J Trauma Acute Care Surg [JOURNAL]
Sun
200 papers
Extracorporeal membrane oxygenation in trauma patients with major pulmonary contusion.
Rafaqat W, Simpson MK, Lagazzi E … +7 more , Nzenwa IC, Panossian VS, Abiad M, Arnold SC, Velmahos GC, DeWane MP, Renne BC
J Trauma Acute Care Surg · 2026 Jun · PMID 42318910 · Publisher ↗
BACKGROUND: Patients with pulmonary contusion (PC) may require extracorporeal membrane oxygenation (ECMO) due to respiratory failure refractory to conventional management. We aimed to compare outcomes in patients with ma...
BACKGROUND: Patients with pulmonary contusion (PC) may require extracorporeal membrane oxygenation (ECMO) due to respiratory failure refractory to conventional management. We aimed to compare outcomes in patients with major PC who received ECMO with those who received conventional management. METHODS: We performed a retrospective cohort study using the Trauma Quality Improvement Program Database (2017-2020). We identified adult patients with major PC who underwent veno-arterial or veno-venous ECMO or had respiratory failure and received mechanical ventilation. The primary outcome was survival to discharge. Secondary outcomes included the rate of pulmonary embolism, stroke, and ventilator-associated pneumonia. We used 1:1 propensity matching to adjust for patient and injury characteristics. We used stepwise logistic regression to identify predictors of survival among PC patients undergoing ECMO. RESULTS: We included 611 patients, of whom 106 (17%) underwent ECMO. Among 102 well-matched pairs, there was no difference in the rate of mortality (37% vs. 29%; p=0.23), pulmonary embolism (5% vs. 6%; p=0.76), or stroke (7% vs. 3%; p=0.19). The rate of ventilator-associated pneumonia was significantly lower in ECMO patients (14% vs. 36%; p<0.001). Among patients undergoing ECMO, 67 (63%) survived to discharge. In-hospital cardiac arrest, severe head injury, and age over 50 years were associated with lower survival, while anticoagulant use was associated with higher odds of survival. CONCLUSION: ECMO is safe in trauma patients with major PC and may be associated with lower morbidity. Young patients without severe head injuries, cardiac arrest, and contraindications to anticoagulation may benefit most from ECMO. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic Study; Level IV.
Prolonged tourniquet use in extremity trauma: What you need to know.
Lammers D, Henry R, McClellan J … +7 more , Armen S, Koch E, Sulava E, Lefebvre T, Eckert M, Inaba K, Holcomb JB
J Trauma Acute Care Surg · 2026 Jun · PMID 42312871 · Publisher ↗
Routine tourniquet use has significantly improved early survival in both military and civilian settings for extremity hemorrhage in trauma patients. However, most supporting evidence revolves around short-duration tourni...
Routine tourniquet use has significantly improved early survival in both military and civilian settings for extremity hemorrhage in trauma patients. However, most supporting evidence revolves around short-duration tourniquet use stemming from trauma systems with rapid evacuation and early surgical care. Emerging military operations and austere civilian settings risk prolonged prehospital times, introducing uncertainty in the management of prolonged tourniquet application. These scenarios present high-risk situations for medical providers and potentially life-threatening complications for patients. Despite this, management strategies during these scenarios remain poorly defined. This review synthesizes current military and civilian literature to address key challenges in prolonged ischemia, including tourniquet conversion, decision-making surrounding limb salvage versus early amputation, and the pathophysiology and management of ischemia reperfusion injury.
Contrast-enhanced ultrasound for the diagnosis of abdominal solid organ injuries in children.
Stoeckel A, Garvey EM, Bailey S … +12 more , Riemann M, Ebert M, Hammer M, Russell KW, Larsen KE, Scholz S, Squires JH, Kwon JK, Volberg F, Taylor GA, Daugherty RJ, Mooney DP
J Trauma Acute Care Surg · 2026 Jun · PMID 42306848 · Publisher ↗
BACKGROUND: Identification of abdominal solid organ injuries in children relies on the use of computerized tomography (CT) scan, despite its radiation. Although ultrasound has a low diagnostic sensitivity for solid organ...
