The molecular adsorbent recirculating system (MARS) is an extracorporeal liver support therapy used in acute liver failure, including cases related to trauma; however, evidence supporting its use in trauma-induced liver dysfunction remains limited. This scoping review aimed to systematically map the available literature on the use of MARS therapy in trauma patients and to identify knowledge gaps to guide future research. The review was conducted according to Joanna Briggs Institute methodology and reported in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines, with a protocol prospectively registered in the Open Science Framework. Six electronic databases and two clinical trial registries were searched through December 2025, with additional backward citation tracking. Four observational studies met inclusion criteria, comprising 247 patients treated with MARS therapy, of whom only 11 had confirmed trauma-related acute liver failure. No randomized controlled trials were identified. Trauma-specific outcomes were inconsistently reported, and adverse events were not uniformly documented. Survival and liver function recovery varied across studies, and methodological heterogeneity precluded reliable assessment of clinical effectiveness or safety. Current evidence remains sparse and insufficient to support routine clinical use in trauma populations.

Objectives:Liver trauma management has evolved over recent decades, shifting from primarily operative to algorithmic approaches incorporating initial non-operative management alongside operative intervention for severe injuries. Inconsistent core outcome measures between studies hamper meaningful clinical research and evidence synthesis. This study aimed to develop a core outcome set (COS) for liver trauma research to standardize outcome reporting and improve study comparability. Methods:A modified Delphi consensus methodology after COMET (Core Outcome Measures in Effectiveness Trials) and COS-STAD (Core Outcome Set-Standards for Development) guidelines was employed and twenty trauma surgery experts were recruited through purposive sampling of high-impact publications and professional networks. Round 1 collected free-text outcome suggestions. Round 2 used a 9-point Likert scale rating of those previously identified outcomes. Consensus was defined as ≥70% rating outcomes as critically important (7-9) and ≤15% as unimportant (1-3). Intraclass correlation (ICC) assessed agreement. Round 3 involved reprioritization of non-consensus outcomes. Results:All 20 experts completed three rounds (95% response rate). From 102 initial suggestions, 41 unique outcomes were identified. By consensus, 12 outcomes were prioritized spanning four domains: operative decision-making, non-operative management success, hepatic complications, and healthcare utilization-related outcomes. The ICC was 0.89 (95% CI 0.84 to 0.94), indicating strong inter-rater reliability. Conclusions:This rigorously developed COS for liver trauma provides standardized outcomes to guide future research and improve cross-study comparability. Adoption of these outcomes may enhance reporting consistency and facilitate evidence synthesis in liver trauma research. Study type:Consensus development study (modified Delphi). Level of evidence:V.

INTRODUCTION:The combined use of Veno-venous extracorporeal membrane oxygenation (VV-ECMO) and damage-control laparotomy/open abdomen (DCL/OA) is not well described in the literature. We hypothesized that the mortality with concurrent VV-ECMO and DCL/OA would not be statistically different from that reported for either intervention alone. METHODS:Patients managed with a DCL/OA and VV-ECMO from March 2014 through March 2022 were retrospectively reviewed from a prospectively collected database at a single quaternary care center. The primary outcome was in-hospital mortality. Survivor and nonsurvivor cohorts were compared using univariate and bivariate analyses with a priori significance at p  ≤ 0.05. A multivariable regression analyses was performed to identify independent predictors of mortality. RESULTS:Fifty-two patients were managed with VV-ECMO and concurrent DCL/OA. The majority of patients were male (58%), with a mean (SD) age of 41 (14) years. The primary indication for VV-ECMO was acute respiratory distress syndrome/pneumonia (83%). The primary indications for DCL/OA were abdominal compartment syndrome (37%) and trauma (19%). Sixty percent of the patients underwent VV-ECMO cannulation after DCL/OA. Survival at hospital discharge was 58%. Survivors had a lower mean Sequential Organ Failure Assessment score (12 vs. 14, p  = 0.02), higher mean Respiratory ECMO Survival Prediction score (3.5 vs. 1.1, p  = 0.004), lower mean preoperative lactic acid level (4 vs. 7, p  = 0.04) and were more likely to receive anticoagulation while on VV-ECMO (70% vs. 30%, p  = 0.012) than nonsurvivors. Postdischarge, survival rates at 3, 6, 9, and 12 months were 90%, 72%, 69%, and 62%, respectively. After adjusting for confounders, the use of anticoagulation (odds ratio, 0.08; 95% confidence interval, 0.01-0.42) and a higher Respiratory ECMO Survival Prediction score (odds ratio, 0.71; 95% confidence interval, 0.53-0.95) were associated with decreased mortality. CONCLUSION:Relatively favorable outcomes are often achieved in acute care surgery patients treated with concomitant VV-ECMO and DCL/OA. Veno-venous extracorporeal membrane oxygenation should not be considered a contraindication to DCL/OA and vice versa. ( J Trauma Acute Care Surg . 2026;101: 136-144. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE:Retrospective Cohort Study; Level III.

