Nonsurvivable Injuries Research Articles

Goals of care are rarely discussed prior to potentially futile trauma transfer: Is it okay to say "No"?

It is unknown how often the physician-to-physician trauma transfer conversation includes a discussion of patient goals of care (GOC). We hypothesized that physicians would rarely discuss GOC on transfer calls when faced with patients with catastrophic injuries. We completed a retrospective case series of trauma patients transferred to an ACS-verified Level I trauma center between 2018 and 2022 who died or were discharged to hospice without surgical intervention within 48 hours. Transfer call recordings were analyzed for GOC conversations. A total of 5,562 patients were accepted as transfers and 82 (1.5%) met inclusion criteria. Eighty of the 82 patients had recorded transfer calls and were analyzed. The most common transfer reason was traumatic brain injury (TBI) and need for neurosurgical capabilities (53%) followed by complex multisystem trauma (23%). There was explicit discussion of code status prior to transfer in 20% and a more in depth GOC conversation for 10% of patients. Appropriateness of transfer was discussed in 21% and at least one physician expressed explicit concerns of futility for 14%, though all were subsequently transferred. Code status was changed immediately upon arrival for 15% for patients and 19% of patients transferred for neurosurgical expertise were deemed to have non-survivable injuries based on imaging and examination that were unchanged from the referring hospital. Among a group of profoundly injured trauma patients at high risk of death, an explicit discussion of GOC occurred in just 10%. This suggests that even when the catastrophic nature of patient injury is understood, transfers still occur, and patients and their families are subjected to an expensive, disruptive, and displacing experience with little to no anticipated benefit. A discussion of GOC and therapeutic objectives should be considered in all severely injured trauma patients prior to transfer. Therapeutic/Care Management; Level IV.

306 Review of CRRT in Burn Patients with Non-survivable Injuries

Abstract Introduction There is a subset of burn patients that have a non-survivable injury. Careful and thoughtful use of health care resources in this population is needed to provide end of life care. The purpose of this quality improvement project was to review patients with non-survivable injuries (NSI), started on continuous renal replacement (CRRT), to identify areas of improvement in end-of-life care. Methods A retrospective review of all patients admitted to one verified burn center from 1/1/2020 – 5/9/2022 who received CRRT as a life prolonging measure in patients with NSI. NSI was defined as modified BAUX predicted mortality of >90 0 and/or significant comorbidities, peri burn events ( i.e. Delayed presentation, cardiac arrest in the field) and physician judgement as documented in the chart. Data points collected include, age, TBSA and BAUX scores, indication for CRRT, any documented goals of care discussions, duration of CRRT, days from admit to initiation of CRRT and additional blood products and CRRT filters. Results A total of 21 patients who received CRRT were reviewed. Of those, 1 survived, 2 had incorrect MRNs in the hospital database, leaving 17 patients who died for analysis. The median age was 68 (IQR 18). The median TBSA was 43% (IQR 42). There were 2 patients with 0 % TBSA, 1 sustained a lightning strike and 1 with inhalation only. The median BAUX was 112 (IQR 37). The median hospital Length of stay (LOS) was 12 days (IQR 24). The median time in days to start of CRRT from time of injury was 2.5 days (IQR 11.5). Median time of CRRT initiation to time of death was 48 hours (IQR 239.5 range of 2.5 hours to 720 hours.). Blood product and filter use related to the initiation of CRRT for the 17 patients is in Table 1. Of the patients included in the review, there were several issues related to the initiation of CRRT. One had a DNR, but family did not provide documentation and/or follow patient’s wishes. Several families were offered CRRT as an option despite futility and then insisted on that progression of care. Others were started on CRRT to allow time for family to be located or to arrive before transitioning to comfort care. Conclusions In patients with NSI, CRRT was often initiated within 24 hours of death. In several cases, when comfort measure only was the known plan of care. This in turn led to increased use of blood products and filters. For patients with non-survivable injuries, establishing early goals of care and discussing end of life care is imperative. Applicability of Research to Practice Early goals of care conversations and thoughtful use of resources in patients with non-survivable injuries should be examined to determine the appropriateness of care offered and interventions provided.

Exploring clinicians' decision-making processes about end-of-life care after burns: A qualitative interview study.

