Blunt ADrenal Gland injUrY in major trauma. BAD GUY project

The Blunt ADrenal Gland injUrY (BAD GUY) project is a structured, multi-phase research program designed to clarify the epidemiology, clinical significance, and prognostic implications of blunt adrenal gland injury (BAGI) in major trauma. Given the increasing detection of adrenal injuries with modern computed tomography and the absence of standardized management or prognostic frameworks, the project aimed to determine whether BAGI represents an independent determinant of adverse outcomes or primarily a marker of overall trauma severity . The first phase consisted of a systematic review and meta-analysis conducted according to PRISMA and AMSTAR guidelines, registered on PROSPERO. Eight retrospective studies encompassing over 379,000 trauma patients were analyzed. BAGI was consistently associated with higher Injury Severity Scores, supporting its role as a marker of high-energy trauma. However, no robust independent association with in-hospital mortality or length of stay was demonstrated after sensitivity analyses, and the certainty of evidence ranged from moderate to low. A major gap identified was the lack of standardized adrenal injury grading and limited evaluation of adrenal insufficiency in trauma populations . The second phase addressed these gaps through a multicenter European retrospective cohort study involving nine trauma centers in Italy and Spain and nearly 2,000 patients with blunt thoraco-abdominal trauma. Using propensity-score matching, the study showed that BAGI was not independently associated with increased mortality or overall injury severity but clustered with complex thoracic and abdominal solid-organ injuries and higher utilization of angiography and interventional procedures. Stratification by Organ Injury Scale (OIS) demonstrated a graded relationship between adrenal injury severity and physiological derangement, transfusion requirements, and operative burden, while laterality analyses revealed distinct anatomical and resource-use patterns . Overall, the BAD GUY project demonstrates that BAGI should not be regarded as a benign incidental finding, nor as an isolated prognostic determinant. Instead, its detection refines trauma severity assessment by signaling injury complexity and resource needs. The findings support the adoption of standardized adrenal injury grading, systematic reporting of laterality, and integration of endocrine evaluation in future prospective, multicenter trauma research.