BackgroundThe purpose of this descriptive study was to characterize the utilization and outcomes of CPB after trauma.MethodsThis is an AAST-sponsored retrospective (2011-2021) multicenter (32 centers) study of all adult trauma patients undergoing CPB. Univariate analysis comparing demographics, clinical characteristics and the study outcomes were performed between those who required CPB≤2 hours, >2-24 hours, and >24 hours from the arrival. The primary outcome was mortality.ResultsThere were 113 patients, 63% sustained blunt trauma. The most common injuries were cardiac (42%), thoracic aorta (42%), and pericardial tamponade (25%). The three most common reasons to use CPB were aortic repair (32%), cardiopulmonary resuscitation (20%), and cardiac repair (15%). CPB was performed within 2 hours in 44(39%), and 21(19%) underwent CPB after 24-hours. Penetrating mechanisms of injury 24 (55%) (P = .009), higher rate of hypotension (SBP <80 mmHg) 15 (71%) (P = .002) were more common in CPB≤2-hours. Septal (P = .001) and valvular (P = .002) injuries were more frequent in CPB >24 hours, otherwise there were no differences in injury patterns among CPB ≤2 hours, >2-24 hours, and >24 hours. Cardiac repair was the most common indications for CPB ≤2 hours (P = .002), aorta repair was more common in CPB 2-24 hours (P = .03). Complications were not different between CPB ≤2 hours, >2-24 hours, and >24 hours. Among survivors, no differences in terms of discharge disposition, hospital LOS were found (all P > .05). Mortality was 22% with 96% of them undergoing CPB in the first 24 hours (P < .001).ConclusionsCPB is rarely used for traumatic injuries. The true impact of CPB is unknown and should be studied in comparison to patients with cardiovascular injuries that are repaired without CPB.Level of EvidenceLevel IV; Therapeutic/Care Management.

Background:Older adults (65 and above) represent a significant portion of trauma admissions in U.S. hospitals, primarily due to falls and motor vehicle accidents. Managing pain effectively and mitigating social isolation in this population is crucial. Traditional opioid treatments, while common, pose risks such as addiction, delirium, and constipation, leading to extended hospital stays and increased costs. Social isolation is another common problem faced by this population that can also exacerbate pain. Nonpharmacological interventions are thus highly recommended. Objective:This pilot study explores the feasibility and acceptability of employing social virtual reality (SVR) as a novel, nonpharmacological approach to address both pain and social isolation among older adult trauma patients. Methods:The study employs a two-phase design to evaluate SVR's potential. This article describes Phase 1, which employed a user-centered, iterative design approach to enhance SVR's feasibility, acceptability, and usability in the target population. We presented existing versions of SVR applications using three platforms, VTimeXR, Spatial, and Engage, to 10 hospitalized older adult trauma patients and used in-depth interviews to gain patient feedback. We made iterative refinements based on this feedback. Results:We present the results of Phase 1, which employed a user-centered, iterative design approach to develop a test environment for use in the second phase of the study. Participants who completed the study indicated environments could serve as effective distractions, facilitate social interaction, and evoke calming emotions. Participants suggested enhancing the realism of nature elements and offering more interactive features, such as tasks, games, or narratively compelling videos. Conclusion:We successfully developed an SVR environment for older adult trauma patients, and early feasibility indicators showed interest and engagement from participants, providing insights to guide refinements for Phase 2 deployment.

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.

