John B. Moore

Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer?

BACKGROUND Recent military experience suggests that immediate 1:1 fresh frozen plasma (FFP); red blood cells (RBC) for casualties requiring >10 units packed red blood cells (RBC) per 24 hours reduces mortality, but no clinical trials exist to address this issue. Consequently, we reviewed our massive transfusion practices during a 5-year period to test the hypothesis that 1:1 FFP:RBC within the first 6 hours reduces life threatening coagulopathy. METHODS We queried our level I trauma centers prospective registry from 2001 to 2006 for patients undergoing massive transfusion. Logistic regression was used to evaluate the independent effect of FFP:RBC in 133 patients who received >10 units RBC in 6 hours on (1) Coagulopathy (international normalized ratio [INR] >1.5 at 6 hours), controlling for our previously described risk factors predictive of coagulopathy, as well as RBC, FFP, and platelet administration (2) Death (controlling for all variables plus age, crystalloids per 24 hours, INR >1.5 at 6 hours). RESULTS Overall mortality was 56%; 50% died from acute blood loss in the operating room. Over 80% of the RBC transfusions were completed in the first 6 hours: (Median RBC: 18 units) Median FFP:RBC survivors, 1:2, nonsurvivors: 1:4. (p < 0.001) INR >1.5 at 6 hours occurred in 30 (23%); 81% died. Regarding mortality, logistic regression showed significant variables (p < 0.05) included: RBC per 6 hours (OR = 1.248, 95%CI: 1.957-53.255), INR at 6 hours >1.5 (OR = 10.208, 95% CI: 1.957-53.255), ED temperature <34 degrees C (OR = 15.491, 95% CI 1.376-174.396), and age >55 years (OR = 40.531, CI 5.315-309.077). The adjusted OR for FFP:RBC ratio including the quadratic term was found to follow a U-shaped association (quadratic term estimate 0.6737 +/- 0.0345, p = 0.0189). CONCLUSION Although our data suggest that 1:1 FFP:RBC reduced coagulopathy, this did not translate into a survival benefit. Our findings indicate that the relationship between coagulopathy and mortality is more complex, and further clinical investigation is necessary before recommending routine 1:1 in the exsanguinating trauma patient.

Major abdominal vascular trauma : a unified approach

Advances in prehospital emergency care have increased the numbers of patients arriving at the hospital with immediate life-threatening trauma. This is a review of our recent 6-year experience with 161 major abdominal vascular injuries in 123 patients. The distribution by injury site and respective mortality were: 18, aortic (56%); 39, aortic branch (37%); 51, inferior vena cava (39%); 30, inferior vena cava branch (45%); and 23, portal venous system (39%). The overall death rate was 37%. Forty-six patients presented with unobtainable blood pressure and 19 (41%) survived. Left thoracotomy and temporary aortic occlusion were required in the resuscitation of 45 patients; when applied in the emergency department the salvage rate was 7%, and in the operating room, 35%. Forty-four patients had more than one major vascular injury and 17 (39% recovered, compared to a survival rate of 76% with single vascular trauma. Others have emphasized that most deaths from major abdominal vascular injury are a result of hemorrhage. In our study although 89% of mortality was due to bleeding, half occurred after control of the major bleeding sites. These findings suggest that coagulopathy, hypothermia, and acidosis are complicating factors which demand as much attention by the surgeon as the initial resuscitation and operative control classically emphasized.

Cervical spine fracture patterns predictive of blunt vertebral artery injury.

BACKGROUND Aggressive screening for blunt cerebrovascular injury (BCVI) has uncovered an astonishing incidence of vertebral artery injuries (VAIs) and associated stroke rate. Stroke incidence is reduced with early recognition and prompt anticoagulation. Because of the proximity of the cervical spine and vertebral arteries, we queried whether all patients with cervical spine fractures required arteriography to rule out VAI. METHODS Four-vessel cerebrovascular angiography remains the standard screening test for patients at risk for BCVI. Patients undergoing angiographic screening for blunt cerebrovascular injuries have been prospectively followed at our regional trauma center since January 1990; however, in January 1996, we began aggressive screening based on injury patterns. RESULTS Ninety-two patients with vertebral artery injuries were identified during the study period from January 1996 to June 2002. Two patients with vertebral injuries had minor cervical fractures, a C6 body fracture and a C7 spinous process/laminar fracture; both underwent diagnostic angiography for injury mechanism. Of the 21 patients without cervical spine fracture, angiographic screening for BCVI was performed for neurologic symptoms (11 patients), basilar skull fracture (6 patients), or severe facial fractures (4 patients). Cervical spine fracture was the sole indication for VAI in 69 patients. The fracture patterns were subluxations in 38 patients (55%) or extension of the fracture through the foramen transversarium in 18 patients (26%). The remaining injuries (18%) were located in the upper cervical spine: isolated C1 arch in eight patients and C2/3 body fractures in five patients. CONCLUSION Blunt vertebral artery injury is associated with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Routine screening should incorporate these findings to maximize yield while limiting the use of invasive procedures.

