Publications

ABSTRACT: Traumatic hemothorax is a common consequence of thoracic injury, with management strategies ranging from observation to tube thoracostomy and operative intervention. This Western Trauma Association algorithm provides a practical framework for the evaluation and management of patients with traumatic hemothorax. Recommendations were developed through review of the available literature, including randomized and observational studies, supplemented by expert consensus where high-quality evidence is limited. The proposed pathway incorporates patient physiology, hemothorax size, adequacy of pleural drainage, and evidence of ongoing hemorrhage to guide management decisions. Because clinical circumstances, institutional resources, and local practice patterns vary, the algorithm is intended to support rather than replace individualized clinical judgment. It may be used as a bedside reference and as a framework for the development of institution-specific protocols.

LEVEL OF EVIDENCE: Consensus algorithm from the Western Trauma Association; Level V.

BACKGROUND: Fibrinolytic phenotypes have been implicated in postinjury pathophysiology and outcomes. While prehospital tranexamic acid (TXA) administration has demonstrated survival benefits, the interaction between TXA administration and distinct fibrinolytic profiles remains poorly defined.

METHODS: We analyzed data from a harmonized dataset combining 2 prospective trials evaluating prehospital TXA use in trauma (Prehospital Tranexamic Acid Use for Traumatic Brain Injury and the Study of Tranexamic Acid During Air and Ground Medical Prehospital Transport Trial). Patients were stratified by initial thromboelastographic (TEG) LY30 into fibrinolytic shutdown (<0.9%), hyperfibrinolysis (>3%), and physiological fibrinolysis (0.9-3%). The primary outcome was 30-day mortality. Secondary outcomes included 24-hour mortality and adverse events. Multivariable regression adjusted for TXA administration, fibrinolysis phenotypes, age, mechanism of injury, injury severity score, and shock index on presentation to the hospital.

RESULTS: Among 1,249 patients, 30-day mortality was 14.5% in the fibrinolytic shutdown group, 6.7% in the hyperfibrinolysis group, and 6.5% in the physiological fibrinolysis group. After multivariable regression, hyperfibrinolysis was associated with increased risk of death (HR 2.87; 95% CI: 1.10-7.53; p 0.03). Patients with fibrinolytic shutdown who were randomized to TXA had decreased risk of death (HR 0.32; 95% CI: 0.11-0.91; p=0.03).

CONCLUSIONS: This multitrial analysis revealed greater statistically significant differences between fibrinolytic phenotypes than analysis of each trial alone. Fibrinolytic phenotypes were independently associated with mortality. Fibrinolytic shutdown in patients randomized to receive TXA was associated with lower risk of death. These findings support the relevance of fibrinolysis profiling during early trauma care and underscore the need for larger studies to further elucidate the prognostic and therapeutic implications in trauma.

LEVEL OF EVIDENCE: II (Subanalysis of Randomized Controlled Trials).

Anaerobic fermentation with microbial communities is an emerging platform for converting lignocellulosic biomass to biofuels and bioproducts. The process relies on diverse anaerobic microbes that interact to deconstruct and convert lignocellulosic biomass into a range of products, such as volatile fatty acids (VFAs), through arresting methanogenesis during fermentation. However, defining the distinct functional roles played by various fungi and bacteria during anaerobic biodegradation remains poorly understood. Here, we performed parallel enrichment experiments from cow feces, goat feces, and anaerobic digester sludge, selecting for fungal- or bacterial-dominated communities that convert sorghum biomass into VFAs. Subsequently, we reconstructed metabolic networks across these enrichments using recovered bacterial metagenome-assembled genomes (MAGs), fungal isolate genomes, and genome-centric metatranscriptomics. This enabled direct comparison of the carbohydrate-active enzymes and fermentation pathways expressed by bacterial and fungal communities during lignocellulose conversion to VFAs. Our findings implicate diverse bacteria affiliated with the Bacteroidales and Lachnospiraceae in the direct conversion of lignocellulosic biomass to propionate and butyrate, respectively, whereas Neocallimastix-dominated fungal enrichments converted lignocellulose to lactate, acetate, and formate. Analysis of carbohydrate-active enzymes revealed that bacterial and fungal communities primarily targeted the same dominant lignocellulosic substrates while employing distinct enzyme repertoires and multidomain carbohydrate-active enzyme architectures, highlighting complementary enzymatic strategies for accessing and deconstructing lignocellulosic biomass. We anticipate that these findings will help inform efforts to develop synthetic consortia with tailored functionality for low-cost conversion of lignocellulosic biomass to fuels and bio-based chemicals.

