J Trauma Acute Care Surg [JOURNAL]
Sun
200 papers
Developing a high-fidelity trauma surgery simulation to enhance team performance: Lessons learned from a complex implementation.
Cohen TN, Marselian A, Kanji F … +9 more , Ravi H, Metcalfe Smith R, Dodd B, Lazzara EH, Keebler JR, Perlman R, Gewertz BL, Barmparas G, Los Angeles, California
J Trauma Acute Care Surg · 2026 Apr · PMID 41972944 · Publisher ↗
BACKGROUND: Effective trauma care depends on technical proficiency and teamwork under pressure. While simulation has become integral to trauma education, few reports detail the methodological processes and lessons learne...
BACKGROUND: Effective trauma care depends on technical proficiency and teamwork under pressure. While simulation has become integral to trauma education, few reports detail the methodological processes and lessons learned from developing highly complex operative simulations designed to both assess and improve team performance. METHODS: We developed and implemented a high-fidelity trauma surgery simulation to evaluate multidisciplinary intraoperative team performance. Twenty-two surgical teams-each composed of an attending surgeon, resident, anesthesiologist, circulating nurse, and scrub technician-completed two trauma scenarios requiring surgical intervention for a patient presenting in hemorrhagic shock: Scenario 1-liver/iliac injuries; Scenario 2-kidney/spleen injuries. Scenario development incorporated multidisciplinary perspectives, high-fidelity simulators, and iterative pilot testing. A dual-layer performance framework was created to operationalize measurement of taskwork and teamwork, using time-stamped video analysis and validated postsimulation surveys assessing teamwork, psychological safety, and shared mental models. RESULTS: Through iterative refinement, rater calibration, and multidisciplinary collaboration, the team established a feasible framework for delivering complex, realistic, surgical trauma team simulations. Challenges and lessons learned are described. CONCLUSIONS: This methods paper outlines the development and execution of a high-fidelity trauma surgery simulation aimed at enhancing operative team readiness. Lessons learned underscore the importance of deliberate scenario design, planning, and multidisciplinary coordination to optimize outcomes. The framework described provides a reproducible model for institutions seeking to implement simulation-based trauma training and performance assessment programs. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.
Modern management of abdominal aortic injuries: What you need to know.
Perkins L, Kobayashi L, Coimbra R … +1 more , Moreno Valley, California
J Trauma Acute Care Surg · 2026 Apr · PMID 41954279 · Publisher ↗
Abdominal aortic injury is a rare but deadly traumatic insult that occurs in <0.1% of trauma patients but carries a mortality rate of 29% to 70%. Penetrating injuries usually present with shock and require rapid hemorrha...
Abdominal aortic injury is a rare but deadly traumatic insult that occurs in <0.1% of trauma patients but carries a mortality rate of 29% to 70%. Penetrating injuries usually present with shock and require rapid hemorrhage control through open abdominal exploration. Blunt injuries are increasingly being managed nonoperatively and with endovascular techniques. Both mechanisms are commonly associated with other severe intra- and extra-abdominal injuries. The trauma surgeon must be prepared to promptly evaluate for intra-abdominal hemorrhage and choose the appropriate clinical pathway to diagnose and manage abdominal aortic injury. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
Impact of frailty and physiological severity on early and medium-term surgical outcomes after open abdomen.
Álvarez-Aguilera M, Durán Muñoz-Cruzado Md V, Bravo Ratón P … +5 more , Martínez-Casas I, Perea Del Pozo E, Padillo Ruiz J, Pareja Ciuró F, Seville, Spain
J Trauma Acute Care Surg · 2026 Apr · PMID 41954278 · Publisher ↗
BACKGROUND: Open abdomen (OA), mainly indicated for sepsis and second-look surgery, may entail severe complications that translate into high morbidity and mortality. Following the World Society of Emergency Surgery 2018...
BACKGROUND: Open abdomen (OA), mainly indicated for sepsis and second-look surgery, may entail severe complications that translate into high morbidity and mortality. Following the World Society of Emergency Surgery 2018 Guidelines leads to an improvement in surgical outcomes. However, how baseline status and fragility might determine patient´s morbidity and survival has not been described yet. METHODS: Retrospective analysis of a prospectively maintained registry of patients undergoing emergency laparotomy with temporary abdominal closure (January 2020-December 2022) and ≥12-month follow-up. Demographics, surgical features, surgical outcomes, and survival were compared across APACHE II and frailty strata. Frailty was assessed using both the Modified Frailty Index-5 and Modified Frailty Index-11 instruments. The APACHE II cutoff was derived by Youden Index; survival was analyzed with Kaplan-Meier/log-rank. RESULTS: Of 3,103 emergency laparotomies, 115 patients (3.7%) required OA (69.6% males; median age: 62 y). The main indications were septic abdomen 44.3%, second-look 31.3%. All received negative-pressure therapy; 73.9%, in addition, underwent mesh-mediated fascial traction. Median time to definitive closure was three days (IQR: 2-4.75). Complication rates were 72% for surgical and 83.5% for systemic complications, Clavien-Dindo III-IV complications were present in 50 (43.5%) patients. In-hospital mortality was 47%; overall 49.6%, including 22.6% within 48 hours. APACHE II ≥16 (Youden cutoff) was associated with lower survival (log-rank p = 0.004) and higher mortality (22.84 ± 8.77 vs 17.98 ± 8.99; p = 0.003). Frailty indices showed no significant association with mortality or survival (p = 0.11; p = 0.081). CONCLUSIONS: Preoperative physiological status acts as a major determinant of systemic complications and mortality in patients requiring OA. The APACHE II score proved to be an independent prognostic factor and could be integrated into routine clinical decision-making. LEVEL OF EVIDENCE: Level III.
