Retrospective Evaluation of Splenic Artery Embolization Outcomes in the Management of Blunt Splenic Trauma: A Single Centre Experience at a Large Level 1 Trauma Centre.

PURPOSE: Retrospective review of splenic artery embolization (SAE) outcomes performed for blunt abdominal trauma. MATERIALS AND METHODS: 11-year retrospective review at a large level-1 Canadian trauma centre. All patients who underwent SAE after blunt trauma were included. Technical success was defined as angiographic occlusion of the target vessel and clinical success was defined as successful non-operative management and splenic salvage on follow-up. RESULTS: 138 patients were included of which 68.1% were male. The median age was 47 years (interquartile range (IQR) = 32.5 years). The most common mechanisms of injury were motor vehicle accidents (37.0%), mechanical falls (25.4%), and pedestrians hit by motor vehicles (10.9%). 70.3% of patients had American Association for the Surgery of Trauma (AAST) grade 4 injuries. Patients were treated with proximal SAE (n = 97), distal SAE (n = 23) or combined SAE (n = 18), and 68% were embolized with an Amplatzer plug. No significant differences were observed across all measures of hospitalization (Length of hospital stay: x2(2) = .358, P = .836; intensive care unit (ICU) stay: x2(2) = .390, P = .823; ICU stay post-procedure: x2(2) = 1.048, P = .592). Technical success and splenic salvage were achieved in 100% and 97.8% of patients, respectively. 7 patients (5%) had post-embolization complications and 7 patients (5%) died during hospital admission, but death was secondary to other injuries sustained in the trauma rather than complications related to splenic injury or its management. CONCLUSION: We report that SAE as an adjunct to non-operative management of blunt splenic trauma can be performed safely and effectively with a high rate of clinical success.

Interdisciplinary strategies to prevent long-term and detrimental opioid use following trauma: a stakeholder consensus study.

OBJECTIVE: Prolonged opioid use is common following traumatic injuries. Although preventive strategies have been recommended, the evidence supporting their use is low. The objectives of this study were to select interdisciplinary strategies to prevent long-term, detrimental opioid use in trauma patients for further evaluation and to identify implementation considerations. DESIGN: A consensus study using the nominal group technique. SETTING: Four trauma systems in Canada. SUBJECTS: Participants included expert clinicians and decision makers, and people with lived experience. METHODS: Participants had to discuss the relevance and implementation of 15 strategies and then rank them using a 7-point Likert scale. Implementation considerations were identified through a synthesis of discussions. RESULTS: A total of 41 expert stakeholders formed the nominal groups. Overall, eight strategies were favored: 1) using multimodal approach for pain management, 2) professional follow-up in physical health, 3) assessment of risk factors for opioid misuse, 4) physical stimulation, 5) downward adjustment of opioids based on patient recovery, 6) educational intervention for patients, 7) training offered to professionals on how to prescribe opioids, and 8) optimizing communication between professionals working in different settings. Discussions with expert stakeholders revealed the rationale for the selected strategies and identified issues to consider when implementing them. CONCLUSION: This stakeholder consensus study identified, for further scientific study, a set of interdisciplinary strategies to promote appropriate opioid use following traumatic injuries. These strategies could ultimately decrease the burden associated with long-term opioid use.

Strategies to prevent long-term opioid use following trauma: a Canadian practice survey.

PURPOSE: To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. METHODS: We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. RESULTS: Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. CONCLUSIONS: Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.

