J Trauma Acute Care Surg [JOURNAL]
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200 papers
Traumatic extraperitoneal bladder repair is associated with fewer leaks and shorter catheter duration.
Holliday TL, Wiseman JE, Cain CD … +5 more , Strong BL, Gupta S, Broderick ME, Scalea TM, Ley EJ
J Trauma Acute Care Surg · 2026 Jul · PMID 42185069 · Publisher ↗
BACKGROUND: Societal guidelines for the management of extraperitoneal bladder injuries (EBIs) are based on limited evidence. Current recommendations support nonoperative management of simple EBIs despite a high persisten...
BACKGROUND: Societal guidelines for the management of extraperitoneal bladder injuries (EBIs) are based on limited evidence. Current recommendations support nonoperative management of simple EBIs despite a high persistent urinary leak rate. Conversely, operative management is often associated with a lower leak rate. This study evaluated clinical outcomes associated with operative versus nonoperative management of EBIs. We hypothesized that cystorrhaphy would be associated with fewer persistent urinary leaks, reduced catheter duration, fewer infectious complications, and decreased interval imaging use and timing. METHODS: An 8-year retrospective review (2017-2024) of EBIs was conducted within a university-based Level I/II trauma system. Those who died during hospitalization, underwent suprapubic catheterization, or sustained ureteral, urethral, or intraperitoneal bladder injuries were excluded. Demographic, injury, and management variables were abstracted. Patients were stratified by initial management strategy (operative vs. nonoperative). Outcomes included persistent urinary leak, catheter duration, infectious complications, and interval imaging use and timing. RESULTS: Seventy patients met the inclusion criteria, of whom 39 (55.7%) underwent operative repair. Demographics and injury characteristics were similar across cohorts, although operative patients had larger (2.3 vs. 1.3 cm, p <0.01) and higher-grade injuries (American Association for the Surgery of Trauma grade ≥3: 71.8% vs. 25.8%, p <0.01). Operative repair was associated with fewer urinary leaks on interval imaging (2.6% vs. 25.8%, p =0.01) and shorter urinary catheter duration (17.6 ± 13.2 vs. 31.1 ± 24.9 d, p =0.01). No significant differences were observed between cohorts with respect to catheter-associated urinary tract infections (38.5% vs. 45.2%, p =0.57), pelvic hardware infections (15.4% vs. 12.9%, p =0.73), frequency (84.6% vs. 96.8%, p =0.12) or timing (15.9 vs. 19.7 d, p =0.39) of interval imaging. CONCLUSIONS: Operative repair of EBIs is associated with reduced urinary leak rates and catheter duration despite greater bladder injury severity. Other outcomes were similar between strategies. Concomitant cystorrhaphy during non-urologic abdominal or pelvic operations may expedite recovery in selected patients. ( J Trauma Acute Care Surg . 2026;101: 65-70. Copyright © 2026 The Author(s). Published byWolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Nonoperative management of rib fractures results in a high incidence of nonunion and malunion.
Hopper W, Roberts J, Kells J … +6 more , Halvorson E, Antes N, Fisher B, Benz C, Dyke C, Fargo, North Dakota
J Trauma Acute Care Surg · 2026 May · PMID 42185053 · Publisher ↗
BACKGROUND: The true incidence of nonunion (NU) and malunion (MU) after traumatic rib fractures is unknown. Furthermore, contributory injury and patient factors to help guide treatment remain unclear. METHODS: We conduct...
BACKGROUND: The true incidence of nonunion (NU) and malunion (MU) after traumatic rib fractures is unknown. Furthermore, contributory injury and patient factors to help guide treatment remain unclear. METHODS: We conducted a retrospective cohort study of hospitalized patients with multiple traumatic rib fractures treated nonoperatively between 2014 and 2025 at a Level I trauma center. We included those with documented computed tomography imaging of the chest obtained at the time of injury and at least six months after injury. Study investigators assessed computed tomography imaging for NU (defined as persistent fracture gap) and MU (defined as abnormal angulation and cortical irregularity). Multivariable logistic regression was used to evaluate fracture charactereistics on the likelihood of developing NU/MU. RESULTS: NU/MU was present in 40 of 219 patients (18.3%) and in 96 of 1229 individual fractures (7.8%). Regression modeling with anatomic rib-level covariates demonstrated bicortical displacement to be associated with NU/MU with an odds ratio of 20.9 (95% CI: 8.2-53.2, p < 0.001). Posterior location, flail segment, and offset fractures were also independently associated with NU/MU. In secondary regression analysis including patient-level covariates, smoking status was an independent predictor of NU/MU development (odds ratio: 2.8; 95% CI: 1.3-6.0, p = 0.006). CONCLUSIONS: NU and MU were common after nonoperative management of chest wall trauma and strongly associated with bicortical displacement. Flail segment, posterior fracture location, and smoking status were also significant risk factors. Further work is needed to explore how surgical stabilization may influence the development or prevention of NU and MU. III. (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.
Initial identification of severely injured pediatric trauma patients-Clinical signs, scoring systems, and anticipating acute intervention needs: What you need to know.
Gomez MK, Piehl MD, Ross SW … +2 more , Neff LP, Winston-Salem, North Carolina
J Trauma Acute Care Surg · 2026 May · PMID 42173520 · Publisher ↗
Severely injured children are often first evaluated at nonpediatric designated hospitals where high-acuity pediatric trauma is seldom encountered, and delays in recognition of physiologic compromise can adversely affect...
