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IMPORTANCE: In-hospital administration of tranexamic acid after injury improves outcomes in patients at risk for hemorrhage. Data demonstrating the benefit and safety of the pragmatic use of tranexamic acid in the prehospital phase of care are lacking for these patients. OBJECTIVE: To assess the effectiveness and safety of tranexamic acid administered before hospitalization compared with placebo in injured patients at risk for hemorrhage. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized clinical trial included injured patients with prehospital hypotension (systolic blood pressure ≤90 mm Hg) or tachycardia (heart rate ≥110/min) before arrival at 1 of 4 US level 1 trauma centers, within an estimated 2 hours of injury, from May 1, 2015, through October 31, 2019. INTERVENTIONS: Patients received 1 g of tranexamic acid before hospitalization (447 patients) or placebo (456 patients) infused for 10 minutes in 100 mL of saline. The randomization scheme used prehospital and in-hospital phase assignments, and patients administered tranexamic acid were allocated to abbreviated, standard, and repeat bolus dosing regimens on trauma center arrival. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day all-cause mortality. RESULTS: In all, 927 patients (mean [SD] age, 42 [18] years; 686 [74.0%] male) were eligible for prehospital enrollment (460 randomized to tranexamic acid intervention; 467 to placebo intervention). After exclusions, the intention-to-treat study cohort comprised 903 patients: 447 in the tranexamic acid arm and 456 in the placebo arm. Mortality at 30 days was 8.1% in patients receiving tranexamic acid compared with 9.9% in patients receiving placebo (difference, –1.8%; 95% CI, –5.6% to 1.9%; P = .17). Results of Cox proportional hazards regression analysis, accounting for site, verified that randomization to tranexamic acid was not associated with a significant reduction in 30-day mortality (hazard ratio, 0.81; 95% CI, 0.59-1.11, P = .18). Prespecified dosing regimens and post-hoc subgroup analyses found that prehospital tranexamic acid were associated with significantly lower 30-day mortality. When comparing tranexamic acid effect stratified by time to treatment and qualifying shock severity in a post hoc comparison, 30-day mortality was lower when tranexamic acid was administered within 1 hour of injury (4.6% vs 7.6%; difference, −3.0%; 95% CI, −5.7% to −0.3%; P

Background The serological safety of transfusing ≤4 units of low titer group O whole blood (LTOWB) in civilian trauma patients has been demonstrated. This study investigated clinical outcomes of LTOWB recipients compared to patients who received only conventional blood components during their resuscitation. Study design and methods A retrospective analysis of trauma patients' medical records who received LTOWB during the first 24 hours of their admission was performed. Using a 12-parameter propensity matching strategy, LTOWB recipients were matched to other patients who received at least one red blood cell (RBC) unit during their first 24 hours of admission but not LTOWB. The primary outcomes were mortality and blood use. Results A total of 135 patients who received LTOWB (median 2 units) were matched to 135 patients who received conventional components. There were no significant differences in the matching parameters between the groups. There were no significant differences in outcomes between the conventional component and LTOWB groups: median (interquartile range) in-hospital mortality, 24.4% vs. 18.5% (respectively, p = 0.24); 24-hour mortality, 12.6% vs. 8.9% (respectively, p = 0.33). The hospital and intensive care unit lengths of stay were not significantly different between groups. The median number of RBC units transfused, including the contribution from the LTOWB, was not significantly different between the groups. The time to normalization of elevated plasma lactate levels tended to be shorter among the LTOWB recipients compared to the conventional component recipients (median 8.1 [3.7-15.4] hr vs. 13.2 [4.4-26.8] hr, respectively, p = 0.05). Conclusion The LTOWB recipients had similar clinical outcomes compared to recipients of conventional component therapy.

Background After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduc...

OBJECTIVEBlunt cerebrovascular injuries (BCVIs) following trauma carry risk for morbidity and mortality. Since patients with BCVI are often asymptomatic at presentation and neurological sequelae often occur within 72 hours, timely diagnosis is essential. Multidetector CT angiography (CTA) has been shown to be a noninvasive, cost-effective, reliable means of screening; however, the false-positive rate of CTA in diagnosing patients with BCVI represents a key drawback. Therefore, the authors assessed the role of DSA in the screening of BCVI when utilizing CTA as the initial screening modality.METHODSThe authors performed a retrospective analysis of patients who experienced BCVI between 2013 and 2015 at 2 Level I trauma centers. All patients underwent CTA screening for BCVI according to the updated Denver Screening Criteria. Patients who were diagnosed with BCVI on CTA underwent confirmatory digital subtraction angiography (DSA). Patient demographics, screening indication, BCVI grade on CTA and DSA, and laboratory values were collected. Comparison of false-positive rates stratified by BCVI grade on CTA was performed using the chi-square test.RESULTSA total of 140 patients (64% males, mean age 50 years) with 156 cerebrovascular blunt injuries to the carotid and/or vertebral arteries were identified. After comparison with DSA findings, CTA findings were incorrect in 61.5% of vessels studied, and the overall CTA false-positive rates were 47.4% of vessels studied and 47.9% of patients screened. The positive predictive value (PPV) for CTA was higher among worse BCVI subtypes on initial imaging (PPV 76% and 97%, for BCVI Grades II and IV, respectively) compared with Grade I injuries (PPV 30%, p < 0.001).CONCLUSIONSIn the current series, multidetector CTA as a screening test for blunt cerebrovascular injury had a high-false positive rate, especially in patients with Grade I BCVI. Given a false-positive rate of 47.9% with an estimated average of 132 patients per year screening positive for BCVI with CTA, approximately 63 patients per year would potentially be treated unnecessarily with antithrombotic therapy at a busy United States Level I trauma center. The authors’ data support the use of DSA after positive findings on CTA in patients with suspected BCVI. DSA as an adjunctive test in patients with positive CTA findings allows for increased diagnostic accuracy in correctly diagnosing BCVI while minimizing risk from unnecessary antithrombotic therapy in polytrauma patients.

BACKGROUND The use of cold-stored low-titer group O whole blood (LTOWB) for civilian trauma patients is gaining popularity. However, hemolysis might occur among non-group O recipients. This study evaluated the serologic safety of transfusing up to 4 units of LTOWB. STUDY DESIGN AND METHODS Hypotensive male and at least 50-year-old female trauma patients who received leukoreduced, uncrossmatched, group O+, low-titer (

Building on the successful military experience, interest has been rekindled in transfusing whole blood (WB) early in the resuscitation of traumatically injured civilians, often before their ABO group is known. WB efficiently provides treatment for shock and coagulopathy, as well as platelet hemostatic function, to patients losing large volumes of blood. Unlike group O uncrossmatched red blood cells (RBCs), group O WB contains a substantial amount of plasma, which is incompatible with the RBCs of all non-group O recipients. Thus, when implementing a WB program, it is important to decide how to mitigate the risk of immune-mediated hemolysis. Other questions that a hospital needs to answer before implementing a WB program include determining which patients will be eligible for this product, how many units eligible patients can receive, for how long it should be stored and under what conditions, and how to monitor for adverse events. The donor center needs to consider if the WB should be leukoreduced, how to comply with the AABB's transfusion-related acute lung injury risk mitigation standard, and into which storage solution it should be collected. This report describes the multidisciplinary approach taken to implementing a civilian WB program at a multihospital health care system in the United States.

