Background:Timely initiation of venous thromboembolism prophylaxis (VTEp) has been known to decrease venous thromboembolism (VTE after trauma; however, early VTEp in patients undergoing neurosurgical interventions (NSIs) is controversial with conflicting reports in the literature from retrospective studies. We aimed to evaluate the safety and outcomes of early VTEp in this high-risk cohort. Methods:The study was a secondary analysis from the prospective multicenter Consortium of Leaders in the Study of Traumatic Thromboembolism database. Traumatic brain injury (TBI) patients receiving NSI were included. Patients were divided into early (≤72 hours) and late (>72 hours) VTEp groups. Mortality, VTE, deep vein thrombosis (DVT), pulmonary embolism, and bleeding adverse events including progression of intracranial hemorrhage (pICH) were compared. Results:Among the total 238 patients, 233 (97.9%) underwent craniotomy or craniectomy, and 140 (58.8%) received early VTEp. Patients with a head Abbreviated Injury Scale score of 5 and craniectomy were more likely to delay VTEp (>72 hours) (all p<0.05). Compared with late VTEp, early VTEp exhibited lower rates of VTE (10.7% vs 16.3%, p=0.28) and DVT (8.6% vs 15.3%, p=0.16), though without achieving statistical significance. Through generalized estimating equation and competing risk analysis, early VTEp did not demonstrate a significant decrease of VTE risk (OR) 0.74, 95% CI 0.33 to 1.67; HR 0.90, 95% CI 0.45 to 1.84), whereas the risk of adverse bleeding events (OR 0.79, 95% CI 0.24 to 2.57) or pICH (OR 1.10, 95% CI 0.30 to 4.03) did not increase with early VTEp either. Conclusion:Early VTEp is not significantly associated with reduced rates of VTE or DVT in patients with severe TBI requiring emergent NSI, but it also does not increase the risk of adverse bleeding event or pICH. Level of evidence:Level IV; therapeutic/care management.

ABSTRACT:Covalent cross-linking of fibrin by the plasma transglutaminase coagulation factor XIII (FXIII) is a key determinant of blood clot stability and function. FXIII-catalyzed formation of ε-N-(γ-glutamyl)-lysyl cross-links is restricted to the fibrin γ-chain and α-chain and follows thrombin-driven fibrin polymerization. Fibrinogen is also cross-linked by tissue transglutaminase (TG2) in a reaction favoring intramolecular and intermolecular α-γ cross-linking. Emerging evidence indicates that fibrinogen is a relevant substrate of TG2 in conditions of acute tissue damage. Remarkably, beyond detection of prototypical FXIII-directed cross-links (ie, α-α, γ-γ), we identified entirely novel covalent cross-links involving the fibrinogen β-chain (ie, β-α, via FGB-Q82). Addition of TG2 to in vitro clotting reactions and analysis of fibrin(ogen) in reducing conditions revealed loss of β-chain polypeptide paired with formation of high-molecular weight β-chain species. Mass spectrometry-based cross-linking proteomic analysis of in vitro clots recapitulated the precise TG2-directed β-chain cross-links observed in clots made using plasma from patients following traumatic injury. The results indicate in vitro and ex vivo cross-linking of the fibrin β-chain and highlight a novel example of TG2 emerging as a relevant plasma transglutaminase.

