Low-Dose Heparin Infusion as Venous Thromboembolism Chemoprophylaxis in Patients With Blunt Cerebrovascular Injury.

INTRODUCTION: Blunt cerebrovascular injury (BCVI) can result in devastating stroke. Because of operative inaccessibility, the most common treatment for BCVI is aspirin or a low-dose systemic heparin infusion. While it is assumed that low dose heparin infusion imparts venous thromboembolism (VTE) prophylaxis, this has not been evaluated in the BCVI population. The purpose of this study was to evaluate VTE rates in patients receiving low-dose heparin infusion as treatment for BCVI. METHODS: Patients diagnosed with BCVI between 2014 and 2018 were reviewed for initiation of low-dose systemic heparin treatment. VTE was defined as a deep vein thrombosis or pulmonary embolism. BCVI patients without systemic heparin treatment were compared to BCVI patients with heparin treatment for overall VTE rates. Comparisons were also made to injured patients without a BCVI in our Trauma Activation Protocol (TAP) database. RESULTS: During the 5-year study period, 265 patients were identified with a BCVI. The majority (61%) were men with a median injury severity score (ISS) 22 (interquartile range [IQR]:14-33). Of these patients, 146 (55.1%) received a heparin infusion to treat BCVI. VTE was identified in eight of these patients (5.5%). Compared to TAP patients (n = 1020) who received standard dosing of VTE chemoprophylaxis, there was no difference in VTE rates compared to BCVI patients who were started on a low dose heparin infusion (3% versus 5.5%, P = 0.16). Area under the receiver operating characteristics (AUROC) was used to evaluate the predictive power of time to initiation of heparin infusion (AUC = 0.64 95% CI 0.42-0.85, P = 0.2) and time to reaching PTT goal (AUC = 0.52 95% CI 0.27-0.77, P = 0.83) as a predictor VTE events. CONCLUSIONS: Low dose heparin infusion is frequently used as an initial treatment of BCVI. In injured patients with BCVI, a low dose heparin infusion is associated with a low rate of VTE, comparable to injured patients without BCVI that received standard VTE chemoprophylaxis.

Assessment of Discharge Analgesic Prescription Patterns for Hospitalized Patients With Rib Fractures.

INTRODUCTION: There is a paucity of data describing opioid prescribing patterns for trauma patients. We investigated pain medication regimens prescribed at discharge for patients with traumatic rib fractures, as well as potential variables predictive of opioid prescribing. METHODS: A single-center, retrospective analysis was performed of 337 adult patients presenting with ≥1 traumatic rib fractures between January and December 2019. The primary outcome was oral morphine milligram equivalents (MME) prescribed on discharge. A multivariable logistic regression analysis was performed to determine factors independently associated with above median (150) MME prescription at discharge. RESULTS: The majority of patients were male (68.8%) with a median age of 53 y. Blunt trauma accounted for 97.3% of cases with a median Injury Severity Score(ISS) of 10. Locoregional pain procedures were utilized in 16.9% of patients. Opioids were the most common analgesic prescribed at discharge, and 74.1% of patients prescribed opioids on discharge were also prescribed a non-opioid adjunct. On multivariable analysis, daily MME prescribed during hospitalization (OR 1.01, 95% CI 1.01-1.02, P < 0.01) and number of rib fractures (OR 2.26, 95% CI 1.36-3.74, P < 0.01) were predictive of high MME prescribed on discharge. CONCLUSIONS: For patients with traumatic rib fractures, daily MME during hospitalization and number of rib fractures were predictive of high MME prescribing on discharge. Further prospective studies evaluating strategies for pain management and protocolized approaches to opioid prescribing are needed to reduce unnecessary and inappropriate opioid use in this patient population.

Comparison of iliac crest versus supraacetabular external fixator in hemodynamically unstable patients with a pelvic ring injury.

