The effects of prehospital TXA on mortality and neurologic outcomes in patients with traumatic intracranial hemorrhage: a subgroup analysis from the prehospital TXA for TBI trial.

BACKGROUND: In the Prehospital Tranexamic Acid (TXA) for TBI Trial, TXA administered within two hours of injury in the out-of-hospital setting did not reduce mortality in all patients with moderate/severe traumatic brain injury (TBI). We examined the association between TXA dosing arms, neurologic outcome, and mortality in patients with intracranial hemorrhage (ICH) on computed tomography (CT). METHODS: This was a secondary analysis of the Prehospital Tranexamic Acid for TBI Trial (ClinicalTrials.gov [NCT01990768]) that randomized adults with moderate/severe TBI (Glasgow Coma Scale<13) and systolic blood pressure > =90 mmHg within two hours of injury to a 2-gram out-of-hospital TXA bolus followed by an in-hospital saline infusion, a 1-gram out-of-hospital TXA bolus/1-gram in-hospital TXA infusion, or an out-of-hospital saline bolus/in-hospital saline infusion (placebo). This analysis included the subgroup with ICH on initial CT. Primary outcomes included 28-day mortality, 6-month Glasgow Outcome Scale-Extended (GOSE) < = 4, and 6-month Disability Rating Scale (DRS). Outcomes were modeled using linear regression with robust standard errors. RESULTS: The primary trial included 966 patients. Among 541 participants with ICH, 28-day mortality was lower in the 2-gram TXA bolus group (17%) compared to the other two groups (1-gram bolus/1-gram infusion 26%, placebo 27%). The estimated adjusted difference between the 2-gram bolus and placebo groups was -8·5 percentage points (95% CI, -15.9 to -1.0) and between the 2-gram bolus and 1-gram bolus/1-gram infusion groups was -10.2 percentage points (95% CI, -17.6 to -2.9). DRS at 6 months was lower in the 2-gram TXA bolus group than the 1-gram bolus/1-gram infusion (estimated difference -2.1 [95% CI, -4.2 to -0.02]) and placebo groups (-2.2 [95% CI, -4.3, -0.2]). Six-month GOSE did not differ among groups. CONCLUSIONS: A 2-gram out-of-hospital TXA bolus in patients with moderate/severe TBI and ICH resulted in lower 28-day mortality and lower 6-month DRS than placebo and standard TXA dosing. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level II.

Safer neighborhoods? Violent crime and trauma volume pre/post targeted police interventions in Dallas, Texas.

BACKGROUND: Project Safe Neighborhoods: Dallas (PSND) is part of a national initiative that partners federal, state, and local stakeholders and law enforcement to reduce violent crime, especially firearm violence, in select communities. The authors' hospital is located centrally in PSND's target areas, and the trauma center's service area fully covers the target areas. This cohort study evaluated PSND's effectiveness by examining if PSND's April 2018 launch was associated with decreases in (1) violent crime or (2) the rate of patients presenting with firearm and assaultive injuries. METHODS: Data on violent crime (murder/non-negligent homicide, robbery, and aggravated assault) were obtained from all municipalities in the county for January 2015 - December 2020. Patient volume data were queried from the trauma registry for the same period. Nonlinear spatiotemporal models were used to calculate estimated rates and confidence intervals; derivatives were used to determine periods of significant change. Spatial point pattern tests assessed potential relocation of criminal activity. Given the importance of reducing violent crime, alpha was set at 0.05. RESULTS: The target areas' violent crime rate remained higher than the non-target areas' throughout the study period, and target area violent crime non-significantly increased after PSND's launch. Violent crime in the non-target area increased significantly between February 2018 and February 2019. Part of this increase was attributable to a 7-fold increase (odds ratio [95% confidence interval] = 7.32 [2.58, 30.65], p < 0.001) in one police patrol beat just outside of the target areas. After years of decreases, rates of patients presenting with assaultive injuries or firearm injuries began significantly increasing and nearly doubled within two years of PSND. CONCLUSIONS: Results suggest PSND was ineffective. Criminal activity in the target area was not reduced relative to its pre-intervention levels or relative to the non-target areas. Offenders may have moved outside the target areas to evade increased scrutiny. Additionally, rates of firearm and assaultive injuries increased. As trusted third parties, trauma centers should consider evaluating local crime and injury prevention programs for effectiveness.

Role of Serial Phlebotomy in the Management of Blunt Solid Organ Injury in Adults.