BACKGROUND:Grading surgical complications and sequelae is of paramount importance for analyzing results and improving patient care and system performance and in optimizing resource allocation and use. Existing systems for surgical complication classification do not consistently account for baseline physiologic vulnerability and often conflate treatment intensity with clinical severity. This limitation reduces interpretability across diverse patient populations, particularly in emergency and elective general surgery. METHODS:A multidisciplinary expert panel conducted a modified Delphi process to develop a dual-axis classification system, the Extended Postoperative Complication Score (EPCS). This system stratifies patients preoperatively into three baseline classes (A, B, C) reflecting physiologic reserve and immunocompetence. Postoperative events are then graded by physiologic impact from Grade 0 (minor, no impact) to Grade IV (death). Sequelae, defined as anticipated events related to underlying pathology or chronic disease, are separately categorized. Representatives of the most relevant international emergency and trauma surgical associations were involved (World Society of Emergency Surgery, European Society for Trauma and Emergency Surgery, American Association for the Surgery of Trauma, Panamerican Trauma Society, EndoVascular and Trauma Management Society, Global Alliance for Infections in Surgery). RESULTS:The EPCS yields 18 mutually exclusive strata, combining five complication grades and three baseline classes, plus three sequelae codes. The matrix enables interpretable outcome reporting across settings, accounting for both event severity and host vulnerability. Expert consensus confirmed conceptual clarity and operational feasibility. The system allows applications to elective, urgent, and emergent operations, and is compatible with clinical audit, observational research, and pragmatic trials. CONCLUSIONS:The EPCS provides a structured, physiologically anchored method for postoperative complication stratification. Its dual-axis design may improve the validity of outcome comparisons and support real-world evaluation of surgical quality. Further validation is warranted through prospective multicenter implementation and time-bound observational methodologies. ( J Trauma Acute Care Surg . 2026;100: 324-330. 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:Prognostic and Epidemiological; Level V.

To map and critically appraise the current literature on Artificial Intelligence (AI) applications in emergency general surgery, with a focus on clinical decision-support tools for preoperative risk stratification and intraoperative assistance, and to identify ethical, structural, and regulatory barriers to implementation. A scoping review was conducted within the ARIES project, following established methodological frameworks. Relevant studies evaluating AI-based tools in emergency surgical settings were systematically identified and analyzed. The literature describes AI applications mainly in two domains: preoperative decision support, including risk prediction and diagnostic or triage models for acute abdominal and traumatic conditions, and intraoperative assistance, largely focused on computer vision–based systems for anatomical recognition, safety guidance, and navigation in minimally invasive emergency procedures. Additional contributions address training and telementoring platforms, as well as cross-cutting ethical, legal, and regulatory considerations relevant to AI adoption in emergency surgical care. AI has the potential to complement emergency surgeons’ clinical judgment, but its routine adoption in emergency surgical practice remains limited. Addressing methodological, ethical, and regulatory challenges, together with the development of robust data infrastructures and targeted training pathways, is essential to support safe, effective, and equitable implementation in acute care settings. In addition, the lack of dedicated investment and sustainable funding models for large-scale clinical implementation and prospective evaluation represents a critical barrier to the translation of AI from research into routine emergency surgical practice.

Ketamine is a dissociative anesthetic often used for airway management in trauma. While perceived to preserve hemodynamic stability, concerns exist regarding its effects on intracranial pressure and cardiac output in critically ill patients. There is a lack of studies evaluating outcomes after ketamine administration in the setting of traumatic brain injury (TBI). This study aimed to investigate the effects of ketamine on outcomes and physiological responses in a large cohort of TBI patients. We hypothesized that ketamine administration would not be associated with differences in survival, vital signs, or disposition outcomes compared with other induction medications when administered following TBI. This was a retrospective, observational study utilizing data from the Linking Investigations in Trauma and Emergency Services registry (2017-2021). Subjects were divided into two groups: those who received only ketamine (n = 429) and those who received other induction medications (etomidate and/or propofol; n = 993). We compared 24-h mortality, initial in-hospital vital signs (systolic blood pressure [SBP], respiratory rate, heart rate, and Glasgow Coma Scale [GCS]), and hospital discharge disposition; a propensity score analysis adjusted for potential confounders including race, injury type, pre-hospital GCS, initial pre-hospital SBP and site location. Ketamine-exposed subjects were younger and presented with a worse clinical profile, including lower pre-hospital GCS (5 vs. 6, p < 0.01) and lower SBP (126.5 vs. 144.0 mmHg, p < 0.01) compared with the ketamine-unexposed group. Unadjusted analysis showed a significantly higher 24-h mortality rate in the ketamine-exposed group (3.5% vs. 1.4%, p = 0.02), as well as lower initial in-hospital vital signs. After propensity score adjustment, the odds of 24-h mortality remained significantly higher for the ketamine-exposed group (OR 2.358, p = 0.042). Hospital discharge disposition was not different between groups in any analysis. In this retrospective analysis, ketamine administration for pre-hospital airway management in TBI patients was associated with an increased 24-h mortality and lower in-hospital SBP, even after adjusting for baseline differences. However, injury severity and the length of time examined for mortality may explain the significant mortality association for ketamine in this study. Prospective studies are needed to examine the relationship between ketamine administration and mortality following TBI.

