Temporal changes in the prehospital management of trauma patients: 2014-2021.

INTRODUCTION: Aggressive prehospital interventions (PHI) in trauma may not improve outcomes compared to prioritizing rapid transport. The aim of this study was to quantify temporal changes in the frequency of PHI performed by EMS. METHODS: Retrospective chart review of adult patients transported by EMS to our trauma center from January 1, 2014 to 12/31/2021. PHI were recorded and annual changes in their frequency were assessed via year-by-year trend analysis and multivariate regression. RESULTS: Between the first and last year of the study period, the frequency of thoracostomy (6% vs. 9%, p â€‹= â€‹0.001), TXA administration (0.3% vs. 33%, p â€‹< â€‹0.001), and whole blood administration (0% vs. 20%, p â€‹< â€‹0.001) increased. Advanced airway procedures (21% vs. 12%, p â€‹< â€‹0.001) and IV fluid administration (57% vs. 36%, p â€‹< â€‹0.001) decreased. ED mortality decreased from 8% to 5% (p â€‹= â€‹0.001) over the study period. On multivariate regression, no PHI were independently associated with increased or decreased ED mortality. CONCLUSION: PHI have changed significantly over the past eight years. However, no PHI were independently associated with increased or decreased ED mortality.

Risk factors associated with early reintubation in trauma patients: a prospective observational study.

BACKGROUND: After mechanical ventilation, extubation failure is associated with poor outcomes and prolonged hospital and intensive care unit (ICU) stays. We hypothesize that specific and unique risk factors exist for failed extubation in trauma patients. The purpose of this study was to identify the risk factors in trauma patients. METHODS: We performed an 18-month (January 2008-June 2009) prospective, cohort study of all adult (8 years or older) trauma patients admitted to the ICU who required mechanical ventilation. Failure of extubation was defined as reintubation within 24 hours of extubation. Patients who failed extubation (failed group) were compared with those who were successfully extubated (successful group) to identify independent risk factors for failed extubation. RESULTS: A total of 276 patients were 38 years old, 76% male, 84% sustained blunt trauma, with an mean Injury Severity Score = 21, Glasgow Coma Scale (GCS) score = 7, and systolic blood pressure = 125 mm Hg. Indications for initial intubation included airway (4%), breathing (13%), circulation (2%), and neurologic disability (81%). A total of 17 patients (6%) failed extubation and failures occurred a mean of 15 hours after extubation. Independent risk factors to fail extubation included spine fracture, airway intubation, GCS at extubation, and delirium tremens. Patients who failed extubation spent more days in the ICU (11 vs. 6, p = 0.006) and hospital (19 vs. 11, p = 0.002). Mortality was 6% (n = 1) in the failed group and 0.4% (n = 1) in the successful extubation group. CONCLUSIONS: Independent risk factors for trauma patients to fail extubation include spine fracture, initial intubation for airway, GCS at extubation, and delirium tremens. Trauma patients with these four risk factors should be observed for 24 hours after extubation, because the mean time to failure was 15 hours. In addition, increased complications, extended need for mechanical ventilation, and prolonged ICU and hospital stays should be expected for trauma patients who fail extubation.

Autologous blood transfusion during emergency trauma operations.

HYPOTHESIS: Intraoperative cell salvage (CS) of shed blood during emergency surgical procedures provides an effective and cost-efficient resuscitation alternative to allogeneic blood transfusion, which is associated with increased morbidity and mortality in trauma patients. DESIGN: Retrospective matched cohort study. SETTING: Level I trauma center. PATIENTS: All adult trauma patients who underwent an emergency operation and received CS as part of their intraoperative resuscitation. The CS group was matched to a no-CS group for age, sex, Injury Severity Score, mechanism of injury, and operation performed. MAIN OUTCOME MEASURES: Amount and cost of allogeneic transfusion of packed red blood cells and plasma. RESULTS: The 47 patients in the CS group were similar to the 47 in the no-CS group for all matched variables. Patients in the CS group received an average of 819 mL of autologous CS blood. The CS group received fewer intraoperative (2 vs 4 U; P = .002) and total (4 vs 8 U; P < .001) units of allogeneic packed red blood cells. The CS group also received fewer total units of plasma (3 vs 5 U; P = .03). The cost of blood product transfusion (including the total cost of CS) was less in the CS group ($1616 vs $2584 per patient; P = .004). CONCLUSION: Intraoperative CS provides an effective and cost-efficient resuscitation strategy as an alternative to allogeneic blood transfusion in trauma patients undergoing emergency operative procedures.