BACKGROUND:The modified Brain Injury Guidelines (mBIG) are an established protocol to triage traumatic brain injury with intracranial hemorrhage (ICH) while reducing resource utilization. However, mBIG do not differentiate between isolated and combined intracranial hemorrhage (cICH). This study evaluated whether patients with multiple ICH subtypes require different triage. METHODS:We performed a retrospective study of adult patients classified as mBIG 1 or mBIG 2 at two Level I trauma centers January 1, 2017, to June 30, 2023. Patients with cICH (≥2 subtypes) were compared with isolated ICH. Primary outcome was clinical deterioration, defined as new focal neurologic findings, pupillary examination changes or Glasgow Coma Scale score of <13 as compared with initial presentation. Secondary outcomes included radiographic progression, neurosurgical consultation, neurosurgical intervention, number of head computed tomography, hospital and intensive care unit length of stay, and readmission. RESULTS:Among 844 patients, 251 (29.7%) had cICH. Compared with isolated, cICH patients had higher Injury Severity Score (14.3 vs. 11.8, p < 0.001), longer intensive care unit length of stay (1 vs. 0, p < 0.001), and greater radiographic progression (20.3% vs. 11.3%, p = 0.002). However, clinical deterioration (1.0% vs. 2.6%, p = 0.252), neurosurgical intervention (0.4% vs. 0.2% p = 0.507), and readmission (5.2% vs. 3.7%, p = 0.413) were rare and did not differ between groups. CONCLUSION:While cICH is associated with more radiographic progression and resource utilization compared with isolated ICH, it is not associated with higher occurrence of clinical deterioration or neurosurgical intervention. These findings support continued use of mBIG for isolated and cICH with escalation of care reserved for neurological deterioration or other high-risk features. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level IV.

Introduction For low-grade colon injury, patients managed with resection with anastomosis (RWA) versus primary repair (PR) demonstrate higher rates of adverse outcomes. However, the relationship between the repair type chosen and mechanism of injury remains unknown. We aim to compare complications between PR and RWA in patients with low grade colon injuries dichotomized by mechanism of injury. Methods This was a secondary analysis of an Eastern Association for the Surgery of Trauma retrospective multicenter trial. Data were collected from 32 level I trauma centers. Patients presenting between 2011 and 2021 who underwent operative intervention were eligible for inclusion. Data, including mechanism of injury and repair type, were collected from operative notes. The type of repair used was at the discretion of the operative surgeon. The primary outcome was composite surgical site infection (SSI) rates inclusive of superficial SSI, deep SSI, and organ space infection. Secondary outcomes include rates of deep and superficial SSI, and organ space infection. Results A total of 2058 patients met inclusion criteria; 79% were male and 58% had penetrating injuries. Among patients with blunt colon injuries, 636 (74%) underwent PR. American Association for the Surgery of Trauma grade, injury location, and fecal contamination differed between repair strategies for patients with a blunt mechanism. Blunt injuries repaired with RWA had increased rates of composite SSI, superficial SSI, organ space infection, and colonic leak. On multivariable logistic regression, after controlling for vital signs at presentation, injury severity score, and fecal contamination, RWA was found to be an independent predictor of composite (adjusted odds ratio (aOR): 2.52, 95% confidence interval (CI): 1.08-5.82) and superficial SSI (aOR: 7.44, 95% CI: 2.12-28.60). In penetrating trauma, 58% of patients underwent PR. Initial systolic blood pressure, injury severity, fecal contamination, and injury location differed between repair types. Patients with penetrating injuries who underwent RWA had higher rates of superficial SSI, deep SSI, organ space infection, colonic leak, and enterocutaneous fistula formation compared to the PR group. On multivariable regression, RWA was independently associated with composite SSI (aOR: 1.56, 95% CI: 1.05-2.33), deep SSI (aOR: 2.57, 95% CI: 1.29-5.40), and suture line failure (aOR: 2.17, 95% CI: 1.03-4.92) after controlling for vital signs at presentation, injury severity score, AAST grade, and fecal contamination. Conclusions Regardless of mechanism, PR was associated with fewer infectious complications than RWA in patients with low-grade colon injuries. PR is the preferred operative strategy in nondestructive injuries when feasible.

