scispace - formally typeset
Search or ask a question

Showing papers in "Journal of Trauma-injury Infection and Critical Care in 2008"


Journal ArticleDOI
TL;DR: The wounding patterns currently seen in Iraq and Afghanistan resemble the patterns from previous conflicts, with some notable exceptions: a greater proportion of head and neck wounds, and a lower proportion of thoracic wounds.
Abstract: BACKGROUND: There have been no large cohort reports detailing the wounding patterns and mechanisms in the current conflicts in Iraq and Afghanistan. METHODS: The Joint Theater Trauma Registry was queried for all US service members receiving treatment for wounds (International Classification of Diseases-9th Rev. codes 800-960) sustained in Operation Iraqi Freedom and Operation Enduring Freedom from October 2001 through January 2005. Returned-to-duty and nonbattle injuries were excluded from final analysis. RESULTS: This query resulted in 3,102 casualties, of which 31% were classified as nonbattle injuries and 18% were returned-to-duty within 72 hours. A total of 1,566 combatants sustained 6,609 combat wounds. The locations of these wounds were as follows: head (8%), eyes (6%), ears (3%), face (10%), neck (3%), thorax (6%), abdomen (11%), and extremity (54%). The proportion of head and neck wounds is higher (p < 0.0001) than the proportion experienced in World War II, Korea, and Vietnam wars (16%-21%). The proportion of thoracic wounds is a decrease (p < 0.0001) from World War II and Vietnam (13%). The proportion of gunshot wounds was 18%, whereas the proportion sustained from explosions was 78%. CONCLUSIONS: The wounding patterns currently seen in Iraq and Afghanistan resemble the patterns from previous conflicts, with some notable exceptions: a greater proportion of head and neck wounds, and a lower proportion of thoracic wounds. An explosive mechanism accounted for 78% of injuries, which is the highest proportion seen in any large-scale conflict. Language: en

987 citations


Journal ArticleDOI
TL;DR: There is limited understanding of the mechanisms by which tissue trauma, shock, and inflammation initiate trauma coagulopathy, and Acute Coagulopathic of Trauma-Shock should be considered distinct from disseminated intravascular coagulation as described in other conditions.
Abstract: Background: Bleeding is the most frequent cause of preventable death after severe injury. Coagulopathy associated with severe injury complicates the control of bleeding and is associated with increased morbidity and mortality in trauma patients. The causes and mechanisms are multiple and yet to be clearly defined. Methods: Articles addressing the causes and consequences of trauma-associated coagulopathy were identified and reviewed. Clinical situations in which the various mechanistic causes are important were sought along with quantitative estimates of their importance. Results: Coagulopathy associated with traumatic injury is the result of multiple independent but interacting mechanisms. Early coagulopathy is driven by shock and requires thrombin generation from tissue injury as an initiator. Initiation of coagulation occurs with activation of anticoagulant and fibrinolytic pathways. This Acute Coagulopathy of Trauma-Shock is altered by subsequent events and medical therapies, in particular acidemia, hypothermia, and dilution. There is significant interplay between all mechanisms. Conclusions: There is limited understanding of the mechanisms by which tissue trauma, shock, and inflammation initiate trauma coagulopathy. Acute Coagulopathy of Trauma-Shock should be considered distinct from disseminated intravascular coagulation as described in other conditions. Rapid diagnosis and directed interventions are important areas for future research.

860 citations


Journal ArticleDOI
TL;DR: Acute coagulopathy of trauma is associated with systemic hypoperfusion and is characterized by anticoagulation and hyperfibrinolysis, which correlates with thrombomodulin activity.
Abstract: BACKGROUND: Coagulopathy is present at admission in 25% of trauma patients, is associated with shock and a 5-fold increase in mortality. The coagulopathy has recently been associated with systemic activation of the protein C pathway. This study was designed to characterize the thrombotic, coagulant and fibrinolytic derangements of trauma-induced shock. METHODS: This was a prospective cohort study of major trauma patients admitted to a single trauma center. Blood was drawn within 10 minutes of arrival for analysis of partial thromboplastin and prothrombin times, prothrombin fragments 1 + 2 (PF1 + 2), fibrinogen, factor VII, thrombomodulin, protein C, plasminogen activator inhibitor-1 (PAI-1), thrombin activatable fibrinolysis inhibitor (TAFI), tissue plasminogen activator (tPA), and D-dimers. Base deficit was used as a measure of tissue hypoperfusion. RESULTS: Two hundred eight patients were studied. Systemic hypoperfusion was associated with anticoagulation and hyperfibrinolysis. Coagulation was activated and thrombin generation was related to injury severity, but acidosis did not affect Factor VII or PF1 + 2 levels. Hypoperfusion-induced increase in soluble thrombomodulin levels was associated with reduced fibrinogen utilization, reduction in protein C and an increase in TAFI. Hypoperfusion also resulted in hyperfibrinolysis, with raised tPA and D-Dimers, associated with the observed reduction in PAI-1 and not alterations in TAFI. CONCLUSIONS: Acute coagulopathy of trauma is associated with systemic hypoperfusion and is characterized by anticoagulation and hyperfibrinolysis. There was no evidence of coagulation factor loss or dysfunction at this time point. Soluble thrombomodulin levels correlate with thrombomodulin activity. Thrombin binding to thrombomodulin contributes to hyperfibrinolysis via activated protein C consumption of PAI-1.