Severely injured children are often first evaluated at nonpediatric designated hospitals where high-acuity pediatric trauma is seldom encountered, and delays in recognition of physiologic compromise can adversely affect outcomes. While the general principles of initial assessment and triage parallel those used in adults, children have important anatomic and physiologic differences that warrant a tailored approach in the early evaluation and resuscitation. Effective stabilization of critically injured children depends not only on clinical expertise but also on institutional preparedness and coordinated multidisciplinary care. Trauma surgeons and frontline physicians must be equipped to recognize subtle signs of deterioration, initiate rapid resuscitation, and mobilize the resources necessary to deliver either definitive or temporizing care prior to transfer. This review provides a practical, high-yield framework for the rapid identification and initial management of critically injured pediatric trauma patients. Ultimately, sustained efforts to increase pediatric readiness across all centers are critical to reduce preventable morbidity and mortality in pediatric trauma.
Antibiotic regimen optimization for severe exsanguination in a live swine model.
Livezey JB, Anklowitz A, Chow DR … +7 more , McKinley TMR, Williams T, Riddle L, Horton J, Kuckelman JP, Aranda M, Fort Gordon, Georgia
J Trauma Acute Care Surg · 2026 Jun · PMID 42172650 · Publisher ↗
BACKGROUND: Sepsis is a significant contributor to mortality for trauma patients beyond 48 hours from their initial trauma, in addition to being a major source of morbidity in the elective surgery population. Prophylacti...
BACKGROUND: Sepsis is a significant contributor to mortality for trauma patients beyond 48 hours from their initial trauma, in addition to being a major source of morbidity in the elective surgery population. Prophylactic antibiotics are recommended for patients presenting with penetrating trauma due to this risk. Current guidelines do not provide definitive recommendations on redosing for patients requiring blood transfusions. We sought to characterize the bioavailability of prophylactic antibiotics in the setting of severe hemorrhage and whole-blood resuscitation in a swine model. METHODS: Sus Scrofa swine underwent a controlled hemorrhage and whole-blood resuscitation protocol following the administration of weight-based vancomycin. Control animals did not undergo hemorrhage or transfusion. Experimental animals underwent a controlled hemorrhage followed by a whole-blood resuscitation starting at 2 units and increasing to 10 units in 2-unit increments. Serum vancomycin levels were collected at regular time intervals over a 4-hour period. RESULTS: There was a shorter time to reach subtherapeutic serum vancomycin levels within the 4, 6, 8, and 10-unit arms compared with the control arm. There was a significant decrease in serum vancomycin level immediately following the hemorrhage and transfusion in the 4, 6, 8, and 10-unit arms when compared with similar time intervals from vancomycin infusion of the control arm. CONCLUSIONS: Prophylactic vancomycin dosing was subtherapeutic after four units of whole-blood resuscitation for massive hemorrhage in our swine model. Redosing at more frequent intervals may be considered for patients who have more than four to six units of hemorrhage. (J Trauma Acute Care Surg. 2026;100:929-935. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic; Level II.
Evaluation of thoracolumbar spine injury utilizing plain film and physical exam in the pediatric population: A multicenter study.
Prabhala T, Herzog A, Scheub R … +14 more , Ata A, Adamo MA, Bevington T, Fabiano T, Pierce D, Salik I, Edelman D, Pierson L, Coffey B, Wakeman DS, Chess M, Wallenstein K, Edwards M, Albany, New York
J Trauma Acute Care Surg · 2026 Jun · PMID 42172649 · Publisher ↗
OBJECTIVES: Pediatric thoracolumbar spinal injuries (TLSIs) are rare and uncommonly require intervention. In adults, plain x-ray is not adequate to screen for spinal injury. In children, plain film utilization for screen...
OBJECTIVES: Pediatric thoracolumbar spinal injuries (TLSIs) are rare and uncommonly require intervention. In adults, plain x-ray is not adequate to screen for spinal injury. In children, plain film utilization for screening is variable and supportive evidence is lacking. Liberal CT screening for TLSI in children results in significant unnecessary radiation exposure. We investigated the utility of plain x-rays and physical exam (PE) to screen children for TLSI. METHODS: Children aged 1 to 18 years with MRI or CT-confirmed TLSI presenting to one of five Level 1 pediatric trauma centers between 2017 and 2022, who had a plain film involving the injured spine, were identified. ICD10 codes for injuries, imaging types, intervention (surgery or bracing), age, mechanism, BMI, fracture type (thoracic, lumbar, both), comorbidities, PE findings, and type of radiograph (spine, chest, abdomen) were identified and compared. RESULTS: Two hundred thirty-two children with MRI or CT-confirmed TLSI and plain x-rays were identified (46% thoracic, 34.9% lumbar, 18.1% both). 57.3% (n=133) of patients underwent dedicated spine radiographs, while the others had only chest (n=87, 37.5%) or only abdominal (n=10, 4.3%) radiographs. In total, 13.79% of patients underwent surgery, 43.9% required bracing, and the remaining had no intervention. Of the patients with dedicated spine films, x-rays alone were 82.7% sensitive for injury and 100% sensitive for injury needing surgery. Patients with lumbar spine injuries who had positive spine x-rays and suspicious PE findings were significantly more likely to require intervention (p<0.0001). No child with a normal spinal x-ray in the lumbar region required intervention, regardless of PE findings. CONCLUSIONS: In this retrospective study, dedicated spinal x-rays combined with PE reliably excluded >99% of all injuries and 100% of injuries requiring intervention. These findings suggest children can be effectively screened for TLSI with PE and spinal x-rays, reserving cross-sectional imaging for positive x-ray findings and persistent PE findings on repeat exam. (J Trauma Acute Care Surg. 2026;100:915-921. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.
