Severe Blunt Trauma Patients Research Articles

LONGITUDINAL ANALYSIS OF TRANSCRIPTOMIC SUBTYPES IN TRAUMA PATIENTS.

ABSTRACTObjective: We previously identified two transcriptomic subtypes (Signature Groups: SG1 vs. SG2) in trauma patients at 12 hours postinjury, with SG1 associated with worse outcomes. In this study, we aimed to further characterize the changes in SG subtype categorization of trauma patients over time after injury and define the corresponding association with outcomes based on the timing of the subtype designation. Methods and Results: This study was a secondary analysis of published data of whole-blood leukocyte transcriptomics, a longitudinal data from 167 severe blunt trauma patients. We assigned trauma patients to SG1 or SG2 subtype for time points between 12 hours and 28 days, inclusive, postinjury and characterized their longitudinal outcomes. SG1 assignment, regardless of time point, was associated consistently with slower recovery. Further analysis revealed that additional prognostic information could be obtained by assessing SG subtype at both 12 hours and 1 day. Conclusions: This study provides a proof of concept that immune status can worsen after admission and highlights the benefit of longitudinally monitoring SG subtypes in trauma patients.

Avoiding immediate whole-body trauma CT: a prospective observational study in stable trauma patients.

High energy blunt trauma patients with normal vital signs are usually investigated with a Contrast Enhanced Computed Tomography (CECT) for torso injuries. CECT involves high levels of radiations, often showing no injuries in patients over-triaged to the trauma center. The aim of our study was to suggest an alternative diagnostic protocol based on Emergency Room (ER) tests (physical exam, blood tests, extended FAST, Chest and Pelvis X-ray) to avoid CECT in selected patients. A prospective cohort study was conducted from September 2018 to September 2019. Five hundred patients fulfilled the inclusion criteria. Patients received torso-CECT scan only if they had at least one positive ER test. The validity of the single component of the protocol and the global validity of the ER tests to detect torso injuries was assessed through sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, positive (+ LR) and negative (-LR) likelihood ratio. Multivariate analysis was performed to identify independent predictors of torso injuries. One hundred and seventy patients received a torso-CECT scan because of positive ER tests. ER tests showed a global sensitivity for torso injuries of 86.96% (95% CI 80.17-92.08) specificity of 83.98%(95% CI 79.79-87.60), PPV of 67.42% (95% CI 61.83-72.54), NPV of 94.41% (95% CI 91.63-96.30) + LR of 5.43 (95% CI 4.25-6.93), -LR of 0.16 (95% CI 0.10-0.24). ER tests in an experienced center seem to be able to identify more severe blunt trauma patients needing CECT. Further studies are advisable to confirm these results.

New injury severity score (NISS) outperforms injury severity score (ISS) in the evaluation of severe blunt trauma patients

PurposeThe injury severity score (ISS) and new injury severity score (NISS) have been widely used in trauma evaluation. However, which scoring system is better in trauma outcome prediction is still disputed. The purpose of this study is to evaluate the value of the two scoring systems in predicting trauma outcomes, including mortality, intensive care unit (ICU) admission and ICU length of stay. MethodsThe data were collected retrospectively from three hospitals in Zhejiang province, China. The comparisons of NISS and ISS in predicting outcomes were performed by using receiver operator characteristic (ROC) curves and Hosmer-Lemeshow statistics. ResultsA total of 1825 blunt trauma patients were enrolled in our study. Finally, 1243 patients were admitted to ICU, and 215 patients died before discharge. The ISS and NISS were equivalent in predicting mortality (area under ORC curve [AUC]: 0.886 vs. 0.887, p = 0.9113). But for the patients with ISS ≥25, NISS showed better performance in predicting mortality. NISS was also significantly better than ISS in predicting ICU admission and prolonged ICU length of stay. ConclusionNISS outperforms ISS in predicting the outcomes for severe blunt trauma and can be an essential supplement of ISS. Considering the convenience of NISS in calculation, it is advantageous to promote NISS in China’s primary hospitals.