BACKGROUND: Trauma systems have undergone substantial evolution over the past several decades. However, we have yet to achieve the National Academies of Sciences, Engineering, and Medicine goal of zero preventable deaths from injury. In this study, we examined preventable deaths within advanced trauma systems to identify opportunities for further improvement.

METHODS: Task Order One, coordinated within the Linking Investigators in Trauma and Emergency Medical Services Network (LiTES) that included over 30 emergency medical service (EMS) agencies transporting to eight level 1 trauma centers in the United States, created an extensive database of severely injured trauma patients. A potentially preventable mortality (PPM) program was developed. Cause of death was reported by study site primary investigators (PIs), cases were selected for review by a prespecified list of prehospital patient/injury characteristics and cause of death. Reports were generated by the data coordination center and reviewed by the LiTES Executive Operating Committee and the site PI.

RESULTS: Of 2,618 deaths, 391 were reviewed based on established criteria. Of these, 99 (25.3%) were determined to be PPM. For reviewed cases, presenting physiology was similar between PPM and non-PPM patients. Higher proportions of PPM compared with non-PPM were seen in patients who were male, black or African American, with a mechanism of firearm injury or other penetrating injury. The most common cause of PPM was uncontrolled hemorrhage (53%) followed by multiple organ failure (19%), ARDS/primary respiratory failure (9.1%), and coagulopathy (6.1%). Deaths due to uncontrolled hemorrhage and coagulopathy occurred earliest during care.

CONCLUSIONS: In this study, we found that approximately one of our reviewed deaths from injury was potentially preventable. Patients who were male, Black or African American, or sustained firearm or other penetrating injuries were at the highest risk for PPM. On the basis of these data, improvements in hemorrhage management, particularly for firearm and other penetrating injuries, are needed.

LEVEL OF EVIDENCE: Level III, sub-analysis of prospective observational study.

BACKGROUND AND OBJECTIVES: Low-titer O whole blood (LTOWB) is found to be associated with a survival advantage in trauma-related major hemorrhage in some prospective studies. The role of LTOWB in non-trauma patients has not been as extensively studied. In this study, we assess the feasibility and safety of administering LTOWB to patients with life-threatening gastrointestinal bleeding (GIB) and post-partum hemorrhage (PPH).

STUDY DESIGN AND METHODS: We performed a retrospective study of patients who received LTOWB at a large regional academic center for life-threatening GIB and PPH according to hospital protocol between 1 December 2023 and 31 December 2025. Demographic, clinical, transfusion, laboratory data, including hemolysis-related variables, and clinical outcomes were compared between group-O and non-group-O patients.

RESULTS: We studied 112 patients, 53 men and 59 women, with a median (interquartile range [IQR]) age of 68 (41-77) years. Of these, 87/112 (77%) had GIB and 25/112 (23%) had PPH; 38/112 (34%) were group-O and 74/112 (66%) non-group-O. In total, 203 LTOWB units were transfused, 155 for GIB and 48 for PPH. The median (IQR) number of LTOWB units transfused to both group-O patients and non-group-O was 2 (1-2). There were no clinically significant laboratory or mortality differences between group-O versus non-group-O patients, which was 3% versus 4% at 24 h, respectively. No hemolytic transfusion reactions were reported.

