion phases.
Cognitive dysfunction after polytrauma in the absence of traumatic brain injury: A systematic review of incidence.
Naumann A, Hinwood M, Balogh ZJ … +1 more , Newcastle, Australia
J Trauma Acute Care Surg · 2026 Jun · PMID 41636752 · Publisher ↗
BACKGROUND: Polytrauma patients frequently experience long-term health impacts, including cognitive impairments. While traumatic brain injury (TBI) is a recognized nonmodifiable cause, polytrauma patients are likely to f...
BACKGROUND: Polytrauma patients frequently experience long-term health impacts, including cognitive impairments. While traumatic brain injury (TBI) is a recognized nonmodifiable cause, polytrauma patients are likely to face cognitive challenges potentially linked to systemic inflammation and multiple surgical interventions even in the absence of TBI. This review aims to describe the incidence and identify factors associated with cognitive dysfunction in adult multiple injury patients without Frank TBI. METHODS: A systematic search was conducted across MEDLINE, CINAHL, EMBASE, and Scopus databases on August 17, 2023, to identify studies reporting on cognitive dysfunction in adults with polytrauma, excluding brain injuries. The Critical Appraisal Skills Programme checklists guided study appraisal, and findings were narratively synthesized. RESULTS: From 2719 articles identified (including one through citation searching), 47 were fully screened, yielding 10 cohort studies for inclusion. The reported incidence of cognitive dysfunction among multiple injury patients without TBI varied widely, from 0% to 60%, with a majority (eight out of ten studies) noting incidences of 30% or higher. No consensus was found for a relationship of other studied factors with cognitive dysfunction. Injury Severity Score was found to not be associated with cognitive dysfunction in selected studies which analyzed this factor. CONCLUSION: This review suggests a high prevalence of cognitive dysfunction in multiple injury patients without TBI. The evidence base is limited by heterogeneity of the inclusion criteria, and the cognitive outcome measures. IMPLICATIONS OF KEY FINDINGS: Multiple injury is associated with long term cognitive dysfunction even without primary brain injury. This aspect of the disease of multiple injury needs further characterization to identify predictors and potential preventive and therapeutic interventions. Standardized reporting is also required to be able to monitor incidence and prevalence. ( J Trauma Acute Care Surg . 2026;100: 973-981. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Systematic Review; Level II.
Trauma-specific revision of the Japanese Association for Acute Medicine disseminated intravascular coagulation criteria improves outcome prediction in severely injured patients.
Sugimoto M, Takayama W, Wada T … +4 more , Ogura T, Morishita K, Japanese Observational Study for Coagulation and Thrombolysis in Early Trauma 2 (J-OCTET2) investigators, , Tokyo, Japan
J Trauma Acute Care Surg · 2026 Jul · PMID 41636725 · Publisher ↗
BACKGROUND: No universal definition of trauma-induced coagulopathy exists, and no validated scoring system accurately evaluates coagulopathy in patients with severe trauma. Although developed for sepsis and other critica...
