Outcomes In Adult Trauma Patients Research Articles

Evaluating Mortality Outcomes, Transfusion Characteristics, and Risk Factors Associated With Cirrhotic Trauma Patients Undergoing Emergency Laparotomy Versus Non-Operative Management: A National Analysis.

Patients with liver cirrhosis (LC) demonstrate significantly elevated mortality rates following a traumatic event. This study aims to examine and compare the clinical outcomes in adult trauma patients with pre-existing LC undergoing laparotomy or non-operative management (NOM). Additionally, the study aims to investigate various patient outcomes, including mortality rate based on transfusion needs and timing. This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) 2017-21 to compare laparotomy vs NOM in adults (≥18years) with pre-existing LC who presented to trauma facilities with isolated blunt solid organ abdominal injuries (Injury Severity Score ≥16, Abbreviated Injury Scale solid organ abdomen ≥3). Among 929 patients, 38.2% underwent laparotomy, while 61.7% received NOM. The in-hospital mortality rate was lower for patients who received NOM (52.3% vs 20.0%, P < .01). The risk of in-hospital mortality was significantly associated with laparotomy (OR 5.22, 95% CI: 2.06-13.18, P < .01) and sepsis (OR 99.50, 95% CI: 6.99-1415.28, P < .01). On average an increase in blood units in 4 hours was observed among those who experienced an in-hospital mortality (OR 5.65, 95% CI: 3.05-8.24, P < .01) and those who underwent laparotomy (OR 3.85, 95% CI: 1.36-6.34, P < .01). Trauma patients with moderate to severe isolated organ injury and Liver cirrhosis had significantly higher mortality rates, acute renal failure, whole blood units received, as well as longer ICU-LOS when undergoing laparotomy compared to non-operative management.

Practices of Adult Spine Immobilization During Trauma Resuscitation: Proposal for Improved Guidelines.

This narrative review aims to evaluate the impact of current spinal immobilization practices on clinical outcomes in adult trauma patients with suspected or confirmed spinal injury to direct the creation of improved practice management guidelines. PubMed, ProQuest, Embase, Google Scholar, and Cochrane were searched for studies that evaluated the impact of spine immobilization practices during resuscitation in adult trauma patients and reported associated clinical outcomes. Outcomes included neurological deficits, in-hospital mortality, hospital length of stay (HLOS), ICU length of stay (ICU-LOS), discharge disposition, long-term functional status (modified Rankin scale), vascular injury rate, and respiratory injury rate. Nine studies were included in this review, divided into two groups based on patient immobilization status. Patients compared with and without cervical immobilization had higher mortality, longer ICU-LOS, and a higher incidence of neurological deficits if immobilized. Immobilization only was associated with a higher incidence of indirect neurological injury and poor functional outcomes. Spinal immobilization during resuscitation in adult trauma patients is associated with a higher risk of neurological injury, in-hospital mortality, and longer ICU-LOS. Further research is needed to provide strong evidence for spinal immobilization guidelines and identify the optimal method and timing for immobilization practices in trauma patients.

Delta De Ritis Ratio Is Associated with Worse Mortality Outcomes in Adult Trauma Patients with Moderate-to-Severe Traumatic Brain Injuries.

This study aimed to investigate whether changes in the De Ritis ratio (DRR) can be used to stratify the mortality risk of patients with moderate-to-severe traumatic brain injury (TBI). This retrospective study reviewed data for 1347 adult trauma patients (134 deaths and 1213 survival) with moderate-to-severe TBI between 1 January 2009, and 31 December 2020, from the registered trauma database. The outcomes of the patients allocated into the two study groups were compared based on the best Delta DRR (ΔDRR) cutoff point. The first and second DRR of patients who died were significantly higher than those of patients who survived. Elevation of DRR 72-96 h later was found for patients who died, but not for those who survived; the ΔDRR of the patients who died was significantly higher than that of those who survived (1.4 ± 5.8 vs. -0.1 ± 3.3, p = 0.004). Multivariate logistic regression analysis revealed that ΔDRR was a significant independent risk factor for mortality in these patients. Additionally, a ΔDRR of 0.7 was identified as the cutoff value for mortality stratification of adult trauma patients at high risk of mortality with moderate-to-severe TBI.

