Journal of Acute Care Surgery

Age-specific risks of midline shift and neurosurgical intervention in small traumatic brain injuries in the United States: a retrospective cohort study: Heather X. Rhodes-Lyons, Adel Elkbuli, Sarah E. Johnson, David L. McClure, Antonio Pepe; J Acute Care Surg 2025;15(3):116-125. Published online November 30, 2025; DOI: https://doi.org/10.17479/jacs.2025.0007

Purpose
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality, particularly in older adults, in whom age-related physiological changes influence injury response and recovery. Smaller-volume TBIs, including subdural hematomas (≤8 mm), epidural hematomas (≤8 mm), and contusions (≤2 cm), are generally considered less severe; however, their clinical impact varies with age. This study aims to assess the effect of age on clinical outcomes, specifically midline shift and neurosurgical interventions, in patients with isolated, smaller-volume blunt TBIs.
Methods
This retrospective registry-based cohort study analyzed American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) Participant Use File data from 2017 to 2022. Patients aged ≥40 years with isolated smaller-volume TBIs were categorized into middle-aged (40–65 years) and older adult (≥65 years) groups. Multivariate logistic regression assessed associations between age, TBI type, midline shift, and neurosurgical interventions, adjusting for demographic, clinical, and injury-related variables.
Results
Among 135,343 patients, older adults with small contusions were 68% lower odds to experience a midline shift (adjusted odds ratio [OR], 0.32; 95% CI, 0.23–0.43; P<0.01). They also had significantly lower odds of undergoing craniotomy (epidural hematomas: adjusted OR, 0.60 [95% CI, 0.37–0.95], P=0.03; contusions: adjusted OR, 0.11 [95% CI, 0.05–0.23], P<0.01) or intracranial pressure monitoring (contusions: adjusted OR, 0.36; 95% CI, 0.18–0.75; P<0.01) compared to middle-aged patients.
Conclusion
Older adults with smaller TBIs are less likely to experience midline shift or undergo neurosurgical intervention. These findings emphasize the need for age-specific management strategies and suggest that a less aggressive intervention approach may be appropriate for older adults with smaller TBIs. Existing guidelines may require age-specific revisions. Further research is needed to explore long-term outcomes.

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Trauma

Traumatic abdominal wall hernia associated with a cow horn in Korea: a case report: Hwajin Shin, Chan Yong Park; J Acute Care Surg 2025;15(2):82-85. Published online July 30, 2025; DOI: https://doi.org/10.17479/jacs.2025.0002

Abstract
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The diagnosis and evaluation of traumatic abdominal wall hernia can be challenging because of its low incidence and nonspecific clinical presentation. Without a high index of clinical suspicion, the detection of traumatic abdominal wall hernia may be delayed. A 71-year-old female patient was struck in the lower abdomen by a cow horn and initially received only conservative management at a local clinic. However, her pain worsened despite conservative measures, and she developed a reducible bulging mass. Computed tomography revealed an abdominal wall defect with small bowel herniation. She was transferred to our hospital's emergency department, where urgent surgery was performed. A laparotomy was conducted to repair the abdominal wall defect and explore potential intra-abdominal injuries. The defect was successfully repaired, and the patient was discharged without complications on postoperative day 10.

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Trauma

Uncommon Mechanism of Mangled Extremity; Three Cases of Rope Entanglement Injury of the Lower Leg: Minsu Noh, Kyu-Hyouck Kyoung, Sungjeep Kim, Min Ae Keum, Seongho Choi, Kyounghak Choi, Jihoon Kim; J Acute Care Surg 2023;13(1):27-31. Published online March 21, 2023; DOI: https://doi.org/10.17479/jacs.2023.13.1.27

Abstract
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Rope entanglement injury is a rare entity. Previous reported studies mainly consisted of finger-related injuries. We describe three cases of rope entanglement injury of the lower leg. In the first patient, a belowthe- knee amputation was performed as the primary treatment for unilateral amputated lower limb. In the second patient, a below-the-knee amputation and perineal wound management were simultaneously performed. The third patient had vascular injury combined with internal soft tissue injury without related bone fracture. He suffered serious sequelae from a delay in transfer from a local hospital. Rope entanglement injuries of the lower leg do not present in a consistent manner, and the treatment of accompanying injuries should be considered from an early stage. Care should be taken to ensure that there are no internal injuries missed because the exterior appears to be stable.

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Trauma, Critical care

Fever in Trauma Patients without Brain Injury: Boyoon Choi, Kiyoung Sung, Jinbeom Cho; J Acute Care Surg 2021;11(1):6-13. Published online March 24, 2021; DOI: https://doi.org/10.17479/jacs.2021.1.6

Abstract
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Purpose
Distinguishing a fever caused by infection from the necessary febrile response in injured patients is difficult, because trauma patients often have concomitant obvious infectious origins. In traumatic brain injury, early fever might be associated with worse clinical outcomes; however, few reports on trauma patients without brain injury are available.

