Mauricio Lynn

Early coagulopathy predicts mortality in trauma.

BACKGROUND Coagulopathy and hemorrhage are known contributors to trauma mortality; however, the actual relationship of prothrombin time (PT) and partial thromboplastin time (PTT) to mortality is unknown. Our objective was to measure the predictive value of the initial coagulopathy profile for trauma-related mortality. METHODS We reviewed prospectively collected data on trauma patients presenting to a Level I trauma center. A logistic regression analysis was performed of PT, PTT, platelet count, and confounders to determine whether coagulopathy is a predictor of all-cause mortality. RESULTS From a trauma registry cohort of 20103 patients, 14397 had complete disposition data for initial analysis and 7638 had complete data for all variables in the final analysis. The total cohort was 76.2% male, the mean age was 38 years (range, 1-108 years), and the median Injury Severity Score was 9. There were 1276 deaths (all-cause mortality, 8.9%). The prevalence of coagulopathy early in the postinjury period was substantial, with 28% of patients having an abnormal PT (2994 of 10790) and 8% of patients having an abnormal PTT (826 of 10453) on arrival at the trauma bay. In patients with disposition data and a normal PT, 489 of 7796 died, as compared with 579 of 2994 with an abnormal PT (6.3% vs. 19.3%; chi2 = 414.1, p < 0.001). Univariate analysis generated an odds ratio of 3.6 (95% confidence interval [CI], 3.15-4.08; p < 0.0001) for death with abnormal PT and 7.81 (95% CI, 6.65-9.17; p < 0.001) for deaths with an abnormal PTT. The PT and PTT remained independent predictors of mortality in a multiple regression model, whereas platelet count did not. The model also included the independent risk factors age, Injury Severity Score, scene and trauma-bay blood pressure, hematocrit, base deficit, and head injury. The model generated an adjusted odds ratio of 1.35 for PT (95% CI, 1.11-1.68; p < 0.001) and 4.26 for PTT (95% CI, 3.23-5.63; p < 0.001). CONCLUSION The incidence of coagulation abnormalities, early after trauma, is high and they are independent predictors of mortality even in the presence of other risk factors. An initial abnormal PT increases the adjusted odds of dying by 35% and an initial abnormal PTT increases the adjusted odds of dying by 326%.

Recombinant activated factor VII for adjunctive hemorrhage control in trauma.

BACKGROUND Recombinant activated factor VII (rFVIIa) was approved for treatment of hemorrhages in patients with hemophilia who develop inhibitors to factors VIII or IX. Conditions with increased thromboembolic risk, including trauma with or without disseminated intravascular coagulation, were considered a contraindication for the drug. The mechanism of action of rFVIIa suggests enhancement of hemostasis limited to the site of injury without systemic activation of the coagulation cascade. Therefore, use of the drug in trauma patients suffering uncontrolled hemorrhage appears to be rational. METHODS Seven massively bleeding, multitransfused (median, 40 units [range, 25-49 units] of packed cells), coagulopathic trauma patients were treated with rFVIIa (median, 120 microg/kg [range, 120-212 microg/kg]) after failure of conventional measures to achieve hemostasis. RESULTS Administration of rFVIIa resulted in cessation of the diffuse bleed, with significant decrease of blood requirements to 2 units (range, 1-2 units) of packed cells (p < 0.05); shortening of prothrombin time and activated partial thromboplastin time from 24 seconds (range, 20-31.8 seconds) to 10.1 seconds (range, 8-12 seconds) (p < 0.005) and 79 seconds (range, 46-110 seconds) to 41 seconds (range, 28-46 seconds) (p < 0.05), respectively; and an increase of FVII level from 0.7 IU/mL (range, 0.7-0.92 IU/mL) to 23.7 IU/mL (range, 18-44 IU/mL) (p < 0.05). Three of the seven patients died of reasons other than bleeding or thromboembolism. CONCLUSION The results of this report suggest that in trauma patients rFVIIa may play a role as an adjunctive hemostatic measure, in addition to surgical hemostatic techniques, and provides the motivation for controlled animal and clinical trials.

Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma.