Physician-led prehospital management is associated with reduced mortality in severe blunt trauma patients: a retrospective analysis of the Japanese nationwide trauma registry

BackgroundAlthough the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management.MethodsThis retrospective cohort study analyzed the data of Japan’s nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics.ResultsA total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78–1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management.ConclusionsPhysician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.

Alcohol does not increase in-hospital mortality due to severe blunt trauma: an analysis of propensity score matching using the Japan Trauma Data Bank.

AimAlcohol‐related problems, including trauma, are a great burden on global health. Alcohol metabolism in the Japanese population is genetically inferior to other races. This study aimed to evaluate the effects of alcohol use among a Japanese severe blunt trauma cohort.MethodsThis retrospective observational study analyzed the data of trauma patients registered in the Japan Trauma Data Bank between 2004 and 2019. The primary outcome of this study was in‐hospital mortality. The lengths of hospital and intensive care unit stay were the secondary outcomes. Propensity score matching was used to adjust the anatomical severity and patient background to reduce the potential alcohol use bias.ResultsWe analyzed 46,361 patients categorized into nondrinking (n = 37,818) and drinking (n = 8,543) groups. After a 1:1 propensity score matching (n = 8,428, respectively), despite the Glasgow Coma Scale and Revised Trauma Score scores being significantly lower in the drinking group (14 vs. 13 and 7.84 vs. 7.55, P < 0.001, respectively) and intensive care unit length of stay being significantly longer in the drinking group (6 vs. 7 days, P = 0.002), in‐hospital mortality was significantly lower in the alcohol group (11.8% vs. 9.0%, P < 0.001) and there were no differences in the duration of hospital stay (19 vs. 19 days, P = 0.848).ConclusionDespite increasing physiological severity on admission, after adjusting for anatomical severity, alcohol consumption could be beneficial in severe blunt trauma patients as regards in‐hospital mortality.

Hybrid emergency room shows maximum effect on trauma resuscitation when used in patients with higher severity.

The hybrid emergency room (ER) system is a novel trauma workflow that uses angio-computed tomography equipment in a trauma resuscitation room. Although the hybrid ER system decreases time to start surgery and endovascular treatments and improves mortality, the optimal target benefitting from this system remained unclear. We aimed to identify a subset of trauma patients likely to receive the greatest benefits from the hybrid ER. This retrospective cohort study was conducted in a tertiary hospital in Japan from August 2007 to January 2020. We consecutively included severe adult blunt trauma patients (Injury Severity Score [ISS], ≥16) and divided them into two groups: conventional group (August 2007 to July 2011) and hybrid ER (August 2011 to January 2020) group. We evaluated the association between the hybrid ER group and 28-day mortality using multivariable logistic regression analysis. The 28-day mortality trend during the study period was evaluated with restricted cubic spline analysis. To evaluate heterogeneity of effects within various patient severities, we evaluated whether the patients' ISS modified the effect of the hybrid ER on survival. Among 1,050 trauma patients, the conventional group comprised 360 patients and the hybrid ER group comprised 690 patients. Injury Severity Score and probability of survival (Ps) were not significantly different between the groups. Twenty-eight-day mortality was significantly lower in the hybrid ER group (Ps-adjusted odds ratio, 0.48; 95% confidence interval, 0.32-0.71; p < 0.001). Restricted cubic spline analysis revealed that Ps-adjusted 28-day mortality sharply decreased approximately 200 days after installation of the hybrid ER. Increase of survival probabilities according to the increase of ISS was significantly improved in hybrid ER group (p = 0.014). Because ISS increased to >25, survival probabilities in the hybrid ER group were higher compared with those in the conventional group. The hybrid ER may improve posttraumatic mortality, especially in patients with higher baseline severity. Therapeutic/care management, level IV.