700 citations


Journal ArticleDOI
TL;DR: Autopsies of the earliest combat deaths from Iraq and Afghanistan and the latest deaths of 2006 were analyzed to assess changes in injury severity and causes of death, finding that the severity of wounds has increased over time.
Abstract: BACKGROUND: The opinion that injuries sustained in Iraq and Afghanistan have increased in severity is widely held by clinicians who have deployed multiple times To continuously improve combat casualty care, the Department of Defense has enacted numerous evidence-based policies and clinical practice guidelines We hypothesized that the severity of wounds has increased over time Furthermore, we examined cause of death looking for opportunities of improvement for research and training METHODS: Autopsies of the earliest combat deaths from Iraq and Afghanistan and the latest deaths of 2006 were analyzed to assess changes in injury severity and causes of death Fatalities were classified as nonsurvivable (NS) or potentially survivable (PS) PS deaths were then reviewed in depth to analyze mechanism and cause RESULTS: There were 486 cases from March 2003 to April 2004 (group 1) and 496 from June 2006 to December 2006 (group 2) that met inclusion criteria Of the PS fatalities (group 1: 93 and group 2: 139), the injury severity score was lower in the first group (27 +/- 14 vs 37 +/- 16, p or=4 (11 +/- 079 vs 15 +/- 083 per person, p < 0001) The main cause of death in the PS fatalities was truncal hemorrhage (51% vs 49%, p = NS) Deaths per month between groups doubled (35 vs 71), whereas the case fatality rates between the two time periods were equivalent (110 vs 98, p = NS) DISCUSSION: In the time periods of the war studied, deaths per month has doubled, with increases in both injury severity and number of wounds per casualty Truncal hemorrhage is the leading cause of potentially survivable deaths Arguably, the success of the medical improvements during this war has served to maintain the lowest case fatality rate on record Language: en

615 citations


Journal ArticleDOI
TL;DR: Exposure to midazolam is an independent and potentially modifiable risk factor for the transitioning to delirium in surgical and trauma ICU patients, keeping with other recent data on benzodiazepines.
Abstract: Background Delirium or acute brain dysfunction is extremely prevalent in medical intensive care unit (ICU) patients, but limited data exist regarding its prevalence and risk factors among surgical (SICU) and trauma ICU (TICU) patients. The purpose of this study was to determine the prevalence and risk factors for delirium in surgical and trauma ICU patients.

491 citations


Journal ArticleDOI
TL;DR: It is demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.
Abstract: Background: The importance of early and aggressive management of trauma-related coagulopathy remains poorly understood. We hypothesized that a trauma exsanguination protocol (TEP) that systematically provides specified numbers and types of blood components immediately upon initiation of resuscitation would improve survival and reduce overall blood product consumption among the most severely injured patients. Methods: We recently implemented a TEP, which involves the immediate and continued release of blood products from the blood bank in a predefined ratio of 10 units of packed red blood cells (PRBC) to 4 units of fresh frozen plasma to 2 units of platelets. All TEP activations from February 1, 2006 to July 31, 2007 were retrospectively evaluated. A comparison cohort (pre-TEP) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. Multivariable analysis was performed to compare mortality and overall blood product consumption between the two groups. Results: Two hundred eleven patients met inclusion criteria (117 pre-TEP, 94 TEP). Age, sex, and Injury Severity Score were similar between the groups, whereas physiologic severity (by weighted Revised Trauma Score) and predicted survival (by trauma-related Injury Severity Score, TRISS) were worse in the TEP group (p values of 0.037 and 0.028, respectively). After controlling for age, sex, mechanism of injury, TRISS and 24-hour blood product usage, there was a 74% reduction in the odds of mortality among patients in the TEP group (p = 0.001). Overall blood product consumption adjusted for age, sex, mechanism of injury, and TRISS was also significantly reduced in the TEP group (p = 0.015). Conclusions: We have demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.

430 citations


Journal ArticleDOI
TL;DR: In patients with combat-related trauma requiring massive transfusion, the transfusion of an increased fibrinogen: RBC ratio was independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage.
Abstract: Background: To treat the coagulopathy of trauma, some have suggested early and aggressive use of cryoprecipitate as a source of fibrinogen. Our objective was to determine whether increased ratios of fibrinogen to red blood cells (RBCs) decreased mortality in combat casualties requiring massive transfusion. Methods: We performed a retrospective chart review of 252 patients at a U.S. Army combat support hospital who received a massive transfusion (≥10 units of RBCs in 24 hours). The typical amount of fibrinogen within each blood product was used to calculate the fibrinogen-to-RBC (F:R) ratio transfused for each patient. Two groups of patients who received either a low (<0.2 g fibrinogen/RBC Unit) or high (≥0.2 g fibrinogen/RBC Unit) F:R ratio were identified. Mortality rates and the cause of death were compared between these groups, and logistic regression was used to determine if the F:R ratio was independently associated with survival. Results: Two-hundred and fifty-two patients who received a massive transfusion with a mean (SD) ISS of 21 (±10) and an overall mortality of 75 of 252 (30%) were included. The mean (SD) F:R ratios transfused for the low and high groups were 0.1 grams/Unit (±0.06), and 0.48 grams/Unit (±0.2), respectively (p < 0.001). Mortality was 27 of 52 (52%) and 48 of 200 (24%) in the low and high F:R ratio groups respectively (p < 0.001). Additional variables associated with survival were admission temperature, systolic blood pressure, hemoglobin, International Normalized Ratio (INR), base deficit, platelet concentration and Combined Injury Severity Score (ISS). Upon logistic regression, the F:R ratio was independently associated with mortality (odds ratio 0.37, 95% confidence interval 0.171-0.812, p = 0.013). The incidence of death from hemorrhage was higher in the low F:R group, 23/27 (85%), compared to the high F:R group, 21/48 (44%) (p < 0.001). Conclusions: In patients with combat-related trauma requiring massive transfusion, the transfusion of an increased fibrinogen: RBC ratio was independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. Prospective studies are needed to evaluate the best source of fibrinogen and the optimal empiric ratio of fibrinogen to RBCs in patients requiring massive transfusion.