A retrospective observational study on management of penetrating gunshot and migrating projectile injuries to the heart during the war in Ukraine.
Maruniak S, Hutsuliak Y, Mokryk I … +7 more , Zelenchuk O, Sudakevych S, Kuzmich I, Batchinsky A, Swol J, Todurov B, Kyiv, Ukraine
J Trauma Acute Care Surg · 2026 Apr · PMID 41949492 · Publisher ↗
BACKGROUND: Penetrating cardiac injuries caused by firearms are associated with extremely high prehospital and early in-hospital mortality. During wartime, civilian cardiac surgery centers are increasingly involved in th...
BACKGROUND: Penetrating cardiac injuries caused by firearms are associated with extremely high prehospital and early in-hospital mortality. During wartime, civilian cardiac surgery centers are increasingly involved in the management of complex gunshot and fragment-related cardiac injuries, yet published evidence from nonmilitary practice remains limited. METHODS: We conducted a retrospective observational study of civilian and military patients with penetrating cardiac gunshot or fragment injuries treated surgically at a tertiary civilian cardiac surgery center between February 2022 and December 2025. Patients with severe cardiogenic shock or rapidly progressing tamponade were typically managed at frontline hospitals; referred patients who survived initial resuscitation underwent definitive cardiac surgery at our institution. Demographic, clinical, imaging, operative, and outcome data were analyzed descriptively. RESULTS: Among 69 patients undergoing cardiac surgery for combat-related injuries, 25 required surgical removal of intracardiac foreign bodies. Median age was 38 years [interquartile range (IQR): 32-47], and 92% were males; 72% were military personnel. Metallic fragments accounted for 92% of foreign bodies, most commonly located in the ventricles. All procedures were performed in a hybrid operating room; cardiopulmonary bypass was used in 32% of cases, while 68% were managed off-pump with bypass standby. Neodymium magnet-assisted extraction was used in 80% of procedures. Median operative time was 117 minutes (IQR: 89-133). Median intensive care unit stay was 3 days (IQR: 2-5), and hospital stay was 13 days (IQR: 8-17). In-hospital and 30-day mortality were both 4%. CONCLUSIONS: Surgical management of penetrating cardiac gunshot and fragment injuries can be safely performed in civilian cardiac surgery centers during wartime. A multimodal imaging strategy, individualized use of cardiopulmonary bypass, hybrid operating room infrastructure, and adjunctive magnet-assisted techniques facilitate effective treatment with favorable early outcomes. (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 IV.
A new pediatric trauma center quality benchmarking metric: Center-level variability in postinjury functional impairment using the Functional Status Scale (FSS).
Castro MR, Shui A, Lee C … +5 more , Niedzwecki C, Nathens AB, Burd RS, Jensen AR, Oakland, CA
J Trauma Acute Care Surg · 2026 Mar · PMID 41949482 · Publisher ↗
BACKGROUND: Over 7 million children are injured annually in the United States, leading to 500,000 disability-adjusted life years. Functional outcomes after injury, however, are not routinely measured. Whether disability...
