Major Trauma Evidence Rundown — Issue 7 (October 2026)

MAJOR TRAUMA EVIDENCE RUNDOWN

Major Trauma Evidence Rundown

Surgery & Critical Care · Issue 7 · October 2026 · UK Edition

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed.

Full archive and PDF downloads at emevidence.org

Lead: WSES evidence-based recommendations on colon and rectal trauma (JAMA Surgery): primary repair or resection with anastomosis is preferred over routine diversion for most stable patients; diversion is reserved for defined physiological criteria; proximal diversion remains the default for extraperitoneal rectal injury. CHANGE TONIGHT: NHSBT O D-negative red cells at Pre-Amber (2 October), with 3.2 days of O negative red cell stock against a 6-day target — use O D-negative only where clinically essential. CHANGE THIS MONTH: MHRA NatPSA/2026/005 on hoists and slings; review emergency thoracotomy governance against the 2026 EMJ update.

BOTTOM LINE UP FRONT — OCTOBER 2026

ACT ON THIS NOW

CHANGE TONIGHT NHSBT O D-negative Pre-Amber: O neg red cells 3.2 days (target 6). Reserve O D-negative for emergencies and switch to group-specific blood as soon as the group is known.

CHANGE THIS MONTH WSES colorectal trauma: primary repair or anastomosis over routine diversion for most stable patients; antibiotic prophylaxis no longer than 24 hours.

CHANGE THIS MONTH Emergency thoracotomy 2026 (EMJ, UK): checklist, SOP, mandatory debrief/audit and equipment governance for every service performing it.

SAFETY MHRA NatPSA/2026/005: hoists and slings — falls causing deaths; relevant to trauma wards and spinal patients.

KNOW FOR NEXT TIME

INFORMING Salovum in severe TBI (Brain, phase II RCT, n=100): 30-day mortality 20% vs 39% (RR 0.52) in Cape Town — promising but small.

INFORMING Cervical spine immobilisation (TraumaRegister DGU, n=31,055): no measurable mortality or neurological benefit, even with confirmed c-spine injury.

INFORMING Paediatric shock thresholds (TQIP, n=233,490): mortality-linked SBP thresholds 15–30 mmHg higher than PALS hypotension definitions.

MCI JESIP response to a Prevention of Future Deaths report: JESIP and ETHANE apply whenever two or more agencies respond, not just to major incidents.

October brings the first GRADE-based international recommendations on colon and rectal trauma, and they confirm the long shift away from routine diversion towards physiology-driven repair. Blood supply is the UK story of the month: NHSBT moved O D-negative red cells to Pre-Amber on 2 October, which matters to every major haemorrhage protocol in the country. The UK emergency thoracotomy update sets out a governance framework that MTCs and trauma units should test their own pathways against. A small but striking phase II trial of antisecretory factor in severe TBI, a large German registry questioning routine cervical immobilisation, and new paediatric shock thresholds round out the research. The Core Revision this month is burns: resuscitation, referral and escharotomy.

WHAT’S INSIDE — ISSUE 7

• Lead: WSES colon and rectal trauma recommendations (JAMA Surg)
• Salovum phase II RCT in severe TBI (Brain)
• Cervical spine immobilisation — TraumaRegister DGU (World J Emerg Surg)
• Hard signs in penetrating neck trauma — diagnostic accuracy with Bayesian table
• Potentially preventable trauma deaths — LITES (J Trauma Acute Care Surg)
• UK: NHSBT O D-negative Pre-Amber; emergency thoracotomy 2026 governance (EMJ); MHRA hoists NatPSA and orthopaedic FSNs
• Haemorrhage: early plasma in TBI (SR); ROTEM-guided transfusion; circulation-first vs airway-first
• Orthopaedic: pelvic ring fractures in older adults; ceftriaxone in Gustilo III fractures; TXA dosing in hip fracture; rib fixation with TBI
• Neurotrauma & burns: hyperosmolar timing; paediatric burn TBSA thresholds; paediatric burn sedation
• Mass casualty: JESIP PFD response; blast vs blunt resource burden; pretriage mislabelling simulation
• Paediatrics: haemodynamic instability thresholds; VTE after severe TBI (SR/MA)
• Core Revision: Burns

CHANGE TONIGHT CHANGE THIS MONTH SAFETY GUIDELINE INFORMING PRACTICE NHSBT MCI UK

FRCS / FINAL FRCA

1 — KEY TRIALS & RESEARCH

LEAD

CHANGE THIS MONTH

GUIDELINE

FRCS

Lead: WSES Evidence-Based Recommendations on Colon and Rectal Injuries — Selective, Physiology-Driven Repair

Ribeiro MAF Jr, Efron DT, Dattwyler MP, et al. Management of colon and rectal injuries from blunt and penetrating trauma: evidence-based recommendations from the World Society of Emergency Surgery. JAMA Surg. 2026 (epub 23 September). doi:10.1001/jamasurg.2026.4263. PMID: 42776522. Method: An international WSES panel prioritised 17 PICO questions across colon, rectum and technical/perioperative domains; structured literature reviews ran to early 2026, and recommendations were graded (strong or conditional; high to very low certainty) using GRADE and harmonised by consensus.

