Mortality In Major Trauma Patients Research Articles

Mean corpuscular volume as a prognostic factor for 30-day mortality in major trauma patients: a retrospective cohort study

We investigated the clinical implications of the mean corpuscular volume (MCV) in patients with major trauma. This single-center retrospective review included 2021 trauma patients admitted to the intensive care unit between January 2016 and June 2020. We included 1218 patients aged ≥\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\ge $$\\end{document} 18 years with an injury severity score ≥\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\ge $$\\end{document} 16 in the final analysis. The clinical and laboratory variables were compared between macrocytosis (defined as MCV ≥\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\ge $$\\end{document} 100 fL) and non-macrocytosis groups. Cox regression analysis was performed to calculate the hazard ratios (HRs) of variables for 30-day mortality, with adjustment for other potential confounding factors. The initial mean value of MCV was 102.7 fL in the macrocytosis group (n = 199) and 93.7 fL in the non-macrocytosis group (n = 1019). The macrocytosis group showed a significantly higher proportion of initial hypotension, transfusion within 4 and 24 h, and 30-day mortality than the non-macrocytosis group. Age (≥\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\ge $$\\end{document} 65 years), hypotension (systolic blood pressure ≤\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\le $$\\end{document} 90 mmHg), transfusion (within 4 h), anemia (Hb < 12 g/day in women, < 13 g/day in men), and macrocytosis were significantly associated with 30-day mortality (adjusted HR = 1.4; 95% confidence interval 1.01–1.94; p = 0.046) in major trauma patients. Thus, initial macrocytosis independently predicted 30-day mortality in patients with major trauma at a Level I trauma center.

Admission S100B fails as neuro-marker but is a good predictor for intrahospital mortality in major trauma patients

BackgroundS100 B is an extensively studied neuro-trauma marker, but its specificity and subsequently interpretation in major trauma patients might be limited, since extracerebral injuries are known to increase serum levels. Thus, we evaluated the potential role of S100B in the assessment of severe traumatic brain injury (TBI) in multiple injured patients upon emergency room (ER) admission and the first days of intensive care unit (ICU) stay. MethodsRetrospective study employing trauma registry data derived from a level 1 trauma center. Four cohorts of patients were grouped: isolated TBI (iTBI), polytrauma patients with TBI (PT + TBI), polytrauma patients without TBI (PT-TBI) and patients without polytrauma or TBI (control). S100B-serum levels were assessed immediately after admission in the emergency room and during the subsequent ICU stay. Values were correlated with injury severity score (ISS), Glasgow Coma Score (GCS) and in-hospital mortality. Results780 predominantly male patients (76 %) with a median age of 48 (30–63) and a median ISS of 24 (17–30) were enrolled in the study. Admission S100B correlated with ISS and TBI severity defined by the GCS (both p < 0.0001) but not with head abbreviated injury score (AIS) (p = 0.38). Compared with survivors, non-survivors had significantly higher median S100B levels in the ER (6.14 μg/L vs. 2.06 μg/L; p < 0.0001) and at ICU-day 1 (0.69 μg/L vs. 0.17 μg/L; p < 0.0001). S100B in the ER predicted mortality with an area under curve (AUC) of 0.77 (95 % CI 0,70–0,83, p < 0.0001), vs. 0.86 at ICU-day 1 (95 % CI 0,80–0,91, p < 0.0001). ConclusionIn conclusion, S100B is a valid biomarker for prediction of mortality in major trauma patients with a higher accuracy when assessed at the first day of ICU stay vs. immediately after ER admission. Since S100B did not correlate with pathologic TBI findings in multiple injured patients, it failed as predictive neuro-marker because extracerebral injuries demonstrated a higher influence on admission levels than neurotrauma. Although S100B levels are indicative for injury severity they should be interpreted with caution in polytrauma patients.

Association of Scene Time with Mortality in Major Traumatic Injuries Arrived by Emergency Medical Service.

