Use In Trauma Patients Research Articles

Long-term outcomes of psychoactive drug use in trauma patients: A multicenter patient-reported outcomes study.

Psychoactive drug use (PDU) is reported in up to 40% of trauma patients and is associated with a higher rate of in-hospital complications. However, little is known about its long-term impact on trauma patients. We aimed to assess the long-term functional, mental, and psychosocial outcomes of PDU in trauma patients 6 to 12 months after injury. Trauma patients with moderate to severe injuries (Injury Severity Score, >9) who had a toxicology screen upon admission to one of three level 1 trauma centers were contacted by phone 6 to 12 months postinjury. Psychoactive drug use was defined as the presence of a psychoactive, nonprescribed substance on toxicology screen including amphetamine, barbiturate, benzodiazepine, cannabinoid, methamphetamine, methadone, opioid, oxycodone, methylenedioxymethamphetamine (ecstasy), phencyclidine, tricyclic antidepressant, and cocaine. The interviews systematically evaluated functional limitations, social functioning, chronic pain, and mental health (posttraumatic stress disorder, depression, anxiety). Patients with a score of ≤47 on the Short-Form Health Survey version 2.0 social functioning subdomain were considered to have social dysfunction. Multivariable regression models were built to determine the independent association between PDU and long-term outcomes. Of the 1,699 eligible patients, 571 (34%) were included in the analysis, and 173 (30.3%) screened positive for PDU on admission. Patients with PDU were younger (median age [interquartile range], 43 [28-55] years vs. 66 [46-78] years, p < 0.001), had more penetrating injuries (8.7% vs. 4.3%, p = 0.036), and were less likely to have received a college education (41.3% vs. 54.5%, p = 0.004). After adjusting for patients' characteristics including the presence of a baseline psychiatric comorbidity, patients with PDU on admission were more likely to suffer from daily chronic pain, mental health disorders, and social dysfunction 6 to 12 months after injury. There was no difference in the functional limitations between patients with and without PDU. On the long term, PDU in trauma patients is strongly and independently associated with worse mental health, more chronic pain, and severe impairment in social functioning. A trauma hospitalization presents an opportunity to identify patients at risk and to mitigate the long-term impact of PDU on recovery. Prognostic/epidemiologic, level III.

Narcotic use in patients following a traumatic injury.

To determine the incidence and factors associated with long-term -opioid use in trauma patients who were previously opioid-naïve. A retrospective cohort study. Level I Trauma Center. Patients admitted to the study institution between January and October 2016 following traumatic injury. Trauma patients were linked with data from the state's Controlled Substance Monitoring Program (CSMP) database regarding controlled substance use. Long-term use (LTU) of opioid medications following hospital discharge. Long-term use was defined as 4 weeks and above based on the Centers for Disease Control and Prevention's recommendation that opioid therapy should not be continued for > 4 weeks without a clinician evaluating the risk versus benefits of continued therapy. The incidence of LTU in previously naïve patients was 46 percent. Pre-existing psychiatric illness (OR = 4.764, 95 percent CI = 1.592-14.260, p = 0.005) and prior controlled substance use (OR = 4.155, 95 percent CI = 1.903-9.072) were determined to be predictors for LTU. Patients with psychiatric comorbid conditions were almost five times more likely to be in the LTU group. Those with prior controlled substance use history were four times more likely to be in the LTU group. These findings provide initial insight concerning the LTU of opioids in previously naïve patients. Application of these data may facilitate early identification of patients at risk for LTU following traumatic injury and serve to influence prescribing practices in these at-risk individuals.

Multimodal Analgesia and Decreased Opioid Use in Adult Trauma Patients.

