Lower Mortality with Cryoprecipitate During Massive Transfusion in Penetrating but Not Blunt Trauma.

BACKGROUND: Balanced blood product transfusion improves the outcomes of trauma patients with exsanguinating hemorrhage, but it remains unclear whether administering cryoprecipitate improves mortality. We aimed to examine the impact of early cryoprecipitate transfusion on the outcomes of the trauma patients needing massive transfusion (MT). METHODS: All MT patients 18 years or older in the 2017 Trauma Quality Improvement Program (TQIP) were retrospectively reviewed. MT was defined as the transfusion of ≥10 units of blood within 24 hours. Propensity score analysis (PSA) was used to 1:1 match then compare patients who received and those who did not receive cryoprecipitate in the first 4 hours after injury. Outcomes included in-hospital mortality, 1-day mortality, in-hospital complications and transfusion needs at 24 hours. RESULTS: Of 1,004,440 trauma patients, 1,454 MT patients received cryoprecipitate and 2,920 did not. After PSA, 877 patients receiving cryoprecipitate were matched to 877 patients who did not. In-hospital mortality was lower among patients who received cryoprecipitate (49.4% v. 54.9%, P = 0.022), as was 1-day mortality. Sub-analyses showed that mortality was lower with cryoprecipitate in patients with penetrating (37.5% versus. 48%, adjusted P = 0.008), but not blunt trauma (58.5% versus. 59.8%, adjusted P = 1.000). In penetrating trauma, the cryoprecipitate group also had lower 1-day mortality (21.8% versus. 38.6%, P <0.001) and a higher rate of hemorrhage control surgeries performed within 24 hours (71.4% versus. 63.3%, P = 0.018). CONCLUSIONS: Cryoprecipitate in MT is associated with improved survival in penetrating, but not blunt, trauma. Randomized trials are needed to better define the role of cryoprecipitate in MT.

Andexanet Alfa or Prothrombin Complex Concentrate for Factor Xa Inhibitor Reversal in Acute Major Bleeding: A Systematic Review and Meta-Analysis.

OBJECTIVES: To combine evidence on andexanet alfa and prothrombin complex concentrates for factor Xa inhibitor-associated bleeding to guide clinicians on reversal strategies. DATA SOURCES: Embase, Pubmed, Web of Science, and the Cochrane Library. STUDY SELECTION: Observational studies and randomized clinical trials studying hemostatic effectiveness of andexanet alfa or prothrombin complex concentrate for acute reversal of factor Xa inhibitor-associated hemorrhage. DATA EXTRACTION: Two independent reviewers extracted the data from the studies. Visualization and comparison of hemostatic effectiveness using Sarode et al or International Society of Thrombosis and Hemostasis Scientific and Standardization Committee criteria at 12 and 24 hours, (venous) thrombotic event rates, and inhospital mortality were performed by constructing Forest plots. Exploratory analysis using a logistic mixed model analysis was performed to identify factors associated with effectiveness and venous thromboembolic event. DATA SYNTHESIS: A total of 21 studies were included (andexanet: 438 patients; prothrombin complex concentrate: 1,278 patients). The (weighted) mean effectiveness for andexanet alfa was 82% at 12 hours and 71% at 24 hours. The (weighted) mean effectiveness for prothrombin complex concentrate was 88% at 12 hours and 76% at 24 hours. The mean 30-day symptomatic venous thromboembolic event rates were 5.0% for andexanet alfa and 1.9% for prothrombin complex concentrate. The mean 30-day total thrombotic event rates for andexanet alfa and prothrombin complex concentrate were 10.7% and 3.1%, respectively. Mean inhospital mortality was 23.3% for andexanet versus 15.8% for prothrombin complex concentrate. Exploratory analysis controlling for potential confounders did not demonstrate significant differences between both reversal agents. CONCLUSIONS: Currently, available evidence does not unequivocally support the clinical effectiveness of andexanet alfa or prothrombin complex concentrate to reverse factor Xa inhibitor-associated acute major bleeding, nor does it permit conventional meta-analysis of potential superiority. Neither reversal agent was significantly associated with increased effectiveness or a higher rate of venous thromboembolic event. These results underscore the importance of randomized controlled trials comparing the two reversal agents and may provide guidance in designing institutional guidelines.

