Casey J. Allen

Do all trauma patients benefit from tranexamic acid

BACKGROUND This study tested the hypothesis that early routine use of tranexamic acid (TXA) reduces mortality in a subset of the most critically injured trauma intensive care unit patients. METHODS Consecutive trauma patients (n = 1,217) who required emergency surgery (OR) and/or transfusions from August 2009 to January 2013 were reviewed. At surgeon discretion, TXA was administered at a median of 97 minutes (1-g bolus then 1-g over 8 hours) to 150 patients deemed high risk for hemorrhagic death. With the use of propensity scores based on age, sex, traumatic brain injury (TBI), mechanism of injury, systolic blood pressure, transfusion requirements, and Injury Severity Score (ISS), these patients were matched to 150 non-TXA patients. RESULTS The study population was 43 years old, 86% male, 54% penetrating mechanism of injury, 25% TBI, 28 ISS, with 22% mortality. OR was required in 78% at 86 minutes, transfusion was required in 97% at 36 minutes, and 75% received both. For TXA versus no TXA, more packed red blood cells and total fluid were required, and mortality was 27% versus 17% (all p < 0.05). The effects of TXA were similar in those with or without TBI, although ISS, fluid, and mortality were all higher in the TBI group. Mortality associated with TXA was influenced by the timing of administration (p < 0.05), but any benefit was eliminated in those who required more than 2,000-mL packed red blood cells, who presented with systolic blood pressure of less than 120 mm Hg or who required OR (all p < 0.05). CONCLUSION For the highest injury acuity patients, TXA was associated with increased, rather than reduced, mortality, no matter what time it was administered. This lack of benefit can probably be attributed to the rapid availability of fluids and emergency OR at this trauma center. Prospective studies are needed to further identify conditions that may override the benefits from TXA. LEVEL OF EVIDENCE Therapeutic study, level IV.

Decreased mortality after prehospital interventions in severely injured trauma patients.

BACKGROUND We test the hypothesis that prehospital interventions (PHIs) performed by skilled emergency medical service providers during ground or air transport adversely affect outcome in severely injured trauma patients. METHODS Consecutive trauma activations (March 2012 to June 2013) transported from the scene by air or ground emergency medical service providers were reviewed. PHI was defined as intubation, needle decompression, tourniquet, cricothyroidotomy, or advanced cardiac life support. RESULTS In 3,733 consecutive trauma activations (71% blunt, 25% penetrating, 4% burns), age was 39 years, 74% were male, Injury Severity Score (ISS) was 5, and Glasgow Coma Score (GCS) was 15, with 32% traumatic brain injury (TBI) and 7% overall mortality. Those who received PHI (n = 130, 3.5% of the trauma activations) were more severely injured: ISS (26 vs. 5), GCS (3 vs. 15), TBI (57% vs. 31%), Revised Trauma Score (RTS, 5.45 vs. 7.84), Trauma and Injury Severity Score (TRISS, 1.32 vs. 4.89), and mortality (56% vs. 5%) were different (all p < 0.05) than those who received no PHI. Air crews transported 22% of the patients; more had TBI, blunt injury, high ISS, and long prehospital times (all p < 0.05), but mortality was similar to those transported by ground. In the most severely injured patients with signs of life who received a PHI, the ISS, prehospital times, and proportions of TBI, blunt trauma, and air transport were similar, but mortality was significantly lower (43% vs. 23%, p= 0.021). CONCLUSION In our urban trauma system, PHIs are associated with a lower incidence of mortality in severely injured trauma patients and do not delay transport to definitive care. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Surveillance and Early Management of Deep Vein Thrombosis Decreases Rate of Pulmonary Embolism in High-Risk Trauma Patients

BACKGROUND Venous duplex ultrasound (VDU) is the modality of choice for surveillance of venous thromboembolism (VTE), but there is controversy about its appropriate implementation as a screening method. We hypothesize that VDU surveillance in trauma patients at high risk for VTE decreases the rate of pulmonary embolism (PE). STUDY DESIGN One thousand two hundred and eighty-two trauma ICU admissions were screened with Greenfields Risk Assessment Profile from August 2011 to September 2014. Four hundred and two patients were identified as high risk for VTE (Risk Assessment Profile ≥10). Those who received weekly VDU to evaluate for deep vein thrombosis (n = 259 [64%]) were compared with those who did not (n = 143 [36%]). Parametric data are reported as mean ± SD and nonparametric data are reported as median (interquartile range). Statistical significance was determined at an α level of 0.05. RESULTS The overall study population was 47 ± 19 years old and 75% were male, 78% of injuries were blunt mechanism, Injury Severity Score was 28 ± 13, Risk Assessment Profile was 14 ± 4, and mortality was 14.3%. Deep vein thrombosis rate was 11.6% (n = 30) in the surveillance group vs 2.1% (n = 3) in the non-surveillance group (p < 0.001). Deep vein thromboses detected in the surveillance group were managed with systemic anticoagulation (43%) or with IVC filter placement (57%). In the surveillance group, the PE rate was 1.9% (n = 5) vs 7.0% (n = 10) in the non-surveillance group (p = 0.014). CONCLUSIONS Trauma patients at high risk for VTE and who received VDU surveillance and early management of deep vein thrombosis have decreased rates of pulmonary embolism.