BACKGROUND: Over 7 million children are injured annually in the United States, leading to 500,000 disability-adjusted life years. Functional outcomes after injury, however, are not routinely measured. Whether disability is modifiable by trauma center care remains unclear. The purpose of this study was to assess variability between trauma centers in functional impairment rates. METHODS: The "Assessment of Health-Related Quality of Life and Functional Outcomes after Pediatric Trauma" prospective observational dataset was analyzed. Functional status among injured children (≤14 y) was assessed at discharge and 6-month follow-up using the Functional Status Scale (FSS). Multivariable logistic regression was used to calculate variability in FSS explained by nonmodifiable patient and injury characteristics. Propensity score modeling was used to estimate the expected functional impairment rates for each trauma center based on age, GCS, injury mechanism, number of body regions injured, and the presence of serious body region-specific injuries. Observed impairment rates were used to calculate observed-to-expected (O:E) ratios for risk-adjusted comparison between centers. RESULTS: The cohort included 427 patients from seven centers. Functional impairment (FSS ≥ 7) occurred in 217 (51%) children at discharge and in 81 of 324 (25%) at follow-up. Patient and injury characteristics explained 55% of the variability in FSS at discharge and 14% at follow-up. Unadjusted functional impairment differed between centers at discharge (range 36-70%, p=0.03), but not significantly at 6-month follow-up (range 12-36%, p=0.06). One high-impairment outlier center [O:E 1.38 (1.01, 1.84)] at discharge and one low-impairment outlier center [O:E 0.50 (0.23, 0.94)] at 6-month follow-up were identified. CONCLUSIONS: Most functional impairment after pediatric injury is explained by patient and injury characteristics, but variability in functional impairment exists between trauma centers after adjusting for these factors. Differences in functional outcomes between centers suggest that these outcomes are modifiable and are associated with the quality of trauma center care. (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.
Socioeconomic disparities and access to care: Fragmentation of care after older adult trauma.
Arda Y, Nzenwa IC, Panossian VS … +7 more , Paranjape CN, Ng-Kamstra JS, Hwabejire JO, Kaafarani HMA, Velmahos GC, DeWane MP, Boston, MA
J Trauma Acute Care Surg · 2026 Apr · PMID 41945332 · Publisher ↗
BACKGROUND: Fragmentation of care (FOC) describes unplanned readmission to a nonindex hospital and is associated with poorer clinical outcomes, particularly in older adults. The aim of this study was to evaluate the impa...
BACKGROUND: Fragmentation of care (FOC) describes unplanned readmission to a nonindex hospital and is associated with poorer clinical outcomes, particularly in older adults. The aim of this study was to evaluate the impact of socioeconomic disparities, particularly patient income and region of residence, on FOC in older adult trauma patients. METHODS: In this retrospective study, we analyzed the 2019 Nationwide Readmissions Database to identify patients 65 years of age or above who were readmitted within 90 days following an index admission for trauma. FOC was defined as an unplanned readmission to a nonindex hospital, and patients were stratified by the presence or absence of FOC. Multivariable logistic regression was used to study the effect of median patient household income (stratified into quartiles) and patient location (urban vs. rural) on FOC. RESULTS: A total of 142,584 patients were included: 73% nonfragmented and 27% fragmented. The median age was 80 years. On univariate analysis, patients residing in rural regions were much more likely to be fragmented (15% vs. 11%, p <0.001). After adjusting for clinically relevant factors, higher income quartiles were associated with a stepwise decrease in the odds of FOC (adjusted odds ratio: 0.96 for second quartile, 0.90 for third quartile, and 0.82 for fourth quartile, first quartile as reference; p <0.001). Rural residence was associated with higher odds of FOC compared with urban residence (adjusted odds ratio: 1.86, 95% CI: 1.77-1.95). These results were unchanged after stratifying patients by index hospital teaching status, with higher income associated with a greater decrease in risk of FOC in the cohort of patients initially admitted to nonteaching hospitals. CONCLUSIONS: Lower income and rural residence were independently associated with higher FOC in the older adult trauma population. These findings highlight the importance of accounting for the impact of socioeconomic disparities on access to care in older adult trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Response to "Critical insights on hemorrhage control strategies in pelvic fracture patients".
Costantini TW, Coimbra R
J Trauma Acute Care Surg · 2026 Jun · PMID 41945320 · Publisher ↗
Abstract loading — click title to view on PubMed.
Trauma critical care in trauma patients during large-scale combat operations: An unresolved capability gap.
Henry R, McClellan J, Eckert M … +7 more , Betzold R, Rokayak O, Barrett C, Schreiber M, Holcomb JB, Lammers D, Chapel Hill, NC
J Trauma Acute Care Surg · 2026 Apr · PMID 41945125 · Publisher ↗
Future large-scale combat operations (LSCO) will invalidate core assumptions of modern trauma care. Contested movement, disrupted logistics, and prolonged or denied evacuation will make timely surgical access and fully r...
Future large-scale combat operations (LSCO) will invalidate core assumptions of modern trauma care. Contested movement, disrupted logistics, and prolonged or denied evacuation will make timely surgical access and fully resourced critical care the exception rather than the rule. While recent conflicts optimized early hemorrhage control, the capacity to sustain critically injured patients in LSCO environments remains poorly defined. In LSCO, trauma care shifts from episodic intervention to prolonged system endurance. Injuries routinely survivable in resource-rich settings will become functionally non-survivable under these conditions. Future combat casualty survival will depend less on maximal capability than what care can be sustained under constant constraint. Without austere-adapted critical care standards, doctrinal alignment, and operationally embedded research, the gains of modern combat casualty care will not translate to the future battlefields where they are needed the most. This review synthesizes contemporary military and civilian literature with operational experience to identify key unresolved capability gaps and examine austere surgical and critical care in LSCO, focusing on hemorrhage control, far-forward surgery, prolonged critical care, evacuation constraints, and ethical decision-making under sustained resource limitation. ( J Trauma Acute Care Surg . 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
Kinetics and dynamics of ionized calcium in a porcine major trauma model.
