Showing papers in "Journal of Trauma-injury Infection and Critical Care in 2006"
TL;DR: Improvements in early hemorrhage control and resuscitation and the prevention and aggressive treatment of coagulopathy appear to have the greatest potential to improve outcomes in severely injured trauma patients.
Abstract: The world-wide impact of traumatic injury and associated hemorrhage on human health and well-being cannot be overstated. Twelve percent of the global disease burden is the result of violence or accidental injury. Hemorrhage is responsible for 30 to 40% of trauma mortality, and of these deaths, 33 to 56% occur during the prehospital period. Among those who reach care, early mortality is caused by continued hemorrhage, coagulopathy, and incomplete resuscitation. The techniques of early care, including blood transfusion, may underlie late mortality and long-term morbidity. While the volume of blood lost cannot be measured, physiologic and chemical measures and the number of units of blood given are readily recorded and analyzed. Improvements in early hemorrhage control and resuscitation and the prevention and aggressive treatment of coagulopathy appear to have the greatest potential to improve outcomes in severely injured trauma patients.
1,209 citations
TL;DR: A systematic literature review of all population-based studies that evaluated trauma system performance showed a 15% reduction in mortality in favor of the presence of a trauma system.
Abstract: Background:The establishment of trauma systems was anticipated to improve overall survival for the severely injured patient. We systematically reviewed the published literature to assess if outcome from severe traumatic injury is improved for patients following the establishment of a trauma system.M
592 citations
TL;DR: The HemCon chitosan-based hemostatic dressing is approved by the US Food and Drug Administration (FDA) for hemorrhage control in both civilian and military trauma patients.
Abstract: Background:Hemorrhage remains a leading cause of death in both civilian and military trauma patients. The HemCon chitosan-based hemostatic dressing is approved by the US Food and Drug Administration (FDA) for hemorrhage control. Animal data have shown the HemCon dressing to reduce hemorrhage and imp
571 citations
TL;DR: The evidence would suggest that prevention of coagulopathy is superior to its treatment and simple ratios such as 1:1:1 RBC:plasma:platelets have the benefit of ease of use and the relatively higher plasma and platelet doses appear to be associated with improved outcome.
Abstract: Background: Massive transfusion, the administration of 10 to more than 100 units of red blood cells (RBC) in less than 24 hours, can be a life saving therapy in the treatment of severe injury. The rapid administration of large numbers of RBC, along with sufficient plasma and platelets to treat or prevent coagulopathy, is frequently a disorderly process. Patient care and collaborative research might be aided with a common protocol. Methods: The authors polled trauma organizations and trauma centers to find examples of massive transfusion protocols. The goals and ease of use of these protocols were evaluated. Results: Massive transfusion protocols exist at a relatively small number of large and well-organized trauma centers. Most of these protocols are designed to treat pre-existing and/or ongoing coagulopathy. Conclusions: The evidence would suggest that prevention of coagulopathy is superior to its treatment. Simple ratios such as 1:1:1 RBC:plasma:platelets have the benefit of ease of use and the relatively higher plasma and platelet doses appear to be associated with improved outcome. Such a standard protocol can foster multicenter research on resuscitation and hemorrhage control. The fixed volume ratios might allow the number and rate of administered units of RBC to be used as surrogates for blood loss and primary treatment effect.
430 citations
TL;DR: In this paper, a simple scoring system that allows an early and reliable estimation for the probability of mass transfusion (MT) as a surrogate for life threatening hemorrhage following multiple trauma was developed.
Abstract: Background:To develop a simple scoring system that allows an early and reliable estimation for the probability of mass transfusion (MT) as a surrogate for life threatening hemorrhage following multiple trauma.Methods:Potential clinical and laboratory variables documented in the Trauma Registry of th
387 citations
TL;DR: The objective was to arrive at terminology and equations that would produce the best insight into the effectiveness of care at different stages of treatment, either pre or post medical treatment facility care.