THE EVALUATION OF THE PATIENT WITH ACUTE ABDOMINAL PAIN: HISTORY AND PHYSICAL AND INITIAL LABORATORIES Evaluation of the patient with abdominal pain begins with a thorough history and physical examination (Fig. 1). Patients typically present with 12 to 24 hours of mid-abdominal pain, which may migrate to the right lower quadrant. In the early course of appendicitis, the physical examination may reveal nonlocalizing, mid-abdominal pain without peritoneal irritation. Additional symptoms may include loss of appetite, abdominal distention, nausea, vomiting, malaise, obstipation, fever, and chills. Patients may also have certain physical signs associated with appendicitis. The psoas sign is an irritation of the iliopsoas muscle in the abdomen, a classic finding of acute appendicitis, which can be elicited by performing passive extension of the right hip with the patient laying on their left side. The Rovsing's sign can also be seen in acute appendicitis and is observed when deep palpation of the left lower quadrant elicits pain in the right lower quadrant. Patients presenting later in the course of the disease process may develop peritoneal inflammation with localized guarding and rebound tenderness adjacent to the appendix in the right lower quadrant.1Figure 1: Acute appendicitis management.Standard laboratory tests should include a complete blood count, urine analysis, and routine chemistry if the patient requires further imaging or operative management. It is important to note that white blood count may not be elevated in early acute appendicitis.2 A urine analysis would assist in ruling out other diagnoses, such as urinary tract infection, pyelonephritis, or renal stones. A pregnancy test is mandatory for women of childbearing age. CALCULATION OF SCORING SYSTEMS FOR APPENDICITIS Utilizing a scoring system such as the Appendicitis Scoring score (Fig. 2) may contribute to the accuracy of clinical decision-making and support shared decision-making by identifying patients at low risk of appendicitis.3Figure 2: Adult appendicitis score. Adapted from Bhangu,3 published under Creative Commons CC-BY-NC-ND license.The Alvarado score (Table 1) is the most commonly used scoring system for predicting the likelihood of acute appendicitis. If a patient scores 1 to 4, the risk of appendicitis drops to 33%. If a patient scores >5, the risk of acute appendicitis is 66% or greater. The Alvarado score can be used to select which patients will proceed for confirmational imaging.4,5 In many current practice settings, abdominal imaging will have been obtained prior to surgical consultation.6,7 TABLE 1 - Alvarado Score (Adapted From Ohle et al.4) Alvarado Score Variable Clinical Findings Score Symptoms Migratory RIF pain 1 Anorexia 1 Nausea and vomiting 1 Signs Tenderness RIF 2 Rebound tenderness 1 Elevated temperature 1 Laboratory Leukocytosis 2 Left shift (bandemia) 1 Total scoreRIF, right iliac fossa. Appendicitis inflammatory response score (Fig. 3) has been shown to perform best in terms of sensitivity, specificity area under the curve values, and usability but has been validated in only a small number of studies. The original Alvarado score outperformed the modified Alvarado score across all three criteria (sensitivity, specificity, and area under the curve values).Figure 3: Appendicitis inflammatory response. Reproduced without changes from Andersson et al.,6 published under Creative Commons Attribution 4.0 International License.IMAGING OF THE PATIENT SUSPECTED OF APPENDICITIS Ultrasound Versus Computed Tomography Scan Ultrasound (US) has been used to evaluate patients suspected of acute appendicitis and has an 85% to 90% positive predictive value with an appendiceal diameter greater than 9 to 10 mm.8 It does not use radiation energy, is repeatable, and is safe for pregnant women. It can also demonstrate other pelvic pathology in women.9,10 Ultrasound is frequently used in pediatric patients and is favored as an initial study in small children. The utility of US is less well documented in the adult population. Computed tomography scan with contrast has been the standard for imaging the abdomen when searching for acute pathology and is used with increasing frequency in the general diagnosis of abdominal pain, especially by nonsurgeons. It provides a high degree of sensitivity and specificity for the diagnosis of acute appendicitis but has the potential to identify radiographic abnormalities of the appendix that are not clinically relevant. Computed tomography imaging should always be interpreted in the context of clinical history and physical examination. Computed tomography can also demonstrate an appendiceal fecalith, periappendiceal fluid collection, or an abscess, findings that may be of importance in clinical decision-making. The sensitivity, specificity, positive, and negative predictive values of computed tomography (CT) scans based on pathology results were 87.9%, 81.8%, 94.7%, and 79.3%, respectively, in patients with low clinical suspicion.11 In many circumstances, the position of the appendix within the abdomen and its relation to the cecum will be demonstrated.12 Women Childbearing Age Pelvic pathology must be ruled out when suspecting acute appendicitis in women of childbearing age. A urine analysis may demonstrate urinary tract infection or potential kidney stones. An US or CT scan may show an adnexal tubo-ovarian abscess or ectopic pregnancy.13 Pregnant Women Ultrasound is the primary imaging modality to assess abdominal pain and make the diagnosis of acute appendicitis in pregnant patients, although magnetic resonance imaging is being used with increasing frequency if US findings are not diagnostic. A CT scan should be considered if a patient is acutely ill, and the diagnosis is still in question.11,14–19 Alternatively, if CT scan does not clearly demonstrate acute appendicitis in the pregnant patient, magnetic resonance imaging has been shown to have a high sensitivity and negative predictive value of 100% in some studies.20 MANAGEMENT OF PATIENTS WITH ACUTE APPENDICITIS (AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA ACUTE APPENDICITIS SEVERITY OF ILLNESS) (Additional classification of appendicitis commonly used are as follows: uncomplicated appendicitis [nonperforated, no abscess, or phlegmon] or complicated appendicitis [perforated appendicitis, periappendicular abscess or peritonitis, defined as acute inflammation of the peritoneum secondary to infection of the appendix].) (Fig. 4)21Figure 4: American Association for the Surgery of Trauma — Appendicitis Grades.21 Reused with permission from the American Association for the Surgery of Trauma. American Association