Elizabeth A. Camp

Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients.

Abstract Objective. Earlier use of plasma and red blood cells (RBCs) has been associated with improved survival in trauma patients with substantial hemorrhage. We hypothesized that prehospital transfusion (PHT) of thawed plasma and/or RBCs would result in improved patient coagulation status on admission and survival. Methods. Adult trauma patient records were reviewed for patient demographics, shock, coagulopathy, outcomes, and blood product utilization from September 2011 to April 2013. Patients arrived by either ground or two different helicopter companies. All patients transfused with blood products (either pre- or in-hospital) were included in the study. One helicopter system (LifeFlight, LF) had thawed plasma and RBCs while the other air (OA) and ground transport systems used only crystalloid resuscitation. Patients receiving PHT were compared with all other patients meeting entry criteria to the study cohort. All comparisons were adjusted in multilevel regression models. Results. A total of 8,536 adult trauma patients were admitted during the 20-month study period, of which 1,677 met inclusion criteria. They represented the most severely injured patients (ISS = 24 and mortality = 26%). There were 792 patients transported by ground, 716 by LF, and 169 on OA. Of the LF patients, 137 (19%) received prehospital transfusion. There were 942 units (244 RBCs and 698 plasma) placed on LF helicopters, with 1.9% wastage. PHT was associated with improved acid–base status on hospital admission, decreased use of blood products over 24 hours, a reduction in the risk of death in the sickest patients over the first 6 hours after admission, and negligible blood products wastage. In this small single-center pilot study, there were no differences in 24-hour (odds ratio 0.57, p = 0.117) or 30-day mortality (odds ratio 0.71, p = 0.441) between LF and OA. Conclusions. Prehospital plasma and RBC transfusion was associated with improved early outcomes, negligible blood products wastage, but not an overall survival advantage. Similar to the data published from the ongoing war, improved early outcomes are associated with placing blood products prehospital, allowing earlier infusion of life-saving products to critically injured patients.

A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions.

Objectives: To determine whether resuscitation of severely injured patients with modified whole blood (mWB) resulted in fewer overall transfusions compared with component (COMP) therapy. Background: For decades, whole blood (WB) was the primary product for resuscitating patients in hemorrhagic shock. After dramatic advances in blood banking in the 1970s, blood donor centers began supplying hospitals with individual components [red blood cell (RBC), plasma, platelets] and removed WB as an available product. However, no studies of efficacy or hemostatic potential in trauma patients were performed before doing so. Methods: Single-center, randomized trial of severely injured patients predicted to large transfusion volume. Pregnant patients, prisoners, those younger than 18 years or with more than 20% total body surface area burns (TBSA) burns were excluded. Patients were randomized to mWB (1 U mWB) or COMP therapy (1 U RBC+ 1 U plasma) immediately on arrival. Each group also received 1 U platelets (apheresis or prepooled random donor) for every 6 U of mWB or 6 U of RBC + 6 U plasma. The study was performed under the Exception From Informed Consent (Food and Drug Administration 21 code of federal regulations [CFR] 50.24). Primary outcome was 24-hour transfusion volumes. Results: A total of 107 patients were randomized (55 mWB, 52 COMP therapy) over 14 months. There were no differences in demographics, arrival vitals or laboratory values, injury severity, or mechanism. Transfusions were similar between groups (intent-to-treat analysis). However, when excluding patients with severe brain injury (sensitivity analysis), WB group received less 24-hour RBC (median 3 vs 6, P = 0.02), plasma (4 vs 6, P = 0.02), platelets (0 vs 3, P = 0.09), and total products (11 vs 16, P = 0.02). Conclusions: Compared with COMP therapy, WB did not reduce transfusion volumes in severely injured patients predicted to receive massive transfusion. However, in the sensitivity analysis (patients without severe brain injuries), use of mWB significantly reduced transfusion volumes, achieving the prespecified endpoint of this initial pilot study.

Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury.