In-Hospital Mortality Risk of Transcatheter Arterial Embolization for Patients with Severe Blunt Trauma: A Nationwide Observational Study.

This study investigated the risk factors for in-hospital mortality of severe blunt trauma patients who underwent transcatheter arterial embolization (TAE). We analysed data from the Japan Trauma Data Bank from 2009 to 2018. Patients with severe blunt trauma and an Injury Severity Score (ISS) ≥ 16 who underwent TAE were enrolled. The primary analysis evaluated patient characteristics and outcomes, and variables with significant differences were included in the secondary multivariate logistic regression analysis. In total, 5800 patients (6.4%) with ISS ≥ 16 underwent TAE. There were significant differences in the proportion of male patients, transportation method, injury mechanism, injury region, Revised Trauma Score, survival probability values, and those who underwent urgent blood transfusion and additional urgent surgery. In multivariable regression analyses, higher age, urgent blood transfusion, and initial urgent surgery were significantly associated with higher in-hospital mortality risk [p < 0.001, odds ratio (OR), 95% confidence interval (CI): 1.01 (1.00–1.01); p < 0.001, 3.50 (2.55–4.79); and p = 0.001, 1.36 (1.13–1.63), respectively]. Inter-hospital transfer was significantly associated with lower in-hospital mortality risk (p < 0.001, OR = 0.56, 95% CI = 0.44–0.71). Treatment protocols for urgent intervention before and after TAE and a safe, rapid inter-hospital transport system are needed to improve mortality risks for severe blunt trauma patients.

Pre-peritoneal pelvic packing for early hemorrhage control reduces mortality compared to resuscitative endovascular balloon occlusion of the aorta in severe blunt pelvic trauma patients: A nationwide analysis

BackgroundEarly hemorrhage control after severe blunt pelvic trauma is life-saving. The aim of this study is to compare the efficacy and outcomes of pre-peritoneal packing (PPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with a subsequent hemorrhage control procedure to control life-threatening pelvic hemorrhage in trauma patients. MethodsA 3-year (2015–2017) retrospective analysis of the Trauma Quality Improvement Program (TQIP) was performed. All blunt trauma patients (aged ≥15 years) who underwent PPP or Zone 3 REBOA placement were included while deaths on arrival and transfers were excluded. Patients were matched on clinical characteristics using propensity score matching (PSM). Univariate analysis was performed to compare mortality, time to procedure, time in ED, transfusion requirements, complications rates, and ICU and hospital length of stay (LOS) amongst patient groups. ResultsOf 420 trauma patients, 307 underwent PPP and 113 REBOA. Patients had similar hemodynamics and ISS upon presentation, but PPP patients had a higher GCS (P = 0.037) and more blunt kidney injuries (P = 0.015). After PSM, 206 trauma patients were included in the analysis. There were no significant differences in blood transfusion, LOS, or major complications. Time to REBOA was shorter than time to PPP (52 vs 77.5 min; P<0.001) with longer time in ED (65 vs 51 min; p = 0.023). The 24-hour (32.4 vs 17.7%; P = 0.23) and in-hospital mortality (52.0 vs 37.3%; P = 0.048) were higher after REBOA. ConclusionPPP is associated with improved survival compared to REBOA placement. Delay in definitive hemorrhage control may provide a potential explanation, but causation remains unresolved. This data suggests that early PPP may offer a benefit over REBOA in the setting of hemorrhage after blunt pelvic trauma. Further, large, multi-institutional studies are warranted to support these findings. Level of EvidencePrognostic study, level III.

Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti

BackgroundBleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA.MethodsPatients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18–65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit.ResultsOne-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group “before” (adjusted odds ratio 0.3, 95%confidence interval 0.1–0.8). They also had a significantly shorter hospital length of stay (p = 0.02).ConclusionsImplementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.