PURPOSE: External fixation has been widely implemented as a resuscitation strategy in combination with pelvic packing for high energy, hemodynamically unstable, pelvic ring injuries. The primary aim of this study is to compare urgent iliac crest (IC) versus supraacetabular (SA) external fixation in the setting of haemodynamic instability. METHODS: This is a retrospective review of a prospectively gathered registry at an urban level one trauma centre comparing placement of pelvic external fixator by SA or IC technique. Outcomes assessed were accuracy of pin placement, duration of procedure, and the effect on true pelvic circumference depending on type of fracture by Young and Burgess Classification system. RESULTS: Ninety-three haemodynamically unstable patients with a pelvic fracture included. Pin malpositioning was more common with IC than SA groups (proportional difference, - 40%; 95% CI, - 57 to - 20%; p < 0.0001). For APC injuries, there was a larger median reduction in pelvic circumference in the SA group than the IC group (median difference [MD], - 12.85 cm; 95% CI, - 27 to 0.1; p = 0.0485). In LC injuries, the SA group had an overall increase in pelvic circumference compared to an overall decrease in IC group (MD, 6.5 cm; 95% CI, 1.5 to 16.8; p = 0.0221). There was no difference in the operating room (OR) time (mean difference, - 5.4 min; 95% CI, - 32 to 22; p = 0.68). CONCLUSIONS: In this clinical setting, we recommend placement of SA external fixator (versus IC) with similar operative times, fewer pin malpositions, and improved stabilization of pelvic circumference in APC and LC injuries.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group.

BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial.

BACKGROUND: Plasma is integral to haemostatic resuscitation after injury, but the timing of administration remains controversial. Anticipating approval of lyophilised plasma by the US Food and Drug Administration, the US Department of Defense funded trials of prehospital plasma resuscitation. We investigated use of prehospital plasma during rapid ground rescue of patients with haemorrhagic shock before arrival at an urban level 1 trauma centre. METHODS: The Control of Major Bleeding After Trauma Trial was a pragmatic, randomised, single-centre trial done at the Denver Health Medical Center (DHMC), which houses the paramedic division for Denver city. Consecutive trauma patients in haemorrhagic shock (defined as systolic blood pressure [SBP] ≤70 mm Hg or 71-90 mm Hg plus heart rate ≥108 beats per min) were assessed for eligibility at the scene of the injury by trained paramedics. Eligible patients were randomly assigned to receive plasma or normal saline (control). Randomisation was achieved by preloading all ambulances with sealed coolers at the start of each shift. Coolers were randomly assigned to groups 1:1 in blocks of 20 according to a schedule generated by the research coordinators. If the coolers contained two units of frozen plasma, they were defrosted in the ambulance and the infusion started. If the coolers contained a dummy load of frozen water, this indicated allocation to the control group and saline was infused. The primary endpoint was mortality within 28 days of injury. Analyses were done in the as-treated population and by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01838863. FINDINGS: From April 1, 2014, to March 31, 2017, paramedics randomly assigned 144 patients to study groups. The as-treated analysis included 125 eligible patients, 65 received plasma and 60 received saline. Median age was 33 years (IQR 25-47) and median New Injury Severity Score was 27 (10-38). 70 (56%) patients required blood transfusions within 6 h of injury. The groups were similar at baseline and had similar transport times (plasma group median 19 min [IQR 16-23] vs control 16 min [14-22]). The groups did not differ in mortality at 28 days (15% in the plasma group vs 10% in the control group, p=0·37). In the intention-to-treat analysis, we saw no significant differences between the groups in safety outcomes and adverse events. Due to the consistent lack of differences in the analyses, the study was stopped for futility after 144 of 150 planned enrolments. INTERPRETATION: During rapid ground rescue to an urban level 1 trauma centre, use of prehospital plasma was not associated with survival benefit. Blood products might be beneficial in settings with longer transport times, but the financial burden would not be justified in an urban environment with short distances to mature trauma centres. FUNDING: US Department of Defense.

Survival after emergency department thoracotomy in the pediatric trauma population: a review of published data.