BACKGROUND Nonoperative multidisciplinary management for severe (American Association for the Surgery of Trauma Grades IV and V) liver injury has been used for two decades. We have previously shown that Damage Control Resuscitation (DCR) using low-volume, balanced resuscitation improves survival of severely injured trauma patients; however, little attention has been paid to organ-specific outcomes. We wanted to determine if implementation of DCR has improved survival and successful nonoperative management after severe blunt liver injury. METHODS A retrospective study was performed on all adult trauma patients with severe blunt liver injury who were admitted from 2005 to 2011. Patients were divided into pre-DCR (2005–2008) and DCR (2009–2011) groups. Patients who died before leaving the emergency department (ED) were excluded. Outcomes (resuscitation products used, survival, and length of stay) were then compared by univariate and multivariate analyses. RESULTS Between 2005 and 2011, 29,801 adult trauma patients were admitted, and 1,412 (4.7%) experienced blunt liver injury. Of these, 244 (17%) sustained Grade IV and V injuries, with 206 patients surviving to leave the ED. The pre-DCR group (2005–2008) was composed of 108 patients, and the DCR group (2009–2011) had 98 patients. The groups were not different in demographics as well as prehospital and ED vital signs or Injury Severity Score (ISS). No change in operative or interventional radiology techniques occurred in this time frame. The DCR cohort had an increase in successful nonoperative management (from 54% to 74%, p < 0.01) as well as a reduction in initial 24-hour packed red blood cell (median, from 13 U to 6.5 U; p < 0.01), plasma (median, from 13 U to 8 U; p < 0.01), and crystalloid (median, from 5,800 mL to 4,100 mL; p < 0.01) administration. The DCR treatment was associated with improved survival, from 73% to 94% (p < 0.01). CONCLUSION In patients with severe blunt liver injury, DCR was associated with less crystalloid and blood product use, a higher successful nonoperative management rate, and improved survival. Resuscitation technique may improve outcomes after severe liver injury. LEVEL OF EVIDENCE Therapeutic/care management, level III.

Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1,376 diaphyseal femur fractures.

BACKGROUND Early fixation (<24 hour) of femur fractures with an intramedullary nail (IMN) has been associated with a decreased incidence of pulmonary complication (PC) in stable trauma patients. Early fixation is in accordance with the “two-hit” hypothesis, that is, an increase in proinflammatory markers during Days 3 to 5 after injury, increases the risk of developing a PC. We hypothesized that early IMN fixation of femur fractures would be associated with a decreased incidence of PC, hospital stay, and overall charges. METHODS A retrospective review of all trauma patients with diaphyseal femur fractures was performed from January 2000 through December 2010 at an academic Level 1 trauma center. The cohort was divided into those who underwent early fixation (<24 hours) and delayed fixation (≥24 hours). Multivariable logistic regression modeling was used to adjust for the anatomic (Injury Severity Score [ISS]) and physiologic (Revised Trauma Score [RTS]) severity of injury. The primary outcome of interest was PC, defined as the presence of pneumonia (PNA), pulmonary embolism, or adult respiratory distress syndrome. Continuous variables are expressed as mean (SD). The analysis was repeated for patients with an ISS of greater than 15 and an ISS of greater than 25. RESULTS During the study period, 1,755 patients were admitted with a diaphyseal femur fracture, of whom 1,376 patients underwent primary IMN. A total of 1,032 (75%) underwent early fixation (median, 7.4 hours; interquartile range [IQR], 3.7–12.9 hours), and 344 (25%) underwent delayed fixation (median, 40.9 hours; IQR, 31.0–64.9 hours). The early fixation group had lower ISS (median [IQR], 10 [10–19] vs. 17.5 [10–27]; p < 0.001) and a higher RTS (median [IQR], 7.84 [7.84–7.84] vs. 7.84 [7.84–7.84]; p < 0.001). PC were reduced in the early fixation group, (3.9% vs. 13.4%, p < 0.001). Specifically, there was a decreased incidence of PNA (2% vs. 11%, p < 0.001), pulmonary embolism (2% vs. 4%, p < 0.21), and adult respiratory distress syndrome (0.002% vs. 0.02%, p < 0.001). After adjustment for anatomic (ISS) and physiologic (RTS) indices of injury severity, early fixation was independently associated with a reduction in PC (odds ratio, 0.43; 95% confidence interval, 0.25–0.72; p = 0.002). The early fixation group also had a decrease in hospital length of stay (median [IQR], 6 [4–11] vs. 10 [6–17]; p < 0.001), ventilator days (median [IQR], 0 [0–0] vs. 0 [0–4]; p < 0.001), and hospital charges (median [IQR],

Evaluation of noninvasive hemoglobin measurements in trauma patients

59,561 [

Seven deadly sins in trauma outcomes research: an epidemiologic post mortem for major causes of bias.