There is an opioid epidemic in the United States. With the increased concern of over-prescribing opioids, physicians are seeking alternative pain management strategies. The purpose of this study is to review the impact of instituting a multimodal analgesia (MMA) guideline on decreasing opioid use in trauma patients at a Level 1 trauma center. In 2017, an MMA guideline was developed and included anti-inflammatories, muscle relaxants, neuropathic agents, and local analgesics in addition to opioids. Staff were educated and the guideline was implemented. A retrospective review of medications prescribed to patients admitted from 2016 through 2018 was performed. Patients admitted in 2016 served as the control group (before MMA). In 2018, all patients received multimodal pain therapy as standard practice, and served as the comparison group. A total of 10 340 patients were admitted to the trauma service from 2016 through 2018. There were 3013 and 3249 patients for review in 2016 and 2018, respectively. Total morphine milligram equivalents were 2 402 329 and 1 975 935 in 2016 and 2018, respectively, a 17.7% decrease (P < .001). Concurrently, there was a statistically significant increase in the use of multimodal pain medications. A secondary endpoint was studied to evaluate for changes in acute kidney injury; there was not a statistically significant increase (0.56% versus 0.68%, P = .55). Implementation of an MMA guideline significantly reduced opioid use in trauma patients. The use of nonopioid MMA medications increased without an increased incidence of acute kidney injury.

Impact of Traumatic Brain Injury on Clinical Institute Withdrawal Assessment Use in Trauma Patients: A Descriptive Study.

Alcohol withdrawal syndrome (AWS) and traumatic brain injury (TBI) present with similar signs and symptoms, yet their treatment strategies differ greatly. AWS treatment includes the Clinical Institute Withdrawal Assessment (CIWA) protocol, which grades withdrawal signs and symptoms. A major purpose of CIWA is to guide the addition and titration of central nervous system (CNS) depressants, most commonly benzodiazepines. Conversely, best practice is to avoid these same CNS depressants in the setting of TBI. Thus, patients with TBI presenting with AWS risk may receive undesirable interventions that could worsen outcome. To describe the relationship of TBI diagnosis with CIWA protocol scores and intervention implementation. Retrospective cohort observational study. Single university-based, level one trauma center. Three hundred seventy-five patients with head trauma or AWS classification, identified through the trauma center's trauma registry. CIWA protocol and related medication use. Frequency of elevated CIWA score, length of CIWA administration, and medication administration incidence were abstracted from patients' medical records. The percentage of elevated CIWA scores increased significantly with TBI severity, from 4.5%(0-60) in the No TBI group, up to 12.5% (0-36) in the Mild TBI group, 27.1% (0-57) in the Moderate TBI group, and 50.0% (14-77) in the Severe TBI group. Nominally, lorazepam use showed a similar pattern of escalation with TBI severity, but it did not reach statistical significance. Haloperidol use did significantly escalate with higher TBI severity. No group differences were observed for total lorazepam equivalents or length on the CIWA protocol. TBI diagnosis and higher TBI severity level correlate with higher CIWA scores, but neither increased nor decreased benzodiazepine usage was observed. Antipsychotic use did escalate with TBI diagnosis and severity. The risks versus benefits of minimizing benzodiazepines in patients with TBI who are at risk for AWS warrant future study.

Role of Tranexamic Acid in the Clinical Setting.

Tranexamic acid (TXA) is labeled as an antifibrinolytic agent that decreases mortality, reduces blood loss after trauma or surgery, and lowers transfusion requirements in trauma patients with bleeding. This review of the literature is related to TXA use in a variety of settings, with a specific focus on trauma patients, to assess therapeutic efficacy and safety. As seen in large, randomized, placebo-controlled trials, TXA has been shown to decrease mortality over placebo in trauma patients, It is also noted to have good safety parameters upon administration and should be recommended for use in trauma patients with bleeding. Further studies are warranted for the use of TXA in gastrointestinal bleeding and pediatric trauma.

Opioid exposure after injury in United States trauma centers: A prospective, multicenter observational study.