for the Surgery of Trauma Grade I (mild) represents mild appendicitis without significant inflammation (uncomplicated appendicitis). The current literature demonstrates that nonoperative management with antibiotics and pain control is noninferior to surgical treatment.22,23 Although early appendectomy is likely the most expeditious treatment, patient-centered concerns such as a desire to avoid surgery or timing of surgery should be discussed and considered as part of shared decision-making. A publicly available decision support tool called AppyOrNot (AppyOrNot.org) provides an educational video to assist patient decision-making. The presence of a fecalith does not preclude nonoperative management, although the likelihood of requiring additional procedures is higher. The report of long-term outcomes from the Comparison of outcomes of antibiotic drugs and appendectomy trial confirmed that the hazard ratio for appendectomy among patients with an appendicolith compared with those without an appendicolith was 2.9 within 48 hours but was not difference thereafter from 48 hours to 30 days (Hazard ratio, 1.4; 95% confidence interval, 0.8–2.4) and from 31 days to 2 years (Hazard ratio, 1.1; 95% confidence interval, 0.8–1.6).24–28 American Association for the Surgery of Trauma Grades II to IV (moderate to severe) (complicated appendicitis) represents increasing degrees of inflammation, development of periappendiceal fluid collections, abscess formation, progression of gangrenous appendicitis, and peritonitis. The decision between initial appendectomy versus initial nonoperative management is complex, as patients with larger phlegmon and more advanced inflammatory changes involving surrounding organs may benefit from initial nonoperative management. Decision-making should be individualized based on patient factors and surgeon experience. Some patients presenting with sepsis will require preoperative fluid resuscitation in addition to early antibiotics. Minimally invasive approaches to appendectomy have become the procedure of choice. If not available, an open appendectomy is indicated.29–33 Patients presenting with perforated appendicitis and a large inflammatory tumor (phlegmon) with abscess are best managed with early broad-spectrum antibiotics and percutaneous drainage (80% successful) for source control. A surgical approach to abscess drainage, either by minimally invasive or open technique, may be indicated if drainage and antibiotics fail to resolve the infection.34 American Association for the Surgery of Trauma Grade V (most severe) represents the most severe presentation of free perforation due to acute appendicitis in the abdominal cavity. Patients are commonly present in septic shock and Sepsis 3 guidelines for resuscitation should be followed.35 These are surgical emergencies. Treatment consists of resuscitation, administration of broad-spectrum antibiotics, pharmacological cardiovascular support, and emergent operative management.36 MANAGEMENT OF COMPLICATED APPENDICITIS DURING PREGNANCY In this retrospective cohort study of 8,087 pregnant women with complicated appendicitis using National Inpatient Sample data (January 2003 to September 2015), immediate appendectomy was associated with lower odds of infectious complications, including amniotic infection and sepsis, compared with successful and unsuccessful nonoperative management. When nonoperative management failed and required delayed operation, it was associated with significantly higher odds of preterm labor, preterm delivery, or abortion. These findings suggest that immediate operation may be the preferred management strategy for complicated appendicitis among pregnant women.37 TIMING OF APPENDECTOMY AND RISK OF APPENDICEAL PERFORATION With early initiation of early empiric intravenous systemic antibiotic therapy for acute uncomplicated appendicitis, appendiceal perforation prior to surgical intervention for uncomplicated appendicitis is now rare. The PERFECT open-label multicenter randomized trial compared appendectomies scheduled within 8 or 24 hours in adult patients (n = 1,803) with predicted uncomplicated acute appendicitis. The appendiceal perforation rate was similar (8% vs. 9%), and no significant differences in complication rates (7% vs. 6%) were found, with no mortality differences noted. A meta-analysis comparison (15 studies, n = 33,596) of daytime versus nighttime appendectomy reported no differences in postoperative mortality or complication rates, but the conversion to laparotomy was almost twofold higher among patients who underwent appendectomy during nighttime. These data support postponing night-time appendectomy to daytime if possible.38,39 ANTIBIOTIC MANAGEMENT In the setting of operative management of American Association for the Surgery of Trauma (AAST) Grade I or II, a single perioperative dose of antibiotics should be sufficient. In AAST Grade III or higher, perioperative antibiotic management should be dictated by source control. Once source control is obtained, a perioperative dose plus four additional days should be sufficient to align with the STOP-IT trial. In the setting of a periappendiceal abscess managed by percutaneous drainage or phlegmon, an initial course of 7 to 10 days of antibiotics is generally chosen, although there is little evidence to support the practice. In the absence of clinical improvement, additional imaging is warranted.40–42 INTERVAL APPENDECTOMY AFTER NONOPERATIVE MANAGEMENT WITH ANTIBIOTICS In patients treated with antibiotics for uncomplicated appendicitis, interval appendectomy is commonly considered for patients with recurrent symptoms or recurrent disease. Appendiceal neoplasm is rare in patients with uncomplicated appendicitis treated with antibiotics. In a review of 4,962 patients with appendicitis (38% complicated, 62% uncomplicated) enrolled in 4 comparative studies, the overall incidence rate of neoplasm in the uncomplicated cohort was 1.49%.43 Importantly, in patients with previous complicated appendicitis treated nonoperatively, a colonoscopy (4–6 weeks after resolution) and an interval appendectomy should be performed (recommended by 2024 SAGES Guideline), as the incidence of appendicular neoplasm is high (3–17%, pooled prevalence 11%) in adult patients with complicated appendicitis. Appendiceal mucinous neoplasms occurred in 43%, adenocarcinoma in 29%, neuroendocrine neoplasm in 21%, goblet cell carcinoma in 13%, and adenoma or serrated lesions in 20% of cases.44–47 American Association for the Surgery of Trauma Grades II to IV may require interval appendectomy, but AAST Grade I may not absolutely require interval appendectomy unless symptoms recurred.

