Showing papers in "Journal of Trauma-injury Infection and Critical Care in 2014"

Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance to antifibrinolytic therapy.

Abstract: BACKGROUND Fibrinolysis is a physiologic process maintaining patency of the microvasculature. Maladaptive overactivation of this essential function (hyperfibrinolysis) is proposed as a pathologic mechanism of trauma-induced coagulopathy. Conversely, the shutdown of fibrinolysis has also been observed as a pathologic phenomenon. We hypothesize that there is a level of fibrinolysis between these two extremes that have a survival benefit for the severely injured patients.

The public health burden of emergency general surgery in the United States: A 10-year analysis of the Nationwide Inpatient Sample--2001 to 2010.

Abstract: BACKGROUNDEmergency general surgery (EGS) represents illnesses of very diverse pathology related only by their urgent nature. The growth of acute care surgery has emphasized this public health problem, yet the true “burden of disease” remains unknown. Building on efforts by the American Association

Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank

Abstract: BACKGROUNDFlail chest injuries are associated with severe pulmonary restriction, a requirement for intubation and mechanical ventilation, and high rates of morbidity and mortality. Our goals were to investigate the prevalence, current treatment practices, and outcomes of flail chest injuries in poly

Predictors of mortality in geriatric trauma patients: A systematic review and meta-analysis

Abstract: BACKGROUND: The rate of mortality and factors predicting worst outcomes in the geriatric population presenting with trauma are not well established. This study aimed to examine mortality rates in severe and extremely severe injured individuals 65 years or older and to identify the predictors of mortality based on available evidence in the literature. METHODS: We performed a systematic literature search on studies reporting mortality and severity of injury in geriatric trauma patients using MEDLINE, PubMed, and Web of Science. RESULTS: An overall mortality rate of 14.8% (95% confidence interval [CI], 9.8Y21.7%) in geriatric trauma patients was observed. Increasing age and severity of injury were found to be associated with higher mortality rates in this patient population. Combined odds of dying in those older than 74 years was 1.67 (95% CI, 1.34Y2.08) compared with the elderly population aged 65 years to 74 years. However, the odds of dying in patients 85 years and older compared with those of 75 years to 84 years was not different (odds ratio, 1.23; 95% CI, 0.99Y1.52). A pooled mortality rate of 26.5% (95% CI, 23.4Y29.8%) was observed in the severely injured (Injury Severity Score [ISS] Q 16) geriatric trauma patients. Compared with those with mild or moderate injury, the odds of mortality in severe and extremely severe injuries were 9.5 (95% CI, 6.3Y14.5) and 52.3 (95% CI, 32.0Y85.5; p e 0.0001), respectively. Low systolic blood pressure had a pooled odds of 2.16 (95% CI, 1.59Y2.94) for mortality. CONCLUSION: Overall mortality rate among the geriatric population presenting with trauma is higher than among the adult trauma population. Patients older than 74 years experiencing traumatic injuries are at a higher risk for mortality than the younger geriatric group. However, the trauma-related mortality sustains the same rate after the age of 74 years without any further increase. Moreover, severe and extremely severe injuries and low systolic blood pressure at the presentation among geriatric trauma patients are significant risk factors for mortality. (J Trauma Acute Care Surg. 2014;76: 894Y901. Copyright* 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Systematic review and meta-analysis, level IV.

The definition of polytrauma revisited: An international consensus process and proposal of the new 'Berlin definition'

Abstract: BACKGROUND: The nomenclature for patients with multiple injuries with high mortality rates is highly variable, and there is a lack of a uniform definition of the term polytrauma. A consensus process was therefore initiated by a panel of international experts with the goal of assessing an improved, database-supported definition for the polytraumatized patient. METHODS: The consensus process involved the following: RESULTS: A total of 28,211 patients in the trauma registry met the inclusion criteria. The mean (SD) age of the study cohort was 42.9 (20.2) years (72% males, 28% females). The mean (SD) ISS was 30.5 (12.2), with an overall mortality rate of 18.7% (n = 5,277) and an incidence of 3% of penetrating injuries (n = 886). Five independent physiologic variables were identified, and their individual cutoff values were calculated based on a set mortality rate of 30%: hypotension (systolic blood pressure ≤ 90 mm Hg), level of consciousness (Glasgow Coma Scale [GCS] score ≤ 8), acidosis (base excess ≤ -6.0), coagulopathy (international normalized ratio ≥ 1.4/partial thromboplastin time ≥ 40 seconds), and age (≥70 years). CONCLUSION: Based on several consensus meetings and a database analysis, the expert panel proposes the following parameters for a definition of "polytrauma": significant injuries of three or more points in two or more different anatomic AIS regions in conjunction with one or more additional variables from the five physiologic parameters. Further validation of this proposal should occur, favorably by mutivariate analyses of these parameters in a separate data set. Language: en

An analysis of prehospital deaths: Who can we save?