Little is known about treatment decision-making experiences and how/why particular attitudes exist amongst specialist burn clinicians when faced with patients with potentially non-survivable burn injuries. This exploratory qualitative study aimed to understand clinicians' decision-making processes regarding end-of-life (EoL) care after a severe and potentially non-survivable burn injury. Eleven clinicians experienced in EoL decision-making were interviewed via telephone or video conferencing in June-August 2021. A thematic analysis was undertaken using a framework approach. Decision-making about initiating EoL care was described as complex and multifactorial. On occasions when people presented with 'unsurvivable' injuries, decision-making was clear. Most clinicians used a multidisciplinary team approach to initiate EoL; variations existed on which professions were included in the decision-making process. Many clinicians reported using protocols or guidelines that could be personalised to each patient. The use of pathways/protocols might explain why clinicians did not report routine involvement of palliative care clinicians in EoL discussions. The process of EoL decision-making for a patient with a potentially non-survivable burn injury was layered, complex, and tailored. Processes and approaches varied, although most used protocols to guide EoL decisions. Despite the reported complexity of EoL decision-making, palliative care teams were rarely involved or consulted.

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Decision Support Tool to Judiciously Assign High-Frequency Neurologic Examinations in Traumatic Brain Injury

IntroductionTraumatic brain injury (TBI) management includes serial neurologic examinations to assess for changes dictating neurosurgical interventions. We hypothesized hourly examinations are overassigned. We conducted a decision tree analysis to determine an algorithm to judiciously assign hourly examinations. MethodsA retrospective cohort study of 1022 patients with TBI admitted to a Level 1 trauma center from January 1, 2019, to December 31, 2019, was conducted. Patients with penetrating TBI or immediate or planned interventions and those with nonsurvivable injuries were excluded. Patients were stratified by whether they underwent an unplanned intervention (e.g., craniotomy or invasive intracranial monitoring). Univariate analysis identified factors for inclusion in chi-square automatic interaction detection technique, classifying those at risk for unplanned procedures. ResultsA total of 830 patients were included, 287 (35%) were assigned hourly (Q1) examinations, and 17 (2%) had unplanned procedures, with 16 of 17 (94%) on Q1 examinations. Patients requiring unplanned procedures were more likely to have mixed intracranial hemorrhage pattern (82% versus 39%; P = 0.001), midline shift (35% versus 14%; P = 0.023), an initial poor neurologic examination (Glasgow Comas Scale ≤8, 77% versus 14%; P < 0.001), and be intubated (88% versus 17%; P < 0.001). Using chi-square automatic interaction detection, the decision tree demonstrated low-risk (2% misclassification) and excellent discrimination (area under the curve = 0.915, 95% confidence interval 0.844-0.986; P < 0.001) of patients at risk of an unplanned procedure. By following the algorithm, 167 fewer patients could have been assigned Q1 examinations, resulting in an estimated 6012 fewer examinations. ConclusionsUsing a 4-factor algorithm can optimize the assignment of neuro examinations and substantially reduce neuro examination burden without sacrificing patient safety.

United States Military Fatalities During Operation Inherent Resolve and Operation Freedom's Sentinel.

Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts. A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%). Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces.

Burn Care Specialists' Views Toward End-of-Life Decision-Making in Patients With Severe Burn Injury: Findings From an Online Survey in Australia and New Zealand.

Burn care clinicians are required to make critical decisions regarding the withholding and withdrawal of treatment in patients with severe and potentially non-survivable burn injuries. Little is known about how Australian and New Zealand burn care specialists approach decision-making for these patients. This study aimed to understand clinician beliefs, values, considerations, and difficulties regarding palliative and end-of-life (EoL) care discussions and decision-making following severe burn injury in Australian and New Zealand burn services. An online survey collected respondent and institutional demographic data as well as information about training and involvement in palliative care/EoL decision-making discussions from nurses, surgeons, and intensivists in Australian and New Zealand hospitals with specialist burn services. Twenty-nine burns nurses, 26 burns surgeons, and 15 intensivists completed the survey. Respondents were predominantly female (64%) and had a median of 15 years of experience in treating burn patients. All respondents received little training in EoL decision-making during their undergraduate education; intensivists reported receiving more on-the-job training. Specialist clinicians differed on who they felt should contribute to EoL discussions. Ninety percent of respondents reported injury severity as a key factor in their decision-making to withhold or withdraw treatment, but less than half reported considering age in their decision-making. Approximately two-thirds indicated a high probability of death or a poor predicted quality of life influenced their decision-making. The three cohorts of clinicians had similar views toward certain aspects of EoL decision-making. Qualitative research could provide detailed insights into the varying perspectives held by clinicians.

Treatment Decisions in Patients With Potentially Nonsurvivable Burn Injury in Australia and New Zealand: A Registry-Based Study.