Costantini, Todd W. MD, FACS; Martin, David MD; Winchell, Robert MD; Napolitano, Lena MD; Inaba, Kenji MD; Biffl, Walter L. MD; Diaz, Jose J. MD; Salim, Ali MD; Livingston, David H. MD; Coimbra, Raul MD, PhD Author Information

BACKGROUND:Trauma Quality Improvement Program guidelines recommend early goals of care discussions (≤72 hours) for older patients with severe injuries. We sought to characterize palliative interventions (PIs) among older adults with traumatic brain injury (TBI) given the high-risk nature of this population. METHODS:Patients (55 years or older) with moderate to severe TBI (head Abbreviated Injury Scale score, ≥3) were retrospectively identified at a level I trauma center (2020-2022). Palliative interventions were defined as family meeting, goals of care discussion, or palliative care consult, with early PI occurring ≤72 hours. Regression analyses were used to evaluate effect of PI timing on hospital and intensive care unit length of stay (LOS). Kaplan-Meier analysis was performed to compare survival by PI timing. RESULTS:Three hundred thirty-seven patients were included, with 25.8% of patients receiving PI, including 98.1% of those who died or entered hospice. Early PI patients were older ( p = 0.011), with higher average Charlson Comorbidity Index ( p = 0.011) and greater injury severity ( p < 0.001). The median hospital LOS for the early PI cohort was 6 days (interquartile range, 3-10 days) versus 15 days (interquartile range, 10-22 days) with late PI. There was no mortality difference between early and late PI ( p = 0.650). Compared with early PI, after adjusting for demographic and clinical characteristics, patients with late PI had longer hospital LOS ( p < 0.001) and longer intensive care unit LOS ( p < 0.001). CONCLUSIONS:Delayed PI is associated with increased LOS in older TBI patients, with no survival difference compared with early PI. Palliative interventions should be introduced early to reduce morbidity in patients with potential poor prognosis. LEVEL OF EVIDENCE:Prognostic and Epidemiologic; Level II.