Key recommendations: Contrast-enhanced CT anchors diagnosis but a negative scan does not exclude injury; bowel wall discontinuity, extraluminal air or active mesenteric extravasation warrant operation. For suspected rectal injury CT is first line, with adjunctive rigid or flexible proctoscopy raising combined sensitivity to about 97%; routine rectal contrast is not recommended. Primary repair or resection with anastomosis is preferred over routine diversion for most stable patients, including many traditionally deemed high risk; for low-grade injuries, primary repair alone is preferred. Selective diversion is reserved for persistent vasopressor dependence after damage control laparotomy, inability to close the fascia at the first re-look, or compounded physiological derangement. Proximal diversion is the default for extraperitoneal rectal injury, and routine presacral drainage and distal rectal washout are not recommended. Stapled and hand-sewn anastomoses are equivalent; antibiotic prophylaxis should not exceed 24 hours; early enteral nutrition is advised in selected patients.

Critical appraisal: The panel used a transparent GRADE process, but the authors acknowledge that much of the supporting evidence remains observational and that prospective study is warranted. The author list is drawn largely from the Americas, so applicability to UK case mix should be considered locally. The physiological triggers for

diversion are pragmatic and match how damage control decisions are made in practice. The 24-hour antibiotic limit is consistent with existing evidence and an easy stewardship win.

UK practice: MTC general surgical and colorectal teams should align local damage control laparotomy and colorectal injury pathways with these recommendations, particularly the default to primary repair or anastomosis in stable patients and stopping prophylactic antibiotics at 24 hours. Mini-GRADE: low to moderate. Implementation friction: low.

INFORMING PRACTICE FINAL FRCA

Salovum (Antisecretory Factor) in Isolated Severe TBI: 30-Day Mortality 20% vs 39% in a Phase II RCT

Cederberg D, Harrington BM, Walker I, et al. Salovum reduces mortality in isolated severe traumatic brain injury: a randomized phase II trial. Brain. 2026 (epub 7 September). doi:10.1093/brain/awag241. PMID: 42705343. NCT03339505. Design: Prospective, double-blind, placebo-controlled phase II trial (September 2017 to February 2022) at a tertiary trauma centre in Cape Town, South Africa. Adults with isolated severe TBI (GCS 6–8) receiving ICP monitoring and neurointensive care were given Salovum (freeze-dried egg yolk powder enriched with antisecretory factor) or placebo (freeze-dried egg yolk powder) by nasogastric tube, 10–17 g every 4 hours by weight, started at a mean of 32.9 hours after injury and continued until ICP monitor removal or a maximum of 5 days.

Results: 100 participants (49 Salovum, 51 placebo; 96% male; mean age 33). 30-day mortality 20% vs 39% (RR 0.52, 95% CI 0.271–0.997; p=0.040). Therapy intensity level and ICP were similar; no significant adverse events.

• −19 pts ARD — 30-DAY MORTALITY
• ~5 NNT (FROM ROUNDED RATES)
• RR 0.52 95% CI 0.27–1.00
• n=100 SEVERE TBI, SINGLE CENTRE

Critical appraisal: Randomised and double-blind with a credible placebo, but small, single-centre and a phase II design: the upper confidence limit sits at 0.997, so the result is fragile. A mortality reduction of this size with no change in ICP or therapy intensity has no clear mechanism, which raises the possibility of chance. The population (young, male, LMIC setting, isolated TBI) differs considerably from UK severe TBI, which is increasingly older and multiply injured. Functional outcome is not reported in the abstract.

UK practice: Not ready for practice; await multicentre RCTs. Continue NICE NG232 and Brain Trauma Foundation-aligned neurocritical care.

INFORMING PRACTICE FRCS

Prehospital Cervical Spine Immobilisation: No Measurable Mortality or Neurological Benefit in 16,922 Matched Registry Patients

Häske D, Hossfeld B, Lefering R, et al. Effect of prehospital cervical spine immobilization on mortality and neurological outcome in trauma patients: TraumaRegister DGU. World J Emerg Surg. 2026;21(1):52. doi:10.1186/s13017-026-00731-w. PMID: 42786484. Design: Retrospective multicentre cohort from TraumaRegister DGU (2020–2022; Germany, Austria, Switzerland), patients aged 1 year or over, with exact 1:1 propensity matching on injury severity, mechanism and prehospital parameters.