BACKGROUND: The management of blunt spleen and liver trauma has become increasingly nonoperative. There is no consensus on timing or duration of serial hemoglobin and hematocrit monitoring in this patient population. OBJECTIVE: This study examined the clinical utility of serial hemoglobin and hematocrit monitoring. We hypothesized that most interventions occur early in the hospital course, based on hemodynamic instability or physical examination findings rather than serial monitoring. METHODS: We conducted a retrospective cohort study of adult trauma patients with blunt spleen or liver injury from November 2014 through June 2019 at our Level II trauma center. Interventions were classified as no intervention, surgical intervention, angioembolization, or packed red blood cell transfusion. Demographics, length of stay, total blood draws, laboratory values, and clinical triggers preceding intervention were reviewed. RESULTS: A total of 143 patients were studied, of whom 73 (51%) received no intervention, 47 (33%) received an intervention within 4 hr of presentation, and 23 (16%) had interventions beyond 4 hr. Of these 23 patients, 13 received an intervention based on phlebotomy results alone. Most of these patients (n = 12, 92%) received blood transfusion without further intervention. Only one patient underwent operative intervention based on serial hemoglobin results on hospital day 2. CONCLUSION: The majority of patients with these injury patterns either require no intervention or declare themselves promptly after arrival. Serial phlebotomy after initial triage and intervention may add little value in the management of blunt solid organ injury.

Tranexamic acid administration in the field does not affect admission thromboelastography after traumatic brain injury.

BACKGROUND: No Food and Drug Administration-approved medication improves outcomes following traumatic brain injury (TBI). A forthcoming clinical trial that evaluated the effects of two prehospital tranexamic acid (TXA) dosing strategies compared with placebo demonstrated no differences in thromboelastography (TEG) values. We proposed to explore the impact of TXA on markers of coagulation and fibrinolysis in patients with moderate to severe TBI. METHODS: Data were extracted from a placebo-controlled clinical trial in which patients 15 years or older with TBI (Glasgow Coma Scale, 3-12) and systolic blood pressure of ≥90 mm Hg were randomized prehospital to receive placebo bolus/placebo infusion (placebo), 1 g of TXA bolus/1 g of TXA infusion (bolus maintenance), or 2 g of TXA bolus/placebo infusion (bolus only). Thromboelastography was performed, and coagulation measures including prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, D-dimer, plasmin-antiplasmin (PAP), thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were quantified at admission and 6 hours later. RESULTS: Of 966 patients receiving study drug, 700 had laboratory tests drawn at admission and 6 hours later. There were no statistically significant differences in TEG values, including LY30, between groups (p > 0.05). No differences between prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were demonstrated across treatment groups. Concentrations of D-dimer in TXA treatment groups were less than placebo at 6 hours (p < 0.001). Concentrations of PAP in TXA treatment groups were less than placebo on admission (p < 0.001) and 6 hours (p = 0.02). No differences in D-dimer and PAP were observed between bolus maintenance and bolus only. CONCLUSION: While D-dimer and PAP levels reflect a lower degree of fibrinolysis following prehospital administration of TXA when compared with placebo in a large prehospital trial of patients with TBI, TEG obtained on admission and 6 hours later did not demonstrate any differences in fibrinolysis between the two TXA dosing regimens and placebo. LEVEL OF EVIDENCE: Diagnostic test, level III.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. Design, Setting, and Participants: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). Main Outcomes and Measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. Results: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16). Conclusions and Relevance: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. Trial Registration: ClinicalTrials.gov Identifier: NCT01990768.

Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multi-institutional study of 720 patients.

BACKGROUND: Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality. METHODS: We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome. RESULTS: From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001). CONCLUSION: GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Mucormycosis: a rare fungal infection in tornado victims.

This article reviews four immunocompetent patients who developed a rare fungal infection, mucormycosis, secondary to multiple traumatic injuries sustained during an EF-5 tornado in Joplin, MO. Commonly found in soil and decaying organic matter, mucorales are fungi associated with soft tissue and cutaneous infections. Onset of this fungal infection can occur without clinical signs, presenting several days to several weeks after injury, delaying diagnosis. A multidisciplinary treatment approach including aggressive antifungal therapy and aggressive surgical debridement is critical. This diagnosis should be considered in all patients presenting with injuries sustained from high-velocity embedment of debris such as natural disasters or explosions. We present four cases of mucormycosis, species Apophysomyces trapeziformis. Data reported includes predisposing factors, number of days between injury and diagnosis of mucormycosis, surgical treatment, antifungal therapy, outcomes, and potential risk factors that may have contributed to the development of mucormycosis.

Pneumomediastinum in the injured patient: inconsequential or predictive?