Trauma is a major cause of death worldwide, and prehospital care is critical to improve patient outcomes. However, there is controversy surrounding the effectiveness of limiting scene time to 10 min or less in the care of major trauma patients. This study aimed to investigate the association between scene time and mortality in major trauma patients. A retrospective cohort study was conducted on major trauma patients treated by the Thammasat University Hospital Emergency Medical Services (EMS) team from 2020 to 2022. We included traumatic adult patients who had an injury severity score (ISS) of 16 or higher. The primary outcome was 24-h mortality. Multivariable risk regression analysis was used to evaluate the independent effect of scene time on 24-h mortality. A total of 104 patients were included, of whom 11.5% died within 24 h. After adjusting for age, systolic blood pressure, Glasgow Coma Scale, and ISS, patients who had a scene time over 10 min showed a significant association with mortality (33.3% vs. 8.7%, P = 0.031). Intravenous fluid administration at the scene showed a trend toward a significant association with mortality. This study provides evidence to support the importance of minimizing scene time for major trauma patients. The findings suggest that a balance between timely interventions and adequate resources should be considered to optimize patient outcomes. Further studies to investigate the impact of prehospital interventions on trauma patient outcomes are needed.

Activating Code Crimson in the emergency department: Expediting definitive care for trauma patients with severe haemorrhage in Singapore

"Trauma activation" is a process adopted across all emergency departments of public healthcare institutions in Singapore, with the aim of rapidly mobilising personnel and resources to care for patients with major trauma. A subset of trauma patients with exsanguinating haemorrhage has a particularly high mortality rate, and they require an additional response beyond the usual trauma activation for definitive haemorrhage control. To address this need, Code Crimson has been developed at Auckland City Hospital in New Zealand and other jurisdictions as a step-up response. This is aimed at early activation of the massive transfusion protocol for haemostatic resuscitation, involvement of additional multidisciplinary teams for rapid decision-making, and expediting definitive haemorrhage control. At present, there is no protocol for activation of Code Crimson in Singapore. Code Crimson may be effective in Singapore, as it has been in other jurisdictions, to reduce morbidity and mortality in major trauma patients with severe haemorrhage.

Hyperglycemia as a positive predictor of mortality in major trauma

Background:Hyperglycemia in the acute phase after trauma is a stress response and a metabolic reflection in humans with injury, which could adversely affect outcome in trauma patients. In this study, we attempted to identify if hyperglycemia a reliable predictor for mortality in major trauma patients.Objectives:In order to identify if hyperglycemia a reliable predictor for mortality in major trauma, we designed and proformed a prospective observational study in a tertiary hospital.Method:We performed a prospective observational study to review the records of 601 patients with major trauma (injury severity scores &gt;15) who visited our hospital's emergency department from August 2012 to July 2015. Logistic regression was performed to assess the effect of hyperglycemia on mortality.Result:Major trauma patients in the hyperglycemia group had low systolic/diastolic blood pressure at triage, low initial Glasgow Coma Scale score, high incidence of hypotension episodes, coagulopathy, acidosis, and anemia. Hyperglycemia was significantly correlated with mortality in major trauma patients in this study (odds ratio: 1.97, 95% confidence interval: 1.04–3.74).Conclusion:In major trauma patients with injury severity scores &gt;15, hyperglycemia has a positive correlation with mortality, which could be a predictor of mortality in clinical practice.

High Interleukin-6 Plasma Concentration upon Admission Is Predictive of Massive Transfusion in Severely Injured Patients.