RéSUMé: OBJECTIF: Évaluer comment les cliniciens canadiens impliqués dans les soins aux patients traumatisés et prescrivant des opioïdes perçoivent l'utilisation et l'efficacité des stratégies visant à prévenir le traitement prolongé par opioïde après un traumatisme. Les obstacles et facilitateurs de la mise en œuvre de ces stratégies ont aussi été analysés. MéTHODES: Nous avons réalisé une enquête transversale via le Web. Les participants potentiels ont été identifiés par les gestionnaires et directeurs de programmes de traumatologie des départements ciblés dans trois provinces canadiennes. Nous avons conçu notre questionnaire en utilisant la méthodologie de recherche usuelle des enquêtes de santé. Le questionnaire a été administré entre avril 2021 et novembre 2021. RéSULTATS: Notre taux de réponse a été de 47 % (350/744) et 52 % (181/350) des participants ont complété l'enquête dans sa totalité. La majorité des personnes interrogées (71 %, 129/181) travaillait dans des hôpitaux universitaires. L'analgésie multimodale (93 %, 240/257), les anti-inflammatoires non stéroïdiens (77 %, 198/257) et la stimulation physique (75 %, 193/257) étaient les stratégies perçues comme étant le plus fréquemment utilisées. Plusieurs stratégies préventives étaient perçues comme étant très efficaces par plus de 80 % des répondants. Parmi celles-ci, certaines étaient signalées comme n'étant pas utilisées très souvent, mais perçues comme étant les plus efficaces, notamment les lignes directrices et protocoles évaluant les facteurs de risque d'utilisation abusive des opioïdes, le suivi de la santé physique par un professionnel, la formation des cliniciens, l'éducation des patients et les systèmes de suivi des prescriptions. La pénurie de personnels, les contraintes de temps et les pratiques de l'établissement ont été identifiées comme étant les principaux obstacles à la mise en place des stratégies préventives classées parmi les premières. CONCLUSIONS: Plusieurs stratégies de prévention du traitement par opioïdes à long terme après un traumatisme sont perçues comme efficaces par ceux qui les prescrivent à cette population de patients. Certaines de ces stratégies apparaissent comme couramment utilisées dans la pratique quotidienne et d'autres moins souvent. La recherche future devrait se concentrer sur la détermination des stratégies préventives auxquelles il faudrait accorder la plus grande priorité de mise en œuvre avant d'évaluer leur efficacité.

Strategies aimed at preventing chronic opioid use in trauma and acute care surgery: a scoping review protocol.

INTRODUCTION: Globally every year, millions of patients sustain traumatic injuries and require acute care surgeries. A high incidence of chronic opioid use (up to 58%) has been documented in these populations with significant negative individual and societal impacts. Despite the importance of this public health issue, optimal strategies to limit the chronic use of opioids after trauma and acute care surgery are not clear. We aim to identify existing strategies to prevent chronic opioid use in these populations. METHODS AND ANALYSIS: We will perform a scoping review of peer-reviewed and non-peer-reviewed literature to identify studies, reviews, recommendations and guidelines on strategies aimed at preventing chronic opioid use in patients after trauma and acute care surgery. We will search MEDLINE, EMBASE, PsycINFO, CINHAL, Cochrane Central Register of Controlled Trials, Web of Science, ProQuest and websites of trauma and acute care surgery, pain, government and professional organisations. Databases will be searched for papers published from 1 January 2005 to a maximum of 6 months before submission of the final manuscript. Two reviewers will independently evaluate studies for eligibility and extract data from included studies using a standardised data abstraction form. Preventive strategies will be classified according to their types and targeted trauma populations and acute care surgery procedures. ETHICS AND DISSEMINATION: Research ethics approval is not required as this study is based on the secondary use of published data. This work will inform research and clinical stakeholders on the required next steps towards the uptake of effective strategies aimed at preventing chronic opioid use in trauma and acute care surgery patients.

Prevalence of risky driving behaviours on popular television series

Summary: Motor vehicle crashes are a leading cause of death among young adults. Social media and television have been shown to affect the likelihood that young adults will engage in risk-taking behaviour. We watched 216 episodes of five popular television series on Netflix and identified 333 separate driving scenes, of which 271 (81.4%) portrayed at least one risky driving behaviour. Unsafe driving (not wearing a seat belt) was the most common risky driving behaviour noted, occurring in 245 (73.6%) of driving scenes. Distracted driving (36 [18.8%]) and driving while using a cellphone (28 [8.4%]) were also noted. Popular television series model unsafe driving behaviours. Seat belts are infrequently used. As well, drivers are often distracted, looking away from the road to talk or talking on their cellphones. Television producers should be sensitive to modelling unsafe driving behaviours, particularly if the audience consists largely of young people.

Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review.