Abstract: BACKGROUNDSince their inception in the late 1970s, trauma networks have saved thousands of lives in the prehospital setting. However, few recent works have been done to evaluate the patients who die in the field. Understanding the epidemiology of these deaths is crucial for trauma system performance

Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon.

Abstract: BACKGROUND The use of catheter-based skills is increasing in the field of vascular trauma. Virtual reality simulation (VRS) is a well-established means of endovascular skills training, and potentially lifesaving skills such as resuscitative endovascular balloon occlusion of the aorta (REBOA) may be obtained through VRS. METHODS Thirteen faculty members in the Division of Trauma and Critical Care performed REBOA six times on the Vascular Intervention System Training Simulator-C after a didactic and instructional session. Subjects were excluded if they had taken a similar endovascular training course, had additional training in endovascular surgery, or had performed this procedure in the clinical setting. Performance metrics included procedural time; accurate placement of guide wire, sheath, and balloon; correct sequence of steps; economy of motion; and safe use of endovascular tools. A precourse and postcourse test and questionnaire were performed by each subject. RESULTS Significant improvements in knowledge (p = 0.0013) and procedural task times (p < 0.0001) were observed at the completion of the course. No correlation was observed with endovascular experience in residency, number of central and arterial catheters placed weekly, or other parameters. All trainees strongly agreed that the course was beneficial, and the majority would recommend this training to other acute care surgeons. CONCLUSION Damage control endovascular procedures can be effectively taught using VRS. Significant improvements in procedural time and knowledge can be achieved regardless of endovascular experience in residency, years since residency, or other parameters. Novice interventionalists (acute care surgeons) can add a specific skill set (REBOA) to their existing core competencies, which has the potential to improve the survival and/or outcomes of severely injured patients.

Epidemiology and risk factors of multiple-organ failure after multiple trauma: an analysis of 31,154 patients from the TraumaRegister DGU.

Abstract: BACKGROUNDIn the severely injured who survive the early posttraumatic phase, multiple-organ failure (MOF) is the main cause of morbidity and mortality. An enhanced prediction of MOF might influence individual monitoring and therapy of severely injured patients.METHODSWe performed a retrospective ana

Persistent inflammation, immunosuppression, and catabolism syndrome after severe blunt trauma.

Abstract: BACKGROUNDWe recently proffered that a new syndrome persistent inflammation, immunosuppression, and catabolism syndrome (PICS) has replaced late multiple-organ failure as a predominant phenotype of chronic critical illness. Our goal was to validate this by determining whether severely injured trauma

Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer?

Abstract: BACKGROUNDThe frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients.METHODSWe

Temporal trends of postinjury multiple-organ failure: Still resource intensive, morbid, and lethal

Abstract: BACKGROUND While the incidence of postinjury multiple-organ failure (MOF) has declined during the past decade, temporal trends of its morbidity, mortality, presentation patterns, and health care resources use have been inconsistent. The purpose of this study was to describe the evolving epidemiology of postinjury MOF from 2003 to 2010 in multiple trauma centers sharing standard treatment protocols.

Long-term outcomes of ground-level falls in the elderly.