Serum levels of NLRP3 and HMGB-1 are associated with the prognosis of patients with severe blunt abdominal trauma

OBJECTIVES:To investigate the relationship between the serum levels of NLRP3 and HMGB-1 and the prognosis of patients with severe blunt abdominal trauma.METHODS:In total, 299 patients were included in the current study from July 2014 to December 2015. All patients were divided into the mild/moderate blunt abdominal trauma group and the severe blunt abdominal trauma group according to their injury severity scores. Serum levels of NLRP3 and HMGB-1 were measured upon admission (0 h) and at 12 h, 24 h, 48 h, 72 h and 7 days after admission.RESULTS:Compared with the healthy controls, both the mild/moderate and severe blunt abdominal trauma groups had higher serum levels of NLRP3 and HMGB-1 at admission. At all points, the serum levels of NLRP3 and HMGB-1 were significantly higher in the severe group than in the mild/moderate group. The serum levels of both NLRP3 and HMGB-1 were significantly higher in the deceased patients than in the living patients. The Kaplan-Meier curve showed that compared with patients with higher levels of NLRP3 or HMGB-1, those with lower levels had longer survival times. The serum levels of both NLRP3 and HMGB-1 were independent risk factors for 6-month mortality in severe blunt abdominal trauma patients.CONCLUSION:The serum levels of NLRP3 and HMGB-1 were significantly elevated in severe blunt abdominal trauma patients, and the serum levels of both NLRP3 and HMGB-1 were correlated with 6-month mortality in severe blunt abdominal trauma patients.

Long-term disability after blunt chest trauma: Don’t miss chronic neuropathic pain!

Introduction The main objective of this prospective study was to assess the incidence of chronic pain and long-term respiratory disability in a single-center cohort of severe blunt chest trauma patients.Methods Over a 10-month period, all consecutive blunt chest trauma patients admitted in Intensive Care Unit (ICU) were screened to participate in a 3-month and 12-month follow-up. The following variables were prospectively assessed: persistence of chronic chest pain requiring regular used of analgesics, neuropathic pain, respiratory disability, physical and mental health status. Univariate and multivariable analysis were conducted to assess variables associated with chronic chest pain, neuropathic chest pain and respiratory disability.Results During the study period, 65 patients were included in the study. Chronic chest pain and respiratory disability were reported in 62% and 57% of patients respectively at 3 months postinjury. Neuropathic pain was reported in 22% of patients, associated with higher impairment of quality of life. A thoracic trauma severity score ≥12 and a pain score ≥4 at SICU discharge were the only variables significantly associated with the occurrence of neuropathic pain at 3 months (OR = 7 [2–32], p = 0.01 and OR = 16 [4–70], p < 0.0001).Conclusion According to the current study, chronic pain and long-term respiratory disability are very common after severe blunt chest trauma patients. Special attention should be paid to neuropathic pain, frequently under-diagnosed and responsible for significant impairment of quality of life.

Whole-Body Computed Tomography During Initial Management and Mortality Among Adult Severe Blunt Trauma Patients: A Nationwide Cohort Study.

Whole-body computed tomography (WBCT) is increasingly being incorporated into the initial management of blunt trauma patients. Several observational studies have suggested that, compared to selective CT, WBCT is associated with lower mortality. In contrast, a randomized controlled trial found no significant difference in survival between patients undergoing WBCT compared to selective CT. Our objective was to confirm the association between WBCT and in-hospital mortality among adult severe blunt trauma patients. This was a retrospective cohort study based on Japan Trauma Data Bank 2004-2015 registry data. The study population comprised adult severe blunt trauma patients with at least one abnormal vital sign: systolic blood pressure ≤100mmHg, heart rate ≥120, respiratory rate ≥30 or ≤10, or Glasgow Coma Score ≤13. The primary outcome was in-hospital mortality. To adjust for both measured and unmeasured confounders, we performed instrumental variable (IV) analysis to compare the in-hospital mortality of patients undergoing WBCT with those undergoing selective CT. Of 40,435 patients who were eligible for this study, 19,766 (48.9%) patients underwent WBCT. The proportion of patients undergoing WBCT significantly increased during the study period, from 10.7% in 2004 to 59.6% in 2015. Primary IV analysis showed a significant association between WBCT and lower in-hospital mortality (odds ratio 0.84, 95% confidence interval 0.72-0.98). WBCT can be beneficial in patients with blunt trauma which has compromised vital signs. These findings from a nationwide study suggest that physicians should consider WBCT for blunt trauma patients when warranted by vital signs.