Readiness accelerators for military general surgeons: Insights from acute care surgery fellowship programs.
Dilday JC, Fannon EEH, Remick K … +8 more , De Moya M, Gurney J, Jurkovich GJ, Galante JM, Elster E, Knudson M, Russo RM, Sacramento, California
J Trauma Acute Care Surg · 2026 May · PMID 42153383 · Publisher ↗
BACKGROUND: Maintaining expeditionary surgical readiness during peacetime is a persistent Military Health System challenge, particularly for general surgeons assigned to low-volume military treatment facilities. Knowledg...
BACKGROUND: Maintaining expeditionary surgical readiness during peacetime is a persistent Military Health System challenge, particularly for general surgeons assigned to low-volume military treatment facilities. Knowledge, Skills, and Abilities-Clinical Activity (KSA-CA) metrics quantify procedural readiness against operational benchmarks, yet many active-duty surgeons do not meet established thresholds. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery (ACS) fellowship includes a dedicated operative year with high-volume trauma and emergency general surgery exposure that could offer insights for how to accelerate procedural readiness, but its performance against KSA-CA standards has not been evaluated. METHODS: We performed a retrospective, cross-sectional analysis of procedural case logs from fellows enrolled in AAST ACS fellowship programs between February 2021 and April 2023, limited to procedures performed during the 12-month ACS operative year. Each logged Current Procedural Terminology code was scored using the general surgery KSA-CA algorithm, which maps >2,000 Current Procedural Terminology codes to 49 procedure groups. Readiness was defined as achieving a KSA-CA score at or above the established threshold. RESULTS: Case logs from 26 of 32 approved AAST ACS fellowship sites contained eligible entries, representing 102 fellows and 24,493 logged procedures. Among fellows meeting inclusion criteria (n = 73), the median cumulative KSA-CA score was 25,464 (IQR, 7,132-42,415). All fellows who completed the ACS year achieved the KSA-CA readiness threshold (100%); 95% achieved readiness before the end of the year, and 93% met readiness within 6 months. Top contributing procedure groups included intra-abdominal open hollow viscus operations, thoracic (or "pneumonectomy" group in KSA nomenclature), and debridement of muscle and fascia. CONCLUSIONS: The AAST ACS fellowship curriculum reliably meets military procedural readiness standards as measured by KSA-CA metrics in 12 months or less. The ACS fellowship sites and curricular structure have the potential to accelerate expeditionary readiness among Military Health System general surgeons. (J Trauma Acute Care Surg. 2026;000: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Diagnostic Tests or Criteria, Level IV.
Characterization of the binding of skeletal muscle myosin to fibrin in trauma.
Yang CJ, Rodolf AA, Garay JP … +18 more , Kelmser EC, Lira AL, Pang J, Vu HH, Deguchi H, Peterson DF, McKibben NS, Hutchison CE, Trapalis T, Shatzel JJ, Puy C, Aslan JE, Working ZM, Schreiber MA, Hutchens MP, Griffin JH, McCarty OJT, Portland, Oregon
J Trauma Acute Care Surg · 2026 May · PMID 42138510 · Publisher ↗
BACKGROUND: The procoagulant phenotype of skeletal muscle myosin (SkM) includes the promotion of thrombin generation to form fibrin, and subsequent increased resistance of fibrin clots to fibrinolysis. The release of SkM...
BACKGROUND: The procoagulant phenotype of skeletal muscle myosin (SkM) includes the promotion of thrombin generation to form fibrin, and subsequent increased resistance of fibrin clots to fibrinolysis. The release of SkM into circulation following localized tissue injury is hypothesized to promote systemic hypercoagulation. Yet, in trauma patients and in animal models of tissue injury, an unexplained decrease in SkM levels has been observed. METHODS: Plasma samples were collected from orthopedic trauma patients at admission and 6 weeks later and from pigs subjected to experimentally extensive muscle injury. Plasma SkM and myoglobin levels were measured. The binding of SkM to fibrin was quantified in vitro using fluorescence imaging assays. Fibrinolysis was measured using turbidimetric assays and thromboelastography. RESULTS: SkM plasma levels in trauma patients were lower at admission compared to 6 weeks later, while plasma myoglobin levels were higher at admission than at 6 weeks. In the pig injury model, plasma SkM levels at 24 hours after injury were decreased, while myoglobin levels were increased. In vitro, SkM bound to fibrin, but not fibrinogen, with an apparent Kd of 0.18 μM and was associated with a decrease in the level of SkM in solution. Fluorescence imaging of the fibrin clots confirmed the presence of SkM within fibrin clots, which increased the resistance of the fibrin clot to fibrinolysis. CONCLUSIONS: Direct binding of SkM to fibrin may explain the reduced circulating SkM levels observed after trauma and may help identify potential roles for SkM in trauma-associated coagulopathy. ( J Trauma Acute Care Surg . 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic; Level III.
Trends in length-of-stay per total body surface area burn in pediatric patients: A report from the pediatric injury and quality improvement collaborative.