Helsloot D, Neyrinck A, Pottel H … +8 more , Groombridge C, Mathew JK, Özman D, Van Beersel D, Missant C, De Meyer SF, Fitzgerald M, Leuven, Belgium
J Trauma Acute Care Surg · 2026 Apr · PMID 41945121 · Publisher ↗
BACKGROUND: Disturbances in ionized calcium (iCa²⁺) are common after major trauma and correlate parabolically with coagulopathy, transfusion, and mortality. However, the mechanisms underlying iCa²⁺ changes during trauma...
BACKGROUND: Disturbances in ionized calcium (iCa²⁺) are common after major trauma and correlate parabolically with coagulopathy, transfusion, and mortality. However, the mechanisms underlying iCa²⁺ changes during trauma and resuscitation remain poorly understood. This exploratory study aimed to develop an experimental animal model to characterize the dynamics and kinetics of iCa²⁺ during trauma and resuscitation. METHODS: A controlled porcine polytrauma model (PT, n=6)-including thoracic, abdominal, musculoskeletal trauma, controlled hemorrhage, and ischemia-reperfusion-was compared with nontrauma controls (C, n=4). Continuous hemodynamic monitoring and serial blood sampling during trauma, hemorrhage, ischemia-reperfusion, damage control resuscitation (DCR), transfusion, and observation enabled analysis of iCa²⁺ in relation to hemodynamic and acid-base status, ion interactions, and endocrine parameters. RESULTS: Two animals in the polytrauma group died during the experiment and were excluded from analysis. Baseline iCa²⁺ levels were comparable between groups (C: 1.38 [95% CI: 1.36-1.41] vs. PT: 1.42 [95% CI: 1.35-1.49] mmol/L, p =0.211) and remained stable in controls. In the polytrauma group, iCa²⁺ initially increased with early respiratory acidosis following thoracic trauma, then progressively decreased during hemorrhagic shock and ischemia-reperfusion. A further rapid decrease followed transfusion of citrated autologous whole blood ( p <0.001). Phosphate, lactate, and magnesium increased during shock, while bicarbonate and albumin decreased. Parathyroid hormone peaked, whereas calcitonin and 25-hydroxy-Vit D reached their lowest levels at the nadir of hypocalcemia. iCa²⁺ recovered during DCR, returning to baseline by the end of observation ( t =240 min, 1.39 [1.30-1.47] mmol/L, p =0.593). CONCLUSIONS: iCa²⁺ changes dynamically during trauma and resuscitation, in parallel with alterations in acid-base status, circulating ions, transfusion, and endocrine responses. iCa²⁺ can spontaneously recover to baseline with adequate resuscitation without calcium supplementation. This exploratory study can contribute to the development of a robust experimental model for future translational research. ( J Trauma Acute Care Surg . 2026;00:00-00. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).
An updated meta-analysis of prognostic factors for secondary amputation following surgical repair of lower-extremity vascular trauma in both civilian and military populations.
Singh Y, Kersey A, Lauria A … +6 more , Yet B, Tai N, Rasmussen T, Ratnayake A, Perkins Z, London, United Kingdom
J Trauma Acute Care Surg · 2026 Jun · PMID 41944883 · Publisher ↗
BACKGROUND: Lower-extremity vascular trauma (LEVT) remains a major cause of limb loss. A thorough understanding of prognostic factors associated with secondary amputation is essential for guiding decision-making, patient...
