J Trauma Acute Care Surg [JOURNAL]
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Winfield RD
J Trauma Acute Care Surg
· 2026 May · PMID 42112658
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Bills CB, Hochheimer CJ, Roberts SC
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, Fishchuk R, Peers J, Simon S, Omelianenko OV, Herych HL, Altanets OV, Beley NA, Bebarta CVS, Keenan CRS, Beaty L, Trent SA, Carlson NE, Ginde AA
J Trauma Acute Care Surg
· 2026 May · PMID 42085537
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BACKGROUND: Traumatic wound infections are a significant contributor to morbidity and mortality during war. Given challenges of performing clinical trials during war and the urgent need for interventions to prevent and t...BACKGROUND: Traumatic wound infections are a significant contributor to morbidity and mortality during war. Given challenges of performing clinical trials during war and the urgent need for interventions to prevent and treat infected traumatic wounds exacerbated by global increases in antimicrobial resistance, we developed the Prevention and Treatment Clinical Trials for Antimicrobial Resistance Research to Improve Outcomes of Traumatic Wounds in Ukraine (PACT-ARROW). We provide an overview of the protocol and implementation strategy. METHODS: PACT-ARROW is a multiarm multistage (MAMS) platform designed to evaluate the safety, efficacy, and effectiveness of device and therapeutic interventions to optimize outcomes of patients hospitalized in Ukraine with acute traumatic wounds. The aim is to improve standard or available care with the possibility to study multiple interventions simultaneously. A platform steering committee will review potential interventions, determine alignment with the mission of the protocol, and promote those with sufficient evidence to warrant testing in a trial. RESULTS: PACT-ARROW has undergone local and national ethics approval in the United States and Ukraine. We began with a prospective observational cohort (ARROW), with over 350 patients enrolled. A corresponding interventional trial, with a targeted enrollment of 150, just began enrollment. Expansion of interventions and target populations is planned. CONCLUSIONS: The intended benefits of the platform include standardized patient enrollment criteria, outcomes tailored to feasible data collection during active war, and improvements in patient care for the treatment of complex and infected traumatic wounds. The design is intended to apply to a broad set of interventions with relevant patient-centered outcomes, all while addressing challenges of performing clinical trials in a war environment. Future studies utilizing the PACT-ARROW master protocol are planned. (J Trauma Acute Care Surg. 2026;000: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). STUDY TYPE: Protocol. LEVEL OF EVIDENCE: Level I.
Branson RD, Blakeman TC, Moore L
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, Lewis M, Bennett B, Gomaa D, Johannigman JA, Mangeot C, Rodriquez D, Goodman M
J Trauma Acute Care Surg
· 2026 May · PMID 42065671
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BACKGROUND: Automated physiologic closed-loop control (PCLC) of inspired oxygen fraction (FIO2) may improve oxygen titration while reducing clinician workload. We conducted a randomized noninferiority trial comparing PCL...BACKGROUND: Automated physiologic closed-loop control (PCLC) of inspired oxygen fraction (FIO2) may improve oxygen titration while reducing clinician workload. We conducted a randomized noninferiority trial comparing PCLC with protocolized manual control (MC) in mechanically ventilated trauma and acute care surgery patients. METHODS: In this randomized, controlled, multicenter trial, adult mechanically ventilated patients were randomized to PCLC or MC FIO2 titration targeting arterial oxygen saturation (SpO2) of 94%±2%. The primary effectiveness outcome was the percentage of time SpO2 remained within the target range. The primary safety outcome was hypoxemia (SpO2 <88% at any time). A noninferiority margin of 10% was prespecified. Secondary outcomes included oxygen utilization and clinician interventions. Analyses were performed using a modified intention-to-treat approach. RESULTS: One hundred ninety-five subjects completed the trial (98 MC and 97 PCLC). The median time within the SpO2 target range was 36.8% (IQR, 22.1-49.6) with MC and 30.1% (IQR, 18.4-44.7) with PCLC, meeting criteria for noninferiority [the mean±SD of the relative duration on the transformed scale was 0.53 (0.37) and 0.61 (0.36). The mean difference between the transformed data was -0.08 with a one-sided lower 97.5% CL of -0.18. Comparing this lower 95% CL with the prespecified noninferiority margin (NM) of -0.35, this difference lay within the NM. Hypoxemia occurred in fewer patients assigned to PCLC compared with MC (22% vs. 38%, p=0.04). PCLC was associated with lower FIO2 exposure, more frequent automated adjustments, and fewer manual FIO2 adjustments. CONCLUSIONS: In mechanically ventilated trauma and acute care surgery patients, PCLC of FIO2 was noninferior to protocolized MC for maintaining target oxygen saturation. PCLC was associated with fewer hypoxemic events, reduced oxygen usage, and more frequent automated FIO2 changes. (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: Randomized Controlled Trial with single blinding; Level II.