Hypothermia on Admission Predicts Poor Outcomes in Adult Trauma Patients

Hypothermia on Admission Predicts Poor Outcomes in Adult Trauma Patients

Alternative shock index cutoffs for pediatric patients outperform the Shock Index Pediatric Age-adjusted (SIPA) on strength of association with adverse outcomes in pediatric trauma patients

BackgroundThe shock index is a tool for evaluating critically ill patients that is defined as the ratio of their heart rate divided by systolic blood pressure. The SI is associated with outcomes in adult trauma patients. The Shock Index Pediatric Age-adjusted was developed as a pediatric-specific tool to account for the physiologic differences of children of varying ages. There is growing interest in Shock Index Pediatric Age-adjusted, which is associated with adverse outcomes in pediatric trauma. We hypothesized that alternative shock index cutoffs based on the Advanced Trauma Life Support or the Pediatric Advanced Life Support vital sign reference ranges would outperform Shock Index Pediatric Age-adjusted. MethodsWe analyzed a retrospective cohort of pediatric trauma patients (age 1 to 16 years old) in the American College of Surgeons Trauma Quality Programs Participant Use File from 2010 to 2018. The primary outcome measure was in-hospital mortality. The Shock Index Pediatric Age-adjusted was compared to an Advanced Trauma Life Support–based and a Pediatric Advanced Life Support–based shock index cutoff system. Our findings were subsequently confirmed with a separate, internal validation data set. ResultsA total of 598,830 Trauma Quality Programs Participant Use File patients were included, 0.9% (n = 5,471) of whom died. For mortality, the Advanced Trauma Life Support–based system yielded the highest positive predictive value (15.8%; 95% confidence interval 15.0%–16.7%) compared with the Pediatric Advanced Life Support–based system (4.3%; 95% confidence interval 4.1%–4.5%). Both the Advanced Trauma Life Support–based and Pediatric Advanced Life Support–based systems achieved higher positive predictive values compared to Shock Index Pediatric Age-adjusted (2.6%; 95% confidence interval 2.5%–2.7%). The negative predictive values were not clinically different. Our findings were validated using a separate internal trauma database, in which the positive predictive value for mortality of the Advanced Trauma Life Support–based system was significantly higher than Shock Index Pediatric Age-adjusted (18.2% [95% confidence interval: 8.2%–32.7%] vs 2.9% [95% confidence interval: 1.6%–5.0%], P < .05). ConclusionAdvanced Trauma Life Support and Pediatric Advanced Life Support–based shock index cutoffs achieved higher positive predictive values and similar negative predictive values compared to Shock Index Pediatric Age-adjusted for adverse outcomes in pediatric trauma.

Improved identification of severely injured pediatric trauma patients using reverse shock index multiplied by Glasgow Coma Scale.

The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients. Patients (aged 1-18 years) in the 2014 to 2018 Pediatric Trauma Quality Improvement Program database with complete heart rate, systolic blood pressure, and total GCS were included. Optimal cut points of rSIG were calculated for predicting blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. From the optimal thresholds, sensitivity, specificity, and area under the curve were calculated from receiver operating characteristics analyses to predict each outcome and compared with SI and SIPA. A total of 604,931 patients with a mean age of 11.1 years old were included. A minority of patients had a penetrating injury mechanism (5.6%) and the mean Injury Severity Score was 7.6. The mean SI and rSIG scores were 0.85 and 18.6, respectively. Reverse shock index multiplied by Glasgow Coma Scale performed better than SI and SIPA at predicting early trauma outcomes for the overall population, regardless of age. Reverse shock index multiplied by Glasgow Coma Scale outperformed SI and SIPA in the early identification of traumatically injured children at risk for early interventions, such as blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. Reverse shock index multiplied by Glasgow Coma Scale adds neurological status in initial patient assessment and may be used as a bedside triage tool to rapidly identify pediatric patients who will likely require early intervention and higher levels of care. Prognostic, level III.

Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda.

BackgroundInjuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K).MethodsData were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).ResultsFrom the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids.ConclusionsInjured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.

Association Between Mode of Transportation and Outcomes of Adult Trauma Patients With Blunt Injury Across Different Prehospital Time Intervals in the United States: A Matched Cohort Study

Helicopter Emergency Medical Services (HEMS) dispatch currently depends on predefined protocols, on first responders' initial assessment, or on medical direction decision in some states. National guidelines do not provide recommendations concerning prehospital time criteria. Our aim was to investigate the association between the mode of transportation (HEMS vs. ground EMS [GEMS]) and survival of adult patients with blunt trauma across different prehospital time intervals. This retrospective matched cohort study was carried out using the 2015 National Trauma Data Bank (NTDB) dataset. Adult patients with blunt injuries transported via HEMS were selected and matched (1 to 1) for 13 variables to those who were transported by GEMS. Survival rates were calculated for the two groups across different prehospital time intervals. Patients transported by HEMS (n=16,269) were compared with those transported by GEMS (n=16,269). Most patients were aged 16 to 64years (84.0%), male (69.4%), and white (88.0%). Overall survival rate to hospital discharge was significantly higher in the HEMS group (96.8% vs. 96.2%; p=0.002). Patients transported by HEMS had higher survival rates in the ≤ 30-min interval (97.7% vs. 93.2%; p=0.004); GEMS patients had higher survival rates in the 61- to 90-min interval (97.4% vs. 96.5%; p=0.038). No difference in survival rates between the two groups was observed in intervals > 90min. In adult patients with blunt trauma, HEMS transport was associated with overall improved survival rates mainly in the first 30min after injury. GEMS transport, however, had a survival advantage in the 61- to 90-min total prehospital time interval.

Serum Copeptin levels in the emergency department predict major clinical outcomes in adult trauma patients

BackgroundEarly prognostication in trauma patients is challenging, but particularly important. We wanted to explore the ability of copeptin, the C-terminal fragment of arginine vasopressin, to identify major trauma, defined as Injury Severity Score (ISS) > 15, in a heterogeneous cohort of trauma patients and to compare its performances with lactate. We also evaluated copeptin performance in predicting other clinical outcomes: mortality, hospital admission, blood transfusion, emergency surgery, and Intensive Care Unit (ICU) admission.MethodsThis single center, pragmatic, prospective observational study was conducted at Arcispedale Santa Maria Nuova, a level II trauma center in Reggio Emilia, Italy. Copeptin determination was obtained on Emergency Department (ED) arrival, together with venous lactate. Different outcomes were measured including ISS, Revised Trauma Score (RTS), hospital and ICU admission, blood transfusion, emergency surgery, and mortality.ResultsOne hundred and twenty five adult trauma patients admitted to the ED between June 2017 and March 2018. Copeptin showed a good ability to identify patients with ISS > 15 (AUC 0.819). Similar good performances were recorded also in predicting other outcomes. Copeptin was significantly superior to lactate in identifying patients with ISS > 15 (P 0.0015), and in predicting hospital admission (P 0.0002) and blood transfusion (P 0.016). Comparable results were observed in a subgroup of patients with RTS 7.84.ConclusionsIn a heterogeneous group of trauma patients, a single copeptin determination at the time of ED admission proved to be an accurate biomarker, statistically superior to lactate for the identification of major trauma, hospital admission, and blood transfusion, while no statistical difference was observed for ICU admission and emergency surgery. These results, if confirmed, may support a role for copeptin during early management of trauma patients.

Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision.

Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs. 4:1 packed red blood cell to fresh frozen plasma transfusion strategy during massive burn excision. Children with >20% total body surface area burns were randomized to a 1:1 or 4:1 packed red blood cell/fresh frozen plasma transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, pediatric risk of mortality (PRISM) scores, pediatric logistic organ dysfunction scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n = 34). Mean age, PRISM scores, estimated blood loss (600 ml (400-1175 ml) vs. 600 ml (300-1150 ml), P = 0.68), ventilator days (5 vs. 9, P = 0.47), and length of stay (57 vs. 60 days, P = 0.24) had no difference. No differences in frequency of blood stream infection (20 vs. 18, P = 0.46) or pneumonia events (68 vs. 116, P = 0.08) were noted. On multivariate analysis, only total body surface area burn size, inhalation injury, and PRISM scores (P < 0.05) were significantly associated with infections.

Factors associated with physical, psychological and functional outcomes in adult trauma patients following Road Traffic Crash: A scoping literature review

ObjectiveRoad Traffic Crashes (RTCs) are a major cause of disability globally, with millions of people being injured or disabled each year. This study aims to identify the factors reported in the literature that are associated with physical, psychological and functional outcomes of adult trauma patients following an RTC. MethodsA scoping literature review was conducted. Peer-reviewed articles were retrieved from MEDLINE, EMBASE, and CINAHL. These databases were chosen as the MeSH and Emtree thesauri allow for high specificity searches. Moreover, these databases index the major biomedical/health journals in the field. ResultsThirty-one studies from 10 countries are reported in a PRISMA chart and summarized in a matrix. This review identified a number of factors that are clustered into six categories; (i.) injury characteristics and hospital predictive factors; (ii.) demographic factors; (iii.) family and social support; (iv.); compensation system process and fault in the RTC (v.); pre-injury health status. A final category was used to represent the range of (vi.) psychological and functional outcomes. ConclusionThese findings highlight the multiple and diverse contributors that influence a person's outcomes following an RTC. These factors are intrinsic and extrinsic and commence from the time of injury as well as highlighting the importance for ongoing support after acute care discharge to enable a quick return to optimal wellbeing. Research examining RTC outcomes must integrate information about the crash response and health care system while simultaneously measuring other factors to appropriately quantify the relative contribution of each variable to psychological and functional outcomes.

Tranexamic acid administration following head trauma in a combat setting: Does tranexamic acid result in improved neurologic outcomes?

Research shows that administration of tranexamic acid (TXA) in severely injured trauma patients can decrease mortality as well as the amount of blood products required. Morbidity and mortality is high for patients with traumatic brain injuries (TBIs). The theory is that progressive of intracranial bleeding, cerebral edema and cerebral ischemia may contribute to the poor outcomes for TBI patients. There have been studies looking at the progression of intracranial bleeding in patients with TBIs after receiving TXA, however these studies have not thoroughly evaluated the effect on clinical outcomes. The goal of this study was to compare neurological outcomes in adult trauma patients who received TXA versus those who did not receive TXA.