BACKGROUND/PURPOSE: The utility of EDT in the adult trauma population, using well-defined guidelines, is well established, especially for penetrating injuries. Since the introduction of these guidelines, reports on the use of EDT for pediatric trauma have been published, and these series reveal a dismal, almost universally fatal, outcome for EDT following blunt trauma in the child. This report reviews the clinical outcomes of EDT in the pediatric population. MATERIALS/METHODS: We performed a review of EDT in the pediatric population using the published data from 1980 to 2017. Variables extracted included mechanism of injury and mortality. To minimize bias, single case reports were not included in the review. RESULTS: Upon review of four decades of published literature on the use of emergency department thoracotomy (EDT) in the pediatric population, mortality rates are comparable between adults and pediatric patients for penetrating thoracic trauma. In contrast, in pediatric patients sustaining blunt trauma, no patient under the age of 15 has survived. CONCLUSION: In patients between 0 and 14 years of age presenting with no signs of life following blunt trauma, withholding EDT should be considered. Patients between the ages of 15 and 18 should be treated in accordance with adult ATLS principles for the management of thoracic trauma. LEVEL OF EVIDENCE: Level IV.

Current trends in the management of hemodynamically unstable pelvic ring injuries.

PURPOSE OF REVIEW: Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries. RECENT FINDINGS: Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization. SUMMARY: Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.

Urinary Glycosaminoglycans Predict Outcomes in Septic Shock and Acute Respiratory Distress Syndrome.

RATIONALE: Degradation of the endothelial glycocalyx, a glycosaminoglycan (GAG)-rich layer lining the vascular lumen, is associated with the onset of kidney injury in animal models of critical illness. It is unclear if similar pathogenic degradation occurs in critically ill patients. OBJECTIVES: To determine if urinary indices of GAG fragmentation are associated with outcomes in patients with critical illnesses such as septic shock or acute respiratory distress syndrome (ARDS). METHODS: We prospectively collected urine from 30 patients within 24 hours of admission to the Denver Health Medical Intensive Care Unit (ICU) for septic shock. As a nonseptic ICU control, we collected urine from 25 surgical ICU patients admitted for trauma. As a medical ICU validation cohort, we obtained serially collected urine samples from 70 patients with ARDS. We performed mass spectrometry on urine samples to determine GAG (heparan sulfate, chondroitin sulfate, and hyaluronic acid) concentrations as well as patterns of heparan sulfate/chondroitin sulfate disaccharide sulfation. We compared these indices to measurements obtained using dimethylmethylene blue, an inexpensive, colorimetric urinary assay of sulfated GAGs. MEASUREMENTS AND MAIN RESULTS: In septic shock, indices of GAG fragmentation correlated with both the development of renal dysfunction over the 72 hours after urine collection and with hospital mortality. This association remained after controlling for severity of illness and was similarly observed using the inexpensive dimethylmethylene blue assay. These predictive findings were corroborated using urine samples previously collected at three consecutive time points from patients with ARDS. CONCLUSIONS: Early indices of urinary GAG fragmentation predict acute kidney injury and in-hospital mortality in patients with septic shock or ARDS. Clinical trial registered with www.clinicaltrials.gov (NCT01900275).

Preperitoneal pelvic packing for exsanguinating pelvic fractures.

Patients with haemodynamic instability due to pelvic fracture-related bleeding can have life-threatening haemorrhage. Management options for haemorrhage control in complex pelvic fractures include bony stabilization, angioembolization, and preperitoneal pelvic packing (PPP). The indications for PPP as well as the operative technique and outcomes will be described in this review. PPP directly addresses the bony and venous bleeding of complex pelvic fractures, which results in the majority of blood loss in exsanguinating patients. As such, PPP should be considered for pelvic fracture patients who remain haemodynamically unstable despite red cell transfusion.

Fat emboli syndrome and the orthopaedic trauma surgeon: lessons learned and clinical recommendations.

