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Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage.We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders.A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02).For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients.Therapeutic/Care Management; Level III.

Despite conflicting data regarding its effectiveness, many massive transfusion protocols (MTPs) include recombinant Factor VIIa (rFVIIa) as an adjunct to hemorrhage control. Over a 3-year period, outcome data for massively transfused patients was compared based on administration of rFVIIa as part of a mature MTP. Of 228 MTP activations, 117 patients were candidates for rFVIIa, and, of these, 39 patients received rFVIIa under the MTP. Comparing patients who received rFVIIa with those who did not based on initial packed red blood cell (PRBC) transfusion requirements, there was no difference in mortality for transfusions ≤ 20 units (25 vs 24%, 24-hour; 25 vs 42%, 30-day) or 21 to 30 units (33 vs 47%, 24-hour; 55 vs 50%, 30-day). For initial requirement ≥ 30 units of PRBCs, 24-hour mortality (26 vs 64%, P = 0.02) was significantly decreased in patients that received rFVIIa (n = 19) compared with those who did not (n = 17). These mortality differences were not maintained at 30 days (68 vs 71%). rFVIIa had minimal clinical impact on outcomes for patients requiring less than 30 units of PRBCs. For patients transfused more than 30 units of PRBCs, differences in 24-hour and 30-day mortality suggest that rFVIIa converted early deaths from exsanguination to late deaths from multiorgan failure.

Supine anteroposterior (AP) chest radiography is an insensitive test for detecting posttraumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) not diagnosed by chest radiography. All previous literature describes the epidemiology of OPTX in patients with blunt polytrauma. Our goal was to identify the frequency of OPTXs in patients with penetrating trauma.All patients with penetrating trauma admitted over a 10-year period to Grady Memorial Hospital with a PTX were identified. We reviewed patients' thoracoabdominal CT scans and corresponding chest radiographs.Records for 1121 (20%) patients with a PTX (penetrating mechanism) were audited; CT imaging was available for 146 (13%) patients. Of these, 127 (87%) had undergone upright chest radiography. The remainder (19 patients) had a supine AP chest radiograph. Fifteen (79%) of the PTXs detected on supine AP chest radiographs were occult. Only 10 (8%) were occult when an upright chest radiograph was used (p0.001). Posttraumatic PTXs were occult on chest radiographs in 17% (25/146) of patients. Fourteen (56%) patients with OPTXs underwent tube thoracostomy, compared with 95% (115/121) of patients with overt PTXs (p0.001).Up to 17% of all PTXs in patients injured by penetrating mechanisms will be missed by standard trauma chest radiographs. This increases to nearly 80% with supine AP chest radiographs. Upright chest radiography detects 92% of all PTXs and is available to most patients without spinal trauma. The frequency of tube thoracostomy use in patients with overt PTXs is significantly higher than for OPTXs in blunt and penetrating trauma.

Trauma with resultant hypovolemic shock remains both prevalent and difficult to treat. Standard strategies using volume resuscitation and catecholamine support have historically yielded poor results. Vasopressin has emerged as a possible pharmacologic adjunct, particularly in patients with shock refractory to the administration of fluids and catecholamines. Much of the data regarding vasopressin is extrapolated from its usefulness in cases of nonhypovolemic human shock, which are supported by convincing animal studies. It is true that humans show a deficiency in vasopressin minutes after significant hemorrhage that can respond to administration of exogenous vasopressin. When given in physiological dosing regimens, vasopressin appears to be a safe adjunct to other therapy. Definite recommendations regarding indications for use, recommended dose, and long-term outcome in patients with hemorrhagic shock await a much needed prospective, randomized, controlled trial.

Temporary intravascular shunts (TIVS) are synthetic intraluminal conduits that maintain arterial and/or venous blood flow. This technique can be used for: 1) replantation; 2) open extremity fractures with extensive soft tissue and arterial injuries; or 3) damage control (extremity/truncal). The literature defining TIVS is composed exclusively of small case series (primarily penetrating injuries). Our goal was to identify the injured population who actually undergoes TIVS using the National Trauma Data Bank (2001 to 2005). TIVS were placed in 395 patients (mean Injury Severity Score = 26; initial hemodynamic instability = 24%; mean based deficit = -7.2; mortality = 14%). Blunt mechanisms caused 64 per cent (251 of 395) of cases. Penetrating injuries were primarily gunshot wounds (97%). Concurrent severe extremity fractures and/or soft tissue defects were present in 185 (74%) blunt-injured patients. Only six of 111 centers performing TIVS used this technique five or more times. Only three centers used TIVS more than 10 times. The volume of TIVS use was similar across the study period (P0.05). TIVS is primarily used in blunt motor vehicle collision trauma with concurrent severe extremity fractures and soft tissue injuries. This provides distal perfusion while surgeons assess/fixate the limb. TIVS are placed relatively uncommonly by a large number of trauma centers with a few hospitals using them much more frequently for penetrating injuries.

Historically, hepatic portal venous gas (HPVG) seen on abdominal radiographic examination indicated serious intra-abdominal pathology requiring urgent operative intervention. The mortality attributed to HPVG is associated closely with its causative source rather than a direct effect of the presence of venous air and, therefore, the finding should be correlated with a careful clinical examination before any therapeutic endeavor. Fourteen cases of HPVG associated with blunt trauma have been reported over the past 20 years, and only half of these have resulted in surgery. We report the case of a 24-year-old woman who presented with no abdominal pathology other than HPVG after a severe motor vehicle crash. She was managed nonoperatively and made a successful recovery.

Background In 2002, our institution published a 5-year retrospective review of 10 patients who developed secondary extremity compartment syndrome (SECS) with a mortality rate of 70%. Since then, we have aggressively screened for the development of SECS in high-risk patients. We postulate that awareness of SECS and vigilant monitoring for its development would result in earlier diagnosis and treatment and improved outcome. Methods Retrospective review of all patients at a level I trauma center developing SECS from 2002 to 2006. Data collected included demographics, mechanism of injury, injury complex, blood transfused prior to development of SECS, affected extremities, creatinine, creatine phosphokinase, management, and outcome. Results Seventeen of 11,468 trauma patients (.148%) developed SECS. Mean admission hematocrit was 31.7 ± 8.9, mean admission base deficit was −13.3, mean worst base deficit was −17.8, and average Injury Severity Score was 36.3 ± 16.6. Patients received 20.9 ± 11.0 units of blood and 24.6 ± 14 L of crystalloid prior to the development of SECS. Average time from admission to diagnosis of the SECS was 32.6 hours. Acute renal failure developed in 6 (35%) patients; 4 required dialysis, and 3 died. The number of affected extremities ranged from 1 to 4. Of the 46 affected extremities, 39 were salvaged and 7 required amputation. Mortality was 35.3%. Conclusions SECS is an uncommon, but devastating complication in severely injured patients with hypotension undergoing massive transfusion, and developing systemic inflammatory response syndrome. Vigilance increases detection. While the overall mortality was reduced by half, patients requiring dialysis have a 75% mortality.