Jana B.A. MacLeod

Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients

BACKGROUND: Recent data from military and civilian centers suggest that mortality is decreased in massive transfusion patients by increasing the transfusion ratio of plasma and platelet (PLT) products, and fibrinogen in relationship to red blood cell (RBC) products during damage control resuscitation and surgery. This study investigates the relationship of plasma:RBC, PLT:RBC, and cryoprecipitate:RBC transfusion ratios to mortality in massively transfused patients at a civilian Level 1 trauma center.

Transfusion Management of Trauma Patients

The management of massively transfused trauma patients has improved with a better understanding of trauma-induced coagulopathy, the limitations of crystalloid infusion, and the implementation of massive transfusion protocols (MTPs), which encompass transfusion management and other patient care needs to mitigate the “lethal triad” of acidosis, hypothermia, and coagulopathy. MTPs are currently changing in the United States and worldwide because of recent data showing that earlier and more aggressive transfusion intervention and resuscitation with blood components that approximate whole blood significantly decrease mortality. In this context, MTPs are a key element of “damage control resuscitation,” which is defined as the systematic approach to major trauma that addresses the lethal triad mentioned above. MTPs using adequate volumes of plasma, and thus coagulation factors, improve patient outcome. The ideal amounts of plasma, platelet, cryoprecipitate and other coagulation factors given in MTPs in relationship to the red blood cell transfusion volume are not known precisely, but until prospective, randomized, clinical trials are performed and more clinical data are obtained, current data support a target ratio of plasma:red blood cell:platelet transfusions of 1:1:1. Future prospective clinical trials will allow continued improvement in MTPs and thus in the overall management of patients with trauma.

Pathophysiology of Early Trauma Induced Coagulopathy: Emerging Evidence for Hemodilution and Coagulation Factor Depletion

BACKGROUND Trauma patients present with a coagulopathy, termed early trauma-induced coagulopathy (ETIC), that is associated with increased mortality. This study investigated hemostatic changes responsible for ETIC. METHODS Case-control study of trauma patients with and without ETIC, defined as prolonged prothrombin time (PT), was performed from prospective cohort of consecutive trauma patients who presented to Level I trauma center. Univariate and multivariate analyses were performed. RESULTS The case-control study group (n = 91) was 80% male, with mean age of 37 years, 17% penetrating trauma and 7% mortality rate. Patients with ETIC demonstrated decreased common and extrinsic pathway factor activities (factors V and VII) and decreased inhibition of the coagulation cascade (antithrombin and protein C activities) when compared with the matched control patients without ETIC. Both cohorts had evidence of increased thrombin and fibrin generation (prothrombin fragment 1.2 levels, thrombin-antithrombin complexes, and soluble fibrin monomer), increased fibrinolysis (d-dimer levels), and increased inhibition of fibrinolysis (plasminogen activator inhibitor-1 activity) above normal reference values. Patients with versus without ETIC had increased mortality and received increased amount of blood products. CONCLUSION ETIC following injury is associated with decreased factor activities without significant differences in thrombin and fibrin generation, suggesting that despite these perturbations in the coagulation cascade, patients displayed a balanced hemostatic response to injury. The lower factor activities are likely secondary to increased hemodilution and coagulation factor depletion. Thus, decreasing the amount of crystalloid infused in the early phases following trauma and administration of coagulation factors may prevent the development.

A Comparison of the Kampala Trauma Score (KTS) with the Revised Trauma Score (RTS), Injury Severity Score (ISS) and the TRISS Method in a Ugandan Trauma Registry. Is Equal Performance Achieved with Fewer Resources?

AbstractBackground:The public health significance of injuries that occur in developing countries is now recognized. In 1996, as part of the injury surveillance registry in Kampala, Uganda, a new score, the Kampala Trauma Score (KTS) was instituted. The KTS, developed in light of the limited resource base of sub-Saharan Africa, is a simplified composite of the Revised Trauma Score (RTS) and the Injury Severity Score (ISS) and closely resembles the Trauma Score and Injury Severity Score (TRISS).Patients and Methods:The KTS was applied retrospectively to a cohort of prospectively accrued urban trauma patients with the RTS, ISS and TRISS calculated. Using ROC (receiver operating characteristics) analysis, logistic regression models and sensitivity and specificity cutoff analysis, the KTS was compared to these three scores.Results:Using logistic regression models and areas under the ROC curve, the RTS proved a more robust predictor of death at 2 weeks in comparison to the KTS. However, differences in screening performance were marginal (areas under the ROC curves were 87% for the RTS and 84% for the KTS) with statistical significance only reached for an improved specificity (67% vs. 47%; p < 0.001), at a fixed sensitivity of 90%. In addition, the KTS predicted hospitalization at 2 weeks more accurately.Conclusion:The KTS statistically performs comparably to the RTS and ISS alone as well as to the TRISS but has the added advantage of utility. Therefore, the KTS has potential as a triage tool in resource-poor and similar health care settings.

