Background:Trauma guidelines have historically recommended intubation prior to transfusion, yet intubation and mechanical ventilation can exacerbate hemodynamic instability. We hypothesized that injured patients resuscitated with a circulation-first approach would require fewer blood transfusions and would have lower mortality than those managed with an airway-first approach. Methods:This secondary data analysis of the Linking Investigations in Trauma and Emergency Services (LITES) database compared trauma patients in hemorrhagic shock who received blood products and intubation within 30 minutes of each other. 'ABC' patients were intubated first, whereas 'CAB' patients received blood first. A subgroup analysis compared patients with penetrating injuries only. Outcomes included transfusion volume, whole blood (WB) utilization, mortality, and hospital length of stay (HLOS). Results:35 CAB and 49 ABC patients were included. The ABC group suffered more blunt injuries (73.5% vs 42.9%, p=0.02) and were more likely to receive WB in the prehospital setting (75.5% vs 48.6%, p=0.02). Transfusion requirements were significantly higher in the CAB group (7195 mL vs 6090 mL, p=0.01), although this was not the case after removal of outliers. In the penetrating cohort (17 CAB, 11 ABC), CAB patients were less likely to be transferred directly from the scene (70.6% vs 72.7%), yet were more likely to receive WB in the prehospital setting (64.7% vs 27.3%). There were no differences with respect to mortality or HLOS. Conclusion:When comparing a circulation-first to an airway-first approach to triage in a unique, severely injured cohort of trauma patients, there was no difference detected in transfusion requirements or mortality. Centers participating in LITES more frequently used CAB over ABC for patients with penetrating trauma. The sample size and characteristics of this cohort limit its generalizability and highlight the need for prospective multicenter trials to guide the triage and management of hemorrhagic shock. Level of evidence:III, prognostic/epidemiological.
Background Thoracic damage control (TDC) is an operative strategy for physiologically depleted patients with severe thoracic injuries. The relationship of TDC complications and mortality has not been comprehensively examined. This study analyzed the association of complications and mortality following TDC. Methods A retrospective registry review at a Level 1 trauma center identified patients ≥16 years undergoing TDC. Demographics, physiological data, injuries, operations, complications, and mortality were abstracted. Univariate and multivariate analyses for mortality risk factors were performed. Results A total of 98 patients met the inclusion criteria. The median age was 31 (23-44) years, 52% male, and 69% had penetrating trauma. The median Injury Severity Score (ISS) was 32 (26-41), chest Abbreviated Injury Scale 4 (4–5), admission systolic blood pressure 112 (77-138), pH 7.16 (6.99–7.25), base deficit −11 (−17 to −7), and lactate 8.1 (5.7–11.3). The operative procedures performed included pulmonary 63.5%, cardiac 29.6%, great vessels 16.2%, and 66.3% had a concomitant damage control laparotomy. Of the entire cohort, 72 (73.5%) patients developed at least one complication, including bacteremia 35%, renal failure requiring continuous renal replacement therapy (CRRT) 23%, pneumonia 18%, and empyema 12%. Mortality was 25.5% (25/98), with 72% (18/25) occurring prior to chest closure. Univariate analysis demonstrated that blunt trauma (p<0.001), male sex (p=0.006), lower pH (p=0.007), higher ISS (p<0.001), and CRRT (p=0.031) were statistically significant risk factors for mortality. On multivariate analysis, only blunt trauma (OR 3.82, 95% CI 1.1 to 13.3, p=0.035) and admission pH <7.1 (OR 3.13, 95% CI 1.03 to 9.5, p=0.044) were independently associated with mortality. Conclusion TDC is an essential operative strategy in patients with severe thoracic injuries presenting in advanced shock. Both blunt trauma and degree of shock are independent risk factors for mortality, which are present on admission. Although complications are frequent and severe, they do not predict mortality. Level of evidence IV, diagnostic test/criteria.
Background Traumatic pancreatic head injury with complete main pancreatic duct (MPD) transection is rare and associated with high morbidity. For the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade IV injuries, pancreaticoduodenectomy is often considered the only definitive option; however, its invasiveness and risk of long-term endocrine and exocrine dysfunction create a major dilemma when pancreaticoduodenectomy may be disproportionate to the anatomic injury. Practical pancreas-preserving strategies remain poorly defined.Case presentation A 25-year-old male sustained a self-inflicted stab wound causing hemorrhagic shock, generalized peritonitis due to gastric perforation, and AAST-OIS Grade IV pancreatic head injury with complete MPD transection. Initial management consisted of staged damage-control surgery with peri-pancreatic gauze packing and negative-pressure therapy for hemorrhage and contamination control. After physiological stabilization, delayed reconstruction was performed using total pancreas-preserving pancreatic injury-site jejunostomy (PP-PIJ), in which viable pancreatic tissue surrounding the injury site was anastomosed to a Roux-en-Y jejunal limb without pancreatic resection. The postoperative course was complicated by a subfascial abdominal wall abscess with wound dehiscence requiring drainage and abdominal wall re-closure; however, no pancreatic fistula or anastomotic failure occurred, and pancreatic function was preserved.Conclusions This report describes the first adult application of PP-PIJ and proposes a pancreas-preserving reconstructive option for traumatic pancreatic head injury with MPD transection. Staged damage-control surgery may serve as a platform for delayed reconstruction. The accompanying decision algorithm may assist operative selection when pancreaticoduodenectomy may be disproportionate to the anatomic injury.