BACKGROUND: Lower-extremity vascular trauma (LEVT) remains a major cause of limb loss. A thorough understanding of prognostic factors associated with secondary amputation is essential for guiding decision-making, patient counselling, and risk stratification. This study aimed to further our understanding by incorporating novel risk factors and distinguishing outcomes between contemporary military and civilian populations. METHODS: A systematic review was conducted to identify prognostic factors for amputation following LEVT repair. Bayesian meta-analysis was employed to calculate each factor's absolute pooled proportion, odds ratio, and 95% credible interval for secondary amputation. RESULTS: Sixty-nine studies, describing 8,553 limbs, were included. The pooled secondary amputation rate was 12.6% (12.0% in civilian and 14.9% in military populations). The strongest predictors were prolonged ischemia, major soft-tissue injury, compartment syndrome, fracture or dislocation, multiple-level arterial injury, and shock. High-energy mechanisms, such as explosive and blunt trauma, were also associated with a greater risk than penetrating injury. Among treatment-related factors, interposition grafting was linked to higher amputation rates than primary repair, while temporary vascular shunt use and prophylactic fasciotomy showed a modest association, particularly in civilian populations. Prehospital tourniquet use was not significantly associated with amputation. Demographic variables, venous repair, and graft type were also not predictive. Notable differences were observed between civilian and military injuries. CONCLUSIONS: Secondary amputation remains common following LEVT repair, affecting approximately one in eight limbs. This meta-analysis reaffirms the prognostic importance of prolonged ischemia, shock, and compartment syndrome, alongside broader markers of injury severity. Emerging treatment-related factors likely reflect injury complexity rather than modifiable determinants. Differences between civilian and military cohorts highlight the need for tailored prognostic algorithms. Decision-making should prioritize early recognition of injury severity, rapid revascularisation, and anticipation of limb recovery trajectory. ( J Trauma Acute Care Surg. 2026;100: 961-972. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level II.
"High and tight to pack and press": Prioritization of tourniquet conversion in unconventional warfare improves outcomes.
Hofmann LJ, Hiles JM, Hetzler M … +6 more , Davis E, Hager E, Oh JS, Armen SB, Grant AA, Boise, Idaho
J Trauma Acute Care Surg · 2026 Apr · PMID 41944821 · Publisher ↗
BACKGROUND: In military conflicts beyond the global war on terror, combatants often lack air superiority, rapid evacuation to surgical care, and sufficient medical resources. Consequently, obtaining definitive care becom...
BACKGROUND: In military conflicts beyond the global war on terror, combatants often lack air superiority, rapid evacuation to surgical care, and sufficient medical resources. Consequently, obtaining definitive care becomes a significant challenge, leading to complications associated with tourniquet (TQ) use in many active combat zones. METHODS: Data were retrospectively analyzed from a mobile surgical team operating in an unconventional warfare environment. Descriptive statistics summarized demographics, injury mechanisms, interventions, and outcomes, with categorical variables reported as frequencies and percentages. RESULTS: Results from a mobile surgical team supporting a MASCAL in unconventional warfare were analyzed. A total of 46 casualties were evaluated and treated. There were 14 TQs utilized on 12 patients. All 14 TQs were evaluated, and 93% (13) of these TQs were converted. Thirty-one percent (4) of the converted TQs required surgical intervention for hemostasis before packing and pressure. One (7%) TQ was transitioned lower on the extremity closer to the point of wounding. There were no deaths from extremity hemorrhage and no complications reported related to TQ use. CONCLUSIONS: Prioritization of TQ conversion in an unconventional warfare environment with prolonged evacuation times can save lives and limbs. (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Pneumatosis intestinalis: Benign or dire? What you need to know.
Tung KH, Tanzer D, Chopko MS … +2 more , Guo WA, New York
J Trauma Acute Care Surg · 2026 Mar · PMID 41941383 · Publisher ↗
ABSTRACT: Pneumatosis intestinalis (PI) is defined as the presence of gas within the gastrointestinal wall and represents a radiologic finding with a broad clinical spectrum, ranging from incidental, benign disease to di...
ABSTRACT: Pneumatosis intestinalis (PI) is defined as the presence of gas within the gastrointestinal wall and represents a radiologic finding with a broad clinical spectrum, ranging from incidental, benign disease to dire, life-threatening bowel ischemia. With the widespread availability of high-resolution computed tomography (CT), PI is increasingly identified in trauma and acute care settings, often prompting surgical consultation despite highly variable clinical significance. The current understanding is that PI is a multifactorial process arising from three nonmutually exclusive theories: mechanical, bacterial, and pulmonary, each rationalizing how gas can migrate and dissect into the intestinal wall. CT is the preferred diagnostic modality and provides critical features for risk stratification, including portomesenteric venous gas, decreased bowel wall enhancement, bowel dilation, and mesenteric fat stranding. Clinical presentations of peritonitis, hemodynamic instability, vasopressor requirement and laboratory evidence of elevated serum lactate (≥2.0 mmol/L), metabolic acidosis, or end-organ dysfunction are some of the strongest predictors of pathologic PI requiring surgical intervention. Management, therefore, requires a comprehensive examination of the patient with integration of imaging, clinical, and laboratory data to distinguish patients appropriate for conservative therapy from those requiring urgent/emergent exploration. This review encompasses current evidence on the pathophysiology, epidemiology, imaging characteristics, and management of PI with an emphasis on practical guidance. We also provided 10 concise clinical pearls to aid bedside decision-making. (J Trauma Acute Care Surg. 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: V.
Unbuckled and unprotected: The deadly cost of no seatbelt law in New Hampshire.