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.

BackgroundSkull fractures are a common heterogenous finding in patients with traumatic brain injury (TBI). Their clinical significance, particularly of displaced and nondisplaced fractures, remains a topic of debate. This study aims to compare injury severity and clinical outcomes between patients with and without skull fractures.MethodsA retrospective study of prospectively triaged adult trauma patients with blunt TBI and radiographic evidence of intracranial hemorrhage (ICH) or skull fracture was performed. Patients were grouped based on the presence or absence of skull fracture. Multivariable logistic regression was used to identify independent predictors of mortality and radiographic progression.ResultsA total of 2543 patients were included in the analysis. Skull fractures were present in 24.6% (n = 626) of the population. Skull fractures were associated with increased incidence of midline shift and all ICH subtypes, SAH being the most prevalent. Skull fracture patients were more likely to have radiographic progression on CT head (CTH) and require neurosurgical intervention. Median hospital and ICU LOS were longer in skull fracture patients. Mortality was significantly higher in patients with skull fractures. Skull fractures were an independent predictor of radiographic progression, but not mortality. Displaced skull fractures had more severe outcomes than nondisplaced fractures; however, nondisplaced fractures had more severe outcomes than no fractures.ConclusionSkull fractures are associated with more severe patterns of intracranial injury, greater need for neurosurgical intervention, and higher mortality in patients with blunt TBI. This underscores the role of skull fractures as a clinically meaningful marker of injury severity and support continued caution in triage and management.

There is debate regarding whether to close the skin in open emergent abdominal cases with class III and IV wounds. We aimed to compare outcomes between open vs closed skin management. A retrospective cohort study of adult patients with class III/IV wounds was performed. Groups included primary skin closure (closed) or non-primary (open) closure. 751 patients were included with 47% in the closed cohort. The open cohort had lower incidence of superficial SSI, but higher incidence of deep SSI in univariable analysis. Organ space SSI did not differ between groups. On multivariable analysis, closed skin was an independent predictor of superficial SSI (AOR = 1.80), but not deep or organ SSI. Open skin management was associated with less superficial SSI despite being used in more complex and high-risk cases; however, it was not protective against deep or organ SSI.

BackgroundPost-pull chest X-rays (ppCXR) are routinely performed after chest tube (CT) removal despite questionable utility. Prior studies suggest that ppCXR rarely alter management, but the impact of timing remains unknown. This study compares early vs delayed ppCXR on radiographic changes and clinical management in asymptomatic trauma patients. We hypothesized ppCXR timing may influence radiographic findings, but not reintervention rates.MethodsA retrospective study of trauma patients undergoing CT placement and removal at a level 1 trauma center from 2019 to 2022. Each ppCXR was classified as early (≤4 h) or delayed (>4 h). Primary outcome was reintervention after CT removal (CT replacement, VATS, or thoracotomy). Secondary outcomes included radiographic changes, unplanned ICU transfer, hospital and ICU LOS, and total CXRs.Results318 patients were included with a mean age of 47.2 years, 25.2% female, and 77.4% with blunt mechanism. Most had delayed ppCXR (78.3%) with mean delay of 7.2 h (2.3 vs 9.5 h, P < .001). No differences were found in radiographic changes (26.1 vs 29.3%, P = .708) or reintervention (4.3 vs 5.6%, P = .999) between groups. Radiographic changes occurred in 28.6% of ppCXR, but these findings display poor sensitivity (65.0%) and specificity (73.4%) for reintervention. Delayed ppCXR had more ICU transfers (0 vs 5.6%, P = .046), but no differences in hospital LOS, ICU LOS, or total CXRs.DiscussionThe timing of ppCXR did not affect detection of radiographic changes or reintervention rates. Our findings support growing evidence questioning routine ppCXR in asymptomatic trauma patients. Future multicenter studies are warranted to establish standardized protocols and reduce unnecessary imaging in trauma care.