Study DesignRetrospective clinical study.PurposeThe purpose of this study was to determine what percentage of patients who underwent nonoperative management of unilateral non-displaced or minimally displaced facet fractures progressed radiographically and to determine what percentage of patients required surgical intervention and to identify risk factors for failure of conservative management.Overview of LiteratureAccording to most commonly used classification systems, unilateral, non-and minimally displaced facet fractures are be amendable to nonoperative management.MethodsA retrospective review of the Trauma Registry of a Level I trauma center was performed to identify all patients diagnosed with a non- or minimally displaced unilateral facet fracture which was managed nonoperatively. Several demographic variables and clinical outcomes were recorded. Using computed tomography scanning and plain radiographs, fracture pattern, listhesis, displacement, angle and percentage of the facet that included the fracture were determined. Radiographic progression was defined as the occurrence of listhesis of more than 10% of the anterior-posterior dimensions of the inferior vertebral body during radiographic follow-up. Failure of conservative management was defined as a patient requiring surgical intervention after initially being managed nonoperatively.ResultsSeventy-four patients were included. Fifteen patients (20%) progressed radiographically. However, only 2 developed radicular symptoms and none developed myelopathy or other catastrophic cord related symptoms. Seven patients (9%) underwent surgery. Indications for surgery included significant radiographic progression and/or radicular symptoms. Risk factors for failure of conservative management included presence of radiculopathy at the time of presentation, a higher body mass index, increased Injury Severity Score, greater initial fracture displacement and more than 2 mm of listhesis.ConclusionsPatients with non-displaced or minimally displaced facet fractures who do not have neurological symptoms at the time of presentation can safely be managed conservatively with careful observation and follow-up.

Rib fractures are identified in 10% of all injury victims and are associated with significant morbidity (33%) and mortality (12%). Significant progress has been made in the management of rib fractures over the past few decades, including operative reduction and internal fixation (rib ORIF); however, the subset of patients that would benefit most from this procedure remains ill-defined. The aim of this project was to develop evidence-based recommendations.Population, intervention, comparison, and outcome (PICO) questions were formulated for patients with and without flail chest. Outcomes of interest included mortality, duration of mechanical ventilation (DMV), hospital and intensive care unit (ICU) length of stay (LOS), incidence of pneumonia, need for tracheostomy, and pain control. A systematic review and meta-analysis of currently available evidence was performed per the Grading of Recommendations Assessment, Development, and Evaluation methodology.Twenty-two studies were identified and analyzed. These included 986 patients with flail chest, of whom 334 underwent rib ORIF. Rib ORIF afforded lower mortality; shorter DMV, hospital LOS, and ICU LOS; and lower incidence of pneumonia and need for tracheostomy. The data quality was deemed very low, with only three prospective randomized trials available. Analyses for pain in patients with flail chest and all outcomes in patients with nonflail chest were not feasible due to inadequate data.In adult patients with flail chest, we conditionally recommend rib ORIF to decrease mortality; shorten DMV, hospital LOS, and ICU LOS; and decrease incidence of pneumonia and need for tracheostomy. We cannot offer a recommendation for pain control, or any of the outcomes in patients with nonflail chest with currently available data.Systematic review/meta-analysis, level III.

BACKGROUND Low-titer group O whole blood (LTOWB) is increasingly being used in the civilian trauma setting, although there is a risk of hemolysis. This study evaluated the impact on hemolytic markers following the transfusion of 4 or more units of uncrossmatched LTOWB. METHODS Civilian adult trauma patients who received four or more units of leukoreduced group O+, low-titer (

Retrospective cohort study.Compare a novel two-step algorithm for indicating a computed tomography angiography (CTA) in the setting of a cervical spine fracture with established gold standard criteria.As CTA permits the rapid detection of blunt cerebrovascular injuries (BCVI), screening criteria for its use have broadened. However, more recent work warns of the potential for the overdiagnosis of BCVI, which must be considered with the adoption of broad criteria.A novel two-step metric for indicating CTA screening was compared with the American College of Surgeons guidelines and the expanded Denver Criteria using patients who presented with cervical spine fractures to a tertiary-level 1 trauma center from January 1, 2012 to January 1, 2016. The ability for each metric to identify BCVI and posterior circulation strokes that occurred during this period was assessed.A total of 721 patients with cervical fractures were included, of whom 417 underwent CTAs (57.8%). Sixty-eight BCVIs and seven strokes were diagnosed in this cohort. All algorithms detected an equivalent number of BCVIs (52 with the novel metric, 54 with the ACS and Denver Criteria, P = 0.84) and strokes (7/7, 100% with the novel metric, 6/7, 85.7% with the ACS and Denver Criteria, P = 1.0). However, 63% fewer scans would have been needed with the proposed screening algorithm compared with the ACS or Denver Criteria (261/721, 36.2% of all patients with our criteria vs. 413/721, 57.3% with the ACS standard and 417/721, 57.8%) with the Denver Criteria, P 0.0002 for each).A two-step criterion based on mechanism of injury and patient factors is a potentially useful guide for identifying patients at risk of BCVI and stroke after cervical spine fractures. Further prospective analyses are required prior to widespread clinical adoption.4.

Background Injured patients are at risk for prolonged opioid use after discharge from care. Limited evidence exists regarding how continued opioid use may be related to opioid medication misuse and opioid use disorder (OUD) following injury. This pilot study characterized opioid consumption patterns, health characteristics, and substance use among patients with active prescriptions for opioid medications following injury care. Methods This study was a cross-sectional screening survey combined with medical record review from February 2017 to March 2018 conducted among outpatient trauma and orthopedic surgery clinic patients. Eligible patients were 18–64 years of age, admitted/discharged for an injury or trauma-related orthopedic surgery, returning for clinic follow-up ≤6 months post hospital discharge after the index injury, prescribed opioid pain medication at discharge, and currently taking an opioid medication (from discharge or a separate prescription post discharge). Data collected included demographic, substance use, mental health, and physical health information. Descriptive and univariate statistics were calculated to characterize the population and opioid-related risks. Results Seventy-one participants completed the survey (92% response). Most individuals (≥75%) who screened positive for misuse or OUD reported no nonmedical/illicit opioid use in the year before the index injury. A positive depression screen was associated with a 3.88 times increased likelihood for misuse or OUD (95% confidence interval [CI] = 1.1–13.5). Nonopioid illicit drug use (odds ratio [OR] = 1.89, 95% CI = 1.1–3.4) and opioid craving (OR = 1.29, 95% CI = 1.1–1.5) were also associated with increased likelihood for misuse or OUD. Number of emergency department visits in the 3 years previous to the index injury was associated with a 22% likelihood of being misuse or OUD positive (95% CI = 1.0–1.5). Conclusions Patients with behavioral health concerns and greater emergency department utilization may have heightened risk for experiencing adverse opioid-related outcomes. Future research must further establish these findings and possibly develop protocols to identify patients at risk prior to pain management planning.

BACKGROUND The purpose of massive transfusion protocols (MTPs) is to provide large quantities of blood products rapidly to exsanguinating patients. The expected rates of blood product transfusion and wastage in this setting have not been defined. This study was undertaken to assess the transfusion and wastage rates for bleeding patients requiring emergency issue of blood components at three American Level I trauma centers. STUDY DESIGN AND METHODS Three hospitals participated, all of which are Level I trauma centers that have MTPs in place where uncrossmatched red blood cells (RBCs) can be ordered with or without platelets (PLTs), plasma, and cryoprecipitate. Data on the transfusion, return to blood bank, and wastage rates were recorded on all products issued within 3 hours after MTP activation. RESULTS The majority of products were issued to the emergency department and/or operating room at all three institutions (84%-95%). The percentage of RBCs, plasma, and PLTs transfused during MTPs were 39% to 65%, 43% to 66%, and 75% to 100%, respectively. Wastage rates were comparable for RBCs (0%-9%), plasma (0%-7%), and PLTs (0%-7%). Cryoprecipitate had the highest wastage rates at all three sites (7%-33%). CONCLUSION A large portion of blood products issued during MTPs are not transfused. Some are wasted due to stringent storage requirements and/or limited shelf lives. The optimum ratio of transfused to returned products in these patients is likely to be determined more by clinical need than by transfusion service policy.