Severe bleeding remains a prominent cause of early in-hospital mortality in major trauma patients. Thus, prompt prediction of patients at risk of massive transfusion (MT) is crucial. We investigated the ability of the inflammatory marker interleukin (IL)-6 to forecast MT in severely injured trauma patients. IL-6 plasma levels were measured upon admission. Receiver operating characteristic curves (ROCs) were calculated, and sensitivity and specificity were determined. In this retrospective study, a total of 468 predominantly male (77.8%) patients, with a median injury severity score (ISS) of 25 (17–34), were included. The Youden index for the prediction of MT within 6 and 24 h was 351 pg/mL. Patients were dichotomized into two groups: (i) low-IL-6 < 350 pg/mL and (ii) high-IL-6 ≥ 350 pg/mL. IL-6 ≥ 350 pg/mL was associated with a lower prothrombin time index, a higher activated partial thromboplastin time, and a lower fibrinogen concentration compared with IL-6 < 350 pg/mL (p <0.0001 for all). Thromboelastometric parameters were significantly different between groups (p <0.03 in all). More patients in the high-IL-6 group received MT (p <0.0001). The ROCs revealed an area under the curve of 0.76 vs. 0.82 for the high-IL-6 group for receiving MT in the first 6 and 24 h. IL-6 ≥ 350 pg/mL predicted MT within 6 and 24 h with a sensitivity of 45% and 58%, respectively, and a specificity of 89%. IL-6 ≥ 350 pg/mL appears to be a reasonable early predictor for coagulopathy and MT within the first 6 and 24 h intervals. Large-scale prospective studies are warranted to confirm these findings.

Study of Coagulation Profile in Patients Admitted to a Trauma Center in a Tertiary Care Hospital

CONTEXT: Globally, trauma is the leading cause of death in young adult population, with approximately accounting for 10% of all deaths. Trauma-induced coagulopathy (TIC) is an independent predictor of morbidity and mortality. AIMS: The aim of the study was to find the prevalence of abnormal test results of coagulation on admission to a trauma center and correlate them with mortality. SETTINGS AND DESIGN: This was a cross-sectional observational study conducted on patients admitted to a trauma center of a tertiary care hospital. SUBJECTS AND METHODS: A total of 149 patients with an Injury Severity Score &gt;15 were included in the study. Blood samples of the patients were collected within 24 h of trauma and 2 h of admission and tested for platelet (PLT) count, prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen (FIB) level. The patients were stratified into two groups – presence/absence of TIC and followed for 2 weeks for mortality. STATISTICAL ANALYSIS USED: Data analysis was done using Microsoft Excel and statistics software SPSS 20 version. RESULTS: Among the 149 patients, 84 had TIC, out of which 71.43% of the patients showed mortality. Of the remaining patients who had no TIC, 35.38% reported mortality. If all the four parameters, that is, PT, APTT, FIB, and PLTs, were considered together, then the percentage of mortality increased to 89.47%. If PT and APTT were studied together, then the percentage of mortality increased to 85.71%. If PT, APTT, and FIB were studied together, the mortality was 84.62%, whereas for parameters PT, APTT, and PLTs together, the mortality was 80%. CONCLUSIONS: Coagulopathy is a strong predictor of mortality in major trauma patients. Basic coagulation tests appear to be sensitive tools for identifying patients at high risk of early death and can be used for early minute diagnosis of TIC. Patients with TIC should be managed aggressively to prevent mortality.

Do pre-hospital physicians improve mortality in major trauma patients? A systematic review

BackgroundOptimal pre-hospital care systems contribute to improvements in trauma survival. The presence of pre-hospital physicians (PHPs) is reported to increase survival in traumatic brain injury, yet the effects of PHPs on outcomes for all trauma patients is currently unreported. The objective of this systematic review was to compare trauma mortality for patients treated by a PHP with those treated by a non-medical pre-hospital practitioner (NMPHP).MethodsA systematic literature search (Medline, Embase, and CINAHL) was performed, on 10th March 2020, to identify original studies comparing the mortality for trauma patients treated by a PHP with those treated by a NMPHP published between 1st January 2010 and 31st December 2019. Methodological quality of studies was assessed using Grade of Recommendations, Assessment, Development and Evaluation (GRADE).ResultsThe search revealed 6,296 studies and 14 met the inclusion criteria, comprising a total of 42,479 patients. Unadjusted mortality suggested a higher mortality for the physician cohort in four studies and no difference in six. However, patients treated by physicians had higher Injury Severity Scores and where adjusted mortality was provided several studies showed a mortality benefit for physicians.ConclusionThis systematic review did not demonstrate a mortality benefit from pre-hospital physicians attending major trauma patients. However, those with higher Injury Severity Scores may benefit from the presence of a PHP. Identifying this patient cohort in the pre-hospital setting to ensure appropriate resource use requires further evaluation.