2 Examining 1:1 Versus 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision

Blood transfusions after major burn injury are common due to operative losses, blood sampling, and burn physiology. Burn patients lose an estimated 2% blood volume per percent burn excised, making large burn excisions a major source of blood loss. While a massive transfusion protocol improves outcomes in adult trauma patients, there remains a paucity of literature examining its effect in the critically ill pediatric population. The purpose of this study was to prospectively examine the outcomes of major pediatric burns receiving a 1:1 vs 4:1 red blood cell (RBC) to fresh frozen plasma (FFP) transfusion strategy during massive burn excision. Children with >20% total body surface area (TBSA) 2nd and 3rd degree burns were randomized to a 1:1 or 4:1 RBC/FFP transfusion ratio during burn excision. Parameters measured included patient demographics, burn size, Pediatric Risk of Mortality (PRISM) scores, Pediatric Logistic Organ Dysfunction (PELOD) scores, clinical laboratory values, and total blood products transfused during operative interventions and hospitalization. Blood stream infections (BSI), urinary tract infections (UTI), and pneumonia (PNU), were documented using the burn consensus guidelines for infection. A total of 68 children were randomized into two groups (34 patients in the 1:1 group and 34 patients in the 4:1 group). Mean age (7.4 ± 5.5 v 8.2 ± 5.3 years), TBSA (39% ± 16 v 43% ± 24), and PRISM scores (9.5 ± 6 v 11 ± 6) did not significantly differ between groups. Estimated blood loss also did not significantly differ between groups (453 cc v 450 cc, p = 0.42). No significant differences were noted in ventilatory days (5 v 9, p = 0.47) or overall length of stay (57 v 60, p = 0.24). An equal number of infections were identified in both populations (24 patients each). Although no differences were identified in blood stream infections (20 v 18, p = 0.46), a higher number of pneumonias were documented in the 4:1 group (68 v 116, p = 0.08). On multivariate analysis, significantly higher TBSA (p < 0.001) and PRISM scores (p < 0.05) were identified in the 4:1 group when controlling for infection count. No significant differences were identified in outcomes between a 1:1 and 4:1 massive transfusion strategy as measured by overall ventilator days, length of stay, or rates of infection. These findings would suggest noninferiority to either transfusion practice based on outcomes. Further work will be necessary to fully elucidate these results. This work is an interim analysis of an ongoing study that suggests higher transfusion requirements may occur in higher risk patients such as those with larger TBSA burn sizes or mortality scores.

The association between seatbelt use and trauma outcomes: Does body mass index matter?

BackgroundNational Highway Traffic Safety Administration (NHTSA) reports that seat belt use results in a significant decrease in MVC mortality. The rate of obesity is currently extensive. There is limited data on the impact of seat belt use and body mass index (BMI) on mortality and trauma outcomes following MVCs. This study aimed to evaluate the impact of seat belt use and BMI on outcomes in adult trauma patients. MethodsA four-year review using our Level I Trauma Center registry. Patients were divided by BMI into normal weight BMI < 25 (NL-BMI), overweight BMI 25–29.9, and obese BMI ≥ 30. Groupings were subdivided by seat belt use into patients wearing a seat belt at the time of injury (seatbeltPOS) and those who were not (seatbeltNEG). Results11,792 patients involved in MVCs were included in our study. 4515 (38.3%) were NL-BMI, 4583 (38.9%) were overweight, and 2694 (22.8%) were obese. SeatbeltPOS patients had significantly lower mortality compared to seatbeltNEG, regardless of BMI, with 12/1394 (0.86%) in seatbeltPOS compared to 274/10,398 (2.64%) deaths in seatbeltNEG patients (p ≪ 0.001). Evaluated by BMI, overweight and obese seatbeltPOS patients had significantly less deaths 7/900 (0.78%) vs overweight and obese seatbeltNEG patients 179/6377 (2.81%) (p = 0.0004). NL-BMI seatbeltPOS patients also had significantly lower mortality 5/494 (1.01%) compared to NL-BMI seatbeltNEG patients 95/4021 (2.36%), (p = 0.048). ConclusionUse of a seat belt reduced Trauma Center mortality regardless of BMI. Seat belts should be used by all patients as a mechanism to significantly reduce mortality.

Epidemiology, prognostic factors, and outcome of trauma patients admitted in a Brazilian intensive care unit.

BackgroundTrauma is a major cause of hospital admissions and is associated with manifold complications and high mortality rates. However, data on intensive care unit (ICU) admissions are scarce in developing and low-income countries, where its incidence has been increasing.ObjectivesTo analyze epidemiological and clinical factors and outcomes in adult trauma patients admitted to the ICU of a public teaching hospital in a developing country as well as to identify risk factors for complications in the ICU.Patients and methodsRetrospective cohort of adult trauma patients admitted to the general ICU of a public teaching hospital in southern Brazil in the year 2012. Demographic, clinical, and outcome data from the ICU were analyzed.ResultsDuring the study period, 144 trauma patients were admitted (83% male, Acute Physiology and Chronic Health Evaluation Score II =18.6±7.2, age =33.3 years, 93% required mechanical ventilation). Of these, 60.4% suffered a traffic accident (52% motorcycle), and 31.2% were victims of violence (aggressions, gunshot wounds, or stabbing); 71% had brain trauma, 37% had chest trauma, and 21% had abdominal trauma. Patients with trauma presented a high incidence of complications, such as infections, acute renal failure, acute respiratory distress syndrome, and thrombocytopenia. The ICU mortality rate was 22.9%.ConclusionIn a Brazilian public teaching ICU, there was a great variability of trauma etiologies (mainly traffic accidents with motorcycles and victims of violence); patients with trauma had a high incidence of complications and mortality in the ICU.

Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO) for Acute Respiratory Failure Following Injury: Outcomes in a High-Volume Adult Trauma Center with a Dedicated Unit for VV ECMO.

The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) has increased over the past decade. The purpose of this study was to evaluate outcomes in adult trauma patients requiring VV ECMO. Data were collected on adult trauma patients admitted between January 1, 2015, and November 1, 2016. Demographics, injury-specific data, ECMO data, and survival to discharge were recorded. Medians [interquartile range (IQR)] were reported. A p value ≤0.05 was considered statistically significant. Eighteen patients required VV ECMO during the study period. Median age was 28.5years (IQR 24-43). Median injury severity score (ISS) was 27 (IQR 21-41); median PaO2/FiO2 (P/F) prior to ECMO cannulation was 61 (IQR 50-70). Median time from injury to cannulation was 3 (IQR 0-6) days. Median duration of ECMO was 266 (IQR 177-379) hours. Survival to discharge was 78%. Survivors had a significantly higher ISS (p=0.03), longer intensive care unit length of stay (ICU LOS) (p<0.0004), hospital LOS (p<0.000004), and time on the ventilator (p<0.0003). Median time of injury to cannulation was significantly longer in patients who survived to discharge (p=0.01). There was no difference in P/F ratio prior to cannulation (p=ns). We have demonstrated improved outcome of patients requiring VV ECMO following injury compared to historical data. Although shorter time from injury to cannulation for VV ECMO was associated with death, select patients who meet criteria for VV ECMO early following injury should be referred/transferred to a tertiary care facility that specializes in trauma and ECMO care.

Multi-institutional analysis of neutrophil-to-lymphocyte ratio (NLR) in patients with severe hemorrhage: A new mortality predictor value.

The neutrophil/lymphocyte ratio (NLR) has been associated as a predictor for increased mortality in critically ill patients. We sought to determine the relationship between NLR and outcomes in adult trauma patients with severe hemorrhage requiring the initiation of massive transfusion protocol (MTP). We hypothesized that the NLR would be a prognostic indicator of mortality in this population. This was a multi-institutional retrospective cohort study of adult trauma patients (≥18 years) with severe hemorrhage who received MTP between November 2014 and November 2015. Differentiated blood cell counts obtained at days 3 and 10 were used to obtain NLR. Receiver operating characteristic (ROC) curve analysis assessed the predictive capacity of NLR on mortality. To identify the effect of NLR on survival, Kaplan-Meier (KM) survival analysis and Cox regression models were used. A total of 285 patients with severe hemorrhage managed with MTP were analyzed from six participating institutions. Most (80%) were men, 57.2% suffered blunt trauma. Median (IQR) age, Injury Severity Score, and Glasgow Coma Scale were 35 (25-47), 25 (16-36), and 9 (3-15), respectively. Using ROC curve analysis, optimal NLR cutoff values of 8.81 at day 3 and 13.68 at day 10 were calculated by maximizing the Youden index. KM curves at day 3 (p = 0.05) and day 10 (p = 0.02) revealed an NLR greater than or equal to these cutoff values as a marker for increased in-hospital mortality. Cox regression models failed to demonstrate an NLR over 8.81 as predictive of in-hospital mortality at day 3 (p = 0.056) but was predictive for mortality if NLR was greater than 13.68 at day 10 (p = 0.036). NLR is strongly associated with early mortality in patients with severe hemorrhage managed with MTP. Further research is needed to focus on factors that can ameliorate NLR in this patient population. Prognostic study, level III.