BACKGROUND:We aimed to describe current practices related to post-discharge prophylaxis (PDP) in hospitalized trauma patients. METHODS:A 30-question survey was distributed to SWSC/SESC members from February-May 2024. Respondent demographics, perception of PDP utility and prescribing patterns were evaluated. K-means clustering identified subgroups based on protocols and prescribing preferences. RESULTS:Forty-nine respondents, 67 ​% physicians and 33 ​% APPs. Most practiced in urban environments (69 ​%) with level I trauma designation (76 ​%). Majority (90 ​%) believed that PDP is warranted in select patients, yet 31 ​% rarely/never prescribe it. Providers most often prescribe enoxaparin (46.9 ​%), DOACs (22 ​%) and aspirin (18 ​%) for PDP. Characteristics of the group demonstrating PDP prescribing behavior most consistent with existing evidence included APP credentials and 80-100 ​% inpatient trauma care. CONCLUSION:Most respondents believe PDP is warranted, yet a notable proportion report rarely prescribing PDP. Provider credentials had the greatest impact on response differences. Future studies are needed to better define PDP.

BACKGROUND:Appropriate chemical prophylaxis can reduce the risk of venous thromboembolism (VTE) in trauma patients. A system-wide VTE clinical practice guideline (CPG) and electronic health record (EHR)-based VTE prophylaxis order set were implemented. The CPG provided guidelines based on bleeding risk, recommended earlier initiation of chemical prophylaxis, and favored low-molecular-weight heparin (LMWH). The purpose of this study was to evaluate the impact of VTE CPG and prophylaxis order set on the rate of VTE. METHODS:A retrospective review was performed on trauma patients 15 years or older admitted to three trauma centers between July 2018 and December 2021. Exclusion criteria included burn injury, readmission, length of stay <2 days, and withdrawal of care. The VTE CPG and EHR order set were implemented in November 2020, and a pre-implementation/postimplementation (POST) comparison was conducted. RESULTS:A total of 12,479 patients were included. There were no differences in age, sex, and Injury Severity Score. The POST group had a higher usage of LMWH (64.0 vs. 67.5%, p < 0.01), a lower rate of no prophylaxis (17.2 vs. 12.5%, p < 0.01), and a shorter time to prophylaxis (29.4 vs. 25.9 hours, p < 0.01). The rates of VTE (1.6 vs. 1.0%, p < 0.01) and deep vein thrombosis (1.1 vs. 0.7%, p = 0.03) were lower in the POST group. There was no difference in the rate of pulmonary embolism (0.6 vs. 0.4%, p = 0.06). The POST group had a higher mortality (0.7 vs. 1.1%, p = 0.03) on univariable analysis, but there were no differences between groups on adjusted analysis. Independent predictors of VTE were longer time to VTE prophylaxis, higher Injury Severity Score, ventilator-associated pneumonia, and longer hospital length of stay. Use of LMWH and postintervention period were protective from VTE. CONCLUSIONS:The implementation of a system-wide VTE CPG and EHR-based prophylaxis order set were associated with a reduced incidence of VTE in trauma patients without an associated mortality difference. LEVEL OF EVIDENCE:Prognostic and Epidemiological; Level IV.