INTRODUCTION: This systematic review looks at the use of noninvasive ventilation (NIV), inclusive of noninvasive positive pressure ventilation (NPPV) and continuous positive pressure ventilation (CPAP), in patients with chest trauma to determine its safety and clinical efficacy in patients with blunt chest trauma who are at high risk of acute lung injury (ALI) and respiratory failure. METHODS: We searched the MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Pairs of reviewers abstracted relevant clinical data and assessed the methodological quality of randomized controlled trials (RCTs) using the Cochrane domain and observational studies using the Newcastle-Ottawa Scale. RESULTS: Nine studies were included (three RCTs, two retrospective cohort studies and four observational studies without a comparison group). There was significant heterogeneity among the included studies regarding the severity of injuries, degree of hypoxemia and timing of enrollment. One RCT of moderate quality assessed the use of NPPV early in the disease process before the development of respiratory distress. All others evaluated the use of NPPV and CPAP in patients with blunt chest trauma after the development of respiratory distress. Overall, up to 18% of patients enrolled in the NIV group needed intubation. The duration of NIV use was highly variable, but NIV use itself was not associated with significant morbidity or mortality. Four low-quality observational studies compared NIV to invasive mechanical ventilation in patients with respiratory distress and showed decreased ICU stay (5.3 to 16 days vs 9.5 to 15 days), complications (0% to 18% vs 38% to 49%) and mortality (0% to 9% vs 6% to 50%) in the NIV group. CONCLUSIONS: Early use of NIV in appropriately identified patients with chest trauma and without respiratory distress may prevent intubation and decrease complications and ICU length of stay. Use of NIV to prevent intubation in patients with chest trauma who have ALI associated with respiratory distress remains controversial because of the lack of good-quality data.

The Advanced Trauma Operative Management course--a two student to one faculty model.

BACKGROUND: The internationally recognized Advanced Trauma Operative Management (ATOM) course uses a 1:1 student-to-faculty teaching model. This study examines a two student to one faculty ATOM teaching model. MATERIALS AND METHODS: We randomly assigned 16 residents to four experienced ATOM faculty members. Half started with the one-student model and the other half with the two-student model and then switched using the same faculty. Students and faculty completed forms on the educational value of the two models (1 = very poor; 2 = poor; 3 = average; 4 = good; and 5 = excellent) and identified educational preferences and recommendations. RESULTS: We assigned educational values for the 13 procedures as follows: All faculty rated the one-student model as excellent; six members rated the two-student model as excellent, and seven as good. Students rated 50%-75% as excellent and 12%-44% as good for the two-student model, and 56%-81% as excellent and 12%-44% as good for the one-student model. Given resource constraints, all faculty and 88% of students preferred the two-student model. With no resource constraints, 75% of students and 50% of faculty chose the two-student model. All faculty and students rated both models "acceptable." Overall, 81% of students and 50% of faculty rated the two-student model better. All faculty members recommended that the models be optional; 94% of students recommended that they be either optional (50%) or a two-student model (44%). Performing or assisting on each procedure twice was considered an advantage of the two-student model. CONCLUSIONS: The two-student teaching model was acceptable and generally preferred in this study. With appropriately trained faculty and students, the two-student model is feasible and should result in less animal usage and possibly wider promulgation.

Ultrasound-guided tracheostomy--not for the many, but perhaps the few... or the one.

Percutaneous tracheostomy has become a routine procedure in most intensive care units, and point of care ultrasound is becoming used with greater frequency to augment diagnosis and therapy for critically ill patients. The case series from Rajajee and colleagues incorporates 'real-time' ultrasound in an effort to improve the safety of percutaneous tracheostomy. While their report does not prove that ultrasound should be used prior to or during all percutaneous tracheostomies, it does reinforce several important safety considerations concerning the anatomy of the neck, and in particular the potential to encounter bleeding complications during these procedures.

Access to trauma systems in Canada.

BACKGROUND: Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care. METHODS: A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care. RESULTS: In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions. DISCUSSION: Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.

Surgisis® in the management of the complex abdominal wall in trauma: a case series and review of the literature.

Managing complex abdominal wall injuries acutely or at the time of reconstruction is challenging. Contaminated surgical fields, devitalized tissue, intestinal fistula and tissues under tension contribute to clinical scenarios where closure is not possible or morbidity is unacceptable. The introduction of an absorbable extracellular matrix derived from porcine small intestinal submucosa (Surgisis) adds a potentially useful tool to the surgeon's armamentarium. A retrospective case series of the initial experience in 5 patients with complex abdominal wall injury following trauma managed with Surgisis is described. A review of the literature describing the use of Surgisis in contaminated fields is also performed.

Assessing response to changing plasma/red cell ratios in a bleeding trauma patient.