Rice WM, Ebangwese S, Tripoli T … +7 more , Phillips JD, Colosimo C, Gallagher SF, Freeman JJ, Agarwal S, Haines KL, Durham, North Carolina
J Trauma Acute Care Surg · 2026 Jul · PMID 41941382 · Publisher ↗
BACKGROUND: Motor vehicle crashes (MVCs) continue to be a leading cause of death in the United States, although broad adoption of seatbelt use has markedly reduced fatality. New Hampshire remains the only state without a...
BACKGROUND: Motor vehicle crashes (MVCs) continue to be a leading cause of death in the United States, although broad adoption of seatbelt use has markedly reduced fatality. New Hampshire remains the only state without a mandatory adult seatbelt law and has the lowest seatbelt usage rate at 78%, compared with the national average of 91%. This study investigates the association between seatbelt legislation and unrestrained MVC fatalities, focusing specifically on crashes occurring in New Hampshire and occupants with New Hampshire driver's licenses. METHODS: This retrospective cross-sectional study analyzed all fatal MVCs in the United States from 2017 to 2023 using the National Highway Traffic Safety Administration's Fatality Analysis Reporting System data. The primary outcome was unrestrained MVC mortality. Exposures included crash state and state driver's license, categorized into New Hampshire, primary enforcement states, and secondary enforcement states. Multivariable logistic regression was adjusted for demographic, environmental, vehicle, and driver-related factors. Secondary analyses evaluated New Hampshire-licensed drivers outside the state and non-New Hampshire-licensed occupants within New Hampshire. RESULTS: Among 146,655 fatal MVCs eligible for analysis, 474 occurred in New Hampshire and 485 involved New Hampshire license holders. The proportion of unrestrained fatal MVCs was highest for MVCs geographically within New Hampshire (71.5%) and for occupants with New Hampshire driver's licenses (68.7%). MVCs in New Hampshire (OR, 2.80; 95% CI, 2.15-3.65) and possessing a New Hampshire license (OR, 2.74; 95% CI, 2.13-3.52) were significantly associated with increased odds of unrestrained MVC fatality. Notably, New Hampshire-licensed drivers exhibited increased unrestrained fatality risk even when traveling outside their home state (OR, 2.06; 95% CI, 1.28-3.33). CONCLUSIONS: Our findings underscore the strong association between New Hampshire's absence of an adult seatbelt law and elevated unrestrained MVC fatality risk. These data highlight the urgent need for policy interventions to enhance occupant safety through mandatory seatbelt legislation in New Hampshire. ( J Trauma Acute Care Surg . 2026;101: 80-88. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Level IV.
Invited commentary: One incision, complete access-Median sternotomy and aortic occlusion in penetrating chest trauma.
Wall MJ, Houston, Texas
J Trauma Acute Care Surg · 2026 May · PMID 41941380 · Publisher ↗
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Increased prehospital to total blood product administration associated with improved hospital outcomes: A secondary analysis of hemorrhagic shock trials.
Furman L, Feeney EV, Bizri N … +10 more , Mitra B, Gruen RL, Medcalf R, Gaines BA, Guyette FX, Moore EE, Holcomb JB, Sperry JL, Leeper CM, Pittsburgh, Pennsylvania
J Trauma Acute Care Surg · 2026 Jul · PMID 41941349 · Full text
BACKGROUND: Early transfusion improves survival of traumatic hemorrhage. We hypothesized that increased ratios of prehospital to total blood (red blood cell or whole blood) transfusion within 24 hours would be associated...
BACKGROUND: Early transfusion improves survival of traumatic hemorrhage. We hypothesized that increased ratios of prehospital to total blood (red blood cell or whole blood) transfusion within 24 hours would be associated with improved outcomes. METHODS: A retrospective cohort study using a harmonized database of six hemorrhagic shock trials was conducted. Decedents within 4 hours and those not transfused within 24 hours were excluded. The primary outcome was 24-hour mortality; secondary outcomes included 28-day mortality, intensive care unit (ICU)-free and ventilator-free days, and incidence of acute lung injury (ALI). Prehospital blood ratio was calculated as volume prehospital transfusion:volume 24-hour total transfusion (prehospital plus 24-h total at the admitting facility). Multivariable analyses adjusted for age, sex, mechanism, Injury Severity Score (ISS), inter-facility transfer, transport mode, arrival systolic blood pressure and Glasgow Coma Scale, treatment group, trial, and transfusion volume were conducted. Sensitivity analyses (prehospital-only recipients, excluding traumatic brain injury) were conducted. RESULTS: Overall, 2,340 subjects were eligible, and 1,024 (43.8%) received prehospital blood. Prehospital recipients were older (median age 41 vs. 38 y, P =0.013), more likely blunt mechanism (81.6% vs. 66.0%; P <0.001), more likely transferred (13.3% vs. 4.3%; P <0.001), more likely transported by air (77.4% vs. 47.1%; P <0.001), and had higher ISS (median 29 vs. 25, P <0.001) compared with in-hospital only recipients. For every 10% increase in prehospital (PH):total blood ratio, there was an 8.8% decrease in odds of ALI (95% CI: 1.8-15.4%; P =0.015) and no significant association with mortality, ICU-free or ventilator-free days. Among prehospital recipients, for every 10% increase in PH:total blood ratio, there was a 16.7% decrease in odds of ALI (95% CI: 5.3-26.6%; P =0.005; n=375) and 0.21 (95% CI: 0.01-0.41; P =0.036; n=909) more ICU-free days. CONCLUSIONS: An increased proportion of resuscitation in the prehospital phase of care was associated with improved secondary clinical outcomes for select subjects. These data support initiating transfusion for hemorrhage as early as feasible. ( J Trauma Acute Care Surg . 2026;101: 39-47. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Is splenic artery embolization beneficial when splenic angiography is negative? A multicenter observational study.