Results: Of 31,055 patients, the prevalence of cervical spine injury (AIS ≥3) was 3.5% and only 65.9% were immobilised. In the matched cohort (n=16,922), hospital mortality was 12.0% with immobilisation vs 13.6% without (p=0.001), judged not clinically meaningful, with no difference in GOS at discharge. In confirmed cervical spine injury (AIS ≥2; n=1,362), mortality was 18.2% immobilised vs 17.9% not (p=0.888), and neurological recovery did not differ.

• 12.0% vs 13.6% MORTALITY, MATCHED COHORT
• 18.2% vs 17.9% MORTALITY, CONFIRMED C-SPINE INJURY
• n=16,922 MATCHED PATIENTS

Critical appraisal: Large and well-matched, but immobilisation was recorded as a binary variable without method or quality, and GOS at discharge is a crude neurological outcome. Residual confounding by indication is likely, because immobilised patients were more severely injured. The study cannot show that immobilisation is harmless to omit in individual high-risk patients.

UK practice: Supports the UK shift towards selective spinal motion restriction (Faculty of Pre-Hospital Care consensus) rather than routine collars and blocks; in-hospital, follow NICE NG41 imaging rules.

INFORMING PRACTICE FRCS

Hard Signs in Penetrating Neck Trauma: Specific but Miss Almost Half of Major Injuries

Barrientos ML, Zapata CAL, Toro DAM, López CAD. Diagnostic accuracy and predictive value of hard signs for operative or endovascular management and major injury in penetrating neck trauma: a single-centre retrospective cohort study. Eur J Trauma Emerg Surg. 2026;52(1):293. doi:10.1007/s00068-026-03343-w. PMID: 42752941. Single-centre retrospective cohort of 310 consecutive patients (2013–2025). Major vascular or aerodigestive injury occurred in 92 (29.7%). Hard signs: sensitivity 55.4% (95% CI 44.7–65.8), specificity 88.1% (83.0–92.1). Major injury occurred in 5/97 with no signs, 36/136 with soft signs only and 51/77 with hard signs. A composite of any sign or haemodynamic instability reached 96.7% sensitivity at 34.4% specificity.

• 55.4% SENSITIVITY
• 88.1% SPECIFICITY
• 4.66 LR+ (CALCULATED)
• 0.51 LR− (CALCULATED)
• n=310 PENETRATING NECK INJURIES

LRs calculated from the reported point estimates (Sn 0.554, Sp 0.881); confidence intervals on LRs not reported. Post-test probabilities calculated by EM Evidence. Caveat: hard signs also informed management decisions, so the management outcome is not independent of the index test.

Appraisal: Retrospective sign assignment and partial verification limit accuracy estimates; the authors call the findings exploratory. The message is clear, though: the absence of hard signs does not exclude major injury. The authors say this is consistent with the rationale for imaging-based selective management, while cautioning that it is not evidence that any particular strategy is safe.

INFORMING PRACTICE

Potentially Preventable Trauma Deaths in Advanced US Trauma Systems: 1 in 4 Reviewed Deaths, Mostly Uncontrolled Haemorrhage

Brito AMP, Wisniewski SR, Jackson A, et al. Examining potentially preventable mortality in trauma: what can we do better? J Trauma Acute Care Surg. 2026 (epub 2 October). doi:10.1097/TA.0000000000005162. PMID: 42826344. LITES Task Order One (over 30 EMS agencies, eight US level 1 centres): of 2,618 deaths, 391 were reviewed and 99 (25.3%) judged potentially preventable. Uncontrolled haemorrhage caused 53%, followed by multiple organ failure (19%), ARDS/respiratory failure (9.1%) and coagulopathy (6.1%); haemorrhage and coagulopathy deaths occurred earliest. Firearm and other penetrating injuries were over-represented. Preventability was judged by site investigators and the LITES executive committee, and only selected deaths were reviewed, so the proportion is not a population rate.

UK practice: Mirrors the UK priority of early haemorrhage control. MTC mortality review (M&M and network peer review) should explicitly classify preventability and timing of haemorrhage deaths.

2 — GUIDELINES & UK UPDATES

CHANGE TONIGHT NHSBT UK

NHSBT: O D-Negative Red Cells at Pre-Amber — 3.2 Days of Stock Against a 6-Day Target

NHS Blood and Transplant. Blood stocks — Hospitals and Science, update 2 October 2026. hospital.blood.co.uk/business-continuity/blood-stocks. On 2 October 2026 NHSBT stated that its O D-negative red cell stock was lower than required and vulnerable to changes in supply and demand, with Pre-Amber status for O and B D-negative red cells, and asked hospitals to read the communication and take action. Stock shown: O negative red cells 3.2 days, B negative 4.8 days, against an aim of 6 days of red cell stock; platelet stocks were at or above the 1-day minimum. NHSBT notes that substitutions may be offered when stocks are low.

