An assessment of nationwide trends in emergency department (ED) resuscitative endovascular balloon occlusion of the aorta (REBOA) use - A trauma quality improvement program registry analysis.

BACKGROUND: Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemorrhage control in severe non-compressible torso trauma remains controversial, with limited data on patient selection and outcomes. This study aims to analyze the nationwide trends of its use in the emergency department (EDs). METHODS: A retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) from 2017 to 2022 was performed, focusing on REBOA placements in EDs. RESULTS: The analysis included 3398 REBOA procedures. Majority patients were male (76 â€‹%) with a median age of 40 years (27-58) and injury severity score of 20 (20-41). The most common mechanism was collision (64 â€‹%), with emergency surgeries most frequently performed for pelvic trauma (14 â€‹%). Level 1 trauma centers performed 82 â€‹% of these procedures, with consistent low annual utilization (<200 facilities). Survival rates were 85 â€‹% at 1-h post-placement, decreasing significantly to 42 â€‹% by discharge. CONCLUSIONS: REBOA usage in remains limited but steady, primarily occurring at level 1 trauma center EDs. While short-term survival rates are favorable, they drop significantly by the time of discharge.

Venous thromboembolic events associated with blood product administration in an era of whole blood use.

BACKGROUND: The risks associated with blood product administration and venous thromboembolic events remains unclear. We sought to determine which blood products were associated with the development of deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS: We analyzed data from patients ≥18 years of age in the Trauma Quality Improvement Program (TQIP) database that received ≥1 blood product and survived ≥24 â€‹h. RESULTS: There were 42,399 that met inclusion, of whom, 2086 had at least one VTE event. In our multivariable logistic regression model, we found that WB had a unit odds ratio (uOR) of 1.05 (95 â€‹% CI 1.02-1.08) for DVT and 1.08 (1.05-1.12) for PE. Compared to WB, platelets had a higher uOR for DVT of 1.09 (1.04-1.13) but similar uOR for PE of 1.08 (1.03-1.14). CONCLUSIONS: We found an association of both DVT and PE with early whole blood and platelets.

Incidence of Traumatic Brain Injuries within the Prehospital Trauma Registry System.

BACKGROUND: Traumatic brain injury (TBI) is often underreported or undetected in prehospital civilian and military settings. This study evaluated the incidence of TBI within the Prehospital Trauma Registry (PHTR) system. METHODS: We reviewed PHTR and the linked Department of Defense Trauma Registry (DoDTR) records of casualties from January 2003 through May 2019 for diagnostic data and surgical reports. RESULTS: A total of 709 casualties met inclusion criteria. The most common mechanism was blast, including 328 (51%) in the non-TBI and 45 (63%) in the TBI cohorts. The median injury severity scores in the non-TBI and TBI cohorts were 5 and 14, respectively. The survival scores in the non-TBI and TBI cohorts were 98% and 92%, respectively. Subdural hematomas, followed by subarachnoid hemorrhages were the most common classifiable brain injuries. Other nonspecific TBIs occurred in 85% of the TBI cohort casualties. Seventy-two cases (10%) were documented by the Role 1 clinician. Based on coding or operative data, 15 of the 72 (21%) were identified as TBIs. Of the 637 cases, which could not be decided based on coding or operative data, TBI was suspected in 42 (7%) cases based on Role 1 records. CONCLUSIONS: Over 1 in 10 casualties presenting to a Role 1 facility had a TBI requiring transfer to a higher level of care. Our findings suggest the need for improved diagnostic technologies and documentation systems at Role 1 facilities for accurate TBI diagnosis and reporting.

Incidence of Coagulopathy After Resuscitation at a Role 1 Facility: The Prehospital Trauma Registry Experience.