Trent SA, Beaty L, Peers J
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, Simon S, Scovorodniev A, Kireeva I, Fishchuk R, Carlson NE, Ginde AA, Bills CB, Denver, Colorado
J Trauma Acute Care Surg
· 2026 May · PMID 42065643
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BACKGROUND: Since Russia's full-scale invasion of Ukraine in 2022, casualties have frequently sustained extensive soft tissue injury and contamination requiring complex wound care and prolonged hospitalization. To charac...BACKGROUND: Since Russia's full-scale invasion of Ukraine in 2022, casualties have frequently sustained extensive soft tissue injury and contamination requiring complex wound care and prolonged hospitalization. To characterize in-country care, we conducted a retrospective case series of adult patients with conflict-related traumatic wounds to describe wound characteristics, microbiologic testing, antibiotic use, and resistance patterns during active conflict in Ukraine. METHODS: We conducted a retrospective case series to identify a consecutive population of adult patients treated at a single, referral hospital in western Ukraine for wounds management. Structured medical record abstraction was performed. The primary outcome was prevalence of complex traumatic wounds. Secondary outcomes included prevalence of antibiotic resistance among cultured wounds, surgical amputation associated with the wound, and length of hospital stay. Descriptive statistics were calculated for all variables. RESULTS: One hundred patients with conflict-related traumatic wounds were included. All were male with injuries occurring on the eastern frontlines from blast-related mechanisms. Median time from injury to hospitalization at study facility was 25.5 days. Overall, 95% of wounds met the case definition of a complex wound, predominantly due to presence of wound necrosis (90%). Wound cultures were obtained in half of patients (51%) with 24% (n=12) showing significant positive bacterial growth. Antibiotic resistance was identified in 9 of the 12 cultures. Nearly all patients received intravenous antibiotics (98%) for a mean duration of 7.3 days. Surgical debridement was performed in 99% of patients, while 2% underwent amputation during hospitalization. Hospital length of stay was a median of 14 days. CONCLUSION: In this cohort of conflict-related traumatic wounds in Ukraine, intravenous antibiotics were used extensively in a manner consistent with cautious, risk-averse combat trauma care. These findings primarily reflect the challenges of clinical decision-making in austere, high-risk environments and underscore the need for supportive, wartime-adapted stewardship frameworks. (J Trauma Acute Care Surg. 2026;000: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved). LEVEL OF EVIDENCE: Level V - Case Series / Epidemiological.
Remondelli MH, Nye KD, Holt DB
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, Bailey JA, Elster EA, Walker PF, Bradley MJ, Bethesda, Maryland
J Trauma Acute Care Surg
· 2026 Apr · PMID 42065641
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Large-scale combat operations will generate casualty volumes and injury patterns that fundamentally differ from routine civilian trauma, yet contingency planning increasingly relies on civilian surgeons and hospitals to...