Background Thoracic damage control (TDC) is an operative strategy for physiologically depleted patients with severe thoracic injuries. The relationship of TDC complications and mortality has not been comprehensively examined. This study analyzed the association of complications and mortality following TDC. Methods A retrospective registry review at a Level 1 trauma center identified patients ≥16 years undergoing TDC. Demographics, physiological data, injuries, operations, complications, and mortality were abstracted. Univariate and multivariate analyses for mortality risk factors were performed. Results A total of 98 patients met the inclusion criteria. The median age was 31 (23-44) years, 52% male, and 69% had penetrating trauma. The median Injury Severity Score (ISS) was 32 (26-41), chest Abbreviated Injury Scale 4 (4–5), admission systolic blood pressure 112 (77-138), pH 7.16 (6.99–7.25), base deficit −11 (−17 to −7), and lactate 8.1 (5.7–11.3). The operative procedures performed included pulmonary 63.5%, cardiac 29.6%, great vessels 16.2%, and 66.3% had a concomitant damage control laparotomy. Of the entire cohort, 72 (73.5%) patients developed at least one complication, including bacteremia 35%, renal failure requiring continuous renal replacement therapy (CRRT) 23%, pneumonia 18%, and empyema 12%. Mortality was 25.5% (25/98), with 72% (18/25) occurring prior to chest closure. Univariate analysis demonstrated that blunt trauma (p<0.001), male sex (p=0.006), lower pH (p=0.007), higher ISS (p<0.001), and CRRT (p=0.031) were statistically significant risk factors for mortality. On multivariate analysis, only blunt trauma (OR 3.82, 95% CI 1.1 to 13.3, p=0.035) and admission pH <7.1 (OR 3.13, 95% CI 1.03 to 9.5, p=0.044) were independently associated with mortality. Conclusion TDC is an essential operative strategy in patients with severe thoracic injuries presenting in advanced shock. Both blunt trauma and degree of shock are independent risk factors for mortality, which are present on admission. Although complications are frequent and severe, they do not predict mortality. Level of evidence IV, diagnostic test/criteria.