SUMMARYBackground/Objectives The safety of administering uncrossmatched, group O, cold-stored, whole blood (cWB) during civilian trauma resuscitation was evaluated. Methods/Materials Male trauma patients with haemorrhage-induced hypotension who received leuko-reduced uncrossmatched group O+, low titre (

BACKGROUND The rate of patient-related clinical adverse events (AEs) associated with the use of intraoperative cell salvage (ICS) was analyzed. STUDY DESIGN AND METHODS The perfusion service and electronic risk management databases in a nine-hospital regional health care system were reviewed over an approximately 11-year period. The number of ICS cases performed during this period and basic patient demographics were also extracted. RESULTS There were 43,198 patients for whom ICS was utilized during the study period. Recovered blood was returned to 33,351 (77.2%) patients. Electronic comments on the ICS procedure were found in 2348 of 33,351 (7.0%) cases. The vast majority of comments (2203/2348, 93.8%) described minor events that did not lead to patient-related AEs such as the surgeon requested higher than normal suction pressure or that no RBCs were returned. Only 144 of 2348 (6.1%) of the comments described procedural or equipment-related events or potential AEs. From these comments two potential AEs were identified: the first was a post-Cesarean section patient who became acutely tachycardic, hypertensive, and dyspneic with rigors. The second was a patient with postpartum hemorrhage who experienced acute dyspnea and hypotension. Both patients were rapidly stabilized and discharged from the hospital shortly thereafter without further complications. It is unclear if these events were caused by ICS reinfusion. No air emboli were reported. The overall rate of patient-related AEs associated with ICS reinfusion was between 0 and 2 per 33,351 (0%-0.006%). CONCLUSIONS The use of ICS is safe with a very low rate of patient-related AEs.

BACKGROUND Massive transfusion practices have undergone several recent developments. We sought to examine institutional practices guiding hemostatic resuscitation in the setting of massive hemorrhage. STUDY DESIGN AND METHODS A 37-question online survey was sent to American Association for the Surgery of Trauma members. RESULTS A total of 191 surgeons from 125 institutions completed the survey. Level I and II centers composed 70 and 18% of responding sites, respectively. A total of 123 institutions have a massive transfusion protocol (MTP); 54% report having an MTP for less than 5 years. The number of coolers and units of red blood cells, plasma, and platelets are highly variable. Tranexamic acid is part of the MTP at 64% of centers; 26% continue to use recombinant activated Factor VII. MTP activation occurs more than five times per month at 32% of centers. MTPs are utilized for nontrauma patients in 82% of institutions. Point-of-care prothrombin time, international normalized ratio, and partial thromboplastin time testing is utilized in 37% of institutions. Only 9% routinely utilize thromboelastography or rotational thromboelastometry (TEG/ROTEM) within their MTP. Just 7% use a validated scoring system to guide MTP activation. The incorporation of TEG/ROTEM into the MTP is associated with the use of a scoring system in regression analysis (p = 0.024). CONCLUSION Most institutions regularly activate recently implemented MTPs for trauma and nontrauma indications; however, few use validated scoring systems for MTP activation. MTP content is highly variable. Few institutions use TEG, while most have incorporated tranexamic acid into their protocol. The lack of consistent practices underscores the need for outcome-based studies to guide transfusion practices.

Mesenteric hematomas may present as a radiologic finding after blunt abdominal trauma that may be associated with surgically significant mesenteric and/or bowel injury. The question of whether to operate or not to operate on patients with mesenteric hematoma remains a topic of debate, especially with the improved imaging technology. This study sought to identify clinical and radiological characteristics for patient selection for operative management (OM) of mesenteric hematoma. A retrospective review of 33 adults with blunt abdominal trauma and mesenteric hematoma on CT scan (2009–2012) was performed. Patients with other intra-abdominal injuries, penetrating trauma, isolated gastric hematoma, contrast extravasation, extraluminal air, and Glasgow Coma Scale < 14 were excluded. Patients requiring surgical treatment within 24 hours of admission were compared with those who did not using chi-squared test, Fisher's exact test, and t test. Parameters included age, gender, race, Glasgow Coma Scale, vital signs, pain, tenderness, ecchymosis, Injury Severity Score, length of stay, and inhospital mortality. Logistic regression was used to determine positive associations with OM. Of the 33 patients, 19 underwent OM and 14 did not. Both groups were similar at baseline. Regression analysis revealed association for pain [odds ratio (OR) = 9.6, confidence interval (CI) = 1.8–49.9, P < 0.01], tenderness (OR = 32, CI = 4.6–222.2, P < 0.01), and free fluid (OR = 10.3, CI = 1.8–60, P < 0.01) with need for operative intervention. Nonoperative management patients had 100 per cent success rate. Of the OM patients, 100 per cent underwent therapeutic laparotomies. Findings of mesenteric hematoma on CT scan in examinable patients with no abdominal pain, tenderness, or free fluid predict successful nonoperative management.

Background A supervised machine learning algorithm was used to generate decision trees for the prediction of massive transfusion at a Level 1 trauma center. Methods Trauma patients who received at least one unit of RBCs and/or low-titer group O whole blood between January 1, 2015, and December 31, 2017, were included. Massive transfusion was defined as the transfusion of 10 or more units of RBCs and/or low-titer group O whole blood in the first 24 hours of admission. A recursive partitioning algorithm was used to generate two decision trees for prediction of massive transfusion using a training data set (n = 550): the first, MTPitt, was based on demographic and clinical parameters, and the second, MTPitt+Labs, also included laboratory data. Decision tree performance was compared with the Assessment of Blood Consumption score and the Trauma Associated Severe Hemorrhage score. Results The incidence of massive transfusion in the validation data set (n = 199) was 7.5%. The MTPitt decision tree had a higher balanced accuracy (81.4%) and sensitivity (86.7%) compared to an Assessment of Blood Consumption Score of 2 or higher (77.9% and 66.7%, respectively) and a Trauma Associated Severe Hemorrhage score of 9 or higher (75.0% and 73.3%, respectively), although the 95% confidence intervals overlapped. Addition of laboratory data to the MTPitt decision tree (MTPitt+Labs) resulted in a higher specificity and balanced accuracy compared to MTPitt without an increase in sensitivity. Conclusions The MTPitt decisions trees are highly sensitive tools for identifying patients who received a massive transfusion and do not require computational resources to be implemented in the trauma setting.