An evidence-based review: helmet efficacy to reduce head injury and mortality in motorcycle crashes: EAST practice management guidelines.

According to the National Highway Traffic Safety Association, in 2008, 5,290 motorcyclists died and 96,000 were injured. Motorcycles make up 3% of all registered vehicles in the United States and account for only 0.4% of all vehicle miles traveled. However, motorcycle crashes accounted for 10% of all motor vehicle crash fatalities, and per mile traveled, motor cycle crashes are 37 times more lethal than automobile crashes. Head injuries are one of the most common injuries after motorcycle crashes and were estimated to be the cause of death in 50% of these fatalities. In close to a third of these victims, the head injury is the sole organ system that is injured. However, in the majority of patients, estimated as high as 90% of some patient cohorts, a head injury is present along with other injuries. Despite these facts, it is estimated that only 50% of motorcyclists routinely wear helmets. It was intuitive even to our earliest ancestors that a hard shell would protect the head from injury. However, establishing the effectiveness of the motorcycle helmet remains a challenging effort especially in light of the powerful opposition to universal helmet laws. Furthermore, quantifying the protective effect of helmets supports the promotion of helmet programs regardless of the controversial nature of legislative efforts. In the United States, an increasing recognition that helmet use is associated with reductions in fatalities without apparent harm increased the implementation of universal helmet laws. In response to the 1966 Federal Highway Act, which withheld federal funds from states that did not enact a helmet law, Georgia became the first state to enact a mandatory universal motorcycle helmet law in 1967. By 1975, 47 of the 50 states had universal helmet laws. However, public and political concerns over individual rights versus public safety opened a new debate. In the following years, political changes reversed and/or limited previous sanctions and grants that encouraged states to enact universal helmet laws, which further eroded support for helmet laws. An increasing number of states either repealed their mandatory laws altogether or significantly reduced the laws to apply only to minors. At present, only 20 states have universal helmet laws, another 26 states require only partial coverage, and 4 states have no helmet laws (Colorado, Illinois, Iowa, and New Hampshire). A large volume of literature has quantified the consequences of not wearing a helmet while riding a motorcycle. Although motorcycle riding and registration are increasing and more states with universal helmet laws are introducing bills to repeal their laws, the debate continues on the personal advantages of helmet usage. Therefore, we have reviewed the literature and summarize the evidence basis for the use of motorcycle helmets. In particular, we have sought to assess the impact of helmet use on overall mortality, head injuryrelated mortality, nonlethal head injury after a motorcycle crash, and the impact universal helmet laws on helmet use.

Trauma and Coagulopathy: A New Paradigm to Consider

Injury, intentional and unintentional, is one of the main causes of death for adult Americans.1 Further, from 1999 to 2003, injury was the main cause of premature mortality (measured as potential years of life lost), ahead of malignancy and heart disease, for Americans who died before their 65th birthday.2 Injuries that cause massive hemorrhage are often associated with the highest mortality rates. More than 50% of patients who present with massive hemorrhage die, and for those who die within hours of the injury event, it is often the most common cause of deatb.

Early trauma induced coagulopathy (ETIC): prevalence across the injury spectrum.

INTRODUCTION Newer studies have hypothesised about a coagulopathy that occurs early after trauma, early trauma induced coagulopathy, ETIC, and is defined by an elevated admission prothrombin time (PT). Also, referred to by some authors as acute traumatic coagulopathy, it has been most often studied in cohorts of severely injured or hypotensive patients. However, we wanted to prospectively investigate ETIC in a large all-comers cohort to confirm its prevalence across the entire spectrum of injury, to evaluate its risk pattern and to determine a possible relationship to reduced survival. METHODS We conducted a prospective cohort study at a Level I trauma centre from July 15, 2008 to November 15, 2009. Demographics, injury mechanism, time from injury and to hospital arrival, fluid and blood administration and vital signs were collected at hospital arrival and to the time of first blood sample collection for all patients admitted for 24h or longer. Our primary outcome was the incidence of mortality by the 28th hospital day, referred to as 28 day in-hospital mortality. RESULTS 701 patients were included in the final study cohort. There was 75.3% male, 25.7% penetrating, with a mean age of 39 years. The overall mortality was 7.3%. ETIC occurred in 114 patients (16.3%) and was found to be independently associated with death (odds of death (per 0.10s increase in PT): 1.10, p=0.001). ETIC patients, as a group, were more severely injured, had more hypotension and head injury and used more crystalloid and blood products than non-ETIC patients. However, even mildly injured patients, who had an ISS<16, normal RTS score, and no fluid resuscitation, had an ETIC prevalence of 11.7% (11/94). CONCLUSIONS ETIC is an early, primary post-injury coagulopathy that occurs in 16.3% of admitted trauma patients. It is associated with an increase in mortality, even when controlling for crystalloids, vital signs, injury severity and head injury. It can also be found in approximately 11% of mildly injured patients (patients without physiological derangement or blood product administration). Therefore, further elucidation of ETIC is strategic to impacting trauma patient outcome.