Mandatory laparotomy for gunshot wounds penetrating the abdomen

A 4 year experience with 245 patients with isolated lower thoracic or anterior abdominal gunshot wounds was reviewed. Twenty-three (16 percent) of the 144 abdominal injuries were clinically superficial and all were managed successfully nonoperatively. Of the remaining 121 patients, 115 were confirmed to have peritoneal violation at laparotomy and 111 (96 percent) of these had significant visceral injuries. Of the 101 patients with lower chest wounds, 47 had peritoneal violation and 45 (96 percent) had intraabdominal injuries. Twenty-six (17 percent) of the 156 patients with intraperitoneal trauma had unimpressive physical signs on admission. these findings support a policy of routine exploration for gunshot wounds violating the peritoneum. When depth of penetration is uncertain, diagnostic peritoneal lavage should be used. Only those patients with unequivocally superficial injuries warrant observation.

National survey of Trauma surgeons' use of alcohol screening and brief intervention

BACKGROUND A variety of policy groups have recommended that screening and brief interventions (BIs) for alcohol disorders be widely implemented in health care settings. This study was conducted to determine the current status of screening and intervention programs in trauma centers and to evaluate specific barriers to implementation of screening and BIs. The hypotheses tested were that surgeons who support screening and brief interventions would be less likely to endorse the purported barriers to screening and intervention and would have a better understanding of the concept of brief interventions. METHODS A postal survey of 711 members of the American Association for the Surgery of Trauma and the Western Trauma Association was performed to assess current screening and treatment practices, along with barriers to screening and intervention. Two logistic regression models were constructed to determine which factors result in support for screening and which factors predict support of BIs to help determine potentially modifiable issues to facilitate implementation. RESULTS Three hundred eighty-three surgeons responded, 315 of whom are currently practicing trauma. The majority of surgeons (267 [83%]) agreed that a trauma center is an appropriate setting for addressing harmful alcohol consumption. Over two thirds frequently check a blood alcohol concentration, with one third of the group reporting that they always do. The use of formal screening questionnaires was much less frequent (25%). Nearly one half (49%) understood the concept of BIs. However, the majority report that less than one half of patients with a suspected alcohol problem at their center have their alcohol problem addressed while they are hospitalized. Several barriers to screening and BIs were identified. Although only 2% thought screening and counseling would significantly increase health care costs, 7% thought screening was too time consuming and 13.6% thought it would compromise patient confidentiality. Screening was perceived to threaten reimbursement by 27%. Over half (55%) stated their facility is currently performing screening. One third (36%) stated their facility is currently performing BIs. Logistic regression revealed that surgeons who support screening were those who thought patients with alcohol problems should be referred for professional alcohol treatment (odds ratio [OR], 6.5; 95% confidence interval [CI], 2.3-18.2) and that a trauma center is an appropriate setting for addressing alcohol disorders (OR, 6.2; 95% CI, 2.7-14.2). In the model of support for BIs, understanding the concept of BIs (OR, 5.7; 95% CI, 3.1-10.5) and lack of the belief that screening and intervention would increase cost too much (OR, 0.14; 95% CI, 0.02-0.96) were the most potent predictors of support for BIs. CONCLUSION Trauma surgeons are screening for alcohol disorders more frequently than they were 5 years ago. Barriers to screening are not as prevalent as previously reported. Support for implementing screening and intervention programs depends on whether surgeons believe trauma centers are appropriate sites for addressing alcohol disorders, whether surgeons believe patients with alcohol problems should be referred for professional treatment, whether surgeons understand the concept of brief interventions, and whether they believe the cost constraints are not prohibitive. Widespread education in the effectiveness and methods of BIs would facilitate implementation of alcohol screening and intervention programs to help reduce recurrent alcohol-related injury.

The evolution of abdominal stab wound management.

The results of the selective management of 300 abdominal stab wound victims have been reviewed for a 5-year period. Initially the need for laparotomy was evaluated by sinography, later physical examination, and most recently by local wound exploration combined with peritoneal lavage. The use of sinography resulted in an unnecessary laparotomy rate of 38%. Exploration based upon physical findings eventuated in 36% unnecessary laparotomies, of which 79% were negative, 17% morbidity, and no mortality. Local wound exploration followed by peritoneal lavage when peritoneal violation was suspected resulted in 8% unnecessary laparotomies of which half were negative, 9% morbidity, and no mortality. Based on this experience we have adopted the following approach to abdominal stab wounds. Patients with unexplained blood loss or overt signs of visceral injury undergo prompt exploration. In all other cass with intact peritoneum are discharged from the Emergency Department. If peritoneal violation is evident peri toneal lavage is performed. If the lavage is positive laparotomy is undertaken, and if negative the patient is hospitalized for an additional 24 hours of observation.