Traumatic diaphragm injuries (TDI) pose both diagnostic and therapeutic challenges in both the acute and chronic phases. There are no published practice management guidelines to date for TDI. We aim to formulate a practice management guideline for TDI using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.The working group formulated five Patient, Intervention, Comparator, Outcome questions regarding the following topics: (1) diagnostic approach (laparoscopy vs. computed tomography); (2) nonoperative management of penetrating right-sided injuries; (3) surgical approach (abdominal or thoracic) for acute TDI, including (4) the use of laparoscopy; and (5) surgical approach (abdominal or thoracic) for delayed TDI. A systematic review was undertaken and last updated December 2016. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members. Consensus was obtained for each recommendation.A total of 56 articles were used to formulate the recommendations. Most studies were retrospective case series with variable reporting of outcomes measures and outcomes frequently not stratified to intervention or comparator. The overall quality of the evidence was very low for all Patient, Intervention, Comparator, Outcomes. Therefore, only conditional recommendations could be made.Recommendations were made in favor of laparoscopy over computed tomography for diagnosis, nonoperative versus operative approach for right-sided penetrating injuries, abdominal versus thoracic approach for acute TDI, and laparoscopy (with the appropriate skill set and resources) versus open approach for isolated TDI. No recommendation could be made for the preferred operative approach for delayed TDI. Very low-quality evidence precluded any strong recommendations. Further study of the diagnostic and therapeutic approaches to TDI is warranted.Guideline; Systematic review, level IV.

Trauma is a leading cause of death and disability in the United States. Although it is generally considered to occur mostly outside of the hospital, traumatic injuries may occur anywhere. Outcomes for patients experiencing major trauma are closely linked to the healthcare response. Appropriate responses to traumatic injuries have been developed over the past 50 years, and are now considered to involve the care of a well-trained trauma team. This team utilizes established protocols to rapidly evaluate and treat injured patients. This chapter discusses the evolution of trauma teams, equipment and supplies, and the primary, secondary, and tertiary surveys used in trauma team response.

To analyze changes in red blood cell (RBC), platelet (PLT), and plasma transfusion volumes 9 years after the implementation of a multifaceted patient blood management (PBM) program across multiple hospitals.Between fiscal years 2007 and 2015, the annual transfusion volumes for seven hospitals in a regional healthcare system were analyzed by hospital, and between 2014 and 2015, by four service lines including emergency department, intensive care unit (ICU), medical/surgical ward, and operating room at each hospital. The number of units of RBCs administered to transfused recipients on the wards and in ICUs was also enumerated.For these seven hospitals combined, there was a 29.9% reduction in the number of RBCs transfused between 2007 and 2015, a 24.8% reduction in plasma units, and a 25.7% reduction in PLT units. The two largest hospitals saw some of the largest reductions in RBC transfusions (40.1, 25.1%), and plasma transfusions (26.1, 33.8%), and one of those hospitals had a 49.5% reduction in PLT transfusions. Smaller-sized hospitals also had reductions in transfusion volumes, while some volumes increased at hospitals when new or expanded clinical services were introduced. The number of RBC units per transfused recipient was generally between 1.5 and 2 units on the wards and slightly higher in the ICUs.Although the overall volume of transfusions has generally decreased at each hospital site over time, the appropriateness of the administered transfusions cannot be evaluated by these data.The system-wide implementation of a PBM program has reduced transfusion volumes.

BACKGROUND Increasingly, cold-stored whole blood (WB) is being considered for the resuscitation of civilian trauma patients. It is unclear whether the WB should be agitated to enhance the function of the platelets (PLTs) or whether agitation will cause RBC damage. STUDY DESIGN AND METHODS WB units were collected by standard procedures using a PLT-sparing inline leukoreduction filter and stored between 1 and 6°C. On Storage Day 3 each unit was divided into 4 subunits that were stored under one of the following conditions for 21 days: unrocked, manually rocked once daily, continuously rocked end over end, or continuously rocked horizontally. From Day 3 to Day 10, hemolysis and the mechanical fragility index (MFI) for RBC injury were measured daily and again on Days 15 and 21 (n = 9-16 units tested each time). On Days 4 and 10, rapid thromboelastogram (rTEG) measurements were performed (n = 8-10 units tested each time). RESULTS Hemolysis and MFI increased significantly between Day 3 and Day 21 (p

SUMMARY Objectives To determine what percentage of red blood cell (RBC) units that were issued to the operating room (OR) were returned unused, and to determine how often all of the RBCs that were issued for a patient were returned unused using the institution's maximum surgical blood ordering schedule (MSBOS) as a guide. Background The MSBOS provides guidelines for blood ordering, but is merely a suggestion for the ordering clinicians. This study examined how closely ordering practices followed the MSBOS, and how often ordered RBCs were actually transfused. Methods For a 4-week period, RBC issue and utilization data were collected on elective surgery patients who were eligible for electronic cross-match at a tertiary care hospital. These data were compared to the MSBOS. Results There were 1350 surgical procedures performed. Of these cases, 439 patients had a type and screen (T&S) performed, and 215/439 (49%) patients had at least 1 RBC issued during their case. To these 215 patients, 742 RBC units were issued and 537/742 (72%) of these units were returned to the blood bank unused. In 152/215 (71%) cases with issued RBCs, all of the RBCs were returned to the blood bank unused. Amongst the surgical categories in this study, the percentage of cases where none of the issued RBCs were transfused ranged from 38 to 93%. Conclusions Significant numbers of RBC units are issued but not transfused during surgery. Involving the surgical team in the blood issuing process and using a data-driven MSBOS may reduce the number of unused units.

Background Positive Focused Assessment with Sonography in Trauma examination and hypotension often indicate urgent surgery. An abdomen/pelvis computed tomography (apCT) may allow less invasive management but the delay may be associated with adverse outcomes. Methods Patients in the Prospective Observational Multicenter Major Trauma Transfusion study with hypotension and a positive Focused Assessment with Sonography in Trauma (HF+) examination who underwent a CT (apCT+) were compared with those who did not. Results Of the 92 HF+ identified, 32 (35%) underwent apCT during initial evaluation and apCT was associated with decreased odds of an emergency operation (odds ratio .11, 95% confidence interval .001 to .116) and increased odds of angiographic intervention (odds ratio 14.3, 95% confidence interval 1.5 to 135). There was no significant difference in 30-day mortality or need for dialysis. Conclusions An apCT in HF+ patients is associated with reduced odds of emergency surgery, but not mortality. Select HF+ patients can safely undergo apCT to obtain clinically useful information.

BACKGROUND: Previous studies of traumatic brain injury (TBI) outcomes in elderly patients on oral antithrombotic (OAT) therapies have yielded conflicting results. Our objective was to examine the effect of premorbid OAT medications on outcomes among elderly TBI patients with intracranial hemorrhage. METHODS: We performed a retrospective analysis of elderly TBI patients (≥65 years) with closed head injury and evidence of brain hemorrhage on computed tomography scan from 2006 to 2010. Patient demographics, injury severity, clinical course, hospital and intensive care unit length of stay, and disposition were collected. Comparison of patients stratified by premorbid OAT use was performed using nonparametric Kruskal-Wallis and Fisher's exact tests. Multivariable logistic regression was used to compare groups and identify predictors of primary outcomes, including mortality, neurosurgical intervention, hemorrhage progression, complications, and infection. RESULTS: A total of 1,552 patients were identified: 543 on aspirin only, 97 on clopidogrel only, 218 on warfarin only, 193 on clopidogrel and aspirin, and 501 on no antithrombotic agent. Blood products were administered to reverse coagulopathy in 77.3% of patients on antithrombotic medications. After adjusting for covariates, including medication reversal, OAT use was associated with increased mortality (p = 0.04). Warfarin use was identified as a key predictor (odds ratio, 2.27; p = 0.05), in contrast to the preinjury use of antiplatelet medications, which was not associated with increased risk of in-hospital death. Rates of neurosurgical intervention differed between groups, with patients on warfarin undergoing intervention more frequently. Survivor subset analysis demonstrated that hemorrhage progression was not associated with preinjury antithrombotic therapy, nor were rates of complication or infection, hospital and intensive care unit lengths of stay, or ventilator days. CONCLUSION: Preinjury use of warfarin, but not antiplatelet medications, influences survival and need for neurosurgical intervention in elderly TBI patients with intracranial hemorrhage; hemorrhage progression and morbidity are not affected. The importance of antithrombotic therapy may lie in its impact on initial injury severity. LEVEL OF EVIDENCE: Epidemiologic study, level III. Language: en