402 citations


Journal ArticleDOI
TL;DR: The 8th edition of ATLS has been revised following broad input by the International ATLS subcommittee and grades levels of evidence were used to evaluate and approve changes to the course content.
Abstract: The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

389 citations


Journal ArticleDOI
TL;DR: The findings indicate that the relationship between coagulopathy and mortality is more complex, and further clinical investigation is necessary before recommending routine 1:1 FFP:RBC in the exsanguinating trauma patient.
Abstract: Background: Recent military experience suggests that immediate 1:1 fresh frozen plasma (FFP); red blood cells (RBC) for casualties requiring >10 units packed red blood cells (RBC) per 24 hours reduces mortality, but no clinical trials exist to address this issue. Consequently, we reviewed our massive transfusion practices during a 5-year period to test the hypothesis that 1:1 FFP:RBC within the first 6 hours reduces life threatening coagulopathy. Methods: We queried our level I trauma center's prospective registry from 2001 to 2006 for patients undergoing massive transfusion. Logistic regression was used to evaluate the independent effect of FFP:RBC in 133 patients who received >10 units RBC in 6 hours on (1) Coagulopathy (international normalized ratio [INR] >1.5 at 6 hours), controlling for our previously described risk factors predictive of coagulopathy, as well as RBC, FFP, and platelet administration (2) Death (controlling for all variables plus age, crystalloids per 24 hours, INR >1.5 at 6 hours). Results: Overall mortality was 56%; 50% died from acute blood loss in the operating room. Over 80% of the RBC transfusions were completed in the first 6 hours: (Median RBC: 18 units) Median FFP:ABC survivors, 1:2, nonsurvivors: 1:4. (p 1.5 at 6 hours occurred in 30 (23%); 81% died. Regarding mortality, logistic regression showed significant variables (p 15 (OR = 10.208, 95% CI: 1.957-53.255), ED temperature 55 years (OR = 40531, CI 5315-309.077). The adjusted OR for FFP:RBC ratio including the quadratic term was found to follow a U-shaped association (quadratic term estimate 0.6737 ± 0.0345, p = 0.0189). Conclusion: Although our data suggest that 1:1 FFP:RBC reduced coagulopathy, this did not translate into a survival benefit. Our findings indicate that the relationship between coagulopathy and mortality is more complex, and further clinical investigation is necessary before recommending routine 1:1 in the exsanguinating trauma patient.

385 citations


Journal ArticleDOI
TL;DR: SG is associated with significantly lower mortality and fewer blood transfusions, but there is a considerable risk of serious device-related complications, and a major and urgent need for improvement of the available endovascular devices.
Abstract: Introduction: The purpose of this American Association for the Surgery of Trauma multicenter study is to assess the early efficacy and safety of endovascular stent grafts (SGs) in traumatic thoracic aortic injuries and compare outcomes with the standard operative repair (OR). Patients: Prospective, multicenter study. Data for the following were collected: age, blood pressure, and Glasgow Coma Scale (GCS) at admission, type of aortic injury, injury severity score, abbreviate injury scale (AIS), transfusions, survival, ventilator days, complications, and intensive care unit and hospital days. The outcomes between the two groups (open repair or SG) were compared, adjusting for presence of critical extrathoracic trauma (head, abdomen, or extremity AIS >3), GCS score ≤8, systolic blood pressure 55 years. Separate multivariable analysis was performed, one for patients without and one for patients with associated critical extrathoradc injuries (head, abdomen, or extremity AIS >3), to compare the outcomes of the two therapeutic modalities adjusting for hypotension, GCS score ≤8, and age >55 years. Results: One hundred ninety-three patients met the criteria for inclusion. Overall, 125 patients (64.9%) were selected for SG and 68 (352%) for OR. SG was selected in 71.6% of the 74 patients with major extrathoracic injuries and in 60.0% of the 115 patients with no major extrathoradc injuries. SG patients were significantly older than OR patients. Overall, 25 patients in the SG group (20.0%) developed 32 device-related complications. There were 18 endoleaks (14.4%), 6 of which needed open repair. Procedure-related paraplegia developed in 2.9% in the OR and 0.8% in the SG groups (p = 0.28). Multivariable analysis adjusting for severe extrathoradc injuries, hypotension, GCS, and age, showed that the SG group had a significantly lower mortality (adjusted odds ratio: 8.42; 95% CI: [2.76-25.69]; adjusted p value <0.001), and fewer blood transfusions (adjusted mean difference: 4.98; 95% CI: [0.14-9.82]; adjusted p value = 0.046) than the OR group. Among the 115 patients without major extrathoradc injuries, higher mortality and higher transfusion requirements were also found in the OR group (adjusted odds ratio for mortality: 13.08; 95% CI [2.53-67.53], adjusted p value = 0.002 and adjusted mean difference in transfusion units: 4.45; 95% CI [139-7.51]; adjusted p value = 0.004). Among the 74 patients with major extrathoracic injuries, significantly higher mortality and pneumonia rate were found in the OR group (adjusted p values 0.04 and 0.03, respectively). Multivariate analysis showed that centers with high volume of endovascular procedures had significantly fewer systemic complications (adjusted p value 0.001), fewer local complications (adjusted? value p = 0.033), and shorter hospital lengths of stay (adjusted p value 0.005) than low-volume centers. Conclusions: Most surgeons select SG for traumatic thoracic aortic ruptures, irrespective of associated injuries, injury severity, and age. SG is associated with significantly lower mortality and fewer blood transfusions, but there is a considerable risk of serious device-related complications. There is a major and urgent need for improvement of the available endovascular devices.