Action: Major haemorrhage protocols rely on O D-negative for unknown-group emergencies. Follow your local O D-negative stock-management policy (for example O D-positive emergency units where it permits), switch to group-specific blood as soon as the group is known, and return unused emergency units promptly.

CHANGE THIS MONTH UK FRCS

Emergency Thoracotomy: How to Do It in 2026 — The Governance Framework for MTCs and Trauma Units

Chesters A, Hughes M, Ley E, O’Meara M, Davies G, Hormis A. Emergency thoracotomy: how to do it in 2026. Emerg Med J. 2026. doi:10.1136/emermed-2026-216110. This UK practice review updates the 2005 Wise technique. For in-hospital teams the key points are the updated indications (thoracotomy within 15 minutes of loss of vital signs), a advice against Foley catheters for cardiac wounds (they can enlarge defects), manual aortic compression or clamping, and management after ROSC: control internal mammary bleeding, partially close the clamshell, and leave the retractor in situ but loosened for rapid re-entry. Where aortic compression continues, intermittent occlusion (for example 45 s on and 15 s off) should be considered. A minimum of two clinicians is needed. The authors recommend four governance components: a three-part checklist (before, during and after) aligned with the WHO Surgical Safety Checklist and NatSSIPS; a service-specific SOP with authorisation and training criteria; immediate senior advice, a mandatory debrief and audit of every case; and agreed equipment governance with the local sterile services department.

Appraisal: Expert practice review rather than primary evidence, but from experienced UK prehospital and hospital clinicians and aligned with ERC 2025. Also covered for ED and prehospital readers in EM Issue 32 and PHEM Issue 9; the trauma angle here is governance and transfer to definitive care.

UK practice: MTCs should check that ED, theatre and cardiothoracic pathways for patients arriving after thoracotomy (including handover with the clamshell partially closed) are explicit, and that every case is debriefed and audited.

SAFETY UK

MHRA: Patient Hoists and Slings NatPSA, and September Orthopaedic Field Safety Notices

MHRA. National Patient Safety Alert NatPSA/2026/005/MHRA; MHRA Safety Roundup: September 2026 (29 September). gov.uk/drug-device-alerts/mhra-safety-roundup-september-2026. Field Safety Notices 31 August–25 September 2026 (gov.uk). NatPSA/2026/005: deaths and serious harm from falls from patient hoists and slings (an average of two deaths per year since 2015), linked to incompatible hoist–sling combinations, damaged or incorrectly seated loops, missed pre-use checks, overdue maintenance and training gaps. This is relevant to trauma wards, spinal injury and polytrauma patients. Orthopaedic FSNs listed: F.H Industrie Calcanail threaded cannulated screw D5; Acumed Acu-Loc 2 VDR plate; Howmedica Osteonics orthopaedic implant components; Heraeus PALACOS R+G pro, PALACOS MV+G pro and COPAL G+C pro bone cements; Summit Medical HiVac MultiMix cement kit. The MHRA list pages do not state the specific issues; see each manufacturer notice.

Action: Confirm trauma ward compliance with the hoist NatPSA; orthopaedic trauma leads should check that theatre stores have acted on the listed FSNs.

3 — HAEMORRHAGE & RESUSCITATION

INFORMING PRACTICE FINAL FRCA

Early Plasma in TBI: Systematic Review Finds Insufficient Evidence of Benefit or Harm

Tahir U, Drennan IR, Kobal P, et al. Early plasma administration in traumatic brain injuries: a systematic review. Transfusion. 2026 (epub 28 September). doi:10.1111/trf.70403. PMID: 42806678. Fifteen studies (183,253 patients), narrative synthesis with GRADE. A secondary analysis of a cluster-randomised trial found lower 24-hour and 30-day mortality with prehospital plasma among patients at risk of haemorrhagic shock later found to have CT-confirmed TBI, seen in direct scene transports but not interfacility transfers. Two small early in-hospital trials showed no mortality benefit, and one reported higher mortality and more delayed or new intracranial haematomas with plasma. Observational data were inconsistent. Certainty very low; the evidence is insufficient to determine benefit or harm.

• 15 STUDIES
• n=183,253 PATIENTS
• Very low GRADE CERTAINTY

Appraisal: Studies varied in product, dose, timing and comparator, and findings were synthesised narratively. The signal that timing matters is biologically plausible but derives from a secondary analysis.