Recent military experience suggests that transfusing fresh frozen plasma and packed red cells in a 1:1 ratio may improve survival in exsanguinating trauma patients. We report the case of a single patient who required massive transfusion after suffering a single gunshot wound. Initially, the patient received FFP:PRBC in 1:2 ratio, but this did not correct laboratory parameters except for INR and clotting factor VII level, which were likely normalized by treatment with recombinant activated factor VII. After receiving FFP:PRBC in a 4:5 ratio, he continued to bleed and his coagulation profile showed no appreciable improvement. In the final phase, he received FFP:PRBC in a 7:5 ratio and his laboratory parameters of coagulopathy normalized, except for factor V level which was improved. He also clinically stopped bleeding.

Abnormal coagulation tests are associated with progression of traumatic intracranial hemorrhage.

BACKGROUND: Intracranial hemorrhage (ICH) is common in traumatic brain injury (TBI) and a major determinant of death and disability. ICH commonly increases in size and coagulopathy has been implicated in such progression. We investigated the association between coagulopathy diagnosed by routine laboratory tests and ICH progression. METHODS: Subgroup post hoc analysis from a randomized controlled trial including adult patients with blunt severe TBI (Glasgow Coma Scale score or=1.3, activated partial thromboplastin time >or=35, or platelet count (PLT)

Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma.

BACKGROUND: Intravenous contrast extravasation (CE) on computed tomography (CT) scan in blunt abdominal trauma is generally regarded as an indication for the need for invasive intervention (either angiography or laparotomy). More recently, improvements in CT scan technology have increased the sensitivity in detecting CE, and, thus, we postulate that not all patients with this finding require intervention. METHODS: This study is a retrospective review of all patients who underwent a CT scan for blunt abdominal trauma between January 1999 and September 2003. Patterns of injury, associated injuries, management, and outcomes were examined for patients with CE. RESULTS: Seventy of 1,435 patients (4.8%) demonstrated CE. Mean age was 44 years and mean Injury Severity Score was 39. The location of CE was intra-abdominal in 25, pelvis/retroperitoneum in 39, and both areas in 3 patients. Six patients received supportive treatment for nonsurvivable head injury and were excluded from further analysis. Overall, 30 (47%) patients underwent immediate intervention (angiography or laparotomy) and 34 (53%) were managed nonoperatively. Of those who had initial nonoperative management, overall seven (20.5%) underwent intervention, with the remainder being managed without intervention. The success for nonoperative management was greater for those with pelvic/retroperitoneal CE (4 of 7: 57%) than for intra-abdominal extravasation (23 of 27: 85%). CONCLUSION: Although evidence of CE may suggest significant vascular injury, our data suggest that not all patients require invasive intervention. Further studies are needed to better define criteria for nonoperative management in patients with CE identified on their initial CT scan.

Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury.

BACKGROUND: There is controversy about the appropriate sequence of urologic investigation in patients with pelvic fracture. Use of retrograde urethrography or cystography may interfere with regular pelvic CT scanning for arterial extravasation. STUDY DESIGN: We performed a retrospective study at a regional trauma center in Toronto, Canada. Included were adult blunt trauma patients with pelvic fractures and concomitant bladder or urethral disruption who underwent initial pelvic CT before operation or hospital admission. Exposure of interest was whether retrograde urethrography (RUG) and cystography were performed before pelvic CT scanning. Main outcomes measures were indeterminate or false negative initial CT examinations for pelvic arterial extravasation. RESULTS: Sixty blunt trauma patients had a pelvic fracture and either a urethral or bladder rupture. Forty-nine of these patients underwent initial CT scanning. Of these 49 patients, 23 had RUG or conventional cystography performed before pelvic CT scanning; 26 had cystography after regular CT examination. Performing cystography before CT was associated with considerably more indeterminate scans (9 patients) and false negatives (2 patients) for pelvic arterial extravasation (11 of 23 versus 0 of 26, p < 0.001) compared with performing urologic investigation after CT. In the presence of pelvic arterial hemorrhage, indeterminate or false negative CT scans for arterial extravasation were associated with a trend toward longer mean times to embolization compared with positive scans (p=0.1). CONCLUSIONS: Extravasating contrast from lower urologic injuries can interfere with the CT assessment for pelvic arterial extravasation, delaying angiographic embolization.

Perioperative vasopressors are associated with an increased risk of gastrointestinal anastomotic leakage.