Efforts to reduce opioid use in trauma patients are currently hampered by an incomplete understanding of the baseline opioid exposure and variation in United States. The purpose of this project was to obtain a global estimate of opioid exposure following injury and to quantify the variability of opioid exposure between and within United States trauma centers. Prospective observational study was performed to calculate opioid exposure by converting all sources of opioids to oral morphine milligram equivalents (MMEs). To estimate variation, an intraclass correlation was calculated from a multilevel generalized linear model adjusting for the a priori selected variables Injury Severity Score and prior opioid use. The centers enrolled 1,731 patients. The median opioid exposure among all sites was 45 MMEs per day, equivalent to 30 mg of oxycodone or 45 mg of hydrocodone per day. Variation in opioid exposure was identified both between and within trauma centers with the vast majority of variation (93%) occurring within trauma centers. Opioid exposure increased with injury severity, in male patients, and patients suffering penetrating trauma. The overall median opioid exposure was 45 MMEs per day. Despite significant differences in opioid exposure between trauma centers, the majority of variation was actually within centers. This suggests that efforts to minimize opioid exposure after injury should focus within trauma centers and not on high-level efforts to affect all trauma centers. Epidemiological, level III.

Are the Benefits of Rapid Source Control Laparotomy Realized after Acute Colonic Perforation?

Background: The indications for damage-control laparotomy (DCL) in patients with intra-abdominal injuries have evolved from its use in trauma patients with hypothermia, coagulopathy, and acidosis to use in general surgical patients with acute intestinal perforations. Whereas some patients may be acidotic, most are not hypothermic or afflicted with coagulopathies. Recent study suggests the benefits to patients of rapid source-control laparotomy (RSCL) are not realized in patients with acute abdominal emergencies. Methods: Three years of data (2014-2016) from The American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) were assessed. The patient populations were separated into RSCL patients who had their fascia left open after the initial source control operation and those who had primary fascial closure (PFC). The principal outcome of interest in this study was death within thirty days. A secondary analysis was performed evaluating complications and length of stay. Results: Of the 1,381 patients who qualified for the study, 396 (28.7%) were managed with RSCL and the remaining 985 patients had PFC. After a univariable analysis, propensity score matching was performed. The median hospital length of stay was 20 days (95% confidence interval [CI] 18-22) versus 14 (95% CI 13-16; p < 0.001) in RSCL and PFC, respectively. A larger number of patients having RSCL went to a rehabilitation facility than those having PFC (18.7%; versus 11.2%; p = 0.014). The 30-day mortality rate in patients in the RSCL group was significantly higher than in the PFC group ((32.6% versus 16.9%; p < 0.001). Conclusion: These data provide strong evidence that RSCL may not be beneficial for routine use in perforated colon surgery.

The Effect of Targeted Beta Blocker Use in Trauma Patients Admitted to the Intensive Care Unit

Beta-blockers are used to reduce heart rate (HR) and thereby reduce myocardial oxygen demand. Current guidelines include a recommendation for the use of beta-blockers titrated to a target HR of 60 to 70 beats per minute (bpm) in certain populations; however, the value of this intervention has not yet been studied in the trauma population. Our objective was to determine whether beta-blockers used to titrate heart rate to 60-70 bpm within the first 24 hours of intensive care unit (ICU) admission affect outcome in trauma patients. We retrospectively examined the trauma registry to identify patients admitted to the ICU of an urban level-I trauma center over the course of January to December 2013; medical records were further reviewed to identify those who received treatment with beta-blockers. Data was collected on patient demographics, maximum/minimum HR within 24 hours of admission, achievement of target HR (60-70 bpm), type of beta-blocker administered, length of stay (LOS), injury severity score (ISS), and survival to discharge. Patients were stratified into two groups based upon whether target HR was achieved at least once during the first 24 hours of ICU admission. Statistical analysis was performed using chi-square analysis or t-test as appropriate. A total of 208 patients, 65 females and 143 males with an average age of 59.3 ± 19.3 years, were included. The majority of patients (88.9%) were treated with metoprolol while the rest received atenolol, labetalol, or carvedilol. Eighty-six patients reached target HR on the first day of ICU admission. Heart rate ranged from 48 to 150 bpm; maximum HR was significantly lower in the target HR achieved group (82 ± 2.4 vs 99.9 ± 2.8 bpm, p<0.001). There was no significant difference between the amount of injury sustained by the target HR achieved (ISS 14.2 ± 1.9) and target HR not achieved (ISS 15.9 ± 1.9) groups. Achievement of target HR was associated with a shorter LOS (5.8 ± 1.3 d vs. 10.5 ± 2.3 d, p-value 0.002) and increased likelihood of survival (OR 5.02, 95%CI 1.67-15.2, p=0.004).