Patterns of invasive mechanical ventilation in patients with severe blunt chest trauma and lung contusion: A French multicentric evaluation of practices.

This study investigated invasive mechanical ventilation modalities used in severe blunt chest trauma patients with pulmonary contusion. Occurrence, risk factors, and outcomes of early onset acute respiratory distress syndrome were also evaluated. We performed a retrospective multicenter observational study including 115 adult patients hospitalized in six level 1 trauma intensive care units between April and September of 2014. Independent predictors of early onset acute respiratory distress syndrome were determined by multiple logistic regression analysis based on clinical characteristics and initial management. Protective ventilation principles were highly implemented, even prophylactically before acute respiratory distress syndrome occurrence. Early onset acute respiratory distress syndrome appeared to be associated with lung contusion of >20% of total lung volume and early onset pneumonia. Predictors of early onset acute respiratory distress syndrome could help with identifying high-risk populations, potentially improving case management through specific protocol development for these patients.

Characteristics of computed tomography in hemodynamically unstable blunt trauma patients: Experience at a tertiary care center.

Emergent exploratory laparotomy is recommended for hemodynamically unstable blunt trauma patients suspected of having hemoperitoneum. However, given the unreliability of ultrasonography and rapid scan speed of computed tomography (CT), CT might help clinicians provide accurate information even in hemodynamically unstable trauma patients. This observational study aimed to describe the bleeding site and hospital course of severe blunt trauma patients with hemoperitoneum diagnosed by CT scan.We enrolled all consecutive adult blunt trauma patients (≥18 years old) who underwent whole-body CT before operation between February 2012 and October 2016. Patients with hemoperitoneum on CT images were included and categorized into hemodynamically stable and unstable (persistent hypotension despite fluid resuscitation) groups.Among 1723 severe blunt trauma patients, 136 patients with hemoperitoneum were included. Of these, 98 (72.1%) patients had documented intraperitoneal injury, and the liver (60.2%) was most frequently damaged site, followed by spleen (23.5%) and mesentery (23.5%). The rate of intraperitoneal organ injury did not differ between hemodynamically stable (n = 107) and unstable (n = 29) groups (69.2% vs 82.8%, P = .15), while the documented active internal bleeding was high in the unstable group (29.9% vs 69.0%, P < .001). In the unstable group, 14 (48.3%) patients underwent emergent operation, while 3 patients underwent embolization, and the others were treated in a conservative manner.Even in hemodynamically unstable hemoperitoneum patients, 17.2% had no documented intraperitoneal injury and over half of the patients were treated without emergent operation.

The Survival Benefit of a Novel Trauma Workflow that Includes Immediate Whole-body Computed Tomography, Surgery, and Interventional Radiology, All in One Trauma Resuscitation Room: A Retrospective Historical Control Study.