Whilst burn-related mortality is rare in high-income countries, there are unique features related to prognostication that make examination of decision-making practices important to explore. Compared to other kinds of trauma, burn patients (even those with nonsurvivable injuries) may be relatively stable after injury initially. Complications or patient comorbidity may make it clear later in the clinical trajectory that ongoing treatment is futile. Burn care clinicians are therefore required to make decisions regarding the withholding or withdrawal of treatment in patients with potentially nonsurvivable burn injury. There is yet to be a comprehensive investigation of treatment decision practices following burn injury in Australia and New Zealand. Data for patients admitted to specialist burn services between July 2009 and June 2020 were obtained from the Burns Registry of Australia and New Zealand. Patients were grouped according to treatment decision: palliative management, active treatment withdrawn, and active treatment until death. Predictors of treatment initiation and withholding or withdrawing treatment within 24 hours were assessed using multilevel mixed-effects logistic regression. Descriptive comparisons between treatment groups were made. Of the 32,186 patients meeting study inclusion criteria, 327 (1.0%) died prior to discharge. Fifty-six patients were treated initially with palliative intent and 227 patients had active treatment initiated and later withdrawn. Increasing age and burn size reduced the odds of having active treatment initiated. We demonstrate differences in demographic and injury severity characteristics as well as end of life decision-making timing between different treatment pathways pursued for patients who die in-hospital. Our next step into the decision-making process is to gain a greater understanding of the clinician's perspective (eg, through surveys and/or interviews).

Surviving Nonsurvivable Injuries: Patients Who Elude the ‘Lethal’ Abbreviated Injury Scale Score of Six

The Abbreviated Injury Scale (AIS) score is used widely to quantify injury severity by body region. The maximal AIS score is 6, which defines a nonsurvivable injury. This study was undertaken to define mortality after AIS-6 injuries in order to determine if they are uniformly lethal and, if not, if differences between survivors and nonsurvivors exist which may aid in prognostication or refinement of the current AIS system. All patients in the National Trauma Data Bank (2007-2017) with ≥1 AIS-6 injury were included. Exclusions were age <16 years, AIS-6 coding in the face/extremities (i.e., coding errors, as there are no AIS-6 injuries in these regions), and missing data. In-hospital mortality defined study groups, i.e., survivors vs. nonsurvivors. Univariable analysis compared clinical/injury data and outcomes. Multivariable analysis examined independent factors associated with mortality. 19,247 patients met inclusion/exclusion criteria. Of these, 25% (n=4,886) survived to hospital discharge and 75% (n=14,361) died. The most common discharge destination among survivors was home (n=2,187,45%) Nonsurvivors had significantly worse GCS in the field (3 vs. 14, p<0.001) and ED (3 vs. 15, p<0.001). Median AIS was higher among nonsurvivors in the Head (5 vs. 3, p<0.001), Abdomen (3 vs. 2, p<0.001), and External regions (1 vs. 1, p<0.001). Median time to death was 0.65h, with maximum time to death 8.76h. Multivariable analysis revealed External AIS-6 injuries were associated with greatest odds of mortality (OR 34.002, p<0.001) followed by Head AIS-6 (OR 10.501, p<0.001). AIS-6 injuries are not uniformly fatal, with 25% of such patients surviving to hospital discharge. Therefore, AIS-6 injuries may not be as catastrophic as previously considered. External and Head AIS-6, i.e. extensive burns and severe traumatic brain injuries, were associated with greatest odds of mortality. When death occurs after AIS-6 injury, it occurs rapidly, with all mortalities in this series occurring <9h after arrival. We suggest that the AIS-6 verbiage be revised to remove 'nonsurvivable'.

United States military fatalities during Operation New Dawn.