Predicting factors for major trauma patient mortality analyzed from trauma registry system

ObjectiveWe investigated the predictors of mortality in major trauma patients using a trauma registry system database. MethodsData were obtained from the trauma registry of a level I trauma center for all patients aged ≥18 years admitted to an intensive care unit (ICU) between January 1, 2006 and December 31, 2013. Models were adjusted for patient demographics, injury mechanism, preexisting comorbidity, Glasgow coma scale (GCS), injury severity score (ISS), emergency department (ED) and ICU procedures, surgical procedures, and complications. Multivariate logistic regression analysis was used to determine predictors of mortality and odds ratios of its associated factors. ResultsIn total, 1561 patients met the inclusion criteria. The overall mortality rate was 13.4%. After controlling for all variables in a logistic regression model, the factors associated with increased mortality risk (P < 0.05) were age ≥ 45 years; ISS > 24; GCS score < 8 and 8–12; fall accident; preexisting comorbidity of renal insufficiency; ED cardiopulmonary resuscitation (CPR) procedures; ICU blood transfusion; and cardiovascular, respiratory, digestive system and infection complications. ConclusionOur data showed some predictors of patient mortality after major trauma, most of which were determined during the trauma event. Only those treatment complications may be improved when performing the treatment procedures.

Factors affecting mortality in major trauma patients in Trinidad and Tobago – A view from the developing world

IntroductionThere are few data on major trauma in the developing world. This study investigated the characteristics and outcomes of seriously injured patients in Trinidad and Tobago, using Trauma and Injury Severity Score (TRISS) methodology. We also aimed to assess the predictive accuracy of the TRISS model in patients in Trinidad and Tobago.MethodsRetrospective data from major trauma patients attending the Emergency Department of a tertiary hospital in Trinidad between 2010 and 2014 were analysed. Patients ≥18 years having an Injury Severity Score &gt;15 were included. The impact of age, gender, comorbidities, mechanisms and patterns of injury on mortality was investigated. Using TRISS methodology, predicted mortality was calculated and compared to actual mortality.ResultsOf 323 patients analysed, 284 were male and 24 were aged ≥65 years. The commonest injury mechanisms in younger people were motor vehicle accidents (34.1%) and stabbings (30.8%) compared to falls (66.7%) and motor vehicle accidents (20.8%) in people aged ≥65 years. The commonest areas injured were the chest in younger patients (81.9%) and the head and neck in patients aged ≥65 years (58.3%). Women’s mortality rates were similar to men (RR 1.8; 95% CI 0.7–4.9). Mortality was higher with age ≥65 years (RR 7.0; 95% CI 3.1–15.9), blunt trauma (RR 7.6; 95% CI 1.8–32.4) and Charlson Comorbidity Index of 1 or more (RR 3.2; 95% CI 1.3–8.0). The TRISS model performed well at lower ISS scores and was excellent at predicting survival (discrimination statistic 0.94).ConclusionMultiple factors influence mortality in major trauma patients in Trinidad and Tobago, including age, co-morbidities and injury mechanism. TRISS methodology accurately predicted survival in this population but was better at predicting mortality in patients with lower Injury Severity Score.