372 citations


Journal ArticleDOI
TL;DR: Coagulopathy, independent of hypothermia but strongly correlated with acidosis and ISS, was associated with mortality in combat casualties, similar to that found in civilian trauma patients.
Abstract: Background: Recent civilian studies have documented a relationship between increased mortality and the presence of an early coagulopathy of trauma diagnosed in the emergency department (ED). We hypothesized that acute coagulopathy (international normalized ratio ≥1.5) in combat casualties was associated with increased injury severity and mortality as is seen in civilian trauma patients. Methods: A retrospective study of combat casualties who received a blood transfusion at a single combat support hospital between September 2003 and December 2004 was performed. Coagulation status, pH, base deficit, and temperature were recorded at arrival to the ED. These were analyzed by Injury Severity Score (ISS), associated injury patterns, and mortality. Results: A total of 3,287 patients were treated at the combat support hospital during the study period. Of these, 391 patients were transfused and primarily admitted, thus meeting the study criteria, 347 had coagulation data, and 92% had a penetrating mechanism. The prevalence of acute coagulopathy in transfused casualties measured with point-of-care devices at arrival in the ED was 38%. Mortality in those who were coagulopathic at arrival to the ED was 24% (32/133) versus 4% (8/214) in those not presenting with coagulopathy (p < 0.001). The prevalence of mortality by coagulopathy increased as ISS increased. Coagulopathy and acidosis were associated with mortality, odds ratio (OR), 5.38 [95% confidence interval (CI), 1.55-11.37] and 6.9 (95% CI, 2.1-19.5), respectively. Temperature did not affect outcomes (OR, 1.1; 95% CI, 0.4-2.6). Conclusions: The early coagulopathy of trauma was rapidly diagnosed in the ED and present in more than one-third of combat casualties who received a transfusion, similar to the incidence found in civilian trauma patients. Coagulopathy, independent of hypothermia but strongly correlated with acidosis and ISS, was associated with mortality in combat casualties, similar to that found in civilian trauma patients. Early diagnosis and treatment of acute traumatic coagulopathy with new resuscitation paradigms may improve outcomes.

Journal ArticleDOI
TL;DR: Increased FFP:RBC and PLT:PRBC ratios during a period of massive transfusion improved survival after major trauma and should be designed to achieve these ratios to provide maximal benefit.
Abstract: Background: Despite recent attention and impressive results with damage control resuscitation, the appropriate ratio of blood products to be transfused has yet to be defined. The purpose of this study was to evaluate whether suggested blood product ratios yield superior survival rates. Materials: After IRB approval, a retrospective evaluation was performed on all trauma exsanguination protocol (TEP, n = 118) activations from February 1, 2006 to July 31, 2007. A comparison cohort (pre-TEP, n = 140) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. We then compared those who received FFP: RBC (2:3) and platelet:RBC (1:5) ratios with those who did not reach these ratios. Multivariate analysis was performed for independent predictors of mortality. Results: A total of 259 patients were available for study. Patients receiving FFP: RBC at a ratio of 2:3 or greater (n = 64) had a significant reduction in 30-day mortality compared with those who received less than a 2:3 ratio (n = 195); 41% versus 62%, p = 0.008. Patients receiving platelets:RBC at a ratio of 1:5 or greater (n = 63) had a lower 30-day mortality when compared with those with who received less than this ratio (n = 196); (38% vs. 61%, p = 0.001). Regression model demonstrated that a ratio of FFP to PRBC is an independent predictor of 30-day mortality, controlling for age and TRISS (OR 1.78, 95% CI 1.01-3.14). Conclusions: Increased FFP:PRBC and PLT:PRBC ratios during a period of massive transfusion improved survival after major trauma. Massive transfusion protocols should be designed to achieve these ratios to provide maximal benefit.

Journal Article
TL;DR: It was hypothesized that prehospital tourniquet use decreased hemorrhage from extremity injuries and saved lives, and was not associated with a substantial increase in adverse limb outcomes, and analysis revealed that four of seven deaths were potentially preventable with functional pre Hospital Tourniquets placement.
Abstract: Background: Up to 9% of casualties killed in action during the Vietnam War died from exsanguination from extremity injuries. Retrospective reviews of prehospital tourniquet use in World War II and by the Israeli Defense Forces revealed improvements in extremity hemorrhage control and very few adverse limb outcomes when tourniquet times are less than 6 hours. Hypothesis: We hypothesized that prehospital tourniquet use decreased hemorrhage from extremity injuries and saved lives, and was not associated with a substantial increase in adverse limb outcomes. Methods: This was an institutional review board-approved, retrospective review of the 31st combat support hospital for 1 year during Operation Iraqi Freedom. Inclusion criteria were any patient with a traumatic amputation, major extremity vascular injury, or documented prehospital tourniquet. Results: Among 3,444 total admissions, 165 patients met inclusion criteria. Sixty-seven patients had prehospital tourniquets (TK); 98 patients had severe extremity injuries but no prehospital tourniquet (No TK). Extremity Acute Injury Scores were the same (3.5 TK vs. 3.4 No TK) in both groups. Differences (p 15) subset of patients. Fifty-seven percent of the deaths might have been prevented by earlier tourniquet use. There were no early adverse outcomes related to tourniquet use.

