A survey of low titer O whole blood use within the trauma quality improvement program registry.

INTRODUCTION: The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB. METHODS: We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period. RESULTS: A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively. CONCLUSIONS: There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.

Novel method for determining when a field-collected donor unit is sufficiently full.

BACKGROUND: Whole blood (WB) collections can occur downrange for immediate administration. An important aspect of these collections is determining when the unit is sufficiently full. This project tested a novel method for determining when a field collection is complete. METHODS: The amount of empty space at the top of WB units, destined to become LTOWB or separated into components, that were collected at blood centers or hospitals was measured by holding a WB unit off the ground and placing the top of a piece of string where the donor tubing entered the bag. The string was marked where it intersected the top of the column of blood in the bag and measured from the top. The WB units were also weighed. RESULTS: A total of 15 different bags, two of which were measured in two different filling volumes, from 15 hospitals or blood centers were measured and weighed. The most commonly used blood bag, Terumo Imuflex SP, had a median string length of 9 mm (range: 2-24 mm) and weighed a median of 565.1 g (range: 524.8-636.7 g). CONCLUSION: Pieces of string can be precut to the appropriate length depending on the type of bag before a mission where field WB collections might be required and a mark placed on the bag before the collection commences to indicate when the unit is full.

MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma.

INTRODUCTION: One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma. METHODS: A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed. RESULTS: Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA. CONCLUSIONS: Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries.

Body Mass Index Does Not Predict Injury Pattern or Outcome After Motorcycle Crash.

INTRODUCTION: The obesity epidemic plagues the United States, affecting approximately 42% of the population. The relationship of obesity with injury severity and outcomes has been poorly studied among motorcycle collisions (MCC). This study aimed to compare injury severity, mortality, injury regions, and hospital and intensive care unit length of stay (LOS) between obese and normal-weight MCC patients. METHODS: Trauma registries from three Pennsylvania Level 1 trauma centers were queried for adult MCC patients (January 1, 2016, and December 31, 2020). Obesity was defined as adult patients with body mass index ≥ 30 kg/m2 and normal weight was defined as body mass index < 30 kg/m2 but > 18.5 kg/m2. Demographics and injury characteristics including injury severity score (ISS), abbreviated injury score, mortality, transfusions and LOS were compared. P ≤ 0.05 was considered significant. RESULTS: One thousand one hundred sixty-four patients met the inclusion criteria: 40% obese (n = 463) and 60% nonobese (n = 701). Comparison of ISS demonstrated no statistically significant difference between obese and normal-weight patients with median ISS (interquartile range) 9 (5-14) versus 9 (5-14), respectively (P = 0.29). Obese patients were older with median age 45 (32-55) y versus 38 (26-54) y, respectively (P < 0.01). Comorbidities were equally distributed among both groups except for the incidence of hypertension (30 versus 13.8%, P < 0.01) and diabetes (11 versus 4.4%, P < 0.01). There was no statistically significant difference in Trauma Injury Severity Score or abbreviated injury score. Hospital LOS, intensive care unit LOS, and 30-day mortality among both groups were similar. CONCLUSIONS: Obese patients experiencing MCC had no differences in distribution of injury, mortality, or injury severity, mortality, injury regions, and hospital compared to normal-weight adults. Our study differs from current data that obese motorcycle drivers may have different injury characteristics and increased LOS.

Geriatric Motorcycle-Related Outcomes: A Pennsylvania Multicenter Study.