The aim of this study was to evaluate the impact of a novel trauma workflow, using an interventional radiology (IVR)-computed tomography (CT) system in severe trauma. In August 2011, we installed an IVR-CT system in our trauma resuscitation room. We named it the Hybrid emergency room (ER), as it enabled us to perform all examinations and treatments required for trauma in a single place. This retrospective historical control study conducted in Japan included consecutive severe (injury severity score ≥16) blunt trauma patients. Patients were divided into 2 groups: Conventional (from August 2007 to July 2011) or Hybrid ER (from August 2011 to July 2015). We set the primary endpoint as 28-day mortality. The secondary endpoints included cause of death and time course from arrival to start of CT and surgery. Multivariable logistic regression analysis adjusted for clinically important variables was performed to evaluate the clinical outcomes. We included 696 patients: 360 in the Conventional group and 336 in the Hybrid ER group. The Hybrid ER group was significantly associated with decreased mortality [adjusted odds ratio (OR), 0.50 (95% confidence interval, 95% CI, 0.29-0.85); P = 0.011] and reduced deaths from exsanguination [0.17 (0.06-0.47); P = 0.001]. The time to CT initiation [Conventional 26 (21 to 32) minutes vs Hybrid ER 11 (8 to 16) minutes; P < 0.0001] and emergency procedure [68 (51 to 85) minutes vs 47 (37 to 57) minutes; P < 0.0001] were both shorter in the Hybrid ER group. This novel trauma workflow, comprising immediate CT diagnosis and rapid bleeding control without patient transfer, as realized in the Hybrid ER, may improve mortality in severe trauma.

Sarcopenia is a predictive factor for prolonged intensive care unit stays in high-energy blunt trauma patients.

Sarcopenia has been increasingly reported as a prognostic factor for outcome in settings such as cirrhosis, liver transplantation, and emergent surgery. We aimed to elucidate the significance of sarcopenia in severe blunt trauma patients. We retrospectively analyzed 84 patients emergently admitted to the intensive care unit at Kyushu University Hospital (Fukuoka, Japan) from May 2012 to April 2015. We assessed the amount of skeletal muscle present according to computed tomography and its relevance to ventilation-free days, patients' length of stay in the intensive care unit, and 28-day mortality. Twenty-five (29.7%) patients were defined as sarcopenic. Sixteen (19.7%) patients required 15 days or more in the intensive care unit. The major reason was a prolonged ventilation requirement due to flail chest (n = 7) or pneumonia (n = 3). Sarcopenic patients' stays in intensive care were significantly longer than those of non-sarcopenic patients (18.7 versus 6.4 days, respectively; P < 0.001). Univariate and multivariate analyses showed sarcopenia to be a significant risk factor for prolonged intensive care unit stay. Sarcopenia is a risk factor that predicts prolonged intensive care unit stay in high-energy blunt trauma patients.

Management of Intra-Abdominal Hemorrhagic Shock Using REBOA

Hemorrhage is the leading cause of potentially preventable death after a traumatic injury. 1 Scott DJ Eliason JL Villamaria C et al. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma Acute Care Surg. 2013; 75: 122-128 Crossref PubMed Scopus (104) Google Scholar , 2 Brenner ML Moore LJ DuBose JJ et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013; 75: 506-511 Crossref PubMed Google Scholar , 3 Norii T Crandall C Terasaka Y Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015; 78: 721-728 Crossref PubMed Scopus (141) Google Scholar Noncompressible torso hemorrhage (NCTH), which is a disruption of the vascular activity of the axial torso vessels, pulmonary parenchyma, solid organs, or the bony pelvis, accompanied by shock, 4 Morrison JJ Stannard A Rasmussen TE et al. Injury pattern and mortality of noncompressible torso hemorrhage in UK combat casualties. J Trauma Acute Care Surg. 2013; 75: S263-S268 Crossref PubMed Scopus (79) Google Scholar has an associated mortality of approximately 45%. 5 Kisat M Morrison JJ Hashmi ZG et al. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013; 184: 414-421 Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar A significant number of these deaths often occur because of the delay in definitive hemorrhage control in an operative theater or interventional radiology suite. Therefore, a need for adjunct hemorrhage control is paramount to attaining temporary control of bleeding until definitive hemostasis can be achieved. 3 Norii T Crandall C Terasaka Y Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015; 78: 721-728 Crossref PubMed Scopus (141) Google Scholar , 4 Morrison JJ Stannard A Rasmussen TE et al. Injury pattern and mortality of noncompressible torso hemorrhage in UK combat casualties. J Trauma Acute Care Surg. 2013; 75: S263-S268 Crossref PubMed Scopus (79) Google Scholar , 5 Kisat M Morrison JJ Hashmi ZG et al. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013; 184: 414-421 Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar A key to improving outcomes in patients with NCTH is a “bundle” of measures that can facilitate early diagnosis, rapid control of hemorrhage, systemic and topical hemostatic support, and a short time at the scene. In the past decade a paradigm shift has occurred in treatment strategies and transfusion algorithms, with emphasis on hemostatic or damage control resuscitation. 2 Brenner ML Moore LJ DuBose JJ et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013; 75: 506-511 Crossref PubMed Google Scholar , 6 Stannard A Eliason JL Rasmussen TE Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011; 71: 1869-1872 Crossref PubMed Scopus (355) Google Scholar Jennifer Adamski is Assistant Professor, Clinical Track, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.