BACKGROUND:Previous trials have found a modest survival benefit from tranexamic acid (TXA) administration after polytrauma, but the early discrimination of the survival benefit observed suggests that the clinical effect of TXA may be multifactorial, not solely through bleeding reduction. Plasmin is known to directly cleave and activate complement proteins, and TXA can inhibit plasmin generation. We hypothesized that polytrauma patients who received TXA would demonstrate less complement activation compared with placebo controls. METHODS:Patient plasma was obtained from 53 polytrauma patients enrolled in the Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Hemorrhage (PATCH) trial of prehospital TXA (1 g bolus plus 1 g drip over 8 hours) versus placebo in the emergency department, at 8 hours, and at 24 hours after admission. Complement activation and regulatory markers were measured via multiplex, and plasmin-antiplasmin levels via enzyme-linked immunosorbent assay. Pairwise comparisons of analytes between TXA and placebo at each time point were performed with significance set at p  < 0.05. RESULTS:The median age was 41.0 years (interquartile range, 28-57 years), 69.8% were male, the median Injury Severity Score was 38.0 (27.0-50.0), and all included patients were blunt mechanism. At early time points (emergency department and 8 hours), patients who received TXA did not demonstrate a reduction in C3a, C5a, sC5b-9, or plasmin-antiplasmin relative to placebo. At 24 hours, there was a significant increase in both C3a (274.0 vs. 416.6 ng/mL, p  = 0.0024) and C5a (9.4 vs. 11.6 ng/mL, p  = 0.0462) in the TXA group. CONCLUSION:A 1 g bolus plus 1 g drip of TXA paradoxically increased complement activation at 24 hours in the TXA group. These findings support that TXA is essential in the inflammatory pathway after trauma. The delayed increase in complement may reflect the timing of TXA dosing and the shift to urokinase as the main plasminogen activator at later time points after injury. These results raise important questions about the optimal dosing of TXA in trauma patients. ( J Trauma Acute Care Surg . 2026;100: 747-753. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE:Therapeutic/Care Management; Level IV.

Universally accepted guidelines to predict futile resuscitation in severely bleeding trauma patients with traumatic brain injury do not exist. These patients may consume vast volumes of blood products in futile cases, which is especially problematic during times of local and national blood scarcity. However, determining which patients have no chance of survival is complicated and often reliant on the traumatologist’s individual judgment, which may be inconsistent. Traumatologists often face the ethical dilemma of balancing their obligations to provide appropriate care for patients and to conserve blood products for other patients. To assist physicians, bedside futility algorithms have been developed, some of which emphasize the negative effects of traumatic brain injury on survival. Bedside futility algorithms may be used during futility time-outs early in the treatment of severely bleeding trauma patients who are unlikely to survive, potentially preventing blood product waste by providing guidance to clinicians in the early determination of futility and the withdrawal of life-sustaining treatment. These algorithms are steps toward the development of ethically grounded, data-driven clinical guidelines regarding the use of blood products in severely bleeding trauma patients. We compare historical and nascently proposed futility algorithms in the context of the ethical challenges of declaring futility in the severely injured population.

Background/Objectives: The United States is facing a national blood shortage, which is a function of the reduced number of donors since the COVID-19 pandemic and the increasing use of balanced hemostatic resuscitation for severely bleeding trauma patients. As a result, recent attempts to define futility based on clinical and laboratory criteria have been proposed. There is no literature on the frequency of institutional futility protocols, either at hospitals or blood collection centers. Methods: The Association for the Advancement of Blood & Biotherapies sent out a survey to 800 United States hospitals and blood collection centers to determine the frequency of trauma futility protocols and the need to limit blood for non-trauma patients due to high use in trauma patients. Results: 213 (26.6%) institutions responded. 10.8% of hospitals and blood collection centers reported having a trauma futility protocol, and those hospitals and blood collection centers with futility protocols were more likely to have needed to limit blood to non-trauma patients due to high consumption by trauma patients. Conclusions: Trauma futility protocols at hospitals and blood collection centers are uncommon. Because of the national shortage of blood products available for trauma and non-trauma cases, implementing institutional trauma futility protocols may help to curb the incidence of blood limitation to non-trauma patients. Increased awareness and communication between blood bankers and traumatologists during the declaration of futility may reduce blood wastage and enhance the nation's blood supply reservoirs.

