Showing papers in "Journal of Trauma-injury Infection and Critical Care in 2015"

The excess morbidity and mortality of emergency general surgery.

Abstract: BACKGROUNDEmergency general surgery (EGS) carries a disproportionate burden of risk from medical errors, complications, and death compared with non-EGS (NEGS). Previous studies have been limited by patient and procedure heterogeneity but suggest worse outcome in EGS patients because of preoperative

Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage.

Abstract: BACKGROUNDHemorrhage remains the leading cause of death in trauma patients. Proximal aortic occlusion, usually performed by direct aortic cross-clamping via thoracotomy, can provide temporary hemodynamic stability, permitting definitive injury repair. Resuscitative endovascular balloon occlusion of

An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma

Abstract: BACKGROUNDWithin the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present

Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta.

Abstract: BACKGROUNDResuscitative endovascular balloon occlusion of the aorta (REBOA) is one of the ultimately invasive procedures for managing a noncompressive torso injury. Since it is less invasive than resuscitative open aortic cross-clamping, its clinical application is expected.METHODSWe retrospectively

The role of REBOA in the control of exsanguinating torso hemorrhage.

Abstract: The management of patients with exsanguinating torso hemorrhage is challenging. Emergency surgery, with the occasional use of resuscitative thoracotomy for patient in extremis, is the current standard. Recent reports of REBOA (resuscitative endovascular balloon occlusion of the aorta) have led to discussions about changing paradigms in the management of patients in both civilian and military are nas. We submit that broad and liberal application of this technique is premature given the current data and in light of historical experience. We propose an algorithm for the management of patients with exsanguinating torso hemorrhage, as well as a set of research questions that we feel can help clarify the role of REBOA in modern trauma care in a variety of trauma settings.

Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients.

Abstract: BACKGROUNDDespite a growing call for use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for critically uncontrolled hemorrhagic shock, there is limited evidence of treatment efficacy. We compared the mortality between patients who received a REBOA with those who did not, adjust

The financial burden of emergency general surgery: National estimates 2010 to 2060.

Abstract: BACKGROUNDAdoption of the acute care surgery model has led to increasing volumes of emergency general surgery (EGS) patients at trauma centers. However, the financial burden of EGS services on trauma centers is unknown. This study estimates the current and future costs associated with EGS hospitaliz

Injury in the aged: Geriatric trauma care at the crossroads

Abstract: In the 2010 US Census, the number of persons age 65 years and older constituted 13% of the population and is projected to constitute 22% of the population by 2020.1 As the US population ages, there is an increasing volume of GTPs; injury is now the seventh leading cause of death for those age 65 years.2 Geriatric trauma is increasing both in absolute number and as a proportion of annual volume presenting to trauma centers. Based on the National Trauma Data Bank, the proportion of trauma patients aged 65 years or older in Level I and II trauma centers increased from 23% in 2003 to 30% in 2009. This is likely a significant underestimate because most GTPs are treated at lower-level or nontrauma centers.3,4 In Washington State, for example, the annual number of GTPs in the state registry has increased from 4,266 in 2000 to 11,226 in 2012, an increase from 30% to 42% of the total trauma population. Clearly, the management of injury in geriatric patients will continue to be a major challenge for trauma care providers. In his presidential address to the AAST entitled “For the care of the undeserved,” Dr. Robert Mackersie identified the growing population of elderly injured patients as medically underserved in terms of limited trauma center access, age-related treatment biases, and as a result, deprived of many of the recent advances in modern trauma care.5 To specifically address these inequalities, he convened an Ad Hoc Geriatric Committee and charged it, “To advise the AAST regarding the problems, issues, and needs of the geriatric patient.” What follows is the work product of the Committee in responding to President Mackersie’s charge. The initial priority was to survey the membership of the AAST to better understand the current conditions under which hospitalized GTPs are receiving care. The second task of the Committee was to enumerate the major problems associated with the care of GTPs and to suggest potential solutions to the identified problems. While the Committee does not presume infallibility in its pronouncements, the material presented is intended to initiate discussion, stimulate research, and to ultimately result in evidence-based guidelines that will better serve this “underserved” segment of our population.

Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012.

