Background Two decades ago, hypotensive trauma patients requiring emergent laparotomy had a 40% mortality. In the interim, multiple interventions to decrease hemorrhage-related mortality have been implemented but few have any documented evidence of change in outcomes for patients requiring emergent laparotomy. The purpose of this study was to determine current mortality rates for patients undergoing emergent trauma laparotomy. Methods A retrospective cohort of all adult, emergent trauma laparotomies performed in 2012–2013 at 12 Level I trauma centers was reviewed. Emergent trauma laparotomy was defined as emergency department (ED) admission to surgical start time in ≤90 minutes. Hypotension was defined as arrival ED systolic blood pressure (SBP) ≤90 mmHg. Cause and time to death was also determined. Continuous data are presented as median [IQR]. Results 1,706 patients underwent emergent trauma laparotomy. The cohort was predominately young (31 years [24, 45]), male (84%), sustained blunt trauma (67%), and with moderate injuries (ISS 19 [10, 33]). The time in ED was 24 minutes [14, 39] and time from ED admission to surgical start was 42 minutes [30, 61]. The most common procedures were enterectomy (23%), hepatorrhaphy (20%), enterorrhaphy (16%), and splenectomy (16%). Damage control laparotomy was utilized in 38% of all patients and 62% of hypotensive patients. The Injury Severity Score for the entire cohort was 19 (IQR 10, 33) and 29 (IQR 18, 41) for the hypotensive group. Mortality for the entire cohort was 21% with 60% of deaths due to hemorrhage. Mortality in the hypotensive group was 46%, with 65% of deaths due to hemorrhage. Conclusion Overall mortality rate of a trauma laparotomy is substantial (21%) with hemorrhage accounting for 60% of the deaths. The mortality rate for hypotensive patients (46%) appears unchanged over the last two decades and is even more concerning, with almost half of patients presenting with a SBP ≤ 90 mmHg dying. Level of Evidence Level III (retrospective epidemiologcal study with up to two negative criteria)