Journal ArticleDOI
TL;DR: In patients requiring>/=8 units of blood after serious blunt injury, an FFP:PRBC transfusion ratio >/=1:1.5 was associated with a significant lower risk of mortality but a higher risk of acute respiratory distress syndrome, providing further justification for the prospective trial investigation into the optimal FFP-PRBC ratio required in massive transfusion practice.
Abstract: Objective: The detrimental effects of coagulopathy, hypothermia, and acidosis are well described as markers for mortality after traumatic hemorrhage. Recent military experience suggests that a high fresh frozen plasma (FFP):packed red blood cell (PRBC) transfusion ratio improves outcome; however, the appropriate ratio these transfusion products should be given remains to be established in a civilian trauma population. Methods: Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in blunt injured adults with hemorrhagic shock. Those patients who required ≥8 units PRBCs within the first 12 hours postinjury were analyzed (n = 415). Results: Patients who received transfusion products in ≥:1.50 FFP:PRBC ratio (high F:P ratio, n = 102) versus <1: 1.50 FFP:PRBC ratio (low F:P, n = 313) required significantly less blood transfusion at 24 hours (16 ± 9 units vs. 22 ± 17 units, p = 0.001). Crude mortality differences between the groups did not reach statistical significance (high F:P 28% vs. low F:P 35%, p = 0.202); however, there was a significant difference in early (24 hour) mortality (high F:P 3.9% vs. low F:P 12.8%, p = 0.012). Cox proportional hazard regression revealed that receiving a high F:P ratio was independently associated with 52% lower risk of mortality after adjusting for important confounders (HR 0.48, p = 0.002, 95% CI 0.3-0.8). A high F:P ratio was not associated with a higher risk of organ failure or nosocomial infection, however, was associated with almost a twofold higher risk of acute respiratory distress syndrome, after controlling for important confounders. Conclusions: In patients requiring ≥8 units of blood after serious blunt injury, an FFP:PRBC transfusion ratio ≥1: 1.5 was associated with a significant lower risk of mortality but a higher risk of acute respiratory distress syndrome. The mortality risk reduction was most relevant to mortality within the first 48 hours from the time of injury. These results suggest that the mortality risk associated with an FFP:PRBC ratio <1:1.5 may occur early, possibly secondary to ongoing coagulopathy and hemorrhage. This analysis provides further justification for the prospective trial investigation into the optimal FFP:PRBC ratio required in massive transfusion Dractice.

Journal ArticleDOI
TL;DR: An FFP to PRBC ratio close to 1:1 confers a survival advantage in patients requiring massive transfusion, and univariate and multivariate analysis were used to assess the relationship between outcome and predictors.
Abstract: analysis. The primary research question was the impact of initial FFP:PRBC ratio on mortality. Other variables for analysis included patient age, gender, mechanism, and Injury Severity Scale score. Both univariate and multivariate analysis were used to assess the relationship between outcome and predictors. Results: A total of 2,746 patients underwent surgical intervention of which 1,985 (72.2%) received no transfusion. Of those that received transfusion, 626 (22.8%) received 10 units of PRBC. Out of the 626 patients that received 10 units PRBC received FFP. In univariate analysis, a significant difference in mortality was found in patients who received >10 units of PRBC (26% vs. 87.5%) when FFP:PRBC ratio was 1:1 versus 1:4 (p 0.0001). Multivariate analysis in the group of patients that received >10 units of PRBC showed a FFP:PRBC ratio of 1:4 was consistent with increased risk of mortality (relative risk, 18.88; 95% CI, 6.32–56.36; p 0.001), when compared with a ratio of 1:1. Patients who received <10 units of PRBC had a trend toward increased mortality (21.2% vs.11.8%) when the FFP:PRBC ratio was 1:4 versus 1:1 (p: 0.06).

Journal ArticleDOI
TL;DR: A review of prehospital tourniquet use in World War II and by the Israeli Defense Forces revealed improvements in extremity hemorrhage control and very few adverse adverse events as discussed by the authors.
Abstract: Background:Up to 9% of casualties killed in action during the Vietnam War died from exsanguination from extremity injuries. Retrospective reviews of prehospital tourniquet use in World War II and by the Israeli Defense Forces revealed improvements in extremity hemorrhage control and very few adverse

Journal Article
TL;DR: The most effective tourniquets were the Emergency Medical Tourniquet (92%) and the Combat Application Tournique (79%) as discussed by the authors, and there was no apparent association of total tournique time and morbidity.
Abstract: Background: Previously we showed that tourniquets were lifesaving devices in the current war. Few studies, however, describe their actual morbidity in combat casualties. The purpose of this study was to measure tourniquet use and complications. Methods: A prospective survey of casualties who required tourniquets was performed at a combat support hospital in Baghdad during 7 months in 2006. Patients were evaluated for tourniquet use, limb outcome, and morbidity. We identified potential morbidities from the literature and looked for them prospectively. The protocol was approved by the institutional review board. Results: The 232 patients had 428 tourniquets applied on 309 injured limbs. The most effective tourniquets were the Emergency Medical Tourniquet (92%) and the Combat Application Tourniquet (79%). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet, whereas six had palsies at the wound level. No association was seen between tourniquet time and morbidity. There was no apparent association of total tourniquet time and morbidity (clots, myonecrosis, rigor, pain, palsies, renal failure, amputation, and fasciotomy). No amputations resulted solely from tourniquet use. However, six (2.6%) casualties with eight preexisting traumatic amputation injuries then had completion surgical amputations and also had tourniquets on for >2 hours. The rate of limbs with fasciotomies with tourniquet time ≤2 hours was 28% (75 of 272) and >2 hours was 36% (9 of 25, = 0.4). Conclusions: Morbidity risk was low, and there was a positive risk benefit ratio in light of the survival benefit. No limbs were lost because of tourniquet use, and tourniquet duration was not associated with increased morbidity. Education for early military tourniquet use should continue.

Journal ArticleDOI
TL;DR: Morbidity risk was low, and there was a positive risk benefit ratio in light of the survival benefit, and education for early military tourniquet use should continue.
Abstract: Background: Previously we showed that tourniquets were lifesaving devices in the current war. Few studies, however, describe their actual morbidity in combat casualties. The purpose of this study was to measure tourniquet use and complications. Methods: A prospective survey of casualties who required tourniquets was performed at a combat support hospital in Baghdad during 7 months in 2006. Patients were evaluated for tourniquet use, limb outcome, and morbidity. We identified potential morbidities from the literature and looked for them prospectively. The protocol was approved by the institutional review board. Results: The 232 patients had 428 tourniquets applied on 309 injured limbs. The most effective tourniquets were the Emergency Medical Tourniquet (92%) and the Combat Application Tourniquet (79%). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet, whereas six had palsies at the wound level. No association was seen between tourniquet time and morbidity. There was no apparent association of total tourniquet time and morbidity (clots, myonecrosis, rigor, pain, palsies, renal failure, amputation, and fasciotomy). No amputations resulted solely from tourniquet use. However, six (2.6%) casualties with eight preexisting traumatic amputation injuries then had completion surgical amputations and also had tourniquets on for >2 hours. The rate of limbs with fasciotomies with tourniquet time 2 hours was 36% (9 of 25, p 0.4). Conclusions: Morbidity risk was low, and there was a positive risk benefit ratio in light of the survival benefit. No limbs were lost because of tourniquet use, and tourniquet duration was not associated with increased morbidity. Education for early military tourniquet use should continue. Key Word: Tourniquet, Hemorrhage, Resuscitation, Mangled extremities, Mass casualties.