BACKGROUND: The development of acute traumatic coagulopathy is associated with increased mortality and morbidity in patients with battlefield traumatic injuries. Currently, the incidence of acute traumatic coagulopathy in the Role 1 setting is unclear. METHODS: We queried the Prehospital Trauma Registry (PHTR) module of the Department of Defense Trauma Registry (DoDTR) for all encounters from inception through May 2019. The PHTR captures data on Role 1 prehospital care. Data from the PHTR was linked to the DoDTR to analyze laboratory data and patient outcomes using descriptive statistics. We defined coagulopathy as an international normalized ratio (INR) of ≥1.5 or platelet count ≤150×109/L. RESULTS: A total of 595 patients met the inclusion criteria; 36% (212) met our definition for coagulopathy, with 31% (185) carrying low platelet numbers, 11% (68) showing an elevated INR, and 7% (41) with both. The baseline (no coagulopathy) cohort had a mean INR of 1.10 (95% CI 1.09-1.12) versus 1.38 (95% CI 1.33-1.43) in the coagulopathic cohort. The mean platelet count was 218 (95% CI 213-223) ×109/L in the baseline cohort versus 117 (95% CI 110-125) ×109/L in the coagulopathic cohort. CONCLUSIONS: Our findings indicate a high incidence of coagulopathy in trauma patients. Approximately one-third of wounded patients had laboratory evidence of coagulopathy upon presentation to a forward medical care facility. Advanced diagnostic facilities are therefore needed to facilitate early diagnosis of acute traumatic coagulopathy. Blood products with a long shelf life can aid in early correction.

Repeat Bronchoscopies Are Poorly Predictive of Outcomes Following Inhalation Injury.

Inhalation injury is an independent predictor of mortality after burn injury. Although bronchoscopy remains the gold standard for diagnosing inhalation injury, there is a paucity of evidence to support repeat bronchoscopies for following inhalation injury during a patient's clinical course. This study looks at the ability of serial bronchoscopies to prognosticate outcomes. This was a secondary analysis of a previously reported prospective observational study. Patients diagnosed with inhalation injury had repeat bronchoscopies with blinded investigators assigning severity scores. The study used multivariate regression analysis to investigate whether inhalation injury severity scores (I-ISS) of the carinal images were predictive of mortality. Secondary outcomes included diagnosis of acute respiratory distress syndrome (ARDS) or pneumonia during hospitalization. The final analysis included 99 patients. After accounting for age, percent total body surface area burn (TBSA), and injury severity scores, there were no days that were significant for predicting outcomes. All days were poor predictors overall, with area under the receiver operating curve to be < 0.8 in all instances. These results do not support the use of serial bronchoscopies for prognostication purposes. Until a larger, randomized clinical trial can evaluate this further, serial bronchoscopies performed for assessment of progression of inhalation injury may provide more risk than benefit.

The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings. STUDY DESIGN AND METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use. RESULTS: We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge. DISCUSSION: We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.

Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study.

BACKGROUND: Identifying patients at imminent risk of death is critical in the management of trauma patients. This study measures the vital sign thresholds associated with death among trauma patients. METHODS: This study included data from patients ≥15 years of age in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Patients with vital signs of zero were excluded. Documented prehospital and emergency department (ED) vital signs included systolic pressure, heart rate, respiratory rate, and calculated shock index (SI). The area under the receiver operator curves (AUROC) was used to assess the accuracy of these variables for predicting 24-hour survival. Optimal thresholds to predict mortality were identified using Youden's Index, 90% specificity, and 90% sensitivity. Additional analyses examined patients 70+ years of age. RESULTS: There were 1,439,221 subjects in the 2019-2020 datasets that met inclusion for this analysis with <0.1% (10,270) who died within 24 hours. The optimal threshold for prehospital systolic pressure was 110, pulse rate was 110, SI was 0.9, and respiratory rate was 15. The optimal threshold for the ED systolic was 112, pulse rate was 107, SI was 0.9, and respiratory rate was 21. Among the elderly sub-analysis, the optimal threshold for prehospital systolic was 116, pulse rate was 100, SI was 0.8, and respiratory rate was 21. The optimal threshold for ED systolic was 121, pulse rate was 95, SI was 0.8, and respiratory rate was 0.8. CONCLUSIONS: Systolic blood pressure (SBP) and SI offered the best predictor of mortality among trauma patients. The SBP values predictive of mortality were significantly higher than the traditional 90mmHg threshold. This dataset highlights the need for better methods to guide resuscitation as initial vital signs have limited accuracy in predicting subsequent mortality.

Precursors to oliguria during major burn resuscitation: An analysis of a prospective observational trial at 5 major US burn centers.