Large-scale combat operations will generate casualty volumes and injury patterns that fundamentally differ from routine civilian trauma, yet contingency planning increasingly relies on civilian surgeons and hospitals to deploy, absorb, and definitively treat combat-injured patients through frameworks such as the National Disaster Medical System and Health Care Personnel Delivery System. Decades of experience, from World War II and the Global War on Terrorism to the current war in Ukraine, demonstrate that civilian surgical volume alone does not reliably translate into readiness for combat casualty care. Contemporary warfare produces blast and high-velocity fragment trauma, severe polytrauma, extensive contamination, complex extremity and vascular injuries, burns, and prolonged evacuation delays, requiring serial operative management and decision making under resource constraints. In contrast, civilian trauma systems are predominantly blunt injury-based with rapid access to definitive resources and subspecialty support. The Military Health System mitigates this readiness gap through the Clinical Readiness Program (CRP), a Knowledge, Skills, and Abilities (KSA) based framework that standardizes combat-relevant education, procedural training, and experience validation. No comparable readiness requirement exists for civilian surgeons despite their anticipated wartime role, creating a mismatch between assumed capacity and validated capability. This opinion argues that civilian clinicians expected to support combat casualty care should be incorporated into a civilian combat casualty care readiness framework modeled on the CRP. Key elements include specialty-specific curricula, knowledge assessments, periodic skills-based training aligned to deployment requirements, and KSA scoring using case log review to enable role assignment across echelons of care. Before activation, clinicians would undergo standardized education, skills verification, and team-based training. A scalable civilian readiness framework would enable rapid, effective, and safe integration of civilian surgeons into large-scale combat operations and responses, ensuring that providers are objectively prepared and ready before the call. (J Trauma Acute Care Surg. 2026;000: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
Reyes AM, Arcieri TR, Hebert AM
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, Sanan A, Byers PM, Lineen EB, Lee C, Namias N, Proctor KG, Valenzuela R, Pust GD, Meizoso JP, Valenzuela JY, Miami, FL
J Trauma Acute Care Surg
· 2026 Apr · PMID 42053154
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BACKGROUND: Powered micromobility devices (PMDs), including electric scooters (e-scooters) and electric bicycles (e-bikes), can operate at speeds approaching those of low-speed motorcycles. Yet PMDs are treated as low-en...BACKGROUND: Powered micromobility devices (PMDs), including electric scooters (e-scooters) and electric bicycles (e-bikes), can operate at speeds approaching those of low-speed motorcycles. Yet PMDs are treated as low-energy mechanisms in trauma surveillance systems and are not classified as distinct mechanisms of injury. Although prior studies report higher head injury rates in PMD crashes than bicycle crashes, injury severity and health care utilization relative to motorcycle crashes are not known. We hypothesized that e-scooter and e-bike crashes demonstrate distinct injury and resource utilization patterns compared with motorcycles and bicycles. METHODS: We performed a retrospective cohort study using the 2023 Florida Agency for Health Care Administration emergency department and inpatient databases. Encounters for motorcycle, bicycle, e-scooter, or e-bike crashes were identified. Patients meeting National Trauma Data Standard criteria were classified as trauma registry-eligible. Multivariable regression evaluated associations between mechanism and severe head and facial injury. RESULTS: Of 50,889 encounters, 10,522 (20.7%) were trauma registry-eligible. Median ISS was highest for motorcyclists [10 (interquartile range: 4-22)], followed by bicyclists [9 (1-14)], e-bike [8 (2-17)], and e-scooter riders [6 (1-15)] (p<0.001). On adjusted analyses, e-scooter and e-bike crashes had no significant differences in adjusted odds ratios (aORs) of severe head injury relative to motorcycle crashes, while e-bike crashes were associated with a higher aOR of severe facial injury (aOR: 1.78, 95% confidence interval: 1.15-2.74). E-bike injuries demonstrated the second-highest intensive care unit utilization and per-encounter hospital charges after motorcycles (both p<0.001). CONCLUSIONS: E-scooter and e-bike crashes demonstrated injury and resource utilization patterns distinct from both traditional bicycles and motorcycles. Head injury risk among PMD riders was similar to that of motorcyclists, while facial injury risk among e-bike riders exceeded that of motorcyclists. Findings highlight the need for improved injury surveillance and evidence-based helmet standards for PMD users, including evaluation of whether full-face protection may be warranted. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.
