BACKGROUND:Tube thoracostomy is performed over one million times annually in the United States, including ~300,000 emergent procedures often without imaging guidance. Conventional open techniques carry complication rates of 25% to 30%, largely due to malpositioning. ThoraSET (Thoracic Safety Enhancing Trocar) is a pressure-sensing trocar system that differentiates tissue layers and provides real-time visual feedback. We hypothesized that ThoraSET would improve placement accuracy and reduce placement time, narrowing the gap between novice and expert users. METHODS:This prospective study combined iterative device development with stakeholder feedback and comparative evaluation on porcine cadaver and mannequin models. Participants across four experience levels (novices, residents, APPs, attending surgeons) completed paired open and ThoraSET-assisted tube thoracostomy trials. Primary outcomes were placement time and anatomical accuracy. Paired t tests and McNemar or exact McNemar tests were used for analysis, with sensitivity analyses by model type. RESULTS:Among 25 participants, ThoraSET reduced placement time for novices (-62%), residents (-26%), and APPs (-43%), but increased time for attendings (+33%). Large effect sizes were observed for novices and APPs. Overall accuracy was higher with ThoraSET (79% vs. 54%; P=0.07). Residents' accuracy improved from 10% to 80%; APPs and attendings remained 100%; novices decreased from 50% to 25%. Sensitivity analyses confirmed similar trends, with significant time reductions on pig (p=0.038, d=-0.57) and mannequin models (P=0.028, d=-0.73). CONCLUSIONS:ThoraSET improved placement speed and accuracy, particularly among less experienced users, and may reduce procedural variability and complications. Its mechanically responsive, blunt trocar provides tactile feedback, enhanced control, and intrathoracic access, supporting safer placement and use of smaller, softer tubes. These pilot results suggest ThoraSET has the potential to elevate safety and standardization in emergency and trauma care, warranting further clinical validation. (J Trauma Acute Care Surg. 2026;00: 000-000.). LEVEL OF EVIDENCE:Therapeutic/Care Management; Level V.
BACKGROUND:Resuscitative thoracotomy (RT) for traumatic cardiac arrest (TCA) carries a high mortality, and national guidance for RT indications varies in their emphasis on signs of life (SOL) and arrest duration. The Eastern Association for the Surgery of Trauma (EAST) prioritizes SOL, while the Western Trauma Association (WTA) emphasizes prehospital arrest time. To evaluate the clinical utility of each framework, we compared survival based on adherence to EAST and WTA RT guidelines. METHODS:We conducted a retrospective review of all TCA patients who underwent RT at our ACS-verified Level 1 trauma center. Demographics, presenting features, and outcomes were abstracted from the electronic medical record. The 2012 WTA and 2015 EAST guidelines were applied to categorize each case as guideline-adherent or nonadherent. Survival outcomes at various timepoints were assessed, including neurologically intact survival (NIS; discharge without hypoxia-related neurological deficit). χ2 analysis compared survival between EAST and WTA-adherent groups. RESULTS:A total of 467 patients underwent RT; overall survival to discharge was 5.8%, and NIS was 4.7%. EAST criteria were met in 460 (98.5%), and adherence was associated with 5.9% survival and 4.8% NIS. WTA criteria were met in 371 patients (79.4%); adherence was associated with 7.0% survival and 5.9% NIS. Patients not meeting either guideline had markedly lower survival. Three survivors lacked documented SOL but met favorable time criteria; all were neurologically intact. Of 96 patients exceeding WTA-arrest time limits, 1 (1.0%) survived, but without neurological recovery. CONCLUSIONS:Despite prioritizing different clinical factors, EAST and WTA guidelines identified similar subsets of potential survivors with comparable survival outcomes. Both SOL and prehospital arrest duration are integral in predicting survival. These findings support the development of a unified, evidence-based guideline that integrates both systems to standardize practice and optimize decision-making around RT. (J Trauma Acute Care Surg. 2026;00: 000-000). LEVEL OF EVIDENCE:Therapeutic/Care Management; Level III.