The use of cold-stored low-titer group O whole blood (LTOWB) for civilian trauma patients is gaining popularity. However, hemolysis might occur among non-group O recipients. This study evaluated the serologic safety of transfusing up to 4 units of LTOWB.Hypotensive male and at least 50-year-old female trauma patients who received leukoreduced, uncrossmatched, group O+, low-titer (50 anti-A and anti-B), platelet-replete whole blood during initial resuscitation were included in this prospective, observational study. Biochemical markers of hemolysis were measured on the day of LTOWB receipt (Day 0) and over the next 2 days. Blood product administration in the first 24 hours of admission and reported transfusion-associated adverse events were also reviewed.There were 102 non-group O and 70 group O recipients of 1 to 4 LTOWB units analyzed. The non-group O recipients received a median volume of 600 mL (range, 300-4100 mL) of ABO-incompatible plasma, including the contribution from the LTOWB units. There were no significant differences in median haptoglobin, lactate dehydrogenase, total bilirubin, creatinine, or potassium levels at any time point between the non-group O and group O recipients. There were also no differences in these markers between the subset of 23 non-group O and 14 group O recipients who received 3 or 4 LTOWB units. No transfusion-associated adverse events were reported.Administration of up to 4 units of LTOWB in civilian trauma resuscitation was not associated with clinical or biochemical evidence of hemolysis. Six units per trauma patient are now permitted at these institutions.

Background Previously, a model to predict massive transfusion protocol (MTP) (activation) was derived using a single-institution data set. The PRospective, Observational, Multicenter, Major Trauma Transfusion database was used to externally validate this model's ability to predict both MTP activation and massive transfusion (MT) administration using multiple MT definitions. Methods The app model was used to calculate the predicted probability of MTP activation or MT delivery. The five definitions of MT used were: (1) 10 units packed red blood cells (PRBCs) in 24 hours, (2) Resuscitation Intensity score ≥ 4, (3) critical administration threshold, (4) 4 units PRBCs in 4 hours; and (5) 6 units PRBCs in 6 hours. Receiver operating curves were plotted to compare the predicted probability of MT with observed outcomes. Results Of 1,245 patients in the data set, 297 (24%) met definition 1, 570 (47%) met definition 2, 364 (33%) met definition 3, 599 met definition 4 (49.1%), and 395 met definition 5 (32.4%). Regardless of the outcome (MTP activation or MT administration), the predictive ability of the app model was consistent: when predicting activation of the MTP, the area under the curve for the model was 0.694 and when predicting MT administration, the area under the curve ranged from 0.695 to 0.711. Conclusion Regardless of the definition of MT used, the app model demonstrates moderate ability to predict the need for MT in an external, homogenous population. Importantly, the app allows the model to be iteratively recalibrated ("machine learning") and thus could improve its predictive capability as additional data are accrued. Level of evidence Diagnostic test study/Prognostic study, level III.

Experience with temporary intravascular shunts (TIVS) for vessel injury comes from the military sector and while the indications might be clear in geographically isolated and under resourced war zones, this may be an uncommon scenario in civilian trauma. Data supporting TIVS use in civilian trauma have been extrapolated from the military literature where it demonstrated improved life and limb salvage. Few non-comparative studies from the civilian literature have also revealed similar favorable outcomes. Still, TIVS placement in civilian vascular injuries is uncommon and by some debatable given the absence of clear indications for placement, the potential for TIVS-related complications, the widespread resources for immediate and definitive vascular repair, and the need for curtailing costs and optimizing resources. This article reviews the current evidence and the role of TIVS in contemporary civilian trauma management.

The maximum surgical blood ordering schedule (MSBOS) provides guidelines for pre-operative pre-transfusion testing for elective surgical procedures. This study compared blood ordering and utilization during the period when the MSBOS was created by achieving consensus between the blood bank and the various surgical specialties, and after the introduction of an MSBOS created by using department-specific red blood cell (RBC) transfusion data (data driven MSBOS, dMSBOS).The dMSBOS was created by analyzing 12 months of RBC transfusion data for each procedure across a regional health system. Pre-transfusion testing and the RBC crossmatch:transfusion (C:T) ratios at 8 of the hospitals were compared between the 12 month period before the dMSBOS was introduced, and the 15 months after its introduction.There were significant reductions in the median monthly number of type and screens not associated with RBC crossmatches (10 714-10 061; p 0.0001) and the median number of type and screens associated with RBC crossmatches (10 127-9 349; p = 0.0014) on surgical patients after dMSBOS implementation. There were significant decreases in the median number of monthly RBC units crossmatched (2 981-2 444; p 0.0001) and transfused (890-791; p 0.0001) to surgical patients after implementing the dMSBOS. The overall system-wide C:T ratio trended down after dMSBOS implementation (from 3.34 to 3.17, p = 0.067).Crossmatching fewer RBC units facilitates more efficient management of the blood bank's inventory.The dMSBOS was effective in reducing the extent of unnecessary pre-transfusion testing before surgery and reduced the number of RBCs that were crossmatched for specific patients.

Background The trauma transfusion literature has yet to resolve which is more important for hemorrhaging patients: transfusing plasma and platelets along with red blood cells (RBCs) early in resuscitation or gradually balancing blood product ratios. In a previous report of PROMMTT results, we found 1) plasma and platelet:RBC ratios increased gradually over the 6 hours following admission, and 2) patients achieving ratios >1:2 (relative to ratios

BACKGROUNDThere are few clinical data to guide the use of cryoprecipitate in severely injured trauma patients. Cryoprecipitate is a rich source of fibrinogen and has been associated with improved survival in animal as well as limited human studies. Our objectives were to identify patterns and predic

BACKGROUND: The Focused Assessment with Sonography for Trauma (FAST) examination is an important variable in many retrospective trauma studies. The purpose of this study was to devise an imputation method to overcome missing data for the FAST examination. Owing to variability in patients' injuries and trauma care, these data are unlikely to be missing completely at random, raising concern for validity when analyses exclude patients with missing values. METHODS: Imputation was conducted under a less restrictive, more plausible missing-at-random assumption. Patients with missing FAST examinations had available data on alternate, clinically relevant elements that were strongly associated with FAST results in complete cases, especially when considered jointly. Subjects with missing data (32.7%) were divided into eight mutually exclusive groups based on selected variables that both described the injury and were associated with missing FAST values. Additional variables were selected within each group to classify missing FAST values as positive or negative, and correct FAST examination classification based on these variables was determined for patients with nonmissing FAST values. RESULTS: Severe head/neck injury (odds ratio [OR], 2.04), severe extremity injury (OR, 4.03), severe abdominal injury (OR, 1.94), no injury (OR, 1.94), other abdominal injury (OR, 0.47), other head/neck injury (OR, 0.57), and other extremity injury (OR, 0.45) groups had significant ORs for missing data; the other group's OR was not significant (OR, 0.84). All 407 missing FAST values were imputed, with 109 classified as positive. Correct classification of nonmissing FAST results using the alternate variables was 87.2%. CONCLUSION: Purposeful imputation for missing FAST examinations based on interactions among selected variables assessed by simple stratification may be a useful adjunct to sensitivity analysis in the evaluation of imputation strategies under different missing data mechanisms. This approach has the potential for widespread application in clinical and translational research, and validation is warranted. Language: en

Background Several predictive models have been developed to identify trauma patients who have had severe hemorrhage (SH) and may need a massive transfusion protocol (MTP). However, almost all these models define SH as the transfusion of ≥10 units of red blood cells (RBCs) within 24 hours of ED admission (aka massive transfusion, MT). This definition excludes some patients with SH, especially those who die before a 10th unit of RBCs could be transfused, which calls the validity of these prediction models into question. We show how a latent class model could improve the accuracy of identifying the SH patients.