Impact of Preinjury Anticoagulation with Warfarin on Outcomes of Adult Trauma Patients: Experience of a Level 1 Trauma Center

Impact of Preinjury Anticoagulation with Warfarin on Outcomes of Adult Trauma Patients: Experience of a Level 1 Trauma Center

Do lactate levels in the emergency department predict outcome in adult trauma patients? A systematic review.

Serum lactate may be associated with clinical outcomes in trauma, even in the absence of physiological abnormality. Sensitive markers of injury and outcomes are needed to guide triage and management of trauma patients within the Emergency Department. We completed a systematic review to determine if lactate levels in adult trauma patients presenting to the Emergency Department were associated with clinical outcomes including mortality. A systematic literature search was conducted in August 2014, updated in March 2016, using MEDLINE, Embase, and CINAHL. Abstracts and full texts were screened for inclusion by two independent reviewers using predetermined inclusion and exclusion criteria. Data extraction and quality assessment was performed by each reviewer using a standardized form. A total of 998 studies were screened; 28 studies were included and reviewed. The 28 studies recruited 44,154 adults in eight countries between 1997 and 2016. Twenty-one studies found a significant association between elevated Emergency Department lactate and risk of mortality. Three studies looked at lactate clearance; two showed poor clearance was an additional determinant of mortality, but the other found no association. Ten studies also found an association between elevated lactate and other clinical outcomes. These included injury severity, Intensive Care Unit admission, length of hospital stay, organ failure, respiratory complications, blood loss, blood product requirement, catecholamine support, or emergency operation. Two studies concluded that lactate levels do not affect management. This review shows that elevated Emergency Department lactate levels are associated with mortality and may be associated with other clinical outcomes in adult trauma patients. We conclude that lactate is a useful marker of outcome in trauma, in addition to current markers of severity. The potential roles of serial lactate measurement and lactate clearance require further research. Systematic review, level III.

Blood component transfusion increases the risk of death in children with traumatic brain injury

Blood transfusion has been associated with worse outcomes in adult trauma patients with traumatic brain injury (TBI). However, the effects in injured children have not been evaluated. We hypothesize that blood transfusion is also associated with worse outcomes in children with TBI. A retrospective review of the trauma database at two Level I pediatric trauma centers was performed. We reviewed all patients 18 years and younger with TBI, who survived at least 24 hours, from 2002 to 2011. Exclusion criteria include those who underwent craniotomy, thoracotomy, exploratory laparotomy, and any orthopedic procedure. A total of 1,607 children with TBI were included in the study population (mean age, 6.4 [5.7] years; 65% male), 178 of whom received a blood transfusion. Mean Injury Severity Score (ISS) was 16.5 (9.1). Patients who received a transfusion had a higher ISS than those who did not (26.7 vs. 15.3). After controlling for age, sex, ISS, Glasgow Coma Scale (GCS) score on presentation, and mechanism of injury, patients who received a blood transfusion were more likely to be admitted to the intensive care unit (p < 0.0001), less likely to survive to hospital discharge (p = 0.02), more likely to be discharged to a rehabilitation facility (p = 0.01) and be dependent on caretakers at follow-up (p < 0.0001), as well as more likely to develop urinary tract infection (p = 0.02) and bacteremia (p = 0.02) during their hospital stay. These differences in outcomes among those who did and did not receive a blood transfusion began to disappear in patients with a nadir hemoglobin of less than 8.0 g/dL. Pediatric patients sustaining TBI who receive blood transfusion and do not require operative intervention have worse outcomes compared with patients who do not receive transfusion. This includes an increased risk of death. These data suggest that a transfusion trigger of hemoglobin level at 8.0 g/dL in injured children with TBI may be beneficial. Epidemiologic study, level III. Therapeutic study, level IV.