Epidemiological study of major pelvic fracture in Hong Kong and analysis of predictors for mortality

Objectives and Background Pelvic fracture causes significant mortality and morbidities. The purpose of this study is to identify the characteristics of patients with pelvic fracture in Hong Kong and to determine the factors predicting mortality. The result could help to identify high-risk patients who might benefit from more intensive evaluation and intervention. Method: Five hundred and eight patients (age &gt; 12 years old) with pelvic fractures were identified from the trauma registries of four designated trauma centres in Hong Kong from 1 January 2005 to 31 December 2012. Patient baseline characteristics and outcomes were analysed. Stepwise logistic regression was performed to identify independent clinical predictors for mortality. Result: Mean age was 45.4 ± 19.2 years, 43.3% were female, mean length of hospital stay was 27.9 ± 42.4 days and mean length of intensive care unit stay was 4.8 ± 6.8 days. Injury severity score was 28.9 ± 18.7, revised trauma score was 7.2 ± 2 and 30-day mortality was 20.9%. Stepwise logistic regression identified patient’s age, presenting systolic blood pressure, initial Glasgow Coma Scale, injuries to the thoracic and abdominal regions, first base excess and the volume of red blood cell transfusion required within the first 6 h to be independent risk factors predicting mortality. Conclusion: Pelvic fracture is associated with significant risk of mortality in major trauma patients. Clinical characteristics obtained during emergency department resuscitation can help in selecting patients for timely aggressive interventions.

Effect of predicted travel time to trauma care on mortality in major trauma patients in Nova Scotia

Trauma is a leading contributor to the burden of disease in Canada, accounting for more than 15 000 deaths annually. Although caring for injured patients at designated trauma centres (TCs) is consistently associated with survival benefits, it is unclear how travel time to definitive care influences outcomes. Using a population-based sample of trauma patients, we studied the association between predicted travel time (PTT) to TCs and mortality for patients assigned to ground transport. Victims of penetrating trauma or motor vehicle collisions (MVCs) in Nova Scotia between 2005 and 2014 were identified from a provincial trauma registry. We conducted cost distance analyses to quantify PTT for each injury location to the nearest TC. Adjusted associations between TC access and injury-related mortality were then estimated using logistic regression. Greater than 30 minutes of PTT to a TC was associated with a 66% increased risk of death for MVC victims (p = 0.045). This association was lost when scene deaths were excluded from the analysis. Sustaining a penetrating trauma greater than 30 minutes from a TC was associated with a 3.4-fold increase in risk of death. Following the exclusion of scene deaths, this association remained and approached significance (odds ratio 3.48, 95% confidence interval 0.98–14.5, p = 0.053). Predicted travel times greater than 30 minutes were associated with worse outcomes for victims of MVCs and penetrating injuries. Improving communication across the trauma system and reducing prehospital times may help optimize outcomes for rural trauma patients.

First rib fractures as indicators of serious intra and extra-thoracic injury in polytrauma and their impact on the morbidity and mortality

Background: First-rib fractures are relatively rare compared with fractures of other ribs because of the broad structure deeply placed and protected location of the first rib. A high amount of energy is needed to cause a first-rib fracture; violent trauma, such as that involving motor vehicle accident, is a frequent cause of these fractures, as well as other serious intra-thoracic, head, cervical spine, and intra-abdominal injuries. First-rib fractures have traditionally been considered indicators of increased injury severity and mortality in major trauma patients. The aim was to study the significance of first-rib fractures as indicators of serious intra-thoracic and extra-thoracic injury in polytrauma and their impact on the morbidity and mortality in a high-altitude area in Al-Taif, Saudi Arabia.Methods: This is a retrospective study conducted in King Abdul-Aziz Specialist Hospital (KASH), Taif City, KSA. Patients with chest injuries who presented to the emergency department and were admitted to the hospital between November 2013 and March 2016 were included in the study. Data regarding first-rib fracture were collected, and the relationship between first-rib injuries and associated intra-thoracic and extra-thoracic injuries was analyzed.Results: There was a high incidence of first-rib fracture (23.45%), and 35.8% were bilateral. The most common associated chest injury was a pulmonary contusion (58.5%), followed by pneumothorax (32.1%), hemopneumothorax (20.7%), and surgical emphysema (20.7%). The most common associated extra-thoracic injuries in our study were skeletal injuries (47.4%), cervical spine injuries (11.3%), and head trauma (24.5%).Conclusions: Fractures of the first-rib are associated with serious thoracic and extra-thoracic injuries; they are associated only with increased morbidity in patients with polytrauma and have no independent impact on mortality.

Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study

Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71–1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03–1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt.

Base Deficit is Superior to Lactate in Trauma: Davis JW, Dirks RC, Kaups KL, Tran P. Am J Surg. 2018; 215(4):682-685

Both lactate and base deficit have been used to guide resuscitation and predict mortality in major trauma patients. However, data conflict as per which is a more accurate biochemical marker for injury severity, mortality risk, and need for blood product transfusion.

Cardiac troponin T is associated with mortality in patients admitted to critical care in a UK major trauma centre: a retrospective database analysis.

Elevated levels of cardiac troponin T are associated with poor outcome in critically ill patients and have been proposed as a prognostic marker in major trauma. This study investigated the relationship between cardiac troponin T levels on admission to intensive care unit (ICU) and all-cause mortality in major trauma patients. A retrospective database analysis of cardiac troponin T levels on admission to the ICU in major trauma patients between 1 August 2015 and 31 December 2016 at a UK Major Trauma Centre was performed. Of the 243 patients, 69 (28.4%) died. Cardiac troponin T levels were significantly higher in patients who died compared to survivors: 42 vs. 13 ng/L, respectively (p < 0.0001); the odds of all-cause mortality increased significantly as troponin increased, independent of age or Acute Physiology and Chronic Health Evaluation score. This confirms cardiac troponin T at ICU admission as a marker of mortality in major trauma. Elevated cardiac troponin T may be seen in patients without evidence of direct cardiac trauma.

Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios

IntroductionHigher transfusion ratios of plasma to packed red blood cells (PRBC) and platelets (PLT) to PRBC have been shown to be associated with decreased mortality in major trauma patients. However, little is known about the effect of transfusion ratios on mortality in patients with isolated severe traumatic brain injury (TBI). The aim of this study was to investigate the effect of transfusion ratios on mortality in patients with isolated severe blunt TBI. We hypothesized that higher transfusion ratios of plasma to PRBC and PLT to PRBC are associated with a lower mortality rate in these patients. MethodsRetrospective observational study. Patients with isolated severe blunt TBI (AIS head≥3, AIS extracranial <3) admitted to an urban level I trauma centre were included. Clinical data were extracted from the institution’s trauma registry, blood transfusion data from the blood bank database. The effect of higher transfusion ratios on in-hospital mortality was analysed using univariate and multivariable regression analysis. ResultsA total of 385 patients were included. Median age was 32 years (IQR 2–50), 71.4% were male, and 76.6% had an ISS≥16. Plasma:PRBC transfusion ratios≥1 were identified as an independent predictor for decreased in-hospital mortality (adjusted OR 0.43 [CI 0.22–0.81]). PLT:PRBC transfusion ratios≥1 were not significantly associated with mortality (adjusted OR 0.39 [CI 0.08–1.92]). ConclusionThis study revealed plasma to PRBC transfusion ratios≥1 as an independent predictor for decreased in-hospital mortality in patients with isolated severe blunt TBI.