UK practice: No change: give plasma for haemorrhagic shock under the major haemorrhage protocol regardless of TBI; there is no evidence to support plasma for isolated TBI coagulopathy outside it.

INFORMING PRACTICE NHSBT

ROTEM-Guided Transfusion in Bleeding Trauma: Less Plasma, More Cryoprecipitate

Dinić R, Šabani A, Životić B, et al. Rotational thromboelastometry-guided transfusion in acute trauma: less plasma, greater precision. Vox Sang. 2026 (epub 23 September). doi:10.1111/vox.70378. PMID: 42778196. Retrospective cohort (October 2023 to March 2025) of 200 bleeding trauma patients: 100 ROTEM-guided vs 100 managed with conventional tests. ROTEM was associated with less FFP (aIRR 0.36, 95% CI 0.24–0.55), more cryoprecipitate (aIRR 1.92, 95% CI 1.40–2.66) and shorter ICU stay; red cell and platelet use, complications and mortality did not differ significantly. The authors caution that the non-randomised design and low red cell exposure mean the findings should not be read as ROTEM reducing bleeding, particularly in massive transfusion.

INFORMING PRACTICE FINAL FRCA

Circulation-First vs Airway-First in Transfused Trauma Patients: No Difference in a Small LITES Analysis

Metheny J, Topper GV, Rosario-Rivera BL, et al. Challenging convention: a secondary data analysis of circulation-first versus airway-first triage in trauma patients receiving blood transfusions. Trauma Surg Acute Care Open. 2026;11(3):e002358. doi:10.1136/tsaco-2026-002358. PMID: 42689001. Secondary analysis of the LITES database: 35 patients transfused before intubation (CAB) vs 49 intubated first (ABC), with both within 30 minutes of each other. Transfusion volume was higher in the CAB group (7,195 vs 6,090 mL), but not after outliers were removed; there were no differences in mortality or length of stay. The groups differed (ABC more blunt injury and more prehospital whole blood), and the sample is far too small for conclusions.

UK practice: UK trauma teams already favour <C>ABC with resuscitation before induction in haemorrhagic shock; this does not change that.

4 — ORTHOPAEDIC & MUSCULOSKELETAL TRAUMA

INFORMING PRACTICE FRCS

Pelvic Ring Fractures in Adults 55 and Over: Operative Management Linked to More VTE and Pneumonia, No Adjusted Survival Benefit

Johnson M, Sabat L, Allam J, Perdue P, Zuelzer D. Operative versus nonoperative management of pelvic ring fractures in older adults: a propensity-matched analysis of mortality and complications. Injury. 2026;57(11):113717. doi:10.1016/j.injury.2026.113717. PMID: 42735548. TriNetX cohort, patients aged 55 or over, 5,314 matched per arm. Mortality did not differ at 30 or 90 days but was lower with surgery at 1 year (p=0.034) and 2 years (p<0.001); neither persisted in the multivariable Cox model (HR 0.939; p=0.296). VTE and pneumonia were more common with surgery at all time points. As a database study, confounding by indication is likely; the authors call for trials assessing fracture characteristics, frailty and function.

UK practice: Older patients with pelvic ring fractures need orthogeriatric co-management; base fixation decisions on fracture pattern and failure to mobilise, recognising the higher VTE and pneumonia risk.

INFORMING PRACTICE FRCS

Ceftriaxone vs Cefazolin Plus Gentamicin in Gustilo III Open Lower Limb Fractures: Similar Infection Rates; Time to Antibiotics Matters

Foster C, Richardson L, Pegg B, et al. Ceftriaxone versus cefazolin plus gentamicin for antibiotic prophylaxis in Gustilo-Anderson type III open lower extremity fractures. J Orthop Trauma. 2026 (epub 23 September). doi:10.1097/BOT.0000000000003286. PMID: 42775682. Single-centre retrospective cohort (2013–2024): 307 type III fractures (229 cefazolin plus gentamicin, 78 ceftriaxone). Fracture-related infection 18.3% vs 12.8% unadjusted (p=0.343); adjusted HR 1.26 (95% CI 0.59–2.68). No difference in AKI. Type IIIB/C injury (HR 3.05) and time to antibiotics over 60 minutes (HR 2.56) independently predicted infection. The groups were imbalanced (more tibial shaft and IIIB injuries with cefazolin plus gentamicin) and the study was underpowered for equivalence.

UK practice: The stronger message is timing: BOAST Open Fractures (BOA/BAPRAS) calls for antibiotics as soon as possible, ideally within 1 hour of injury. Follow local microbiology for agent choice.

