James R. Dunne

Blood transfusion, independent of shock severity, is associated with worse outcome in trauma.

BACKGROUND We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/systolic blood pressure) as covariates. METHODS Prospective data were collected on 15,534 patients admitted to a Level I trauma center over a 3-year period (1998-2000) and stratified by age, gender, race, Glasgow Coma Scale score, and Injury Severity Score. Admission anemia and blood transfusion were assessed as independent predictors of mortality, ICU admission, ICU LOS, and hospital LOS by logistic regression analysis, with base deficit, serum lactate, and shock index as covariates. RESULTS Blood transfusion was a strong independent predictor of mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.82-4.40; p < 0.001), ICU admission (OR, 3.27; 95% CI, 2.69-3.99; p < 0.001), ICU LOS (p < 0.001), and hospital LOS (Coef, 4.37; 95% CI, 2.79-5.94; p < 0.001) when stratified by indices of shock (base deficit, serum lactate, shock index, and anemia). Patients who underwent blood transfusion were almost three times more likely to die and greater than three times more likely to be admitted to the ICU. Admission anemia (hematocrit < 36%) was an independent predictor of ICU admission (p = 0.008), ICU LOS (p = 0.012), and hospital LOS (p < 0.001). CONCLUSION Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.

Trauma-related Infections in Battlefield Casualties From Iraq

Objective:To describe risks for, and microbiology and antimicrobial resistance patterns of, war trauma associated infections from Operation Iraqi Freedom. Background:The invasion of Iraq resulted in casualties from high-velocity gunshot, shrapnel, and blunt trauma injuries as well as burns. Infectious complications of these unique war trauma injuries have not been described since the 1970s. Methods:Retrospective record review of all trauma casualties 5 to 65 years of age evacuated from the Iraqi theatre to U.S. Navy hospital ship, USNS Comfort March to May 2003.War trauma-associated infection was defined by positive culture from a wound or sterile body fluid (ie, blood, cerebrospinal fluid) and at least two of the following infection-associated signs/symptoms: fever, dehiscence, foul smell, peri-wound erythema, hypotension, and leukocytosis. A comparison of mechanisms of injury, demographics, and clinical variables was done using multivariate analysis. Results:Of 211 patients, 56 met criteria for infection. Infections were more common in blast injuries, soft tissue injuries, >3 wound sites, loss of limb, abdominal trauma, and higher Injury Severity Score (ISS). Wound infections accounted for 84% of cases, followed by bloodstream infections (38%). Infected were more likely to have had fever prior to arrival, and had higher probability of ICU admission and more surgical procedures. Acinetobacter species (36%) were the predominant organisms followed by Escherichia coli and Pseudomonas species (14% each). Conclusions:Similar to the Vietnam War experience, gram-negative rods, particularly Acinetobacter species, accounted for the majority of wound infections cared for on USNS Comfort during Operation Iraqi Freedom. Multidrug resistance was common, with the exception of the carbapenem class, limiting antibiotic therapy options.

Epidemiology of sepsis in patients with traumatic injury.