BACKGROUND:Patients undergoing elective procedures at altitudes >4000 ​ft have higher deep venous thrombosis (DVT) rates compared to those performed at ​≤ ​1000 ​ft. DESIGN:We reviewed the American College of Surgeons Trauma Quality Improvement Program (TQIP) database from 2014 to 2019. Adults are divided into LOW (<1001 ​ft) or HIGH (>4000 ​ft) altitude treatment with DVT rates compared by multivariable regression analysis as well as using a 2:1 propensity matched model. RESULTS:Risk-adjusted odds ratio (OR) for DVT at high altitude was 1.53 [95 ​% CI 1.42-1.64]. In patients with an Injury Severity Score (ISS) ​≥ ​16, the DVT rate was 1.10 ​% (LOW) vs 1.59 ​% (HIGH); risk-adjusted OR for DVT at high altitude with ISS ​≥ ​16 was 1.67 [1.53-1.83]. Under the propensity matched model, DVT rates at higher altitude had an OR of 1.59 [1.46-1.74]. CONCLUSION:Following traumatic injury, DVT rates are increased in higher altitude treatment facilities compared to their low elevation peers.

BACKGROUND:The management of traumatic low-grade (American Association for the Surgery of Trauma [AAST] grades I and II) colon injuries has evolved. Recent data suggest that primary repair (PR) or resection over colostomy decreases morbidity and mortality. However, data comparing patients undergoing PR versus resection with anastomosis (RWA) are lacking. We hypothesized that patients presenting with low-grade colon injuries undergoing PR would have fewer postoperative complications than patients undergoing RWA. METHODS:This was a retrospective, multicenter analysis of all patients presenting with AAST grades I and II colon injuries to 32 Level 1 trauma centers from 2011 to 2021. Based on operative documentation, patients were dichotomized into two groups, those who underwent PR or RWA. Outcomes included length of stay, infectious complications, and mortality. Multivariate logistic regression was performed to determine the independent effect of operative technique on outcomes. RESULTS:A total of 2,022 patients met the inclusion criteria for this study. Most were young (36 [24-44] years), male (79.6%), and presented after penetrating trauma (58.2%). A total of 1,013 patients presented with a grade I injury, while 1,009 patients presented with a grade II injury. Furthermore, 1,314 patients underwent PR, and 708 underwent RWA. While there was no difference in Injury Severity Score between PR and RWA, RWA was associated with more adverse outcomes including surgical site infections, suture line failure/leak, fascial dehiscence, and a longer hospital length of stay (all p < 0.001). When controlling for mechanism of injury, AAST grade, Injury Severity Score, and number of intra-abdominal injuries RWA were independently associated with more infectious complications including superficial, deep, and organ space surgical site infections. CONCLUSION:Resection with anastomosis was independently associated with more adverse outcomes including multiple infectious complications and longer hospital length of stay compared with PR, suggesting that low-grade colon injuries can be safely managed with PR alone. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level III.

INTRODUCTION:Prehospital tourniquet placement is not a required criterion for standard trauma team activation (TTA-S) as recommended by the American College of Surgeons Committee on Trauma. Educational campaigns such as STOP THE BLEED have led to an increase in tourniquet applications in the prehospital setting. We intend to evaluate if using extended trauma team activation (TTA-T) criteria, which includes tourniquet application, would lead to an acceptable amount of overtriage. METHODS:This was a multicenter retrospective analysis, utilizing the American Association for the Surgery of Trauma Major Extremity Trauma Tourniquet Database, comparing the overtriage rate of TTA-S criteria against the TTA-T criteria. RESULTS:A total of 1235 patients were included, with 687 meeting the TTA-S criteria and an additional 175 patients meeting the TTA-T criteria. The overtriage rate was calculated to be 21.2%, within the accepted over triage rate of 25%-35%. CONCLUSIONS:Field tourniquet application for life-threatening hemorrhage, although not an American College of Surgeons Committee on Trauma criterion for TTA, should be considered for full TTA. Utilizing this as a criterion for TTA is associated with an acceptable rate of overtriage, while also having the benefit of rapid surgical team evaluation and intervention for possible life- or limb-threatening injuries.