BACKGROUND: Identification of abdominal solid organ injuries in children relies on the use of computerized tomography (CT) scan, despite its radiation. Although ultrasound has a low diagnostic sensitivity for solid organ injuries, contrast-enhanced ultrasound (CEUS) has high sensitivity in single-center analyses. We conducted a prospective multicenter trial to identify the sensitivity of CEUS in the identification of abdominal solid organ injuries. METHODS: Stable patients with an abdominal solid organ injury on CT scan underwent grayscale/Doppler and CEUS within 48 hours. US and CEUS images were interpreted locally and centrally by radiologists blinded to CT results and were compared with their respective CT's. RESULTS: Sixty-seven patients had 82 organ injuries identified on local CT review, 55 (67.1%) were identified on grayscale/Doppler ultrasound and 67 (81.7%) on CEUS. Nine organ injuries missed by CEUS were wrongly diagnosed in an organ adjacent to a CT-diagnosed organ injury. The remaining six missed organ injuries were grade 1 or 2, two of which were not seen on central CT. The local CEUS positive predictive value (PPV) was 93.0%, negative predictive value (NPV): 94.1%, sensitivity: 81.7%, and specificity: 98.0%. There were no adverse events. Image transmission concerns precluded central review of 10 injuries in 33 organs. Seventy-two organ injuries were identified on central CT, 33 of which were identified on grayscale/Doppler (45.8%) and 56 (77.8%) on CEUS. CEUS missed sixteen organ injuries, 10 of which were adjacent to a CT-identified organ injury. The remaining six missed organ injuries were grade 1 or 2. Central CEUS PPV was 91.8%, NPV: 93.3%, sensitivity: 77.8%, and specificity: 96.9%. CONCLUSIONS: CEUS identifies around 80% of CT-diagnosed abdominal solid organ injuries in this multicenter trial and may be a valuable first imaging study in certain children with potential abdominal solid organ injuries. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level II.
Letter to the editor regarding "reassessing the timing of percutaneous gastrostomy tube placement: too many too soon".
Ni Y, Zhang F, Zhang R
J Trauma Acute Care Surg · 2026 Jun · PMID 42301242 · Publisher ↗
Abstract loading — click title to view on PubMed.
Traumatic hemothorax activates complement, stimulates proinflammatory cytokine release, and primes neutrophils for local inflammatory reactive oxygen species production.
Barmettler NK, White CM, Gawargi FI … +17 more , Maginot ER, Moody TB, Sextro K, Hiser D, Clegg AA, Hamed M, Tierney JF, Cantrell E, Lamb GD, Matos M, Veatch J, Moore EE, Moore HB, Moore PK, Bauman ZM, Henry R, Barrett CD
J Trauma Acute Care Surg · 2026 Jun · PMID 42299516 · Publisher ↗
BACKGROUND: Traumatic hemothorax (HTX) is a frequent complication of chest wall injury, with ~300,000 cases annually in the United States. Pain often signifies underlying inflammation and may contribute to secondary comp...
BACKGROUND: Traumatic hemothorax (HTX) is a frequent complication of chest wall injury, with ~300,000 cases annually in the United States. Pain often signifies underlying inflammation and may contribute to secondary complications after chest wall injury. We hypothesized that HTX leads to local, intrapleural complement activation and release of proinflammatory cytokines that can prime neutrophils for inflammatory reactive oxygen species (ROS) release. METHODS: Adult trauma patients (N=15) with chest wall injury and HTX were consented for the study with IRB approval. HTX fluid and corresponding blood plasma were obtained in 3.2% citrate. Multiplex assays for complement analytes and proinflammatory cytokines were performed. Neutrophils from healthy donors were obtained and co-incubated with control platelet-poor plasma (PPP), trauma PPP, or corresponding HTX fluid and then challenged with vehicle control or N-formyl-methionyl-leucyl-phenylalanine (fMLP) in the presence of luminol, with ROS measured as luminescence over time. Pairwise comparisons were performed. Significance was set at p <0.05. RESULTS: Compared with circulating trauma PPP, HTX fluid had significant local elevations of complement components Ba, C3a, C4a, and sC5b-9 (all p <0.01). Inflammatory cytokines showed a similar local elevation in HTX relative to trauma PPP, including TNF-alpha, IFN-gamma, IL-8, and MCP-1 (all p <0.05). Neutrophils did not generate significant ROS in response to healthy PPP, trauma PPP, or HTX in the absence of fMLP. When challenged with fMLP, HTX co-incubated neutrophils generated marked ROS that was significantly greater than trauma PPP co-incubated neutrophils ( p <0.05), demonstrating marked local neutrophil priming in HTX, while plasma co-incubated neutrophils were not primed for ROS generation. CONCLUSIONS: Traumatic HTX is a highly inflammatory condition with locally enhanced complement activation, proinflammatory cytokine release, and inflammatory neutrophil priming for ROS production beyond that of circulating trauma plasma. Pain and secondary complications after chest wall injury with HTX may benefit from anti-inflammatory treatments in addition to pain control and drainage. ( J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). STUDY TYPE: Original Research. LEVEL OF EVIDENCE: Basic Science; N/A.
Clinical outcomes of hemostatic interventions in patients with traumatic injury: A systematic review of randomized controlled trials.