INTRODUCTION: Geriatric patients (GeP) often experience increased morbidity and mortality following traumatic insult and as a result, require more specialized care due to lower physiologic reserve and underlying medical comorbidities. Motorcycle injuries (MCCI) occur across all age groups; however, no large-scale studies evaluating outcomes of GeP exist for this particular subset of patients. Data thus far are limited to elderly participation in recreational activities such as water and alpine skiing, snowboarding, equestrian, snowmobiles, bicycles, and all-terrain vehicles. We hypothesized that GeP with MCCI will have a higher rate of mortality when compared with their younger counterparts despite increased helmet usage. METHODS: We performed a multicenter retrospective review of MCCI patients at three Pennsylvania level I trauma centers from January 2016 to December 2020. Data were extracted from each institution's electronic medical records and trauma registry. GeP were defined as patients aged more than or equal to 65 y. The primary outcome was mortality. Secondary outcomes included ventilator days; hospital, intensive care unit, and intermediate unit length of stays; complications; and helmet use. 3:1 nongeriatric patients (NGeP) to GeP propensity score matching (PSM) was based on sex, abbreviated injury scale (AIS), and injury severity score (ISS). P ≤ 0.05 was considered significant. RESULTS: One thousand five hundred thirty eight patients were included (GeP: 7% [n = 113]; NGP: 93% [n = 1425]). Prior to PSM, GeP had higher median Charlson Comorbidity Index (GeP: 3.0 versus NGeP: 0.0; P ≤ 0.001) and greater helmet usage (GeP: 73.5% versus NGeP: 54.6%; P = 0.001). There was a statistically significant difference between age cohorts in terms of ISS (GeP: 10.0 versus NGeP: 6.0, P = 0.43). There was no significant difference for any AIS body region. Mortality rates were similar between groups (GeP: 1.7% versus NGeP: 2.6%; P = 0.99). After PSM matching for sex, AIS, and ISS, GeP had significantly more comorbidities than NGeP (P ≤ 0.05). There was no difference in trauma bay interventions or complications between cohorts. Mortality rates were similar (GeP: 1.8% versus NGeP: 3.2%; P = 0.417). Differences in ventilator days as well as intensive care unit length of stay, intermediate unit length of stay, and hospital length of stay were negligible. Helmet usage between groups were similar (GeP: 64.5% versus NGeP: 66.8%; P = 0.649). CONCLUSIONS: After matching for sex, ISS, and AIS, age more than 65 y was not associated with increased mortality following MCCI. There was also no significant difference in helmet use between groups. Further studies are needed to investigate the effects of other potential risk factors in the aging patient, such as frailty and anticoagulation use, before any recommendations regarding management of motorcycle-related injuries in GeP can be made.

Risk factors for massive transfusion in obstetrical hemorrhage and consideration of a whole blood program.

BACKGROUND: Postpartum hemorrhage (PPH) is one of the leading causes of obstetric complications. The goal of this study was to identify risk factors for obstetric (OB) massive transfusion (MT) and determine the feasibility of developing a low-titer group O RhD-positive whole blood (LTO + WB) protocol for OB hemorrhage. STUDY DESIGN AND METHODS: A retrospective study of OB patients who received transfusion within 24 h. MT patients were those who received >3 U of pRBC within 1 h or > 10 U in 24 h. Patient demographics, OB history, comorbidities, blood type, antibody status, and known risk factors for PPH and maternal-fetal outcomes were compared. Logistic regression was used for univariate and multivariate analyses. RESULTS: Of the 610 transfused OB patients, 12.0% (n = 73) required MT. Groups were well matched for body mass index (BMI), maternal comorbidities, and history of spontaneous vaginal deliveries. The incidence of the previous cesarean section was higher in the MT group. Exactly 93.9% of patients were RhD-positive and 3.77% of all patients possessed an antibody on pretransfusion testing. Patients with MT had a longer length of stay (LOS), higher rate of intensive care unit (ICU) admission, fetal death, and hysterectomy. Multivariate analysis found age >35, PPH, placenta percreta, accreta, and increta to be significant (p < .05) risk factors for MT. DISCUSSION: Patients over 35 years and those with abnormal placentation are at increased risk of requiring MT. With a time to delivery of 2 days, potential MT patients can be identified early, and with a 94% rate of RhD-positive+, they are eligible to receive low-titer O whole blood (LTOWB) providing hemostatic resuscitation with reduced donor exposure.