Marijuana self-report compared with testing in trauma patients before and after legalization

Background: Both marijuana use and legalization are increasing, and the cognitive effects of marijuana may play a role in trauma. Our objective was to assess the proportion of patients with a urine drug screen who self-reported use in a population of trauma patients.Methods: Self-report of marijuana use in trauma patients was recorded for patients with a positive urine toxicology screen at a Level 1 trauma center in Arizona prior to (1/2011 to 4/13/2011) and following (4/14/2011 to 9/2014) legalization of marijuana for medical indications.Results: Among patients with a positive toxicology screen who were able to report to utilization, 52.5% patients with a positive UDS for marijuana overall reported use. In the pre-legalization group, 59.3% reported use, while in the post-legalization group, 51.4% reported use (p = .188).Conclusion: Only about half of trauma patients with a positive urine drug screen for marijuana reported use. Self-reporting among UDS-positive patients demonstrated no significant change with the legalization of marijuana for medical reasons.

A Peripherally Inserted Central Catheter is a Safe and Reliable Alternative to Short-Term Central Venous Catheter for the Treatment of Trauma Patients

Purpose To determine whether a peripherally inserted central catheter (PICC) meets the goals of a low infection rate and long-term use in trauma patients. Methods From January 2016 to June 2018, the medical records of patients who underwent central venous catheterization at a level I trauma center were retrospectively reviewed. Data collected included age, sex, injury severity score, site of catheterization, place of catheterization (intensive care unit [ICU], emergency department, or general ward), type of catheter, length of hospital stay during catheterization, types of cultured bacteria, time to development of central line-associated bloodstream infection (CLABSI), and complications. Results During the study period, 333 central vein catheters (CVC) were inserted with a total of 2,626 catheter-days and 97 PICCs were placed with a total of 2,227 catheter-days. The CLABSI rate was significantly lower in the PICC group when the analysis was limited to patients for whom the catheter was changed for the first time in the ICU after CVC insertion in the ER with similar indication and catheter insertion times (18.6 vs. 10.3/1,000 catheter-days, respectively, p<0.05). The median duration of catheter use was significantly longer in the PICC group than in the CVC group (16 vs. 6 days, respectively, p<0.05). Conclusions The study results showed that the duration of catheter use was longer and the infection rate were lower in the PICC group than in the CVC group, suggesting that PICC is a safe and reliable alternative to conventional CVC. Keywords: Catheterization; peripheral; Central venous catheters; Catheter related infections; Trauma centers

Cannabis Use is Associated with Increased Mechanical Ventilation and Polysubstance Use in Trauma Patients

Recent policy changes in California regarding cannabis use underscore the need to study outcomes and prevalence of this drug in trauma. Our study aims to study the prevalence of cannabis use and associations with injury types and outcomes in Los Angeles County trauma patients. Data were reviewed from 21,276 adult patients from a Los Angeles countywide database spanning five years (2012-2016), who underwent urine toxicology testing in the ED after sustaining a traumatic injury. The percentage of trauma patients using marijuana increased from 36 to 43 per cent over the five-year period. On univariate analysis, cannabis-positive patients were significantly younger and more likely male, with lower median systolic blood pressure and heart rate on arrival in the ED. A higher proportion of cannabis users had penetrating trauma, and 48 per cent of cannabis users also tested positive for amphetamines, cocaine, opioids, or Phencyclidine. On multivariate analysis, cannabis was associated with an increase in need for mechanical ventilation after adjusting for age, admission Glasgow Coma Score, gender, polysubstance use, blunt or penetrating mechanism, and Injury Severity Score, and was not associated with increases in mortality or ICU length of stay.