Surgical stabilization of rib fractures (SSRF) is increasingly performed in patients with severe rib fractures or flail chest. It has been shown to reduce ventilator days and pulmonary complications. Nevertheless, SSRF carries perioperative morbidity, particularly pulmonary and cardiac events, and the optimal preoperative cardiac risk stratification tool for this population has not been established. This study evaluated the association between the Revised Cardiac Risk Index (RCRI) and in-hospital mortality and cardiopulmonary complications in SSRF patients. This retrospective cohort study used the ACS-TQIP National Trauma Data Bank (2019–2023) to identify adult patients undergoing SSRF. Patients with AIS ≥ 2 in non-thoracic regions, blunt cardiac injury (AIS ≥ 2), or aortic injury were excluded. Because SSRF is an intrathoracic procedure, each patient carried a minimum RCRI of 1; patients were stratified into RCRI = 1, RCRI = 2, and RCRI ≥ 3. The primary outcomes were in-hospital mortality and a composite of cardiopulmonary complications (myocardial infarction, cardiac arrest, pneumonia, ARDS, deep vein thrombosis, and pulmonary embolism). Modified Poisson regression with robust standard errors estimated adjusted risk ratios (RRs), with RCRI = 1 as the reference and adjustment for demographics, regional and chest AIS, fixation details, and comorbidities. After exclusions, 6,139 patients were analyzed (RCRI = 1, n = 4,678; RCRI = 2, n = 1,208; RCRI ≥ 3, n = 253). Adverse outcomes increased stepwise with higher RCRI in both unadjusted and adjusted analyses. Compared with RCRI = 1, RCRI ≥ 3 was associated with significantly higher adjusted risks of in-hospital mortality (RR 3.34, 95

Colorectal trauma management remains variable worldwide. This study evaluated contemporary practice patterns using an anatomically stratified international survey. An anonymous, electronic survey assessing contemporary colorectal trauma management was distributed internationally through social media platforms and professional surgical societies to capture current practice patterns and variations in clinical decision-making. A total of 280 surgeons from 59 countries responded. For hemodynamically stable intraperitoneal colorectal injuries, 196/280 (70.00%) selected resection, when indicated, with primary repair or anastomosis, and routine colostomy was avoided by 227/280 (81.07%). Routine colostomy use differed by professional training (p = 0.018), with higher rates among general surgery residents (13/31, 41.94%) compared with attending trauma surgeons (17/107, 15.89%) and attending colorectal surgeons (5/42, 11.90%). Differences were also observed by hospital type (p = 0.037), with higher use in non-academic public general hospitals (10/35, 28.57%) and no routine use in Level II trauma centers (0/18, 0.00%). In hemodynamically unstable intraperitoneal colorectal injuries, colostomy was reported by 148/280 (52.86%). Colostomy reversal was most commonly scheduled between 3 and 6 months (146/280, 52.14%), without differences by training level or hospital type. Reported management of hemodynamically stable intraperitoneal colorectal injuries is predominantly colostomy-sparing, whereas reported approaches for unstable intraperitoneal injuries show mixed diversion practices. Differences by professional training and hospital type suggest persistent variability in contemporary colorectal trauma decision-making.

Background:Despite being high risk for post-traumatic stress disorder, Black men survivors of gun violence, and particularly young men aged 18-24, seldom participate in mental health services after injury. The aim of this study was to identify barriers to participation in mental health services for this population. Methods:Over a 2-year period, 1 hour-long focus group was conducted with three counselors of the local hospital-based violence intervention program and 21 individual, semistructured in-depth interviews were held with Black men who were hospitalized for a firearm-related injury. All interviews were recorded and transcribed. Transcripts were coded using open coding and grounded theory methodology and ultimately grouped into themes using MAXQDA V.2022 software. Results:Median age of participants was 34 years (IQR=11). Barriers to participation revolved around competing priorities/stressors, expense, difficulty with trust and openness and the demands of street life. Motivating factors included cultural competence, persistence, availability, reliability and genuineness of the therapy staff. Most participants denied negative social stigma of therapy as a barrier but emphasized that the individual must value therapy to participate. Young, Black men were perceived as struggling with self and peer-imposed views of masculinity that conflicted with therapy participation. Conclusion:Black men who have experienced violent firearm injury face strong social pressures that conflict with participation in mental health services. Programs must be integrated with other social services and be responsive to community conditions to be successful. Level of evidence:IV.