Winearls J, Ashrafi E, Wang E … +5 more , McPaul A, Reade MC, Wake E, Higgins A, McQuilten ZK
J Trauma Acute Care Surg · 2026 Jun · PMID 42296330 · Publisher ↗
BACKGROUND: Hemorrhage is a leading cause of preventable death following trauma, and numerous randomized controlled trials (RCTs) have evaluated hemostatic interventions. However, inconsistency in outcome reporting hinde...
BACKGROUND: Hemorrhage is a leading cause of preventable death following trauma, and numerous randomized controlled trials (RCTs) have evaluated hemostatic interventions. However, inconsistency in outcome reporting hinders evidence synthesis and guideline development. We systematically reviewed outcomes reported in RCTs of hemostatic interventions for trauma to identify variability in outcome domains, definitions, and measurement time points. METHODS: Following the PRISMA guidelines, we searched Ovid MEDLINE, EMBASE, and CENTRAL from inception to May 2025. Eligible studies were RCTs evaluating hemostatic interventions in trauma patients of any age. Two reviewers independently screened records, extracted data, and categorized outcomes into domains. Data were summarized descriptively. The review was prospectively registered with PROSPERO (ID:). RESULTS: Of 6,752 records screened, 110 studies were included (2005-2025). Most trials were parallel-group RCTs (88.2%), with a median sample size of 314 participants (IQR, 99-680). Tranexamic acid was the most common intervention studied (39.1%). Mortality was reported as the primary outcome in 56.4% studies, most frequently assessed at 28 to 30 days. Of all trials, 36.4% reported a statistically significant difference in the primary outcome. Patient-centered outcomes were infrequently assessed: quality of life (7.3%), functional status (2.7%), and disability (25.5%). CONCLUSIONS: Outcome reporting in RCTs of hemostatic interventions for trauma remains highly heterogeneous. Mortality is the most common primary endpoint, whereas patient-centered outcomes are rarely reported. Consensus on a Core Outcome Set with patient input would standardize reporting, improve comparability, and strengthen evidence for future trauma care research and policy, while also ensuring outcomes reflect patient priorities. (J Trauma Acute Care Surg. 2026;000: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Systematic Review; Level I.
Contemporary outcomes of flail chest injuries: An update from ACS-TQIP (2017-2023).
Gabriel L, Ramesh H, Amarasinghe R … +3 more , Gaddam M, Dehghan N, Kartiko S
J Trauma Acute Care Surg · 2026 Jun · PMID 42296258 · Publisher ↗
BACKGROUND: Flail chest represents one of the most severe forms of blunt thoracic injury and is associated with significant morbidity and mortality. Much of the understanding of flail chest epidemiology, and outcomes cam...
BACKGROUND: Flail chest represents one of the most severe forms of blunt thoracic injury and is associated with significant morbidity and mortality. Much of the understanding of flail chest epidemiology, and outcomes came from Dehghan et al. (2014). Since then, flail chests management has undergone substantial evolution. Given these changes, we sought to examine the outcomes of flail chest that accurately reflects current clinical practice. METHODS: This is a retrospective study analyzing the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) 2017 to 2023 data on flail chest patients. Propensity-score matching was performed to compare clinical outcomes in patients SSRF versus no SSRF. Multivariable analysis was performed to compare the outcome of flail chest patients with concomitant head injury or pulmonary contusion. Our primary outcome is in-hospital mortality, with mechanical ventilation, hospital and Intensive Care Unit (ICU) length of stay (LOS), and the rate of pneumonia, sepsis, and tracheostomy. RESULTS: A total of 41,542 patients with flail chests were identified, 19,170 after matching. Overall, 29.08% required mechanical ventilation, 4.99% tracheostomy, 6.24% in-hospital mortality, 3.66% VAP incidence, and 2.22% ARDS. SSRF patients had a significantly lower rate of in-hospital mortality compared with nonoperative patients (3.3% vs. 9.2%, p<0.01). However, SSRF was associated with a longer hospital LOS (11.9 vs. 7.2 days, p<0.01), ICU LOS (8 vs. 5 days, p<0.01), and higher rate of unplanned ICU admission (7.5% vs. 4.4%, p<0.01) in flail chest patients. CONCLUSIONS: Compared with Dehghan et al. (2014), our analysis demonstrates significant improvements: mechanical ventilation rate decreased from 59% to 29.08%, tracheostomy from 21% to 4.99%, and mortality from 16% to 6.24%. These reductions in morbidity and mortality reflect a decade of optimized critical care and standardized management in flail chest trauma. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level III (Prognostic/ Epidemiological).
An in vivo assessment of green plasma: The potential hemostatic superiority of a currently discarded blood product.
Williams JM, Redden SC, Sun DJ … +5 more , Wang YW, McNutt MK, Cardenas JC, Olson SD, Cotton BA
J Trauma Acute Care Surg · 2026 Jun · PMID 42296209 · Publisher ↗
INTRODUCTION: Approximately 5% of donated plasma has a green appearance, due to elevated ceruloplasmin levels from increased estrogen. These products are currently discarded based on color alone. However, studies have sh...