Use of Cold-Stored Whole Blood is Associated With Improved Mortality in Hemostatic Resuscitation of Major Bleeding: A Multicenter Study.

OBJECTIVE: The aim of this study was to identify a mortality benefit with the use of whole blood (WB) as part of the resuscitation of bleeding trauma patients. BACKGROUND: Blood component therapy (BCT) is the current standard for resuscitating trauma patients, with WB emerging as the blood product of choice. We hypothesized that the use of WB versus BCT alone would result in decreased mortality. METHODS: We performed a 14-center, prospective observational study of trauma patients who received WB versus BCT during their resuscitation. We applied a generalized linear mixed-effects model with a random effect and controlled for age, sex, mechanism of injury (MOI), and injury severity score. All patients who received blood as part of their initial resuscitation were included. Primary outcome was mortality and secondary outcomes included acute kidney injury, deep vein thrombosis/pulmonary embolism, pulmonary complications, and bleeding complications. RESULTS: A total of 1623 [WB: 1180 (74%), BCT: 443(27%)] patients who sustained penetrating (53%) or blunt (47%) injury were included. Patients who received WB had a higher shock index (0.98 vs 0.83), more comorbidities, and more blunt MOI (all P <0.05). After controlling for center, age, sex, MOI, and injury severity score, we found no differences in the rates of acute kidney injury, deep vein thrombosis/pulmonary embolism or pulmonary complications. WB patients were 9% less likely to experience bleeding complications and were 48% less likely to die than BCT patients ( P <0.0001). CONCLUSIONS: Compared with BCT, the use of WB was associated with a 48% reduction in mortality in trauma patients. Our study supports the use of WB use in the resuscitation of trauma patients.

The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage.

Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations.

Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.

BACKGROUND: Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion. STUDY DESIGN AND METHODS: A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed. RESULTS: A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05). DISCUSSION: This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.

Whole blood for postpartum hemorrhage: early experience at two institutions.

BACKGROUND: Death from postpartum hemorrhage (PPH) remains a significant preventable problem worldwide. Cold-stored, low-titer, type-O whole blood (LTOWB) is increasingly being used for resuscitation of injured patients, but it is uncommon in PPH patients, and it is unclear what its role may be in this population. STUDY DESIGN AND METHODS: Brief report of the early experience of WB use for PPH in two institutions, one university hospital and one private hospital. RESULTS: Different approaches have been implemented at the two institutions, one designed for emergency release, uncrossmatched transfusion of LTOWB as part of a massive transfusion protocol (MTP) and one for high-risk obstetric patients with known placental abnormalities. A total of 7 PPH patients have received a total of 17 units of LTOWB between the two institutions. No severe adverse transfusion reactions were observed clinically in either institution and the clinical outcomes were favorable in all cases. CONCLUSION: In our early experience, LTOWB can be implemented for two different PPH clinical scenarios. Larger studies are needed to compare outcomes between LTOWB and traditional component resuscitation strategies.

From battlefront to homefront: creation of a civilian walking blood bank.

Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.

Previous Laparotomy Scar Preventing Abdominal Injury from Gunshot Wound.

Diagnostic laparoscopy has been used in select patients with penetrating abdominal trauma. Here we present a case report where a midline surgical scar from a previous trauma laparotomy potentially prevented intra-abdominal injury. Furthermore, laparoscopy was used to exclude other intra-abdominal injuries and retrieve the projectile from within a hematoma cavity. This avoided the morbidity of a trauma laparotomy.

Effect of Standardized Reminder Calls on Trauma Patient No-Show Rate.