Significant bleeding due to pelvic fracture is associated with high mortality and must be treated promptly to optimize outcomes. The initial evaluation should focus on hemostatic resuscitation, placement of a pelvic binder, and evaluation for additional nonpelvic sources of hemorrhage. There are several options for pelvic hemorrhage control including external fixator placement, angioembolization, preperitoneal pelvic packing, and open internal iliac ligation or surgical embolization of the internal iliac artery. The specific hemorrhage control intervention selected to control pelvic bleeding must be tailored to the patient's physiologic status and local resource availability. This article discusses "What You Need to Know" to provide optimal care for patients with hemorrhage due to severe pelvic fracture.

Introduction: Veno-venous extracorporeal membrane oxygenation (VV ECMO) improves hypoxemia and carbon dioxide clearance in patients with severe respiratory derangements. A greater understanding of the potential benefits of VV ECMO in trauma patients could lead to broader adoption. We hypothesize that trauma patients who receive VV ECMO have improved mortality outcomes when compared to those receiving conventional ventilator management given the rapid stabilization VV ECMO promotes. Methods: We performed a single-center, propensity score-matched cohort study. All trauma patients from January 1, 2014, to October 30, 2023, who were placed on VV ECMO or who would have met institutional guidelines for VV ECMO but were managed with conventional ventilator strategies were matched 1:1. The primary outcome analysis was survival at hospital discharge. Significance was defined as P < 0.05. Results: Eighty-one trauma VV ECMO patients and 128 patients who received conventional management met criteria for inclusion. After matching, VV ECMO and conventional treatment cohort characteristics were similar in age and mechanism of injury. Matched ISS, SI, lactate levels, and frequency of traumatically brain injured were also similar. Finally, respiratory parameters including preintervention, pH, partial pressure of carbon dioxide, lactate levels, and oxygen saturation were similar between matched groups. VV ECMO patients had higher survival rates at discharge when compared to the matched conventional treatment group (70% vs. 41%, P < 0.001). Corresponding hazard ratio for VV ECMO use was 0.31 (95% CI 0.18-0.52; P < 0.001). The odds ratio of mortality in matched trauma patients who receive VV ECMO versus conventional treatment was 0.29 (95% CI 0.14-0.58; P < 0.001). Conclusion: VV ECMO may represent a safe, alternative treatment approach for appropriately screened trauma patients with acute respiratory failure; however, further studies are warranted.

BACKGROUND:Indirect calorimetry (IC) in patients receiving extracorporeal membrane oxygenation (ECMO) is complicated. This study presents a novel IC method for this population and compares energy expenditure (EE) from IC with predictive equations. METHODS:IC was performed at the native lung using a Q-NRG+ indirect calorimeter. A CO2 sensor connected to the ECMO oxygenator primary exhalation port collected FeCO2 during IC studies. ECMO-VO2 and ECMO-VCO2 were calculated from sweep gas oxygen concentration, FeCO2, and sweep flow. EE was calculated from the combined readings. EE was compared with 25 kcal/kg, 30 kcal/kg, and Mifflin St Jeor. Subanalysis compared EE over time (ECMO days 1-3, 4-10, 11-21, and >21) and between venoarterial and venovenous patients. RESULTS:In total, 90 assessments in 52 patients were analyzed. The cohort was 67.3% male with a median age of 54 years, and median ECMO duration of 207 h. EE was 1523 ± 432 kcal/day (18.9 ± 6.9 kcal/kg/day). Energy needs did not vary significantly over time (P = 0.24); however, readings from days 11 to 21 were higher than days 1-3 (P = 0.0497). No significant differences between cannulation types were observed. EE was significantly lower than all predicted results (P < 0.001). Mean difference between EE and predicted energy ranged from 413 to 1099 kcal/day. No equation was strongly correlated with EE (rs = 0.15-0.61) overall or after stratification by cannulation type. CONCLUSION:This study presents a viable method for incorporating IC in patients receiving ECMO. Using this method, EE in patients receiving ECMO was significantly lower than predicted. Using IC may help prevent overfeeding.