Direct Oral Anticoagulants Are a Potential Alternative to Low-Molecular-Weight Heparin for Thromboprophylaxis in Trauma Patients Sustaining Lower Extremity Fractures.

BACKGROUND: Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Use of direct oral anticoagusants (DOACs) for VTE prophylaxis is effective in elective orthopedic surgery, but currently not approved for trauma patients. The primary objective of this study was to compare the effectiveness and safety of thromboprophylaxis of DOACs with low-molecular-weight heparin (LMWH) in trauma patients sustaining LEF. MATERIALS AND METHODS: We included adult trauma patients admitted to trauma quality improvement program participating trauma centers (between 2013 and 2016), who sustained LEF and were started on DOACs or LMWH for thromboprophylaxis after admission. Propensity score matching was performed to compare symptomatic VTE and bleeding control interventions between the groups. RESULTS: Of 1,009,922 patients in trauma quality improvement program, 167,640 met inclusion criteria (165,009 received LMWH and 2631 received DOACs). After propensity score matching, 2280 predominantly elderly (median age: 67 y) isolated femur fracture patients (median ISS: 10) were included in each group (4560 patients in total). Symptomatic VTE occurred in 1.4% of patients in both matched groups (P = 0.992). Bleeding control interventions occurred less often in the DOAC group, albeit statistically insignificant (5.8% versus 6.0%, P = 0.772). CONCLUSIONS: This study found similar rates of VTE and bleeding control measures for thromboprophylaxis with DOACs or LMWH in matched trauma patients with LEF. Further prospective research is warranted to consolidate the safety of DOAC thromboprophylaxis in trauma patients with LEF. Favorable oral administration and likely increased adherence could benefit this high-risk population.

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility.

BACKGROUND: Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS: Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS: Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS: The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

Equivalence of DOACS and LMWH for thromboprophylaxis after hip fracture surgery: Systematic review and meta-analysis.

BACKGROUND: Patients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF. MATERIALS AND METHODS: We searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH. RESULTS: The search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25-1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding. CONCLUSIONS: Meta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH.

[Regulated market failure in healthcare; quality comparisons can improve competition in the Dutch healthcare market]. / Gereguleerd marktfalen in de zorg.

Competition in healthcare markets is controversial, as financial interests may negatively influence patient interests. In The Netherlands, public healthcare quality indicators are published annually, but no comparisons are made between hospitals and private healthcare facilities (PHF) operating in the Dutch healthcare market. Just nine such indicators could be compared, demonstrating an overall equivalence of success and complication rates. It is known that PHFs treat healthier patients, and as such their quality of care may in fact be lower. However, without casemix information, no conclusions on healthcare quality can be drawn from the Dutch experiment with regulated competition in the healthcare market. This lack of full, transparent information is a cause of market failure, but can be improved by implementing quality comparisons using routinely collected casemix variables.

Critically Appraising the Quality of Reporting of American College of Surgeons TQIP Studies in the Era of Large Data Research.

BACKGROUND: The American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database is one of the most widely used databases for trauma research. We aimed to critically appraise the quality of the methodological reporting of ACS-TQIP studies. STUDY DESIGN: The ACS-TQIP bibliography was queried for all studies published between January 2018 and January 2021. The quality of data reporting was assessed using the Strengthening the Reporting of Observational studies in Epidemiology-Reporting of Studies Conducted Using Observational Routinely Collected Health Data (STROBE-RECORD) statement and the JAMA Surgery checklist. Three items from each tool were not applicable and thus excluded. The quality of reporting was compared between high- and low-impact factor (IF) journals (cutoff for high IF is >90th percentile of all surgical journals). RESULTS: A total of 118 eligible studies were included; 12 (10%) were published in high-IF journals. The median (interquartile range) number of criteria fulfilled was 5 (4-6) for the STROBE-RECORD statement (of 10 items) and 5 (5-6) for the JAMA Surgery checklist (of 7 items). Specifically, 73% of studies did not describe the patient population selection process, 61% did not address data cleaning or the implications of missing values, and 76% did not properly state inclusion/exclusion criteria and/or outcome variables. Studies published in high-IF journals had remarkably higher quality of reporting than those in low-IF journals. CONCLUSION: The methodological reporting quality of ACS-TQIP studies remains suboptimal. Future efforts should focus on improving adherence to standard reporting guidelines to mitigate potential bias and improve the reproducibility of published studies.

Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls.

INTRODUCTION: Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. METHODS: We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. RESULTS: A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15-0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36-7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15-2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06-1.87) compared to controls. CONCLUSION: Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.

Do not forget the platelets: The independent impact of red blood cell to platelet ratio on mortality in massively transfused trauma patients.

BACKGROUND: Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion. METHODS: Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality. RESULTS: A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT >2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP >2 (1,160 [12.6%]) (p < 0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p < 0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18-2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74-4.24]). CONCLUSION: Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Development of a field artificial intelligence triage tool: Confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds.

BACKGROUND: In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury. METHODS: Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables. RESULTS: A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery. CONCLUSION: Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings. LEVEL OF EVIDENCE: Prognostic, Level III.

Bilateral internal iliac artery embolization for pelvic trauma: Effectiveness and safety.

INTRODUCTION: Bilateral internal iliac artery embolization (BIIAE) with temporary embolic materials epitomizes damage-control principles in the treatment of exsanguinating hemorrhage from pelvic trauma. However, instances of ischemic complications have been reported. The aim of our study was to assess safety and effectiveness of BIIAE. METHODS: All patients who received BIIAE for pelvic trauma at a Level I Trauma Center between 1998 and 2018 were reviewed. Effectiveness was assessed by radiographic bleeding control and clinical bleeding control, i.e. stabilization of vital signs and reduction in blood transfusion. Safety was assessed by any evidence for ischemic damage of pelvic organs or tissues. RESULTS: Of 61 patients undergoing BIIAE, bleeding control was confirmed radiographically in 60 (98%) and clinically in 55 (90%), including 4 (7%) patients who required repeat embolization. Six (10%) patients died due to insufficient pelvic bleeding control. No BIIAE-related complications were identified. CONCLUSION: The overall clinical effectiveness and safety rates of BIIAE for pelvic bleeding control, when combined with other methods of hemostasis, were 90% and 100% respectively.

Evaluation of oral factor Xa inhibitor-associated extracranial bleeding reversal with andexanet alfa.

INTRODUCTION: A reversal agent for factor Xa (FXa) inhibitors, andexanet alfa, was Food and Drug Administration approved without extensive study of clinical effectiveness, due to an overwhelming demand for FXa inhibitor reversal. In this study, we aimed to describe patient selection, clinical effectiveness, and safety of FXa inhibitor reversal with andexanet alfa in patients presenting with extracranial bleeding. METHODS: Consecutive patients who received andexanet alfa for reversal of FXa inhibitor-associated extracranial hemorrhage were identified. The primary outcome of interest was hemostatic efficacy, assessed using the Sarode et al criteria. Secondary outcomes of interest included incidence of thrombotic episodes post-reversal until discharge and in-hospital mortality. RESULTS: Twenty-one patients met the inclusion criteria (61.9% male, mean age: 73 years). Anticoagulation reversal with andexanet alfa was deemed effective (excellent [n = 3], good [n = 7]) in 10 (47.6%) patients, and poor in 11 patients (52.4%). Eight (38.1%) patients died, of which three were surgically managed, with all causes of death attributed to hemorrhage. Six ischemic complications occurred in four patients (19.0%); ischemic stroke (n = 2], pulmonary embolism (n = 1), deep vein thrombosis (n = 1), liver ischemia (n = 1), and bowel ischemia (n = 1). CONCLUSION: We report poor overall outcomes, a low rate of hemostatic effectiveness, and a high rate of ischemic complications and mortality in this retrospective analysis of oral FXa inhibitor reversal with andexanet alfa for extracranial bleeds. More rigorous epidemiological, and ideally randomized studies, are needed to determine the role of andexanet alfa for FXa inhibitor-associated bleeding for extracranial hemorrhages, where large variation in severity and presentation exists.