INTRODUCTION:The optimal imaging strategy for pediatric cervical spine clearance remains controversial. The primary objective of this study was to determine the sensitivity of computed tomography (CT) in detecting clinically significant cervical spine injury in children. We hypothesized that CT is sufficiently sensitive to allow for definitive clearance of the pediatric cervical spine after blunt trauma. METHODS:We conducted a prospective, multicenter, observational study from March 1, 2022, to July 31, 2025, at 72 diverse adult, mixed, and pediatric trauma centers across the United States. All children <18 years who underwent cervical spine imaging after blunt trauma were included. The primary outcome was the ability of CT to identify a clinically significant cervical spine injury requiring operative intervention or halo placement. We performed a post hoc panel review of all cases with normal imaging that required surgery. The diagnostic test characteristics and 95% CI of CT were calculated. RESULTS:We prospectively enrolled 19,651 pediatric patients, of whom 12,693 (65%) underwent cervical spine CT and comprise the analytic cohort. The median age was 12 (interquartile range, 6-15), 37% (n=4,673) were female, and 19% (n=2,389) were obtunded, defined as GCS ≤13. The sensitivity of CT at the treating hospitals to identify a clinically significant injury was 94.7% [CI: 89.4%-97.5%], with a negative predictive value of 99.9% [CI: 99.9%-100%]. Error analysis identified eight patients with false-negative CT interpretations, of which six injuries were identifiable on retrospective review. Accounting for retrospectively identifiable injuries, CT sensitivity for detecting clinically significant injury was 98.7% [CI: 94.8%-99.8%], with a negative predictive value of 100% [CI: 99.9%-100%]. CONCLUSIONS:In pediatric blunt trauma patients evaluated for cervical spine injury, CT is highly sensitive for detecting clinically significant injuries. These findings support pediatric cervical spine clearance based on a normal cervical spine CT. (J Trauma Acute Care Surg. 2026;00: 000-000. © 2026 The Author(s). Published by Wolters Kluwer Health, LLC. on behalf of the American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE:Prospective Cohort Study; Level II.
BACKGROUND:Interpersonal violence is one of the leading causes of death and disability. Hospital-based violence intervention programs (HVIPs) have been employed to address the psychosocial, educational, mental health, and other needs of injured patients. The objective of this systematic review and meta-analysis was to evaluate the impact of HVIPs in the United States or Canada on violent injury recidivism. METHODS:US or Canadian studies with clearly defined adult-only or adult-and-pediatric patient populations were analyzed to evaluate the efficacy of HVIPs (intervention) compared with no HVIPs (comparator) in preventing violent reinjury recidivism (outcomes). A systematic literature search and review was conducted, and the quality of evidence was evaluated per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. We performed a meta-analysis with leave-one-out sensitivity analysis of studies meeting criteria for quantitative assessment. RESULTS:Seventeen studies met our selection criteria and were included in the qualitative analysis, including one subgroup study. Of these, 10 studies were included in a meta-analysis, with results favoring HVIP programs (OR, 0.60; 95% CI, 0.38-0.94; Cochran's Q p=0.0025) for the prevention of violent injury recidivism. Overall evidence quality was deemed to be low, with substantial heterogeneity (I² = 64.7%) between studies. CONCLUSIONS:We conditionally recommend HVIP programs in urban trauma centers with substantive violent injury in adult-only or mixed adult-pediatric populations in the United States or Canada for the prevention of violent injury recidivism, with centers evaluating program design and benefit locally. Given the heterogeneity of reported results and program offerings, we also recommend continuing research on this topic, with the creation of a standard definition of HVIP programs and outcomes of interest. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.). LEVEL OF EVIDENCE:Systematic Review with Meta-Analysis; Level IV.