BACKGROUND:Lower-extremity fracture infections in patients with trauma represent a substantial burden; however, quality improvement initiatives are limited to the acute hospital admission, for a complication that often develops after discharge. We tracked patients with a lower-extremity fracture who developed an infection after discharge from their index trauma center admission and characterized factors associated with this complication using collaborative quality initiative data. METHODS:Trauma collaborative quality initiative data (1/2018-9/2022) were analyzed from 35 American College of Surgeons Committee on Trauma-verified Level 1 and Level 2 trauma centers and were linked to insurance claims to create a longitudinal patient record. Inpatient and postdischarge lower-extremity fracture infection rates and the location of subsequent follow-up were captured. Multivariable logistic regression assessed the factors associated with developing a postdischarge infection. RESULTS:There were 11,017 patients with a lower-extremity fracture and 380 (3.4%) developed an infection after discharge, and very few during the index trauma center admission. An open injury increased the probability of an infection by 3.61 percentage points, along with male sex (0.93 percentage points) and multiple medical comorbidities. Almost two-thirds of the infections were diagnosed at a location other than the index trauma center. CONCLUSION:The overwhelming majority of lower-extremity fracture infections occur after discharge from the index trauma center, and most patients seek care at another location. Known risk factors for developing an infection were confirmed in this large population-based cohort. We successfully linked trauma registry patients with insurance claims to create a longitudinal patient record, which will allow for further studies in this population.

ABSTRACT Acute kidney injury is associated with poor outcomes in the trauma and emergency general surgery population, and recent consensus definitions have allowed for significant advances in defining the burden of disease. The current definitions rely on overall functional measures (i.e., serum creatinine and urine output), which can be confounded by a variety of clinical factors. Biomarkers are increasingly being investigated as more direct diagnostic assays for the diagnosis of acute kidney injury and may allow earlier detection and more timely therapeutic intervention. Etiologies fall into two general categories: disorders of renal perfusion and exposure to nephrotoxic agents. Therapy is largely supportive, and prevention offers the best chance to decrease clinical impact.

Background During the first COVID-19 pandemic wave, non–intensive care unit (non-ICU) nurses were deployed to temporary ICUs to provide critical care for the patient surge. A rapid critical care training program was designed to prepare them to care for patients in either temporary or permanent ICUs. Objective To evaluate the effectiveness of this training program in preparing non-ICU nurses to provide critical care for COVID-19 patients in temporary ICUs. Methods A survey was used to evaluate the impact of rapid critical care training on nurses’ critical care skills and compare the experiences of nurses deployed to temporary versus permanent ICUs. Data were analyzed with χ2 and Spearman ρ tests with α = .05. Results Compared with nurses in other locations, nurses deployed to temporary ICUs were less likely to report improved capability in managing mechanical ventilation; infusions of sedative, vasoactive, and paralytic agents; and continuous renal replacement therapy. Nurses in temporary ICUs also reported being less prepared to care for critically ill patients (all P < .05). Conclusions The rapid training program provided basic critical care knowledge for nurses in temporary ICUs, but experiences differed significantly between those deployed to temporary versus permanent ICUs. Although participants believed they provided safe care, nurses with no critical care experience cannot be expected to learn comprehensive critical care from expedited instruction; more formal clinical support is needed for nurses in temporary ICUs. Rapid critical care training can meet emergency needs for nurses capable of providing critical care.

Introduction Operative volume is associated with improved outcomes across many surgical specialties, but this relationship has not been illustrated clearly in trauma. This study sought to evaluate the relationship between operative trauma volume and mortality, hypothesizing that increased volume would be associated with improved survival. Materials and Methods The National Trauma Data Bank was queried for patients ≥18 y undergoing hemorrhage control surgery at level I or II trauma centers from 2017 to 2020. Hierarchical logistic regression was performed to evaluate the association between operative volume and in-hospital mortality, controlling for demographic and clinical characteristics. Results 55,469 patients were included and treated at 516 centers. After adjustment, the operative volume was significantly associated with reduced mortality (OR 0.999, 95% CI 0.997-0.999, P = 0.018). However, there was considerable variability in volumes, with the busiest 5% of centers performing 90-294 operations per year, compared to 7-35 in the middle 50% of centers. To evaluate whether volume exhibited a uniform effect, the top 5% of trauma centers were excluded on subset analysis, with operative volume becoming nonsignificant in the remaining 491 centers (OR 0.999, 95% CI 0.996-1.001, P = 0.274). Conclusions Higher operative trauma volume is associated with reduced mortality for patients undergoing hemorrhage control surgery, but this mortality benefit appears to arise solely from very high-volume centers. The time-sensitive nature of hemorrhage control surgery makes centralization at this level impractical. Future efforts should focus on investigating the relationship between patient proximity to trauma centers and center volume as well as identifying modifiable factors common to high-volume centers that may be widely implemented.