BACKGROUND: Most patients who sustain a traumatic injury require outpatient follow-up. A common barrier to outpatient postadmission care is patient failure to follow-up. One of the most significant factors resulting in failure to follow-up is age more than 35 years. Recent work has shown that follow-up telephone calls reduce readmission rates. Our aim was to decrease no-show appointments by 10% in 12 months. STUDY DESIGN: The electronic medical records at our level I and II trauma centers were queried for all outpatient appointments for trauma between July 1, 2020, and June 9, 2021, and whether the patient attended their follow-up appointment. Patients with visits scheduled after August 1, 2021, received 24- and 48-hour previsit reminder calls. Patients with visits scheduled between July 1, 2020, and August 1, 2021, did not receive previsit calls. Both groups were compared using multivariable direct logistic regression models. RESULTS: A total of 1,822 follow-up opportunities were included in the study. During the pre-implementation phase, there was a no-show rate of 30.9% (329 of 1,064 visits). Postintervention, a 12.2% reduction in overall no-show rate occurred. A statistically significant 11.2% decrease (p < 0.001) was seen in elderly patients. Multivariate analysis showed standardized calls resulted in significantly decreased odds of failing to keep an appointment (adjusted odds ratio = 0.610, p < 0.001). CONCLUSIONS: Reminder calls led to a 12.2% reduction in no-show rate and were an independent predictor of a patient's likelihood of attending their appointment. Other predictors of attendance included insurance status and abdominal injury.

TXA combined with whole blood transfusion in trauma patients does not increase the risk of VTE but shock index does.

INTRODUCTION: Previous studies have demonstrated the benefits of tranexamic acid (TXA) administration in combination with packed red blood cell (PRBC) transfusion in trauma patients without increasing the risk of venous thromboembolism (VTE). However, the effect of TXA in combination with whole blood (WB) has not been studied. Injury, abbreviated injury severity scores (ISS and AIS) and the need for blood transfusions are historically associated with VTE. The objective of this study was to determine the relationship between VTE and the combination of TXA administration and transfusion of PRBCs vs. WB. METHODS: Our institutional trauma registry was queried for trauma patients between 2015 and 2022 who received either WB â€‹+ â€‹TXA or PRBC â€‹+ â€‹TXA either prehospital or within 4 â€‹h of arrival. Multivariate analysis was utilized to determine independent risk factors for VTE, which were defined as either a deep vein thrombosis (DVT) or a pulmonary embolism (PE). Model covariates included age, mechanism of injury (MOI), ISS, lower extremity AIS, comorbid conditions, and shock index (SI). Additional outcomes analyzed were hospital length of stay (LOS), ICU LOS, and ventilator days. RESULTS: Three hundred and five patients had complete data and were included in the analysis. Of those, 251 received WB â€‹+ â€‹TXA and 54 received PRBC â€‹+ â€‹TXA. A total of 34 patients were found to have VTE event (11.1 â€‹%); 28 (11.2 â€‹%) and 6 (11.1 â€‹%) from the WB â€‹+ â€‹TXA and PRBC â€‹+ â€‹TXA groups, respectively. An elevated pre-hospital SI was independently associated with increased VTE rate (OR 1.85, 95 â€‹% CI 1.07-3.20). WB transfusion, TXA administration, ISS, and MOI did not influence the rate of VTE. CONCLUSION: These data demonstrate that the combination of WB â€‹+ â€‹TXA administered to trauma patients has no higher risk of VTE than patients who receive PRBC â€‹+ â€‹TXA, a comparison that has not been studied clinically to date. Despite the pro thrombotic state enhanced by TXA and the decreased dilutional coagulopathy seen in WB resuscitation, there was no increased risk of VTE compared to TXA â€‹+ â€‹PRBC. There is no evidence that TXA combined with whole blood transfusion is associated with an increased risk of VTE. However, higher pre-hospital SI was associated with an elevated rate of VTE. These clinical features provide insight into patients who may be at an increased risk of developing VTE and may benefit from targeted prevention strategies.

The Association of Calcium Derangements With 24-Hour Outcomes in the Deployed Combat Setting.