INTRODUCTION: Approximately 5% of donated plasma has a green appearance, due to elevated ceruloplasmin levels from increased estrogen. These products are currently discarded based on color alone. However, studies have shown improved trauma outcomes from female donors. In an ex vivo study, we recently noted accelerated and increased clot production with green plasma. The purpose of this study was to assess whether these findings could be confirmed in an in vivo animal model of severe hemorrhage. METHODS: We utilized a well-established rat model of uncontrolled hemorrhage. Following cannulation and anesthesia, 33 rats underwent midline laparotomy followed by excision of 50% of the middle hepatic lobe to induce hemorrhage. After 60 seconds, GREEN (11 rats), standard FEMALE (11), or MALE plasma (11) were infused at a fixed volume of 5 mL. Abdominal cavity blood was collected to evaluate blood loss every 15 minutes for 60 minutes. Deaths occurring before experiment termination were recorded. RESULTS: Rats resuscitated with GREEN plasma had improved shock index compared with FEMALE and MALE at 15 (3.7 vs. 6.2 vs. 10.2; p=0.092), 30 (3.8 vs. 8.2 vs. 6.5; p=0.039), and 60 minutes (3.9 vs. 29.9 vs. 7.1; p=0.015). Mean arterial pressures in GREEN plasma-resuscitated rats were higher at 30 (p=0.032) and 60 minutes (p=0.115). Cumulative percent blood volume lost was lower at each time point in those receiving GREEN plasma. Survival to 60 minutes was 100% among GREEN and FEMALE plasma rats but only 64% among MALE resuscitated ones (p<0.001). CONCLUSIONS: Our study demonstrated that green plasma has improved efficacy for reducing bleeding and restoring hemodynamic stability compared with standard plasma in a rodent model of uncontrolled hemorrhage. Combined with our recent ex vivo data noting equivalent (often superior) hemostatic potential compared with standard units, we recommend reintroducing this often-discarded AABB-approved product back into the plasma donor pool. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level V.
CAB versus ABC in trauma resuscitation: When physiology meets selection bias.
Hachimi-Idrissi S
J Trauma Acute Care Surg · 2026 Jun · PMID 42296084 · Publisher ↗
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Risk factors associated with significant posttraumatic brain hemorrhage as per the QueBIC categories: A retrospective multicenter study.
Benhamed A, Crombé A, Matichard R … +7 more , Seux M, Frassin L, L'Huillier R, Millon D, Emond M, Tazarourte K, Gorincour G
J Trauma Acute Care Surg · 2026 Jun · PMID 42283508 · Publisher ↗
BACKGROUND: Among adults with mild traumatic brain injury (mTBI), only a minority develop clinically significant intracranial hemorrhage requiring neurosurgical intervention or causing death. The Quebec Brain Injury Cate...
BACKGROUND: Among adults with mild traumatic brain injury (mTBI), only a minority develop clinically significant intracranial hemorrhage requiring neurosurgical intervention or causing death. The Quebec Brain Injury Categories (QueBIC) stratifies risk based on computed tomography (CT) morphology, with complications occurring mainly in moderate/high-risk categories. Identifying pre-CT clinical predictors of these categories could help prioritize imaging and monitoring. We aimed to identify such predictors in complicated mTBI and assess concordance between QueBIC and the Canadian CT Head Rule (CCHR). METHODS: We conducted a retrospective multicenter cohort study of adults ≥18 years with complicated mTBI (GCS 13-15 plus intracranial hemorrhage and/or skull fracture) who underwent head CT between January 2020 and December 2022. QueBIC categories were assigned from radiology reports by two radiologists and two emergency physicians. Multivariable logistic regression identified independent pre-CT predictors of moderate/high QueBIC risk. Diagnostic performance metrics were estimated, and QueBIC-CCHR concordance was described. RESULTS: Among 2,253 patients (median age 66.3 y [IQR: 47.9-80.6]; 65.6% male), 42.6% were classified as moderate/high by QueBIC. Antithrombotic medication independently increased the risk of moderate/high QueBIC: antiplatelet therapy, OR: 1.41 (95% CI: 1.06-1.88); anticoagulants, OR: 2.25 (1.40-3.60); and dual therapy, OR: 2.49 (1.11-5.55). Older age was associated with higher risk: 65-74 years, OR: 1.52 (1.11-2.08); ≥75 years, OR: 1.66 (1.24-2.22). Confusion was the strongest clinical correlate, with an OR of 18.67 (13.06-27.33). Suspected skull vault fracture was also associated, OR: 2.09 (1.61-2.72). CCHR frequently assigned high risk where QueBIC remained low or moderate: among CCHR-high patients, 48.5% were QueBIC-low, 36.3% QueBIC-moderate, and 15.2% QueBIC-high. Conversely, among CCHR-low patients, 79.6% were QueBIC-low. CONCLUSIONS: In complicated mTBI, pre-CT risk per QueBIC is mainly driven by antithrombotic exposure, older age, confusion, and suspected skull fracture. CCHR shows moderate concordance and tends to overestimate risk compared with morphology-based stratification. These findings support using QueBIC-informed pathways to guide imaging and monitoring. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVELS OF EVIDENCE: Prognostic and Epidemiological Study, Level III.