PURPOSE: Fat emboli syndrome is a rare but well-described complication of long-bone fractures classically characterised by a triad of respiratory failure, mental status changes and petechial rash. In this paper, we present the case of a patient who sustained bilateral femoral fractures and subsequently developed FES. Our aim was to review and summarise the current literature regarding the pathophysiology and management of fat emboli syndrome (FES) and propose an algorithm for treating patients with bilateral femoral fractures to reduce the risk of FES. METHODS: A literature analysis was performed to determine implications in the clinical setting. RESULTS: Currently, there exists little high-quality evidence to guide the orthopaedic surgeon in identifying patients at highest risk of FES or in preventing FES in patients with multiple long-bone fractures. However, the literature does suggest that the risk is directly related to the volume of marrow displaced and inversely related to both the time to fracture stabilisation and the respiratory reserve of the patient. Based on these correlations, we propose an algorithm for treating patients with bilateral femoral fractures, taking into consideration haemodynamic and pulmonary stability. CONCLUSIONS: Our algorithm for managing bilateral femoral fractures prioritises early stabilisation with external fixation, staged intramedullary nailing and conversion to plate fixation if FES develops. This protocol is meant to be the basis of future investigations of optimal treatment strategies.

Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays.

BACKGROUND: Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA). METHODS: This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation. Upon MTP activation, patients were randomized to be managed either by an MTP goal directed by TEG or by CCA (ie, international normalized ratio, fibrinogen, platelet count). Primary outcome was 28-day survival. RESULTS: One hundred eleven patients were included in an intent-to-treat analysis (TEG = 56, CCA = 55). Survival in the TEG group was significantly higher than the CCA group (log-rank P = 0.032, Wilcoxon P = 0.027); 20 deaths in the CCA group (36.4%) compared with 11 in the TEG group (19.6%) (P = 0.049). Most deaths occurred within the first 6 hours from arrival (21.8% CCA group vs 7.1% TEG group) (P = 0.032). CCA patients required similar number of red blood cell units as the TEG patients [CCA: 5.0 (2-11), TEG: 4.5 (2-8)] (P = 0.317), but more plasma units [CCA: 2.0 (0-4), TEG: 0.0 (0-3)] (P = 0.022), and more platelets units [CCA: 0.0 (0-1), TEG: 0.0 (0-0)] (P = 0.041) in the first 2 hours of resuscitation. CONCLUSIONS: Utilization of a goal-directed, TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation.

Analysis of Total Human Urinary Glycosaminoglycan Disaccharides by Liquid Chromatography-Tandem Mass Spectrometry.

The determination of complex analytes, present at low concentrations, in biological fluids poses a difficult challenge. This study relies on an optimized method of recovery, enzymatic treatment, and disaccharide analysis by liquid chromatography-tandem mass spectrometry to rapidly determine low concentrations of glycosaminoglycans in human urine. The approach utilizes multiple reaction monitoring (MRM) of glycosaminoglycan disaccharides obtained from treating urine samples with recombinant heparin lyases and chondroitin lyase. This rapid and sensitive method allows the analysis of glycosaminoglycan content and disaccharide composition in urine samples having concentrations 10- to 100-fold lower than those typically analyzed from patients with metabolic diseases, such as mucopolysaccharidosis. The current method facilitates the analysis low (ng/mL) levels of urinary glycosaminoglycans present in healthy individuals and in patients with pathological conditions, such as inflammation and cancers, that can subtly alter glycosaminoglycan content and composition.

A multicenter, randomized clinical trial of IV iron supplementation for anemia of traumatic critical illness*.