38,618–

Prospective Evaluation of Prehospital Trauma Ultrasound During Aeromedical Transport

106,780] vs.

Early surgical intervention for blunt bowel injury: The Bowel Injury Prediction Score (BIPS)

97,018 [48,249–205,570]; p < 0.001). Mortality was low in both groups (0.4% vs. 1.7%, p < 0.01). Similar results were seen in patients with an ISS of greater than 15 and ISS of greater than 25. CONCLUSION Controlling for anatomic and physiologic severity of injury, early femoral IMN was associated with an almost 60% reduction in odds of developing PCs. Early fixation was also associated with a reduction ventilator days, hospital length of stay, and overall hospital charges. As the list of “never events” continues to expand and improving quality of care while reducing costs is emphasized, early (<24 hours) definitive operative intervention seems to decrease complications, achieve early hospital discharge, and reduce hospital charges. LEVEL OF EVIDENCE Therapeutic study, level IV.

Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management

BACKGROUND Reliable, accurate, noninvasive, and continuous determination of hemoglobin would be an important advance in the care of trauma patients. The aim of this study was to evaluate the utility of the Masimo Radical 7 device in severely injured trauma patients. METHODS Highest level trauma activation patients were enrolled over a 1-year period. Laboratory hemoglobin values were compared with Masimo hemoglobin values using Bland-Altman analysis. RESULTS A total of 525 patients were enrolled in the study. Comparison of 861 paired values from 418 patients showed a variance of 3.89 to -3.84 g/dL, showing a nonsignificant correlation between Masimo hemoglobin and laboratory hemoglobin values. CONCLUSIONS The Masimo Radical 7 system evaluated in this study holds promise, but it is not ready to be used as an initial noninvasive evaluation tool in the acute treatment of severely injured trauma patients. There was a poor correlation between Masimo hemoglobin and laboratory hemoglobin and large numbers of missing data. On the basis of the poor correlation, the Masimo Radical 7 device cannot currently be used to guide transfusion therapy.

Hypercoagulability after injury in premenopausal females: A prospective, multicenter study

BACKGROUND Because randomized clinical trials in trauma outcomes research are expensive and complex, they have rarely been the basis for the clinical care of trauma patients. Most published findings are derived from retrospective and occasionally prospective observational studies that may be particularly susceptible to bias. The sources of bias include some common to other clinical domains, such as heterogeneous patient populations with competing and interdependent short- and long-term outcomes. Other sources of bias are unique to trauma, such as rapidly changing multisystem responses to injury that necessitate highly dynamic treatment regimens such as blood product transfusion. The standard research design and analysis strategies applied in published observational studies are often inadequate to address these biases. METHODS Drawing on recent experience in the design, data collection, monitoring, and analysis of the 10-site observational PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, 7 common and sometimes overlapping biases are described through examples and resolution strategies. RESULTS Sources of bias in trauma research include ignoring (1) variation in patients’ indications for treatment (indication bias), (2) the dependency of intervention delivery on patient survival (survival bias), (3) time-varying treatment, (4) time-dependent confounding, (5) nonuniform intervention effects over time, (6) nonrandom missing data mechanisms, and (7) imperfectly defined variables. This list is not exhaustive. CONCLUSION The mitigation strategies to overcome these threats to validity require epidemiologic and statistical vigilance. Minimizing the highlighted types of bias in trauma research will facilitate clinical translation of more accurate and reproducible findings and improve the evidence-base that clinicians apply in their care of injured patients.