Evaluation of Fundamental Critical Care Course in Kenya: Knowledge, Attitude, and Practice

BACKGROUND Critical care training for medical personnel is crucial for the survival of the highest acuity patients. The Fundamental Critical Care Course (FCCS), a critical care course developed by the Society of Critical Care Medicine, permits course adaption and, thus, has potential for global dissemination. The FCCS course was provided in two Kenyan hospitals after minimal adaption. Participant knowledge and confidence gain as well as FCCS applicability to an African context were evaluated. METHODS Questionnaires and a multiple-choice test were administered to assess knowledge, attitude, and self-reported confidence or self-efficacy. For applicability, the pre-course questionnaire assessed participant expectations and existing levels of confidence/knowledge in the care of the critically ill patient. Post-course, the participant evaluated the overall quality of the course, lectures, and skill stations along with context applicability questions. RESULTS There were 100 participants, 45 doctors, 45 nurses, and 10 clinical officers. There was a 22.7% gain in the mean test score (P < 0.0001) after the course, with 98% of participants showing improvement. Confidence to perform new skills post-course, or self-efficacy, was demonstrated by a median of 4 or greater on a Likert scale of 5 (most confident) in 10 of 12 clinical scenarios and in 11 of 14 new procedures. There was a consistency between areas reported as needed expertise, and participant evaluation of similar lecture and skill stations quality and appropriateness. The most common areas reported were mechanical ventilation, patient monitoring, and their related procedures. CONCLUSIONS The FCCS course met participants expectations and was reported as applicable for the Kenyan context with minimal adaption. Post-course, knowledge improved and confidence increased for implementation of new skills in clinical care situations. We confirmed the effectiveness and relevancy of the FCCS course for other resource-constrained health care settings.

Intensive medical student involvement in short-term surgical trips provides safe and effective patient care: a case review

BackgroundThe hierarchical nature of medical education has been thought necessary for the safe care of patients. In this setting, medical students in particular have limited opportunities for experiential learning. We report on a student-faculty collaboration that has successfully operated an annual, short-term surgical intervention in Haiti for the last three years. Medical students were responsible for logistics and were overseen by faculty members for patient care. Substantial planning with local partners ensured that trip activities supplemented existing surgical services. A case review was performed hypothesizing that such trips could provide effective surgical care while also providing a suitable educational experience.FindingsOver three week-long trips, 64 cases were performed without any reported complications, and no immediate perioperative morbidity or mortality. A plurality of cases were complex urological procedures that required surgical skills that were locally unavailable (43%). Surgical productivity was twice that of comparable peer institutions in the region. Student roles in patient care were greatly expanded in comparison to those at U.S. academic medical centers and appropriate supervision was maintained.DiscussionThis demonstration project suggests that a properly designed surgical trip model can effectively balance the surgical needs of the community with an opportunity to expose young trainees to a clinical and cross-cultural experience rarely provided at this early stage of medical education. Few formalized programs currently exist although the experience above suggests the rewarding potential for broad-based adoption.

The Epidemiology of Traumatic Hemothorax in a Level I Trauma Center: Case for Early Video-assisted Thoracoscopic Surgery.

Objective:Hemothorax is a common sequela of chest trauma. Complications after chest trauma include retained hemothorax and empyema requiring multiple interventions. We studied the epidemiology of hemothorax and its complications at a level I trauma center.Methods:The trauma registry was reviewed from Jan 1995 toMay 2005.Allpatients ≥16 years of agewhowere admitted with hemothorax, an AIS chest score of ≥ 3, and did not receive an immediate thoracotomy were entered in the study cohort. The patient demographics, details of the injury event, treatments, hospital length of stay (LOS), complications and outcome were analyzed.Results:The study cohort of 522 patients with a hemothorax were treated with 685 chest thoracostomy tubes. Overall, the median ISS was 18 and 62% were penetrating injuries. 109 patients (21%) had a retained hemothorax and required placement of ≥ 2 chest tubes with a median LOS of 15 days longer than patients with no retained hemothorax (p < 0.0001). The overall complication rate was 5% (26/522). Of these, 20 patients had empyema (3.8%), 8 patients required decortication, and 6 patients received streptokinase treatment.Conclusion:More than 1 out of every 5 patients undergoing intervention for trauma-induced hemothorax develops a complication. The development of retained hemothorax is associated with empyema in 15.6% of cases and a 2-week median increase in length of stay. Future research into interventions such as Video-assisted thoracoscopic surgery (VATS) on the day of admission to completely evacuate hemothorax is warranted to reduce complication rates, length of stay and cost.