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.

BACKGROUND:Morel-Lavallee lesions are traumatic closed degloving injuries. Operative intervention remains the primary treatment approach. However, high-quality postoperative outcomes data are limited. This study aimed to determine the rate of wound complications associated with Morel-Lavallee lesions and identify risk factors for postoperative wound complications. METHODS:A prospective, multicenter, observational study (2021-2024) was conducted across 15 trauma centers. Adult patients with a Morel-Lavallee lesion who underwent operative management were included. The primary outcome was incidence of wound complications, defined as cellulitis, deep wound infection, skin necrosis, necrotizing soft tissue infection, and organized hematoma. Multivariable logistic regression was performed to identify predictors of wound complications. RESULTS:Among 134 patients who underwent operative intervention for Morel-Lavallee lesions, 27 (20.1%) developed a postoperative wound complication. Wound complications included skin necrosis (n = 10, 7.5%), deep wound infection (n = 9, 6.7%), cellulitis (n = 7, 5.2%), organized hematoma (n = 7, 5.2%), and necrotizing soft tissue infection (n = 3, 2.2%). In patients with wound complications, more frequent mechanisms of injury were bicycle collision (14.8% vs. 1.9%, P = .004) and pedestrian struck by motor vehicle (37.0% vs. 15.0%, P = .010). On multivariable analysis, only pedestrian struck by motor vehicle mechanism of injury (odds ratio 3.44, 95% CI 1.29-9.17, P = .014) was an independent predictor of increased wound complications when also controlling for closure of dead space, current tobacco use, and diabetes. CONCLUSION:More than one fifth of patients undergoing operative management of Morel-Lavallee lesions developed a postoperative wound complication. The only independent predictor of wound complications was pedestrian struck by motor vehicle mechanism of injury. These findings may help guide patient counseling.

INTRODUCTION: Outcomes following urgent video-assisted thoracoscopic surgery (VATS) after penetrating thoracic trauma in pediatric patients is unknown. We hypothesized that patients undergoing urgent VATS would have a higher risk of in-hospital mortality and complications, compared to similarly matched patients not undergoing VATS. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for patients <17-years of age presenting after isolated penetrating thoracic trauma. Patients undergoing VATS within 6-hours were compared to those not undergoing VATS using a 1:1 propensity-score model. RESULTS: From 18,596 isolated penetrating trauma patients, 369 (2.0%) underwent VATS within six hours. 360 patients undergoing VATS were matched to 360 patients not undergoing VATS. There were no differences in age, sex, race, and comorbidities (all p>0.05). The VATS group had a higher rate of hypotension on admission (10.8% vs. 2.6%, p<0.001) and more often required blood transfusions within the first 4-hours (22.0% vs. 9.4%, p<0.001). The VATS group had a higher rate of injuries to the lung (26.1% vs. 11.4%, p<0.001), diaphragm (11.7% vs. 0.6%, p<0.001), spine (10.0% vs. 3.3%, p<0.001), and heart (5.3% vs. 0.6%, p<0.001). The overall rate and associated risk of major complications (5.8% vs. 0.3%, p<0.001; OR 22.24, CI 2.98-166.24, p=0.003) were higher in the VATS group, as was the risk of death (5.8% vs. 0.3%, p<0.001; OR 7.00 CI 2.06-23.77, p=0.002). CONCLUSION: Urgent pediatric VATS after isolated penetrating thoracic trauma occurs in 2% of cases. These patients have a 22-fold higher associated risk of complications and 7-fold higher risk of death.