Journal ArticleDOI
TL;DR: In case of severe bleeding, buffering toward physiologic pH values is recommended, especially with massive transfusions of older RBCCs displaying exhausted red blood cell buffer systems, and the prevention and timely correction is crucial for the treatment of hemorrhagic coagulopathy.
Abstract: Background: Beside the often discussed topics of consumption and dilution coagulopathy, additional perioperative impairments of coagulation are caused by acidosis, hypocalcemia, anemia, hypothermia, and combinations. Methods: Reviewing current literature, cutoff values of these parameters become obvious at which therapy should commence. Results: A notable impairment of hemostasis arises at a pH ≤7.1. Similar effects are caused by a BE of −12.5 or less. Thus, in case of severe bleeding, buffering toward physiologic pH values is recommended, especially with massive transfusions of older RBCCs displaying exhausted red blood cell buffer systems. It completes the optimization of the volume homeostasis to ensure an adequate tissue perfusion. Results: Combining beneficial cardiovascular and coagulation effects, the level for ionized calcium concentration should be held ≥0.9 mmol/L. Results: From the hemostatic point of view, the optimal Hct is higher than the one required for oxygenation. Even without a “classical” transfusion trigger, the therapy of acute, persistent bleeding should aim at reaching an Hct ≥30%. Results: A core temperature of ≤34°C causes a decisive impairment of hemostasis. A controlled hypotensive fluid resuscitation should aim at reaching a mean arterial pressure of ≥65 mm Hg (possibly higher for cerebral trauma). Prevention and later aggressive therapy of hypothermia by exclusive infusion of warmed fluids and the use of warming devices are prerequisites for the cure of traumatic coagulopathy. Results: Combined appearance of single preconditions cause additive impairments of the coagulation system. Conclusions: The prevention and timely correction, especially of the combination acidosis plus hypothermia, is crucial for the treatment of hemorrhagic coagulopathy.

Journal ArticleDOI
TL;DR: In Australia and New Zealand, mortality and favorable neurologic outcomes after TBI were similar to published data before the advent of evidence-based guidelines, suggesting a high incidence of prehospital secondary brain insults and an ageing population may have contributed to these outcomes.
Abstract: Background:An epidemiologic profile of traumatic brain injury (TBI) in Australia and New Zealand was obtained following the publication of international evidence-based guidelines.Methods:Adult patients with TBI admitted to the intensive care units (ICU) of major trauma centers were studied in a 6-mo

Journal ArticleDOI
TL;DR: Comparisons between the two AAST studies in 1997 and 2007 showed a major shift in the diagnosis of the aortic injury, with the widespread use of CT scan and the almost complete elimination of aortography and TEE.
Abstract: Background:The diagnosis and management of blunt thoracic aortic injuries has undergone many significant changes over the last decade. The present study compares clinical practices and results between an earlier prospective multicenter study by the American Association for the Surgery of Trauma comp

Journal ArticleDOI
TL;DR: There are significant similarities between pediatric and adult patients with pelvic injuries and the mortality rate of children is not different from that of adults and the survival rate of patients sustaining pelvic fracture has improved significantly within the last decade.
Abstract: BACKGROUND: Pelvic and acetabular fractures are rare injuries and account for approximately 3% to 8% of all fractures. Often the result of high energy blunt trauma, most of the patients sustaining pelvic injuries are at high risk of associated injuries strongly influencing outcome and survival rates. Because of anatomic differences it has been suggested that pediatric pelvic fractures are different injuries as compared with that of adults. However, this has been controversially discussed. Aim of this multicenter register study was to identify similarities and differences between pediatric and adult pelvic trauma and evaluate the influence of changes in medical treatment by comparison of two treatment periods. METHODS: In this multicenter register study, data of 4,291 patients treated from 1991 to 1993 (n = 1,723) or 1998 to 2000 (n = 2,568) for pelvic fractures in one of the 23 participating hospitals were evaluated for age, gender, Injury Severity Score (ISS), Hannover Polytrauma Score (PTS), fracture type (using Tile's classification), peripelvic soft tissue injury, need for emergency measures, mortality, cause of death, and need for operative stabilization. We compared the patients' characteristics of the two treatment periods and pediatric with adult pelvic injuries. Statistical analysis was performed using SAS software. RESULTS: There was no difference in terms of ISS, PTS, and presence of peripelvic soft tissue injuries between the two observation periods. Mortality rate dropped significantly from 7.9% to 5% (p Language: en