BACKGROUND: The purpose of this study was to investigate the effect of vasopressors on gastrointestinal (GI) anastomotic leaks. Vasopressors are commonly used in surgical patients admitted to the intensive care unit (ICU) and their effects on GI anastomotic integrity are unknown. PATIENTS AND METHODS: Surgical patients admitted to the ICU in our tertiary university hospital following the creation of a GI anastomosis were studied by a retrospective chart analysis for anastomotic leaks and complications RESULTS: A total of 223 patients with 259 GI anastomoses, mostly for cancer, were admitted to the ICU immediately after surgery. Twenty-two patients developed anastomotic leaks (9.9%). The two groups (leak versus no-leak) had similar demographics, surgery type and indication, type of anastomosis, co-morbidities, cancer, steroid use, blood transfusion, drains, and epidural catheters. Vasopressor use was associated with increased anastomotic leakage (p = 0.02, OR 3.25). Multiple vasopressors and prolonged exposure caused even higher leaking rates. This effect was independent of the medical status and operative morbidity (APACHE II, POSSUM). Blood pressure preceding vasopressor use was similar in both groups. Vasopressors might have been occasionally used to treat hypovolemia. Patients with leaks had higher reoperation rates (41% versus 1%, p < 0.0001) and mortality (21% versus 4%, p = 0.002). CONCLUSIONS: Vasopressors appear to increase anastomotic leaks threefold, independent of clinical/surgical status or hypotension. Evidence-based guidelines are warranted for the optimal use of vasopressors in postoperative patients admitted to the ICU.

Preventable deaths from hemorrhage at a level I Canadian trauma center.

BACKGROUND: Studies of trauma deaths have had a tremendous impact on the quality of contemporary trauma care. We studied causes of trauma death at a Level I Canadian trauma center, and tabulated preventable deaths from hemorrhage using explicit criteria. METHODS: Trauma registry data were used to identify all trauma deaths at our institution from January 1, 1999 to December 31, 2003. Demographics, mechanism, and time or location of death were recorded. Registry data analysis and selective chart or autopsy review were then performed to assign causes of death. RESULTS: A total of 558 consecutive trauma deaths were reviewed. Mean age was 48.7 (46.7-50.6), and mean Injury Severity Score was 38.8 (37.6-40.0); 29% were females. Blunt trauma represented 87% of all cases; penetrating injuries were only 13%. Central nervous system (CNS) injuries were the most frequent cause of death (60%), followed by hemorrhage (15%), and then combination CNS and hemorrhagic injuries (11%). Multiple organ failure caused 5% of deaths and 9% of deaths were from other causes. Of hemorrhagic deaths, 48% (n = 41) were from blunt injury, and 52% (n = 45) were from a penetrating mechanism. Of these hemorrhagic deaths, 16% were judged to be preventable because of significant delays in identifying the major source of hemorrhage. Hemorrhage from blunt pelvic injury was the major cause of exsanguination in 12 of 14 of these preventable deaths. CONCLUSIONS: Blunt injury is the major mechanism leading to trauma deaths. Massive bleeding from blunt pelvic injury is the major cause of preventable hemorrhagic deaths in our study.

Radiation exposure from diagnostic imaging in severely injured trauma patients.

BACKGROUND: Trauma patients often require multiple imaging tests, including computed tomography (CT) scans. CT scanning, however, is associated with high-radiation doses. The purpose of this study was to measure the radiation doses trauma patients receive from diagnostic imaging. METHODS: A prospective cohort study was conducted from June 1, 2004 to March 31, 2005 at a Level I trauma center in Toronto, Canada. All trauma patients who arrived directly from the scene of injury and who survived to discharge were included. Three dosimeters were placed on each patient (neck, chest, and groin) before radiologic examination. Dosimeters were removed before discharge. Surface doses in millisieverts (mSv) at the neck, chest, and groin were measured. Total effective dose, thyroid, breast, and red bone marrow organ doses were then calculated. RESULTS: Trauma patients received a mean effective dose of 22.7 mSv. The standard "linear no threshold" (LNT) model used to extrapolate from effects observed at higher dose levels suggests that this would result in approximately 190 additional cancer deaths in a population of 100,000 individuals so exposed. In addition, the thyroid received a mean dose of 58.5 mSv. Therefore, 4.4 additional fatal thyroid cancers would be expected per 100,000 persons. In all, 22% of all patients had a thyroid dose of over 100 mSv (mean, 156.3 mSv), meaning 11.7 additional fatal thyroid cancers per 100,000 persons would result in this subgroup. CONCLUSION: Trauma patients are exposed to significant radiation doses from diagnostic imaging, resulting in a small but measurable excess cancer risk. This small individual risk may become a greater public health issue as more CT examinations are performed. Unnecessary CT scans should be avoided.