Background:The "surgical soul" indicates a small spherical area at the head of pancreas with adjacent major vessels. Traumatic injuries to this area are known for the extreme complexity to manage. The aim of this study was to describe the characteristics and outcomes of patients with wounded surgical soul using a nationwide dataset. Methods:We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database (2013-2018). We included patients (age ≥16 years) with Abbreviated Injury Scale (AIS) ≥4 pancreatic and/or duodenal injuries with associated injuries to any of the following vessels: inferior vena cava (IVC), superior mesenteric artery/vein injury (SMA/SMV), portal vein (PV), renal vein (RV), and splenic vein (SV). Multivariate logistic regression was performed to identify factors associated with in-hospital mortality. Results:A total of 219 patients were identified. Of those, 178 (81.3%) sustained penetrating trauma. Pancreatic injury accounted for 73.5% of all patients, 39.8% with duodenal injury, 45.2% with IVC injury, 11.0% with SMA injury, and 56.6% with PV/SMV/RV/SV injury. Liver (56.2%), colon (47.0%), and stomach (37.9%) were common associated injuries. The overall in-hospital mortality rate was 58% with most deaths occurring <48 hours. In the multivariate analysis, older age, systolic blood pressure <90 mm Hg, chest AIS>3, abdominal aortic injury, and packed red blood cell transfusion >10 units within 24 hours were factors associated with mortality. Conclusions:Injuries to the surgical soul are rare but associated with a significant mortality risk. The surgical strategy should focus on early hemorrhage control to improve the likelihood of patient survival. Level of evidence:Prognostic/epidemiological, level IV.

Morel-Lavallee lesions (MLLs) are traumatic closed degloving injuries with operative intervention (OI), especially excisional debridement, remaining the mainstay of treatment. However, high-quality evidence describing operative techniques and outcomes remains limited. This study aimed to characterize current OI practices and associated outcomes, especially among patients undergoing excisional debridement, hypothesizing an increased risk of wound complications with this approach for MLLs.MethodsThis prospective (2021-2024), multicenter, observational study was conducted across 15 trauma centers and included patients diagnosed with MLL who underwent OI. The association between operative technique (eg, excisional debridement) and the primary outcome of wound complications was evaluated. Wound complications were defined as cellulitis, deep wound infection, skin necrosis, necrotizing soft tissue infection (NSTI), and/or organized hematoma.ResultsOf 88 MLL patients undergoing OI, 36 (40.9%) had excisional debridement, with 4 (11.1%) limited excision to skin, 20 (55.6%) extended to subcutaneous tissue, and 12 (33.3%) down to muscle. Excisional debridement had higher rates of skin necrosis (22.2% vs. 1.9%, P = .002). Although overall rates of wound complications were statistically similar between cohorts (33.3% vs. 17.3%, P = .098), univariate analysis demonstrated excisional debridement had increased risk of wound complications (OR 2.52, CI 1.07-5.97, P = .035).ConclusionThis prospective multicenter study over three years demonstrated that a fifth of MLLs undergoing excisional debridement developed postoperative skin necrosis. Excisional debridement also had a more than two-fold increased risk of wound complications compared to other OIs. These findings underscore the importance of investigating alternative operative techniques, such as incision and drainage or minimally invasive debridement methods.

INTRODUCTION:The socioeconomic status has impact on trauma, but, how area deprivation index (ADI) or distressed communities index (DCI), relates to mechanisms of injury (MOI) is unknown. METHODS:All trauma cases in 2021 with 9 or 5-zip codes of living location were included. MOI patterns based on ADI or DCI score was examined. Binary logistic regression was performed to assess the relationship between MOI and neighborhoods with socioeconomic disadvantage. RESULT:Overall, 3933 patients for ADI and 4497 patients for DCI metric were included. Greater disadvantage areas determined by ADI or DCI were strongly associated with increased penetrating injuries (both p ​< ​0.001). Assault/abuse mechanisms and vehicular injurie were associated with DCI (both p ​< ​0.001) but not ADI. Direct comparison of ADI versus DCI categorizations showed a weak correlation (R ​= ​0.35, p ​< ​0.001). CONCLUSION:There was only a weak correlation between DCI and ADI, with DCI demonstrating greater ability to differentiate injury mechanism patterns and incidence.