Abstract: BACKGROUND: The United Kingdom was at war in Iraq and Afghanistan for more than a decade. Despite assertions regarding advances in military trauma care during these wars, thus far, no studies have examined survival in UK troops during this sustained period of combat. The aims of this study were to examine temporal changes of injury patterns defined by body region and survival in a population of UK Military casualties between 2003 and 2012 in Iraq and Afghanistan. METHODS: The UK Military Joint Theatre Trauma Registry was searched for all UK Military casualties (survivors and fatalities) sustained on operations between January 1, 2003, and December 31, 2012. The New Injury Severity Score (NISS) was used to stratify injury severity. RESULTS: There were 2,792 UK Military casualties sustaining 14,252 separate injuries during the study period. There were 608 fatalities (22% of all casualties). Approximately 70% of casualties injured in hostile action resulted from explosive munitions. The extremities were the most commonly injured body region, involved in 43% of all injuries. The NISS associated with a 50% chance of survival rose each year from 32 in 2003 to 60 in 2012. CONCLUSION: An improvement in survival during the 10-year period is demonstrated. A majority of wounds are a result of explosive munitions, and the extremities are the most commonly affected body region. The authors recommend the development of more sophisticated techniques for the measuring of the performance of combat casualty care systems to include measures of morbidity and functional recovery as well as survival. LEVEL OF EVIDENCE: Epidemiologic study, level III. Language: en

Clinical evidence of inflammation driving secondary brain injury: a systematic review.

Abstract: Background Despite advances in both prevention and treatment, traumatic brain injury (TBI) remains one of the most burdensome diseases; 2% of the US population currently lives with disabilities resulting from TBI. Recent advances in the understanding of inflammation and its impact on the pathophysiology of trauma have increased the interest in inflammation as a possible mediator in TBI outcome.

National estimates of predictors of outcomes for emergency general surgery.

Abstract: BACKGROUNDIdentifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions. However, similar work has yet to be done for factors affecting outcomes of emergency general surgery (EGS). The objective of this study was to determine the

Evaluation and management of blunt traumatic aortic injury: A practice management guideline from the Eastern Association for the Surgery of Trauma

Abstract: BACKGROUNDBlunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Sur

Tourniquet use at the Boston Marathon bombing: Lost in translation.

Abstract: BACKGROUNDThe Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe lower extremity injuries. First responders, including trained professionals and civilian bystanders, rushed to aid the injured. The purpose of this review was to determine how severely bleeding

A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial.

Abstract: Background Optimal resuscitation of hypotensive trauma patients has not been defined. This trial was performed to assess the feasibility and safety of controlled resuscitation (CR) versus standard resuscitation (SR) in hypotensive trauma patients. Methods Patients were enrolled and randomized in the out-of-hospital setting. Nineteen emergency medical services (EMS) systems in the Resuscitation Outcome Consortium participated. Eligible patients had an out-of-hospital systolic blood pressure (SBP) of 90 mm Hg or lower. CR patients received 250 mL of fluid if they had no radial pulse or an SBP lower than 70 mm Hg and additional 250-mL boluses to maintain a radial pulse or an SBP of 70 mm Hg or greater. The SR group patients received 2 L initially and additional fluid as needed to maintain an SBP of 110 mm Hg or greater. The crystalloid protocol was maintained until hemorrhage control or 2 hours after hospital arrival. Results A total of 192 patients were randomized (97 CR and 95 SR). The CR and SR groups were similar at baseline. The mean (SD) crystalloid volume administered during the study period was 1.0 L (1.5) in the CR group and 2.0 L (1.4) in the SR group, a difference of 1.0 L (95% confidence interval [CI], 0.6-1.4). Intensive care unit-free days, ventilator-free days, renal injury, and renal failure did not differ between the groups. At 24 hours after admission, there were 5 deaths (5%) in the CR group and 14 (15%) in the SR group (adjusted odds ratio, 0.39; 95% CI, 0.12-1.26). Among patients with blunt trauma, 24-hour mortality was 3% (CR) and 18% (SR) with an adjusted odds ratio of 0.17 (0.03-0.92). There was no difference among patients with penetrating trauma (9% vs. 9%; adjusted odds ratio, 1.93; 95% CI, 0.19-19.17). Conclusion CR is achievable in out-of-hospital and hospital settings and may offer an early survival advantage in blunt trauma. A large-scale, Phase III trial to examine its effects on survival and other clinical outcomes is warranted. Level of evidence Therapeutic study, level I.

Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE.