INTRODUCTION: Calcium derangements remain poorly characterized in the combat trauma population. We describe the incidence of emergency department (ED) calcium derangements, associated physiologic derangements, and 24-hour mortality from the deployed combat setting. MATERIALS AND METHODS: We analyzed adult casualties from 2007 to 2023 from the DoD Trauma Registry for U.S. military, U.S. contractor, and coalition casualties that had at least 1 ionized calcium value documented in the ED at a Role 2 or Role 3 military treatment facility. We constructed a series of multivariable logistic regression models to test for the association of hypocalcemia and hypercalcemia with physiological derangements, blood product consumption, and survival. Vital signs and other laboratory studies were based on the concurrent ED encounter. RESULTS: There were 941 casualties that met inclusion for this analysis with 26% (245) having at least 1 calcium derangement. Among those, 22% (211) had at least 1 episode of hypocalcemia and 5% (43) had at least 1 episode of hypercalcemia in the ED. The vast majority (97%, 917) received calcium at least once. Median composite injury severity scores were lower among those with no calcium derangement (8 versus 17, P < .001). Survival was higher during the total hospitalization (98% versus 93%) among those with calcium derangements but similar at 24 hours (99% versus 98%, P = .059). After adjusting for confounder, any hypocalcemic measurement was associated with an elevated international normalized ratio (odds ratio 1.94, 95% CI 1.19-3.16), acidosis (1.66, 1.17-2.37), tachycardia (2.11, 1.42-3.15), hypotension (1.92, 1.09-3.38), depressed Glasgow coma scale (3.20, 2.13-4.81), elevated shock index (2.19, 1.45-3.31), submassive transfusion (3.97, 2.60-6.05), massive transfusion (4.22, 2.66-6.70), supermassive transfusion (3.65, 2.07-6.43), and all hospital stay mortality (2.30, 1.00-5.29). Comparatively, any hypercalcemic measurement was associated with acidosis (2.96, 1.39-6.32), depressed Glasgow coma scale (4.28, 1.81-10.13), submassive transfusion (3.40, 1.37-8.43), massive transfusion (6.25, 2.63-14.83), and supermassive transfusion (13.00, 5.47-30.85). CONCLUSIONS: Both hypocalcemia and hypercalcemia in the ED were associated with physiological derangements and blood product use, with a greater extent observed in those with hypocalcemia compared to those with hypercalcemia. Prospective studies are underway to better explain and validate these findings.

Retrospective analysis of the effects of hypocalcemia in severely injured trauma patients.

BACKGROUND: It has been suggested that the Lethal Triad be modified to include hypocalcemia, coined as the Lethal Diamond. Hypocalcemia in trauma has been attributed to multiple mechanisms, but new evidence suggests that traumatic injury may result in the development of hypoCa independent of blood transfusion. We hypothesize that hypocalcemia is associated with increased blood product requirements and mortality. METHODS: A retrospective study of 1,981 severely injured adult trauma patients from 2016 to 2019. Ionized calcium (iCa) levels were obtained on arrival and subjects were categorized by a threshold iCa level of 1.00 mmol/L and compared. Univariable and multivariable logistic regression analysis was performed. RESULTS: The hypocalcemia (iCa <1.00 mmol/L) group had increased rate of overall (p = 0.001), 4-hr (p = 0.007), and 24-hr (p = 0.003) mortality. There was no difference in prehospital transfusion volume between groups (p = 0.25). Hypocalcemia was associated with increased blood product requirements at 4 h (p <0.001), 24 h (p <0.001), and overall hospital length of stay (p <0.001). Logistic regression analysis showed increased odds of 4-hour mortality (OR 0.077 [95 % CI 0.011, 0.523], p = 0.009) and 24-hour mortality (OR 0.121 [95 % CI 0.019, 0.758], p = 0.024) for every mmol/L increase in iCa. CONCLUSIONS: This study shows the association of hypoCa and traumatic injury. Severe hypoCa was associated with increased odds of early and overall mortality and increased blood product requirements. These results support the need for future prospective trials assessing the role of hypocalcemia in trauma.