This JAMA Insights discusses evidence about the care of patients with firearm injury, including management of chronic pain, peripheral nerve injury, and lead toxicity from bullet fragments.

Tourniquets are crucial for controlling life-threatening hemorrhage and, therefore, in preventing avoidable deaths in both military and civilian settings. Its increased use since the launch of the Stop the Bleed campaign, however, has raised concerns regarding possible complications associated with its application, including limb ischemia and amputation. The objective of this study was to synthesize the existing evidence regarding complications associated with the use of tourniquets for extremity injuries and identify gaps in knowledge to guide future research on this topic. A review of the literature between 2016 and 2024 was performed including open access retrospective studies, case series, clinical cases, and systematic reviews that addressed tourniquet use in a civilian or military setting in patients with extremity injuries, following the PRISMA-ScR 2018 checklist. PubMed, ScienceDirect, and Cochrane databases were queried, identifying 1,398 articles on the use of extremity tourniquets in military and civilian contexts, focusing on complications. Of these, 1,343 articles were excluded due to duplication or irrelevance based on the title. From the 55 remaining, 37 were excluded after abstract review for not meeting inclusion criteria. Of the 18 full-text articles reviewed, 10 were excluded due to insufficient data, leaving 8 studies for detailed analysis. Prolonged application in emergency situations may lead to severe complications, such as nerve injuries, post-tourniquet syndrome and thromboembolic event risks. Nerve palsy has been identified as the most prevalent complication associated with prolonged tourniquet use. Improved training is essential to help providers accurately assess bleeding severity and apply appropriate interventions, reducing complications and enhancing outcomes. Future research opportunities should consider: (1) prospective interventional randomized controlled studies aiming to compare the use of tourniquets to different methods of hemorrhage control; (2) development and validation of easy-to-use scores predicting complications and the need of amputation in both civilian and military settings including upper and lower extremities, to better guide clinical decisions and future guidelines; (3) development of better ways to teach lay providers to recognize life threatening bleeding; and (4) development of guidelines for timing of tourniquet loosening, removal or conversion.

Modern vascular trauma is complex and requires multidisciplinary care to assure optimal patient outcomes. Recognizing this, the American Association for the Surgery of Trauma (AAST) Associate Member Council hosted grand rounds to explore key issues in contemporary vascular trauma care and potential solutions. Current training paradigms may not adequately prepare either general surgery residents or integrated vascular surgery residents to care for these patients alone. The current iteration of the AAST Acute Care Surgery fellowship program hopes to overcome these limitations with a formal curriculum in vascular trauma. New attending surgeons must actively seek out and maintain vascular surgery skills, which can be done in collaboration with fellow trauma partners or vascular colleagues and will depend on the local culture of each institution. We also share a model of care implemented at the R Adams Cowley Shock Trauma Center, highlighting lessons learned from a team-based approach to modern vascular trauma care.

Introduction In damage control laparotomy (DCL) for trauma, intestinal injuries are often left in discontinuity. This study compared outcomes in patients with intestinal discontinuity versus immediate anastomosis. Methods Prospective multicenter, AAST study, included patients requiring DCL with intestinal resection. Patients were categorized into bowel Discontinuity and Continuity groups.Data collection included clinical characteristics, injury severity, peritoneal contamination, intraoperative blood products, crystalloids and vasopressors, operative time, takeback operative findings, fascia closure and postoperative complications. Outcomes included mortality, bowel ischemia, postoperative complications, fascia closure, and hospital stay. Results 246 patients from 16 centers. Using propensity score matching, 132 patients in the Discontinuity group were well-matched with 66 in the Continuity group. Discontinuity was associated with significantly higher mortality and septic complications. Fascia closure was more likely to be achieved in the Continuity group at the 2nd takeback operation. Conclusions Intestinal discontinuity in DCL is associated with increased mortality and septic complications