Introduction Focused assessment with sonography for trauma (FAST) is commonly used to facilitate the timely diagnosis of life-threatening hemorrhage in injured patients. Most patients with positive findings on FAST require laparotomy. Although it is assumed that an increasing time to operation (T-OR) leads to higher mortality, this relationship has not been quantified. This study sought to determine the impact of T-OR on survival in patients with a positive FAST who required emergent laparotomy. Methods We retrospectively analyzed patients from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study who underwent laparotomy within 90 minutes of presentation and had a FAST performed. Cox proportional hazards models including Injury Severity Score (ISS), age, base deficit, and hospital site were created to examine the impact of increasing T-OR on in-hospital survival at 24 hours and 30 days. The impact of time from the performance of the FAST examination to operation (TFAST-OR) on in-hospital mortality was also examined using the same model. Results One hundred fifteen patients met study criteria and had complete data. Increasing T-OR was associated with increased in-hospital mortality at 24 hours (hazard ratio [HR], 1.50 for each 10-minute increase in T-OR; confidence interval [CI], 1.14-1.97; p = 0.003) and 30 days (HR, 1.41; CI, 1.18-2.10; p = 0.002). Increasing TFAST-OR was also associated with higher in-hospital mortality at 24 hours (HR, 1.34; CI, 1.03-1.72; p = 0.03) and 30 days (HR, 1.40; CI, 1.06-1.84; p = 0.02). Conclusion In patients with a positive FAST who required emergent laparotomy, delay in operation was associated with increased early and late in-hospital mortality. Delays in T-OR in trauma patients with a positive FAST should be minimized.

Acute lung injury following trauma resuscitation remains a concern despite recent advances. With the use of the PROMMTT study population, the risk of hypoxemia and potential modifiable risk factors are studied.Patients with survival for 24 hours or greater with at least one intensive care unit day were included in the analysis. Hypoxemia was categorized using the Berlin definition for adult respiratory distress syndrome: none (PaO₂-to-FIO₂ ratio [P/F]300 mm Hg), mild (P/F, 201-300 mm Hg), moderate (P/F, 101-200 mm Hg) or severe (P/F ≤ 100 mm Hg). The cohort was dichotomized into those with none or mild hypoxemia and those with moderate or severe injury. Early resuscitation was defined as that occurring 0 hour to 6 hours from arrival; late resuscitation was defined as that occurring 7 hours to 24 hours. Multivariate logistic regression models were developed controlling for age, sex, mechanisms of injury, arrival physiology, individual Abbreviated Injury Scale (AIS) scores, blood transfusions, and crystalloid administration.Of the patients 58.7% (731 of 1,245) met inclusion criteria. Hypoxemia occurred in 69% (mild, 24%; moderate, 28%; severe, 17%). Mortality was highest (24%) in the severe group. During early resuscitation (0-6 h), logistic regression revealed age (odd ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.04), chest AIS score (OR, 1.31; 95% CI, 1.10-1.57), and intravenously administered crystalloid fluids given in 500 mL increments (OR, 1.12; 95% CI, 1.01-1.25) as predictive of moderate or severe hypoxemia. During late resuscitation, age (OR, 1.02; 95% CI, 1.00-1.04), chest AIS score (OR, 1.33; 95% CI, 1.11-1.59), and crystalloids given during this period (OR, 1.05; 95% CI, 1.01-1.10) were also predictive of moderate-to-severe hypoxemia. Red blood cell, plasma, and platelet transfusions (whether received during early or late resuscitation) failed to demonstrate an increased risk of developing moderate/severe hypoxemia.Severe chest injury, increasing age, and crystalloid-based resuscitation, but not blood transfusions, were associated with increased risk of developing moderate-to-severe hypoxemia following injury.

Missing data are inherent in clinical research and may be especially problematic for trauma studies. This study describes a sensitivity analysis to evaluate the impact of missing data on clinical risk prediction algorithms. Three blood transfusion prediction models were evaluated using an observational trauma data set with valid missing data.The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study included patients requiring one or more unit of red blood cells at 10 participating US Level I trauma centers from July 2009 to October 2010. Physiologic, laboratory, and treatment data were collected prospectively up to 24 hours after hospital admission. Subjects who received 10 or more units of red blood cells within 24 hours of admission were classified as massive transfusion (MT) patients. Correct classification percentages for three MT prediction models were evaluated using complete case analysis and multiple imputation. A sensitivity analysis for missing data was conducted to determine the upper and lower bounds for correct classification percentages.PROMMTT study enrolled 1,245 subjects. MT was received by 297 patients (24%). Missing percentage ranged from 2.2% (heart rate) to 45% (respiratory rate). Proportions of complete cases used in the MT prediction models ranged from 41% to 88%. All models demonstrated similar correct classification percentages using complete case analysis and multiple imputation. In the sensitivity analysis, correct classification upper-lower bound ranges per model were 4%, 10%, and 12%. Predictive accuracy for all models using PROMMTT data was lower than reported in the original data sets.Evaluating the accuracy clinical prediction models with missing data can be misleading, especially with many predictor variables and moderate levels of missingness per variable. The proposed sensitivity analysis describes the influence of missing data on risk prediction algorithms. Reporting upper-lower bounds for percent correct classification may be more informative than multiple imputation, which provided similar results to complete case analysis in this study.

BACKGROUND: The classic definition of massive transfusion, 10 or more units of red blood cells (RBCs) in 24 hours, has never been demonstrated as a valid surrogate for severe hemorrhage and can introduce survival bias. In addition, the definition fails to capture other products that the clinician may have immediately available, and may use, during the initial resuscitation. Assuming that units of resuscitative fluids reflect patient illness, our objective was to identify a rate of resuscitation intensity (RI) that could serve as an early surrogate of sickness for patients with substantial bleeding after injury. METHODS: Adult patients surviving at least 30 minutes after admission and receiving one or more RBCs within 6 hours of admission from 10 US Level 1 trauma centers were enrolled in the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Total fluid units were calculated as the sum of the number of crystalloid units (1 L = 1 U), colloids (0.5 L = 1 U), and blood products (1 RBC = 1 U, 1 plasma = 1 U, 6 pack platelets = 1 U). Univariable and multivariable logistic regressions were used to evaluate associations between RI and 6-hour mortality, adjusting for age, center, penetrating injury, weighted Revised Trauma Score (RTS), and Injury Severity Score (ISS). RESULTS: A total of 1,096 eligible patients received resuscitative fluids within 30 minutes, including 620 transfused with blood products. Despite varying products used, the total fluid RI was similar across all sites (3.2T 2.5 U). Patients who received four or more units of any resuscitative fluid had a 6-hour mortality rate of 14.4% versus 4.5% in patients who received less than 4 U. The adjusted odds ratio of 6-hour mortality for patients receiving 4 U or more within 30 minutes was 2.1 (95% confidence interval, 1.2Y3.5). CONCLUSION: Resuscitation with four or more units of any fluid was significantly associated with 6-hour mortality. This study suggests that early RI regardless of fluid type can be used as a surrogate for sickness and mortality in severely bleeding patients. ( JT rauma Acute Care Surg. 2013;74: S16YS23. Copyright * 2013 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Background The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of "surgical rescue" in the practice of ACS. Methods A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. Results Of 2,410 ACS patients, 320 (13%) required "surgical rescue": most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients ("local"), whereas 38% were referred from another surgical service ("institutional") and 26% referred from another institution ("regional"). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between "local" and "institutional" patients, but hospital length of stay and discharge to home were significantly worse in "institutional" referrals. Conclusion We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the "surgical rescue" of surgical and procedural complications. Level of evidence Epidemiological study, level III; therapeutic/care management study, level IV.