CONCLUSION: LTOWB transfusion for life-threatening GIB or PPH is feasible and not associated with hemolysis in non-group-O recipients. Further studies are required to determine the clinical utility of this transfusion strategy.

IMPORTANCE: Recent studies suggest racial disparities exist in prehospital interventions among injured patients. Further evaluation is needed to understand how other social determinants of health may influence these findings and if these disparities translate to differences in outcomes.

OBJECTIVE: To evaluate the association between race and ethnicity and receiving prehospital interventions, how these associations change based on neighborhood social determinants of health, and if these interventions are associated with patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS: This is a retrospective cohort study of the Linking Investigations in Trauma and Emergency Medical Services Task Order 1 database from 2017 through 2021. Patients included were 18 years or older with an injury severity score higher than 9 and had race and ethnicity data available. Data were linked to the Distressed Communities Index (DCI). These data were analyzed from January 2025 to June 2025.

MAIN OUTCOMES AND MEASURES: Associations between race and prehospital interventions were evaluated, including prehospital blood products, prehospital needle decompression, prehospital airway, prehospital intubation, and prehospital tourniquet placement. The study team also evaluated if receiving prehospital interventions was associated with 24-hour and in-hospital mortality.

RESULTS: A total of 18 280 patients meeting inclusion criteria were identified, of which 4327 self-identified as Black, 11 140 as White, and 2813 as other race. Patients of other race were more likely to receive prehospital blood products (492 [4.4%]) and prehospital intubation (882 [7.9%]) compared with Black patients (101 [2.3%] and 171 [4.0%], respectively). White patients were more likely to receive prehospital airway (1018 [9.1%]) and intubation (882 [7.9%]) compared with Black patients (250 [5.8%] and 171 [4.0%], respectively). Patients in socially disadvantaged neighborhoods were less likely to receive prehospital airway and intubation compared with more affluent communities. No significant interactions or significant mediation by the DCI was seen. Prehospital airway and prehospital intubation were associated with a 30% and 37% reduction in odds of in-hospital mortality (adjusted odds ratio [aOR], 0.70; 95% CI, 0.52-0.93 P = .05) and (aOR, 0.63; 95% CI, 0.46-0.86; P = .004).

CONCLUSIONS AND RELEVANCE: These results demonstrate that disparities in prehospital interventions among injured patients exist and these disparities are not significantly explained by neighborhood social determinants of health. Further studies are needed to better understand the underlying causes and employ targeted interventions.

BACKGROUND: Postoperative venous thromboembolism (VTE) remains a major cause of surgical morbidity despite guideline-based prophylaxis. Whether VTE timing and thromboprophylaxis patterns differ across surgical subspecialties is incompletely characterized.

STUDY DESIGN: Retrospective cohort study of adults with imaging-confirmed postoperative VTE during the index admission within a multihospital healthcare system (2013-2019). VTE events were identified using natural language processing and confirmed by chart review. Primary outcome was time to postoperative VTE; secondary outcome was time to thromboprophylaxis. Kaplan-Meier analyses and multivariable Cox proportional hazards models evaluated associations across surgical specialties.

RESULTS: Among 1,520 patients with postoperative VTE, 24.9% had deep vein thrombosis (DVT) only, 67.2% pulmonary embolism (PE) only, and 7.9% both. Median time to VTE was 4 days (IQR 2.0-8.0); PE occurred earlier than DVT (3 vs 6 days; p<0.001). Neurosurgery had the highest VTE incidence (0.23% of neurosurgical cases), whereas orthopedic surgery demonstrated the highest adjusted hazard for postoperative VTE. Overall, 76% received postoperative thromboprophylaxis beginning a median of 1.3 days after surgery (IQR 0.8-1.7). Patients without thromboprophylaxis developed VTE earlier than those receiving prophylaxis (2.0 vs 4.0 days; p<0.001). Cardiac surgery demonstrated the lowest adjusted likelihood of thromboprophylaxis, whereas thoracic surgery had the highest (HR 5.8, 95% CI 2.8-12.1; reference cardiac), and trauma patients were less likely to receive prophylaxis (HR 0.44, 95% CI 0.34-0.57).