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.

BACKGROUND:Autogenous arteriovenous fistulas (AVFs) are considered the gold standard for haemodialysis access; however, successful fistula maturation is often not achieved. Females and patients with comorbidities such as diabetes and obesity suffer lower rates of fistula maturation, meaning many must rely on catheters or synthetic grafts for access. Therefore, we aimed to compare human acellular tissue engineered vessel (ATEV) with AVF for functional and secondary patency, as well as duration of use over 1 year in patients with end-stage kidney disease. METHODS:In this multicentre, randomised, controlled, phase 3 trial, patients with end-stage kidney disease were recruited from 31 centres across the USA. Patients with end-stage kidney disease on haemodialysis using an indwelling catheter, who were candidates for placement of either an AVF or an arteriovenous graft, underwent screening for enrolment. Centres were selected for their ability to conduct a randomised controlled trial, and with investigators experienced in haemodialysis access procedures; site selection ensured broad generalisability across the US haemodialysis population. Patients were randomly assigned 1:1 to receive either an AVF or a ATEV for haemodialysis access via central software and database in the operating room, by study site personnel and before any initial skin incisions. The surgeon, patient, and site staff were unmasked to the allocation. The coprimary outcomes were functional patency at 6 months and secondary patency at 12 months, evaluated separately and analysed together to report global relative patency. Efficacy analyses included all randomly assigned participants and safety analyses included all participants who underwent study access creation; missing data were handled according to prespecified estimand-based methods detailed in the statistical analysis plan. This trial is registered with ClinicalTrials.gov (NCT03183245) and is now complete. FINDINGS:From Sept 29, 2017, to April 22, 2023, we enrolled 242 patients. 70 (29%) patients were female, 172 (71%) were male. 119 (49%) patients were assigned to receive an autogenous AVF, and 123 (51%) patients were assigned to receive an ATEV. Superiority of the ATEV was achieved for the coprimary endpoints, with a global relative patency of 1·17 (95% CI 1·04-1·31, p=0·0090). Functional patency at 6 months was 81·3% for patients who received an ATEV and 66·4% for those who received an AVF. Secondary patency at 12 months was 67·5% for the ATEV group and 62·2% for the AVF group. Duration of usability at 1 year was 7·4 months for the ATEV group versus 6·0 months for the AVF group (95% CI for difference 0·16-2·43, p=0·025). Access infection rates between groups were similar; the ATEV group required more interventions overall compared with the AVF group. Greater benefits of ATEV were observed in female patients and in male patients who were both diabetic and obese. In this subgroup (ie, female patients and male patients with diabetes and obesity), the global relative patency was 1·66 (95% CI 1·34-2·04) in favour of ATEV. INTERPRETATION:ATEV provides superior haemodialysis access outcomes at 1 year compared with AVF, with pronounced benefits observed in female patients and in male patients with obesity and diabetes. FUNDING:Humacyte.