Bergus KC, Thakkar R, Wurster LA … +13 more , Aguayo P, Fabia R, Garmon B, Hodgman E, Horvath K, Klein J, Malaniak M, Marx D, Vitale L, Waibel E, Wharton K, Schwartz D, Columbus, Ohio
J Trauma Acute Care Surg · 2026 May · PMID 42138466 · Publisher ↗
BACKGROUND: Previous studies have shown that a length of stay (LOS) of one day per percent total body surface area (TBSA) burn is expected in children with burn injuries, with variability by mechanism. Recent practice ha...
BACKGROUND: Previous studies have shown that a length of stay (LOS) of one day per percent total body surface area (TBSA) burn is expected in children with burn injuries, with variability by mechanism. Recent practice has shifted towards earlier discharge and outpatient management. We predicted that an updated multi-institutional analysis of LOS/TBSA burn would demonstrate a downward trend. METHODS: A retrospective study from five pediatric burn centers conducted between March 2022 and February 2025 of burn patient demographics and clinical course metrics. LOS/TBSA burn ratios were calculated and compared across multiple variables using χ2 and Kruskal-Wallis tests. p <0.05 was considered statistically significant. RESULTS: Among 1,543 unique patients, 57.4% were male and the median age was 2.52 years [interquartile range (IQR), 1.32-7.1]. Burn etiology was most commonly scald burn (55.3%), as well as flame/fire-related burns (10.7%), and other mechanisms (34.0%). Most burns were small, with 56.0% of patients presenting with TBSA burn <5% and 27.4% of patients with TBSA burn 5% to 10%. Inhalation injury was rare (2.7%). Median LOS/TBSA for all burn patients was 0.6 days (IQR, 0.33-1.2). Patients with accidental injuries had significantly shorter median LOS/TBSA than those with nonaccidental injuries [0.61 d (IQR, 0.33-1.14) vs. 1.31 d (IQR, 0.50-2.31); p<0.001]. Median LOS/TBSA also varied significantly by mechanism of burn injury [cald 0.48 d (IQR, 0.29-0.88) vs. fire-related 0.90 d (IQR, 0.50-1.60) vs. other 1.00 d (IQR, 0.50-2.00); p<0.001]. CONCLUSIONS: Data from this multi-institutional cohort of pediatric burn patients reports updated burn injury demographics and establishes that the median LOS/TBSA burn is less than the previously established one-day/TBSA burn. Focus on earlier discharge and frequent outpatient visits likely decreased median LOS/TBSA. Factors such as nonaccidental etiology and fire-related burn led to higher predicted LOS/TBSA, and these families should be counseled accordingly. Total burn care delivered, rather than inpatient census, should be used to set standards for pediatric burn centers. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level II.
Limitations of blood supply and walking blood bank implementation in Forward Resuscitative Surgical Detachments during large-scale combat operations: A Monte Carlo simulation model.
Nye K, Wang JC, Remondelli MH … +16 more , Wang A, Seamons B, Wang M, Atwood RE, Yuan TT, Ho VB, Bozzay JD, Do WS, Green JT, Powell EK, Gurney JM, Burmeister DM, Elster EA, Bradley MJ, Walker PF, Bethesda, Maryland
J Trauma Acute Care Surg · 2026 May · PMID 42138372 · Publisher ↗
BACKGROUND: Hemorrhage remains the leading cause of preventable battlefield mortality. Although early whole blood resuscitation improved outcomes during the Global War on Terror, this relied on permissive operational con...
BACKGROUND: Hemorrhage remains the leading cause of preventable battlefield mortality. Although early whole blood resuscitation improved outcomes during the Global War on Terror, this relied on permissive operational conditions unlikely to persist in future large-scale combat operations (LSCO). Projected LSCO casualty volumes may rapidly overwhelm current Role 2 Forward Resuscitative Surgical Detachments (FRSDs), and walking blood banks (WBB) may provide only minimal augmentation. This study evaluates blood supply resilience for a Role 2 FRSD across LSCO casualty scenarios and quantifies the incremental benefit of WBB augmentation. METHODS: A discrete-time, daily-step simulation model was developed in Python to model whole blood dynamics for a Role 2 FRSD over a 30-day conflict. Inventory was tracked using an age-segmented inventory. Baseline stock was 120 units with a resupply of 120 units every 3 days. A 100-donor WBB (56-day deferral) was incorporated. Daily casualties were stochastically generated across escalating intensity, with transfusion demand calculated assuming 20% of casualties required transfusion at 8 units per patient. Primary outcomes included days-to-failure (first unmet unit) and percent demand met over 30 days. RESULTS: Model-generated aggregate demand closely matched LSCO planning estimates (mean, 30-day demand 10,075.2 units vs. expected 10,080). Conventional supply alone failed rapidly once average casualties exceeded 30/day [median, 2 days; interquartile range (IQR), 1-5]. WBB augmentation extended survivability from 30 casualties/day to 11 days (IQR, 7-22) but declined to 5 days (IQR, 2-7) at 40 casualties/day and to 2 days (IQR, 2-4) at 50 casualties/day, with near-immediate failure at higher rates. Demand fulfillment declined sharply as casualty rates increased and was only modestly improved by WBB support. CONCLUSIONS: Current FRSD blood supply strategies are not sustainable under LSCO casualty conditions. WBBs provide limited surge buffering but cannot replace scalable resupply and forward sustainment in contested environments. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Consensus Statement on the management of patients with rib fractures.