Yoo R, Muller A, Cook C … +26 more , Castater C, Cullinane D, Udekwu PO, Lewis R, Jawa RS, Martin J, Teicher E, Hall CM, Canaan L, Perea LL, Leneweaver K, Chang G, Martin M, Jacobson LE, Trankiem C, Radow BS, Guido JM, Ahmeti M, Oh S, Seamon M, Bugaev N, Zhong PS, Ong A, Splenic Angiography Study Group,, Reading, Pennsylvania, Splenic Angiography Study Group, and Reading, Pennsylvania
J Trauma Acute Care Surg · 2026 Mar · PMID 41941334 · Publisher ↗
BACKGROUND: While a positive splenic arteriography (SA) usually requires splenic artery embolization (SAE), the benefit of SAE after a negative SA is unclear. We hypothesized that SAE in patients with a negative SA would...
BACKGROUND: While a positive splenic arteriography (SA) usually requires splenic artery embolization (SAE), the benefit of SAE after a negative SA is unclear. We hypothesized that SAE in patients with a negative SA would improve splenic salvage compared with no SAE. METHODS: A multicenter, retrospective, observational study was performed across 21 level 1 and 2 trauma centers from 2018 to 2023. Included were blunt trauma patients who underwent both computed tomography and SA. Patients arriving more than 48 hours after injury or without admission computed tomography were excluded. The primary endpoint was splenectomy within 30 days. SA was categorized as positive or negative based on prespecified criteria. Among patients with negative SA, those who underwent SAE were compared with those who did not. Cox proportional hazards and frailty models assessed the relative risk for splenectomy. RESULTS: Seven hundred twenty-six patients were included (median age, 44.5 y; median Injury Severity Score, 25). Of 332 with a negative SA, 80% underwent SAE. SAE was associated with lower splenectomy (5% vs. 16%, p=0.003) and mortality rates (2% vs. 10%, p=0.004). Adjusted Cox models showed reduced splenectomy risk with SAE when controlling for center splenectomy rate (HR, 0.33, 95% CI, 0.13-0.81, p=0.02) and urgent splenectomy rate (HR, 0.30, 95% CI, 0.13-0.65, p=0.005) but not when adjusting for SA utilization rate (HR, 0.69, 95% CI, 0.22-2.15, p=0.53) or including trauma center as a random effect (HR, 0.77, 95% CI, 0.27-2.30, p=0.65). Yet, complications requiring interventions after SAE (n=652) were not significantly different compared with those without SAE (n=74) (1.5% vs. 0%, p=0.34). CONCLUSIONS: In patients with negative SA, SAE was associated with reduced 30-splenectomy risk, but this association was not significant when including trauma center as a random effect. These findings suggest a possible association between SAE and splenic salvage in this selected cohort. (J Trauma Acute Care Surg. 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Why research articles in acute care surgery get rejected: 10 critical mistakes to avoid.
Stahel PF, Ziran N, Butler N … +2 more , Coimbra R, Parker, Colorado
J Trauma Acute Care Surg · 2026 May · PMID 41941333 · Full text
This manuscript synthesizes the authors' anecdotal experience as editors and peer reviewers by summarizing 10 commonly encountered flaws in the presentation of submitted research manuscripts in the field of trauma and ac...
This manuscript synthesizes the authors' anecdotal experience as editors and peer reviewers by summarizing 10 commonly encountered flaws in the presentation of submitted research manuscripts in the field of trauma and acute care surgery that may contribute to editorial decisions to reject. Notably, most of the listed mistakes are preventable through strict adherence to scientific reporting, coherent formatting, and proofreading before submission. ( J Trauma Acute Care Surg . 2026;100:831-835. Copyright © 2026 The Author(s). Published byWolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).
Beyond rural versus urban: A gradient of mortality risk among injured children across a four-level rurality scale.