Military operations vary by scope, purpose, and intensity, each having unique forces and actions to execute a mission. Evaluation of military operation fatalities guides current and future casualty care. A retrospective study was conducted of all US military fatalities from Operation New Dawn in Iraq, 2010 to 2011. Data were obtained from autopsies and other records. Population characteristics, manner of death, cause of death, and location of death were analyzed. All fatalities were evaluated for concomitant evidence of underlying atherosclerosis. Nonsuicide trauma fatalities were also reviewed for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. Of 74 US military Operation New Dawn fatalities (median age, 26 years; male, 98.6%; conventional forces, 100%; prehospital, 82.4%) the leading cause of death was injury (86.5%). The manner of death was primarily homicide (55.4%), followed by suicide (17.6%), natural (13.5%), and accident (9.5%). Fatalities were divided near evenly between combatants (52.7%) and support personnel (47.3%), and between battle injury (51.4%) and disease and nonbattle injury (48.6%). Natural and suicide death was higher (p < 0.01, 0.02) among support personnel who were older (p = 0.05) with more reserve/national guard personnel (p = 0.01). Total population prevalence of underlying atherosclerosis was 18.9%, with more among support personnel (64.3%). Of 46 nonsuicide trauma fatalities, most died of blast injury (67.4%) followed by gunshot wound (26.1%) and multiple/blunt force injury (6.5%). The leading mechanism of death was catastrophic tissue destruction (82.6%). Most had nonsurvivable injuries (82.6%) and nonpreventable deaths (93.5%). Operation New Dawn fatalities were exclusively conventional forces divided between combatants and support personnel, the former succumbing more to battle injury and the latter to disease and nonbattle injury including self-inflicted injury. For nonsuicide trauma fatalities, none died from a survivable injury, and 17.4% died from potentially survivable injuries. Opportunities for improvement included providing earlier blood products and surgery. Therapeutic, level V and epidemiological, level IV.

Regional ethics of surgeon resuscitation for organ transplantation after lethal injury

BackgroundTrauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of deciding whether, when, and how to resuscitate a patient who will not directly benefit from it. As there are no established guidelines to follow, we aimed to describe resuscitation practices for organ transplantation; we hypothesized that resuscitation practices vary regionally. MethodOver a 3-month period, we surveyed trauma surgeons practicing in Levels I and II trauma centers within a single state using an instrument to measure resuscitation attitudes and practices for organ preservation. Descriptive statistics were calculated for practice patterns. ResultsThe survey response rate was 51% (31/60). Many (81%) had experience with resuscitations where the primary goal was to preserve potential for organ transplantation. Many (90%) said they encountered this dilemma at least monthly. All respondents were willing to intubate; most were willing to start vasopressors (94%) and to transfuse blood (84%) (range, 1 unit to >10 units). Of respondents, 29% would resuscitate for ≥24 hours, and 6% would perform a resuscitative thoracotomy. Respect for patients’ dying process and future organ quality were the factors most frequently considered very important or important when deciding to stop or forgo resuscitation, followed closely by concerns about excessive resource use. ConclusionTrauma surgeons’ regional resuscitation practices vary widely for this patient population. This variation implies a lack of professional consensus regarding initiation and extent of resuscitations in this setting. These data suggest this is a common clinical challenge, which would benefit from further study to determine national variability, areas of equipoise, and features amenable to practice guidelines.

Redefining Preventable Death—Potentially Survivable Motorcycle Scene Fatalities as a New Frontier

BackgroundThe National Academies of Science, Engineering, and Medicine defined a roadmap to achieve zero preventable trauma deaths. In the United States, there are over 5000 motorcycle fatalities annually. Florida leads the nation in annual motorcycle crash (MCC) deaths and injuries. It is unknown how many are potentially preventable. We hypothesize that certain patterns of injuries in on-scene fatalities that are potentially survivable and aim to make recommendations to achieve the National Academies of Science, Engineering, and Medicine objective. Materials and methodsMiami-Dade County medical examiner reports of MCC deaths pronounced on scene, and emergency medical service or law enforcement reports from 2010 to 2012 were reviewed by board-certified trauma surgeons. Causes of death were categorized into exsanguination, traumatic brain injury or decapitation, crushed chest, or airway complications. Determination of potentially survivable versus nonsurvivable injuries was based upon whether the riders had potentially survivable injuries and had they been transported immediately to a trauma center. Traumatic brain injury cases were reviewed by a board-certified neurosurgeon. ResultsSixty MCC scene deaths were analyzed. Ninety-five percent were men, 55% were helmeted, and 42% had positive toxicology. The median Injury Severity Score was 41 (Range 14-75, IQR 31-75). Nineteen (32%) deaths were potentially survivable, with death due to airway in 14 (23%) and exsanguination in 4 (7%) patients. ConclusionsOne-third of on-scene urban motorcycle deaths are potentially survivable in a young patient population. ISS score comparison demonstrates the lower injury burden in those deemed potentially survivable. Automatic alert systems in motorcycles and first responder training to police are recommended to improve trauma system efficacy in reducing preventable deaths from MCCs.

Factors Associated with Survival After Emergency Department Thoracotomy for Adult Trauma Patients in the United States.