Free air in the peritoneum is a portent of significant pathology in the patient with abdominal trauma. The finding of a pneumomediastinum (PM) on a thoracic computed tomography scan (CT) of a trauma patient is, however, not clinically well-defined. The objectives of this study were to evaluate the incidence, pattern, and outcome of CT-diagnosed PM in a cohort of injured patients. The trauma registry and radiology reports were reviewed retrospectively for all injured patients admitted over an 8-year period to determine the incidence of PM. Medical and radiological records of patients with a PM on thoracic CT were then reviewed to determine the pattern and outcome of the injuries. There were 1364 thoracic CTs performed in the study-period. The prevalence of PM was 5.2 per cent (71/1364). For the cohort of patients with a PM, the mean age was 34.8 years, and 14.7 per cent (10/68) had penetrating injuries. Of these 68 patients, 10.3 per cent (7/68) presented with nine clinically significant injuries to the esophagus, trachea, larynx, or bronchus. These injuries were suspected clinically by an associated open wound or significant symptoms, and only 5.8 per cent of (4/68) patients required surgical repair. The remaining 89.7 per cent (61/68) of patients with a PM did not develop any sequelae nor require further directed treatment. A finding of a pneumomediastinum on a thoracic CT in injured patients is rare and clinically nonspecific. Pneumomediastinum alone does not seem to be predictive of severe injury and warrants detailed investigation only when clinical symptoms are present.

Acetabular and isolated pelvic ring fractures: a comparison of initial assessment and outcome.

The purpose of this study was to describe the comparative outcomes of patients with pelvic ring fractures, acetabular fractures, and combinations of the same. Patients with pelvic or acetabular fractures were identified in the Hospital Trauma Registry, and all appropriate data were collected by reviewing the patients' medical records, the hospital operative logs, transfusion records, and the records of surgical morbidity conferences. Patient management was consistent over the time period of the study. Univariate analysis of continuous variables was done using Student's t test; and categorical variables were analyzed with X2 analysis. All statistical analysis was performed using JMP software (SAS International Inc., Cary, NC) with significance set at P < 0.05. One thousand, three hundred and thirty-four patients with 320 acetabular, 826 pelvic ring, and 188 combination fractures over 10 years were analyzed. Age, race, and gender were typical of trauma patients and similar amongst groups. Injury Severity Score was significantly higher (21.3 vs 12.9, P < 0.05) and Glasgow Coma Scale was significantly lower (12.5 vs 13.6, P < 0.05) in patients with pelvic ring fractures as compared with acetabular fractures. Hypotension was more common in patients with pelvic ring fractures (13.9% vs 5.3%, P < 0.05). Patients with pelvic ring fractures required more blood transfusions (3.83 vs 1.36, P < 0.05) and base deficit was lower (-6.7 vs -5.5, P = 0.03). Mortality was significantly higher among patients with pelvic ring fractures (16.5% vs 5.6%, P < 0.01). Among survivors, hospital length of stay (LOS) (18.7 vs 14.8 days, P = 0.08) and intensive care unit LOS (7.8 vs 4.7 days, P = 0.008) were significantly longer with pelvic ring fractures. Functional Independence Measurement scores trended to a higher functional outcome in patients with acetabular fractures (10.3 vs 10.0, P = 0.08). Patients with pelvic ring fractures have a worse admission base deficit, higher transfusion requirements, and increased hypotension on admission. This is reflected in their significantly higher mortality and longer hospital and intensive care unit LOS in survivors. Such clinical information is helpful when caring for patients with acetabular vs pelvic ring fractures.

Effect of DHEA on the hemodynamic response to resuscitation in a porcine model of hemorrhagic shock.

BACKGROUND: Hemorrhagic shock is a major cause of death from trauma. Pharmacologic treatment has not been satisfactory. The objective of this study was to use a porcine model of hemorrhagic shock and resuscitation to access the hemodynamic effects of dehydroepiandrosterone (DHEA), an adrenal steroid hormone reported to improve cardiac function in patients. METHODS: Hemorrhagic shock was produced in 20- to 30-kg male Yorkshire pigs anesthetized with 2% isoflurane by withdrawing blood through a carotid cannula to a mean arterial pressure (MAP) of 40 to 45 mm Hg and maintaining that level for 60 minutes by further removals of blood. Resuscitation was with 21 mL/kg Ringer's lactate (LR), with (n = 6) or without (n = 6) DHEA (4 mg/kg) dissolved in propylene glycol. The animals were killed after 7 days. Continuous cardiac output (CCO) was recorded using a modified Swan-Ganz catheter system. MAP, heart rate (HR), central venous pressure (CVP), and pulmonary arterial pressure (PAP) were measured every 5 minutes until 60 minutes postresuscitation. From MAP, CCO, HR, and CVP, we calculated total peripheral resistance (TPR), stroke volume (SV), and left ventricular stroke work (SW). RESULTS: The MAP, CCO, SV, and SW decreased significantly during hemorrhagic shock, and then gradually increased to baseline levels during and 1 hour after resuscitation. The TPR was increased during hemorrhagic shock, and then gradually decreased to baseline levels during and after resuscitation. DHEA administration was associated with no significant improvement. CONCLUSION: DHEA when added to standard fluid resuscitation showed no added benefit as resumed by the hemodynamic response.