Abstract: Maintaining good hospital records during military conflicts can provide medical personnel and researchers with feedback to rapidly adjust treatment strategies and improve outcomes. But to convert the resulting raw data into meaningful conclusions requires clear terminology and well thought out equations, utilizing consistent numerators and denominators. Our objective was to arrive at terminology and equations that would produce the best insight into the effectiveness of care at different stages of treatment, either pre or post medical treatment facility care. We first clarified three essential terms: 1) the case fatality rate (CFR) as percentage of fatalities among all wounded; 2) killed in action (KIA) as percentage of immediate deaths among all seriously injured (not returning to duty); and 3) died of wounds (DOW) as percentage of deaths following admission to a medical treatment facility among all seriously injured (not returning to duty). These equations were then applied consistently across data from the WWII, Vietnam and the current Global War on Terrorism. Using this clear set of definitions we used the equations to ask two basic questions: What is the overall lethality of the battlefield? How effective is combat casualty care? To answer these questions with current data, the three services have collaboratively created a joint theater trauma registry (JTTR), cataloging all the serious injuries, procedures, and outcomes for the current war. These definitions and equations, consistently applied to the JTTR, will allow meaningful comparisons and help direct future research and appropriate application of personnel.
373 citations
TL;DR: This is the first report on silver toxicity in a patient with 30% burns who received Acticoat for local treatment, and the possibility of a toxic silver effect in burn patients treated with silver-coated wound dressing in mind is kept in mind.
Abstract: Background: Treatment of acute burn wounds with silver sulfadiazine (SSD) has raised concern about potential silver toxicity. Numerous adverse reactions and side effects have been reported and an increasing resistance to SSD, especially in Pseudomonas strains, have motivated researchers to search for an alternative wound dressing. Methods: Recently, a silver-coated wound dressing Acticoat (Smith & Nephew, Inc.) has become available for use in burn patients. It is a three-ply dressing, consisting of an inner rayon/ polyester absorptive core between two layers of silver-coated, high-density polyethylene mesh. In a moist environment, the nanocrystals of silver are released and improve the microbial control in the wound. Results: After 1 week of local treatment with Acticoat in a young, previously healthy 17-year-old boy with 30% mixed depth burns, hepatotoxicity and argyrialike symptoms, a grayish discoloration of the patient’s face, appeared. The silver levels in plasma (107 g/kg) and urine (28 g/kg) were clearly elevated, as well as the liver enzymes. As soon as the local application of Acticoat was aborted, the clinical symptoms and liver enzymes returned to the normal values. Conclusions: This is the first report on silver toxicity in a patient with 30% burns who received Acticoat for local treatment. Due to substantial experiences with adverse SSD reactions and side effects, it is appropriate to keep the possibility of a toxic silver effect in burn patients treated with Acticoat silver-coated wound dressing in mind. The silver levels in plasma and/or urine should be monitored.
321 citations
TL;DR: Temporary vascular shunts are common in the management of wartime vascular injury and have high patency rates compared with those placed in distal injuries, and represent a safe and effective damage control technique.
Abstract: Background: While the use of vascular shunts as a damage control adjunct has been described in series from civilian institutions no contemporary military experience has been reported. The objective of this study is to examine patterns of use and effectiveness of temporary vascular shunts in the contemporary management of wartime vascular injury. Materials: From September 1, 2004 to August 31, 2005, 2,473 combat injuries were treated at the central echelon III surgical facility in Iraq. Vascular injuries were entered into a registry and reviewed. Location of shunts was divided into proximal and distal, and shunt patency, complications and limb viability were examined. Results: There were 126 extremity vascular injuries treated. Fifty-three (42%) had been operated on at forward locations and 30 of 53 (57%) had temporary shunts in place upon arrival to our facility. The patency for shunts in proximal vascular injuries was 86% (n = 22) compared with 12% (n = 8) for distal shunts (p < 0.05). All shunts placed in proximal venous injuries were patent (n = 4). Systemic heparin was not used and there were no shunt complications. All shunted injuries were reconstructed with vein in theater and early viability for extremities in which shunts were used was 92%. Conclusions: Temporary vascular shunts are common in the management of wartime vascular injury. Shunts in proximal injuries including veins have high patency rates compared with those placed in distal injuries. This vascular adjunct represents a safe and effective damage control technique and is preferable to attempted reconstruction in austere conditions.
307 citations
TL;DR: This ongoing randomized study has demonstrated decreased drainage and improved wound healing following both hematomas and severe fractures, and a significant difference was present at current enrollment for infection or wound breakdown.
Abstract: Purpose:To evaluate the use of negative pressure wound therapy (NPWT) to augment healing of surgical incisions and hematomas after high-energy trauma.Materials:This study is a prospective randomized evaluation of NPWT in trauma patients, randomizing patients with draining hematomas to either a press
291 citations
Johns Hopkins University1, Carolinas Medical Center2, University of Maryland, Baltimore3, Wake Forest University4, University of Minnesota5, University of Washington6, University of Texas Southwestern Medical Center7, Southern Illinois University Carbondale8, MetroHealth9, Orlando Regional Medical Center10
TL;DR: Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.