Wallace MW, Wan HY, Morris D
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, Russell KW, Swendiman RA, Salt Lake City, UT
J Trauma Acute Care Surg
· 2026 Apr · PMID 42047641
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BACKGROUND: Previous data suggest that there may be increased use of invasive interventions for pediatric blunt solid organ injury at nonpediatric trauma centers. In pediatric high-grade (AAST Grades III-V) blunt hepatic...BACKGROUND: Previous data suggest that there may be increased use of invasive interventions for pediatric blunt solid organ injury at nonpediatric trauma centers. In pediatric high-grade (AAST Grades III-V) blunt hepatic injuries (BHI), specifically, previous single-center and state-level studies have demonstrated that presentation to adult trauma centers independently predicts increased use of angioembolization and hemorrhage control laparotomy, but this observation has not been validated using a large, nationwide dataset. This study evaluated the use of invasive interventions (hemorrhage control laparotomy and/or hepatic angioembolization) and mortality in children with BHI across pediatric, adult, and hybrid trauma centers (PTCs, ATCs, and HTCs). METHODS: We retrospectively reviewed children aged 17 and below, with high-grade BHI (AAST Grades III-V, defined by AIS) in the ACS Trauma Quality Improvement Program database from 2017 to 2022. Univariate analyses compared demographics, injury characteristics, management strategies, and outcomes between ATCs, HTCs, and PTCs. Backward stepwise regression evaluated predictors of hemorrhage control laparotomy, angioembolization, and mortality. RESULTS: In total, 5,498 children were included. Children presenting to an ATC were older (p<0.01). There was no difference in the distribution of Grade III, IV, or V injuries between center types (p=0.50). On univariate analyses, PTC-presentation was associated with lower injury severity score, higher rates of isolated injury, lower rates of positive shock index, and lower rates of early blood transfusion (p<0.01). ATC-presentation was associated with higher rates of hepatic angioembolization (ATC: 2.7%, HTC: 1.8%, PTC: 1.0%, p<0.01), hemorrhage control laparotomy (ATC: 3.3%, HTC: 2.3%, PTC: 1.1%, p<0.01), and mortality (ATC: 7.1%, HTC: 5.0%, PTC: 3.2%, p<0.01). However, on regression analysis, trauma center verification status did not independently predict angioembolization, hemorrhage control laparotomy, or mortality. CONCLUSIONS: Contrary to prior data in smaller populations, in this national analysis of high-grade pediatric blunt hepatic trauma, hospital verification status did not independently influence the likelihood of hepatic angioembolization, hemorrhage control laparotomy, or mortality. LEVEL OF EVIDENCE: Cohort Study; Level III.
Clements TW, Williams J, Cannon J
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, Schreiber M, Moore E, Namias N, Guyette F, Sperry J, Cotton BA, Van Gent JM, Houston, Texas
J Trauma Acute Care Surg
· 2026 Apr · PMID 42047640
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BACKGROUND: While supported by a randomized trial and America College of Surgeon Trauma Quality Improvement Program(TQIP) guidelines, the inflection point in transfusion volumes at which balanced ratios (1:1) begin to af...BACKGROUND: While supported by a randomized trial and America College of Surgeon Trauma Quality Improvement Program(TQIP) guidelines, the inflection point in transfusion volumes at which balanced ratios (1:1) begin to affect mortality has not been fully explored. We sought to evaluate transfusion volumes at which a difference in mortality is observed. METHODS: Four studies of bleeding trauma patients were analyzed: two conducted before whole blood (WB) availability; a single institution experience (Pre-WB Single Center, 2010-2016) and a randomized, multicenter trial [Pre-WB Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR), 2012-2013] and two conducted with WB use; one single institution experience (WB Single Center 2017-2021) and a prospective, multicenter study [WB Shock, Whole blood And Traumatic brain injury (SWAT), 2018-2021]. Patients were divided into balanced [1:1 or less, red blood cell (RBC):plasma] and unbalanced (>1:1) cohorts. RBC units transfused in the first four hours were evaluated (0-6, 7-10, then 10-unit intervals). Primary outcome was 30-day mortality. Secondary outcomes were four-hour and 24-hour mortality. RESULTS: The Pre-WB Single Center (n = 730 1:1 or less, n = 536 >1:1) and Pre-WB PROPPR (n = 342, n = 338) noted mortality differences once >10 units of RBCs were transfused (11-20 units: 26% vs. 32%, P = 0.151 and 20% vs 30%, P = 0.090; 21-30 units: 43% vs. 71%, P = 0.013 and 32% vs. 61%, P = 0.017). The WB Single Center study (n = 1,239, n = 879) and WB SWAT (n = 447, n = 587) noted outcome separation >6 units (7-10 units: 14% vs. 22%, P = 0.139 and 14% vs. 18%, P = 0.198; 11-20: 28% vs. 41%, P = 0.118 and 17% vs. 31%, P = 0.030). Absolute differences tended to widen with greater units transfused. Differences remained at 24-hours for 7 to 10 units for Pre-WB Single Center and 11 to 20 units for Pre-WB PROPPR, WB Single Center, and WB SWAT studies. CONCLUSIONS: In this analysis of almost 5,000 patients, balanced resuscitation had a protective effect during or after the second transfusion cooler (>6 or >10 units of RBCs). This highlights the need for early 1:1 resuscitation with suspicion for massive hemorrhage, utilizing early WB to stay balanced and storing more immediately available plasma. LEVEL OF EVIDENCE: Retrospective comparative study without negative criteria, Study type: Therapeutic; Level III.
