Narong Kulvatunyou

Bio: Narong Kulvatunyou is an academic researcher from University of Arizona. The author has contributed to research in topics: Injury Severity Score & Poison control. The author has an hindex of 37, co-authored 217 publications receiving 4691 citations. Previous affiliations of Narong Kulvatunyou include University of Oklahoma & University of Minnesota.

Increasing trauma deaths in the United States.

Abstract: OBJECTIVE:: To determine the impact of the increasing aging population on trauma mortality relative to mortality from cancer and heart disease in the United States. BACKGROUND:: The population in the United States continues to increase as medical advancements allow people to live longer. The resulting changes in the leading causes of death have not yet been recognized. METHODS:: Data were obtained (2000-2010) from the Web-based Injury Statistics Query and Reporting System database of the Centers for Disease Control and Prevention. We defined trauma deaths as unintentional injuries, suicides, and homicides. RESULTS:: From 2000 to 2010, the US population increased by 9.7% and the number of trauma deaths increased by 22.8%. Trauma deaths and death rates deceased in individuals younger than 25 years but increased for those 25 years and older. During this period, death rates for cancer and heart disease decreased. The largest increases in trauma deaths were in individuals in their fifth and sixth decades of life. Since 2000, the largest proportional increase (118%) in crude trauma deaths occurred in 54-year-olds. Overall, in 2010, trauma was the leading cause of death in individuals 46 years and younger. Trauma remains the leading cause of years of life lost.Trauma is now the leading cause of death for individuals 46 years and younger. The largest increase in the number of trauma deaths and the highest crude number of trauma deaths occurred in baby boomers. Policy makers allocating resources should be made aware of the larger impact of trauma on our aging and burgeoning US population. Language: en

Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis

Abstract: Importance The Frailty Index (FI) is a known predictor of adverse outcomes in geriatric patients. The usefulness of the FI as an outcome measure in geriatric trauma patients is unknown. Objective To assess the usefulness of the FI as an effective assessment tool in predicting adverse outcomes in geriatric trauma patients. Design, setting, and participants A 2-year (June 2011 to February 2013) prospective cohort study at a level I trauma center at the University of Arizona. We prospectively measured frailty in all geriatric trauma patients. Geriatric patients were defined as those 65 years or older. The FI was calculated using 50 preadmission frailty variables. Frailty in patients was defined by an FI of 0.25 or higher. Main outcomes and measures The primary outcome measure was in-hospital complications. The secondary outcome measure was adverse discharge disposition. In-hospital complications were defined as cardiac, pulmonary, infectious, hematologic, renal, and reoperation. Adverse discharge disposition was defined as discharge to a skilled nursing facility or in-hospital mortality. Multivariate logistic regression was used to assess the relationship between the FI and outcomes. Results In total, 250 patients were enrolled, with a mean (SD) age of 77.9 (8.1) years, median Injury Severity Score of 15 (range, 9-18), median Glasgow Coma Scale score of 15 (range, 12-15), and mean (SD) FI of 0.21 (0.10). Forty-four percent (n = 110) of patients had frailty. Patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001) and adverse discharge disposition (odds ratio, 1.6; 95% CI, 1.1-2.4; P = .001). The mortality rate was 2.0% (n = 5), and all patients who died had frailty. Conclusions and relevance The FI is an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients. This index should be used as a clinical tool for risk stratification in this patient group.

Validating Trauma-Specific Frailty Index for Geriatric Trauma Patients: A Prospective Analysis

Abstract: Background The Frailty Index has been shown to predict discharge disposition in geriatric patients. The aim of this study was to validate the modified 15-variable Trauma-Specific Frailty Index (TSFI) to predict discharge disposition in geriatric trauma patients. We hypothesized that TSFI can predict discharge disposition in geriatric trauma patients. Study Design We performed a 2-year (2011–2013) prospective analysis of all geriatric trauma patients presenting to our Level I trauma center. Patient discharge disposition was dichotomized into unfavorable (discharge to skilled nursing facility or death) and favorable (discharge to home or rehabilitation center) discharge disposition. Patients were evaluated using the developed 15-variable TSFI. Multivariate logistic regression was performed to identify factors that predict unfavorable discharge disposition. Results A total of 200 patients were enrolled for validation of TSFI. Mean age was 77 ± 12.1 years, median Injury Severity Score was 15 (interquartile range [IQR] 9 to 20), median Glasgow Coma Scale score was 14 (IQR 13 to 15), and median Frailty Index score was 0.20 (IQR 0.17 to 0.28); 29.5% (n = 59) patients had unfavorable discharge. After adjusting for age, sex, Injury Severity Score, Head Abbreviated Injury Scale, and vitals on admission, Frailty Index (odds ratio = 1.5; 95% CI, 1.1–2.5) was the only significant predictor for unfavorable discharge disposition. Age (odds ratio = 1.2; 95% CI, 0.9–3.1; p = 0.2) was not predictive of unfavorable discharge disposition. Conclusions The 15-variable TSFI is an independent predictor of unfavorable discharge disposition in geriatric trauma patients. The Trauma-Specific Frailty Index is an effective tool that can aid clinicians in planning discharge disposition of geriatric trauma patients. Level of Evidence II Prognostic Studies−Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

Emergency General Surgery in the Elderly: Too Old or Too Frail?