Recent advancements in AI and medical imaging offer transformative potential in emergency head CT interpretation for reducing assessment times and improving accuracy in the face of an increasing request of such scans and a global shortage in radiologists. This study introduces a 3D foundation model for detecting diverse neuro-trauma findings with high accuracy and efficiency. Using large language models (LLMs) for automatic labeling, we generated comprehensive multi-label annotations for critical conditions. Our approach involved pretraining neural networks for hemorrhage subtype segmentation and brain anatomy parcellation, which were integrated into a pretrained comprehensive neuro-trauma detection network through multimodal fine-tuning. Performance evaluation against expert annotations and comparison with CT-CLIP demonstrated strong triage accuracy across major neuro-trauma findings, such as hemorrhage and midline shift, as well as less frequent critical conditions such as cerebral edema and arterial hyperdensity. The integration of neuro-specific features significantly enhanced diagnostic capabilities, achieving an average AUC of 0.861 for 16 neuro-trauma conditions. This work advances foundation models in medical imaging, serving as a benchmark for future AI-assisted neuro-trauma diagnostics in emergency radiology.

INTRODUCTION:Hepatic angioembolization is highly effective for hemorrhage control in hemodynamically stable patients with traumatic liver injuries and contrast extravasation. However, there is a paucity of data regarding the specific location of angioembolization within the hepatic arterial vasculature and its implications on patient outcomes. METHODS:A post-hoc analysis of a multicenter prospective observational study across 23 centers was performed. Adult patients undergoing main hepatic artery angioembolization or segmental hepatic artery angioembolization within 8 hours of arrival were included. The primary outcome was liver-related complications, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. Secondary outcomes were liver-related complication interventions, length of stay, and mortality. RESULTS:A total of 55 patients underwent hepatic angioembolization, with 23 (41.8%) undergoing main hepatic artery angioembolization and 32 (58.2%) receiving segmental hepatic artery angioembolization. Both groups were comparable in age, vitals, mechanism of injury, liver injury grade distribution, and injury severity score (all P > .05). The main hepatic artery angioembolization group had greater rates of overall liver-related complications (65.2% vs 31.2%, P = .039), specifically perihepatic fluid collection (26.1% vs 6.3%, P = .040) and bile-leak/biloma (34.8% vs 12.5%, P = .048). Main hepatic artery angioembolization had greater rates of 2 or more liver-related complications (47.8% vs 9.4%, P = .001) and readmission within 30 days (30.4% vs 9.4%, P = .046). No significant differences were observed in hospital length of stay and mortality (all P > .05). CONCLUSIONS:Main hepatic artery angioembolization is associated with increased rates of liver-related complications, multiple liver-related complications, and readmission within 30 days compared with segmental hepatic artery angioembolization. Thus, main hepatic artery angioembolization should be reserved for use only when segmental hepatic artery angioembolization is not feasible, albeit with significantly increased morbidity.

BACKGROUND:Depression and suicidal ideation rates among geriatric trauma patients admitted to the hospital are currently unknown. This study aimed to determine the prevalence of depressive symptoms, suicidal ideation and prior attempts, and lethal means access among older patients admitted to trauma centers in the United States. We hypothesized that a significant number of these patients may have unrecognized symptoms of depression and/or suicidal ideation not identified prior to hospital discharge. METHODS:These data are from a multicenter survey study of injured older (≥55 years) patients admitted to non-ICU inpatient trauma services at five US trauma centers. Patients were approached to complete a tablet-based survey with two components: (1) validated depression and suicidal ideation screening tool (PHQ-9) and (2) household firearm ownership. RESULTS:From November 2022 through May 2024, five level 1 trauma centers in five states administered surveys to 408 patients, who were mostly male, White, and older than 70 years. Overall, more than one-third (34.8%) screened positive for depressive symptoms and nearly 40% kept a firearm at home. Twenty percent of those patients experiencing suicidal ideation kept a firearm in the home. CONCLUSIONS:We identified high rates of depressive symptoms among older patients admitted to trauma centers, with one-third of patients having access to firearms in their home. Identifying depressive symptoms and suicidal ideation among patients admitted to trauma centers may allow for mental health intervention and lethal means safety counseling prior to hospital discharge. LEVEL OF EVIDENCE:Prognostic and Epidemiological; Level III.