Abstract: BACKGROUNDNonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new

Tourniquet use for civilian extremity trauma.

Abstract: Background Unlike in the military setting, where the use of tourniquets has been well established, in the civilian sector their use has been far less uniform. The purpose of this study was to examine the outcomes associated with the use of tourniquets for civilian extremity trauma. Study design Adult (≥18 years) patients admitted to our institution with an extremity injury requiring tourniquet application from January 2007 to June 2014 were retrospectively reviewed. The primary outcome analyzed was limb loss. Secondary outcomes included death, hospital length of stay, and complications. Results There were 87 patients who met inclusion criteria. Average age was 35.3 years, 90.8% were male, and 66.7% had penetrating injuries, with a median Injury Severity Score (ISS) of 6. Tourniquets were placed in the prehospital setting in 50.6%, in the emergency department in 39.1%, and in the operating room in 10.3% of patients. The windlass type Combat Application Tourniquet was the most commonly used type (67.8%), followed by a pneumatic system (24.1%) and self-made tourniquet (8.0%). The median duration of use was 75 minutes (interquartile range, 91) with no differences between groups (p = 0.547). Overall, 80.5% had a vascular injury (70.1% arterial), and a total of 99 limb operations were performed, including 15 amputations. Fourteen amputations (93.3%) occurred at the scene or were directly attributed to the extent of tissue damage with a median Mangled Extremity Severity Score (MESS) of 7 (interquartile range, 2). In the remaining patient, the tourniquet was lifesaving but likely contributed to limb loss. Seven patients sustained 13 other complications; however, none was directly attributed to tourniquet use. Conclusion Tourniquet use in the civilian sector is associated with a low rate of complications. With the low complication rate and high potential for benefit, aggressive use of this potentially lifesaving intervention is justified. Level of evidence Epidemiologic/prognostic study, level III.

Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data.

Abstract: : Preventing death from traumatic injury in both adult and pediatric patients requires the rapid, accurate identification of those who have bled significantly or who harbor injuries with significant bleeding potential. Identifying such patients early and responding with data-driven treatment strategies represent the singular focus of numerous ongoing investigative efforts in the trauma community. Delivery of a massive transfusion (MT) has been used by some to identify patients at risk for death from hemorrhage.1 MT has classically been defined as the administration of a large volume of whole blood (WB) or packed red blood cells (PRBCs) over a given time period (e.g., one blood volume over 24 hours).1,2 However, most definitions are based on arbitrary volumes of products transfused over different time frames and have never been validated as predictive of mortality. 3Y5 Ultimately, the principal obstacle to creating a valid definition of MT is the heterogeneity of populations studied.1,6,7 For pediatric patients, all current MT variations in the adult literature have little relevance because of differences in patient size, patient physiology, and injury demographics.8,9 The most commonly held MT definition in the field of pediatric transfusion is the administration of 50% circulating blood volume over 24 hours. However, like the adult MT definitions, this definition is arbitrary and has never been validated, leading some to question the very utility of such a measure.

Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system.

Abstract: BACKGROUNDAccording to Donabedian’s health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma sy

Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma.

Abstract: Cervical spine (C-spine) collar clearance or removal is well established for the alert patient with or without symptoms; 1,2 however, for the obtunded adult blunt trauma patient, it is unclear whether primary screening with computed tomography (CT) is sufficient or whether a second diagnostic adjunct is required.3 The imprecise and possible overly broad interpretation of the word obtunded along with continual advances in imaging technology confound the decision to remove the cervical collar after blunt traumatic injury. Despite the multispecialty impact that a guideline directing efficient cervical collar clearance in the obtunded adult blunt trauma patient would have, there is no consensus recommendation available. With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group,4–6 our aims were to perform a systematic review and to develop evidence-based recommendations that might be used to direct decision making in the removal of a cervical collar from the adult obtunded blunt trauma patient.