Abstract: Background Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in elective surgical cases. Emerging literature suggests the superiority of frailty measurements to chronological age in predicting outcomes. The aim of this study was to assess the outcomes in elderly patients undergoing EGS using an established Rockwood frailty index. Study Design We prospectively measured preadmission frailty in all geriatric (aged 65 years and older) patients undergoing EGS at our institution during a 2-year period. Frailty index (FI) was calculated using the modified 50-variable Rockwood Preadmission FI. Frail patients were defined by FI ≥ 0.25. Outcomes measures were in-hospital complications, development of major complications, and mortality. Multivariate regression analysis was performed. Results A total of 220 patients were enrolled, of which 82 (37%) were frail. Frailty index score did not correlate with age ( R = 0.64; R 2 = 0.53; p = 0.1) and poorly correlated with American Society of Anesthesiologists score ( R = 0.51; R 2 = 0.44; p = 0.045). Thirty-five percent (n = 77) of patients had postoperative complications and 19% (n = 42) had major complications. Frailty index was an independent predictor for development of in-hospital complications (odds ratio = 2.13; 95% CI, 1.09-4.16; p = 0.02) and major complications (odds ratio = 3.87; 95% CI, 1.69-8.84; p = 0.001). Age and American Society of Anesthesiologists score were not predictive of postoperative and major complications. Our FI model had 80% sensitivity, 72% specificity, and area under the curve of 0.75 in predicting complications in geriatric patients undergoing EGS. The overall mortality rate was 3.2% (n = 7) and all patients who died were frail. Conclusions Frailty index independently predicts postoperative complications, major complications, and hospital length of stay in elderly patients undergoing emergency general surgery. Use of FI will provide insight into the hospital course of elderly patients, allowing for identification of patients in need and more efficient allocation of hospital resources.

Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma.

Abstract: Importance The need for improved methods of hemorrhage control and resuscitation has resulted in a reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA). However, there is a paucity of data regarding the use of REBOA on a multi-institutional level in the United States. Objective To evaluate the outcomes in trauma patients after REBOA placement. Design, Setting, and Participants A case-control retrospective analysis was performed of the 2015-2016 American College of Surgeons Trauma Quality Improvement Program data set, a national multi-institutional database of trauma patients in the United States. A total of 593 818 adult trauma patients (aged ≥18 years) were analyzed and 420 patients were matched and included in the study; patients who were dead on arrival or were transferred from other facilities were excluded. Trauma patients who underwent REBOA placement in the ED were identified and matched with a similar cohort of patients (the no-REBOA group). Both groups were matched in a 1:2 ratio using propensity score matching for demographics, vital signs, mechanism of injury, injury severity score, head abbreviated injury scale score, each body region abbreviated injury scale score, pelvic fractures, lower extremity vascular injuries and fractures, and number and grades of intra-abdominal solid organ injuries. Main Outcomes and Measures Outcome measures were the rates of complications and mortality. Results Of 593 818 trauma patients, 420 patients (the REBOA group, 140 patients; 36 women and 104 men; mean [SD] age, 44 [20] years; the no-REBOA group, 280 patients; 77 women and 203 men; mean [SD] age, 43 [19] years) were matched and included in the analysis. Among the REBOA group, median injury severity score was 29 (interquartile range [IQR], 18-38) and 129 patients (92.1%) had a blunt mechanism of injury. There was no significant difference between groups in median 4-hour blood transfusion (REBOA: packed red blood cells, 6 U [IQR, 3-8 U]; platelets, 4 U [IQR, 3-9 U], and plasma, 3 U [IQR, 2-5 U]; and no-REBOA: packed red blood cells, 7 U [IQR, 3-9 U]; platelets, 4 U [IQR, 3-8 U], and plasma, 3 U [IQR, 2-6 U]) or 24-hour blood transfusion (REBOA: packed red blood cells, 9 U [IQR, 5-20 U]; platelets, 7 U [IQR, 3-13 U], and plasma, 9 U [IQR, 6-20 U]; and no-REBOA: packed red blood cells, 10 U [IQR, 4-21 U]; platelets, 8 U [IQR, 3-12 U], and plasma, 10 U [IQR, 7-20 U]), median hospital length of stay (REBOA, 8 days [IQR, 1-20 days]; and no-REBOA, 10 days [IQR, 5-22 days]), or median intensive care unit length of stay (REBOA, 5 days [IQR, 2-14 days]; and no-REBOA, 6 days [IQR, 3-15 days]). The mortality rate was higher in the REBOA group as compared with the no-REBOA group (50 [35.7%] vs 53 [18.9%];P = .01). Patients who underwent REBOA placement were also more likely to develop acute kidney injury (15 [10.7%] vs 9 [3.2%];P = .02) and more likely to undergo lower extremity amputation (5 [3.6%] vs 2 [0.7%];P = .04). Conclusions and Relevance Placement of REBOA in severely injured trauma patients was associated with a higher mortality rate compared with a similar cohort of patients with no placement of REBOA. Patients in the REBOA group also had higher rates of acute kidney injury and lower leg amputations. There is a need for a concerted effort to clearly define when and in which patient population REBOA has benefit.