Recombinant activated coagulation factor VII and bleeding trauma patients.

BACKGROUND: Recombinant activated coagulation factor VII (rFVIIa) is increasingly being administered to massively bleeding trauma patients. rFVIIa has been shown to correct coagulopathy and to decrease transfusion requirements. However, there is no conclusive evidence to suggest that rFVIIa improves the survival of these patients. The purpose of this study was to determine whether or not rFVIIa has an effect on the in-hospital survival of massively bleeding trauma patients. METHODS: A retrospective cohort study was conducted from January 1, 2000 to January 31, 2005, at a Level I trauma center in Toronto, Canada. Inclusion criteria included trauma patients requiring transfusion of 8 or more units of packed red cells within the first 12 hours of admission. The primary exposure of interest was the administration of rFVIIa. Primary outcome was a 24-hour survival and secondary outcome was overall in-hospital survival. RESULTS: There were 242 trauma patients identified who met inclusion criteria; 38 received rFVIIa. rFVIIa patients were younger, had more penetrating injuries, and fewer head injuries. However, rFVIIa patients required more red cell transfusions initially, and were more acidotic. Administering rFVIIa was associated with improved 24-hour survival, after adjusting for baseline demographics and injury factors. The odds ratio (OR) for survival was 3.4 (1.2-9.8). Furthermore, there was a strong trend toward increased overall in-hospital survival. The OR of in-hospital survival was 2.5 (0.8-7.6). Also, subgroup analysis of rFVIIa patients showed that 24-hour survivors required a slower initial rate of red cell transfusion (4.5 vs. 2.9 units/hr, p = 0.002), had higher platelet counts (175 vs. 121 [x10(-9)/L], p = 0.05) and smaller base deficits (7.1 vs. 14.3, p = 0.001) compared with rFVIIa patients who died during the first 24 hours. CONCLUSION: rFVIIa may be able to improve the early survival of massively bleeding trauma patients. However, surgical control of massive hemorrhage still has primacy, as rFVIIa did not appear efficacious if extremely high red cell transfusion rates were required. Also, correction of acidosis and thrombocytopenia may be important for rFVIIa efficacy. Prospective studies are required.

Association between alcohol and mortality in patients with severe traumatic head injury.

HYPOTHESIS: Admission blood alcohol concentration (BAC) is associated with in-hospital death in patients with severe brain injury from blunt head trauma. DESIGN: Retrospective cohort study. SETTING: Academic level I trauma center in Toronto, Ontario. PATIENTS: Using trauma registry data, between January 1, 1988, and December 31, 2003, we identified 1158 consecutive patients with severe brain injury from blunt head trauma. INTERVENTION: There was no active intervention. The primary exposure of interest was the BAC at admission, stratified into the following 3 levels: 0, no BAC; 0 to less than 230 mg/dL, low to moderate BAC; and 230 mg/dL or greater, high BAC. MAIN OUTCOME MEASURE: In-hospital death. RESULTS: In patients with severe brain injury, low to moderate BAC was associated with lower mortality than was no BAC (27.9% vs 36.3%; P = .008). High BAC was associated with higher mortality than was no BAC (44.7% vs 36.3%), although this was not statistically significant (P = .10). These associations were all statistically significant after adjusting for demographic data and injury factors using logistic regression analysis. The odds ratio for death was 0.76 (95% confidence interval, 0.52-0.98) for low to moderate BAC compared with no BAC. The odds ratio for death was 1.73 (95% confidence interval, 1.05-2.84) for high BAC compared with no BAC. CONCLUSIONS: Low to moderate BAC may be beneficial in patients with severe brain injury from blunt head trauma. In contrast, high BAC seems to have a deleterious effect on in-hospital death in these patients, which may be related to its detrimental hemodynamic and physiologic effects. Alcohol-based fluids may have a role in the management of patients with severe brain injury after they have been well resuscitated.