Bauman ZM, Sarani B, Pieracci FM
… +2 more
, Whitbeck SS, White TW
J Trauma Acute Care Surg
· 2026 Jul · PMID 42047633
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El-Menyar A, Naduvilekandy M, Al-Hassani I
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, Elmenyar E, Fawzy I, Al-Hassani A, Al-Thani H
J Trauma Acute Care Surg
· 2026 Apr · PMID 42047632
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Jones TJ, Barry CL, Davis KA
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, Martin ND, Prendergast CO, Duncan TK, Hildreth AN, Inaba K, Jensen AR, Jones AT, Moran SL, Palmieri TL, Stassen NA, Kaups KL, Stein DM
J Trauma Acute Care Surg
· 2026 Jul · PMID 42047630
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Peuker F, Houwert RM, Beeres FJP
J Trauma Acute Care Surg
· 2026 Jul · PMID 42041126
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Johnston W, Arzave J, Yuengert C
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, Park DJ, Costantini TW, Eliceiri BP, Weaver JL, La Jolla, California
J Trauma Acute Care Surg
· 2026 May · PMID 42030095
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BACKGROUND: Traumatic brain injuries (TBIs) are a common cause of morbidity and mortality after major trauma. In addition to local injury effects, TBI is associated with a systemic inflammatory response and acute lung in...BACKGROUND: Traumatic brain injuries (TBIs) are a common cause of morbidity and mortality after major trauma. In addition to local injury effects, TBI is associated with a systemic inflammatory response and acute lung injury (ALI), which increases mortality and worsens neurological outcomes. The exact mechanism of this ALI is not known. Extracellular vesicles (EVs) are small cell-derived particles involved in cell-cell communication that carry a wide variety of payloads, including proteins and microRNAs (miRNAs), which can mediate inflammation. We sought to characterize EV-derived miRNAs associated with TBI-induced ALI. METHODS: C57BL/6J mice underwent controlled cortical impact as a TBI injury model or sham procedure (anesthesia only). Bronchoalveolar lavage fluid (BALF) was then collected 4 hours postinjury. ALI after injury was determined via BALF protein concentration and H&E lung histology grading. BALF EVs were isolated using size exclusion chromatography, and EV concentration was confirmed via vesicle flow cytometry. EV miRNA sequencing was performed, comparing sham and injured mice. The effect of miR-362-3' on lung epithelium was evaluated using proteome profiler and western blot analysis. RESULTS: ALI after TBI injury was demonstrated by increased total protein concentration in BALF (p=0.006) and increased lung histologic injury score (p<0.0001). EVs were isolated using size exclusion chromatography and verified with vesicle flow cytometry. miRNA sequencing of BALF EVs demonstrated downregulation of 17 different miRNAs, most notably miRNA-362-3'. Treatment of MLE-12 with miRNA-362-3' loaded EVs resulted in the downregulation of the proinflammatory cytokine TIMP-1. CONCLUSIONS: We successfully identified multiple downregulated miRNAs from BALF in an in vivo model of TBI-induced ALI. Treatment with one of these downregulated miRNAs, miRNA-362-3', resulted in the downregulation of TIMP-1 in lung epithelial cells. This suggests that the downregulation of miR-362-3' contributes to TBI-induced ALI. (J Trauma Acute Care Surg. 2026;100:779-786. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
Tatakis A, Wilson D, Al Tannir AH
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, Sciarretta JD, Cage K, Kessler JJ, Kozar RA, Yeates EO, Medvecz A, Kopelman T, Slivinski A, Echeverria-Rosario K, Florea IB, Cowan J, Wong A, Stephens D, Chaar MA, Weger K, Chang G, Flage M, Von Husen L, Berndtson AE, Anderson J, Newman P, Nowak B, Smoot B, Farrell M, Oller K, Murthy A, Moore J, Swaminathan S, Cocanour C, Kim E, LaSeur D, Boyle K, Blank J, de Moya M
J Trauma Acute Care Surg
· 2026 Apr · PMID 42029153