Analysis of the Safety Profile of Commonly Used Procoagulants Using the FDA Adverse Event Reporting System

Introduction:Though less commonly used than their anticoagulant counterparts, procoagulants have an important role in the reversal of anticoagulation. Four-factor prothrombin complex concentrate (4PCC) is now approved by the U.S. Food & Drug Administration (FDA) for the reversal of major bleeding associated with warfarin, and is often used off-label to reverse direct oral anticoagulants. Three-factor concentrate (3PCC) and off-label use of recombinant activated factor VII (rFVIIa) have filled this role in the past. Vitamin K is also used as a common antidote for warfarin-induced coagulopathy. Comparative data evaluating the safety profiles and relative thrombotic risks of the PCCs and rFVIIa is limited. In order to better evaluate their comparative safety we calculated the rate of adverse events reported to the FDA of each procoagulant.Methods:We evaluated the FDA Adverse Event Reporting System (FAERS) database, which compiles drug-related adverse events reported to the FDA from 1969 onwards, to assess the rate of adverse events reported with various procoagulants. Safety profiles were assessed using proportional reporting ratios (PRR) with the total number of reported cases as the denominator. Adverse events data for each drug (vitamin K, rFVIIa, 3PCC, 4PCC) was gathered from FAERS. Both generic and brand names were used to query the database. Adverse events data was filtered by including only events reported by healthcare professionals. Specific adverse events were chosen apriori based on hypothesized potential complications and included hemorrhagic and thrombotic complications. The PRR with 95% confidence interval was generated for each event, with a cut-off of 2 being used to identify associations.Results:As shown in Table 1 and Figure 1, rFVIIa was associated with increased reports of mortality while 4PCC was associated with ischemic stroke, and all but rFVIIa were associated with high INR. 3PCC displayed an increased association with reports of intracranial hemorrhage (ICH), although there was a low rate of reports for 3PCC. Lesser associations were found between rFVIIa and myocardial infarction (MI), 3PCC and deep-vein thrombosis (DVT), and 4PCC and DVT and ICH. In general, vitamin K had the weakest associations among adverse events.Conclusions:Our analysis found that the rate of reports of death and MI were higher with rFVIIa than other procoagulants, while reports of ischemic stroke and intracranial hemorrhage were more common with PCCs. rFVIIa has been associated with cardiovascular before, a finding reiterated by our study. There are notable limitations of this type of analysis, including the reliance on the accurate reporting of adverse events to the FDA, possibility of duplications of reports in the FAERS database, and the importance of not conflating correlation with causation as it relates to these events. The association between rFVIIa and increased death may be due to rFVIIa's history of off-label use in trauma patients and other patient groups at higher risk for mortality. While 4PCC may be the procoagulant of the present, it does not have a perfect safety profile, and further study is needed to better characterize the complications of 4PCC and ensure that it is used in such a way as to not under- or over-treat the condition. DisclosuresNo relevant conflicts of interest to declare.