Abstract: Background:A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries.Methods:Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who
265 citations
TL;DR: The first report of the use of a negative pressure dressing (wound VAC) as part of the definitive management of high-energy soft tissue wounds in a deployed wartime environment is reported, suggesting that conventional wound management doctrine may be improved with the wound VAC, resulting in earlier more reliable primary closure of wartime injuries.
Abstract: Background:Wartime missile injuries are frequently high-energy wounds that devitalize and contaminate tissue, with high risk for infection and wound complications. Debridement, irrigation, and closure by secondary intention are fundamental principles for the management of these injuries. However, cl
TL;DR: This presentation explains how medical lessons learned from Vietnam and previous military conflicts led to the development of civilian trauma systems in the United States and their application in Operation Iraqi Freedom.
Abstract: Background:Medical lessons learned from Vietnam and previous military conflicts led to the development of civilian trauma systems in the United States. Operation Iraqi Freedom represents the first protracted, large-scale, armed conflict since the advent of civilian trauma systems in which to evaluat
TL;DR: Patients with severe TBI should be transported directly to a Level I or Level II trauma center with capabilities as delineated in the Guidelines for the Prehospital Management of Traumatic Brain Injury, even if this center may not be the closest hospital.
Abstract: Background:Prehospital management of traumatic brain injury (TBI) and trauma system development and organization are aspects of TBI care that have the potential to significantly impact patient outcome. This multi-center study was conducted to explore the effect of prehospital management decisions on
TL;DR: Under extreme and austere circumstances, the risk:benefit ratio of whole blood transfusion favors its use, and fresh whole blood may, at times, be advantageous even when conventional component therapy is available.
Abstract: Background:Most indications for whole blood transfusion are now well managed exclusively with blood component therapy, yet the use of fresh whole blood for resuscitating combat casualties has persisted in the U.S. military.Methods:Published descriptions of whole blood use in military and civilian se
TL;DR: This review analyzes the current literature pertaining to four of the most promising products (dry fibrin sealant dressing, Rapid Deployment Hemostat, HemCon chitosan dressing, and QuikClot) that have been suggested for use in combat casualty care applications and takes into account the characteristics of the animal models used for efficacy testing of these products.
Abstract: A number of new hemostatic products have been developed recently for use in trauma settings of severe uncontrolled bleeding. Currently, the literature on these products is controversial, with efficacy demonstrated under some circumstances but not others. In this review, we analyze the current literature pertaining to four of the most promising products (dry fibrin sealant dressing, Rapid Deployment Hemostat, HemCon chitosan dressing, and QuikClot) that have been suggested for use in combat casualty care applications. In particular, this analysis takes into account the characteristics of the animal models used for efficacy testing of these products, the desired characteristics of hemostatic dressings, and specific safety considerations. Animal models ranged from those featuring low-pressure/low-flow bleeding to those featuring high-pressure/high-flow bleeding. When data are viewed in the context of the specific characteristics of the differing animal models used, seemingly disparate experimental results related to efficacy and safety become quite complementary and lead to recommendations for the use of different products in different injury scenarios. Mission and training requirements will dictate the use of these products by military and civilian prehospital care providers.
TL;DR: Early use of plasma and platelets at the upper end of recommended doses appears to reduce the incidence of coagulopathy in massively transfused individuals.
Abstract: Background:Massive blood transfusion can be lifesaving in the treatment of severe trauma. Guidelines for the use of non-RBC blood components in the early phase of trauma resuscitation are largely based on extensions of expert recommendations for general surgery.Methods:The logic and evidence for the
Journal Article•
TL;DR: In this article, the authors reviewed the logic and evidence for the use of plasma, platelets, and cryoprecipitate early in the course of massive transfusion for trauma and concluded that early use of platelets at the upper end of recommended doses appears to reduce the incidence of coagulopathy in massively transfused individuals.