Objective:To characterize the epidemiology of sepsis in trauma. Design:Analysis of a prospectively collected administrative database (Pennsylvania trauma registry). Setting:All trauma centers in the state of Pennsylvania (n = 28) Patients:All patients (n = 30,303) with blunt or penetrating injury admitted to Pennsylvania trauma centers over a 2-yr period (January 1996–December 1997). Interventions:None. Measurements and Main Results:Incidence of sepsis in trauma, independent predictors of sepsis, and associated mortality were evaluated. Analyses controlled for age, gender, preexisting disease, injury type, Revised Trauma Score, Injury Severity Score, and admission vital signs. Sepsis occurred in 2% of all patients and was associated with a significant increase in mortality (23.1% vs. 7.6%, p < .001) compared with nonseptic patients. Respiratory tract infections were the most common cause of sepsis. Septic trauma patients had increased ICU length of stay (21.8 vs. 4.7 days, p < .001) and hospital length of stay (34.1 vs. 7.0 days, p < .001). Logistic regression identified Injury Severity Score, Revised Trauma Score, lower admission Glasgow Coma Scale score, and preexisting diseases as significant independent predictors of sepsis, whereas female gender was associated with a decreased risk of sepsis. Increasing injury severity measured by Injury Severity Score was associated with increased incidence of sepsis. Moderate (Injury Severity Score 15–29) and severe injury (Injury Severity Score ≥30) had a six-fold and 16-fold, respectively, increased incidence of sepsis compared with mild injury. Multivariate analysis confirmed that the effect of sepsis on mortality was greater in trauma patients with mild injury than those with moderate or severe injury. Conclusions:This study reports the incidence of sepsis and its associated mortality and critical care resource utilization in a large, state-wide population-based trauma registry. Increasing injury severity, measured by Injury Severity Score, was a significant independent predictor of sepsis in trauma and was associated with increased intensive care unit resource utilization and mortality. These results suggest that future studies should attempt to delineate interventional strategies to prevent sepsis in trauma patients with moderate and severe injury, given their significantly increased risk.

Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system.

BACKGROUND During the past 5 years of Operation Iraqi Freedom (OIF), a significant majority of the severe closed and penetrating head trauma has presented for definitive care at the National Naval Medical Center (NNMC) in Bethesda, MD, and at the Walter Reed Army Medical Center (WRAMC) in Washington, DC. The purpose of this article is to review our experience with this population of patients. MATERIALS A retrospective review of all inpatient admissions from OIF was performed during a 5-year period (April 2003 to April 2008). Criteria for inclusion in this study included either a closed or penetrating head trauma suffered during combat operations in Iraq who subsequently received a neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all patients for whom primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow coma scale (GCS) and injury severity score at admission, and Glasgow outcome scale (GOS) at discharge, 6 months, and 1 to 2 years. RESULTS Five hundred thirteen consultations were performed by the neurosurgery service on the aforementioned population. Four hundred eight patients met the inclusion criteria for this study (401:7, male: female; 228 penetrating brain injury, 139 closed head injury, 41 not specified). Explosive blast injury (229 patients; 56%) constituted the predominant mechanism of injury. The rates of pulmonary embolism (7%), cerebrospinal fluid leak (8.6%), meningitis (9.1%), spinal cord or column injury (9.8%), and cerebrovascular injury (27%) were characterized. Cerebrospinal fluid leak, vasospasm, penetrating head injury, and lower presenting GCS were statistically associated with longer intensive care unit stays and higher presenting injury severity scores (p < 0.05). While presenting GCS 3-5 correlated with worsened short-term and long-term GOS scores (p < 0.001), almost half of these patients achieved GOS >or=3 at 1- to 2-year follow-up. Total mortality after reaching NNMC/WRAMC was 4.4%. CONCLUSIONS OIF has resulted in the highest concentration of severe closed and penetrating head trauma to return to NNMC and WRAMC since the Vietnam Conflict. Management scenarios were complex, incorporating principles designed to maximize outcomes in all body systems. Meaningful survival can potentially be achieved in a subset of patients with presenting GCS <or=5.