Transfusion of plasma, platelets, and red blood cells in a 1: 1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial

Abstract: Importance Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. Objective To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. Design, Setting, and Participants Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. Interventions Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). Main Outcomes and Measures Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. Results No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, −4.2% [95% CI, −9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, −3.7% [95% CI, −10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P P Conclusions and Relevance Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. Trial Registration clinicaltrials.gov Identifier:NCT01545232

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

Abstract: Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

The injury fact book

Abstract: This book includes detailed information on many of the factors surrounding injuries--the man-made systems and products involved, the groups at greatest risk, and effective ways to protect people from injuries. The circumstances under which injuries occur, the etiologic agents, and the characteristics of the people involved are examined. Chapter 2 summarizes the importance of injuries in relation to other prominent health problems. Subsequent chapters describe injury mortality and, in cases where good population-based studies are available, nonfatal injuries. The analyses in Chapters 3-15 are primarily of injury deaths during 1977-1979, the most recent years for which detailed mortality data were available in mid-1983 for deaths other than those related to motor vehicles. Most of these data were collected by the U.S. Department of Health and Human Services, National Center for Health Statistics (NCHS). Chapters 16-20 summarize data on deaths from motor vehicle-related injuries. Most of these detailed data were obtained from the U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA). Data from the 1980 census provided denominators for the rates throughout the book, except for trendline calculations which were based on interpolations between census years. The purpose of this book is to improve understanding of the nature and magnitude of the injury problem in the United States. Although it includes some discussion of ameliorative approaches, there is no comprehensive coverage of injury research, theory, or prevention, since these have been comprehensively discussed elsewhere. This book is a thorough documentation of the injury problem. Most of the information presented is new, the product of analyses not previously published in any form.

European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage

Abstract: Background Intracerebral hemorrhage (ICH) accounted for 9% to 27% of all strokes worldwide in the last decade, with high early case fatality and poor functional outcome In view of recent randomized controlled trials (RCTs) of the management of ICH, the European Stroke Organisation (ESO) has updated its evidence-based guidelines for the management of ICH Method A multidisciplinary writing committee of 24 researchers from 11 European countries identified 20 questions relating to ICH management and created recommendations based on the evidence in RCTs using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach Results We found moderate- to high-quality evidence to support strong recommendations for managing patients with acute ICH on an acute stroke unit, avoiding hemostatic therapy for acute ICH not associated with antithrombotic drug use, avoiding graduated compression stockings, using intermittent pneumatic compression in immobile patients, and using blood pressure lowering for secondary prevention We found moderate-quality evidence to support weak recommendations for intensive lowering of systolic blood pressure to <140 mmHg within six-hours of ICH onset, early surgery for patients with a Glasgow Coma Scale score 9‐12, and avoidance of corticosteroids Conclusion These guidelines inform the management of ICH based on evidence for the effects of treatments in RCTs Outcome after ICH remains poor, prioritizing further RCTs of interventions to improve outcome

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine.

Abstract: The use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes. The Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, organized an international, multi-institutional committee with expertise in neurocritical care, neurology, neurosurgery, stroke, hematology, hemato-pathology, emergency medicine, pharmacy, nursing, and guideline development to evaluate the literature and develop an evidence-based practice guideline. Formalized literature searches were conducted, and studies meeting the criteria established by the committee were evaluated. Utilizing the GRADE methodology, the committee developed recommendations for reversal of vitamin K antagonists, direct factor Xa antagonists, direct thrombin inhibitors, unfractionated heparin, low-molecular weight heparin, heparinoids, pentasaccharides, thrombolytics, and antiplatelet agents in the setting of intracranial hemorrhage. This guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.