BACKGROUND: Prior studies evaluating observation versus angioembolization (AE) for blunt liver injuries (BLT) with contrast extravasation (CE) on computed tomography imaging have yielded inconsistent conclusions, primarily due to limitations in single-center and/or retrospective study design. Therefore, this multicenter study aims to compare an observation versus AE-first approach for BLT, hypothesizing decreased liver-related complications (LRCs) with observation. METHODS: We conducted a post hoc analysis of a multicenter, prospective observational study (2019-2021) across 23 centers. Adult patients with BLT + CE undergoing observation or AE within 8 hours of arrival were included. The primary outcome was LRCs, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. A multivariable logistic regression analysis was used to evaluate risk factors associated with LRCs. RESULTS: From 128 patients presenting with BLT + CE on imaging, 71 (55.5%) underwent observation-first and 57 (45.5%) AE-first management. Both groups were comparable in age, vitals, mechanism of injury, and shock index (all p > 0.05), however the AE group had increased frequency of American Association for the Surgery of Trauma Grade IV injuries (51.0% vs. 22.0%, p = 0.002). The AE cohort demonstrated increased rates of in-hospital LRCs (36.8% vs. 12.7%, p = 0.038), emergency department representation (25.0% vs. 10.0%, p = 0.025), and hospital readmission for LRCs (12.3% vs. 1.4%, p = 0.012). However, the two cohorts had similar mortality rates (5.7% vs. 5.3%, p = 0.912). After adjusting for age, ISS, and grade of liver injury, an AE-first approach had a similar associated risk of LRCs compared with observation-first management (odds ratio, 1.949; 95% confidence interval, 0.673-5.643; p = 0.219). CONCLUSION: Patients with blunt liver injury and CE undergoing an observation-first approach were associated with a similar adjusted risk of LRCs and rate of mortality compared with AE-first approach. Overall, this calls for reevaluation of the role of routine AE in blunt liver trauma patients with CE. Future prospective randomized trials are needed to confirm these findings.

Background Debate continues over chest tube (CT) size for traumatic hemothorax (HTX) and pneumothorax (PTX). We compared CT failure and opioid use between large-bore chest tubes (LB-CT) and small-bore chest tubes (SB-CT). Methods A retrospective study comparing trauma patients with SB-CT (≤14Fr) or LB-CT (≥24Fr) was performed. CT failure includes HTX, PTX, or empyema requiring intervention. Secondary outcomes included opioid use (MME), mortality, and favorable discharge. Results Of 252 patients, 65.1 ​% had SB-CT. SB-CT were older with lower ISS. Failure rate was lower for SB-CT (9.2 vs 22.7 ​%, p ​= ​0.003), as was opioid use (332 vs 767, p ​< ​0.001). In adjusted analysis there was no difference in CT failure between SB-CT and LB-CT. Subgroup analysis found SB-CT had lower total MME (234 vs 342, p ​= ​0.018). Conclusions This study found no major differences in CT failure or opioid use by CT size, suggesting SB-CT are a safe, and effective alternative to LB-CT in trauma.