Abdominal wall hernias: risk factors for infection and resource utilization

BACKGROUND Abdominal wall hernia repairs are common surgical procedures. Several recent reports have studied the outcomes of elderly patients undergoing inguinal hernia repair and documented a morbidity rate ranging from 5-57% and a mortality rate ranging from 1.6-14%. However, there has been limited data documenting the risk factors associated with postoperative morbidity and mortality from abdominal wall hernia repairs in general. Therefore, we sought to investigate the incidence of complications in patients undergoing abdominal wall hernia repair and to evaluate the risk factors for infection and resource utilization in these patients. METHODS Prospective data (NSQIP) were collected on 6301 noncardiac surgical patients at the VA Maryland Healthcare System from 1995 to 2000. From this data set, 487 (7.7%) patients underwent abdominal wall hernia repairs and comprised the study cohort. Logistic and linear regression analyses were performed to identify risk factors for infection and hospital length of stay. RESULTS The mean age of the study cohort was 60 +/- 14 and the mean ASA class was 2.4 +/- 0.7. Descriptive data revealed 99% were male, 43% used tobacco, 8.4% were diabetic, 7.4% used alcohol, 6.3% had chronic obstructive pulmonary disease (COPD), 2.1% were malnourished (defined as >/= 10% weight loss over prior 6 months), 1.6% used steroids, 1.2% had ascites, and 0.2% had coronary artery disease (CAD). The mortality rate was low at 1% but the morbidity rate was higher with a 4.3% incidence of wound infections and a 15.1% incidence of recurrent hernias. The mean preoperative serum albumin level was 4.1 +/- 0.6 g/dL, and the mean hospital length of stay was 1.4 +/- 4.8 days. Multiple logistic and linear regression analyses documented that CAD, COPD, low preoperative serum albumin, and steroid use were independent risk factors for increased postoperative wound infections (P < 0.05) and increased hospital length of stay (P < 0.05). CONCLUSIONS Abdominal wall hernia repair is associated with significant morbidity in this predominantly elderly cohort but mortality rates were low. COPD and low preoperative serum albumin were independent predictors of wound infections and CAD, COPD, low preoperative serum albumin, and steroid use were independent predictors of increased hospital length of stay. Therefore, consideration should be given to optimizing patients cardiopulmonary and nutritional status before abdominal wall hernia repair.

Invasive mold infections following combat-related injuries.

BACKGROUND Major advances in combat casualty care have led to increased survival of patients with complex extremity trauma. Invasive fungal wound infections (IFIs) are an uncommon, but increasingly recognized, complication following trauma that require greater understanding of risk factors and clinical findings to reduce morbidity. METHODS The patient population includes US military personnel injured during combat from June 2009 through December 2010. Case definition required wound necrosis on successive debridements with IFI evidence by histopathology and/or microbiology (Candida spp excluded). Case finding and data collected through the Trauma Infectious Disease Outcomes Study utilized trauma registry, hospital records or operative reports, and pathologist review of histopathology specimens. RESULTS A total of 37 cases were identified: proven (angioinvasion, n=20), probable (nonvascular tissue invasion, n=4), and possible (positive fungal culture without histopathological evidence, n=13). In the last quarter surveyed, rates reached 3.5% of trauma admissions. Common findings include blast injury (100%) during foot patrol (92%) occurring in southern Afghanistan (94%) with lower extremity amputation (80%) and large volume blood transfusion (97.2%). Mold isolates were recovered in 83% of cases (order Mucorales, n=16; Aspergillus spp, n=16; Fusarium spp, n=9), commonly with multiple mold species among infected wounds (28%). Clinical outcomes included 3 related deaths (8.1%), frequent debridements (median, 11 cases), and amputation revisions (58%). CONCLUSIONS IFIs are an emerging trauma-related infection leading to significant morbidity. Early identification, using common characteristics of patient injury profile and tissue-based diagnosis, should be accompanied by aggressive surgical and antifungal therapy (liposomal amphotericin B and a broad-spectrum triazole pending mycology results) among patients with suspicious wounds.