Pediatric emergency department thoracotomy: A large case series and systematic review

BACKGROUND/PURPOSE The emergency department thoracotomy (EDT) is rarely utilized in children, and is thus difficult to identify survival factors. We reviewed our experience and performed a systematic review of reports of EDT in pediatric patients. METHODS Patients age ≤18 years who received an EDT from 1991 to 2012 at our institution and all published case series were reviewed. Data analyzed include age, sex, mechanism of injury (MOI), injury patterns, presence of vital signs (VS) or signs of life (SOL) in the field/ED, return of spontaneous circulation (ROSC), and survival. RESULTS A total of 252 patients were analyzed. 84% were male. 51% sustained penetrating injuries, and median age was 15 years. Upon arrival, 17% had VS, and 35% had SOL. After EDT, 30% experienced ROSC. The survival rate was 1.6% for blunt trauma, 10.2% for penetrating injuries, and 6.0% overall. CONCLUSION Survival of pediatric patients following EDT is comparable to recent analyses in adults. Children who sustain blunt injury and are without SOL have been uniformly unsalvageable. Children who sustain penetrating trauma and have SOL or are without SOL for a short time prior to arrival have been salvageable. There are no reported EDT survivors less than 14 years of age following blunt injury.

Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes

INTRODUCTION Timely hemorrhage control is paramount in trauma; however, a critical time interval from emergency department arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS Data of adults (n = 309) with hypotension and GSW to the torso requiring immediate operation from January 2004 to September 2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring more than 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Statistical significance was considered at p ⩽ 0.05. RESULTS The study population was aged 32 ± 12 years, 92% were male, Injury Severity Score was 24 ± 15, systolic blood pressure was 81 ± 29 mm Hg, Glasgow Coma Scale score was 13 ± 4. Overall mortality was 27%. Mean time to operation was 19 ± 13 minutes. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared with those who arrived in 10 minutes or less (HR, 1.89; 95% CI, 1.10–3.26; p = 0.02); this was also true in the severely hypotensive patients with systolic blood pressure of 70 mm Hg or less (HR, 2.67; 95% CI, 0.97–7.34; p = 0.05). The time associated with a 50% cumulative mortality was 16 minutes. CONCLUSIONS Delay to the operating room of more than 10 minutes increases the risk of mortality by almost threefold in hypotensive patients with GSW. Protocols should be designed to shorten time in the emergency department. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE Therapeutic study, level IV.

Lost information during the handover of critically injured trauma patients: a mixed-methods study

Background Clinical information may be lost during the transfer of critically injured trauma patients from the emergency department (ED) to the intensive care unit (ICU). The aim of this study was to investigate the causes and frequency of information discrepancies with handover and to explore solutions to improving information transfer. Methods A mixed-methods research approach was used at our level I trauma centre. Information discrepancies between the ED and the ICU were measured using chart audits. Descriptive, parametric and non-parametric statistics were applied, as appropriate. Six focus groups of 46 ED and ICU nurses and nine individual interviews of trauma team leaders were conducted to explore solutions to improve information transfer using thematic analysis. Results Chart audits demonstrated that injuries were missed in 24% of patients. Clinical information discrepancies occurred in 48% of patients. Patients with these discrepancies were more likely to have unknown medical histories (p<0.001) requiring information rescue (p<0.005). Close to one in three patients with information rescue had a change in clinical management (p<0.01). Participants identified challenges according to their disciplines, with some overlap. Physicians, in contrast to nurses, were perceived as less aware of interdisciplinary stress and their role regarding variability in handover. Standardising handover, increasing non-technical physician training and understanding unit cultures were proposed as solutions, with nurses as drivers of a culture of safety. Conclusion Trauma patient information was lost during handover from the ED to the ICU for multiple reasons. An interprofessional approach was proposed to improve handover through cross-unit familiarisation and use of communication tools is proposed. Going beyond traditional geographical and temporal boundaries was deemed important for improving patient safety during the ED to ICU handover.

Hypercoagulability and venous thromboembolism in burn patients

To our knowledge, this is the first comprehensive review on the subject of venous thromboembolism (VTE) and hypercoagulability in burn patients. Specific changes in coagulability are reviewed using data from thromboelastography and other techniques. Disseminated intravascular coagulation in burn patients is discussed. The incidence and risk factors associated with VTE in burn patients are then examined, followed by the use of low-molecular-weight heparin thromboprophylaxis and monitoring techniques using antifactor Xa levels. The need for large, prospective trials in burn patients is highlighted, especially in the areas of VTE incidence and safe, effective thromboprophylaxis.