CONCLUSIONS: Postoperative VTE risk, timing, and thromboprophylaxis practices vary substantially across surgical subspecialties. These findings support specialty-specific VTE risk assessment, prophylaxis strategies, and postoperative surveillance.

BACKGROUND: Trauma guidelines have historically recommended intubation prior to transfusion, yet intubation and mechanical ventilation can exacerbate hemodynamic instability. We hypothesized that injured patients resuscitated with a circulation-first approach would require fewer blood transfusions and would have lower mortality than those managed with an airway-first approach.

METHODS: This secondary data analysis of the Linking Investigations in Trauma and Emergency Services (LITES) database compared trauma patients in hemorrhagic shock who received blood products and intubation within 30 minutes of each other. 'ABC' patients were intubated first, whereas 'CAB' patients received blood first. A subgroup analysis compared patients with penetrating injuries only. Outcomes included transfusion volume, whole blood (WB) utilization, mortality, and hospital length of stay (HLOS).

RESULTS: 35 CAB and 49 ABC patients were included. The ABC group suffered more blunt injuries (73.5% vs 42.9%, p=0.02) and were more likely to receive WB in the prehospital setting (75.5% vs 48.6%, p=0.02). Transfusion requirements were significantly higher in the CAB group (7195 mL vs 6090 mL, p=0.01), although this was not the case after removal of outliers. In the penetrating cohort (17 CAB, 11 ABC), CAB patients were less likely to be transferred directly from the scene (70.6% vs 72.7%), yet were more likely to receive WB in the prehospital setting (64.7% vs 27.3%). There were no differences with respect to mortality or HLOS.

CONCLUSION: When comparing a circulation-first to an airway-first approach to triage in a unique, severely injured cohort of trauma patients, there was no difference detected in transfusion requirements or mortality. Centers participating in LITES more frequently used CAB over ABC for patients with penetrating trauma. The sample size and characteristics of this cohort limit its generalizability and highlight the need for prospective multicenter trials to guide the triage and management of hemorrhagic shock.

LEVEL OF EVIDENCE: III, prognostic/epidemiological.

Acute kidney injury (AKI) develops in 20-40% of critically injured patients and contributes to poor outcomes. In sepsis and critical illness, dysregulated coagulation and fibrinolysis are linked to microangiopathic kidney dysfunction, but similar relationships in trauma are not well characterized. We performed a secondary analysis of a single-center randomized controlled trial of severely injured adult trauma patients. Plasma thrombin-antithrombin (TAT), plasmin-2-antiplasmin (PAP), and fibrinogen were measured within 2 hours of injury and 6 hours later. The primary outcome was AKI, defined by the RIFLE (Risk, Injury, Failure, Loss, End-stage kidney disease) criteria. Adjusted logistic regression models evaluated biomarker associations with AKI. Receiver operating characteristic analyses identified discriminatory thresholds. Among 149 patients, 30 (20.1%) developed AKI. Patients with AKI had higher TAT and PAP concentrations and lower fibrinogen levels at both time points. The 6-hour TAT-to-fibrinogen ratio was independently associated with AKI (Adjusted OR 7.17; 95% CI 2.34-21.9, p = 0.001, AUC = 0.88). Supplemental analyses demonstrated consistent associations for TAT and fibrinogen individually, whereas PAP was not independently predictive. A 6-hour TAT level < 99 pg/mL identified patients unlikely to develop AKI (negative predictive value [NPV] 93.9%). Fibrinogen levels > 173 mg/dL showed a low likelihood of AKI (NPV 88.2%). Elevated TAT and reduced fibrinogen measured 6 hours after injury were independently associated with AKI. This suggests that early coagulation imbalance may reflect evolving microvascular kidney dysfunction in injured patients and potentially warrants the evaluation of the TAT-to-fibrinogen ratio as an early marker of trauma-related AKI. (NCT02535949).