Introduction: Rib fractures are consequential injuries for geriatric trauma patients. Frailty has been associated with adverse outcomes in this population. The Rib Fracture Frailty Index (RFF) and 5-factor modified Frailty Index (mFI) are 2 validated frailty metrics. Research assessing inclusion of frailty metrics in geriatric rib fractures triage protocols is limited. Methods: A retrospective cohort study was performed for trauma patients >= 50 years old with rib fractures admitted to a Level I trauma center, which currently uses percent predicted forced vital capacity (FVC%) to triage rib fractures patients. Frailty metrics (RFF & mFI) were calculated retrospectively, stratifying patients as low, moderate, or severe frailty. Unfavorable discharge disposition (UDD) was defined as discharge to facility or death. Unadjusted and adjusted odds ratios were used to assess frailty with outcome variables. Results: In total, 834 patients were included from August 2018 - May 2023, with mean age of 69.1. A majority had low frailty (64.0 vs 40.3%), followed by moderate frailty (21.1 vs 30.7%), then severe frailty (14.9 vs 29.0%) for RFF and mFI, respectively. Age, sex, and ISS differed between groups. For RFF, increased frailty was associated with longer hospital and ICU length of stay. Neither frailty metric was associated with unplanned ICU transfer or intubation. In the adjusted analysis, frail patients were more likely to have UDD (OR 8.9, CI 3.4-23.0, P < .0001). Conclusion: While both frailty metrics were predictive of UDD, neither was associated with ICU transfer or intubation, suggesting that frailty does not enhance the accuracy of our current protocol using FVC%.

INTRODUCTION:This study aimed to assess perioperative bleeding complications and in-hospital mortality in patients requiring emergency general surgery presenting with a history of antiplatelet (AP) versus direct oral anticoagulant (DOAC) versus warfarin use. METHODS:A prospective observational study across 21 centers between 2019 and 2022 was conducted. Inclusion criteria were age 18 years or older, and DOAC, warfarin, or AP use within 24 hours of an emergency general surgery procedure. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using analysis of variance, χ 2 , and multivariable regression models. RESULTS:Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, and 40 (9.7%) warfarin use. The most common indications for surgery were obstruction (23% [AP], 45% [DOAC], and 28% [warfarin]), intestinal ischemia (13%, 17%, and 23%), and diverticulitis/peptic ulcers (7%, 7%, and 15%). Compared with DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (odds ratio [OR], 4.4 [95% confidence interval (CI), 2.0-9.9]). There was no significant difference in perioperative bleeding complication between DOAC and AP use (OR, 0.7 [95% CI, 0.4-1.1]). Compared with DOAC use, there was no significant difference in mortality between warfarin use (OR, 0.7 [95% CI, 0.2-2.5]) or AP use (OR, 0.5 [95% CI, 0.2-1.2]). After adjusting for confounders, warfarin use (OR, 6.3 [95% CI, 2.8-13.9]), medical history, and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR, 1.3 [95% CI, 0.39-4.7]), whereas intraoperative vasopressor use (OR, 4.7 [95% CI, 1.7-12.8]), medical history, and postoperative bleeding (OR, 5.5 [95% CI, 2.4-12.8]) were. CONCLUSION:Despite ongoing concerns about the increase in DOAC use and lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease and comorbidities rather than type of AP or anticoagulant use. LEVEL OF EVIDENCE:Prognostic and Epidemiological; Level III.

BACKGROUND:High-grade liver injuries with extravasation (HGLI ​+ ​Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI ​+ ​Extrav. Therefore, we evaluated the management of HGLI ​+ ​Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS:HGLI ​+ ​Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS:From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p ​= ​0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p ​> ​0.05). CONCLUSION:Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI ​+ ​Extrav patients.

Background Patients with isolated traumatic subarachnoid hemorrhage (iTSAH) are managed according to the modified Brain Injury Guidelines (mBIG) class. The current study aimed to describe patients with iTSAH and analyze their clinical outcomes. Methods A retrospective analysis was performed on trauma patients with iTSAH. Exclusion criteria were Glasgow Coma Scale (GCS) < 13 and pre-injury antiplatelet/anticoagulant use. Results 276 patients were identified over the 8-year study period. The median number of head CT scans was 2. Neurosurgery consultation was obtained in 80.4% of patients. A total of 19 (8.6%) patients had radiographic progression. Six (2.2%) patients had neurologic deterioration. No patients required operative intervention or readmission. No deaths were related to iTSAH. Conclusions There were no patients with iTSAH that required neurosurgical consultation despite a subset of patients having radiographic or neurologic progression. These patients may not require repeat head CT scan or neurosurgical consult, necessitating a change of SAH definitions in the mBIG.