INFORMING PRACTICE FRCS

TXA in Fragility Hip Fracture Surgery: Halves Transfusion; Beyond Two Doses Adds Little

Davis S, Solomito MJ, McCracken C, Kumar M. The influence of multiple doses of intravenous tranexamic acid on transfusions and complications in the treatment of fragility hip fractures. J Orthop Trauma. 2026 (epub 9 September). doi:10.1097/BOT.0000000000003274. PMID: 42714041. Single-centre retrospective cohort, n=1,691 (no TXA 632, single dose 551, multiple doses 508). Transfusion 31.8% with no TXA vs 15.9% single dose vs 14.2% multiple doses (p<0.001). VTE was lowest with a single dose (0.9% vs 2.7% in both other groups; p=0.040); 1-year mortality did not differ. Regression suggested no further reduction beyond two doses. Non-randomised dosing by institutional protocol limits causal inference.

• 31.8% → 15.9% TRANSFUSION, NONE VS SINGLE DOSE
• 0.9% vs 2.7% VTE, SINGLE VS NONE/MULTIPLE
• n=1,691 FRAGILITY HIP FRACTURES

INFORMING PRACTICE FRCS

Rib Fixation in Patients With TBI: Lower Adjusted Mortality in Focal and Diffuse TBI Phenotypes (TQIP)

Zangbar B, Peisepar M, Mehta R, et al. Rib fixation still helps: surgical stabilization of rib fractures in traumatic brain injury, a TQIP study. J Trauma Acute Care Surg. 2026 (epub 10 September). doi:10.1097/TA.0000000000005171. PMID: 42721363. TQIP 2017–2023: 73,965 adults with head and thoracic AIS ≥3 and ≥3 rib fractures; 3.3% had SSRF and 12.8% died. SSRF was associated with lower odds of death in focal TBI (OR 0.262, 95% CI 0.206–0.328) and diffuse TBI (phenotype-specific OR 0.058), with non-significant interactions for mixed and concussion-only phenotypes; no statistically significant association with pulmonary complications (OR 1.23, p=0.073) or ventilator days; more tracheostomy (OR 2.50). Immortal time and selection bias (patients well enough for theatre) almost certainly inflate the mortality association.

5 — NEUROTRAUMA & BURNS

INFORMING PRACTICE FINAL FRCA

Early Hyperosmolar Therapy (Within 3 Hours) in Severe TBI: No Fewer Operations, Shorter Ventilation

Ahmed N, Kuo YH. Association of early hyperosmolar therapy and operative interventions in severe traumatic brain injury. Injury. 2026;57(11):113671. doi:10.1016/j.injury.2026.113671. PMID: 42784910. TQIP 2019–2023, 174 propensity-matched pairs with GCS ≤8: early (≤3 h) vs later hyperosmolar therapy. Operative intervention 13.8% vs 20.1% (p=0.161) and mortality 37.4% vs 31.6% (p=0.295) did not differ; ICU days (6 vs 8) and ventilator days (4 vs 5) were shorter with early therapy. Small matched sample and unmeasured indication for therapy limit interpretation.

INFORMING PRACTICE PAEDS

Paediatric Burns: Age-Specific TBSA Thresholds for ICU, Surgery and Infection

Hilewitz D, Har-Shai L, Keller A, et al. Age-specific TBSA thresholds for pediatric burn complications: a 13-year single-center inpatient retrospective cohort. Injury. 2026;57(11):113683. doi:10.1016/j.injury.2026.113683. PMID: 42731144. 942 children admitted to an Israeli tertiary paediatric centre (2012–2025; mean age 4.6, mean TBSA 5.0%, scalds 74.5%). Event rates: fever 29.0%, ICU transfer 4.4%, surgery 7.7%, infection 5.2%. ICU transfer and surgery rarely occurred without fever. The authors suggest earlier ICU consideration at about 8–10% adjusted TBSA in toddlers and about 15% in school-age children and adolescents, with depth- and site-driven surgical review (hands, joints, perineum, buttocks). Single-centre retrospective derivation; thresholds need testing in other populations.

UK practice: Referral remains governed by the National Burn Care Referral Guidance; these thresholds may help in planning the level of care, not in deciding on referral.

INFORMING PRACTICE PAEDS

Procedural Sedation for Paediatric Burn Dressings: 13% Adverse Events (Mostly Transient Respiratory), No Serious Events

Tumberger J, Ganatra H, Burns A, et al. Safety and adverse event profile of procedural sedation for pediatric burn wound care. J Burn Care Res. 2026 (epub 16 September). doi:10.1093/jbcr/irag165. PMID: 42747383. 626 intensivist-led sedations in 208 children (median age 3, median TBSA 5%) at a US PICU (2016–2025). Adverse events 13.1%, mainly desaturation (9.1%) and airway obstruction (8.1%); no unplanned intubations or deaths. Propofol (OR 5.10) and ketamine (OR 2.64) independently predicted adverse events.