The dose-dependent relationship between blood transfusions and infections after trauma: A population-based study.

OBJECTIVE: The relationship between total transfusion volume and infection in the trauma patient remains unclear, especially at lower volumes of transfusion. We sought to quantify the cumulative, independent impact of transfusion within 24 hours of admission on the risk of infection in trauma patients. METHODS: Using the Trauma Quality Improvement Program 2013 to 2016 database, we included all patients who received blood transfusions in the first 4 hours. Patients who were transferred or had incomplete/wrongly coded information on transfusion volume were excluded. Patients were divided into 20 cohorts based on the total blood product volume transfused in the first 24 hours. A composite infection variable (INF) was created, including surgical site infection, ventilator-associated pneumonia, urinary tract infection, central line associated blood stream infection, and sepsis. Univariate and stepwise multivariable logistic regression analyses were performed to study the relationship between blood transfusion and INF, controlling for demographics (e.g., age, sex), comorbidities (e.g., cirrhosis, diabetes, steroid use), severity of injury (e.g., vital signs on arrival, mechanism, Injury Severity Score), and operative and angiographic interventions. RESULTS: Of 1,002,595 patients, 37,568 were included. The mean age was 42 ± 18.6 years, 74.6% were males, 68% had blunt trauma, and median Injury Severity Score was 25 [17-34]. Adjusting for all available confounders, odds of INF increased incrementally from 1.00 (reference, 0-2 units) to 1.23 (95% confidence interval, 1.11-1.37) for 4 units transfused to 4.89 (95% confidence interval, 2.72-8.80) for 40 units transfused. Each additional unit increased the odds of INF by 7.6%. CONCLUSION: Transfusion of the bleeding trauma patient was associated with a dose-dependent increased risk of infectious complications. Trauma surgeons and anesthesiologists should resuscitate the trauma patient until prompt hemorrhage control while avoiding overtransfusion. LEVEL OF EVIDENCE: Retrospective cohort study, Therapeutic IV.

Fresh Frozen Plasma-to-Packed Red Blood Cell Ratio and Mortality in Traumatic Hemorrhage: Nationwide Analysis of 4,427 Patients.

BACKGROUND: Despite the presence of highly reliable data, studies on packed red blood cells (pRBC):fresh frozen plasma (FFP) ratio suffer from limited sample size and the presence of survivor bias. We sought to study the association between FFP:pRBC and early mortality in the hemorrhaging trauma patient. STUDY DESIGN: This was a retrospective nationwide cohort that included all TQIP participating hospitals (2013 to 2016). We included all trauma patients who were transfused ≥10 pRBCs and ≥1 FFP within 24 hours. We excluded transferred patients and those who died in the emergency department or had missing/inaccurate transfusion data. Patients were assigned to 7 FFP:pRBC cohorts (range 1:1 to 1:6, and 1:6+) only if the ratio was similar at 4 and 24 hours and, to avoid survival bias, were excluded otherwise. Multivariable analyses correcting for all available confounders (age, demographics, comorbidities, vital signs, Injury Severity Score [ISS] and mechanism, procedures performed) were derived to study the independent relationship between FFP:pRBC and 24-hour mortality. RESULTS: Of 1,002,595 patients, 4,427 patients were included. Mean age was 41 years, 79% were males, 61% had blunt trauma, and median ISS was 29. Most patients were transfused in a 1:1, 1:2, or 1:3 ratio (31%, 41%, and 11%, respectively); mortality ranged between 28% for 1:1 and 62% for 1:4. In multivariable analyses, the odds of mortality independently and incrementally increased to 1.23 (95% CI 1.02 to 1.48) for a 1:2 ratio, 2.11 (95% CI 1.42 to 3.13) for 1:4, and as high as 4.11 (95% CI 2.31 to 7.31) for 1:5 (all p < 0.05). CONCLUSIONS: A 1:1 FFP:pRBC ratio is associated with the lowest mortality in the hemorrhaging trauma patient, and mortality increases with decreasing ratios.