Tracking the big picture during wartime: A national trauma registry perspective.
Amir T, Talmy T, Radomislensky I … +13 more , Givon A, Khanchin G, Dym I, Akler D, Gershgoren H, Eidelman P, Shapiro A, Benov A, Afek A, Gendler S, Israel Trauma Group (ITG), Ramat Gan, Israel, Israel Trauma Group (ITG) and Ramat Gan, Israel
J Trauma Acute Care Surg · 2026 Jun · PMID 42283458 · Publisher ↗
BACKGROUND: Trauma registries are a core component of modern trauma systems for surveillance, quality improvement, and research. During armed conflicts, the need for timely, population-level data increases; however, the...
BACKGROUND: Trauma registries are a core component of modern trauma systems for surveillance, quality improvement, and research. During armed conflicts, the need for timely, population-level data increases; however, the functioning of national trauma registries during active war has been sparsely described. This study describes the performance of Israel's National Trauma Registry (INTR) during the 2023-2025 Swords of Iron War, and reports key wartime injury epidemiology alongside the central operational processes implemented to support both civilian and military health care systems. METHODS: We conducted a retrospective analysis of all hospitalized civilian and military casualties with war-associated injuries recorded in the INTR between October 7, 2023, and July 31, 2025. The primary analysis focused on descriptive epidemiology and clinical outcomes, while a secondary descriptive component addressed operational adaptations of the national trauma registry during the conflict. RESULTS: A total of 4,317 war-related trauma casualties were recorded, including 3,071 military personnel (71.1%) and 1,246 civilians (28.9%). Admissions peaked during the initial 48 to 72 hours of the war. Military casualties more frequently sustained penetrating injuries, with a higher proportion of critical injury (ISS ≥25) compared with civilians (10.8% vs. 5.8%). Serious thoracic, abdominal, facial, and upper-extremity injuries (Abbreviated Injury Scale≥3) were more common among military personnel; civilians exhibited a higher burden of lower-extremity trauma. More than half of all casualties underwent operative intervention, one-fifth of military casualties required intensive care, and overall in-hospital mortality remained low (~2%). CONCLUSIONS: INTR maintained continuous, high-quality surveillance of casualties throughout the Swords of Iron War. Through targeted operational and methodological adaptations, the registry enabled real-time characterization of evolving wartime injury patterns, system burden, and outcomes, while supporting clinical and policy decisions under extreme conditions. These findings highlight the critical role of national trauma registries for trauma system management during armed conflicts. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: IV.
Executing balanced resuscitation in bleeding combat casualties: Good versus good enough?
Van Gent JM, Staudt AM, Gurney JM … +1 more , Cotton BA
J Trauma Acute Care Surg · 2026 Jun · PMID 42283455 · Publisher ↗
BACKGROUND: Data-driven best practices recommend balanced resuscitation in a 1:1:1 (RBC:FFP:PLT) ratio - supported by a randomized trial demonstrating a reduction in mortality from exsanguination. Although adoption of th...
BACKGROUND: Data-driven best practices recommend balanced resuscitation in a 1:1:1 (RBC:FFP:PLT) ratio - supported by a randomized trial demonstrating a reduction in mortality from exsanguination. Although adoption of this is widely advertised, recent civilian literature has shown that adherence is poor. We sought to evaluate the adherence to balanced resuscitation in the first 6 hours among combat casualties injured in Iraq and Afghanistan. METHODS: A retrospective analysis was performed using the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock data set. Injured combat casualties, with available transfusion timing data, treated at US military medical treatment facilities in Afghanistan and Iraq between 2002 and 2022, were included. Patients who received any whole blood (WB) were compared with those who received only component therapy (CT). Primary outcomes were calculated as RBC:FFP and RBC:PLT ratios, at 15-minute intervals from the time of injury through 6 hours. RESULTS: In all, 4,500 casualties met the inclusion criteria, with 793 receiving WB and 3,707 receiving only CT. The median age was 25 (21, 30), 96% were male, with a mortality rate of 13.5%. Among these, 66% sustained blast/explosion mechanism, with a median injury severity score of 18 (12, 29). By 6 hours, 52% versus 48% and 80% versus 69% of WB versus CT patients had achieved a 1:1 and 1.5:1 RBC:FFP ratio, respectively. Median RBC:PLT ratios showed greater variability, ranging from 1:1 to 2:1 in WB patients and 2:1 to 4:1 in CT patients. At all time points, WB patients achieved better ratios for both plasma and platelets. CONCLUSIONS: Approximately 50% of US combat casualties are resuscitated in a balanced fashion, far greater than that observed in recent civilian data. However, a higher proportion of patients with an early use of WB achieved 1:1:1. Wider availability of WB and increasing inventory of platelets and plasma products should be explored to improve battlefield resuscitation. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic and Epidemiological (Retrospective comparative study with up to two negative criteria); Level III.