(22) Use of ECMO in Pediatric Multi-trauma Patient with Severe Pulmonary Airleak

INTRODUCTION: Extracorporeal Membrane Oxygenation (ECMO) for Acute Respiratory Distress Syndrome after trauma is controversial. Most lung injury after trauma resolves with conventional ventilation. Venovenous ECMO is utilized for refractory respiratory failure in non-surgical patients; its use in trauma patients is controversial due to concerns of catastrophic bleeding, the presence of intracranial pathology, acute coagulopathy and the potential for multiple surgical interventions. CASE REPORT: Patient is an 11-year-old male who was ejected through the sunroof during a motor vehicle collision (MVC). EMS intubated him at the scene. He had bilateral chest …

Analysis for Patient Survival after Open Abdomen for Torso Trauma and the Impact of Achieving Primary Fascial Closure: A Single-Center Experience

Open abdomen indicates the abdominal fascia is unclosed to abbreviate surgery and to reduce physiological stress. However, complications and difficulties in patient care are often encountered after operation. During May 2008 to March 2013, we performed a prospective protocol-directed observation study regarding open abdomen use in trauma patients. Bogota bag is the temporary abdomen closure initially but negative pressure dressing is used later. A goal-directed ICU care is applied and primary fascial closure is the primary endpoint. There were 242 patients received laparotomy after torso trauma and 84 (34.7%) had open abdomen. Twenty patients soon died within one day and were excluded. Among the included 64 patients, there were 49 (76.6%) males and the mean Injury Severity Score was 31.7. Uncontrolled bleeding was the major indication for open abdomen (64.1%) and the average duration of open abdomen was about 4.2 ± 2.2 days. After treatment, 53(82.8%) had primary fascia closure, which is significant for patient survival (odds ratio 21.6; 95% confidence interval: 3.27–142, p = 0.0014). Factors related to failed primary fascia closure are profound shock during operation, high Sequential Organ Failure Assessment Score in ICU and inadequate urine amount at first 48 hours admission.

Effects of Tranexamic Acid on Mortality and Blood Transfusion in Trauma Patients with Significant Hemorrhage: A Clinical Trial

Extensive hemorrhage is a significant cause of mortality in trauma patients. Tranexamic acid has been used for controlling bleeding in cardiovascular surgeries and dental manipulations in patients with hemophilia. However, in traumatic patients with bleeding, its use dates back to more recent years. This study aims to examine the effects of this drug on reducing mortality and blood transfusion rate in trauma patients with significant hemorrhage. A total of 60 patients with significant trauma-related hemorrhage (systolic blood pressure &lt; 90 mmHg/heart rate &gt; 110/min) from the emergency department of Imam Reza Hospital (Tabriz, Iran), were randomized in two groups. The case group received intravenous Tranexamic acid (1 g in 10 min and then 1 g over 8 h). The control group received placebo. Rate of transfusion and rate of one-month mortality were compared between the study groups. The mean ICU stay and overall hospitalization times did not have significant difference between two groups (p&lt;0.05). Transfusion of packed cells was 6.03±1.50 and 6.03±1.22 units in case and control groups respectively. Transfusion of fresh frozen plasma (FFP) was 2.50±1.36 and 3.03±0.96 units in case and control groups respectively (p=0.09). Transfusion of platelets was 0.40±0.20 1.33±0.31 units in case and control groups respectively (p=0.01). Three patients (10%) in the case group and 4 patients (13.3%) in the control group were expired (p=0.50). Tranexamic acid is safe and effective in reducing platelet transfusion rate in patients with trauma-related significant hemorrhage. However, transfusion need and mortality would not reduce by its use in trauma patients.

Tranexamic acid in major trauma: implementation and evaluation across South West England.

To carry out a prospective evaluation of tranexamic acid (TXA) use in trauma patients. TXA was introduced to all emergency ambulances and emergency departments in the South West, UK, on 1 December 2011. We carried out a prospective evaluation of TXA use in trauma patients in the South West Peninsula between December 2011 and December 2012. We collected prehospital and hospital data on TXA administration using the Trauma Audit Research Network database. Data on prehospital administration of TXA were cross-checked with the South Western Ambulance Service Trust. Data were analysed using SPSS (version 20). Altogether, 82 patients were administered TXA during the study period. The median age of the patients was 49 years (IQR 30, 66), and 72% were men. One-third of the patients arrived at hospital by air ambulance. During the first 3 months, administration of TXA was limited to one patient each month receiving the drug. However, an upward trend was observed after June until October 2012, with the increment being more than 10 fold in July, September and October 2012. This is the first study to evaluate the use of TXA in civilian practice in the UK. Our study shows that ambulance service personnel and emergency departments can effectively administer TXA.