Park C, Schwed AC, Buhavac M … +8 more , Coleman JR, Cross A, Jacovides CL, Yoo B, Agarwal S, Rappold J, Savage SA, Philadelphia, Pennsylvania
J Trauma Acute Care Surg · 2026 May · PMID 42138302 · Publisher ↗
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Early surgical stabilization of multiple rib fractures: A data-derived timing threshold and the case for systems-based chest wall care.
Shaikh FA, Charles EJ, Curran T … +1 more , Nemeth ZH
J Trauma Acute Care Surg · 2026 May · PMID 42130336 · Publisher ↗
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The extended postoperative complication score: A dual-axis reporting plan for general surgery.
Coccolini F, Cicuttin E, Chirica M … +22 more , Reva V, Coimbra R, Sartelli M, Isik A, Biffl WL, Cremonini C, Colli A, Besola L, Mariani D, Kluger Y, Ceresoli M, Kurihara H, Cimino M, Moore EE, Kessel B, Horer T, Ferrada P, Kirkpatrick AW, Pikoulis M, Catena F, Bass G, Pisa, Italy
J Trauma Acute Care Surg · 2026 May · PMID 42130329 · Publisher ↗
BACKGROUND: Grading surgical complications and sequelae is of paramount importance for analyzing results and improving patient care and system performance and in optimizing resource allocation and use. Existing systems f...
BACKGROUND: Grading surgical complications and sequelae is of paramount importance for analyzing results and improving patient care and system performance and in optimizing resource allocation and use. Existing systems for surgical complication classification do not consistently account for baseline physiologic vulnerability and often conflate treatment intensity with clinical severity. This limitation reduces interpretability across diverse patient populations, particularly in emergency and elective general surgery. METHODS: A multidisciplinary expert panel conducted a modified Delphi process to develop a dual-axis classification system, the Extended Postoperative Complication Score (EPCS). This system stratifies patients preoperatively into three baseline classes (A, B, C) reflecting physiologic reserve and immunocompetence. Postoperative events are then graded by physiologic impact from Grade 0 (minor, no impact) to Grade IV (death). Sequelae, defined as anticipated events related to underlying pathology or chronic disease, are separately categorized. Representatives of the most relevant international emergency and trauma surgical associations were involved (World Society of Emergency Surgery, European Society for Trauma and Emergency Surgery, American Association for the Surgery of Trauma, Panamerican Trauma Society, EndoVascular and Trauma Management Society, Global Alliance for Infections in Surgery). RESULTS: The EPCS yields 18 mutually exclusive strata, combining five complication grades and three baseline classes, plus three sequelae codes. The matrix enables interpretable outcome reporting across settings, accounting for both event severity and host vulnerability. Expert consensus confirmed conceptual clarity and operational feasibility. The system allows applications to elective, urgent, and emergent operations, and is compatible with clinical audit, observational research, and pragmatic trials. CONCLUSIONS: The EPCS provides a structured, physiologically anchored method for postoperative complication stratification. Its dual-axis design may improve the validity of outcome comparisons and support real-world evaluation of surgical quality. Further validation is warranted through prospective multicenter implementation and time-bound observational methodologies. ( J Trauma Acute Care Surg . 2026;100:700-706. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).
Early cystography after traumatic bladder repair is associated with shorter catheter duration and fewer CAUTIs without increased detection of postoperative leaks.
Holliday TL, Wiseman JE, Cain CD … +6 more , Strong BL, Gupta S, Broderick ME, Scalea TM, Ley EJ, Baltimore, Maryland
J Trauma Acute Care Surg · 2026 May · PMID 42112998 · Publisher ↗
BACKGROUND: Optimal postoperative management after traumatic bladder repair, such as imaging strategies and catheter duration, remains unclear and may affect the rate of catheter-associated urinary tract infections (CAUT...
BACKGROUND: Optimal postoperative management after traumatic bladder repair, such as imaging strategies and catheter duration, remains unclear and may affect the rate of catheter-associated urinary tract infections (CAUTIs). We evaluated early (≤7 d) versus late (≥8 d) or no postoperative cystography for traumatic bladder repairs, hypothesizing that early imaging would reduce catheter duration and CAUTI rates without increasing the rate of urinary leak detection. METHODS: We retrospectively reviewed trauma registry data from a university-based Level I and II trauma system from 2017 to 2024. Patients with full-thickness bladder injuries undergoing cystorrhaphy were included. Those with in-hospital mortality or concomitant ureteral and/or urethral injuries were excluded. Patients were stratified by timing of initial postoperative cystography: early versus late and early versus none. Primary outcomes included catheter duration, CAUTI rate, and urinary leak rate on initial postoperative imaging. RESULTS: One hundred eighteen patients met the inclusion criteria: 62 (52.5%) isolated intraperitoneal, 39 (33.1%) isolated extraperitoneal, and 17 (14.4%) combined injuries. Eighty-six (71.9%) sustained blunt trauma. Twenty-nine (24.6%) patients underwent early, 70 (59.3%) late, and 19 (16.1%) no postoperative imaging. There were more AAST grade 4 bladder injuries (79.3% vs. 45.7%, p<0.01) in the early versus late cystography cohort. Otherwise, there were no differences in patient demographics, mechanism, injury severity, associated injuries or interventions, or management strategies. Early postoperative imaging was associated with reduced catheter duration (7 [6-10] vs. 14 [11-18] d, p<0.01) and CAUTI rates (6.9% vs. 30%, p=0.02) compared with late imaging. Rates of urinary leak (3.5% vs. 8.6%, p=0.67) were similar. Early postoperative cystography was associated with reduced catheter duration (7 [6-10] vs. 10 [9-15] d, p<0.01) compared with no cystography. CONCLUSIONS: Despite having more high-grade injuries, early postoperative cystography was associated with reduced catheter duration and CAUTI rates without an increased urinary leak rate. Early imaging facilitates earlier catheter removal and improves outcomes. (J Trauma Acute Care Surg. 2026;000:000-000. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Characterizing bleeding risk of extracorporeal limb salvage with concomitant vascular injury.