Historical redlining and neighborhood deprivation are associated with caregiver exclusion following evaluation for suspected child physical abuse: A multicenter study.
Wilson NA, Lima SM, Lillvis D … +16 more , Wu YS, Fabiano T, Nordin AB, Edwards M, Mechlowicz S, Desai M, Vu N, Duron V, Wallenstein K, Salik I, Wilson S, Sofjan I, Philipose J, Bullaro F, Klein-Cloud R, Wakeman DS
J Trauma Acute Care Surg · 2026 Jun · PMID 42283443 · Publisher ↗
BACKGROUND: Neighborhood socioeconomic disadvantage, measured by Area Deprivation Index (ADI), is associated with disparities in health care and child welfare responses following evaluation for suspected child physical a...
BACKGROUND: Neighborhood socioeconomic disadvantage, measured by Area Deprivation Index (ADI), is associated with disparities in health care and child welfare responses following evaluation for suspected child physical abuse. We sought to determine whether historical redlining and contemporary spatial social polarization strengthen associations between neighborhood disadvantage and caregiver exclusion at discharge, a system-level outcome reflecting child welfare involvement. METHODS: This multicenter retrospective cohort study included children (age <18 y) admitted with suspected/ confirmed physical abuse at 7 New York pediatric trauma centers (2011-2023). Home addresses were linked to neighborhood disadvantage measures, including ADI, Social Vulnerability Index, Child Opportunity Index, Index of Concentration at the Extremes for race, income, and racialized economic segregation, and a Historic Redlining Score (HRS). The primary outcome was caregiver exclusion at discharge (legal removal from the home environment). Univariable and multivariable mixed-effects models adjusted for age, Injury Severity Score, and admission year. RESULTS: Of 1,242 patients, 517 (41.6%) experienced caregiver exclusion. These children were more often Black (29.6% vs. 20.0%, p < 0.001) and lived in neighborhoods with greater disadvantage [median (interquartile range); ADI: 78.0 (52.3 to 93.0) vs 52.5 (18.0 to 84.0); Child Opportunity Index: 26.0 (5.0 to 51.0) vs 31.0 (8.0 to 62.5), p < 0.001], compared with those without caregiver exclusion. Compared with ADI Quartile 1, children in the most disadvantaged neighborhoods (ADI: Q4) had 4.93-fold higher odds of caregiver exclusion (95% CI: 2.75 to 8.85). Inclusion of HRS improved model performance (area under the curve: 0.825 → 0.833); each unit increase in HRS increased the odds of caregiver exclusion by 38% (p = 0.045). CONCLUSIONS: Neighborhood deprivation is strongly associated with caregiver exclusion following hospitalization for suspected child physical abuse. This relationship is strengthened by incorporating historical redlining measures. These findings highlight the intersection of structural neighborhood disadvantage and system-level responses to child safety concerns, suggesting that historic patterns of disinvestment may continue to shape child welfare involvement. (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. STUDY TYPE: Multicenter Retrospective Cohort Study.
Buprenorphine analgesia: Impacts on opioid burden and clinical trajectory in acute trauma care.
Conde-Yassin S, Gillen J, Stodghill J … +4 more , Collins M, Bower K, Faulks E, Collier B
J Trauma Acute Care Surg · 2026 Jun · PMID 42283437 · Publisher ↗
BACKGROUND: Schedule II opioids are widely used for trauma analgesia but carry dose-dependent risks of respiratory depression, tolerance, hyperalgesia, and addiction. Buprenorphine, a Schedule III opioid, is a potent ana...