Journal Article
TL;DR: In this article, a retrospective cohort study was conducted at a single combat support hospital to identify risk factors for massive transfusion (MT) in patients with traumatic injuries, and independent predictors for MT were identified in a cohort of severely injured patients requiring transfusions.
Abstract: Background: Massive transfusion (MT) is associated with increased morbidity and mortality in severely injured patients. Early and aggressive use of blood products in these patients may correct coagulopathy, control bleeding, and improve outcomes. However, rapid identification of patients at risk for MT has been difficult. We postulated that evaluation of clinical variables routinely assessed upon admission would allow identification of these patients for earlier, more effective intervention. Methods: A retrospective cohort study was conducted at a single combat support hospital to identify risk factors for MT in patients with traumatic injuries. Demographic, diagnostic, and laboratory variables obtained upon admission were evaluated. Univariate and multivariate analyses were performed. An algorithm was formulated, validated with an independent dataset and a simple scoring system was devised. Results: Three thousand four hundred forty-two patient records were reviewed. At least one unit of blood was transfused to 680 patients at the combat support hospital. Exclusion criteria included age less than 18 years, transfer from another medical facility, designation as a security internee, or incomplete data fields. The final number of patients was 302, of whom 26.5% (80 of 302) received a MT. Patients with MT had higher mortality (29 vs. 7% \p 105 bpm, systolic blood pressure <110 mm Hg, pH <7.25, and hematocrit <32.0%. An algorithm was created to analyze the risk of MT (area under the curve [AUC] = 0.839). In an independent data set of 396 patients the ability to accurately identify those requiring MT was 66% (AUC = 0.747). Conclusions: Independent predictors for MT were identified in a cohort of severely injured patients requiring transfusions. Patients requiring a MT can be identified with variables commonly obtained upon hospital admission.

Journal ArticleDOI
TL;DR: For trauma patients transfused at least one unit of a blood product, FFP and RBC amounts were independently associated with increased survival and decreased survival, respectively.
Abstract: Background: The amount and age of stored red blood cells (RBCs) are independent predictors of multiorgan failure and death in transfused critically ill patients. The independent effect of plasma transfusion on survival has not been evaluated. Our objective was to determine the independent effects of plasma and RBC transfusion on survival for patients with combat-related traumatic injuries receiving any blood products. Methods: We performed a retrospective review of 708 patients transfused at least one unit of a blood product at one combat support hospital between November 2003 and December 2004. Admission vital signs, laboratory values, amount of blood products transfused in a 24-hour period, and Injury Severity Score (ISS) were analyzed by multivariate logistic regression to determine independent associations with in-hospital mortality. Results: Seven hundred and eight of 3,287 (22%) patients admitted for traumatic injuries were transfused a blood product. Median ISS was 14 (range, 9-25). In-hospital mortality was 12%. Survival was associated with admission Glasgow Coma Scale score, SBP, temperature, hematocrit, base deficit, INR, amount of RBCs transfused, and massive transfusion. Each transfused FFP unit was independently associated with increased survival (OR: 1.17; 95% CI: [1.06-1.29]; p = 0.002); each transfused RBC unit was independently associated with decreased survival (OR: 0.86; [0.8-0.92]; p = 0.001). A subset analysis of patients (n = 567) without massive transfusion (1-9 RBC/FWB units) also revealed an independent association between each FFP unit and improved survival (OR: 1.22; 95% CI: [1.0-1.48]; p = 0.05) and between each RBC unit and decreased survival (OR: 0.77; [0.64-0.92]; p = 0.004). Conclusion: For trauma patients transfused at least one unit of a blood product, FFP and RBC amounts were independently associated with increased survival and decreased survival, respectively. Prospective studies are needed to determine whether the early and increased use of plasma and decreased use of RBCs affect mortality for patients with traumatic injuries requiring transfusion.

Journal ArticleDOI
TL;DR: Thrombelastography was a more accurate indicator of blood product requirements in patients with penetrating traumatic injuries than prothrombin time, partial thromboplastin time, and International Normalization Ratio.
Abstract: Background: Bleeding is a major cause of death in patients with traumatic injuries. Recently, thrombelastograph (TEG) has been suggested as an additional means of evaluating coagulation in trauma patients. We hypothesized that TEG data would aid in defining the coagulopathy of trauma in patients with penetrating traumatic injuries. Methods: A retrospective study was performed of patients (n = 44) with penetrating injuries admitted to a combat support hospital during a 2-month period in 2004. Recorded data included standard laboratory data, TEG parameters, and blood product use in the first 24 hours after admission. Values were compared with clinically accepted ranges and those obtained from the Haemoscope Corporation. Results: At admission, International Normalization Ratio, prothrombin time, and partial thromboplastin time were increased in 39% (≥1.5), 31% (>16 seconds), and 37% (>40 seconds) of patients, respectively, suggesting hypocoagulation, but these variables did not correlate with the use of blood products (p > 0.05). TEG values obtained within 24 hours of admission (6 hours ± 5.7 hours; median of 4.5 hours) demonstrated hypocoagulation based on delayed propagation of the clot (increased K time and reduced α-angle) and decreased clot strength (reduced maximal amplitude [MA]). MA correlated (r = 0.57, p < 0.01) with blood product use as well as platelet count (r = 0.61, p < 0.01). Patients with reduced MA (n = 23) used more blood products and had reduced platelet counts and hematocrit. Conclusion: Thrombelastography was a more accurate indicator of blood product requirements in our patient population than prothrombin time, partial thromboplastin time, and International Normalization Ratio. Thrombelastography enhanced by platelet count and hematocrit can guide blood transfusion requirements.