BACKGROUND: No universal definition of trauma-induced coagulopathy exists, and no validated scoring system accurately evaluates coagulopathy in patients with severe trauma. Although developed for sepsis and other critical illnesses, the conventional Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) score's applicability to trauma populations remains controversial. This study aimed to evaluate the JAAM DIC score's diagnostic performance in patients with severe trauma and develop a trauma-specific coagulopathy scoring system based on its original components. METHODS: This retrospective study analyzed data from a multicenter trauma cohort between April 1, 2018, and March 31, 2019. Patients 18 years or older with severe trauma and an Injury Severity Score of ≥16 were included. The primary outcome was defined as all-cause in-hospital mortality. The secondary outcomes were 24-hour mortality, cause-specific in-hospital mortality (exsanguination, traumatic brain injury [TBI], and others), and massive transfusion incidence. The conventional JAAM DIC variables' predictive performance for all-cause in-hospital mortality, 24-hour mortality, death due to exsanguination, TBI-induced death, and massive transfusion occurrence were assessed using receiver operating characteristic curves. A new trauma DIC score was developed using the optimal cutoff values and compared with the conventional scores. RESULTS: Among 719 patients analyzed, optimal cutoff values for predicting in-hospital mortality were a prothrombin time-international normalized ratio of 1.080, fibrin degradation products of 116.0 μg/mL, and platelet count of 17.0 (×10 4 /μL). The DIC group had higher all-cause mortality rates than the non-DIC group. The new trauma DIC score outperformed the conventional score for predicting all-cause mortality, 24-hour mortality, TBI-induced death, and massive transfusion requirements; however, both performed similarly for exsanguination-induced death. CONCLUSION: We developed a trauma-specific DIC score that outperformed the conventional score for predicting clinical outcomes in patients with severe trauma. While promising for trauma populations, external validation in various clinical settings is warranted. ( J Trauma Acute Care Surg. 2026;101: 121-128. © 2026 The Author (s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE: Multicenter Retrospective Cohort Study; Level IV.
Thrombocytosis is desirable in polytrauma: Natural history and clinical outcomes.
Ramzee AF, Thevathasan A, King KL … +3 more , Hinwood M, Balogh ZJ, New Castle, Australia
J Trauma Acute Care Surg · 2026 Jun · PMID 41636723 · Publisher ↗
BACKGROUND: Thrombocytosis in major trauma patients has been reported with equivocal clinical relevance. We aimed to describe the incidence and natural history of thrombocytosis in intensive care unit (ICU)-admitted poly...
BACKGROUND: Thrombocytosis in major trauma patients has been reported with equivocal clinical relevance. We aimed to describe the incidence and natural history of thrombocytosis in intensive care unit (ICU)-admitted polytrauma patients at risk of multiple-organ failure (MOF). METHODS: A 19-year retrospective study ending in December 2023 was performed on a Level 1 center's prospective institutional MOF database. All adults with an Injury Severity Score (ISS) of >15 and ICU patients who survived >48 hours were included. All adults with nonmechanical trauma, isolated traumatic brain injury (TBI), or spinal cord injury or those without sequential platelet monitoring were excluded. Platelet counts were collected until death, discharge, or 28 days. Thrombocytosis and extreme thrombocytosis (ET) were defined as >450,000/μL and >1,000,000/μL. Descriptive statistics were calculated, and mortality, MOF, and venous thromboembolic outcomes were compared between groups. For mortality, multivariable logistic regression was performed adjusting for age, ISS, TBI, and systolic blood pressure. RESULTS: A total of 797 patients were included (age, 48.8 years; 75% male; 96% blunt; median ISS, 29). Incidence of thrombocytosis was 63% (503 of 797 patients) with ET of 16.5% (83 of 797 patients). Thrombocytosis patients had higher admission counts peaking at 14 to 17 days. Groups did not differ in sex and TBI severity. Thrombocytosis patients were younger and had lower systolic blood pressure on admission and longer median ICU and hospital length of stay (8 vs. 6 and 27 vs. 12, p < 0.005). Incidence of MOF and venous thromboembolism did not differ. Mortality was lower in the thrombocytosis group (7.6% vs. 18%, p < 0.001). One ET patient died. Multiple-organ failure developed in 176 (22%) with incidence of thrombocytosis of 5% (103 of 176 patients). The mean Denver scores between thrombocytosis and no thrombocytosis did not differ, but mortality was lower in the thrombocytosis group (adjusted odds ratio, 0.05; 95% confidence interval, 0.01-0.15). CONCLUSION: Thrombocytosis (63%) is frequent in polytrauma patients and is associated with favorable outcomes without higher risk for complications. Early thrombocytosis and rising platelet trajectories may act as a surrogate marker for better chance to survive, and its therapeutic potential warrants detailed exploration. ( J Trauma Acute Care Surg . 2026;100:922-928. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Retrospective and observational study, level III.
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