INTRODUCTION Approximately one third of stable patients with significant intra-abdominal injury do not have significant intraperitoneal blood evident on admission. We hypothesized that a delayed, repeat ultrasound study (Secondary Ultrasound--SUS) will reveal additional intra-abdominal injuries and hemoperitoneum. METHODS We performed a prospective observational study of trauma patients at our Level I trauma center from April 2003 to December 2003. Patients underwent an initial ultrasound (US), followed by a SUS examination within 24 hours of admission. Patients not eligible for a SUS because of early discharge, operative intervention or death were excluded. All US and SUS exams were performed and evaluated by surgical/emergency medicine house staff or surgical attendings. RESULTS Five hundred forty-seven patients had both an initial US and a SUS examination. The sensitivity of the initial US in this patient population was 31.1% and increased to 72.1% on SUS (p < 0.001) for intra-abdominal injury or intra-abdominal fluid. The specificity for the initial US was 99.8% and 99.8% for SUS. The negative predictive value was 92.0% for the initial US and increased to 96.6% for SUS (p = 0.002). The accuracy of the initial ultrasound was 92.1% and increased to 96.7% on the SUS (p < 0.002). No patient with a negative SUS after 4 hours developed clinically significant hemoperitoneum. CONCLUSION A secondary ultrasound of the abdomen significantly increases the sensitivity of ultrasound to detect intra-abdominal injury.

Early use of recombinant factor VIIa improves mean arterial pressure and may potentially decrease mortality in experimental hemorrhagic shock: a pilot study.

BACKGROUND Recombinant factor VIIa (rFVIIa) is used for treatment of bleeding episodes in hemophilia patients who develop inhibitors to factors VIII and IX. We tested the hypothesis that administration of rFVIIa early after injury would decrease bleeding and improve survival after experimental hepatic trauma. METHODS Anesthetized swine were cannulated for blood sampling and hemodynamic monitoring. Avulsion of left median lobe of the liver induced uncontrolled hemorrhage. After a 10% reduction of mean arterial pressure, animals were blindly randomized to receive intravenous rFVIIa (180 microg/kg) (n = 6) or placebo (n = 7). RESULTS Mortality was 43% (three of seven) in controls versus 0% with rFVIIa (p = 0.08, chi2). Significantly shorter prothrombin time and higher mean arterial pressures were observed in the rFVIIa group. CONCLUSION Intravenous administration of rFVIIa early after induction of hemorrhage shortens prothrombin time and improves mean arterial pressure. A trend toward improved survival was observed.

Can surgeons evaluate emergency ultrasound scans for blunt abdominal trauma

OBJECTIVE To determine whether surgeons and residents with minimal training can evaluate accurately emergency ultrasound (US) examinations compared with radiologists for blunt abdominal trauma. METHODS Over 7 months, we conducted a prospective study comparing the evaluation of emergency US for blunt abdominal trauma by surgeons and attending radiologists. US readings from the surgical team and the radiologists were correlated with outcome. RESULTS One hundred-twelve patients were included in the study. Ninety-two patients had an US read as negative by the surgical and radiology services with no subsequent injuries identified. Eighteen patients had an US deemed positive by the surgical service and radiologists. Injuries were confirmed in this group by operation or computed tomography. One patient had an US deemed positive by the surgical team and subsequently negative by the radiologist. A diagnostic peritoneal lavage was performed which was negative. Another patient had an US interpreted as negative by the surgical evaluator and positive by the radiologist. Exploratory laparotomy was negative for intraabdominal hemorrhage or organ injury. Overall results reveal an accuracy on US reading of 99% for the surgical team and 99% for the attending radiologists. CONCLUSION Surgeons and surgical residents at different levels of training can accurately interpret emergency ultrasound examinations for blunt trauma from the real-time images, at a level comparable to attending radiologists.

Prehospital blood transfusion in prolonged evacuation

BACKGROUND Prehospital blood transfusion for hemorrhaging trauma patients has been used infrequently and is controversial. Currently, there is no satisfactory nonsanguineous fluid therapy for use during prolonged transport, such as in military or rural trauma. METHODS We retrospectively reviewed prehospital data and hospital charts of all trauma patients in Israel who had received prehospital blood transfusion during a period of 30 months. RESULTS Forty patients received 60 U of Rh-positive type O packed red blood cells. Mean time from injury to hospital admission was 120 minutes. Twenty-one of 31 patients admitted to the hospital alive (68%) received additional blood transfusions during the initial resuscitation phase, justifying the prehospital transfusion. Of nine documented admissions with hemoglobin of less than 7 g/dL, one patient died of exsanguination. There was one case of a minor adverse reaction that could be attributed to prehospital transfusion. CONCLUSION Prehospital blood transfusion is justified in certain trauma patients, especially when long prehospital transport is required. Blood may be safely maintained and used by physicians with little experience in care of major trauma.