6 — MASS CASUALTY & MAJOR INCIDENT

MCI UK

JESIP Responds to a Prevention of Future Deaths Report: JESIP and ETHANE Apply Whenever Two or More Agencies Respond

Joint Emergency Services Interoperability Programme. Response to Prevention of Future Deaths report 2026-0345 (letter dated 14 August 2026, published by the Judiciary). judiciary.uk. The coroner’s concern, in the Prevention of Future Deaths report concerning Miss Saffron Hannabel Wednesday Cole-Nottage, was that there had been insufficient or no consideration of applying JESIP (including the ETHANE message format) in a single-casualty incident with a multi-agency response, with the exception of the Fire Service. JESIP’s response: a revised 6-hour JESIP Interoperability Leadership Training course (launched 27 July 2026) for operational and tactical commanders, stressing that JESIP and ETHANE are not limited to major incidents and should be used whenever two or more agencies respond; strategic commanders to attend the College of Policing MAGIC course; short videos on M/ETHANE messaging and on each service’s capabilities; and a free JESIP app for constructing and sending M/ETHANE messages.

UK practice: Hospital trauma and EPRR leads should make sure that receiving teams recognise ETHANE messages from ambulance and fire services in multi-agency single-casualty incidents, not only in declared major incidents.

MCI INFORMING PRACTICE

Blast vs Blunt Trauma: Blast Patients Have Three-Fold Higher Odds of High Institutional Resource Use, Across ISS Strata

Quint E, Barsky G, Osyntsov A, Replyanski I, Shaked G. The burden of blast injuries on a level I trauma center: a comparative analysis of blast versus blunt trauma. Eur J Trauma Emerg Surg. 2026;52(1):300. doi:10.1007/s00068-026-03356-5. PMID: 42803783. Israeli level I centre: 321 blast patients vs 1,481 propensity-matched blunt controls (age, sex, ISS). High institutional resource burden 78.2% vs 51.2% (OR 3.42, 95% CI 2.59–4.51). Blast predicted shock-room triage (OR 10.60), urgent surgery (OR 7.49), three or more operations (OR 12.40), MTP activation (OR 11.68) and ICU admission (OR 5.54), in both ISS <16 and ≥16 strata. Matching on ISS did not remove the difference, which matters for surge planning.

UK practice: In MTC major incident plans, scale theatre, ICU and blood requirements for blast casualties above what ISS-based estimates would suggest.

MCI INFORMING PRACTICE

Pretriage Mislabelling at an Advanced Medical Post Delays Critical Interventions: Full-Scale Simulation at the World Economic Forum

Walter M, Thiel S, Junge H, et al. Impact of inaccurate pretriage labeling at Advanced Medical Post entry on time-critical care processes: a pilot simulation study. Disaster Med Public Health Prep. 2026;20:e166. PMID: 42808144. doi:10.1017/dmp.2026.10443. Two full-scale exercises of the AMP deployed at WEF 2026. In 4 of 5 comparisons, red patients mislabelled yellow had longer time to the first critical action (delays of 5 to 24 minutes); two crossed deterioration thresholds, and one further mislabelled patient reached the scripted death threshold. No correctly labelled red patient deteriorated. Only six paired observations, so this is hypothesis-generating, but it reinforces continuous re-triage (sieve then sort) at casualty clearing.

7 — PAEDIATRIC & SPECIAL POPULATIONS

INFORMING PRACTICE PAEDS FINAL FRCA

Paediatric Haemodynamic Instability: Mortality-Linked SBP Thresholds 15–30 mmHg Higher Than PALS Hypotension

Annesi CA, Acharya P, Griffin R, et al. Data-driven re-evaluation of hemodynamic instability in the pediatric trauma population. J Am Coll Surg. 2026 (epub 9 September). doi:10.1097/XCS.0000000000002112. PMID: 42714053. TQIP 2018–2023, 233,490 injured children aged 1–15. Optimal mortality-associated SBP thresholds were consistently 15–30 mmHg higher than PALS hypotension definitions; heart rate thresholds differed by 0–30 beats/min; derived shock index thresholds closely matched SIPA. The largest divergence was in children aged 1–2.

• n=233,490 INJURED CHILDREN
• +15–30 mmHg SBP THRESHOLDS VS PALS
• SIPA VALIDATED BY DERIVED SI

Appraisal: Youden-optimised thresholds trade sensitivity against specificity, and US registry data may not transfer directly to UK children. Even so, the message that hypotension is a late sign in injured children is consistent with APLS teaching.

UK practice: Do not wait for PALS-defined hypotension before activating paediatric major haemorrhage protocols; shock index adjusted for age (SIPA) is a useful adjunct.