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BACKGROUND: Traumatic hemothorax (HTX) contributes significantly to trauma morbidity and is frequently managed with tube thoracostomy (TT). However, TT placement has complications and some HTXs can be successfully observ...BACKGROUND: Traumatic hemothorax (HTX) contributes significantly to trauma morbidity and is frequently managed with tube thoracostomy (TT). However, TT placement has complications and some HTXs can be successfully observed. Optimal observation criteria remain unclear, and management practices vary. This multicenter study aimed to characterize current practices, determine observation failure rates, and identify predictors of safe observation. METHODS: We conducted a prospective observational study from July 2023 to June 2025 across 16 trauma centers. Adult patients with computed tomography-confirmed HTX were included. Exclusions included age under 18 years, TT before computed tomography, concurrent pneumothorax >35 mm, death within 48 hours, or observation failure due to operative intervention. HTX volume was calculated using Mergo's formula (V=d2×L). Each hemithorax was analyzed independently. The primary outcome was observation failure. HTX >300 mL was evaluated as a predictor of failure in a multivariable logistic regression model. RESULTS: Among 962 HTXs in 932 patients, 68% (n=657) were initially observed. The observation group had shorter hospital (7 vs. 9 d) and intensive care unit stays (1 vs. 3 d) compared with immediate TT (p<0.001). Observation failure rate was 22% (n=141), most commonly from HTX progression (54%). Failed observation patients had longer hospital stays (13 vs. 9 d, p<0.001) but similar complication rates, secondary intervention needs, and 30-day outcomes compared with early TT. HTX volume >300 mL strongly predicted observation failure (adjusted odds ratio, 16.01; 95% confidence interval, 8.25-31.06). Management practices varied: 52% received antibiotics with TT, 16% underwent irrigation, and thoracostomy tube sizes ranged from 8 to 36 Fr. CONCLUSIONS: Initial observation of HTX is frequently successful, with HTX volume >300 mL being the strongest predictor of failure. Failed observation patients experience longer stays but similar outcomes to early TT placement. Notable practice variation highlights opportunities for research and standardization through unified practice management guidelines. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Tisherman SA, Manning J, Baltimore, Maryland
J Trauma Acute Care Surg
· 2026 Jun · PMID 42029149
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Lu L, Truong EI, Boland S
… +3 more
, Byrd T, Silver D, Brown JB
J Trauma Acute Care Surg
· 2026 Jul · PMID 42029145
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BACKGROUND: Air medical transport (AMT) has demonstrated a survival benefit for select patients. The Air Medical Prehospital Triage (AMPT) score identifies patients with a survival benefit from AMT. Patients with positiv...BACKGROUND: Air medical transport (AMT) has demonstrated a survival benefit for select patients. The Air Medical Prehospital Triage (AMPT) score identifies patients with a survival benefit from AMT. Patients with positive AMPT score may be heterogenous with different levels of benefit. Our objective was to identify phenotypes of injured patients with a positive AMPT score with differential benefits of AMT compared with ground emergency medical services. METHODS: Patients 16 years or above transported by AMT or ground emergency medical services from the scene (>3 and <40 miles) and met AMPT score criteria in the Pennsylvania Trauma Outcomes Study 2000-2017 were included. Patients were clustered using latent class analysis (LCA) and k-modes clustering. From the two class memberships, we then assessed the association between in-hospital survival and actual transport mode using multilevel generalized linear models, adjusting for demographics, injury characteristics, vital signs, and in-hospital variables. To validate our membership assignments, the same analysis was performed on separately on NTDB data. RESULTS: In total, 22,569 patients were included from the Pennsylvania Trauma Outcomes Study, with 7,607 (35%) actually undergoing AMT. LCA resulted in five phenotype classes. Among these, Class 2, composed of patients with physiological plus anatomic triage criteria and Glasgow Coma Scale (GCS)≤13, and Class 5, composed of a GCS≤13 plus abnormal respiratory rate, demonstrated profound survival benefit [aOR, 1.83 (1.41, 2.36) and 2.23 (1.76, 2.81)]. K-modes also resulted in five classes. Among these, Classes 2, 4, and 5 also composed of patients with physiological plus anatomic criteria, GCS≤13 and/or abnormal respiratory rate. These groups also demonstrated profound survival benefit [aOR, 1.85 (1.33, 2.59), 2.02 (1.49, 2.73) and 2.5 (1.97, 3.17)]. Replication in NTDB illustrated similar results. CONCLUSIONS: These findings suggest that patients with GCS≤13 and abnormal respiratory rate or physiological plus anatomic triage criteria should be prioritized in AMT use. ( J Trauma Acute Care Surg . 2026;101: 71-79. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic; Level IV.