Consequences of pre-injury utilization of direct oral anticoagulants in patients with traumatic brain injury: A systematic review and meta-analysis.

BACKGROUND: The rapid adoption and widespread use of direct oral anticoagulants (DOACs) has outpaced research efforts to establish their effects in bleeding trauma patients. In patients with complicated traumatic brain injury (TBI) caused by intracranial hemorrhage, DOAC use may be associated with higher bleeding volume and potentially more disastrous sequelae than use of vitamin K antagonists (VKAs). In the current systematic review and meta-analysis we set out to evaluate the literature on the relationship between preinjury DOAC use and course of the intracranial hemorrhage. (ICH), its treatment and mortality rates in TBI patients, and to compare these outcomes to those of patients with preinjury VKA use. METHODS: PubMed, Embase, Web of Science, and the Cochrane Library were searched using a search strategy including three main terms: "traumatic brain injury," "direct oral anticoagulants," and "vitamin K antagonists." There were 1,446 abstracts screened, and ultimately, six included articles. Random effects modeling meta-analysis was performed on in-hospital mortality, ICH progression and neurosurgical intervention rate. RESULTS: All cohorts had similar baseline and emergency department parameters. Within individual studies surgery rate, reversal agents used, ICH progression and in-hospital mortality differed significantly between DOAC and VKA cohorts. Meta-analysis showed no significant difference in in-hospital mortality (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.23-4.06; I = 76%; p = 0.97), neurosurgical interventions (OR, 0.48; 95% CI, 0.14-1.63; p = 0.24), or ICH progression rates (OR, 1.86; 95% CI, 0.32-10.66; p = 0.49) between patients that used preinjury DOACs versus patients that used VKAs. CONCLUSION: Direct oral anticoagulant-using mild TBI patients do not appear to be at an increased risk of in-hospital mortality, nor of increased ICH progression or surgery rates, compared with those taking VKAs. LEVEL OF EVIDENCE: Systematic review, level III.

Trauma systems around the world: A systematic overview.

BACKGROUND: Implementation of trauma care systems has resulted in improved patient outcomes, but international differences obviously remain. Improvement of care can only be established if we recognize and clarify these differences. The aim of the current review is to provide an overview of the recent literature on the state of trauma systems globally. METHODS: The literature review over the period 2000 to 2016 was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Prehospital care, acute hospital care and quality assurance were classified using the World Health Organization Trauma System Maturity Index in four levels from I (least mature) to IV (most mature). RESULTS: The search yielded 93 articles about trauma systems in 32 countries: 23 high-income (HI), 8 middle-income (MI) countries and 1 low-income (LI) country. Trauma-related mortality was highest in the MI and LI countries. Level IV prehospital care with Advanced Life Support was established in 19 HI countries, in contrast to the MI and LI countries where this was only reported in Brazil, China, and Turkey. In 18 HI countries, a Level III/IV hospital-based trauma system was implemented, whereas in nine LI- and MI countries Level I/II trauma systems were seen, mostly lacking dedicated trauma centers and teams. A national trauma registry was implemented in 10 HI countries. CONCLUSION: Despite the presence of seemingly sufficient resources and the evidence-based benefits of trauma systems, only nine of the 23 HI countries in our review have a well-defined and documented national trauma system. Although 90% of all lethal traumatic injuries occur in middle and LI countries, according to literature which our study is limited to, only few of these countries a hold formal trauma system or trauma registry. Much can be gained concerning trauma systems in these countries, but unfortunately, the economic situation of many countries may render trauma systems not at their top priority list. LEVEL OF EVIDENCE: Systematic review, level III.