BACKGROUND:Traumatic hemothorax (HTX) is a frequent complication of chest wall injury, with ~300,000 cases annually in the United States. Pain often signifies underlying inflammation and may contribute to secondary complications after chest wall injury. We hypothesized that HTX leads to local, intrapleural complement activation and release of proinflammatory cytokines that can prime neutrophils for inflammatory reactive oxygen species (ROS) release. METHODS:Adult trauma patients (N=15) with chest wall injury and HTX were consented for the study with IRB approval. HTX fluid and corresponding blood plasma were obtained in 3.2% citrate. Multiplex assays for complement analytes and proinflammatory cytokines were performed. Neutrophils from healthy donors were obtained and co-incubated with control platelet-poor plasma (PPP), trauma PPP, or corresponding HTX fluid and then challenged with vehicle control or N-formyl-methionyl-leucyl-phenylalanine (fMLP) in the presence of luminol, with ROS measured as luminescence over time. Pairwise comparisons were performed. Significance was set at p <0.05. RESULTS:Compared with circulating trauma PPP, HTX fluid had significant local elevations of complement components Ba, C3a, C4a, and sC5b-9 (all p <0.01). Inflammatory cytokines showed a similar local elevation in HTX relative to trauma PPP, including TNF-alpha, IFN-gamma, IL-8, and MCP-1 (all p <0.05). Neutrophils did not generate significant ROS in response to healthy PPP, trauma PPP, or HTX in the absence of fMLP. When challenged with fMLP, HTX co-incubated neutrophils generated marked ROS that was significantly greater than trauma PPP co-incubated neutrophils ( p <0.05), demonstrating marked local neutrophil priming in HTX, while plasma co-incubated neutrophils were not primed for ROS generation. CONCLUSIONS:Traumatic HTX is a highly inflammatory condition with locally enhanced complement activation, proinflammatory cytokine release, and inflammatory neutrophil priming for ROS production beyond that of circulating trauma plasma. Pain and secondary complications after chest wall injury with HTX may benefit from anti-inflammatory treatments in addition to pain control and drainage. ( J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). STUDY TYPE:Original Research. LEVEL OF EVIDENCE:Basic Science; N/A.

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.

Despite the availability of several appendicitis grading systems and ongoing efforts toward standardization, substantial variability persists worldwide in the management of acute appendicitis. Differences are particularly evident in operative approach, stump closure, postoperative antibiotic use and duration, drainage, interval appendectomy after non operative management and follow-up strategies. The PAMAP-W project was designed as a sequential mixed-method study to explore real-world practice patterns and to develop grade-linked expert statements to support clinical and surgical decision-making. The study consisted of two complementary phases. First, an international cross-sectional web-based survey was conducted among surgeons involved in emergency and acute care surgery to assess practices and attitudes regarding appendicitis severity classification and grade-linked management. The questionnaire explored demographics, surgical approach, appendiceal stump management, intra-abdominal lavage and drainage, postoperative antibiotic therapy, and follow-up strategies according to acute appendicitis severity. Second, a Delphi consensus process involving an international expert panel was carried out to review and refine candidate grade-linked management statements derived from areas of heterogeneity identified in the survey. Consensus thresholds were predefined for each Delphi round. A total of 467 surgeons from 64 countries completed the survey, providing an international snapshot of contemporary appendicitis management. Laparoscopy was the preferred approach across all grades, although increasing disease severity was associated with greater variability in operative choices and postoperative management. Considerable heterogeneity was observed in stump closure techniques, use of drainage, duration of antibiotic therapy, and follow-up strategies, particularly in complicated appendicitis. Fifty international experts were invited to participate in the Delphi process, 37 and 33 completed rounds 1 and 2, respectively. Most candidate statements achieved consensus after two rounds, resulting in a set of grade-linked expert statements intended to support more consistent interpretation and management of appendicitis severity. Marked international heterogeneity persists in the intraoperative and postoperative management of acute appendicitis, particularly in complicated disease. The PAMAP-W project combines real-world practice mapping with expert consensus refinement to support a pragmatic, grade-linked framework for clinical and surgical decision-making. The WSES Acute Appendicitis grading system is intended to complement, not replace, formal evidence-based recommendations. Further studies are needed to assess its reproducibility, implementation, and impact on clinical outcomes.