Tranexamic Acid (TXA) in Trauma Patients: Barriers to Use among Trauma Surgeons and Emergency Physicians.

Objective. Tranexamic Acid (TXA) is currently the only drug with prospective clinical evidence supporting its use in bleeding trauma patients. We sought to better understand the barriers preventing its use and elicit suggestions to further its use in trauma patients in the state of Maryland. Methods. This is a cross-sectional study. Results. The overall response rate was 38%. Half of all participants reported being familiar with the CRASH-2 trial and MATTERs study. Half reported being aware of TXA as part of their institution's massive transfusion protocol. The majority of participants felt that TXA would have a significant positive impact on the survival of trauma patients. A majority also felt that the use of TXA would increase if its administration was the responsibility of both trauma surgeons and emergency physicians. Conclusion. Only half of responders reported being aware of TXA as being part of their institution's massive transfusion protocol. Lack of awareness of the clinical data supporting its use is a major barrier. However, most trauma providers and emergency physicians do have a favorable view of TXA and support its incorporation into massive transfusion protocols. We believe that more studies of this kind on both state and national level are needed.

Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients.

BackgroundDeep Vein Thrombosis (DVT) is a common complication in trauma patients. Venous duplex surveillance is used widely for the diagnosis of DVT, however, there is controversy concerning its appropriate use. The Wells criterion is a clinically validated scoring system in an outpatient setting, but its use in trauma patients has not been studied. This study evaluated the application of the Wells scoring system in trauma population.MethodsWells scores were calculated retrospectively for all patients who were admitted to the trauma service and underwent Venous Duplex Scanning (VDS) at the author’s institution between 2012 and 2013. Correlation of Wells score with DVT and its efficacy in risk stratifying the patients after trauma was analyzed using linear correlation and receiver operating characteristic (ROC) curve. Sensitivity and specificity of Wells score in ruling out or ruling in DVT were calculated in various risk groups.ResultsOf 298 patients evaluated, 18 (6 %) patients were positive for DVT. A linear correlation was present between Wells score and DVT with R2 = 0.88 (p = 0.0016). Median Wells score of patients without DVT was 1 (1–3) compared to a median score of 2 (1–5) in those with DVT (p < 0.0001). In low risk patients (scores <1), Wells scoring was able to rule out the possibility of DVT with a sensitivity of 100 % and NPV of 100 %, while in moderate-high risk patients (scores ≥2), it was able to predict DVT with a specificity of 90 %. Area under ROC curve was 0.859 (p < 0.0001) demonstrating the accuracy of Wells scoring system for DVT risk stratification in post trauma patients.ConclusionsA Wells score of <1 can reliably rule out the possibility of DVT in the trauma patients. Risk of developing DVT correlates linearly with Wells score, establishing it as a valid pretest tool for risk stratification.Electronic supplementary materialThe online version of this article (doi:10.1186/s13017-016-0078-1) contains supplementary material, which is available to authorized users.

Prehospital administration of tranexamic acid in trauma patients.