Massive transfusion in critical haemorrhage following trauma: Aren't we missing something?

We read with interest the recent review by Olaussen et al., presenting 36 models for prediction of critical haemorrhage following trauma. The authors present the different models, their respective variables and their performance. They also discuss the utility of the individual variables. As mentioned in the publication, early diagnosis of haemorrhagic shock is a key step in improving outcomes after severe trauma. Critical bleedings indeed require aggressive treatments and need them to be applied as early as possible. Moreover, any unilateral approach would cause harm as critical bleedings require integrative care associating a mechanical (surgical or endovascular) strategy to stop the bleeding with adequate haemostatic resuscitation. Damage control resuscitation (DCR) associates damage control surgery (DCS), massive transfusion (MT) with the optimal 1/1/1 ratio of blood products, permissive hypotension and careful attention for identification and correction of the early acute coagulopathy of trauma (EACT). Adequate and early selection of trauma patients in need for DCR is pivotal to prevent wasting time as well as unnecessary activation of the technical and human resources needed for DCR. The presented models all have been developed by retrospective identification of individual parameters independently associated with MT. Massive transfusion is commonly defined as the transfusion of more than 10 units of red blood cells (RBC) within the first 24 hours of care. This definition is problematic since it excludes trauma patients presenting to hospital with active bleeding and a need for an emergent surgical control of the bleeding. Thanks to a highly effective DCR, some of those patients do not need a large number of RBC transfusions. Moreover, severe blunt trauma patients can suffer from an EACT and are in need of a specific haemostatic resuscitation (associating treatments such as tranexamic acid, plasma, platelets or fibrinogen concentrate) and not necessarily in need of massive RBC transfusion. Defining critical haemorrhage with MT therefore does not properly consider the other crucial components of DCR (DCS and correction of EACT) which are as important as RBC transfusion. Shouldn’t we both in the clinical setting and in clinical research change our perspective, going from a massive transfusion approach to a critical haemorrhage approach? Other scoring systems have been developed with a different endpoint. The coagulopathy of severe trauma (COAST) score, developed by the same team of the present review, aims to identify trauma patients suffering from EACT. The trauma induced coagulopathy clinical score (TICCS) aims to identify trauma patients associating EACT, the need for blood products transfusion and the need for emergent surgery. There is no doubt that the presented models are all very useful in clinical practice as they bring an objective tool for prediction of critical haemorrhage. We would like to know the authors’ opinion about choosingMT as the focused outcome variable and if it is the answer to critical haemorrhage after trauma.

Clostridium difficile Infections after Blunt Trauma: A Different Patient Population?