Trauma, acute care surgery, and surgical critical care clinicians routinely manage patients in whom small differences in timing, technique, and patient selection can meaningfully influence outcomes. Each year, emerging literature refines clinical decision-making across trauma surgery, emergency general surgery, pediatric trauma, and surgical critical care. A narrative review of the literature was conducted with primary emphasis on studies published in 2025. Selected high-impact articles from 2024 were included when they directly informed contemporary practice. Articles were identified through a structured review of the tables of contents of 17 high-impact general medical, surgical, trauma, and critical care journals and were supplemented by key articles known to the author group based on subject-matter expertise. The search was conducted between June 3, 2025, and December 31, 2025, and was limited to English-language publications. Priority was given to randomized clinical trials and large multicenter observational studies, with additional consideration of methodological rigor, citation impact, and journal-recognized distinctions. Thirteen studies were included, encompassing randomized trials, multicenter cohorts, and observational studies. These investigations addressed critical decision points across the continuum of care, including early resuscitation strategies, timing of life-saving interventions, analgesia and sedation, ventilator management, infection prevention, transfusion timing, perioperative antibiotics, diagnostic imaging strategies in older adults, and diagnostic and management pathways in pediatric trauma. Recent literature supports incremental refinement of trauma, acute care surgery, and surgical critical care practice, emphasizing selective application of established interventions, appropriate timing, and patient-centered decision-making. Collectively, these studies advance a more deliberate, evidence-informed approach to care across trauma surgery, emergency general surgery, pediatric trauma, and surgical critical care.Level of evidenceNarrative review.
Background Acute appendicitis is one of the most common surgical pathologies. While literature reports safe day-case appendicectomies in uncomplicated cases, hesitancy exists in discharging patients on the day of surgery. This study addresses the criteria for day-case surgery, patient selection, reported clinical risks versus benefits, complications, rates of readmission and patient satisfaction.Methods A literature review was carried out in PubMed and Medline for day-case appendicectomy, patient safety, day case surgery and National Health Service. British Association of Day Surgery recommendations were reviewed in relation to appendicectomy as a day-case.Results From the 146 identified papers, 19 fulfilled the inclusion criteria. Variability was noted in the definition of same-day discharge. Included patients had uncomplicated appendicitis, postoperative pain well managed by non-opioid analgesia, no clinical concerns and care at home. Age under 65 years, American Society of Anaesthesiologists (ASA) 1 or 2, absence of insulin-dependent diabetes and immunosuppressant therapy were also part of the inclusion criteria. No statistically significant difference was found in rates of reintervention and reoperation between admitted and discharged patients. Reasons for overnight admission were due to patient (age, comorbidities, etc) and system-related factors (theater availability and standardized pathways). Readmission occurred for wound infection, wound hematoma and minor bleeding. Patient satisfaction rates were high (59.4% to 91.2%).Conclusions Day-case appendicectomies are safe and achievable with robust patient selection criteria, clear pathways and improvements in theater availability and education of staff and patients. Clear guidelines are required with standardized care pathways to safely achieve day-case discharge of patients after appendicectomy.
Objective This case series examines 27 trauma patients who met criteria for ultra massive transfusion protocol (UMTP), defined as receiving over 20 units of packed red blood cells (pRBCs) within 24 hours of admission.Methods In this case series, 27 trauma patients were identified (≥16 years old) who received over 20 units of pRBCs within the first 24 hours of presentation in the emergency department (2016 to 2020). The data collected included patient demographics, injury type, initial Glasgow Coma Scale (GCS), transfusions, hemostatic adjunct use within 24 hours, lactate, in-hospital complications, length of stay, injury severity score, and mortality. The study was approved by the institutional review board. Descriptive statistics were used to characterize the data.Results This series primarily consisted of penetrating injuries (79%) and males (81%) with a median age of 31 years. Median admission GCS was 12 (IQR 10 to 15) (survivors: 14 (IQR 14 to 15), non-survivors: 8 (IQR 8 to 15)). Median length of stay was 10 days. Seven patients underwent resuscitative thoracotomy (29% survival), and all 27 patients required operation. Three patients (11%) received cardiopulmonary resuscitation (CPR) during transport, all of whom died. Median transfusion volumes within 24 hours were 36 units of pRBCs, 26 units of fresh frozen plasma (FFP), five units of PLT, and three units of cryoprecipitate.50% of patients received unbalanced ratios (>1.5:1) of pRBCs to FFP, and 60.7% received unbalanced ratios of pRBCs to PLT. Despite aggressive resuscitation, nearly half of the patients died by discharge, demonstrating the severity of their conditions.Conclusion UMTPs represent a critical component of modern trauma care. Although advancements have been made in protocol development, challenges remain in optimizing outcomes. Admission GCS of 3, age >50 years, resuscitative thoracotomy, and thrombocytopenia are important mortality predictors and should be considered with transport factors when analyzing which patients will benefit from aggressive resuscitation.Level of evidence IV.