Currently, urine output is the leading variable used to tailor fluid resuscitation in patients with large TBSA burns. However, this metric often lags with respect to resuscitation. Our group sought to identify derangements in variables that precede development of oliguria (<30 cc/hr) that we hypothesize will aid in more efficient resuscitation. We performed a retrospective analysis of 146 adult patients admitted within 4 h of a large TBSA (>20%) burn. We then divided them into two cohorts: those who developed oliguria within 6 h of admission and those who did not. Patients who experienced early oliguria had a higher incidence of invasive SBP < 90 (p = 0.02) or DBP < 40 (p = 0.009), lower minimum bicarbonate level (p = 0.04), more full thickness burns (p = 0.004), and higher TBSA (p = 0.01). More female patients were found in the oliguric group (p = 0.003). Multivariate analysis was used to develop a model to predict development of oliguria. When evaluated together, minimum DBP, sex, TBSA (or percent full thickness burn), and maximum base deficit constituted the most parsimonious model that significantly predicted oliguria (AUC = 0.92). Interestingly, the model lost significance when DBP was omitted, highlighting the importance of diastolic pressure in the development of oliguria.

A survey of low titer O whole blood use within the trauma quality improvement program registry.

INTRODUCTION: The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB. METHODS: We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period. RESULTS: A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively. CONCLUSIONS: There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.

Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis.

BACKGROUND: The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the consumption of blood products in this setting. STUDY DESIGN AND METHODS: We analyzed data from 2007 to 2023 from the Department of Defense Trauma Registry (DODTR) that received care at a Role 2. We used descriptive and inferential statistics to characterize the volumes of blood products consumed in this setting. We also performed a secondary analysis of US military, Coalition, and US contractor personnel. RESULTS: Within our initial cohort analysis of 15,581 encounters, 17% (2636) received at least one unit of PRBCs or whole blood, of which 11% received a submassive transfusion, 4% received a massive transfusion, and 1% received a supermassive transfusion. There were 6402 encounters that met inclusion for our secondary analysis. With this group, 5% received a submassive transfusion, 2% received a massive transfusion, and 1% received a supermassive transfusion. CONCLUSIONS: We described volumes of blood products consumed at the Role 2 during recent conflicts. The maximum number of units consumed among survivors exceeds currently recommended available blood supply. Our findings suggest that rapid resupply and cold-stored chain demands may be higher than anticipated in future conflicts.

An Assessment of Clinical Accuracy of Vital Sign-based Triage Tools Among U.S. and Coalition Forces.

INTRODUCTION: Early appropriate allocation of resources for critically injured combat casualties is essential. This is especially important when inundated with an overwhelming number of casualties where limited resources must be efficiently allocated, such as during mass casualty events. There are multiple scoring systems utilized in the prehospital combat setting, including the shock index (SI), modified shock index (MSI), simple triage and rapid treatment (START), revised trauma score (RTS), new trauma score (NTS), Glasgow Coma Scale + age + pressure (GAP), and the mechanism + GAP (MGAP) score. The optimal score for application to the combat trauma population remains unclear. MATERIALS AND METHODS: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry from January 1, 2007 through March 17, 2020. We constructed univariable analyses to determine the area under the receiving operator characteristic (AUROC) for the scoring systems of interest. Our primary outcomes were early death (within 24 hours) or early massive transfusion, as defined by ≥3 units. RESULTS: There were 12,268 casualties that met inclusion criteria. There were 168 (1%) who died within the first 24 hours and 2082 (17%) that underwent significant transfusion within the first 24 hours. When assessing the predictive capabilities for death within 24 hours, the AUROCs were 0.72 (SI), 0.69 (MSI), 0.89 (START), 0.90 (RTS), 0.83 (NTS), 0.90 (GAP), and 0.91 (MGAP). The AUROCs for massive transfusion were 0.89 (SI), 0.89 (MSI), 0.82 (START), 0.81 (RTS), 0.83 (NTS), 0.85 (MGAP), and 0.86 (GAP). CONCLUSIONS: This study retrospectively applied seven triage tools to a database of 12,268 cases from the Department of Defense Trauma Registry to evaluate their performance in predicting early death or massive transfusion in combat. All scoring systems performed well with an AUROC >0.8 for both outcomes. Although the SI and MSI performed best for predicting massive transfusion (both had an AUROC of 0.89), they ranked last for assessment of mortality within 24 hours, with the other tools performing well. START, RTS, NTS, MGAP and GAP reliably identified early death and need for massive transfusion, with MGAP and GAP performing the best overall. These findings highlight the importance of assessing triage tools to best manage resources and ultimately preserve lives of traumatically wounded warfighters. Further studies are needed to explain the surprising performance discrepancy of the SI and MSI in predicting early death and massive transfusion.