Dvir M, Nye K, Qadri S … +6 more , Price C, Benike A, Tai N, Walker PF, Morrison JJ, Salt Lake City, UT
J Trauma Acute Care Surg · 2026 May · PMID 42112957 · Publisher ↗
BACKGROUND: Acute limb ischemia following trauma is a time-critical surgical emergency in which warm ischemia duration strongly determines limb salvage. Delays to revascularization are common in both civilian and militar...
BACKGROUND: Acute limb ischemia following trauma is a time-critical surgical emergency in which warm ischemia duration strongly determines limb salvage. Delays to revascularization are common in both civilian and military settings, prompting interest in extracorporeal limb perfusion strategies such as Lower Extremity Extracorporeal Distal Revascularization (LEEDR). However, concern exists that extracorporeal perfusion could exacerbate hemorrhage in the presence of uncontrolled vascular injury. METHODS: A porcine model of standardized groin hemorrhage was used to evaluate hemorrhage risk during LEEDR. Yorkshire swine were assigned to femoral arterial injury (FAI) or combined femoral arterial and venous injury (FAVI). Percutaneous vascular access was obtained in the contralateral femoral and ipsilateral saphenous vein. After controlled free bleeding of 300 mL via a 5 mm incision to the applicable vasculature and hemostasis with combat gauze, LEEDR was initiated using contralateral femoral arterial inflow and distal saphenous artery outflow. Pump speed was increased in 1,000 RPM increments every 10 minutes to a programmed maximum of 8,000 RPM or until system limits were reached. Hemorrhage during LEEDR was quantified, and injured vessels underwent histologic analysis at study completion. RESULTS: Twelve animals (FAI n=6, FAVI n=6) successfully underwent LEEDR. Maximal achieved RPM did not differ significantly between groups (6,708±990 vs. 6,442±1,107 RPM; p=0.67). No additional hemorrhage occurred in the FAI group. One FAVI animal experienced additional bleeding at high RPM, but overall post-LEEDR blood loss did not differ between groups (0±0 vs. 175±428.7 mL; P=0.34). Histology demonstrated intact early thrombus in arterial and venous injuries without evidence of washout. CONCLUSIONS: In this porcine model, LEEDR did not meaningfully exacerbate hemorrhage despite progressively increasing extracorporeal perfusion. Distal arterial resistance and favorable shear conditions may preserve thrombus integrity. These findings suggest vascular injury may represent a relative, rather than absolute, contraindication to LEEDR, supporting further feasibility evaluation. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level V evidence.
Surgical care at sea: A retrospective review of the maritime surgical and quality improvement database.
Schermerhorn SMV, Adkins CF, Sawczuk LM … +6 more , Capacio BA, Harding EP, Cannon KA, Wrenn-Maresh K, Tadlock MD, San Diego, California
J Trauma Acute Care Surg · 2026 May · PMID 42112953 · Publisher ↗
BACKGROUND: Surgical care aboard US Navy warships is delivered in a uniquely austere and operationally complex environment characterized by limited diagnostic resources, constrained evacuation options, and independent su...
BACKGROUND: Surgical care aboard US Navy warships is delivered in a uniquely austere and operationally complex environment characterized by limited diagnostic resources, constrained evacuation options, and independent surgical practice within an active weapons platform. Despite its importance to military medical readiness, objective outcomes-based evaluations of surgical care performed at sea remain limited. METHODS: We performed a retrospective review of a prospectively maintained Maritime Surgery and Quality Improvement database from February 2021 through December 2024, supplemented by longitudinal outcome data from the electronic medical record. Operative cases performed at sea were analyzed to characterize case mix, complication rates, and short and long-term outcomes. Complications were assessed intraoperatively, within 30 days, and up to one year following surgery when electronic follow-up was available. RESULTS: A total of 839 entries were recorded, including 322 operative cases and 22 nonoperative patients requiring MEDEVAC. Operative procedures encompassed a broad range of general surgical, orthopedic, gynecologic, urologic, and endoscopic pathology. Maritime surgeons managed both routine and high-acuity conditions, frequently outside traditional general surgery scope, in the absence of subspecialty support. Among operative cases, one intraoperative complication (0.3%) and 24 early postoperative complications (7.1%) were observed. Delayed complications occurred in 11 patients (5.3%) with available long-term follow-up. No deaths were attributed to surgical complications. Selected higher-acuity procedures, including laparoscopic cholecystectomy and diagnostic laparoscopy, were successfully performed at sea in carefully selected patients. CONCLUSIONS: In this multiyear, multiplatform cohort, carefully selected surgical interventions were performed safely at sea across a wide range of operative pathologies, with complication rates comparable to civilian benchmarks despite significant resource constraints. These findings provide objective data to inform operative decision-making, support surgeon-command risk assessment, and guide the development of evidence-informed clinical practice guidelines for surgical care in the deployed maritime environment. (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level IV.
Video versus direct laryngoscopy for tracheal intubation in trauma: A secondary analysis of the DEVICE trial.