ABSTRACT:Gastric outlet obstruction (GOO) can result from several etiologies. GOO due to peptic ulcer disease occurs in fewer than 5% of all patients with complicated duodenal ulcers and in <1% to 2% of those with gastric ulcers. Malignant disease is now a more common etiology. Patients with GOO present with severe vomiting, abdominal pain, severe dehydration, and electrolyte derangement requiring resuscitation. The initial imaging evaluation is a computed tomography scan with po contrast, which will demonstrate the obstruction and possible etiologies. An EGD should be done to assess the degree of GOO structure and obtain a tissue biopsy. The management of benign GOO can range from balloon dilation that can be repeated or consider other endoscopic options. Surgical management of severe GOO is occasionally required with either pyloroplasty or resection of the GOO with a Billroth I/II or Roux-en-Y reconstruction. Management of malignant disease can become complex, as the initial goal would be operative management of resectable malignant disease. If not resectable, there are several endoscopic alternatives to bypassing an obstruction. Surgical bypass options with a Billroth II are still an option.
BACKGROUND:Surgical stabilization of rib fractures (SSRF) for severe chest wall injury has increased, with research showing improved outcomes compared with nonoperative management. Ideally, SSRF is performed within 3 days of injury. We hypothesize that late SSRF (days 5 to 14 post-injury) provides benefit over nonoperative treatment in patients with severe chest trauma. METHODS:We analyzed a prospectively collected database (2016 to 2024) from an urban level I trauma center, including patients with ≥3 severely displaced rib fractures. Propensity score matching (PSM, 1:2) was used to compare patients undergoing late SSRF (days 5 to 14 post-injury) to those hospitalized ≥5 days who did not receive SSRF. Outcomes measured were daily morphine milligram equivalents (MME), epidural use, opioid prescription at discharge, hospital length of stay (LOS), ICU-free days, ventilator-free days (VFD), pneumonia, tracheostomy, and mortality. RESULTS:Among 364 SSRF patients, 28 (8%) underwent late SSRF; these patients were matched to 56 No-SSRF patients. Both groups had similar demographics. SSRF patients had lower injury severity score (ISS) (17 vs. 26) but higher RibScore (3.5 vs. 3.0). Late-SSRF patients had significantly lower maximum daily MME post-day 5 (60 mg vs. 148 mg, P=0.045) and nonsignificantly lower median MME (56 mg vs. 67 mg, P=0.47) than No-SSRF patients. There were nonsignificant differences in use of epidurals (8% vs. 33%, P=0.22) and discharge with opioids (75% vs. 87%, P=0.38). Late SSRF was associated with more ICU-free days (6.5 vs. 3.5, P=0.02), shorter hospital LOS (9.0 vs. 16.5 d, P=0.008), and reduced pneumonia incidence (0% vs. 33%, P=0.03). Nonsignificant differences in tracheostomies, VFD, and mortality between the study groups. CONCLUSIONS:Late SSRF is associated with improved in-hospital outcomes. Although early intervention remains ideal, late SSRF may provide clinical benefits in selected patients. (J Trauma Acute Care Surg. 2026;00: 000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved. LEVEL OF EVIDENCE:Level III, retrospective review.
BACKGROUND:Surgical stabilization of rib fractures (SSRF) is increasingly used for flail chest, yet practice remains heterogeneous. We aimed to identify predictors of SSRF, quantify hospital-level variation, and evaluate whether hospital SSRF volume and utilization rate are associated with outcomes in flail chest. METHODS:Using ACS-TQIP 2017 to 2020, we conducted a retrospective cohort study of trauma patients older than or equal to 18 years with flail chest. Mixed-effects logistic regression evaluated predictors of SSRF and between-hospital variation. Hospitals that performed ≥1 SSRF were grouped into quintiles by SSRF case volume and by SSRF utilization rate (proportion of flail chest patients undergoing SSRF), and associations with in-hospital mortality, 28-day ventilator-free days, ICU length of stay (LOS), and hospital LOS were assessed using adjusted regression models. RESULTS:Among 718 centers treating flail chest, 216 (30.1%) did not perform SSRF. Among 15,380 flail chest patients treated at 502 SSRF-performing trauma centers, 3,484 (22.7%) underwent SSRF. Older age (≥65 y), female sex, Black race, self-pay status, and traumatic brain injury (AIS head ≥3) were associated with lower odds of SSRF; pulmonary contusion, hemothorax, and higher Injury Severity Score were associated with higher odds. Median odds ratio was 3.08 (95% CI: 2.75-3.49), indicating that for two otherwise similar patients treated at two randomly selected hospitals, the median difference in odds of receiving SSRF was 3.08-fold. Higher hospital SSRF volume was associated with more ventilator-free days and shorter ICU and hospital LOS without mortality differences. Higher SSRF utilization rate was associated with fewer ventilator-free days and longer ICU and hospital LOS without mortality differences. CONCLUSIONS:SSRF use for flail chest varied widely across trauma centers. These findings suggest that not only whether patients receive SSRF, but also how hospitals use SSRF within their systems, may be critical to optimizing outcomes in flail chest. LEVEL OF EVIDENCE:Level III, therapeutic/care management.