Importance:The initial treatment by emergency medical services (EMS) significantly affects the outcomes for severely injured patients. Effective control of hemorrhage, proper administration of blood products, and adherence to traumatic brain injury guidelines can reduce morbidity and mortality after trauma. Additionally, the experience of prehospital clinicians in high-acuity nontrauma conditions is associated with improved outcomes. Objective:To evaluate the association of annual trauma patient volume and outcomes at the individual EMS clinician level. Design, Setting, and Participants:A secondary subset analysis was performed of the Linking Investigations in Trauma and Emergency Services (LITES) Task Order 1 study, a prospective observational cohort from 2017 to 2021. It includes severely injured patients, identified by an Injury Severity Score of 9 or higher, who were transported to a trauma center by 1 air and 1 ground agency. Data were analyzed from February 2023 to June 2024. Exposures:EMS crew mean 3-year adult trauma volume and 6-hour mortality and several EMS industry quality metrics. Main Outcomes and Measures:Patient-level risk-adjusted regression models were constructed to determine the association between EMS crew mean 3-year adult trauma volume and 6-hour mortality and several EMS industry quality metrics. The association of airway success metrics and procedural intubation volume was also assessed. Results:A total of 6769 patient-clinician interactions involving 359 clinicians and 3649 patients (median [IQR] age, 54 [33-70] years; 2490 male [68.2%]) were included in this study. For every increase of 5 adult trauma patients annually per crew, there was a 10% decrease in 6-hour mortality (adjusted odds ratio [aOR], 0.899; 95% CI, 0.811-0.996) and a 2.6% decrease in in-hospital mortality (aOR, 0.974; 95% CI, 949-0.999). In subgroup analyses including traumatic brain injury (aOR, 0.974; 95% CI, 0.949-0.999) and prehospital shock (aOR, 0.974; 95% CI, 0.949-0.999), volume was associated with reduced 6-hour mortality. Highest trauma volume among treating EMS crew members, nontrauma volume, and years of experience were not significantly associated with differences in mortality. Among EMS industry quality metrics, decreasing scene time (regression coefficient, -0.134; 95% CI, -0.191 to -0.077) was significantly associated with higher clinician volume. Intubation procedural volume was associated with greater odds of success without hypotension or hypoxia (aOR, 1.110; 95% CI, 1.040-1.190). Conclusions and Relevance:Results of this cohort study suggest that higher patient volumes per EMS clinician were associated with lower early mortality rates after trauma. Exploring this association further is essential to optimize staffing, education strategies, and performance benchmarks.

Background Depletion of fibrinogen is an early event in trauma-induced coagulopathy (TIC), while hyperfibrinogenemia increases thrombotic risk in end-stage renal disease (ESRD). Viscoelastic tests aim to provide rapid fibrinogen estimates, yet their accuracy to define abnormal fibrinogenemia remains debated. Objectives We assessed the accuracy of thrombelastography (TEG)-TEG 5000 and TEG 6s-in measuring normal and abnormal fibrinogen levels across healthy volunteers, patients with ESRD, and trauma patients at risk for TIC. Methods We compared the von Clauss functional fibrinogen (gold standard) with TEG 5000 functional fibrinogen level (FLEV) in 118 healthy volunteers, 52 patients with ESRD who underwent arteriovenous fistula surgery, and 265 severely injured patients. We compared Clauss fibrinogen with TEG 6s citrated functional fibrinogen (CFF) in 140 trauma patients at high risk for TIC. Pearson correlation was used. Results Clauss fibrinogen correlated moderately with TEG 5000-FLEV in healthy volunteers (r = 0.52; P < .0001) and patients with ESRD overall (r = 0.62; P < .0001). Correlation, however, deteriorated and became nonsignificant in patients with ESRD with fibrinogen of > 500 mg/dL. Trauma patients showed moderate overall correlation (r = 0.58; P < .0001), but the correlation decreased substantially with fibrinogen of <150 mg/dL (r = 0.20; P = .29). TEG 6s-CFF had better overall correlation (r = 0.66; P < .0001), though decreased at fibrinogen<200 mg/dL (r = 0.39; P = .04). Conclusion Both TEG 5000-FLEV and TEG 6s-CFF correlated moderately with Clauss fibrinogen but decreased in correlation in both hyperfibrinogenemia and hypofibrinogenemia. Thus, we caution relying on TEG 5000 or TEG 6s to be the only laboratory measurement to guide fibrinogen replacement when resuscitating trauma patients at risk for TIC and TEG 5000-FLEV for assessing fibrinogen in patients with ESRD at risk for thrombotic events.