OBJECTIVE: To evaluate the efficacy of IV iron supplementation of anemic, critically ill trauma patients. DESIGN: Multicenter, randomized, single-blind, placebo-controlled trial. SETTING: Four trauma ICUs. PATIENTS: Anemic (hemoglobin < 12 g/dL) trauma patients enrolled within 72 hours of ICU admission and with an expected ICU length of stay of more than or equal to 5 days. INTERVENTIONS: Randomization to iron sucrose 100 mg IV or placebo thrice weekly for up to 2 weeks. MEASUREMENTS AND MAIN RESULTS: A total of 150 patients were enrolled. Baseline iron markers were consistent with functional iron deficiency: 134 patients (89.3%) were hypoferremic, 51 (34.0%) were hyperferritinemic, and 64 (42.7%) demonstrated iron-deficient erythropoiesis as evidenced by an elevated erythrocyte zinc protoporphyrin concentration. The median baseline transferrin saturation was 8% (range, 2-58%). In the subgroup of patients who received all six doses of study drug (n = 57), the serum ferritin concentration increased significantly for the iron as compared with placebo group on both day 7 (808.0 ng/mL vs 457.0 ng/mL, respectively, p < 0.01) and day 14 (1,046.0 ng/mL vs 551.5 ng/mL, respectively, p < 0.01). There was no significant difference between groups in transferrin saturation, erythrocyte zinc protoporphyrin concentration, hemoglobin concentration, or packed RBC transfusion requirement. There was no significant difference between groups in the risk of infection, length of stay, or mortality. CONCLUSIONS: Iron supplementation increased the serum ferritin concentration significantly, but it had no discernible effect on transferrin saturation, iron-deficient erythropoiesis, hemoglobin concentration, or packed RBC transfusion requirement. Based on these data, routine IV iron supplementation of anemic, critically ill trauma patients cannot be recommended (NCT 01180894).

Management of Pelvic Trauma.

Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.

Factors Associated With Pelvic Infection After Pre-Peritoneal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures.

Background: Preperitoneal pelvic packing (PPP) and external fixation has led to improved mortality after devastating pelvic trauma. However, there is limited literature on infection after this intervention. We aim to study the risk factors associated with pelvic infection after PPP. Patients and Methods: A retrospective review of patients who underwent PPP at a single level 1 trauma center was performed. Results: Over the 18-year study period, 222 patients were identified. Twenty-three percent of patients had an open fracture. Pelvic angiography was performed in 24% of patients with 16% requiring angioembolization (AE). The average time to packing removal was two (one to two days) days, although 10% of patients had their pelvis re-packed. Overall infection rate was 14% (n = 31); if pelvic re-packing was performed, the infection rate increased to 45%. Twenty-two of the patients with an infection required additional procedures for their infection, and ultimately hardware removal occurred in eight patients. On univariable analysis, patients with pelvic infections had more open fractures (55% vs. 17%; p < 0.01), underwent AE more frequently (29% vs. 14%; p = 0.04), were more likely to undergo repacking (32% vs. 6%; p < 0.01), and had packing in place for longer (2 [1,2] vs. 2 [2,3]; p = 0.01). On logistic multivariable regression analysis, open fracture (odds ratio [OR], 5.8; 95% confidence interval [CI], 2.4-14.1) and pelvic re-packing (OR, 4.7; 95% CI, 1.2-18.5) were independent risk factors for pelvic infection. Conclusions: Pelvic infection after PPP is a serious complication independently associated with open fracture and re-packing of the pelvis. Re-intervention was required in most patients with infection.

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study.

BACKGROUND: High-grade liver injuries with extravasation (HGLI â€‹+ â€‹Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â€‹+ â€‹Extrav. Therefore, we evaluated the management of HGLI â€‹+ â€‹Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â€‹+ â€‹Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â€‹= â€‹0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â€‹> â€‹0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â€‹+ â€‹Extrav patients.

Revisiting early postinjury mortality: are they bleeding because they are dying or dying because they are bleeding?