Is there an optimal time for laparoscopic cholecystectomy in acute cholecystitis

BackgroundLaparoscopic cholecystectomy (LC) is safe in acute cholecystitis, but the exact timing remains ill-defined. This study evaluated the effect of timing of LC in patients with acute cholecystitis.MethodsProspective data from the hospital registry were reviewed. All patients admitted with acute cholecystitis from June 1994 to January 2004 were included in the cohort.ResultsLaparoscopic cholecystectomy was attempted in 1,967 patients during the study period; 80% were women, mean patient age was 44 years (range, 20–73 years). Of the 1,967 LC procedures, 1,675 were successful, and 292 were converted to an open procedure (14%). Mean operating time for LC was 1 h 44 min (SD ± 50 min), versus 3 h 5 min (SD ± 79 min) when converted to an open procedure. Average postoperative length of stay was 1.89 days (± 2.47 days) for the laparoscopic group and 4.3 days (± 2.2 days) for the conversion group. No clinically relevant differences regarding conversion rates, operative times, or postoperative length of stay were found between patients who were operated on within 48 h compared to those patients who were operated on post-admission days 3–7.ConclusionsThe timing of laparoscopic cholecystectomy in patients with acute cholecystitis has no clinically relevant effect on conversion rates, operative times, or length of stay.

Management of conventional mass casualty incidents: ten commandments for hospital planning.

The successful management of mass casualty incidents (MCIs) requires standardization of planning, training, and deployment of response. Recent events in the United States, most importantly the Hurricane season in 2005, demonstrated a lack of a unified response plan at local, regional, state, and federal levels. A standard Israeli protocol for hospital preparedness for conventional MCIs, produced by the Office of Emergency Preparedness of the Israeli Ministry of Health, has been reviewed, modified, adapted, and tested in both drills and actual events at a large university medical center in the United States. Lessons learned from this process are herein presented as the10 most important steps (ie, Commandments) to follow when preparing hospitals to be able to respond to conventional MCIs. The standard Israeli emergency protocols have proved to be universally adaptable, flexible, and designed to be adapted by any healthcare institution, regardless of its size and location.

The incision of choice for pregnant women with appendicitis is through McBurney’s point

BACKGROUND There is uncertainty over the optimal incision for gravid patients with appendicitis. METHODS Data were collected retrospectively from January 1, 1995, through December 31, 2000, on 374 women of childbearing age who underwent appendectomies. Of these, 23 gravid patients were evaluated. RESULTS Eighteen incisions were made over McBurneys point and five were created superior to McBurneys point. Patients in the third trimester of pregnancy all received incisions over McBurneys point. The appendix was located without difficulty in all 4 of the third trimester patients. The appendix was easily located in 94% of the incisions made through McBurneys point and 80% of the incisions made above McBurneys point. CONCLUSIONS Our clinical experience indicates that the incision for the removal of the appendix in pregnant patients in all trimesters can be successfully made over McBurneys point.

Do pre-hospital trauma alert criteria predict the severity of injury and a need for an emergent surgical intervention?

OBJECTIVE Efficient triage may have a major influence on mortality and morbidity as well as financial consequences. A continuous effort to improve this decision making process and update the trauma alert criteria is being made. However, criteria for determining the evacuation priority are not well developed. We performed a prospective study to evaluate which pre-hospital parameters identify major trauma victims with an emphasis on a need for emergent surgical procedures. METHODS A prospective cohort included 601 patients admitted to a level one trauma centre over a three months period. The pre-hospital trauma alert criteria were recorded and set as independent variables. All major surgical procedures were graded in real time as: emergent, urgent, or not urgent. The ISS was calculated after completion of all the diagnostic workup. Patients were classified as major trauma victims if their calculated ISS was 16 or greater, and those needed an urgent intervention or intensive care. The relative risks (RR) for major trauma and a need for an emergent operation were calculated. RESULTS 243 (40%) patients were classified as having a major trauma. 39 (6.5%) patients required an emergent operative intervention: 24 for an active bleeding, 5 for a pericardial tamponade and 10 for an imminent cerebral herniation. Paramedic judgement and a penetrating injury to the trunk were the most common causes for over triage. However, a penetrating injury to the trunk had been the only clue that the victim needed an emergent operation in five cases. 128 patients had a pre-hospital Glasgow coma score (GCS) ≤ 12. Altered mental status was the most common and a significant predictor of both major trauma (RR of 3.00 with a 95% confidence interval (CI) of 1.98-4.53) and a need for an emergent operation (RR, 95% CI: 4.43, 2.28-8.58). Also, a systolic blood pressure ≤ 90 mmHg was highly associated with an emergent operation (RR, 95% CI: 11.69, 5.85-23.36). CONCLUSION For determining the evacuation priority, we suggest a triage system based on three major criteria: mental status, hypotension and a penetrating injury to the trunk. Overall, the set of trauma alert criteria system can be further simplified and enable better utilisation of resources.