Butler EK, Johnson R, Saltzman DA … +2 more , Segura BJ, Minneapolis, Minnesota
J Trauma Acute Care Surg · 2026 Mar · PMID 41925627 · Publisher ↗
BACKGROUND: Children living in rural areas experience an increased incidence of injury and higher mortality relative to those in urban areas. Our aim was to better characterize rural-urban disparities in pediatric trauma...
BACKGROUND: Children living in rural areas experience an increased incidence of injury and higher mortality relative to those in urban areas. Our aim was to better characterize rural-urban disparities in pediatric trauma outcomes among children admitted to US hospitals. METHODS: This is a retrospective, observational study of US hospitalizations of injured children and adolescents <20 years of age using the Kids' Inpatient Database (2016, 2019, and 2022). We categorized children's home counties as large urban, small urban, micropolitan, and rural. We compared demographics and injury characteristics of injured children among differing levels of rurality. We determined the unadjusted and adjusted risk of inpatient mortality using quasibinomial logistic regression, accounting for survey design, by level of rurality. RESULTS: A representative weighted 402,255 injured children were admitted in the survey years. The median age was 13 (IQR, 5-17) years and 39.1% were female. Motor vehicle crash (21.1%) and falls (21.1%) were the most common mechanisms of injury. As the level of rurality increased, the proportion of severely injured children (ISS >25) increased (7.0% large urban, 7.9% small urban, 9.6% micropolitan, and 10.9% rural areas). When adjusted for risk of mortality, compared to large urban counties, rural county was associated with 32% higher odds [odds ratio (OR), 1.32, 95% CI, 1.16-1.51], micropolitan 30% higher odds (OR, 1.30, 95% CI, 1.16-1.46), and small urban 22% higher odds (OR, 1.22, 95% CI, 1.12-1.32) of inpatient mortality. CONCLUSIONS: Among injured children admitted to US hospitals, children residing outside of large urban areas have a higher risk of death independent of injury severity. To address disparities in pediatric rural injury outcomes, we must further investigate the root causes of this disparity, which may include nonoptimal location of pediatric trauma centers, long transport times, and low pediatric readiness in rural hospitals. (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.
When blood runs thin: A national analysis of failure of nonoperative management of high-grade splenic injuries in patients on pre-injury anticoagulant or antiplatelet therapy.
Dhillon NK, Firek M, Zakhary B … +3 more , Allison-Aipa T, Coimbra R, Moreno Valley, California
J Trauma Acute Care Surg · 2026 Mar · PMID 41925620 · Publisher ↗
BACKGROUND: The proportion of trauma patients on anticoagulant and/or antiplatelet (AC/AP) therapy is increasing. Currently, there are no clinical guidelines on how to best manage blunt splenic injuries in patients on pr...
BACKGROUND: The proportion of trauma patients on anticoagulant and/or antiplatelet (AC/AP) therapy is increasing. Currently, there are no clinical guidelines on how to best manage blunt splenic injuries in patients on pre-injury AC/AP. This study aims to compare failure rates of nonoperative management (FNOM) among patients with high-grade splenic injuries who were on pre-injury AC/AP to those who were not. We hypothesized that patients with high-grade splenic injuries on AC/AP have higher rates of FNOM compared with those not on AC/AP. METHODS: A retrospective study was conducted using the Trauma Quality Improvement Program dataset from 2017 to 2021 of patients aged 18 years and older admitted with a high-grade (grades III-V) blunt splenic injury. Those who died within 24 hours of admission or had an extra-abdominal abbreviated injury scale (AIS) of three or greater were excluded. Patients were categorized based on whether they were on prehospital AC/AP or not. The primary outcome was FNOM. Inverse probability of treatment weighting was used to control for confounders. A logistic regression model was run on the weighted data with FNOM as the outcome. A separate multivariable logistic regression analysis was performed to identify risk factors associated with FNOM. RESULTS: A total of 18,589 patients met the inclusion criteria, of which 4.0% were on AC/AP. AC/AP patients were older (70 vs. 38 y, p<0.001) and more likely to have undergone splenic angioembolization. AC/AP patients had a higher FNOM rate (9.2% vs. 5.4%, p<0.001). FNOM rates were similar after inverse probability of treatment weighting, irrespective of whether angioembolization was performed. AC/AP status was not independently associated with FNOM [AOR=1.38 (95% CI=0.91-2.08), p=0.126]. CONCLUSIONS: Patients on AC/AP with high-grade splenic injuries have higher rates of FNOM. However, AC/AP status alone is not associated with FNOM. AC/AP status should not preclude a trial of NOM for patients who are otherwise candidates for this care pathway. (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved). LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.
The long game: Building a legacy of sustainable service.
Fox N
J Trauma Acute Care Surg · 2026 Jul · PMID 41925573 · Publisher ↗
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