BACKGROUND: Intense debate continues in the search of the optimal ratio of blood components to deliver preemptively in the critically injured patient anticipated to require a massive transfusion. A major challenge is distinguishing patients with refractory coagulopathy versus those with overwhelming injuries who will perish irrespective of blood component administration. The hypothesis of this clinical study is that a predominant number of early deaths from hemorrhage are irretrievable despite an aggressive transfusion policy. MATERIALS AND METHODS: During the 7-y period ending in December 2009, there were 772 in-hospital trauma deaths. Each of these deaths had been assigned a cause of death via concurrent review by the multidisciplinary hospital trauma quality improvement committee. Emergency department deaths and patients arriving from outside facilities were excluded from this study. RESULTS: Of the 382 patients (49.5% of total) who died secondary to acute blood loss, 84 (22.0%) survived beyond the ED; of these 84, 68 (81%) were male, mean age was 31 y, and 30 (36%) sustained blunt trauma. Cause of death was determined to be exsanguination in 63 (75%), coagulopathy in 13 (15%), metabolic failure in 5 (6%), and indeterminate in 3 patients (4%). CONCLUSION: These data indicate that 75% of patients who succumb to postinjury acute blood loss are bleeding because they are dying rather than dying because they are bleeding. Conversely, only 13 (2%) of the hospital deaths were attributed to refractory coagulopathy. These critical facts need to be considered in designing studies to determine optimal massive transfusion protocols.

Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk.

INTRODUCTION: A child's risk of developing cancer from radiation exposure associated with computed tomography (CT) imaging is estimated to be as high as 1/500. Chest CT (CCT), often as part of a "pan-scan," is increasingly performed after blunt trauma in children. We hypothesized that routine CCT for the initial evaluation of blunt injured children does not add clinically useful information beyond chest radiograph (CXR) and rarely changes management. METHODS: Pediatric (<15 y) trauma team evaluations over 6 y at an academic Level I trauma center were reviewed. Demographic data, injuries, imaging, and management were identified for all patients undergoing CT. Effective radiation dose in milliSieverts (mSv) was calculated using age-adjusted scales. RESULTS: Fifty-seven of 174 children (33%) undergoing CT imaging had a CCT; 55 (97%) of these had a CXR. Pathology was identified in significantly fewer CXRs compared with CCTs (51% versus 83%, P < 0.001). All 7/57 (12%) emergent or urgent chest interventions were based on information from CXR. In 53 children (93%), the CCT was ordered as part of a pan-scan, resulting in a radiation dose of 37.69 ± 7.80 mSv from initial CT scans. Radiation dose was significantly greater from CCT than from CXR (8.7 ± 1.1 mSv versus 0.017 ± 0.002 mSv, P < 0.001). CONCLUSIONS: Clinically useful information found on CCT had good correlation to information obtained from CXR and did not change patient management, however, did add significantly to the radiation exposure of initial imaging. We recommend selective use of CCT, particularly in the presence of an abnormal mediastinal silhouette on CXR after a significant deceleration injury.

Natural history and nonoperative management of penetrating cerebrovascular injury.

INTRODUCTION: There is a modern precedent for nonoperative management of select penetrating cerebrovascular injuries (PCVIs); however, there is minimal data to guide management. PATIENTS AND METHODS: This study assessed treatments, radiographic injury progression, and outcomes for all patients with PCVIs managed at an urban Level I trauma center from 2016 to 2021 that underwent initial nonoperative management (NOM). RESULTS: Fourteen patients were included. There were 11,635 trauma admissions, 378 patients with blunt cerebrovascular injury, and 18 patients with operatively-managed PCVI during this timeframe. All patients received antithrombotic therapy, but this was delayed in some due to concomitant injuries. Three patients had stroke (21%): two before antithrombotic initiation, and one with unclear timing relative to treatment. Three patients underwent endovascular interventions. On follow-up imaging, 14% had injury resolution, 36% were stable, 21% worsened, and 29% had no follow-up vascular imaging. One patient died (7%), one had a bleeding complication (7%), and no patient required delayed operative intervention. DISCUSSION: Early initiation of antithrombotic therapy, early surveillance imaging, and selective use of endovascular interventions are important for nonoperative management of PCVI.