Abstract: Background: Massive blood transfusion can be lifesaving in the treatment of severe trauma. Guidelines for the use of non-RBC blood components in the early phase of trauma resuscitation are largely based on extensions of expert recommendations for general surgery. Methods: The logic and evidence for the use of plasma, platelets, and cryoprecipitate early in the course of massive transfusion for trauma were reviewed. Large series of consecutive patients were sought. Findings: Resuscitation of the most severely iniured and massively hemorrhaeine patients usually starts with crystalloid fluids and progresses to uncross-matched RBC. Low blood volume, insensible losses, consumption, and resuscitation with plasma poor RBC concentrates rapidly lead to plasma coagulation factor concentrations of less than 40%. This typically occurs before 10 U of RBC have been transfused. Early initiation of plasma therapy is often delayed by its lack of immediate availability in the trauma center. Platelets usually fall to concentrations of 50-100× 109/L after 10-20 units of RBC have been given, but platelet concentrations in individual patients are quite variable and can decrease more quickly. Ideal platelet concentrations in trauma patients are not known, but are generally held to be greater than 50 × 10 9 /L. Cryoprecipitate can rapidly increase the concentrations of fibrinogen and von Willebrand's factor, but the advantages of higher than normal concentrations are speculative. Conclusions: Early use of plasma and platelets at the upper end of recommended doses appears to reduce the incidence of coagulopathy in massively transfused individuals.
TL;DR: Hypoxia in the prehospital setting in patients with potentially survivable brain injuries significantly increases the odds of mortality after brain injury controlled for multiple variables.
Abstract: Background:The goals of this study were to determine the incidence and duration of hypotension and hypoxia in the prehospital setting in patients with potentially survivable brain injuries, and to prospectively examine the association of these secondary insults with mortality and disability at hospi
TL;DR: Both age and warfarin anticoagulation are independent predictors of mortality after blunt TBI, and age and age were found to be predictive of survival in a binary logistic regression model.
Abstract: Background:A large population of patients on oral anticoagulants is exposed to the risk of traumatic brain injury (TBI). Effects of age and anticoagulation on TBI outcomes need to be assessed separately.Methods:Retrospective analysis of consecutive series of TBI patients (age 18 years and older) in
TL;DR: Outcomes after treatment with HV appear inferior to those achieved with CO or OP, and major complications occurred in 66% of HV patients compared with 36% of non-HV patients.
Abstract: Background:Odontoid fractures are the most common cervical spine fractures in elderly patients. Treatment options included operative fixation (OP) or nonoperative management with either a halo-vest (HV) or rigid cervical orthosis (CO). Our previous study suggested increased morbidity and mortality w
TL;DR: Norepinephrine modulates the inflammatory and proliferative phases of wound healing in a temporally defined, cell-specific manner and appears to play a protective role in defense against infection.
Abstract: Background:Injury results in the massive release of norepinephrine (NE) into the peripheral circulation. Recent investigations have demonstrated functional adrenoreceptors on the cellular mediators of cutaneous wound healing and NE-induced phenotypic alterations in immune cells have been demonstrate
TL;DR: It is confirmed that patients with severe SIRS had significantly lower total anaerobic bacterial counts and 2 log higher "pathogenic" Staphylococcus and Pseudomonas group counts than those of healthy volunteers.
Abstract: Background:The gut is considered an important target organ of injury after severe insult such as sepsis, trauma, and shock. The impact of bacterial translocation or mesenteric lymph on systemic inflammatory response and multiple organ damage has been investigated in animals, but dynamic changes in t
TL;DR: FWB transfusions were most frequent when demands for massive transfusions wiped out existing blood supplies, and mortality did not differ significantly between FWB and non-FWB patients overall or for massively transfused patients.
Abstract: The transfusion of fresh whole blood (FWB) for trauma-induced coagulopathy is unusual in civilian practice. However, US military physicians have used FWB in every combat operation since the practice was introduced in World War I and continue to do so during current military operations. We discuss our review of all blood products administered to US military casualties in Operation Iraqi Freedom (OIF) between March and December 2003. FWB transfusions were most frequent when demands for massive transfusions wiped out existing blood supplies. FWB patients had the highest blood product requirements; however, mortality did not differ significantly between FWB and non-FWB patients overall or for massively transfused patients. We review the current military practice of FWB transfusion in combat theaters and conclude that FWB transfusion is convenient, safe, and effective in certain military situations.
TL;DR: The results support the use of plating with bicortical locked screws as an alternative to conventional plating for comminuted diaphyseal fractures in osteoporotic bone and suggest use of plates with unicortical screws for the described fracture is not recommended.