Journal ArticleDOI
TL;DR: Independent predictors for MT were identified in a cohort of severely injured patients requiring transfusions and patients requiring a MT can be identified with variables commonly obtained upon hospital admission.
Abstract: Background:Massive transfusion (MT) is associated with increased morbidity and mortality in severely injured patients. Early and aggressive use of blood products in these patients may correct coagulopathy, control bleeding, and improve outcomes. However, rapid identification of patients at risk for

Journal ArticleDOI
TL;DR: Hypothermia inhibited clotting times and clotting rate, whereas hemorrhage impaired clot strength, and only TEG differentiated mechanism related to clotting abnormalities, and thus may allow focused treatment of clotting alterations associated with hypothermia and hemorrhagic shock.
Abstract: : Hypothermia and hemorrhagic shock contribute to coagulopathy after trauma. In this study, we investigated the independent and combined effects of hypothermia and hemorrhage with resuscitation on coagulation in swine and evaluated clinically relevant tests of coagulation. Methods: Pigs (n = 24) were randomized into four groups of six animals each: sham control, hypothermia, hemorrhage with resuscitation, and hypothermia, hemorrhage with resuscitation combined. Hypothermia to 32 Degrees C was induced with a cold blanket. Hemorrhage was induced by bleeding 35% of total blood volume followed by resuscitation with lactated Ringer's solution. Coagulation was assessed by thrombin generation, prothrombin time (PT), activated partial thromboplastin time (aPTT), activated clotting time (ACT), and thrombelastography (TEG) from blood samples taken at baseline and 4 hour after hypothermia and/or hemorrhage with resuscitation. Data were compared with analysis of variance. Results: Baseline values were similar among groups. There were no changes in any measurements in the control group. Compared with baseline values, hemorrhage with resuscitation increased lactate to 140% + or - 15% ( p less than 0.05). Hypothermia decreased platelets to 73% + or - 3% (p less than 0.05) with no effect on fibrinogen. Hemorrhage with resuscitation reduced platelets to 72% + or - 4% and fibrinogen to 71% + or - 3% (both p less than 0.05), with similar decreases in platelets and fibrinogen observed in the combined group. Thrombin generation was decreased to 75%+ or - 4% in hypothermia, 67% + or - 6% in hemorrhage with resuscitation, and 75% + or - 10% in the combined group (all p less than 0.05). There were no significant changes in PT or aPTT by hemorrhage or hypothermia. ACT was prolonged to 122% + or - 1% in hypothermia, 111% + or - 4% in hemorrhage with resuscitation, and 127% + or - 3% in the combined group (all p less than 0.05).

Journal ArticleDOI
TL;DR: QuikClot, a zeolite that works by absorbing water and concentrating coagulation factors to stop bleeding in a series of patients, has been effectively used by a wide range of providers in the field and hospital to control hemorrhage.
Abstract: Background:Local hemostatics have recently been introduced for field use to control external hemorrhage. The objective of this report is to describe the initial clinical experience with QuikClot, a zeolite that works by absorbing water and concentrating coagulation factors to stop bleeding in a seri

Journal ArticleDOI
TL;DR: Although larger volumes of blood, irrespective of age, are associated with increased odds of mortality, the transfusion of blood stored beyond 2 weeks appears to potentiate this association despite a practice of universal leukoreduction.
Abstract: Background: The transfusion of relatively older stored blood has been associated with an increased risk of multiple organ failure, infection, and death. It remains unknown whether this phenomenon is mitigated by transfusion of leukoreduced red cell units. The purpose of this study was to evaluate the influence of stored blood age on mortality in injured patients who universally received leukoreduced blood. Methods: Trauma patients who received ≥1 unit of blood during the first 24 hours after hospital arrival were selected for inclusion. Patients were stratified both according to total units and "old" units (≥14 days) versus "young" units (<14 days) received in the initial 24 hours. Odds ratios and 95% confidence intervals (CIs) were calculated for the association between mortality and the age and amount of blood transfused, adjusted for age, sex, injury severity, injury mechanism, number of units transfused, and length of stay. Results: Over 7.5 years, 1,813 patients met study criteria. Among patients who received a total of 1 to 2 or 3 to 5 units in the first 24 hours, there was no association between the amount and age of transfused blood and mortality. For patients who received a total of ≥6 units, the presence of ≥3 units of young blood was associated with a 3.8-fold increased odds of death (CI: 1.1-12.7), compared with a 7.8-fold (CI: 2.3-26.3) increased odds of death associated with the presence of ≥3 units of old blood (p = 0.0024). Conclusion: Although larger volumes of blood, irrespective of age, are associated with increased odds of mortality, the transfusion of blood stored beyond 2 weeks appears to potentiate this association despite a practice of universal leukoreduction. For patients who receive relatively smaller transfusion volumes, blood age appears to have no effect on mortality.

Journal ArticleDOI
TL;DR: MESH and VAC are both useful methods for abdominal coverage, and are equally likely to produce delayed primary closure, and neither method precludes secondary abdominal wall reconstruction.
Abstract: Objective: The options for abdominal coverage after damage control laparotomy or abdominal compartment syndrome vary by institution, surgeon preference, and type of patient. Some advocate polyglactin mesh (MESH), while others favor vacuum-assisted closure (VAC). We performed a single institution prospective randomized trial comparing morbidity and mortality differences between MESH and VAC. Methods: Patients expected to survive and requiring open abdomen management were prospectively randomized to either MESH or VAC. After randomization, an enteral feeding tube was inserted and the closure device placed. VAC patients returned to the operating room every 3 days for a total of three changes at which time polyglactin mesh was placed if closure was not possible. The MESH group had twice daily assessments for the possibility of bedside mesh cinching and closure. Both groups underwent split thickness skin grafting when granulation tissue was evident, if delayed primary closure was not possible. Results: Fifty-one patients were randomized. Both cohorts were matched for Injury Severity Scale score, gender, blunt/ penetrating/abdominal compartment syndrome and age. Three patients died within 7 days and were excluded from closure rate calculation. There were no differences between delayed primary fascial closure rates in the VAC (31%) or MESH (26%) groups. The fistula rate in the VAC group was 21 % but not statistically different from the 5% rate for MESH. Intraabdominal rates were not statistically different. All VAC fistulas were related to feeding tubes and suture line areas; the MESH fistula followed a retroperitoneal colon leak remote from the mesh. Conclusions: MESH and VAC are both useful methods for abdominal coverage, and are equally likely to produce delayed primary closure. The fistula rate for VAC is most likely due to continued bowel manipulation with VAC changes with a feeding tube in place-enteral feeds should be administered via nasojejunal tube. Neither method precludes secondary abdominal wall reconstruction.