Allyson M. Hynes

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.

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This is the Western Trauma Association's recommended algorithm for the management of a traumatic lung injury. The current algorithm and recommendations are based on available published randomized trials, observational studies, systematic reviews, and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represent a safe and reasonable approach to this common problem. We recognize that there may be variability in decision-making, local resources, institutional consensus, and patient-specific factors that may require deviations from the presented algorithm. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians.

Trauma, acute care surgery, and surgical critical care clinicians routinely manage patients in whom small differences in timing, technique, and patient selection can meaningfully influence outcomes. Each year, emerging literature refines clinical decision-making across trauma surgery, emergency general surgery, pediatric trauma, and surgical critical care. A narrative review of the literature was conducted with primary emphasis on studies published in 2025. Selected high-impact articles from 2024 were included when they directly informed contemporary practice. Articles were identified through a structured review of the tables of contents of 17 high-impact general medical, surgical, trauma, and critical care journals and were supplemented by key articles known to the author group based on subject-matter expertise. The search was conducted between June 3, 2025, and December 31, 2025, and was limited to English-language publications. Priority was given to randomized clinical trials and large multicenter observational studies, with additional consideration of methodological rigor, citation impact, and journal-recognized distinctions. Thirteen studies were included, encompassing randomized trials, multicenter cohorts, and observational studies. These investigations addressed critical decision points across the continuum of care, including early resuscitation strategies, timing of life-saving interventions, analgesia and sedation, ventilator management, infection prevention, transfusion timing, perioperative antibiotics, diagnostic imaging strategies in older adults, and diagnostic and management pathways in pediatric trauma. Recent literature supports incremental refinement of trauma, acute care surgery, and surgical critical care practice, emphasizing selective application of established interventions, appropriate timing, and patient-centered decision-making. Collectively, these studies advance a more deliberate, evidence-informed approach to care across trauma surgery, emergency general surgery, pediatric trauma, and surgical critical care. Level of evidence Narrative review.

BACKGROUND: Despite evidence supporting high fresh frozen plasma (FFP)–to–packed red blood cell (PRBC) ratios, the optimal initial blood product in severe injury is unknown. We hypothesized that an FFP-first approach is associated with improved survival. METHODS: An observational Trauma Quality Improvement Program (2013–2021), including patients who received at least 5 units of PRBCs and 1 unit of FFP within four hours of arrival, was performed. Nonsurvivable injury patterns and pre-existing coagulopathy were excluded. Treatment effects were estimated with propensity score-weighted risk adjustment models, clustering by center. The primary outcome was six-hour mortality. Secondary outcomes were 24-hour and in-hospital mortality. A subanalysis was performed on the severe head-injured, and a sensitivity analysis examined inclusion criteria and additional blood products (platelets and cryoprecipitate). Effect modification was assessed for injury type. RESULTS: A total of 50,580 patients were included, with 13,818 in the FFP-first approach. Mean age was 39 years, with 77% males, 60% blunt trauma, and a mean Injury Severity Score of 27. Subanalysis included 15,912 patients, and the exposure sensitivity analysis included 27,217 patients. Unadjusted six-hour, 24-hour, and in-hospital mortality for the PRBC-first approach were 9.8%, 15%, and 28%, respectively, compared with 8.9%, 14%, and 27% for the FFP-first approach. A PRBC approach was independently associated with worse six-hour (adjusted Odds Ratio [aOR], 1.10; 95% CI, 1.02–1.18), 24-hour (1.11; 1.05–1.18), and in-hospital mortality (1.06; 1.01–1.11). The subgroup analysis of the PRBC aOR was 1.08 (95% CI, 0.95–1.23). In the exposure sensitivity analysis, the PRBC aOR was 1.02 (95% CI, 0.94–1.09). The blood products analysis was congruent with the main analysis. Effect modification was not present for injury type; however, penetrating mechanism was significantly associated with early death. CONCLUSIONS: Although the effect was modest in magnitude, a FFP-first approach was independently associated with improved survival through hospital discharge. Future prospective or randomized trials are warranted. ( J Trauma Acute Care Surg 2026;00:000–000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

In the emergency department, emergency medicine (EM) physicians should be familiar with advanced cardiovascular devices, such as extracorporeal membrane oxygenation (ECMO), intra-aortic balloon pumps (IABPs), and resuscitative endovascular balloon occlusion of the aorta (REBOA) catheters. Therefore, we developed a module to help learners integrate these modalities in the acute care setting to enhance patient care. Third- and fourth-year medical students interested in EM, as well as EM interns, participated in the module during their Introduction to Critical Care in EM course. The session involved a 60-minute flipped classroom online curriculum. Students received prerecorded lectures and PDF materials before the session. Students had to pass a premodule knowledge quiz and complete a postmodule quiz using 5-point Likert scales (1 = strongly disagree, 5 = strongly agree) assessing the module's effectiveness. Thirty students provided overwhelmingly positive feedback, indicating that the module effectively taught the basics of advanced devices and how the devices apply to EM and critical care (each, median score 5). Participants expressed increased confidence in managing IABPs, ECMO, and REBOA (each, median score 5). Free-text comments highlighted that the material was challenging but helpful. Students’ premodule median knowledge score was 2 (interquartile range [IQR] 2–3), versus a median score of 4 (IQR 4–4) postmodule (p < .001). This advanced cardiovascular device module offers a structured approach to teaching ECMO, IABP, and REBOA cardiovascular management to students interested in EM. Our module effectively addressed the educational gap and helped students achieve the learning objectives.

Objectives: Emergency medicine (EM) surgical critical care (SCC) trained physicians offer many advantages to SCC. However, several fields of critical care (CC) compete with SCC for EM intensivists. We hypothesized that there are definable and potentially modifiable factors related to the pathway selection. Design: Cross-sectional survey. Setting: Four national EM societies. Subjects: EM trainees (residents and fellows). Interventions: None. Measurements and Main Results: The primary outcome included the top factors leading to pathway selection. Secondary outcomes included influential factors for entering CC and individual components of a CC fellowship that interest the EM trainee. One hundred eleven EM trainees responded—42 fellows and 69 residents. Median age was 32 (interquartile range, 30–35). Sixty-seven were matched (fellows + matched residents). Intended fields of practice: 49 anesthesiology CC (26 matched), 58 medicine CC (29 matched), two neurology CC (1 matched), six resuscitation (one matched), 15 SCC (eight matched), and five non-CC (two matched). Top factors for pathway selection included exposure to specialty units, geography and specialty multidisciplinary teams ( p < 0.05). Ease of board certification was not influential. Only 28% of trainees had exposure to EM-SCC fellowships at their residency institution and only 42% had exposure to surgical intensivists during training. However, 41% envisioned practicing in a surgical ICU. Before application season, 8.2% did not have exposure to a surgical ICU/trauma ICU/trauma service that managed their ICU patients in contrast to the 3.2% of applicants not having medical ICU exposure. The highest-ranking factor for entering CC was intellectual appeal over job opportunities and lifestyle ( p < 0.05). When assessing components of individual fellowship programs, CC knowledge, the institutional value of EM/critical care medicine, and extracorporeal membrane oxygenation exposure ranked highly. Conclusions: Given the complexity of the modifiable barriers for EM-SCC matriculation, a multifaceted approach is necessary to increase matriculants. Interventions specific to the specialty are required at professional societal, institutional, and training program levels.