Background Gun violence is the leading cause of death in children and a public health epidemic, disproportionately affecting Black youth. The Future is Now (Non-violent Options Win) was established in 2023 as a multiorganizational partnership and primary violence prevention effort. Medical student volunteers host once-a-month education sessions for children ages 4–15 on healthcare topics and wellness practices. Our study aimed to better characterize program participants and assess its initial impact.Methods We used a mixed-methods approach. We invited children and guardians to complete questionnaires, which included demographics and questions focused on their perceptions of healthcare and the program on a five-point Likert scale. We then conducted in-depth, semistructured individual interviews with the guardians to further understand the impact of the program and ways to expand. We used thematic analysis to identify and compare common themes.Results A total of eight guardians and seven children completed the questionnaires. Four out of eight guardians completed the interview. Seven (88%) of the guardians and six (86%) of the children were Black. The remaining guardian and child were White. Three (38%) of the guardians who completed the questionnaire and one (25%) of those interviewed reported that they had witnessed or experienced gun violence. Major themes from the interview analysis included positive feelings towards healthcare and the Future is NOW program, with the most impactful aspects being the hands-on activities, exposure to different topics and careers, and interactions with the volunteers. Most of the children experienced bullying; the guardians recommended including education about bullying. Other recommendations included bringing in more representative guest speakers and teaching violence prevention.Conclusion This primary prevention program appears to have positively influenced the involved children and guardians. Additional efforts will be made to expand the curriculum to address the needs of the participants and reach more children in the community.
High-acuity surgical and trauma care requires rapid decision-making under conditions of uncertainty, fragmented information flow, and competing physiological priorities. Patients frequently move across multiple services, each bringing distinct clinical expertise and discrete perspectives on prognosis, treatment goals, and acceptable outcomes. Within this dynamic environment, variation in prognostic framing and communication is common. Families often receive subtly different messages about the patient’s expected trajectory, which can foster confusion and mistrust. Clear, aligned communication is therefore not an adjunct to technical excellence; it is an essential component of high-quality trauma and surgical care.Contemporary surgical practice increasingly intersects with palliative care principles. Surgical patients experience significant symptom burden, uncertain recovery, and frequent inflection points requiring reconsideration of goals of care. Surgeons occupy a central role in these early conversations. Early surgeon-initiated discussions about values and acceptable outcomes improve alignment between treatment plans and patient preferences, clarify expectations as clinical conditions evolve, and support family decision-making under stress. Yet, there is little formal training of surgeons in this area. Specialty palliative care is an essential partner when complexity, symptom burden, or decisional conflict exceed routine surgical management. Together, surgeon-led communication and selective palliative collaboration create a model in which trauma care remains both aggressive when appropriate and consistently grounded in what matters most to patients and families. This review, recently discussed at the American Association for the Surgery of Trauma online Grand Rounds, will address several of the most common obstacles encountered by acute care surgeons navigating multidisciplinary goals-of-care and prognostic discussions, as well as complex surrogate situations. Specifically, it examines how to create and deliver a cohesive and consistent message from a multidisciplinary team, the role of surgeon-led palliative care discussions with and without formal palliative care service consultation, and strategies for managing discordant surrogate decision-makers.
Background Hospital-based violence intervention programs (HVIPs) have been identified as an important intervention to reduce the likelihood that people who are violently injured return to the hospital for a similar injury. However, these programs often struggle with the recruitment and retention of participants. Methods Drawing on long-term multisited ethnographic research at the programs associated with the two busiest trauma centers in the state of Maryland, we examine how survivors of violent injury, their loved ones, and program staff evaluate the effectiveness of HVIPs. Results In centering the perspectives of these stakeholders, our analysis shows a clear disconnect between the goals of HVIPs and the realities survivors face. Thematic analysis included the inability of program services to increase participant safety, the limited impact of HVIP services on reducing retaliatory violence, and the need for community-engaged collaboration. Conclusions These insights suggest a need for HVIP models that prioritize long-term care and social change. Level of Evidence Level IV, Economic & Value-based Evaluations.