Abstract: BACKGROUND: For older adults, even ground-level falls (GLFs) can result in multiple injuries and are associated with significant morbidity and mortality. Previous studies have focused on in-hospital outcomes and patients with isolated injuries. Our study examined outcomes following discharge for older adults who were hospitalized following a GLF. METHODS: A retrospective cohort study of patients older than 65 years admitted to a regional Level I trauma center, from 2005 to 2008, after a GLF was conducted. Hospital trauma registry data were linked to state hospital discharge data and the death certificate registry. Skilled nursing facilities (SNFs) were contacted to verify ultimate patient placement, with follow-up through December 2010. Kaplan-Meier and Cox proportional hazards models were used to analyze postdischarge mortality. RESULTS: There were 1,352 consecutive admissions; 48% had an Injury Severity Score (ISS) greater than 15, and 12% died during admission. Of the patients who survived hospitalization, 51% were discharged to an SNF, 33% to home without assistance, 6% to home with assistance, and 5% to inpatient rehabilitation facilities. Within 1 year of injury, 44.6% of the patients were readmitted. The 1-year mortality for the overall cohort was 33%; for patients who were discharged alive, the 1-year mortality was 24%. After adjusting for confounders, patients discharged to an SNF had a threefold greater risk of 1-year mortality (hazard ratio, 2.82; 95% confidence interval, 1.86-4.28), compared with patients discharged home with no assistance. Of the patients discharged to an SNF, 48% died by the end of the follow-up period (mean, 28.2 months), and 61% of these patients died while residing at an SNF. CONCLUSION: GLFs in the elderly result in severe injury, high rate of readmissions, and increased mortality, both in-hospital and after discharge. Overall, only one third of the patients were discharged home to independent living. Future efforts should examine whether improvements in the quality of posthospital care affect both mortality and functional outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III. Language: en

The BIG (brain injury guidelines) project: Defining the management of traumatic brain injury by acute care surgeons

Abstract: BACKGROUNDIt is becoming a standard practice that any “positive” identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines—based on each patie

Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: A systematic review and meta-analysis

Abstract: BACKGROUNDTraumatic injury in the United States is the Number 1 cause of mortality for patients 1 year to 44 years of age. Studies suggest that early identification of major injury leads to better outcomes for patients. Imaging, such as computed tomography (CT), is routinely used to help determine t

Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX).

Abstract: Background Early administration of tranexamic acid (TXA) has been associated with a reduction in mortality and blood product requirements in severely injured adults. It has also shown significantly reduced blood loss and transfusion requirements in major elective pediatric surgery, but no published data have examined the use of TXA in pediatric trauma. Methods This is a retrospective review of all pediatric trauma admissions to the North Atlantic Treaty Organization Role 3 hospital, Camp Bastion, Afghanistan, from 2008 to 2012. Univariate and logistic regression analyses of all patients and select subgroups were performed to identify factors associated with TXA use and mortality. Standard adult dosing of TXA was used in all patients. Results There were 766 injured patients 18 years or younger (mean [SD] age, 11 [5] years; 88% male; 73% penetrating injury; mean [SD], Injury Severity Score [ISS], 10 [9]; mean [SD] Glasgow Coma Scale [GCS] score, 12 [4]). Of these patients, 35% required transfusion in the first 24 hours, 10% received massive transfusion, and 76% required surgery. Overall mortality was 9%. Of the 766 patients, 66 (9%) received TXA. The only independent predictors of TXA use were severe abdominal or extremity injury (Abbreviated Injury Scale [AIS] score ≥ 3) and a base deficit of greater than 5 (all p 15) and transfused patients. There was no significant difference in thromboembolic complications or other cardiovascular events. Propensity analysis confirmed the TXA-associated survival advantage and suggested significant improvements in discharge neurologic status as well as decreased ventilator dependence. Conclusion TXA was used in approximately 10% of pediatric combat trauma patients, typically in the setting of severe abdominal or extremity trauma and metabolic acidosis. TXA administration was independently associated with decreased mortality. There were no adverse safety- or medication-related complications identified. Level of evidence Therapeutic study, level IV.

Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage.

Abstract: BACKGROUNDTrauma hemorrhage continues to carry a high mortality rate despite changes in modern practice. Traditional approaches to the massively bleeding patient have been shown to result in persistent coagulopathy, bleeding, and poor outcomes. Hemostatic (or damage control) resuscitation developed

Fibrinogen and platelet contributions to clot formation: implications for trauma resuscitation and thromboprophylaxis.

Abstract: BACKGROUND Thromboelastography (TEG) is used to diagnose perturbations in clot formation and lysis that are characteristic of acute traumatic coagulopathy (ATC). With novel functional fibrinogen (FF) TEG, fibrin- and platelet-based contributions to clot formation can be elucidated to tailor resuscitation and thromboprophylaxis. We sought to describe the longitudinal contributions of fibrinogen and platelets to clot strength after injury, hypothesizing that low levels of functional fibrinogen and a low contribution of fibrinogen to clot strength on admission would be associated with coagulopathy, increased transfusion requirements, and worse outcomes.

Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it.

Abstract: BACKGROUNDAggressive screening to diagnose blunt cerebrovascular injury (BCVI) results in early treatment, leading to improved outcomes and reduced stroke rates. While computed tomographic angiography (CTA) has been widely adopted for BCVI screening, evidence of its diagnostic sensitivity is margina

Unconscious race and class bias: its association with decision making by trauma and acute care surgeons.

Abstract: BACKGROUNDRecent studies have found that unconscious biases may influence physicians’ clinical decision making. The objective of our study was to determine, using clinical vignettes, if unconscious race and class biases exist specifically among trauma/acute care surgeons and, if so, whether those bi

Do all trauma patients benefit from tranexamic acid

Abstract: BACKGROUNDThis study tested the hypothesis that early routine use of tranexamic acid (TXA) reduces mortality in a subset of the most critically injured trauma intensive care unit patients.METHODSConsecutive trauma patients (n = 1,217) who required emergency surgery (OR) and/or transfusions from Augu

The Mayo Clinic experience with Morel-Lavallée lesions: establishment of a practice management guideline.

Abstract: BACKGROUNDAlthough uncommon, Morel-Lavallee lesions (also called closed degloving injuries) are associated with considerable morbidity in trauma patients. There is lack of consensus regarding proper management of these lesions. Management options include nonoperative therapies, along with percutaneo

Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) Course: Curriculum Development, Content Validation, and Program Assessment

Abstract: BACKGROUNDThe management of hemorrhage shock requires support of central aortic pressure including perfusion to the brain and heart as well as measures to control bleeding. Emerging endovascular techniques including resuscitative endovascular balloon occlusion of the aorta serve as potential lifesav

Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention.

Abstract: BACKGROUNDWe hypothesized that patients with pelvic fractures and hemorrhage admitted during daytime hours were undergoing interventional radiology (IR) earlier than those admitted at night and on weekends, thereby establishing two standards of time to hemorrhage control.METHODSThe trauma registry (

The impact of preinjury anticoagulants and prescription antiplatelet agents on outcomes in older patients with traumatic brain injury.

Abstract: Background Anticoagulants and prescription antiplatelet (ACAP) agents widely used by older adults have the potential to adversely affect traumatic brain injury (TBI) outcomes. We hypothesized that TBI patients on preinjury ACAP agents would have worse outcomes than non-ACAP patients. Methods This was a 5.5-year retrospective review of patients 55 years and older admitted to a Level I trauma center with blunt force TBI. Patients were categorized as ACAP (warfarin, clopidogrel, dipyridamole/aspirin, enoxaparin, subcutaneous heparin, or multiple agents) or non-ACAP. ACAP patients were further stratified by class of agent (anticoagulant or antiplatelet). Initial and subsequent head computerized tomographic results were examined for type and progression of TBI. Patient preadmission living status and discharge destination were identified. Primary outcome was in-hospital mortality. Secondary outcomes were progression of initial TBI, development of new intracranial hemorrhage (remote from initial), and the need for an increased level of care at discharge. Results A total of 353 patients met inclusion criteria: 273 non-ACAP (77%) and 80 ACAP (23%). Upon exclusion of three patients taking a combination of agents, 350 were available for advanced analyses. ACAP status was significantly related to in-hospital mortality. After adjustment for patient and injury characteristics, anticoagulant users were more likely than non-ACAP patients to show progression of initial hemorrhage and develop a new hemorrhagic focus. However, compared with non-ACAP users, antiplatelet users were more likely to die in the hospital. Among survivors to discharge, anticoagulant users were more likely to be discharged to a care facility, but this finding was not robust to adjustment. Conclusion Older TBI patients on preinjury ACAP agents experience a comparatively higher rate of inpatient mortality and other adverse outcomes caused by the effects of antiplatelet agents. Our findings should inform decision making regarding prognosis and caution against grouping anticoagulant and antiplatelet users together in considering outcomes. Level of evidence Therapeutic study, level IV.

Tracheostomy timing in traumatic brain injury: a propensity-matched cohort study.