Impact of joint theater trauma system initiatives on battlefield injury outcomes

INTRODUCTION The US military forces developed and implemented the Joint Theater Trauma System (JTTS) and Joint Theater Trauma Registry (JTTR) using US civilian trauma system models with the intent of improving outcomes after battlefield injury. METHODS The purpose of this analysis was to elaborate the impact of the JTTS. To quantify these achievements, the JTTR captured mechanism, acute physiology, diagnostic, therapeutic, and outcome data on 23,250 injured patients admitted to deployed US military treatment facilities from July 2003 through July 2008 for analysis. Comparative analysis to civilian trauma systems was done using the National Trauma Data Bank (NTDB). RESULTS In contrast to civilian trauma systems with an 11.1% rate of penetrating injury, 68.3% of battlefield wounds were by penetrating mechanism. In the analyzed cohort, 23.3% of all patients had an Injury Severe Score (ISS) > or = 16, which is similar to the civilian rate of 22.4%. In the military injury population, 66% of injuries were combat-related. In addition, in the military injury group, 21.8% had metabolic evidence of shock with a base deficit > or = 5, 29.8% of patients required blood transfusion, and 6.4% of the total population of combat casualties required massive transfusion (>10 U red blood cells/24 hours). With this complex and severely injured population of battlefield injuries, the JTTS elements were used to recognize and remedy more than 60 trauma system issues requiring leadership and advocacy, education, research, and alterations in clinical care. Of particular importance to the trauma system was the implementation and tracking of performance improvement indicators and the dissemination of 27 evidence-based clinical practice guidelines (CPGs). In particular, the damage control resuscitation guideline was associated with a decrease in mortality in the massively transfused from 32% pre-CPG to 21% post-CPG. As evidence of the effectiveness of the JTTS, a mortality rate of 5.2% after battlefield hospital admission is comparable to a case fatality rate of 4.3% reported in an age-matched cohort from the NTDB. CONCLUSIONS JTTS initiatives contributed to improved survival after battlefield injury. The JTTS has set the standard of trauma care for the modern battlefield using contemporary systems-based methodologies.

Prevention of infections associated with combat-related extremity injuries

During combat operations, extremities continue to be the most common sites of injury with associated high rates of infectious complications. Overall, ∼ 15% of patients with extremity injuries develop osteomyelitis, and ∼ 17% of those infections relapse or recur. The bacteria infecting these wounds have included multidrug-resistant bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella species and Escherichia coli, and methicillin-resistant Staphylococcus aureus. The goals of extremity injury care are to prevent infection, promote fracture healing, and restore function. In this review, we use a systematic assessment of military and civilian extremity trauma data to provide evidence-based recommendations for the varying management strategies to care for combat-related extremity injuries to decrease infection rates. We emphasize postinjury antimicrobial therapy, debridement and irrigation, and surgical wound management including addressing ongoing areas of controversy and needed research. In addition, we address adjuvants that are increasingly being examined, including local antimicrobial therapy, flap closure, oxygen therapy, negative pressure wound therapy, and wound effluent characterization. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Inflammatory biomarkers in combat wound healing.

Background:Modern war ballistics and blast injuries inflict devastating extremity injuries, violating soft tissue, bone, and neurovascular structures. Despite advances in complex wound management, appropriate timing of war wound closure remains subjective. In addition, the pathophysiology of acute wound failure is poorly defined. Methods:Patients with penetrating extremity wounds sustained during combat were prospectively studied and followed for 30 days after definitive wound closure. The primary outcome was wound healing. Wound dehiscence was defined as spontaneous partial or complete wound disruption after closure. Serum, wound effluent, and wound bed tissue biopsy were collected at each surgical wound debridement. Serum and wound effluent were analyzed with a multiplex array of 22 cytokines and chemokines, and wound tissue for corresponding gene transcript expression. Results:Fifty-two penetrating extremity war wounds in 33 male patients were investigated. Nine (17%) wounds dehisced. Concomitant vascular injury, increased wound size, and higher injury severity score correlated with wound dehiscence. Both serum and wound effluent cytokine and chemokine protein profiles were statistically associated with healing outcome at various time points. Wound biopsy gene transcript expression demonstrated increased tissue inflammation associated with wound failure. Multiple protein and gene transcript biomarkers predictive of wound healing were identified. Conclusions:The cytokine and chemokine protein and gene transcript expression patterns demonstrate a condition of inflammatory dysregulation associated with war wound failure. A molecular biomarker panel may predict combat wound healing outcome and warrants prospective validation.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update endorsed by the infectious diseases society of America and the surgical infection society

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.