BACKGROUND:There is a lack of high-quality evidence regarding the most appropriate pharmacologic venous thromboembolism chemoprophylaxis (VTEp) agent in traumatic brain injury (TBI). Low-Molecular Weight Heparin (LMWH) is presumed to reduce VTE events; however, concerns of worsening intracranial hemorrhage (ICH) persist. The aim of the present study is to compare the efficacy and safety of LWMH versus Unfractionated Heparin (UFH) in patients with non-operative TBI. METHODS:We performed a single-center retrospective review of all adult TBI patients (age ≥18years) admitted to a Level I trauma center (2015-2022). Exclusion criteria included neurosurgical intervention prior to VTEp, absence of VTEp, worsened ICH prior to VTEp initiation, and death or discharge within 48 ​h of admission. The study population was stratified into those who received LMWH versus UFH as VTEp. The primary outcome of interest was VTE events. Secondary outcomes included worsening ICH, transfusion requirements, and in-hospital mortality. RESULTS:A total of 2176 patients met inclusion criteria (median age 62 years and 64 ​% male) of whom 68 ​% received UFH while 32 ​% received LMWH. Overall, there was no significant difference in demographics, injury characteristics, and time to VTEp initiation; however, compared to patients who received UFH, those who received LMWH were younger (51 vs 68 years p ​< ​0.001) and less likely to present with a subdural hematoma (59 ​% vs 65 ​% p ​= ​0.02). The LMWH cohort had a lower rate of VTE events (1.4 ​% vs 3.0 ​%; p ​= ​0.03) and in-hospital mortality (1.4 ​% vs 3.9 ​%; p ​< ​0.01). No significant differences in worsening ICH (2.8 ​% vs 3.3 ​%; p ​= ​0.2) or transfusion requirements (7.7 ​% vs 8.2 ​%; p ​= ​0.6) were detected. After controlling for age, ISS, BMI, and presence of SDH, LMWH was associated with lower odds of VTE events (AOR: 0.47, 95 %CI: 0.30-0.86) but not mortality (AOR: 0.65, 95%CI: 0.47-1.22). CONCLUSION:Compared to UFH, LMWH is a safe and effective chemoprophylactic agent in patients with non-operative stable TBI. LEVEL OF EVIDENCE:Level III, Therapeutic/Care Management.

This comparative effectiveness research uses data from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized clinical trial to compare benefits with balanced resuscitation for thoracic vs abdominopelvic traumatic hemorrhage.

Schellenberg, Morgan MD; Coimbra, Raul MD, PhD; Croft, Chasen A. MD; Fox, Charles MD; Hartwell, Jennifer MD; Keric, Natasha MD; Lorenzo, Manuel MD, MBA; Martin, Matthew J. MD; Magee, Gregory A. MD, MSc; Moore, Laura J. MD; Privette, Alica R. MD; Schuster, Kevin M. MD; Tesoriero, Ronald MD; Weinberg, Jordan A. MD; Stein, Deborah M. MD, MPH Author Information

