Norman E. McSwain

Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years?

BACKGROUND Recent military experience reported casualties who receive > 10 units of packed red blood cells (PRBC) in 24 hours have 20% versus 65% mortality when the fresh-frozen plasma (FFP) to PRBC ratio was 1:1 versus 1:4, respectively. We hypothesize a similar improvement in mortality in civilian trauma patients that require massive transfusion and are treated with a FFP to PRBC ratio closer to 1:1. METHODS Four-year retrospective study of all trauma patients who underwent emergency surgery in an urban Level I Trauma Center. Patients were divided into two groups; those that received < or = 10 units or > 10 units of PRBC during and after initial surgical intervention. Only patients who received transfusion of both FFP and PRBC were included in the analysis. The primary research question was the impact of initial FFP:PRBC ratio on mortality. Other variables for analysis included patient age, gender, mechanism, and Injury Severity Scale score. Both univariate and multivariate analysis were used to assess the relationship between outcome and predictors. RESULTS A total of 2,746 patients underwent surgical intervention of which 1,985 (72.2%) received no transfusion. Of those that received transfusion, 626 (22.8%) received < or = 10 units of PRBC and 135 (4.9%) > 10 units of PRBC. Out of the 626 patients that received < or = 10 units of PRBC, 250 (39.9%) received FFP and 376 (60.1%) received no FFP. All the patients that received > 10 units PRBC received FFP. In univariate analysis, a significant difference in mortality was found in patients who received > 10 units of PRBC (26% vs. 87.5%) when FFP:PRBC ratio was 1:1 versus 1:4 (p = 0.0001). Multivariate analysis in the group of patients that received > 10 units of PRBC showed a FFP:PRBC ratio of 1:4 was consistent with increased risk of mortality (relative risk, 18.88; 95% CI, 6.32-56.36; p = 0.001), when compared with a ratio of 1:1. Patients who received < or = 10 units of PRBC had a trend toward increased mortality (21.2% vs.11.8%) when the FFP:PRBC ratio was 1:4 versus 1:1 (p: 0.06). CONCLUSION An FFP to PRBC ratio close to 1:1 confers a survival advantage in patients requiring massive transfusion.

Damage control resuscitation: the new face of damage control.

Juan C. Duchesne, MD, FACS, FCCP, Norman E. McSwain, Jr., MD, FACS, Bryan A. Cotton, MD, FACS, John P. Hunt, MD, MPH, FACS, Jeff Dellavolpe, MD, Kelly Lafaro, MD, MPH, Alan B. Marr, MD, FACS, Earnest A. Gonzalez, MD, FACS, Herb A. Phelan, MD, FACS, Tracy Bilski, MD, FACS, Patrick Greiffenstein, MD, James M. Barbeau, MD, JD, Kelly V. Rennie, MD, Christopher C. Baker, MD, FACS, Karim Brohi, MD, FRCS, FRCA, Donald H. Jenkins, MD, FACS, and Michael Rotondo, MD, FACS

Damage control resuscitation in combination with damage control laparotomy: a survival advantage.

BACKGROUND Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). METHODS This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Students t test followed by multiple logistic regression. RESULTS One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). CONCLUSION This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.

Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest: Joint position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma

1. Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel’s thorough primary patient assessment, is found apneic, pulseless, and without organized ECG activity upon the arrival of EMS at the scene. 2. Victims of penetrating trauma found apneic and pulseless by EMS, based on their patient assessment, should be rapidly assessed for the presence of other signs of life, such as pupillary reflexes, spontaneous movement, or organized ECG activity. If any of these signs are present, the patient should have resuscitation performed and be transported to the nearest emergency department or trauma center. If these signs of life are absent, resuscitation efforts may be withheld. 3. Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with injuries obviously incompatible with life, such as decapitation or hemicorporectomy. 4. Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with evidence of a significance time lapse since pulselessness, including dependent lividity, rigor mortis, and decomposition. 5. Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with clinical condition, suggesting a nontraumatic cause of the arrest, should have standard resuscitation initiated 6. Termination of resuscitation efforts should be considered in trauma patients with EMS-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and cardiopulmonary resuscitation (CPR). 7. Traumatic cardiopulmonary arrest patients with a transport time to an emergency department or trauma center of more than 15 minutes after the arrest is identified may be considered nonsalvageable, and termination of resuscitation should be considered. 8. Guidelines and protocols for TCPA patients who should be transported must be individualized for each EMS system. Consideration should be given to factors such as the average transport time within the system, the scope of practice of the various EMS providers within the system, and the definitive care capabilities (that is, trauma centers) within the system. Airway management and intravenous (IV) line placement should be accomplished during transport when possible. 9. Special consideration must be given to victims of drowning and lightning strike and in situations where significant hypothermia may alter the prognosis. 10. EMS providers should be thoroughly familiar with the guidelines and protocols affecting the decision to withhold or terminate resuscitative efforts. Presented as a Position Development Forum at the NAEMSP Annual Meeting at Sanibel Island, FL January 2001.

Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy.

BACKGROUND Although hemostatic resuscitation with a 1:1 ratio of fresh-frozen plasma (FFP) to packed red blood cells (PRBC) after severe hemorrhage has been shown to improve survival, its benefit in patients with traumatic-induced coagulopathy (TIC) after >10 units of PRBC during operation has not been elucidated. We hypothesized that a survival benefit would occur when early hemostatic resuscitation was used intraoperatively after injury in patients with TIC. METHODS A 7-year retrospective study of patients with emergency department diagnosis of TIC after transfusion of >10 units of PRBC in the operating room. TIC was defined as initial emergency department international normalized ratio > 1.2, prothrombin time > 16 seconds, and partial thromboplastin time > 50 seconds. Patients were divided into FFP:PRBC ratios of 1:1, 1:2, 1:3, and 1:4. Patients with diagnosis of TIC who received transfusion of both FFP and PRBC during surgery were included. Other variables evaluated included age, gender, mechanism of injury, initial base deficit, mean operative time, trauma intensive care unit length of stay (TICU LOS) and Injury Severity Score. The primary outcome measure evaluated was the impact of the early FFP:PRBC ratio on mortality. RESULTS Four hundred thirty-five patients underwent emergency operations postinjury and received FFP with >10 units of PRBC in the operating room; 135 (31.0%) of these patients had TIC and 53 died (39.5% mortality). Mean operative time was 137 minutes (SD +/- 49). There were no differences with regard to age, gender, mechanism of injury, initial base deficit, or Injury Severity Score among all groups. A significant difference in mortality was found in patients who received >10 units of PRBC when FFP:PRBC ratio was 1:1 versus 1:4 (28.2% vs. 51.1%, p = 0.03). Intermediate mortality rates were noted in patients with 1:2 and 1:3 ratios (38% and 40%, respectively). From a linear regression model, 13 days of increased TICU LOS was observed among 1:4 group compared with 1:1 group (p < 0.01). CONCLUSION TIC is common after severe injury and is associated with a high mortality in patients transfused with >10 units of PRBC during surgery. Early hemostatic resuscitation during first hours after injury improves survival with shorter TICU LOS in patients with TIC.

A comparison of chest compressions between mechanical and manual CPR by monitoring end-tidal Pco2 during human cardiac arrest

STUDY OBJECTIVE To compare the use of mechanical and manual chest compressions during cardiac arrest based on continuous monitoring of end-tidal PCO2 (PETCO2). DESIGN Prospective, randomized, crossover design. SETTING AND PARTICIPANTS Fifteen consecutive adults ranging in age from 33 to 78 years who presented in nontraumatic cardiac arrest to the emergency department of a large teaching hospital. INTERVENTIONS Study protocols were begun late in the resuscitation after initial resuscitation attempts were unsuccessful. Patients received four alternating five-minute trials (two manual and two mechanical), being randomized to begin with either technique. Mechanical compressions were performed by a mechanical device at a compression depth of 2 in. Both mechanical and manual compressions were delivered at a rate of 80 with a ventilation delivered after every fifth compression. Persons performing manual CPR were experienced American Heart Association basic life support providers, and no person performed manual CPR more than once during the study period. No resuscitative drugs were administered during the study period. PETCO2 was monitored continuously; those performing manual CPR were blinded to the PETCO2 monitor. Data were analyzed with repeated-measures analysis of variance and Scheffé multiple comparisons with the alpha error rate set of .05. MEASUREMENTS AND RESULTS Mean PETCO2 during mechanical CPR was 13.6 +/- 4.14 mm Hg compared with 6.9 +/- 2.42 mm Hg during manually performed CPR (P < .001), a difference of 97%. Average mechanical CPR PETCO2 was higher in all cases. No patient was resuscitated successfully. Capnography also indicated that most CPR providers were inconsistent in their chest compressions. CONCLUSION This study suggests that cardiac output produced with mechanical chest compressions is greater than that produced with manual compressions as demonstrated by the significantly higher PETCO2 levels during mechanical CPR. Reasons for this are unclear. In addition, monitoring of PETCO2 may help optimize chest compressions during CPR.