Background Rivaroxaban has gained popularity as an anticoagulant (AC) for stroke prevention in nonvalvular atrial fibrillation (afib) and venous thromboembolism (VTE). Although adverse bleeding events are associated with all AC, lack of point-of-care testing to measure the effect of rivaroxaban in emergent situations has contributed to perceived increased risk among physicians. Methods This study aims to describe a single-center experience with trauma and emergency general surgery (EGS) patients taking rivaroxaban and evaluate outcomes compared with patients taking warfarin using a propensity score analysis. Trauma and EGS patients taking rivaroxaban or warfarin for afib/VTE over a 2-year period were eligible for inclusion and matched for injury/illness severity in a 1:2 ratio using propensity score matching. In a single quaternary referral center, 192 warfarin patients were matched to 96 rivaroxaban patients. Groups were well matched with no significant difference in age/sex, admission systolic blood pressure/heart rate, admission hemoglobin, injury severity score (trauma patients), or need for ICU admission. Conditional logistic regression determined association of AC type with bleeding complications, adjusting for age/sex, AC indication, coagulation laboratory values, antiplatelet medications or other AC, comorbidities, renal impairment, and operative intervention. Primary outcome was bleeding complications, defined as hemorrhage during admission or as a presenting problem. Secondary outcomes included invasive interventions, AC reversal, VTE complications, and mortality. Results There was no difference between rivaroxaban and warfarin for bleeding complications (37% vs. 39%, p = 0.49), VTE complications (4.2% vs. 5.7%, p = 0.44), or mortality (4.2% vs. 5.8%, p = 0.63). Fewer rivaroxaban patients underwent surgical or interventional radiology procedures during admission (32% vs. 43%, p = 0.01), but there was no difference in procedures specifically for bleeding (10% vs. 12% p = 0.68). Rivaroxaban patients less frequently underwent AC reversal (34% vs. 46%, p = 0.01) or received multiple reversal agents (20% vs. 29%, p = 0.02). Regression analysis confirmed AC type was not associated with bleeding complications (rivaroxaban vs. warfarin relative risk 1.02; 95% CI 0.85-1.22, p = 0.85). Conclusion Reversal of rivaroxaban was less common and required fewer agents, whereas bleeding complications and hemostatic interventions do not seem to be different between these AC types. Level of evidence Therapeutic study, level II.

Early predictors of massive transfusion (MT) would prevent undertriage of patients likely to require MT. This study validates triggers using the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study.All enrolled patients in PROMMTT were analyzed. The initial emergency department value for each trigger (international normalized ratio [INR], systolic blood pressure, hemoglobin, base deficit, positive result for Focused Assessment for the Sonography of Trauma examination, heart rate, temperature, and penetrating injury mechanism) was compared for patients receiving MT (≥ 10 U of packed red blood cells in 24 hours) versus no MT. Adjusted odds ratios (ORs) for MT are reported using multiple logistic regression. If all triggers were known, a Massive Transfusion Score (MTS) was created, with 1 point assigned for each met trigger.A total of 1,245 patients were prospectively enrolled with 297 receiving an MT. Data were available for all triggers in 66% of the patients including 67% of the MTs (199 of 297). INR was known in 87% (1,081 of 1,245). All triggers except penetrating injury mechanism and heart rate were valid individual predictors of MT, with INR as the most predictive (adjusted OR, 2.5; 95% confidence interval, 1.7-3.7). For those with all triggers known, a positive INR trigger was seen in 49% receiving MT. Patients with an MTS of less than 2 were unlikely to receive MT (negative predictive value, 89%). If any two triggers were present (MTS ≥ 2), sensitivity for predicting MT was 85%. MT was present in 33% with an MTS of 2 greater compared with 11% of those with MTS of less than 2 (OR, 3.9; 95% confidence interval, 2.6-5.8; p0.0005).Parameters that can be obtained early in the initial emergency department evaluation are valid predictors for determining the likelihood of MT.Diagnostic, level II.

Introduction: An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments. Methods: We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT). Results: Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event. Conclusion: An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.

Introduction Computed tomography (CT) has become an essential tool in the assessment of the stable trauma patient. Intravenous (IV) contrast is commonly relied upon to provide superior image quality, particularly for solid-organ injury. However, a substantial proportion of injured patients have contraindications to IV contrast. Little information exists concerning the repercussions of CT imaging without IV contrast, specifically for splenic injury. Methods We performed a retrospective analysis using data from our trauma registry and chart review as part of a quality improvement project at our institution. All patients with splenic injury, during a 3-year period (2008–2010), where a CT of the abdomen without IV contrast (DRY) early during their admission were selected. All splenic injuries had to have been verified with abdominal CT imaging with IV contrast (CONTRAST) or via intraoperative findings. DRY images were independently read by a single, blinded, radiologist and assessed for parenchymal injury or “suspicious” splenic injury findings and compared with CONTRAST imaging results or intraoperative findings. Results During the time period of the study, 319 patients had documented splenic injury with 44 (14%) patients undergoing DRY imaging, which was also verified by CONTRAST imaging or operative findings. Splenic parenchymal injury was only visualized in 38% of patients DRY patients. “Suspicious” splenic injury radiographic findings were common. When these less-specific findings for splenic injury were incorporated in the radiographic assessment, DRY imaging had more than 93% sensitivity for detecting splenic injury. Conclusion DRY imaging is increasingly being performed after injury and has a low sensitivity in detecting splenic parenchymal injury. However, less-specific radiographic findings suspicious for splenic injury in combination provide high sensitivity for the detection of splenic injury. These results suggest CONTRAST imaging is preferred to detect splenic injury; however, in those patients who have contraindications to IV contrast, DRY imagining may be able to select those who require close monitoring or intervention.

Posttraumatic stress disorder (PTSD) is associated with significant morbidity following injury. The incidence and risk factors for PTSD are not well described in the civilian trauma population. We proposed to screen all trauma patients in the outpatient trauma clinic for acute PTSD symptoms and identify risk factors for PTSD.We prospectively screened 1,386 injured patients who presented for follow-up in trauma clinic (January 2009 to September 2010) using an established PTSD screening test (PTSD Checklist-Civilian, PCL-C). A PCL-C score of ≥35, with a known sensitivity of85% for PTSD, was considered screen-positive (PCL-C-POS). Backward stepwise logistic regression was used to determine independent risk factors for PCL-C-POS.Over 25% of trauma clinic patients met the threshold for positive PTSD screen (PCL-C-POS). The highest incidence (43%) was in patients who sustained assault (blunt or penetrating). Regression analysis revealed that age55 years, female gender, motor vehicle collision, and assaultive mechanism (blunt or penetrating, excluding self-inflicted or accidental injury) were independent predictors of PCL-C-POS status. As the severity of symptoms increased (higher PCL-C scores), the risk associated with assaultive mechanism significantly increased in a dose-response fashion (p0.05).This study confirms the high incidence of acute PTSD symptoms in trauma patients and supports the feasibility of PTSD screening in the outpatient trauma clinic. Among all mechanisms of injury, patients who sustain interpersonal violence are at the highest risk of developing acute PTSD symptoms. These results suggest that PTSD screening in outpatient trauma clinic may allow early detection and referral of patients with PTSD.II.

