Triple Negative and Trouble: Management and Outcomes of Hypotensive Blunt Trauma Patients With Negative Chest X-Ray,...

BackgroundDuring initial trauma assessment, chest x-ray (CXR), pelvis x-ray (PXR), and Focused Assessments with Sonography for Trauma (FAST) are standard imaging adjuncts in blunt trauma. Hypotensive patients with negative CXR/PXR/FAST results "triple negative" present diagnostic challenges. The aim of this study was to characterize injury patterns, management strategies, and outcomes in this high-risk cohort.MethodsThis is a retrospective cohort study (2015-2024) at an urban Level 1 trauma center. Blunt trauma patients aged ≥16 years presenting with systolic blood pressure<90 mmHg and negative CXR/PXR/FAST results were included. Negative CXR/PXR results were defined by consensus review from two trauma surgeons and a trauma radiologist, who determined whether the imaging results could explain hemodynamic instability. Descriptive analyses evaluated etiologies of hypotension, diagnostic pathways, interventions, and outcomes.ResultsA total of 73 patients met inclusion criteria (median age: 42 years, 69.9% male). Blood products were administered in 65.7%, with massive transfusion protocol activated in 13.7%; 17.8% required vasopressors in the Emergency Department. Following initial evaluation, 93.2% underwent computed tomography, while two proceeded directly to the operating room, and one died following resuscitative thoracotomy. Common injury patterns were hemorrhage from extremity injuries, high spinal cord injuries, abdominal solid organ injuries, and severe traumatic brain injuries. Overall, 21.9% required emergent operative and 11.0% required emergent endovascular intervention. Mortality was 5.5%, with all deaths due to severe neurologic injury.ConclusionDespite negative initial adjunct imaging, hypotensive blunt trauma patients frequently harbor injuries requiring emergent operative or endovascular intervention, with hemorrhagic and neurologic injuries among the most common causes.