Methods
In this retrospective observational study, consecutive trauma patients without brain injury who were admitted to the surgical intensive care unit during a 3 year period were included. The surgical and clinical outcomes were compared according to body temperature. Locally weighted scatterplot smoothing was used to identify the relationship between body temperature and injury severity.

Results
A total of 111 patients were included. Body temperature increased as the injury severity score increased up to 47.717, above which it decreased. Mortality was high in hypothermic patients (72.7%; p < 0.001); however, few differences were observed between normothermic and hyperthermic patients (3.5% and 2.4%, respectively). The nonsurvivors had lower body temperatures on the 1st and 2nd days after admission (36 ˚C and 36.9 ˚C) compared with the survivors (37.3 ˚C and 37.7 ˚C; p < 0.001 and p = 0.006). In severely injured patients, low levels of inflammatory biomarkers and low body temperature were correlated with mortality.

Conclusions
Fever in trauma patients without brain injury is correlated with injury severity but not with prognosis. Hypothermia on the 1st and 2nd days after admission was significantly correlated with mortality. In severely injured patients, a decreased inflammatory response might play a certain role in promoting a high mortality rate.

Citations

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Fever in the Trauma Bay: A Marker for Greater Risk of Adverse Outcomes
Samir M. Fakhry, Yan Shen, Gina M. Berg, James R. Dunne, Parker Hu, Darrell L. Hunt, Mark G. McKenney, Nicholas W. Sheets, R. Joseph Sliter, Matthew M. Carrick, Jeneva M. Garland, Alessandro Orlando
Surgical Infections.2025; 26(4): 255. CrossRef
Prognostic factors in patients with gastrointestinal perforation under the acute care surgery model : a retrospective cohort study
Kiyoung Sung, Sanguk Hwang, Jaeheon Lee, Jinbeom Cho
BMC Surgery.2024;[Epub] CrossRef

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Procedure, Trauma

Successful Endovascular Management of Post-Traumatic Phlegmasia Cerulea Dolens from Rupture of the External Iliac Vein: Chan Yong Park, Hyun Min Cho, Kwang Hee Yeo, June Pill Seok, Chan Kyu Lee; J Acute Care Surg 2017;7(2):87-89. Published online October 30, 2017; DOI: https://doi.org/10.17479/jacs.2017.7.2.87

Abstract
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We report a rare case of a 47-year-old male with posttraumatic phlegmasia cerulea dolens caused by a ruptured right external iliac vein and treated with an endovascular venous stent graft. The patient was the victim of motor vehicle accident, and suffered direct injuries to the head and abdomen. The patient had a cyanotic and swollen right lower leg. Abdominal and lower extremity computed tomography angiography revealed a large retroperitoneal hematoma caused by a ruptured right external iliac vein, and grade I liver injury. The right external iliac vein rupture was successfully treated with a venous stent graft, followed by inferior vena cava filtering, because a venous thrombus was identified below the stent graft. He initially was hemodynamically unstable but recovered following treatment. The patient was comatose when presenting at the emergency department. He was discharged, fully recovered, on hospital day 18.

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Critical care, Basic

Tranexamic Acid in Trauma Management: Chan Ik Park, Jae Hun Kim, Sung Jin Park, Seon Hee Kim; J Acute Care Surg 2015;5(2):47-51. Published online October 31, 2015; DOI: https://doi.org/10.17479/jacs.2015.5.2.47

Abstract
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Hemorrhage is the major cause of death in patients with severe trauma. The early coagulopathy that occurs in patients with severe trauma, known as acute traumatic coagulopathy (ATC), has a major effect on morbidity and mortality. About a quarter of all patients with severe injury are reported to have coagulopathy at the time of arrival to hospital. The important mechanism of ATC is hyperfibrinolysis by up-regulation of activated protein C. Therefore anti-fibrinolytics are needed to treat trauma patients with ATC. Tranexamic acid (TXA) is a common anti-fibrinolytic broadly used in clinical practice. TXA is a lysine analogue and binds to lysine-binding site on plasminogen, interfering with plasminogen binding to fibrin. By inactivating plasmin, TXA can prevent hyperfibrinolysis. Clinical randomization of an anti-fibrinolytic in significant hemorrhage-2 proved TXA effective for patients significantly bleeding from traumatic injuries, reducing mortality in bleeding trauma patients without increasing the risk of thrombosis. The results of this trial led many trauma centers to include TXA in their major hemorrhage protocols. Early use of TXA is the simplest and most effective treatment to improve patient outcomes in trauma patients with significant hemorrhage. Therefore use of TXA should be considered in patients with major trauma.

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Naveed Hossain, Vasha Kaur, Mostafa Mahran, Abdul Quddus, Santanu Mukhopadhyay, Akshat Shah, Sanjay Agrawal
Obesity Surgery.2024; 34(2): 396. CrossRef
Suspected anaphylactic shock associated with administration of tranexamic acid in a dog
Jin-Young CHOI, Jung-Hyun KIM, Hyun-Jung HAN
Journal of Veterinary Medical Science.2019; 81(10): 1522. CrossRef