Emergency department thoracotomy (EDT) is done to control life threatening hemorrhage and injuries. Literature examining this topic is limited to relatively small studies from single trauma centers. This study identifies factors associated with survival to hospital discharge of patients undergoing EDT using the largest U.S. national trauma database. This retrospective cohort study used the U.S. National Trauma Data Bank 2015. We conducted univariate and bivariate analyses followed by a multivariate analysis that adjusted for confounders to identify factors associated with survival. Two thousand four hundred eighty-six patients who underwent EDT were included. Most patients were 16 to 64years of age (92.3%) with a male predominance (84.9%) and without any previous comorbidities (62.8%). Penetrating injury was most common (60.2%), mainly as a result of assault (51.0%) by firearm (45.1%). Overall survival to hospital discharge was 38.2%. After adjusting for confounders, factors associated with increased survival were cut/piece injuries, presenting with signs of life, Glasgow Coma Scale score ≥8, systolic blood pressure >90mm Hg, and transportation to the ED through helicopter/fixed-wing ambulance or public/private vehicle (reference, ground ambulance). Factors associated with survival in patients undergoing EDT were identified. The clinical indication of presence of appropriate resources to continue and repair EDT was validated, along with the contraindications of lack of signs of life and presence of major nonsurvivable injuries. Future studies should focus on validation of all criteria of EDT, namely hemodynamic instability despite appropriate fluid resuscitation, duration of time of cardiopulmonary resuscitation and pulselessness, cardiac rhythm on arrival, and the presence of pericardial tamponade.

Potential survivability of prehospital injury deaths in New Zealand: a cross-sectional study

IntroductionAcknowledging a notable gap in available evidence, this study aimed to assess the survivability of prehospital injury deaths in New Zealand.MethodsA cross-sectional review of prehospital injury death postmortems (PM) undertaken...

Maintaining Trauma Care Access During the COVID-19 Pandemic: An Urban, Level-1 Trauma Center's Experience.

Maintaining Trauma Care Access During the COVID-19 Pandemic: An Urban, Level-1 Trauma Center's Experience.

Mortality review of US Special Operations Command battle-injured fatalities.

Comprehensive analyses of battle-injured fatalities, incorporating a multidisciplinary process with a standardized lexicon, is necessary to elucidate opportunities for improvement (OFIs) to increase survivability. A mortality review was conducted on United States Special Operations Command battle-injured fatalities who died from September 11, 2001, to September 10, 2018. Fatalities were analyzed by demographics, operational posture, mechanism of injury, cause of death, mechanism of death (MOD), classification of death, and injury severity. Injury survivability was determined by a subject matter expert panel and compared with injury patterns among Department of Defense Trauma Registry survivors. Death preventability and OFI were determined for fatalities with potentially survivable or survivable (PS-S) injuries using tactical data and documented medical interventions. Of 369 United States Special Operations Command battle-injured fatalities (median age, 29 years; male, 98.6%), most were killed in action (89.4%) and more than half died from injuries sustained during mounted operations (52.3%). The cause of death was blast injury (45.0%), gunshot wound (39.8%), and multiple/blunt force injury (15.2%). The leading MOD was catastrophic tissue destruction (73.7%). Most fatalities sustained nonsurvivable injuries (74.3%). For fatalities with PS-S injuries, most had hemorrhage as a component of MOD (88.4%); however, the MOD was multifactorial in the majority of these fatalities (58.9%). Only 5.4% of all fatalities and 21.1% of fatalities with PS-S injuries had comparable injury patterns among survivors. Accounting for tactical situation, a minority of deaths were potentially preventable (5.7%) and a few preventable (1.1%). Time to surgery (93.7%) and prehospital blood transfusion (89.5%) were the leading OFI for PS-S fatalities. Most fatalities with PS-S injuries requiring blood (83.5%) also had an additional prehospital OFI. Comprehensive mortality reviews of battlefield fatalities can identify OFI in combat casualty care and prevention. Standardized lexicon is essential for translation to civilian trauma systems. Epidemiological, level IV.

United States Special Operations Command fatality study of subcommands, units, and trends.