OBJECTIVE:Mounting evidence supports early initiation of pharmacological venous thromboembolism (VTE) prophylaxis after traumatic brain injury. However, the effectiveness and safety of VTE prophylaxis after penetrating brain injury (PBI) is unclear. The objective of this study was to evaluate the effectiveness and safety of pharmacological VTE prophylaxis in patients with firearm-related PBI. METHODS:This was a retrospective cohort study of patients aged ≥ 16 years with isolated firearm-related PBI treated at level I or II trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (2017-2019). The exposure was the timing of VTE prophylaxis initiation measured in days from admission (prophylaxis delay). The primary outcome was VTE. Secondary outcomes were the need for late neurosurgical decompression (craniotomy/craniectomy after 48 hours) and in-hospital mortality. Hierarchical logistic regression estimated the association between prophylaxis delay and the outcomes after adjusting for patient baseline and injury characteristics. Effect modification was tested to determine if observed associations varied by type of early neurosurgical intervention: craniotomy/craniectomy, intracranial monitor/drain placement, or no intervention. RESULTS:The authors identified 2012 patients with isolated firearm-related PBI. The median presenting Glasgow Coma Scale score was 8 (IQR 3-14) and 31% had an abnormal pupillary response. Nearly half of the cohort received early neurosurgical intervention (craniotomy/craniectomy, 40%; intracranial monitor/drain, 8%). The median VTE prophylaxis delay was 3 days (IQR 2-5 days). VTE occurred in 6% of patients. Overall, late neurosurgical decompression was required in 9%, and 10% died. After risk adjustment, each additional day of prophylaxis delay was associated with 6% increased odds of VTE (OR 1.06 per day, 95% CI 1.02-1.11). However, the association between timing of prophylaxis and late neurosurgical decompression depended on type of early neurosurgical intervention. Specifically, each day of prophylaxis delay was associated with decreased odds of late decompression among patients who underwent intracranial monitor/drain only (OR 0.51, 95% CI 0.35-0.75) or no intervention (OR 0.85, 95% CI 0.75-0.95). Timing of prophylaxis was not associated with late neurosurgical decompression for patients who underwent early craniotomy/craniectomy. There was no association with in-hospital mortality. CONCLUSIONS:Among patients with firearm-related PBI, earlier pharmacological prophylaxis was associated with decreased odds of VTE. However, earlier prophylaxis was also associated with late neurosurgical decompression among patients who underwent intracranial monitor/drain placement or no intervention, an effect not observed for patients who underwent early craniotomy/craniectomy. These findings suggest that while early prophylaxis should be prioritized, prospective study is needed to clarify safe timing of initiation in different patient groups.

PURPOSE:Abdominal vascular injury (AVI) often coincides with bowel injury and abdominal contamination. Prosthetic materials may be necessary for vascular reconstruction, but outcomes are poorly understood. We examined outcomes in patients undergoing autologous vs. prosthetic open repair of AVI using a national database. METHODS:This retrospective cohort study (2013-2023) utilized the PROOVIT registry. Patients with abdominal aorta, inferior vena cava, iliac artery/vein, renal vein, or portal vein injuries who underwent open repair and survived ≥72 ​h were included. Univariate and multivariate analyses assessed the association between repair type and in-hospital vascular complications, including re-intervention, amputation, and bowel resection, as well as re-intervention outcomes specifically. Post-discharge data was also reviewed. RESULTS:A total of 142 patients met inclusion criteria, with 124 (87.3%) undergoing autologous repair, primarily as primary repairs with only 5 autologous vein grafts, and 18 (12.7%) undergoing prosthetic repair, including synthetic grafts and bovine pericardial patches, predominantly for arterial injuries (iliac artery, abdominal aorta). In univariate analysis, no significant differences were observed in in-hospital vascular complications, re-intervention, and infection. In adjusted analysis, prosthetic repairs showed a higher risk of in-hospital vascular complications (aOR 5.253, p ​= ​0.017), but comparable risk of re-interventions (aOR 3.046, p ​= ​0.138). Follow-up data (N ​= ​36) revealed 2 complications (5.6%): one infection (autologous) and one thrombosis (prosthetic). Notably, no prosthetic repair required revision due to infection, either in-hospital or during extended follow-up. CONCLUSIONS:Prosthetic repairs may be associated with higher overall complication rates compared to autologous repairs. However, despite the increased complexity of prosthetic repairs and adjustment for injury severity, the autologous cohort did not demonstrate a clear advantage in terms of re-intervention rates. Future studies with more homogeneous cohorts are needed to further confirm or refute the impact of different graft materials on patient outcomes.

SummaryAlthough blood transfusion as a clinical practice dates back several centuries, the optimal approach remains controversial. In the last decade there has been renewed interest in whole blood transfusion over component therapy for trauma patients. A recent multicentre prospective study assessed the impact of whole blood resuscitation on survival among injured patients in hemorrhagic shock presenting to trauma centres in the United States. We have undertaken an Evidence Based Review in Surgery of that study to appraise how its authors tackled an important clinical question with increasing relevance in modern trauma practice: What is the role of whole blood in trauma resuscitation?