Impact of telemedicine upon rural trauma care.

OBJECTIVES Only preliminary reports have evaluated the impact of telemedicine in trauma care. This study will analyze outcomes before (pre-TM) and after (post-TM) implementation of telemedicine in the management of rural trauma patients initially treated at local community hospitals (LCH) before trauma center (TC) transfer. METHODS Seven rural hospital emergency departments in Mississippi were equipped with dual video cameras with remote control capability. All trauma patients initially treated at these LCH with TC consultation were reviewed. Data included patient demographics, Injury Severity Score, institutional volume of patients, mode of transportation, length of stay in LCH, transfer time (TT), mortality, and hospital cost. Patients were grouped in the pre-TM and post-TM periods. Statistical testing was with two-sample Students t test or chi analysis as appropriate. RESULTS During 5 years, 814 traumatically injured patients (pre-TM, n = 351; post-TM, n = 463) presented to the LCH. In the pre-TM period, 351 patients were transferred directly from the LCH for definitive management to the TC. In the post-TM period, 463 virtual consults were received, of which 51 patients were triaged to the TC. There were no differences in patient age, sex, or mode of transportation. When comparing post-TM with pre-TM era, patients had a higher Injury Severity Score (18 vs. 10, p < 0.001); less incidence of blunt trauma 35 (68%) versus 290 (82%), p < 0.05; a decrease in length of stay at LCH 1.5 hours versus 47 hours, p < 0.001; as well as TT LCH to TC 1.7 hours versus 13 hours, p < 0.001. After arrival to TC during the post-TM era patients received more units of packed red bed cell 13 units versus 5 units, p < 0.001 but without difference in mortality 4 (7.8%) versus 17 (4.8%), when compared with pre-TM era. Of statistical significance there was a dramatic decrease in hospital cost when comparing post-TM and pre-TM eras (

Motorcycle helmets--medical costs and the law

1,126,683 vs.

Emergency thoracoscopy: a logical approach to chest trauma management.

7,632,624, p < 0.001). CONCLUSION Telemedicine significantly improved rural LCH evaluation and management of trauma patients. More severely injured trauma patients were identified and more rapidly transferred to the TC. Total TC hospital costs were significantly decreased without significant changes in TC mortality. Introduction of telemedicine consultation to rural LCH emergency departments expanded LCH trauma capabilities and conserved TC resources, which were directed to more severely injured patients.

An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma

Since 1975, 26 states have repealed or modified their motorcycle (M/C) helmet laws. Louisiana (LA) reinstated the M/C helmet law in 1982. The medical and financial impact of repeal in Kansas (KS), reinstatement in LA (accident, fatality, and critical injury rates) have been studied through 1987. Current FARS data and studies from KS, LA, 10 states and 5 countries are compared and reported. Without M/C helmet legislation, the user rate drops from 99% to 50%. With reinstatement, the user rate rises to greater than 95%. Average hospital stay (days) for helmeted (H) riders is 5.8, non-helmeted (NH), 11.8. Fatality rate/1,000 M/C registrations is 6.2 NH, 1.6 H. Changes effected through M/C helmet legislation: fatality rate was 1.17 (1981), falling to 0.44 (1987) with legislation (62% decrease) (LA); 66% change Colorado, 42% Oklahoma; fatality rate/1,000 accidents changed 28% from 42.68 NH to 30.81 H; injury accidents 84% to 73%, critical injury reduction 44% (1981 to 1987). Risk of head injury: NH 2.07 greater than H. Risk of a fatal accident: NH 1.44 greater than H. Accident rate is less with M/C helmet legislation than without (19% KS, 48% LA). The medical costs (LA 1981 to 1987) decreased 48.8%. Length of stay decreased 37%. The major impact hospital stay greater than 20 days: 80% decline. Cost of long-term disability greater than 30 days: 81.2% decrease (LA). Average disability was 26.7 vs. 51.1 days (KS); 25.5 H required hospitalization per 100 accidents vs. 41.6 NH. Medical costs: NH 306% greater than H (KS). Based on 1989 dollars,