Fibrinogen is an independent predictor of mortality in major trauma patients: A five-year statewide cohort study

IntroductionFibrinogen may be reduced following traumatic injury due to loss from haemorrhage, increased consumption and reduced synthesis. In the absence of clinical trials, guidelines for fibrinogen replacement are based on expert opinion and vary internationally. We aimed to determine prevalence and predictors of low fibrinogen on admission in major trauma patients and investigate association of fibrinogen levels with patient outcomes. Patients and methodsData on all major trauma patients (January 2007–July 2011) identified through a prospective statewide trauma registry in Victoria, Australia were linked with laboratory and transfusion data. Major trauma included any of the following: death after injury, injury severity score (ISS) >15, admission to intensive care unit requiring mechanical ventilation, or urgent surgery for intrathoracic, intracranial, intra-abdominal procedures or fixation of pelvic or spinal fractures. Associations between initial fibrinogen level and in-hospital mortality were analysed using multiple logistic regression. ResultsOf 4773 patients identified, 114 (2.4%) had fibrinogen less than 1g/L, 283 (5.9%) 1.0–1.5g/L, 617 (12.9%) 1.6–1.9g/L, 3024 (63.4%) 2–4g/L and 735 (15%) >4g/L. Median fibrinogen was 2.6g/L (interquartile range 2.1–3.4). After adjusting for age, gender, ISS, injury type, pH, temperature, Glasgow Coma Score (GCS), initial international normalised ratio and platelet count, the lowest fibrinogen categories, compared with normal range, were associated with increased in-hospital mortality (adjusted odds ratio [OR] for less than 1g/L 3.28 [95% CI 1.71–6.28, p<0.01], 1–1.5g/L adjusted OR 2.08 [95% CI 1.36–3.16, p<0.01] and 1.6–1.9g/L adjusted OR 1.39 [95% CI 0.97–2.00, p=0.08]). Predictors of initial fibrinogen <1.5g/L were younger age, lower GCS, systolic blood pressure <90mmHg, chest decompression, penetrating injury, ISS >25 and lower pH and temperature. ConclusionsInitial fibrinogen levels less than the normal range are independently associated with higher in-hospital mortality in major trauma patients. Future studies are warranted to investigate whether earlier and/or greater fibrinogen replacement improves clinical outcomes.

Hyperchloremia is associated with 30-day mortality in major trauma patients: a retrospective observational study.

BackgroundChloride is important for maintaining acid-base balance, muscular activity, osmosis and immunomodulation. In patients with major trauma, chloride levels increase after fluid therapy; this is associated with poor clinical outcomes. The purpose of this study was to determine whether hyperchloremia was associated with increased mortality in patients who had sustained major trauma.MethodsThis study enrolled 266 major trauma patients by retrospective chart review, from January 2011 to December 2015. Patients were older than 16 years; were admitted to an intensive care unit; survived more than 48 h; and had sustained major trauma, defined as an injury severity score ≥ 16. Hyperchloremia was defined as a chloride level > 110mEq/L. Delta chloride (Δchloride) was defined as the difference between the serum chloride level measured 48-h post-admission and the initial level. Clinical and laboratory variables were compared between survivors (n = 235) and non-survivors (n = 31). A multivariate logistic regression analysis was performed to assess the association between hyperchloremia 48-h post-admission (hyperchloremia-48) and 30-day mortality.ResultsThe overall 30-day mortality was 11.7 % (n = 31). Hyperchloremia-48 occurred in 65 patients (24.4 %) and the incidence was significantly different between survivors and non-survivors (19.6 vs. 61.3 %, respectively, p < 0.001). Multivariate logistic analysis identified hyperchloremia-48 and Δchloride as independent predictive factors for 30-day mortality in major trauma patients.DiscussionInfusion of chloride-rich solutions, such as normal saline, is itself associated with hyperchloremia, which has been associated with poor patient outcomes. Patients receiving normal saline were more likely to suffer major postoperative complications, acute kidney injury, and infections. Moreover, large changes in serum chloride levels correlated with greater in-hospital mortality. ConclusionHyperchloremia 48-h post-admission and Δchloride was associated with 30-day mortality in major trauma patients. These indices may be useful prognostic markers.

Factors affecting mortality in major trauma patients in Trinidad and Tobago – a view from the developing world

Factors affecting mortality in major trauma patients in Trinidad and Tobago – a view from the developing world