Purpose Coronavirus disease 2019 (COVID-19) has underscored how ill-prepared healthcare systems are for mass casualty events (MCEs,) especially as MCEs increase worldwide. We hypothesized that resident physicians (RPs) across multiple specialties are underprepared for MCE. Methods Two similar surveys were conducted to assess awareness of disaster plans (DPs) and individual’s roles and responsibilities therein. Initially, we surveyed exclusively trainees who are trauma team members (TTMs,) including physician assistants (PAs), residents from emergency medicine (EMRs) and general surgery (GSRs.) Subsequently, we surveyed multi-specialty RPs, except GSRs and EMRs, and their program directors/associate program directors (PDs/APDs.) RPs’ awareness, knowledge of, and confidence in hospital MCE response plans were assessed, and barriers encountered were queried. Data were consolidated except with respect to PDs/APDs, who were queried only in the second survey. The Fisher exact test for multiple-group comparisons was used. Alpha = 0.05. Results For the first survey, the response rate was 74% (123/166), whereas 34% (129/380) responded to the second survey. Combined, the response rate was 46% (252/546.) Considering the RPs only for the two surveys combined, 103 (53%) respondents reported no awareness of institutional MCE response plans, 73% (n = 143) did not know/were unsure whether they were expected to contact someone, and 68% (n = 134) reported no formal MCE/disaster management (DM) training over the prior year. Additionally, the median response reported for level of knowledge of the MCE response plan among all RPs was “not at all,” with a significant difference observed between those aware of the plan and those who were not (p < 0.001). The median response reported for confidence level of RPs in MCE/DM training, excluding GSRs and EMRs (TTMs,) was “not at all,” with significant differences between surgical and non-surgical specialty RPs (p = 0.031), and between junior and senior RPs (p = 0.027). PDs/APDs (n = 12) reported “time” as the main barrier to implementation. Conclusions RPs across all surveyed specialties reported low levels of knowledge and minimal training regarding MCE/DM. Incorporation of MCE/DM preparedness into residency training in all specialties involving direct patient care is essential. Curricular restructuring will be required for meaningful participation of RPs in MCEs.

BACKGROUND Firearm injuries are a growing public health issue, with marked increases coinciding with the coronavirus disease 2019 (COVID-19) pandemic. This study evaluates temporal trends over the past decade, hypothesizing that despite a growing number of injuries, mortality would be unaffected. In addition, the study characterizes the types of centers affected disproportionately by the reported firearm injury surge in 2020. METHODS Patients 18 years and older with firearm injuries from 2011 to 2020 were identified retrospectively using the National Trauma Data Bank (NTDB®). Trauma centers not operating for the entirety of the study period were excluded to allow for temporal comparisons. Joinpoint regression and risk-standardized mortality ratios (SMR) were used to evaluate injury counts and adjusted mortality over time. Subgroup analysis was performed to describe centers with the largest increases in firearm injuries in 2020. RESULTS A total of 238,674 patients, treated at 420 unique trauma centers, met inclusion criteria. Firearm injuries increased by 31.1% in 2020, compared to an annual percent change of 2.4% from 2011 to 2019 ( p = 0.01). Subset analysis of centers with the largest changes in firearm injuries in 2020 found that they were more often Level I centers, with higher historic trauma volumes and percentages of firearm injuries ( p < 0.001). Unadjusted mortality decreased by 0.9% from 2011 to 2020, but after controlling for demographics, injury characteristics and physiology, there was no difference in adjusted mortality over the same time period. However, among patients with injury severity scores ≥25, adjusted mortality improved compared with 2011 (SMR of 0.950 in 2020; 95% confidence interval, 0.916–0.986). CONCLUSION Firearm injuries pose an increasing burden to trauma systems, with Level I and high-volume centers seeing the largest growth in 2020. Despite increasing numbers of firearm injuries, mortality has remained unchanged over the past decade. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.