INFORMING PRACTICE PAEDS

VTE After Severe Paediatric TBI: 7% Pooled Frequency, 20% With Central Lines (SR/MA)

Hoffmann I, Chit M, Mayeden S, et al. Venous thromboembolism in pediatric traumatic brain injury: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2026 (epub 15 September). doi:10.1097/TA.0000000000005170. PMID: 42743555. 29 studies; 20 in severe TBI (n=64,215, mean age 14.1) pooled: VTE frequency 7% (95% CI 4.4–10.2%), 20% with central venous lines. Risk factors included injury severity and multimodality TBI treatment. Registry-based data and inconsistent surveillance may underestimate the true rate, and heterogeneity in study designs limits interpretation.

• 7% POOLED VTE FREQUENCY
• 20% WITH CENTRAL VENOUS LINES
• n=64,215 SEVERE PAEDIATRIC TBI

UK practice: Assess VTE risk in adolescents with severe TBI, especially those with central lines, and agree local chemoprophylaxis criteria with neurosurgery.

8 — QUICK HITS

Pre-injury anticoagulation, ages 40–60 (TraumaRegister DGU, n=64,215) 6.7% on antithrombotics; more coagulopathy, but matched mortality 6.5% vs 6.2%.

Eur J Trauma Emerg Surg 2026. PMID: 42709220

Female sex and traumatic shock (NTDB, n=109,819) Female sex associated with lower mortality (aOR 0.86), largest at age 55 or over; hypothesis-generating.

J Am Coll Surg 2026. PMID: 42803444

IR vs surgery for high-grade blunt renal trauma (TQIP) IR associated with lower in-hospital mortality in stable (aOR 0.210) and unstable patients; selection bias likely.

Injury 2026. PMID: 42691890

Prehospital transfusion need, Paris region 19.7% of included severe trauma patients met ABC ≥2 with prehospital time over 20 minutes.

Injury 2026. PMID: 42727312

MCI triage reference standards (scoping review) Of 60 sources, only 5 used real MCI data; time windows were reported in only 40%.

Prehosp Disaster Med 2026. doi:10.1017/S1049023X2610908X

Oral ketamine before burn dressings (n=52) Opioid use fell from a median of 225 to 180 mg OME (p=0.008); midazolam unchanged.

J Burn Care Res 2026. doi:10.1093/jbcr/irag159

CORE REVISION — ISSUE 7 — FRCS / FINAL FRCA

Major Burns: Assessment, Resuscitation, Referral and Escharotomy

The first 24 hours in the ED, theatre and ICU

Exam goal: Estimate burn size, start and titrate fluid resuscitation, recognise inhalation injury, know UK referral criteria and the indications for escharotomy.

1. ESTIMATING TBSA

2. FLUID RESUSCITATION

3. AIRWAY, INHALATION AND TOXICITY

4. ESCHAROTOMY AND REFERRAL

FRCS / Final FRCA focus: (1) Lund and Browder for children; do not count erythema. (2) Parkland is a starting point; titrate to urine output and watch for fluid creep. (3) Intubate early when the airway is threatened, with an uncut tube. (4) Suxamethonium is safe only in the first 24 h. (5) Escharotomy for circumferential full-thickness burns impairing perfusion or ventilation.

ACTION POINTS

• Blood stock: Brief the trauma team and lab on NHSBT O D-negative Pre-Amber status; switch to group-specific blood promptly.
• Colorectal trauma: Align damage control laparotomy pathways with the WSES recommendations; stop prophylactic antibiotics at 24 hours.
• Thoracotomy governance: Check that a checklist, SOP, debrief and audit process exists for every resuscitative thoracotomy.
• Hoists and slings: Confirm trauma ward compliance with NatPSA/2026/005.
• Orthopaedic FSNs: Theatre stores to action the September notices (Calcanail screw, Acu-Loc 2 plate, Heraeus PALACOS and COPAL cements).
• Open fractures: Audit time to antibiotics against the 1-hour BOAST standard.
• Paediatric shock: Do not wait for PALS hypotension; use SIPA and clinical signs to trigger the major haemorrhage protocol.
• Major incident: Make sure ED and trauma teams recognise ETHANE messages in multi-agency single-casualty incidents.

TRIALS TO WATCH

RECENTLY REPORTED

Salovum TBI Phase II RCT, Brain September 2026 (this issue); multicentre trials needed.

RECRUITING / ONGOING

EVITA Running at BHH.

NEEDED

Early plasma in TBI RCTs with standardised timing, dose and indications (very low-certainty evidence at present).

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. Major Trauma Evidence Rundown — October 2026 — Surgery & Critical Care · UK Edition Published by EM Evidence. For clinical use only — verify against local guidelines before implementing changes in practice. Feedback form · emevidence.org · emevidence999@gmail.com