Remondelli MH, Nye KD, Holt DB
… +2 more
, Elster EA, Bradley MJ
J Trauma Acute Care Surg
· 2026 Apr · PMID 42023952
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The Military Health System faces increasing readiness strain as global peer competition, sustained operational demands and post COVID-19 workforce and budget constraints reduce military treatment facility (MTF) capabilit...
The Military Health System faces increasing readiness strain as global peer competition, sustained operational demands and post COVID-19 workforce and budget constraints reduce military treatment facility (MTF) capability and shift care to civilian networks. This trend erodes readiness-relevant clinical experience across undergraduate and graduate medical education, threatening the ability to generate and sustain a ready medical force capable of delivering combat casualty care at the scale anticipated in large-scale combat operations, humanitarian crises, and mass casualty events. High-performing civilian Academic Health Systems (AHS) provide a proven framework to integrate clinical care, education and research into a single learning enterprise that improves outcomes, enables rapid adaptation during crisis, and accelerates innovation. The National Capital Region (NCR) already contains the core components of such a system, including the Uniformed Services University, the National Capital Consortium, and multiple major MTFs, yet remains limited by service parochialism, soloed governance, and misaligned referral management. Multiple National Defense Authorization Acts provide legal precedent supporting modernization and explicitly authorize the creation of an AHS in the NCR. We propose an NCR pilot integrated military AHS centered on physician-led clinical departments and a unified practice plan to align clinical volume, education, and research with readiness requirements, streamline referrals across the enterprise, and accelerate military-relevant innovation. Timely implementation would strengthen trauma readiness, improve medical force generation, and provide a scalable model for other Defense Health Networks. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
Maginot ER, Barmettler NK, Gawargi FI
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, Moore EE, White CM, Hiser DC, Clegg AA, Sextro KS, Moody TB, Volk GE, Moore HB, Goodman N, Bobr A, Henry R, Barrett CD, Omaha, Nebraska
J Trauma Acute Care Surg
· 2026 Apr · PMID 42023949
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BACKGROUND: Whole blood transfusion is increasingly used in trauma resuscitation. However, stored whole blood units demonstrate increasing susceptibility to tissue plasminogen activator-mediated fibrinolysis despite para...BACKGROUND: Whole blood transfusion is increasingly used in trauma resuscitation. However, stored whole blood units demonstrate increasing susceptibility to tissue plasminogen activator-mediated fibrinolysis despite paradoxical increases seen in plasminogen activator inhibitor-1 (PAI-1) activity over time. Whether early variability in PAI-1activity exists across whole blood units and the biologic contributors to this variability remain unclear. Two distinct donor pools were identified: one with high PAI-1 activity and one with low PAI-1 activity. We set out to determine whether PAI-1 activity in whole blood donors primarily comes from the endothelium or from platelet degranulation. METHODS: Plasma from whole blood units (n = 28) was generated via serial centrifugation at two time points during storage (Days 1-3 and Day 21). Activity assays were performed for PAI-1 using a modified enzyme-linked immunosorbent assays that only captures active PAI-1. Soluble CD40 ligand (sCD40L), a platelet-derived marker of activation, degranulation and death, and total von Willebrand Factor antigen levels, which are highly specific for endothelial degranulation, were quantified using enzyme-linked immunosorbent assays. Statistical analysis was performed via two-tailed t-tests. Significance was set at p <0.05. RESULTS: Whole blood units stratified into distinct high and low PAI-1 activity cohorts at early storage time points. Over storage, PAI-1 activity increased overall. sCD40L levels increased approximately 4-fold during storage, consistent with a platelet storage lesion. At early time points, both sCD40L and von Willebrand Factor antigen levels were significantly higher in the high PAI-1 cohort, suggesting contributions from both platelet-derived and donor endothelial factors. CONCLUSION: Stored whole blood demonstrates early, donor-dependent heterogeneity in antifibrinolytic potential, reflected by distinct PAI-1 activity cohorts at time of donation. This appears to have a mixed source, with evidence for both endothelial and platelet factors that may differ from donor to donor. (J Trauma Acute Care Surg. 2026;000: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). STUDY TYPE: Basic science. LEVEL OF EVIDENCE: Basic Science, Level V.