BACKGROUND: Schedule II opioids are widely used for trauma analgesia but carry dose-dependent risks of respiratory depression, tolerance, hyperalgesia, and addiction. Buprenorphine, a Schedule III opioid, is a potent analgesic with a more favorable safety profile; however, its integration into trauma care remains uncharacterized. METHODS: A single-center observational study included adult trauma patients admitted to a Level I trauma center from January 2021 to June 2024. The trauma service formalized buprenorphine analgesia in June 2023. Outcomes were assessed by (1) an unadjusted pre/post June 2023 analysis (pre-BΔ vs. post-BΔ) and (2) a 1:1 nearest-neighbor propensity score-matched comparison of post-BΔ patients who received (Bup+) or did not receive (Bup-) buprenorphine. Bup+ and Bup- groups were matched by demographics and injury characteristics. Sublingual/buccal and parenteral buprenorphine were assigned morphine milligram equivalents (MME) conversion factors of 30 and 100, respectively. Incidence rate ratios (IRRs) with 95% CI were calculated; significance was set at p <0.05. RESULTS: Unadjusted analysis included 3,935 patients (2,777 pre-BΔ; 1,158 post-BΔ). Increased buprenorphine use was associated with reduced MME (median, 138 pre-BΔ vs. 75 post-BΔ; p < 0.001; IRR, 0.70; 95% CI, 0.69-0.71), lower intensive care unit (ICU) admission rates (IRR, 0.78; 95% CI, 0.73-0.83), and shortened ICU length of stay (IRR, 0.87; 95% CI, 0.80-0.94). In the matched post-BΔ cohort (n = 544) buprenorphine use was associated with lower ICU admission (IRR, 0.63; 95% CI, 0.54-0.73) and shorter ICU length of stay (IRR, 0.67; 95% CI, 0.59-0.75); median MME did not differ (114 vs. 91, p = 0.187), though IRR analyses demonstrated lower opioid exposure (IRR, 0.82; 95% CI, 0.81-0.83). Across analyses, no differences were observed in survival or adverse events. CONCLUSIONS: In trauma patients, Schedule III buprenorphine analgesia was associated with reduced inpatient opioid exposure and ICU escalation. Further validation may establish buprenorphine as an advance in opioid stewardship for vulnerable trauma populations. (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.
Ionized calcium after trauma should be interpreted as a pH-dependent resuscitation trajectory.
Yang Y
J Trauma Acute Care Surg · 2026 Jun · PMID 42283426 · Publisher ↗
Abstract loading — click title to view on PubMed.
Combat casualty care in the American Revolution: Perils of a fragmented medical command structure.
Hiroshige KM, Stein JY, Stewart BJ … +2 more , Barr J, Cannon JW
J Trauma Acute Care Surg · 2026 Jun · PMID 42283418 · Publisher ↗
In 1775, American medicine faced its first and arguably greatest test: building a military medical system while actively fighting a superior enemy. In the wake of the Battle of Bunker Hill, the Continental Congress hasti...
In 1775, American medicine faced its first and arguably greatest test: building a military medical system while actively fighting a superior enemy. In the wake of the Battle of Bunker Hill, the Continental Congress hastily passed a perfunctory resolution creating the Continental Army Medical Department. Leaders of this fledgling department struggled to manage bitterly divided and inexperienced teams, critical supply shortages, and overwhelming patient numbers. With varying degrees of success, they worked to overcome these daunting challenges to care for America's army. This article explores leadership lessons from America's inaugural military medical system, offering actionable insights for modern surgical leaders striving to restore and sustain military medical readiness today.
Fresh frozen plasma-first approach is independently associated with improved survival in severely injured patients undergoing massive transfusion.
Hynes AM, Westein RJ, Turner TJ … +5 more , Conrardy RD, Yang K, Boyle KA, Levin JH, de Moya MA
J Trauma Acute Care Surg · 2026 Jun · PMID 42275580 · Publisher ↗
BACKGROUND: Despite evidence supporting high fresh frozen plasma (FFP)-to-packed red blood cell (PRBC) ratios, the optimal initial blood product in severe injury is unknown. We hypothesized that an FFP-first approach is...
BACKGROUND: Despite evidence supporting high fresh frozen plasma (FFP)-to-packed red blood cell (PRBC) ratios, the optimal initial blood product in severe injury is unknown. We hypothesized that an FFP-first approach is associated with improved survival. METHODS: An observational Trauma Quality Improvement Program (2013-2021), including patients who received at least 5 units of PRBCs and 1 unit of FFP within four hours of arrival, was performed. Nonsurvivable injury patterns and pre-existing coagulopathy were excluded. Treatment effects were estimated with propensity score-weighted risk adjustment models, clustering by center. The primary outcome was six-hour mortality. Secondary outcomes were 24-hour and in-hospital mortality. A subanalysis was performed on the severe head-injured, and a sensitivity analysis examined inclusion criteria and additional blood products (platelets and cryoprecipitate). Effect modification was assessed for injury type. RESULTS: A total of 50,580 patients were included, with 13,818 in the FFP-first approach. Mean age was 39 years, with 77% males, 60% blunt trauma, and a mean Injury Severity Score of 27. Subanalysis included 15,912 patients, and the exposure sensitivity analysis included 27,217 patients. Unadjusted six-hour, 24-hour, and in-hospital mortality for the PRBC-first approach were 9.8%, 15%, and 28%, respectively, compared with 8.9%, 14%, and 27% for the FFP-first approach. A PRBC approach was independently associated with worse six-hour (adjusted Odds Ratio [aOR], 1.10; 95% CI, 1.02-1.18), 24-hour (1.11; 1.05-1.18), and in-hospital mortality (1.06; 1.01-1.11). The subgroup analysis of the PRBC aOR was 1.08 (95% CI, 0.95-1.23). In the exposure sensitivity analysis, the PRBC aOR was 1.02 (95% CI, 0.94-1.09). The blood products analysis was congruent with the main analysis. Effect modification was not present for injury type; however, penetrating mechanism was significantly associated with early death. CONCLUSIONS: Although the effect was modest in magnitude, a FFP-first approach was independently associated with improved survival through hospital discharge. Future prospective or randomized trials are warranted. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.