Abstract: Background:Locking plates are an alternative to conventional compression plate fixation for diaphyseal fractures. The objective of this study was to compare the stability of various plating with locked screw constructs to conventional nonlocked screws for fixation of a comminuted diaphyseal fracture
TL;DR: The expression and release of sIgA was markedly augmented after 3-days of bifidobacteria-supplementation formula and it returned to normal range on postburn day 5, suggesting Supplementation of exogenous b ifidob bacteria could improve gut barrier function, and attenuate bacterial/endotoxin translocation secondary to major burns.
Abstract: Background:Early multiple organ dysfunction syndrome appears to be facilitated with bacterial translocation in severe burn injury, yet the mechanisms of bacterial translocation remain in dispute. The aim of this study was to characterize the potential role of intestinal bifidobacteria in the pathoge
TL;DR: A strong correlation between pH levels and impairment of the coagulation is found, where the clot strength is increased much slower at pH levels below 7.4 even though the initiation of the clotting seems to be normal.
Abstract: Background:Coagulopathy is a contributor to and predictor of death in bleeding patients. Acidosis is known to be a predictor of worse outcome in trauma patients and to be a coexisting factor in coagulopathic patients, but it has not been studied if it is a causal factor in the development of coagulo
Journal Article•
TL;DR: The coagulopathy of trauma is a syndrome of non-surgical bleeding from mucosal lesions, serosal surfaces, and wound and vascular access sites associated with serious injury, hypothermia, acidosis, hemodilution, and occasionally with classic disseminated intravascular coagulation (DIC) as discussed by the authors.
Abstract: The coagulopathy of trauma is a syndrome of non-surgical bleeding from mucosal lesions, serosal surfaces, and wound and vascular access sites associated with serious injury, hypothermia, acidosis, hemodilution, and occasionally with classic disseminated intravascular coagulation (DIC). It can be largely explained by the effects of cold on platelet function, the effect of pH on coagulation factor activity, and the dilutional effects of resuscitation fluids and conventional blood products. DIC occurs acutely after trauma when brain, fat, amniotic fluid, or other strong thromboplastins enter the circulation. It occurs subacutely when endothelial inflammation or failure reduces clearing of activated coagulation factors allowing microthrombi to cause secondary injury. The coagulopathy of trauma should be anticipated in massive transfusion situations. Early treatment with plasma can delay its onset. The underlying mechanisms should be confirmed with laboratory testing.
TL;DR: All patients on warfarin should have an INR performed, and a CT scan should be done in most anticoagulated patients, and Routine repeat CT scanning at 12 to 18 hours or when even subtle signs of neurologic worsening occur is a strong recommendation.
Abstract: Background:Coumadin is widely used in the elderly population. Despite its widespread use, little is known about its effect on the outcome of elderly traumatic brain-injured patients. This study was undertaken to describe the outcomes of such a cohort.Methods:Clinical material was identified from a L
TL;DR: Liberal screening with 16-slice CTA is appropriate and is likely to miss very few significant injuries, but a multicenter trial will help to clarify risk factors and the accuracy of noninvasive diagnostic modalities.
Abstract: Background:In light of their potential for devastating consequences, a liberalized screening approach for blunt cerebrovascular injuries (BCVI) is becoming increasingly accepted. The gold standard for diagnosis of BCVI is arteriography (ART), but noninvasive diagnostic alternatives offer clear advan
TL;DR: The coagulopathy of trauma is a syndrome of non-surgical bleeding from mucosal lesions, serosal surfaces, and wound and vascular access sites associated with serious injury, hypothermia, acidosis, hemodilution, and occasionally with classic disseminated intravascular coagulation.
Abstract: The coagulopathy of trauma is a syndrome of non-surgical bleeding from mucosal lesions, serosal surfaces, and wound and vascular access sites associated with serious injury, hypothermia, acidosis, hemodilution, and occasionally with classic disseminated intravascular coagulation (DIC). It can be largely explained by the effects of cold on platelet function, the effect of pH on coagulation factor activity, and the dilutional effects of resuscitation fluids and conventional blood products. DIC occurs acutely after trauma when brain, fat, amniotic fluid, or other strong thromboplastins enter the circulation. It occurs subacutely when endothelial inflammation or failure reduces clearing of activated coagulation factors allowing microthrombi to cause secondary injury. The coagulopathy of trauma should be anticipated in massive transfusion situations. Early treatment with plasma can delay its onset. The underlying mechanisms should be confirmed with laboratory testing.