Trent SA, Schauer SG, Prekker ME … +17 more , Driver BE, Gaillard JP, Herbert JT, Imhoff B, Latimer AJ, Mitchell SH, Page DB, Resnick-Ault D, Self WH, Shapiro NI, Smith LM, Whitson MR, Rice TW, Casey JD, Semler MW, Ginde AA, Pragmatic Critical Care Research Group, Denver, CO
J Trauma Acute Care Surg · 2026 May · PMID 42112946 · Publisher ↗
BACKGROUND: Endotracheal intubation is the most common airway intervention in the deployed combat setting, including far-forward Role 1 battalion aid stations. Intubation in this setting is often performed by novice intu...
BACKGROUND: Endotracheal intubation is the most common airway intervention in the deployed combat setting, including far-forward Role 1 battalion aid stations. Intubation in this setting is often performed by novice intubators, adding to the complexity of this time-sensitive intervention. Two types of laryngoscopes are commonly used to perform tracheal intubation: a direct laryngoscope (DL) and a video laryngoscope (VL). Data to inform deployed clinical practice guidelines for the best device are currently lacking. METHODS: We performed a preplanned secondary analysis of the DEVICE trial-a multicenter, pragmatic, randomized, parallel-group trial comparing the use of a VL to a DL for emergency intubation of critically ill adults. Only patients intubated in the setting of traumatic injury were included in this secondary analysis. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of a severe complication during intubation. The main analysis for both the primary and secondary outcomes was an unadjusted, intention-to-treat comparison of the outcome between groups using a χ2 test. RESULTS: Of the 1,417 patients in the DEVICE trial, 338 patients (24%) were intubated in the setting of a traumatic injury. Successful intubation on the first attempt occurred in 151 of 171 (88%) of patients randomized to a VL as compared to 114 of 167 (68%) of patients randomized to a DL (absolute risk difference 20%, 95% CI, 11%-29%). The incidence of severe complications during intubation and in-hospital outcomes did not significantly differ between groups. CONCLUSIONS: Among adults undergoing tracheal intubation in the setting of trauma, use of a VL significantly increased the incidence of successful intubation on the first attempt. Future guidelines, including the Joint Trauma System guidelines, should encourage VL use as the first-line approach for emergency intubation in trauma, especially for operators with limited experience. (J Trauma Acute Care Surg. 2026;00: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management, secondary analysis (retrospective) of prospectively collected data in a large RCT with a large effect, with only one negative criterion-inadequate power for secondary outcomes; Level II.
Optimizing aeromedical evacuation in combat: Balancing trauma system efficiency and patient outcomes.
Eidelman P, Dym I, Bendor CD … +13 more , Akler D, Radomislensky I, Dimand I, Amir T, Gershgoren H, Zemer-Tov B, Hershcovich I, Melaku E, Shapiro A, Benov A, Beer ZA, Nadler R, Ramat Gan, Israel
J Trauma Acute Care Surg · 2026 May · PMID 42112940 · Publisher ↗
BACKGROUND: The Israel Defense Forces Medical Corps (IDF-MC) operates an echelon-based system, evacuating combat casualties to civilian trauma centers. During multiarena conflicts, aeromedical evacuation of urgent casual...
BACKGROUND: The Israel Defense Forces Medical Corps (IDF-MC) operates an echelon-based system, evacuating combat casualties to civilian trauma centers. During multiarena conflicts, aeromedical evacuation of urgent casualties is directed to frontline-adjacent medical centers (FLAMCs) or to default medical centers (DMCs; Level I trauma centers) to prevent FLAMCs overwhelming. This study aims to assess the impact of casualty distribution on mortality outcomes. METHODS: This is a retrospective cohort study of IDF combat casualties evacuated by helicopter during the "Swords of Iron" war, between October 27, 2023, and January 19, 2025. Prehospital data from the IDF Trauma Registry were linked with in-hospital records from the Israel National Trauma Registry. Urgent casualties (danger to life or limb) evacuated by air with signs of life on board were included. Primary outcomes were 24-hour and 30-day mortality. Multivariable logistic regression was applied to compare outcomes among FLAMCs versus DMCs in the severely injured casualties (ISS ≥16) and fatalities. RESULTS: Of 5,649 casualties treated, 1,443 casualties met the inclusion criteria; 969 (67%) were routed to DMCs and 474 (33%) to FLAMCs. The predominant mechanism of injury was penetrating trauma (85%). Median evacuation time was 68 minutes (IQR: 54-93), 73 minutes (IQR: 59-97) to DMCs versus 60 minutes (IQR: 46-77) to FLAMCs (p<0.001). Prehospital shock (31% vs. 9.1%; p<0.001) and en route blood product administration (32% vs. 14%; p<0.001) were more frequent among casualties evacuated to FLAMCs. Evacuation to DMCs was associated with lower 24-hour and 30-day mortality rates (OR: 0.27; 95% CI: 0.09-0.70 and OR: 0.40; 95% CI: 0.17-0.87, respectively). CONCLUSIONS: In multiarena conflicts, aeromedical evacuation policy enables a well-balanced distribution of a high volume of casualties among medical centers while preventing overwhelming of frontline facilities, without worsening outcomes. LEVEL OF EVIDENCE: Prognostic and Epidemiological Study; Level III.
Beyond formatted criteria: Letter to the Editor to "Why research articles in acute care surgery get rejected: 10 critical mistakes to avoid".