The epidemiology of Clostridium difficile-associated infection (CDI) has changed, and it is evident that susceptibility is related not only to exposures and bacterial potency, but host factors as well. Several small studies have suggested that CDI after trauma is associated with a different patient phenotype. The purpose of this study was to examine and describe the epidemiologic factors associated with C. difficile in blunt trauma patients without traumatic brain injury using the Trauma-Related Database as a part of the "Inflammation and Host Response to Injury" (Glue Grant) and the University of Florida Integrated Data Repository. Previously recorded baseline characteristics, clinical data, and outcomes were compared between groups (67 C. difficile and 384 uncomplicated, 813 intermediate, and 761 complicated non-C. difficile patients) as defined by the Glue Grant on admission and at days seven and 14. The majority of CDI patients experienced complicated or intermediate clinical courses. The mean ages of all cohorts were less than 65 y and CDI patients were significantly older than uncomplicated patients without CDI. The CDI patients had increased days in the hospital and on the ventilator, as well as significantly higher new injury severity scores (NISS), and a greater percentage of patients with NISS >34 points compared with non-CDI patients. They also had greater Marshall and Denver multiple organ dysfunction scores than non-CDI uncomplicated patients, and greater creatinine, alkaline phosphatase, neutrophil count, lactic acid, and PiO2:FiO2 compared with all non-CDI cohorts on admission. In addition, the CDI patients had higher glucose concentrations and base deficit from uncomplicated patients and greater leukocytosis than complicated patients on admission. Several of these changes persisted to days seven and 14. Analysis of severe blunt trauma patients with C. difficile, as compared with non-CDI patients, reveals evidence of increased inflammation, immunosuppression, worse acute kidney injury, higher NISS, greater days in the hospital and on the ventilator, higher organ injury scores, and prolonged clinical courses. This supports reports of an increased prevalence of CDI in a younger population not believed previously to be at risk. This unique population may have specific genomic or inflammation-related risk factors that may play more important roles in disease susceptibility. Prospective analysis may allow early identification of at-risk patients, creation of novel therapeutics, and improved understanding of how and why C. difficile colonization transforms into infection after severe blunt trauma.

Abstract 184: Consideration of the Patient’s Age Is Important to Predict the Need for Massive Transfusion in Patients with Severe Blunt Trauma

Back Ground: The aging of society is progressing rapidly, and the aging of the trauma patient has also progressed over time. Age-related physiologic or anatomic loss of organ function, muscle atrophy, osteoporosis, and reduction in the average amount of subcutaneous tissue may lead to more serious effects of a traumatic injury. The aim of this study is to investigate the effect of patient’s age in the need for massive transfusion. Material and Methods: This study was conducted at a single institution, all patients in this study experienced blunt traumatic injuries. Patients with out-of-hospital cardiac arrest or isolated head trauma were excluded. We reviewed data from severely injured trauma patients admitted between Jan. 2008 and Mar. 2012. The following parameters were evaluated: age, sex, systolic blood pressure (SBP), heart rate (HR), Glasgow Coma Scale (GCS), results of the Focused Assessment with Sonography for Trauma (FAST), unstable pelvic fracture, femoral fracture, serum lactate, base excess, hemoglobin level (Hb), platelet count (Plt), prothrombin time (PT), antithrombotic agents, active outer bleeding, and Injury Severity Score (ISS). Massive transfusion was defined as the transfusion of 10 or more units of packed red blood cells, within 24 hours of the time of injury. We compared the parameters in patients who underwent massive transfusion (the MT group) with those who did not (the non-MT group), and independent contributed variables were detected by multiple logistic regression analysis. Results: 232 patients were included. Age, positive FAST, serum lactate, active outer bleeding, the presence of unstable pelvic fracture, and ISS in the MT group were all significantly greater than in the non-MT group. SBP, GCS, Hb, Plt, and PT were significantly less in the MT group than in the non-MT group. Age (p=0.02), SBP (p&lt;0.01), positive FAST (p&lt;0.01), the presence of unstable pelvic fracture (p&lt;0.01), PT (p=0.01), and ISS (p&lt;0.01) were independent contributed variables for massive transfusion. Conclusion: Elderly blunt trauma patient tended to be transfused massively, and consideration of the patient’s age is important to predict the need for massive transfusion in severe blunt trauma patients.