Death from injury occurs predominantly in prehospital settings. Injury prevention and prehospital care of military forces is the responsibility of combatant commanders. Medical examiner and trauma systems should routinely study fatalities and inform commanders of mortality trends. Data reported on US Special Operations Command (USSOCOM) fatalities who died while performing duties from September 11, 2001, to September 10, 2018, were reevaluated to compare subcommands, units, and trends. Injury was assessed by mechanism, severity, operational posture, and survivability. Death was assessed by manner, cause, classification, mechanism, and preventability. Of 614 USSOCOM fatalities (median age, 30 years; male, 98.5%), 67.6% occurred in the Army command, of which 49.2% occurred in the Special Forces command. Battle injury accounted for 60.1% of USSOCOM fatalities. Most battle-injured fatalities in each subcommand had nonsurvivable injuries and nonpreventable deaths. For each subcommand except Marine Corps, fatalities with nonsurvivable injuries sustained injuries primarily while mounted. By subcommand, the primary cause of death for fatalities with nonsurvivable injuries was blast for Army (57.6%), multiple/blunt force for Navy (60.0%), gunshot wound for Air Force (55.6%), and split between blast (50.0%) and gunshot wound (50.0%) for Marine Corps. For each subcommand except Air Force, fatalities with potentially survivable-survivable injuries sustained injuries primarily while dismounted, and the mechanism of death was primarily hemorrhage plus other mechanism or hemorrhage alone. Hemorrhage only mechanism of death was surpassed over time by complex multimechanism death. Potential for injury survivability and death preventability was greatest during early and later years of conflict. Organizational differences in mortality characteristics and trends were identified from which commanders can refine efforts to prevent and treat injury and improve survival. Fatality analyses inform operational risk matrices and advance casualty prevention and response efforts. Prevention, assessment, and treatment strategies must evolve to reduce death from hemorrhage plus coexisting mechanisms. Performance Improvement and Epidemiological, level IV.

Preventable death and interpersonal violence in the United States: Who can be saved?

Public health initiatives to reduce mortality from penetrating trauma have largely developed from patterns of injury observed in military casualties, with a focus on hemorrhage control and use of tourniquets. Recent efforts show that injury patterns differ between civilian mass casualty events and combat settings, and no studies characterize wounding patterns in all types of civilian homicide. We hypothesize that many homicide deaths are due to nonsurvivable injuries, and that an effective strategy to reduce mortality must focus on both primary prevention as well as improvement in trauma prehospital care. We analyzed homicides from the National Violent Death Reporting System from 2012 to 2015. We excluded deaths due to poisoning, intentional neglect, or unknown weapon. Deaths were classified as "dead on scene" (DOS), "dead on arrival" (DOA), or "dead at or after hospital" (DAH) if the patient was admitted to a hospital. Injury patterns for penetrating weapons (firearms and sharp instruments) were further categorized. We included 18,051 homicides, the vast majority of which were due to firearms (n = 12,901 or 71.5%) or sharp instruments (n = 2,265 or 12.5%). The most common injury patterns included wounds to the chest or head, with isolated extremity injuries representing a minority of both firearms deaths (n = 397 of 12,901, 3.1%) and deaths from sharp instruments (n = 50 of 2,265, 2.2%). Furthermore, over half of all deaths occurred prehospital, with only 13.3% of victims admitted prior to death. The vast majority of deaths from interpersonal violence are due to firearm injuries. Few deaths appear to be related to extremity hemorrhage alone, and over half of all fatally injured died at the scene. Strategies to decrease mortality from interpersonal violence must go beyond treating injuries that have already occurred, and must address violence prevention directly. Epidemiological study, level IV.

Defining massive transfusion in civilian pediatric trauma

PurposeThe purpose of this study was to identify an optimal definition of massive transfusion (MT) in civilian pediatric trauma. MethodsSeverely injured children (age ≤18 years, injury severity score ≥25) in the Trauma Quality Improvement Program research datasets 2014–2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Early mortality was defined as death within 24 h and delayed mortality as death after 24 h from hospital admission. Receiver operating curves and sensitivity and specificity analysis identified an MT threshold. Continuous variables are presented as median [IQR]. ResultsOf the 270 included children, the overall mortality was 27% (N = 74). There were no differences in demographics or mechanism of injury between children that lived or died. Sensitivity and specificity for early mortality was optimized at a 4-h transfusion volume of 37 ml/kg. After controlling for other significant variables, a threshold of 37 ml/kg/4 h predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25–17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96–9.16; p < 0.01). ConclusionAn MTP threshold of 37 mL/kg/4 h of transfused blood products predicted the need for hemorrhage control procedures and early mortality. This threshold may provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization. Type of StudyDiagnostic Test. Level of EvidenceIII.

A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children

BackgroundMassive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear. Material and methodsA retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios. ResultsThere were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups. ConclusionsA high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.