The American Association for the Surgery of Trauma Prospective Observational Vascular Injury Treatment (proovit) registry: Multicenter data on modern vascular injury diagnosis, management, and outcomes

Abstract: BACKGROUND There is a need for a prospective registry designed to capture trauma-specific, in-hospital, and long-term outcomes related to vascular injury. METHODS The American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry was used to collect demographic, diagnostic, treatment, and outcome data on vascular injuries. RESULTS A total of 542 injuries from 14 centers (13 American College of Surgeons-verified Level I and 1 American College of Surgeons-verified Level II) have been captured since February 2013. The majority of patients are male (70.5%), with an Injury Severity Score (ISS) of 15 or greater among 32.1%. Penetrating mechanisms account for 36.5%. Arterial injuries to the head/neck (26.7%), thorax (10.4%), abdomen/pelvis (7.8%), upper extremity (18.4%), and lower extremity (26.0%) were identified, along with 98 major venous injuries. Hard signs of vascular injury, including hypotension (systolic blood pressure < 90 mm Hg, 11.8%), were noted in 28.6%. Prehospital tourniquet use for extremity injuries occurred in 20.2% (47 of 233). Diagnostic modalities included exploration (28.8%), computed tomographic angiography (38.9%), duplex ultrasound (3.1%), and angiography (10.7%). Arterial injuries included transection (24.3%), occlusion (17.3%), partial transection/flow limiting defect (24.5%), pseudoaneurysm (9.0%), and other injuries including intimal defects (22.7%). Nonoperative management was undertaken in 276 (50.9%), with failure in 4.0%. Definitive endovascular and open repair were used in 40 (7.4%) and 126 (23.2%) patients, respectively. Damage-control maneuvers were used in 57 (10.5%), including ligation (31, 5.7%) and shunting (14, 2.6%). Reintervention of initial repair was required in 42 (7.7%). Amputation was performed in 7.7% of extremity vascular injuries, and overall hospital mortality was 12.7%. Follow-up ranging from 1 month to 7 months is available for 48 patients via a variety of modalities, with reintervention required in 1 patient. CONCLUSION The PROOVIT registry provides a contemporary picture of the management of vascular injury. This resource promises to provide needed information required to answer questions about optimal diagnosis and management of these patients-including much needed long-term outcome data. LEVEL OF EVIDENCE Epidemiologic study, level V.

Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90.

Abstract: BACKGROUND: Undertriage is a concern in geriatric patients. The National Trauma Triage Protocol (NTTP) recognized that systolic blood pressure (SBP) less than 110 mm Hg may represent shock in those older than 65 years. The objective was to evaluate the impact of substituting an SBP of less than 110 mm Hg for the current SBP of less than 90 mm Hg criterion within the NTTP on triage performance and mortality. METHODS: Subjects undergoing scene transport in the National Trauma Data Bank (2010-2012) were included. The outcome of trauma center need was defined as Injury Severity Score (ISS) greater than 15, intensive care unit admission, urgent operation, or emergency department death. Geriatric (age > 65 years) and adult (age, 16-65 years) cohorts were compared. Triage characteristics and area under the curve (AUC) were compared between SBP of less than 110 mm Hg and SBP of less than 90 mm Hg. Hierarchical logistic regression was used to determine whether geriatric patients newly triaged positive under this change (SBP, 90-109 mm Hg) have a risk of mortality similar to those triaged positive with SBP of less than 90 mm Hg. RESULTS: There were 1,555,944 subjects included. SBP of less than 110 mm Hg had higher sensitivity but lower specificity in geriatric (13% vs. 5%, 93% vs. 99%) and adult (23% vs. 10%, 90% vs. 98%) cohorts. AUC was higher for SBP of less than 110 mm Hg individually in both geriatric and adult (p CONCLUSION: SBP of less than 110 mm Hg increases sensitivity. SBP of less than 110 mm Hg has discrimination as good as that of SBP of less than 90 mm Hg, with superior improvements in undertriage relative to overtriage in geriatric patients. Geriatric patients newly triaged to be positive under this change have a risk of mortality similar to those under the current SBP criterion. This change in SBP criteria may be merited in geriatric patients, warranting further study to consider elevation to a Step 1 criterion in the NTTP. LEVEL OF EVIDENCE: Diagnostic study, level IV. Language: en

Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients.

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

2014 Consensus conference on viscoelastic test-based transfusion guidelines for early trauma resuscitation: Report of the panel.