Blunt cerebrovascular injury after ground-level falls: Yield of CT angiography and relevance of the expanded Denver criteria.
Furtmann A, Lopez-Schultz S, Howk A … +1 more , Gerard J
J Trauma Acute Care Surg · 2026 Jun · PMID 42268658 · Publisher ↗
BACKGROUND: Blunt cerebrovascular injuries (BCVI) are nonpenetrating traumatic injuries to the carotid or vertebral arteries that can result in stroke. While the incidence of BCVI in admitted trauma patients is estimated...
BACKGROUND: Blunt cerebrovascular injuries (BCVI) are nonpenetrating traumatic injuries to the carotid or vertebral arteries that can result in stroke. While the incidence of BCVI in admitted trauma patients is estimated at 1% to 2%, the risk specifically after ground-level falls (GLF) is not well described. Current screening practices vary, with some centers using criteria such as the expanded Denver criteria while others have adopted universal computed tomographic angiography (CTA) screening. This study aimed to quantify BCVI incidence following GLF and describe the distribution of BCVI by expanded Denver criteria in this population. METHODS: A single-center retrospective cohort study was conducted at a regional Level I trauma center from 2016 to 2024. Adult GLF patients evaluated by the trauma team who underwent CTA at index trauma evaluation comprised the primary imaging cohort, with BCVI incidence as the primary outcome. Patients were stratified by expanded Denver criteria status. An administrative database separately identified GLF patients with a stroke diagnosis during the same hospitalization who underwent structured physician adjudication to determine BCVI attribution. RESULTS: Of 1,732 GLF patients with CTA performed, 1,045 met the inclusion criteria. BCVI was identified in 67 patients (6.4%), all of whom met expanded Denver criteria. Among Denver criteria-positive patients, BCVI was identified in 67/599 (11.2%), while none of the 446 criteria-negative patients had BCVI. Among 193 GLF patients with confirmed strokes adjudicated separately, none were BCVI-attributable. CONCLUSIONS: All identified BCVIs in this cohort occurred in patients meeting expanded Denver criteria, and no BCVIs were identified among criteria-negative patients. Among 193 adjudicated stroke patients, none were BCVI-attributable. Strict application of expanded Denver criteria would have avoided 446 CTAs in criteria-negative patients, supporting its use as a resource-conscious selective screening strategy in GLF patients. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Diagnostic Study; Level III.
Reconciling the academic mission with workforce reality in acute care surgery.
Murphy PB, Patel MB, Joseph B … +6 more , Cripps MW, Callcut RA, Evans C, de Moya M, Milwaukee, WI,, Society of Acute Care Surgery Chiefs (SACSC)
J Trauma Acute Care Surg · 2026 Jun · PMID 42258835 · Publisher ↗
ABSTRACT: Recent multicenter studies have explored the current and desired clinical work for acute care surgeons. Acute care surgeons oversee and provide comprehensive care in trauma, surgical critical care, emergency ge...
ABSTRACT: Recent multicenter studies have explored the current and desired clinical work for acute care surgeons. Acute care surgeons oversee and provide comprehensive care in trauma, surgical critical care, emergency general surgery, and burn patients. While these studies provide crucial data to guide planning at individual institutions to help address understaffed programs, translating this research into local practice and culture requires nuance and consideration of system (regional, institutional, department, and divisional) factors and individual surgeon goals. This opinion piece confronts the paradox at the heart of academic acute care surgery: how can surgeons deliver on educational and research missions when staffing models place the highest prioritization on clinical work? We present a practical, evidence-based framework that aligns sustainable clinical staffing with preservation of the tripartite academic mission in acute care surgery. LEVEL OF EVIDENCE: Level V.
Interpreting prophylactic antibiotic use in closed basilar skull fractures: caution in claims-based evidence.
Wang Y
J Trauma Acute Care Surg · 2026 Jun · PMID 42257860 · Publisher ↗
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