BACKGROUND:Previous research has demonstrated that pediatric-onlyhospitals (POHs) and combined pediatric-adult trauma centers (CPACs) have comparable outcomes in generalized pediatric trauma populations. However, infants and toddlers have distinct injuries and physiology that may be infrequently seen at CPACs. This study compared pediatric trauma patients (PTPs) ≤2 years old treated at POHs versus CPACs, hypothesizing similar associated risk of mortality and in-hospital complications between hospital types. METHODS:The 2017 to 2023 TQIP database was queried for PTPs ≤2 years old. Patients were grouped by treatment at POHs or CPACs. Hypotension was defined as systolic blood pressure <70 mm Hg, tachypnea as respiratory rate >40 breaths per minute, and tachycardia as heart rate >190 beats per minute (bpm) for PTPs ≤1 year old and >140 bpm for PTPs 2 years old. Bivariate analyses and multivariable logistic regression controlling for age, injury severity score (ISS), and vitals on arrival were performed. RESULTS:Of 39,373 PTPs ≤2 years old, 26,412 (67.1%) were treated at POHs and 12,961 (32.9%) at CPACs. Demographics, ISS (4 vs. 4), and rates of emergent operation (12.1% vs. 12.5%) were similar between cohorts (all p>0.05). On arrival, POH patients were less often hypotensive (0.6% vs. 0.9%, p=0.002) and tachycardic (≤1 y old: 1.4% vs. 1.7%, p=0.007; 2 y old: 27.9% vs. 32.9%, p<0.001), but more commonly tachypneic (3.8% vs. 2.4%, p<0.001). The CPAC cohort had increased complications (1.3% vs. 1.0%, p=0.03); however, this was not significant after multivariable analysis (OR 0.87, CI: 0.71-1.08, p=0.21). Mortality rate (1.3% vs. 1.6%, p=0.07) and associated risk (OR 1.08, CI: 0.86-1.37, p=0.51) were also similar between groups. CONCLUSIONS:This seven-year national analysis demonstrated that in PTPs ≤2 years old, the associated risks of in-hospital mortality and complications were similar between POHs and CPACs. These findings reinforce that trauma verification is maintaining similar outcomes across both hospital types, even among infants and toddlers. STUDY TYPE:Retrospective database. LEVEL OF EVIDENCE:Therapeutic/care management; Level IV.
ABSTRACT:Gastrointestinal (GI) oncologic emergencies are increasingly common as the population ages and as systemic therapies extend the survival of patients with advanced malignancy. The management of these emergencies frequently falls to the acute care surgeon, who must often act on incomplete information, without the benefit of complete staging, a multidisciplinary tumor board, or nutritional optimization, and frequently under considerable time pressure. This review addresses five emergencies most likely to be encountered: malignant bowel obstruction, GI hemorrhage, perforation, biliary obstruction with cholangitis, and neutropenic enterocolitis. Several principles recur across these entities: resuscitation and control of sepsis or hemorrhage take precedence over oncologic considerations; endoscopic and other nonoperative options are often preferable in appropriately selected patients; and recent antiangiogenic therapy, profound neutropenia, and heavy contamination should each lower the threshold for diversion rather than primary anastomosis. The choice of intervention must also account for the altered physiology and disease biology unique to this population, and GOC discussions should be integrated early enough to inform, and not follow, the decision to operate. This review summarizes the available evidence and relevant guidelines to provide a practical framework for individualized decision-making at the bedside. (J Trauma Acute Care Surg. 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.). LEVEL OF EVIDENCE:Level IV, descriptive/narrative literature review.