Abstract: BACKGROUNDThe optimal timing of tracheostomy in patients with severe traumatic brain injury (TBI) is controversial; observational studies have been challenged through confounding by indication, and interventional studies have rarely enrolled patients with isolated TBI.METHODSWe included a cohort of

Measuring anatomic severity of disease in emergency general surgery.

Abstract: BACKGROUNDCurrently, there is no established system for assessing disease severity in emergency general surgery (EGS) patients. The purpose of this project was to develop a uniform grading system for measuring anatomic severity of disease in this patient population.METHODSThe Committee on Patient As

Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates

Abstract: BACKGROUNDEvidence-based guidelines for prophylactic antibiotic use in open fractures recommend short-course, narrow-spectrum antibiotics for Gustilo Grade I or II open fractures and broader gram-negative coverage for Grade III open fractures. No studies to date have assessed the impact of these gui

Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality.

Abstract: BACKGROUNDUnstable pelvic fracture is predominantly caused by high-energy blunt trauma and is associated with a high risk of mortality. The epidemiology in the United States is largely unknown. The purpose of this study was to examine the epidemiology of unstable pelvic fracture based on patient and

Traumatic brain injury causes platelet adenosine diphosphate and arachidonic acid receptor inhibition independent of hemorrhagic shock in humans and rats.

Abstract: BACKGROUND—Coagulopathy in traumatic brain injury (CTBI) is a well-established phenomenon, but its mechanism is poorly understood. Various studies implicate protein C activation related to the global insult of hemorrhagic shock or brain tissue factor release with resultant platelet dysfunction and depletion of coagulation factors. We hypothesized that the platelet dysfunction of CTBI is a distinct phenomenon from the coagulopathy following hemorrhagic shock. METHODS—We used thrombelastography with platelet mapping as a measure of platelet function, assessing the degree of inhibition of the adenosine diphosphate (ADP) and arachidonic acid (AA) receptor pathways. First, we studied the early effect of TBI on platelet inhibition by performing thrombelastography with platelet mapping on rats. We then conducted an analysis of admission blood samples from trauma patients with isolated head injury (n = 70). Patients in shock or on clopidogrel or aspirin were excluded. RESULTS—In rats, ADP receptor inhibition at 15 minutes after injury was 77.6% ± 6.7% versus 39.0% ± 5.3% for controls (p < 0.0001). Humans with severe TBI (Glasgow Coma Scale [GCS] score ≤ 8) showed an increase in ADP receptor inhibition at 93.1% (interquartile range [IQR],

Developing best practices to study trauma outcomes in large databases: an evidence-based approach to determine the best mortality risk adjustment model.

Abstract: BACKGROUND: The National Trauma Data Bank (NTDB) is an invaluable resource to study trauma outcomes. Recent evidence suggests the existence of great variability in covariate handling and inclusion in multivariable analyses using NTDB, leading to differences in the quality of published studies and potentially in benchmarking trauma centers. Our objectives were to identify the best possible mortality risk adjustment model (RAM) and to define the minimum number of covariates required to adequately predict trauma mortality in the NTDB. METHODS: Analysis of NTDB 2009 was performed to identify the best RAM for trauma mortality. For each plausible NTDB covariate, univariate logistic regression was performed, and the area under the receiver operating characteristics curve (AUROC, with 95% confidence interval [CI]) was calculated. Covariates with p RESULTS: A total of 630,307 patients from NTDB 2009 were analyzed. A total of 16 of 106 NTDB covariates tested on univariate analyses were selected for inclusion in the initial multivariate model. The best RAM included only six covariates (age, hypotension, pulse, total Glasgow Coma Scale [GCS] score, Injury Severity Score [ISS], and a need for ventilator use) yet still demonstrated excellent discrimination between survivors and nonsurvivors (AUROC, 0.9578; 95% CI, 0.9565-0.9590). In addition, this model was validated on 665,138 patients included in NTDB 2010 (AUROC, 0.9577; 95% CI, 0.9564-0.9589). Similar results were obtained for the subset analyses. CONCLUSION: This quantitative synthesis proposes a framework and a set of covariates for studying trauma mortality outcomes. Such analytic standardization may prove critical in implementing best practices aimed at improving the quality and consistency of NTDB-based research. LEVEL OF EVIDENCE: Prognostic study, level III. Language: en