Background Significant differences in outcomes have been demonstrated between Level I trauma centers. Usually these differences are ascribed to regional or administrative differences, although the influence of variation in clinical practice is rarely considered. This study was undertaken to determine whether differences in early mortality of patients receiving a massive transfusion (MT, ≥ 10 units pf RBCs within 24 hours of admission) persist after adjustment for patient and transfusion practice differences. We hypothesized differences among centers in 24-hour mortality could predominantly be accounted for by differences in transfusion practices as well as patient characteristics. Methods Data were retrospectively collected over a 1-year period from 15 Level I centers on patients receiving an MT. A purposeful variable selection strategy was used to build the final multivariable logistic model to assess differences between centers in 24-hour mortality. Adjusted odds ratios for each center were calculated. Results : There were 550 patients evaluated, but only 443 patients had complete data for the set of variables included in the final model. Unadjusted mortality varied considerably across centers, ranging from 10% to 75%. Multivariable logistic regression identified injury severity score (ISS), abbreviated injury scale (AIS) of the chest, admission base deficit, admission heart rate, and total units of RBC transfused, as well as ratios of plasma:RBC and platelet:RBC to be associated with 24-hour mortality. After adjusting for severity of injury and transfusion, treatment variables between center differences were no longer significant. Conclusions In the defined population of patients receiving an MT, between-center differences in 24-hour mortality may be accounted for by severity of injury as well as transfusion practices.

Computed tomography (CT) has a high sensitivity and specificity for detecting abdominal injuries. Expeditious abdominal imaging in "quasi-stable" patients may prevent negative laparotomy. However, the significance of potential delay to laparotomy secondary to abdominal imaging remains unknown. We sought to analyze whether the use of abdominal CT (ABD CT) in patients with abdominal injury requiring laparotomy results in a significant delay and a higher risk of poor outcome.A retrospective analysis of data from the National Trauma Data Bank (version 7.1) was performed. Inclusion criteria were adult patients (age14 years), a scene admission (nontransfer), hypotension on arrival (emergency department systolic blood pressure90 mm Hg), an abdominal Abbreviated Injury Scale (AIS) score3, and undergoing a laparotomy within 90 minutes of arrival. Patients with severe brain injury (head AIS score3) were excluded. The independent mortality risk associated with a preoperative ABD CT was determined using logistic regression after controlling important confounders.This cohort of patients (n=3,218) was significantly injured with a median Injury Severity Score of 25 ([interquartile range, 16-34]). Patients who underwent ABD CT had similar Glasgow Coma Scale scores, a lower head AIS, longer time delays to the operating room, and a higher crude mortality (45% vs. 30%; p=0.001). Logistic regression revealed that ABD CT was independently associated with more than a 70% higher risk of mortality (odds ratios, 1.71; 95% CI, 1.2-2.2; p0.001). When stratified by injury mechanism, intubation status and whether or not a head CT was performed, the mortality risk remained significantly increased for each subgroup. When the laparotomy was able to occur within 30 minutes of arrival, an ABD CT was independently associated with more than a sevenfold higher risk of mortality (odds ratios, 7.6; p=0.038).Delay secondary to abdominal imaging in patients who require operative intervention results in an independent higher risk of mortality. ABD CT imaging is an important and useful tool after injury; however, these results suggest that delay caused by overreliance on ABD CT may result in poor outcome in specific patients. Clinicians who take care of critically injured patients should be aware of and understand these potential risks.

Background With liberal use of computed tomography in the diagnostic management of trauma patients, incidental findings are common and represent a major patient-care and medical–legal concern. Consequently, we began an initiative to capture, notify, and documentadequately incidental finding events with a dedicated incidental finding coordinator. We hypothesized a dedicated incidental finding coordinator would increase incidental finding capture and promote notification, follow-up, and documentation of incidental finding events. Methods A quality-improvement project to record and follow-up incidental findings postinjury was initiated at our level I trauma center (April 2007–March 2008, prededicated incidental finding). Because of concerns for inadequate documentation of identified incidental finding events, we implemented a dedicated incidental finding coordinator (April 2008–March 2009, postdedicated incidental finding). The dedicated incidental finding coordinator documented incidental findings daily from trauma admission radiology final reads. Incidental findings were divided into 3 groups; category 1: attention prior to discharge; category 2: follow-up with primary doctor within 2 weeks; category 3: no specific follow-up. For category 1 incidental findings, in-hospital consultation of the appropriate service was verified. On discharge, patient notification, follow-up, and documentation of events were confirmed. Certified mail or telephone contact was used to notify either the patient or the primary doctor in those who lacked appropriate notification or documentation. Results Admission rates and incidental finding categories were similar across the 2 time periods. Implementation of a dedicated incidental finding coordinator resulted in more than a 165% increase in incidental finding capture (n = 802 vs n = 302; P < .001). Patient notification was attempted, and appropriate documentation of events was confirmed in 99.8% of patients. Patient notification was verified, and follow-up was initiated in 95.8% of cases. Conclusion The implementation of a dedicated incidental finding coordinator resulted in more than a 2.5-fold higher capture of incidental findings. Dedicated attention to incidental findings resulted in a near complete initiation of patient notification, follow-up, and hospital record documentation of incidental finding events. Inadequate patient notification and follow-up would delay appropriate care and potentially would result in morbidity or even mortality. A dedicated incidental finding coordinator represents a potential solution to this patient-care and medical–legal dilemma.

Agrowing body of literature has emerged providing evidence for the beneficial effects attributable to 3-hydroxy-3-methyl-glut aryl-CoA reductase inhibitors (statins).1 Statins are emerging as one of the most frequently prescribed medications in the elderly population, and they have been shown to be effective in reducing low-density lipoprotein cholesterol levels, resulting in protection from cardiovascular morbidity.2 The use of prehospital statins has been shown to be associated with a reduction in mortality and morbidity in critically ill patients with sepsis.3-9 This has been hypothesized to result not from their cholesterol lowering properties but rather from a so-called “pleiotrophic modulation” of the inflammatory cascade.4,10 Statin use has been shown to bring about an attenuation of isoprenoid synthesis, which enhances endothelial function, provides antithrombotic effects, normalizes platelet aggregation, and results in a significant anti-inflammatory effect.10-12 Despite the high prevalence of statin use and the similarities between the inflammatory host response in septic and injured patients, there remains a paucity of literature, which characterizes the effects of prehospital statin use after injury. There exists only a single observational cohort study demonstrating an independent lower risk of mortality associated with preinjury statin (PIS) use after injury,13 whereas the proposed inflammatory modulating effects of PIS use and their association with the development of organ dysfunction and infection risk postinjury remains poorly characterized. We sought to characterize these relevant clinical outcomes and their association with PIS use in a large cohort of severely injured blunt trauma patients. Specifically, we sought to determine the effect of PIS use on multiple organ failure (MOF), the development of nosocomial infection (NI), as well as mortality after injury. We hypothesized that PIS use would be associated with a decreased risk of MOF, NI, and mortality in the severely injured trauma patient.