Arcieri TR, Cobler-Lichter MD, Delamater JM
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, Reyes AM, Kronenfeld JP, Namias N, Proctor KG, Meizoso JP, Ginzburg E, Miami, FL
J Trauma Acute Care Surg
· 2026 Apr · PMID 42023940
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BACKGROUND: Traumatic brain injury (TBI) is a leading cause of trauma-related mortality. While high ratios of fresh frozen plasma (FFP):red blood cells (RBC) improve survival in hemorrhagic shock, the role of FFP in poly...BACKGROUND: Traumatic brain injury (TBI) is a leading cause of trauma-related mortality. While high ratios of fresh frozen plasma (FFP):red blood cells (RBC) improve survival in hemorrhagic shock, the role of FFP in polytrauma patients with TBI not requiring massive transfusion is unclear. We hypothesized that higher FFP ratios would be associated with improved early and late survival across TBI severities. METHODS: Adult trauma patients (age 18 or older) with suspected TBI (head AIS ≥1) who received ≥1 unit of blood product from 2020 to 2021 were identified in the American College of Surgeon's Trauma Quality Improvement Project database. Burns, interfacility transfers, and massive transfusion (≥5 RBC-containing units within 4 hours) were excluded. Patients were stratified by head AIS (mild 1-2, moderate 3-4, and severe 5-6). FFP ratio was calculated as FFP: total transfused blood products, and patients were categorized as receiving no FFP, low FFP, or high FFP, with the median of non-zero FFP ratios used to divide low from high. Multivariable logistic regression was performed to assess the association between FFP ratios and 6-hour and 30-day mortality. Subgroup analyses of isolated TBI patients and sensitivity analyses excluding whole blood recipients were performed. RESULTS: In 23,362 patients, 40.1% had mild TBI, 35.9% moderate, and 24.0% severe. Overall, 6-hour and 30-day mortality rates were 12.6% and 32.4%, respectively. High FFP ratios were associated with lower 6-hour mortality in moderate and severe TBI, with a sustained 30-day survival benefit only in moderate TBI. Low FFP ratios decreased only early mortality in moderate and severe TBI. Subgroup and sensitivity analyses demonstrated the greatest survival benefit in moderate TBI. CONCLUSION: The association between FFP and mortality varies across TBI severity groups and proportions of FFP given in initial resuscitation. These findings suggest that moderate TBI patients may benefit most from high-ratio FFP resuscitation. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Cripps MW, Livingston DH
J Trauma Acute Care Surg
· 2026 Apr · PMID 42023938
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Duodenal injuries are uncommon, limiting most surgeon's experience in their management. The retroperitoneal location of the duodenum combined with associated major abdominal vascular and adjacent injuries further complic...
Duodenal injuries are uncommon, limiting most surgeon's experience in their management. The retroperitoneal location of the duodenum combined with associated major abdominal vascular and adjacent injuries further complicate the management decisions in treating duodenal trauma. Keys to successful management include wide exposure, achieved through a wide Kocher maneuver, dissection of the lesser sac, and mobilization of the ligament of Treitz to fully visualize the entire duodenum. Careful inspection of the medial wall is necessary to fully identify the extent of the injury. Primary repair, either in one or two layers, is the superior and preferred for almost all degrees of injuries except for destructive injuries and those associated with a significant pancreatic injury where a primary duodenojejunostomy or a pancreaticoduodenectomy may be required. Adjunctive maneuvers such as pyloric exclusion or tube duodenostomies have not been demonstrated to prevent or decrease the severity of a leak. External drainage in the absence of an associated pancreatic injury is not required. The appearance of a leak in the early postoperative period mandates reoperation. Providing enteral nutritional support is critical in improving outcomes, especially in the setting of a duodenal leak. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).