Matsubara S
J Trauma Acute Care Surg · 2026 May · PMID 42112757 · Publisher ↗
Abstract loading — click title to view on PubMed.
The long road home: A WTA multicenter study of patient preferences and risk tolerance in the regionalization of acute care surgery.
Ambrose C, McGillen P, Forman S … +19 more , Maneval A, Gonzalez S, Shen A, Barmparas G, Zucker A, Jebbia M, Nahmias J, Montenegro M, Abdullah S, Luo-Owen X, Rosenthal M, Moren A, Rodriguez E, Gallagher S, Siletz A, Matsushima K, Inaba K, Martin MJ, Los Angeles, California
J Trauma Acute Care Surg · 2026 May · PMID 42112691 · Publisher ↗
BACKGROUND: Regionalization of acute care surgery (ACS) aims to improve outcomes by transferring complex cases from local hospitals to tertiary centers. Although improved outcomes have been demonstrated for select condit...
BACKGROUND: Regionalization of acute care surgery (ACS) aims to improve outcomes by transferring complex cases from local hospitals to tertiary centers. Although improved outcomes have been demonstrated for select conditions, regionalization may impose social and financial burdens, and patient preferences in the ACS setting remain poorly characterized. We evaluated patient preferences and risk tolerance related to ACS regionalization in a multicenter cohort. METHODS: We prospectively surveyed 602 adults with trauma or emergency general surgery (EGS) conditions at five trauma centers. Using a modified standard gamble utility assessment, patients indicated preferences for local care versus regional transfer under scenarios of equal perioperative risk and increasing hypothetical risks at their local hospital (absolute increases of 2%, 4%, 6%). Demographics and clinical variables were collected. Univariate analyses identified factors associated with local versus regional preference, and multivariable logistic regression determined independent predictors of site preference. RESULTS: Among 602 patients [67% EGS, 33% trauma, median age 50 (interquartile range: 24-61); 60% males], most preferred local care when complication or mortality risks were equivalent between hospitals (93% and 92%, respectively). As local risk increased, preference for local care declined; however, nearly half of patients preferred to remain at their local hospital despite a doubling of complication or mortality risk (4% vs. 2%). Preference for regional transfer at this inflection point was associated with higher household income, younger age, willingness to travel for specialty care, intensive care unit admission, and prior transfer. Trauma versus EGS diagnosis and mechanism did not predict site preference. Substantial variation in risk tolerance was observed across centers. CONCLUSIONS: ACS patients strongly prefer local care when outcomes are equivalent, and many are willing to forego interhospital transfer despite substantially increased risk. These findings highlight a discordance between patient preferences, risk tolerance, and regionalization practices, underscoring the need to incorporate patient perspectives into ACS transfer decision-making. (J Trauma Acute Care Surg. 2026;000: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prospective Observational Survey Study, Level III.
Neurosurgical and prehospital timing in severe traumatic brain injury: Insights from the prospective Resuscitation Outcomes Consortium hypertonic saline trial.
Kramer P, Vattipally VN, Menta AK … +11 more , Jillala RR, Jiang K, Aude CA, Bhimreddy M, Jo J, Suarez JI, Sakran JV, Haut ER, Huang J, Bettegowda C, Azad TD
J Trauma Acute Care Surg · 2026 May · PMID 42112670 · Publisher ↗
BACKGROUNDAND OBJECTIVES: Prompt management is critical in severe traumatic brain injury (TBI) to prevent secondary injury, but an unanswered question is whether, by the time patients reach the operating room, the injury...
BACKGROUNDAND OBJECTIVES: Prompt management is critical in severe traumatic brain injury (TBI) to prevent secondary injury, but an unanswered question is whether, by the time patients reach the operating room, the injury has largely become irreversible. We aimed to evaluate the impact of prehospital time, emergency department (ED) length of stay, and time to neurosurgical intervention on mortality and functional outcomes for these patients. METHODS: A retrospective cohort study was conducted using data from the prospective Resuscitation Outcomes Consortium TBI trial. Our cohort included adult patients with severe [ie, Glasgow Coma Scale (GCS) ≤8] TBI. Multivariable logistic and ordinal regression models were specified to test associations between prehospital time, ED length of stay, and time to neurosurgical intervention with inpatient mortality and functional outcomes at discharge. RESULTS: Among 859 patients included (median age, 34 y), most patients presented with a GCS of 3 (median, 3; interquartile range, 3-4). Multivariable logistic regression among the full cohort revealed no association between prehospital time or time to intracranial pressure (ICP) monitor placement and inpatient mortality. However, in a high acuity subgroup of 104 patients who underwent craniotomy within 12 hours and ICP monitoring, increasing time to ICP monitor placement was significantly associated with increased inpatient mortality [odds ratio (OR), 1.07 per hour; 95% confidence interval (CI), 1.00-1.16; p=0.04], reduced Glasgow Outcome Scale Extended (GOSE) at discharge (OR, 0.93 per hour; 95% CI, 0.87-1.00; p=0.03), and reduced GOSE at 6 months follow-up (OR, 0.93 per hour; 95% CI, 0.84-0.99; p=0.04). CONCLUSION: While prehospital and ED time intervals were not meaningfully associated with outcomes, delays in ICP monitor placement among patients needing urgent cranial surgery were significantly linked to higher mortality and poorer neurologic recovery, highlighting the importance of timely neurosurgical intervention in severe TBI. (J Trauma Acute Care Surg. 2026;000: 000-000. Copyright ©2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level 2. STUDY TYPE: Retrospective study.
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