Abstract: There has been an increased interest in the use of viscoelastic testing to guide blood product replacement during the acute resuscitation of the injured patient. Currently, no uniformly accepted guidelines exist for how this technology should be integrated into clinical care. In September 2014, an international multidisciplinary group of leaders in the field of trauma coagulopathy and resuscitation was assembled for a 2-day consensus conference in Philadelphia, Pennsylvania. This panel included trauma surgeons, hematologists, blood bank specialists, anesthesiologists, and the lay public.Nine questions regarding the impact of viscoelastic testing in the early resuscitation of trauma patients were developed before the conference by panel consensus. Early use was defined as baseline viscoelastic test result thresholds obtained within the first minutes of hospital arrival-when conventional laboratory results are not available. The available data for each question were then reviewed in person using standardized presentations by the expert panel. A consensus summary document was then developed and reviewed by the panel in an open forum. Finally, a two-round Delphi poll was administered to the panel of experts regarding viscoelastic thresholds for triggering the initiation of specific treatments including fibrinogen, platelets, plasma, and prothrombin complex concentrates. This report summarizes the findings and recommendations of this consensus conference.

Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study

Abstract: BACKGROUNDBlunt thoracic aortic injuries (BTAIs) are composed of a spectrum of lesions ranging from intimal tear to rupture, yet optimal management and ultimate outcome have not been clearly established.METHODSThis is a retrospective multicenter study of BTAIs from January 2008 to December 2013. Dem

Massive transfusion policies at trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program.

Abstract: Background Massive transfusion protocols (MTPs) have been developed to implement damage control resuscitation (DCR) principles. A survey of MTP policies from American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) participants was performed to establish which MTP activation, hemostatic resuscitation, and monitoring aspects of DCR are included in the MTP guidelines. Methods On October 10, 2013, ACS-TQIP administration administered a cross-sectional electronic survey to 187 ACS-TQIP participants. Results Seventy-one percent (132 of 187) of responses were analyzed, with 62% designated as Level I and 38% designated as Level II ACS-TQIP trauma centers. Sixty-nine percent of sites indicated that they have plasma immediately available for MTP activation. By policy, in the first group of blood products administered, 88% of sites target high (≥1:2) plasma-to-red blood cell (RBC) ratios and 10% target low ratios. Likewise, 79% of sites target high platelet-to-RBC ratios and 16% target low ratios. Eighteen percent of sites reported incorporating point-of-care thromboelastogram into MTP policies. The most common intravenous hemostatic adjunct incorporated into MTPs was tranexamic acid (49%). Thirty-four percent of sites reported that some or all of their emergency medical service agencies have the ability to administer blood products or hemostatic agents during prehospital transport. There were minimal differences in MTP policies or capabilities between Level I and II sites. Conclusion The majority of ACS-TQIP participants reported having MTPs that support the use of DCR principles including high plasma-to-RBC and platelet-to-RBC ratios. Immediate availability of plasma and product use by emergency medical services are becoming increasingly common, whereas the incorporation of point-of-care thromboelastogram into MTP policies remains low.

The new metric to define large-volume hemorrhage: results of a prospective study of the critical administration threshold.

Abstract: BACKGROUNDDefinitions of massive transfusion (MT), 10 or more units of packed red blood cells (PRBCs) in 24 hours, focus on static volumes over fixed times. This arbitrary volume definition promotes survivor bias and fails to identify the “massively” transfused patient. In previous work, the critica

Mechanisms of early trauma-induced coagulopathy: The clot thickens or not?

Abstract: Traumatic-induced coagulopathy (TIC) is a hemostatic disorder that is associated with significant bleeding, transfusion requirements, morbidity and mortality. A disorder similar or analogous to TIC was reported around 70 years ago in patients with shock, hemorrhage, burns, cardiac arrest or undergoing major surgery, and the condition was referred to as a "severe bleeding tendency," "defibrination syndrome," "consumptive disorder," and later by surgeons treating US Vietnam combat casualties as a "diffuse oozing coagulopathy." In 1982, Moore's group termed it the "bloody vicious cycle," others "the lethal triad," and in 2003 Brohi and colleagues introduced "acute traumatic coagulopathy" (ATC). Since that time, early TIC has been cloaked in many names and acronyms, including a "fibrinolytic form of disseminated intravascular coagulopathy (DIC)." A global consensus on naming is urgently required to avoid confusion. In our view, TIC is a dynamic entity that evolves over time and no single hypothesis adequately explains the different manifestations of the coagulopathy. However, early TIC is not DIC because an increased thrombin-generating potential in vitro does not imply a clinically relevant thrombotic state in vivo as early TIC is characterized by excessive bleeding, not thrombosis. DIC with its diffuse anatomopathologic fibrin deposition appears to be a latter phase progression of TIC associated with unchecked inflammation and multiple organ dysfunction.

Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta.

Abstract: BACKGROUNDMany hemodynamically stable patients with blunt abdominal solid organ injuries are successfully managed nonoperatively, while unstable patients often require urgent laparotomy. Recently, therapeutic angioembolization has been used in the treatment of intra-abdominal hemorrhage in hemodynam

Saving lives and saving money: hospital-based violence intervention is cost-effective.

Abstract: BACKGROUND: Victims of violence are at significant risk for injury recidivism, including fatality. We previously demonstrated that our hospital-based violence intervention program (VIP) resulted in a fourfold reduction in injury recidivism, avoiding trauma care costs of $41,000 per injury. Given limited trauma center resources, assessing cost-effectiveness of interventions is fundamental to inform use of these programs in other institutions. This study examines the cost-effectiveness of hospital-based VIP. METHODS: We used a decision tree and Markov disease state modeling to analyze cost utility for a hypothetical cohort of violently injured subjects, comparing VIP versus no VIP at a trauma center. Quality-adjusted life-years (QALYs) were calculated using differences in mortality and published health state utilities. Costs of trauma care and VIP were obtained from institutional data, and risk of recidivism with and without VIP were obtained from our trial. Outcomes were QALYs gained and net costs over a 5-year horizon. Sensitivity analyses examined the impact of uncertainty in input values on results. RESULTS: VIP results in an estimated 25.58 QALYs and net costs (program plus trauma care) of $5,892 per patient. Without VIP, these values are 25.34 and $5,923, respectively, suggesting that VIP yields substantial health benefits (24 QALYs) and savings ($4,100) if implemented for 100 individuals. In the sensitivity analysis, net QALYs gained with VIP nearly triple when the injury recidivism rate without VIP is highest. Cost-effectiveness remained robust over a range of values; $6,000 net cost savings occur when 5-year recidivism rate without VIP is at 7%. CONCLUSION: VIP costs less than having no VIP with significant gains in QALYs especially at anticipated program scale. Across a range of plausible values at which VIP would be less cost-effective (lower injury recidivism, cost of injury, and program effectiveness), VIP still results in acceptable cost per health outcome gained. VIP is effective and cost-effective and should be considered in any trauma center that takes care of violently injured patients. Our analyses can be used to estimate VIP costs and results in different settings. LEVEL OF EVIDENCE: Economic and value-based evaluation, level 2. Language: en

Indications for use of damage control surgery and damage control interventions in civilian trauma patients: A scoping review.

Abstract: BACKGROUND: Variation in the use of damage control (DC) surgery across trauma centers may partially be driven by uncertainty as to when the procedure is indicated. We sought to scope the literature on DC surgery and DC interventions, identify their reported indications, and examine the content and evidence upon which they are based. METHODS: We searched MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and the Cochrane Library (1950-February 14, 2014) and the grey literature for original and nonoriginal citations reporting indications for DC surgery or DC interventions in civilian trauma patients. RESULTS: Among 27,732 citations identified, we included 270 peer-reviewed articles in the scoping review. Of these, 156 (57.8%) represented original research, primarily (75.0%) cohort studies. The articles reported 1,099 indications for DC surgery and 418 indications for 15 different DC interventions. The majority of indications for DC interventions were for abdominal (56.5%) procedures, including therapeutic perihepatic packing (56.5%), temporary abdominal closure/open abdominal management (40.7%), and staged pancreaticoduodenectomy (2.8%). Most DC surgery indications were based on intraoperative findings (71.7%) and represented characteristics of the injured patient (94.5%), including their physiology (57.6%), injuries (38.9%), and/or the amount or type of resuscitation provided (14.3%). Others were dependent on characteristics of the treating surgeon (12.1%), the patient's physiologic response to trauma care (9.6%), and/or the trauma care environment (1.5%). Approximately half (49.5%) included a decision threshold (e.g., pH < X) and, while most (74.7%) were based on a single clinical finding/injury, 25.3% required the presence of multiple findings concurrently. Only 87 indications were evaluated in original research studies and only 9 by more than one study. CONCLUSION: The vast number, varying underlying content, and lack of original research relating to indications for DC suggests that substantial uncertainty exists around when the procedure is indicated and highlights the need to establish evidence-informed consensus indications.