ABSTRACT:Hemorrhage accounts for significant preventable death among trauma patients. The advent of endovascular technology and development of more advanced imaging techniques have paved the way for catheter-based endovascular therapies to diagnose and treat hemorrhage. Angioembolization is now a cornerstone in the minimally invasive treatment of vascular trauma. Though it is highly effective and frequently obviates the need for major open surgery, its complications can be significant and warrant consideration in the management decisions for these patients. Complications range from mild self-limiting conditions to failure of endovascular therapy with need for open surgery.
BACKGROUND:The rib cage is classically described as seven true ribs, three false ribs, and two floating ribs. Recent cadaveric studies have shown that there is variability in the cartilaginous attachments of the rib cage; however, these studies were done on Caucasian specimens only. We sought to determine if the anatomy of the rib cage can be assessed via computed tomography (CT) and describe the anatomic variations. METHODS:The trauma registry was used to identify recent patients evaluated by the trauma program who did not have rib fractures. These patients were sorted by race and gender and randomly assigned for review by experienced chest wall surgeons. CT scans were evaluated in three-dimensional, axial, sagittal, coronal, and tangential images to evaluate the number of ribs, aberrant anatomy, and cartilaginous attachments. Data was analyzed by SPSS v.30. RESULTS:Two hundred seventy-eight patients were evaluated with an average age of 49+/-25 years, and 54% were male. In all, 11 pairs of ribs were noted in 3.5% of patients and 13 ribs in 1% of patients. Variability was noted in the number of the lowest true ribs: sixth rib 19%, seventh rib 75%, eighth rib 6%, and a different number of true ribs on each side 5%. The number of true ribs was greater in males (6.9+/-0.5) versus females (6.8+/-0.5), p=0.008. Significantly more females had ribs that connected at the midline without sternal attachment: 24.4% (31/127) versus 14.5% (22/127), p=0.037. Comparing the right and left rib cage, 72% of patients were asymmetric. Super/infranummary pairs of ribs occur in 5% of patients. CONCLUSIONS:Significant variability from the presumed normal anatomy of the costal cartilages was seen. Compared with females, males have more true ribs. Most people do not have symmetrical rib cages, and the majority of patients exhibit variability in their costal cartilage. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.). LEVEL OF EVIDENCE:Level IV.
BACKGROUND:The risk of venous thromboembolism (VTE) in subsets of the most severely injured patients can approach 30%. Statins have anti-inflammatory properties and exert beneficial effects on the endothelium, but few previous studies have evaluated their effects on VTE in risk-stratified groups. We hypothesized that statin use was associated with lower VTE in high-risk trauma patients. METHODS:All patients admitted to the trauma intensive care unit (ICU) from 1/2024 to 11/2024 at a single level 1 trauma center were risk-stratified using the Greenfield Risk Assessment Profile (RAP). Nontrauma patients and burn patients were excluded. Outcomes were compared between patients with and without VTE, defined by deep vein thrombosis or pulmonary embolism. Univariate analyses and multivariate logistic regression evaluated the association between statin use and VTE. Statistical significance was assessed at p≤0.05. RESULTS:In 509 patients (age 52±22 y, 71% male, 18% penetrating injury), the average RAP score was 10±5, the overall VTE rate was 17%, and mortality was 5%. Compared with statin nonusers, statin users (n=100) were older, with more blunt injury, similar RAP scores and thromboprophylaxis use, but had a significantly lower VTE rate (8 vs. 19%, P=0.007). After RAP-based stratification, the high-risk group (RAP≥10) had a VTE rate of 28%. After controlling for confounding variables with multivariate logistic regression, statin use was independently associated with decreased VTE with an odds ratio of 0.209 (95% CI: 0.065-0.670, P=0.008). CONCLUSIONS:Severely injured patients have high rates of VTE despite thromboprophylaxis;, however, the incidence of VTE was significantly lower among statin users. In the highest risk patients, statin use was independently associated with decreased odds of VTE. Because of their pleiotropic effects, including anti-inflammatory and endothelial protective properties, statins may be an important adjunctive therapy in VTE chemoprophylaxis. (J Trauma Acute Care Surg. 2026;00: 000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.). LEVEL OF EVIDENCE:Level III, therapeutic/care management.