Emergency department thoracotomy in children ― A critical analysis

Abstract Recent clinical reviews have helped to clarify the role of Emergency Department (E.D.) thoracotomy in critically injured adults. However, guidelines in the pediatric population remain ill defined. The purpose of this report is to examine the yield of E.D. thoracotomy in patients less than or equal to 18 years of age to allow for a more cost-effective application of this heroic measure. From an 11-year experience of 689 consecutive E.D. thoracotomies, 83 patients (12%) were less than or equal to 18 years old. Mechanism of injury was blunt trauma in 57%, gunshot wound in 30%, and stab wound in 13%. Mean age was 15 years and 71% were male. Survival by injury mechanism was 9% (1/11) for stab wound, 4% (1/25) for gunshot wound, and 2% (1/47) for blunt trauma. Sixty-nine patients presented to the E.D. without vital signs and only one, a 16-year-old with stab wounds to the chest and abdomen, survived. In contrast, two (14%) among 14 patients presenting with vital signs were salvaged. As in adults, outcome was largely determined by injury mechanism and physiologic status on E.D. presentation. Blunt trauma, the predominant mechanism of lethal injuries in children, had a dismal outcome, with only 2% salvage and no survivors when vital signs were absent. This study demonstrates a similar outcome for E.D. thoracotomy in children compared to adults, and supports a selective policy of liberal use in penetrating injury irrespective of physiologic status but limited in those arriving lifeless following blunt trauma.

Abdominal injuries associated with penetrating trauma in the lower chest

A 5 year experience of 248 patients with isolated penetrating lower chest injury was reviewed. Twenty-two (15 percent) of the stab wounds and 46 (46 percent) of the gunshot wounds caused associated intraabdominal injury. Among those taken to the operating room for laparotomy, physical examination proved misleading in 40 percent of the patients with stab wounds and 30 percent of those with gunshot wounds. The diagnostic accuracy of peritoneal lavage, used selectively, was 93 per cent for the patients with stab wounds and 90 percent for those with gunshot wounds. The morbidity was high in patients with combined injuries, with major complications occurring in 27 percent of those with stab wounds and 43 percent of those with gunshot wounds. Two thirds or more of these complications were thoracic. There was one death (4 percent) among the patients with thoracoabdominal stab wounds and six (13 percent) among those with gunshot wounds.

Comparison of penetrating injuries of the right and left colon.

Controversy still exists whether penetrating injuries of the right colon behave more favorably than those to the left. The importance of the issue rests in the operative management. This is a review of 50 cases of penetrating injuries of the right colon and 55 of the left treated at our institution from 1975 to 1980. The two patient groups were similar with respect to mechanism of injury, presence of shock at admission, degree of fecal contamination, severity of injury, and the percentage of cases with associated intra-abdominal injuries. The number of patients managed by primary repair or resection (52 vs. 45%), repair or resection with exteriorization (20 vs. 22%), and colostomy (28 vs. 33%) were also comparable in right versus left injuries. The treatment of right colon injuries resulted in 32% morbidity rate and 2% mortality rate, and that of left sided injuries 33% morbidity rate and 4% mortality rate. These findings indicate that, despite known anatomic and physiologic differences, penetrating trauma to the right and left colon should be managed similarly.

Conservative Management of Combined Pancreatoduodenal Injuries

We have reviewed our recent 12-year experience in treating 62 patients with combined injuries to the pancreas and duodenum; 60 percent were the consequence of penetrating wounds and 40 percent due to blunt trauma. For analysis, grades I through V were assigned to reflect severity of injury. Grade I (16 percent) and II injuries (23 percent) were treated with simple repair and drainage. Grades III (19 percent) and IV (32 percent) were managed primarily by pyloric exclusion, whereas grade V injuries (10 percent) underwent pancreatoduodenectomy. Pancreatic and duodenal complications developed in 35 percent and 2 percent, respectively. The overall mortality was 19 percent; 83 percent died within the first 24 hours from exsanguination or severe head injury. Although no single procedure uniformly applies to the combined pancreatoduodenal trauma, active sump drainage of the pancreas, pyloric exclusion of the duodenum, and early nutritional support through needle catheter jejunostomy are the mainstay treatment principles.