BACKGROUND:The extended focused assessment with sonography in trauma (eFAST) examination includes additional thoracic views beyond the standard focused assessment with sonography in trauma examination. Its validation has predominantly been conducted in blunt trauma cases. Our aim was to evaluate the eFAST examination in a targeted population with penetrating thoracic trauma. METHODS:Patients with thoracic gunshot wounds who underwent eFAST between 2017 and 2021 were included from a local trauma registry. Performance metrics for each component of eFAST in each window and pathological condition were analyzed across the entire population, as well as within two cohorts: survived and deceased patients. Chest tube placement rates were compared within true-positive and false-negative (FN) eFAST results for subgroups with pneumothorax or hemothorax. RESULTS:A total of 288 patients were included (male, 91% male; Injury Severity Score ≥15, 48%; and died, 17%). Thirty-nine percent required chest tube, and 18% required urgent thoracic surgical intervention. Although specificity was high (91-100%) for all components, the sensitivity was less than 50% for all thoracic views, except for "no cardiac motion" (100% sensitivity). Sensitivity for pericardial fluid was 47%; for pneumothorax, 22%; for hemothorax, 36%; and for peritoneal fluid, 51% in the total population. Comparing survived versus deceased cohort, the eFAST sensitivity was higher among deaths for all components. The majority of patients (>70%) with a FN eFAST for pneumothorax or hemothorax received chest tube. CONCLUSION:The eFAST examination showed highly variable performance metrics among patients with penetrating thoracic trauma, with all thoracic components demonstrating high specificity but low overall sensitivity. Urgent interventions were frequently received in patients with FN studies. LEVEL OF EVIDENCE:Diagnostic Test/Criteria; Level III.

Recent guidelines discourage liberal utilization of ED thoracotomy(EDT), though proponents cite additional considerations (ex. training, ethics, organ donation). We examined these factors at a center with a liberal EDT policy through a mixed-methods study including an eight-year retrospective review and provider survey. Among 428 patients who underwent EDT, six groups were defined by mechanism, injury location and signs of life (SOL). Survival was highest in penetrating thoracic with SOL(8.3%) and lowest in penetrating extrathoracic or blunt without SOL(0%). ROSC was frequent across groups. Organ referral occurred in 79%, yet only 1% became donors(13 organs), all from blunt injury largely without SOL. Blood-product utilization was highest in penetrating thoracic and blunt with SOL. Surveys showed low support of EDT for teaching or blunt trauma without SOL, though nearly half supported for donation. Occupational exposure occurred in 17%, with 50% requiring prophylaxis. Ethical and practical guidance is needed to refine EDT utilization.

Background Non-occlusive mesenteric ischemia (NOMI) occurs in the critically ill and often requires laparotomy. Associated mortality is high, but there is little data on short-term patient-centered outcomes. Methods This single-center retrospective cohort study included patients undergoing laparotomy for suspected NOMI (2020-2023). Predictive factors and postoperative outcomes were assessed. Results Twenty-one patients were identified, 15 with bowel ischemia and 6 with negative laparotomies. Patients with bowel ischemia had lower preoperative lactate (4.7±3.2 mmol/L vs. 11.1±9.1, p=0.029). Pneumatosis intestinalis on preoperative computed tomography (CT) was more prevalent with bowel ischemia (53% vs 0%, p=0.023). Mortality at 30 days was 60% with bowel ischemia group and 83% with negative laparotomy group (p=0.31). Outcomes included a 71% chance of having NOMI at time of decision for laparotomy; 33% survival; 29% ostomy rate in survivors; median 0 ICU- and ventilator-free days. Conclusion Quantification of risks and likely outcomes is critical to shared decision-making regarding laparotomy for suspected NOMI.