Causes of death differ between elderly and adult falls

BACKGROUND As the population ages, mortality from falls will soon exceed that from all other forms of injury. Tremendous resources are focused on this problem, but how these patients die is unclear. To fill this gap, we tested the hypothesis that falls among the elderly are related to patient, rather than to injury factors when compared with falls among younger adults. METHODS From January 2002 to December 2012, 7,293 fall admissions were reviewed. Data are reported as mean ± SD if normally distributed or median (interquartile range) if not. RESULTS In 2002 to 2007, 25% of all falls were in elderly patients (≥65 years), but in 2008 to 2012, this proportion increased to 30% (p < 0.001). When comparing adult (n = 5,216) with elderly (n = 2,077) admissions, characteristics were as follow: Injury Severity Score (ISS) of 8 (4–13) versus 9 (5–17), length of stay (in days) of 3 (1–7) versus 6 (2–11), and mortality of 3.8% versus 13.7% (all p < 0.001). After controlling for variables associated with mortality using multiple logistic regression, elderly age was the strongest independent predictor of mortality (odds ratio, 8.18; confidence interval, 4.88–13.71). When comparing adult (n = 198) with elderly (n = 285) fatalities, ground-level falls occurred in 31% versus 91%, ISS was 27 (25–41) versus 25 (16–36), and length of stay (in days) was 2 (0–6) versus 4 (1–11) (all p < 0.001). Death occurred directly from fall in 82% versus 63%, from complications in 10% versus 20%, and from a fatal event preceding the fall in 8% vs. 17% (all p < 0.001). CONCLUSION The proportion of fall admissions in the elderly is growing in this trauma system. Elderly age is the strongest independent predictor of mortality following a fall. In those who die, death is less likely a direct effect of the fall. LEVEL OF EVIDENCE Epidemiologic study, level III.

Risk factors for venous thromboembolism after pediatric trauma.

BACKGROUND/PURPOSE The purposes of this study were to identify independent predictors of venous thromboembolism (VTE), to evaluate the relative impact of adult VTE risk factors, and to identify a pediatric population at high-risk for VTE after trauma. METHODS 1934 consecutive pediatric admissions (≤ 17 years) from 01/2000 to 12/2012 at a level 1 trauma center were reviewed. Logistic regression was used to identify predictors of VTE. RESULTS Twenty-two patients (1.2%) developed a VTE, including 5% of those requiring orthopedic surgery, 14% of those with major vascular injury (MVI), and 36% of those with both. Most (84%) were diagnosed at the primary site of injury. 86% of those who developed a VTE were receiving thromboprophylaxis at the time of diagnosis. Independent predictors were age (odds ratio (OR): 1.59, 95% confidence interval (CI): 1.11-2.25), orthopedic surgery (OR: 8.10, CI: 3.10-21.39), transfusion (OR: 3.37, CI: 1.26-8.99), and MVI (OR: 15.43, CI: 5.70-41.76). When known risk factors for VTE in adults were adjusted, significant factors were age ≥ 13 years (OR: 9.16, CI: 1.08-77.89), indwelling central venous catheter (OR: 4.41, CI: 1.31-14.82), orthopedic surgery (OR: 6.80, CI: 2.47-18.74), and MVI (OR: 14.41, CI: 4.60-45.13). CONCLUSION MVI and orthopedic surgery are synergistic predictors of pediatric VTE. Most children who developed a VTE were receiving thromboprophylaxis at the time of diagnosis.

Delayed gastric emptying after pylorus preserving pancreaticoduodenectomy--does gastrointestinal reconstruction technique matter?

BACKGROUND The best gastrointestinal reconstruction route after pylorus preserving pancreaticoduodenectomy remains debatable. We aimed to evaluate the incidence of delayed gastric emptying (DGE) after antecolic (AC) and retrocolic (RC) duodenojejunostomy in these patients. DATA SOURCES Studies comparing AC to RC reconstruction after pylorus preserving pancreaticoduodenectomy were identified from literature databases (PubMed, MEDLINE, EMBASE, SCOPUS, and Cochrane). The meta-analysis included 10 studies with a total of 1,067 patients, where 504 patients underwent AC and 563 patients underwent RC reconstruction. The incidence of DGE was significantly lower with AC reconstruction in both randomized controlled trials (risk ratio = .44, confidence interval = .24 to.77, P = .005) and retrospective studies (risk ratio .21, confidence interval .14 to .30, P < .001) with less output and days of nasogastric tube use. AC reconstruction was associated with a decreased length of stay. There was no difference in operative time, blood loss, pancreatic fistula, and abdominal abscess/collections. CONCLUSIONS AC reconstruction seems to be associated with less DGE, with no association with pancreatic fistula or abscess formation.