BackgroundEvidence on prehospital administration of the antifibrinolytic tranexamic acid (TXA) in civilian trauma populations is scarce. The aim was to study whether prehospital TXA use in trauma patients was associated with improved outcomes.MethodsThe prehospital database of the ADAC (General German Automobile Club) Air Rescue Service was linked with the TraumaRegister of the German Trauma Society to reidentify patients documented in both registries. Primarily admitted trauma patients (2012 until 2014) who were treated with TXA during the prehospital phase were matched with patients who had not received prehospital TXA, applying propensity score-based matching.ResultsThe matching yielded two identical cohorts (n = 258 in each group), since there were no significant differences in demographics or injury characteristics (mean Injury Severity Score 24 ± 14 [TXA] vs. 24 ± 16 [control]; p = 0.46). The majority had sustained blunt injury (90.3 % vs. 93.0 %; p = 0.34). There were no differences with respect to prehospital therapy, including rates of intubation, chest tube insertion or both administration of i.v. fluids and catecholamines. During ER treatment, the TXA cohort received fewer numbers of red blood cells and plasma units, but without reaching statistical significance. Incidences of organ failure, sepsis or thromboembolism showed no significant differences as well, although data were incomplete for these parameters. Early mortality was significantly lower in the TXA group (e.g., 24-h mortality 5.8 % [TXA] vs. 12.4 % [control]; p = 0.01), and mean time to death was 8.8 ± 13.4 days vs. 3.6 ± 4.9 days, respectively (p = 0.001). Overall hospital mortality was similar in both groups (14.7 % vs. 16.3 %; p = 0.72). The most pronounced mortality difference was observed in patients with a high propensity score, reflecting severe injury load.ConclusionsThis is the first civilian study, to our knowledge, in which the effect of prehospital TXA use in trauma patients has been examined. TXA was associated with prolonged time to death and significantly improved early survival. Until further evidence emerges, the results of this study support the use of TXA during prehospital treatment of severely injured patients.

Three-factor versus Four-factor Prothrombin Complex Concentrates to Reverse Oral Anticoagulation in Trauma Patients

Background: The use of prothrombin complex concentrates (PCCs), namely three-factor PCC (3F-PCC) or four-factor PCC (4F-PCC) for urgent anticoagulation reversal is critical for damage control resuscitation. However, few reports if any in the trauma literature directly compares 3F-PCC vs. 4F-PCC use in trauma patients. We hypothesize that 3F-PCC and 4F-PCC differ in their efficacy, adverse effects and cost-effectiveness when used in trauma patients. Methods: All consecutive trauma patients with coagulopathy (INR ≥ 1.5) secondary to warfarin and rivaroxaban who received either 3F-PCC or 4F-PCC from 2010-2014 at our trauma center were reviewed. Multivariate analysis was conducted to control for confounding variables using IBM/SPSS version 19; p<.05 was considered statistically significant. Results: 46 patients received 3F-PCC and 18 received 4F-PCC. Indications for warfarin (95%) or rivaroxaban (5%) were: atrial fibrillation (67%), venous thromboembolism (28%) cerebrovascular vascular accident (13%), mechanical valve (8.7%), and other (4.4%). The initial PCC dose (IU/kg) was 30 for 3F-PCC and 26 for 4F- PCC. INR decreased after PCC from 3.4 to 1.6 for 3F-PCC and from 3.1 to 1.3 for 4F-PCC (p=.001). Successful reversal rates in patients were: 3F-PCC (50%) and 4F-PCC (83%), p=.022. After controlling for relevant covariates 4F-PCC was retained as an independent predictor for successful anticoagulation reversal: OR=5, 95% CI (1.2 – 19.6), p=.021. There were no deaths. Thromboembolic events were observed in 15% of patients with 3F-PCC vs. 0% with 4F-PCC (p=.177). Cost-effectiveness favored 4F- PCC ($5382 vs. $3797). Conclusions: In this retrospective study, 4F-PCC was associated with increased successful anticoagulation reversals without concomitant increase in thromboembolic events compared with 3F-PCC (83% vs. 50%). This improved rate led to a more favorable cost effectiveness profile for 4F-PCC. Replacing 3F-PCC with 4F-PCC for urgent coagulopathy reversal may benefit patients. Future prospective and long term follow-up studies are needed to validate these observations. Level of evidence: Level III retrospective comparative study without negative criteria. Study type: Therapeutic