ABSTRACT:High acuity, low occurrence (HALO) procedures are time-critical, life-saving interventions whose intrinsic rarity traditionally limits opportunities for individual clinicians to build and maintain proficiency through clinical exposure alone. The traditional volume-outcome paradigm, which assumes higher procedural volume correlates with better outcomes, confronts a structural paradox: these procedures demand advanced expertise precisely where experiential learning is least available. Evidence from registries on resuscitative endovascular balloon occlusion of the aorta, emergency department thoracotomy, and extracorporeal cardiopulmonary resuscitation consistently demonstrates that outcome variation tracks institutional rather than individual-operator volume. We propose a conceptual framework that distinguishes Individual Skill, the bounded, transferable psychomotor competencies required for procedural execution, from institutional competence, the organizational capacity to deploy those skills safely and reproducibly through deliberate integration of clinical governance, engineered readiness, structured training, and continuous quality learning. Individual skill, while necessary, is insufficient: a skilled operator working outside a competent institution represents a risk rather than an asset. The framework identifies institutional commitment as a prerequisite and defines five jointly necessary operational domains: clinical governance, training and skill maintenance, readiness engineering, downstream pathway integration, and continuous quality learning. This distinction carries implications for credentialing, governance, and resource allocation: competence standards should evaluate systems alongside operators, and institutions serving populations where HALO procedures should commit to building and sustaining these capabilities.
BACKGROUND:Each year, hundreds of thousands of children are treated for injuries related to micromobility use. Helmet use is a proven preventive measure, yet use remains low. Recently, the rise in electric vehicles (EVs) has introduced new risks. The study aimed to characterize pediatric micromobility accidents from motorized and nonmotorized bicycle, scooter, and skateboard accidents, with a focus on helmet use and its impact on injury severity. METHODS:We conducted a retrospective study at a Level 1 adult and Level 2 pediatric trauma center, analyzing 285 cases of pediatric injury from motorized and nonmotorized bicycle, scooter, and skateboard accidents between January 1, 2020, and December 31, 2024. Data from the trauma registry and electronic health records were reviewed. Helmet use and its association with demographic factors, injury severity score, and clinical outcomes were analyzed. RESULTS:On average, there were 57 cases of micromobility injuries each year, with cases increasing from 45 to 77 between 2020 and 2024. Overall, helmet use was 23.5%. Helmet use declined from 31.1% in 2020 to 23.4% in 2024. Lower helmet use was significantly associated with lower socioeconomic status and non-White riders. From 2020 to 2024, EV-related injuries increased from 0% to 37.7%. Increased EV use was significantly associated with older age and male gender. CONCLUSIONS:Despite a helmet mandate in New Jersey, helmet use in our cohort was lower than national estimates, and the issue is getting worse in recent years, especially among non-White individuals from low-opportunity neighborhoods. While helmet use among patients presenting for trauma care did not correlate with lower injury severity, this likely reflects injuries prevented or lessened by helmets, reducing the need for trauma care. EVs constitute an increasingly large percentage of injury mechanisms in our cohort, especially among young males. Our work highlights the need for targeted interventions among the most vulnerable populations. (J Trauma Acute Care Surg. 2026;00: 000-000. Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.). LEVEL OF EVIDENCE:Prognostic/Epidemiology; Level III.