An analysis of the effect of low titer O whole blood (LTOWB) proportions for resuscitation after trauma on 6-hour and 24-hour survival.

INTRODUCTION: Hemorrhage is a leading cause of death. Blood products are used for the treatment of hemorrhagic shock. The use of low titer group O whole blood (LTOWB) has become more common. METHODS: Data from patients ≥15 years of age in the Trauma Quality Improvement Program (TQIP) database that received ≥10 units of packed red cells and/or LTOWB within the first 4-h of hospital arrival were included. The proportion of LTWOB of total blood products administered was correlated to 6- and 24-h mortality. RESULTS: 12,763 met inclusion, 3827 (30 %) received LTOWB. On multivariable logistic regression (MVLR), there was no difference in survival at 6 h with a LTOWB. When assessing 24-h survival, there was improved survival with LTOWB ≥10 % (OR 1.18, 1.08-1.28). CONCLUSIONS: In this analysis of TQIP data, patients receiving ≥10 units of PRBC or LTOWB, we found that higher proportions of LTOWB transfusion relative to the total volume of blood products transfused during the first 4 h were associated with improved 24-h, but not 6-h survival.

FAST and Furious About Quality: Impact of Continuous Review and Feedback on Point-of-Care Ultrasound Examinations.

Background: Focused Assessment with Sonography in Trauma (FAST) examination is a point-of-care ultrasound study used to evaluate for abdominal hemorrhage, pneumothorax, or pericardial blood in trauma patients as an adjunct to their initial assessment. The quality of the image can be limited, and its diagnostic value is heavily dependent on operator skill. Our objective was to determine whether a standardized review process improved image quality and reduced incidence of nondiagnostic or insufficient imaging by 10% over a 6-month period. Study Design: Between July 1, 2021, and March 31, 2022, we evaluated 1106 trauma activations at our level II trauma center. Two exams per practitioner per month were reviewed by an emergency medicine trained traumatologist with specialized training in point-of-care ultrasound and board certification in echocardiography. Priority was given to exams on patients with known injuries identified on other studies. If there were no exams that matched these criteria, random exams were selected. Images were reviewed for image quality, diagnostic accuracy, and labeling with counseling given to the provider if indicated. Categorical variables were compared using chi squared analysis, while continuous non-normally distributed variables were compared using the Mann-Whitney U test. Results: A total of 305 FAST exams were reviewed (186 pre-intervention and 119 during intervention). Image quality improved from 46.3% (n = 31/65) to 79.0% (n = 94/119) (P < .01) with need for counseling falling from 63.1% (n = 41/65) pre-QI to 42.0% (n = 50/119) post-QI (P < .01). Incidence of detectable injury, BMI, ISS, and AIS body regions were consistent across the study period. This was seen in both the geriatric and non-geriatric cohorts despite a significant increase in ISS in the post-intervention geriatric patients.Discussion: A FAST review program is associated with improvement in image quality and decreased need for counseling of trauma providers.

Venous thromboembolic events associated with blood product administration in an era of whole blood use.

BACKGROUND: The risks associated with blood product administration and venous thromboembolic events remains unclear. We sought to determine which blood products were associated with the development of deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS: We analyzed data from patients ≥18 years of age in the Trauma Quality Improvement Program (TQIP) database that received ≥1 blood product and survived ≥24 â€‹h. RESULTS: There were 42,399 that met inclusion, of whom, 2086 had at least one VTE event. In our multivariable logistic regression model, we found that WB had a unit odds ratio (uOR) of 1.05 (95 â€‹% CI 1.02-1.08) for DVT and 1.08 (1.05-1.12) for PE. Compared to WB, platelets had a higher uOR for DVT of 1.09 (1.04-1.13) but similar uOR for PE of 1.08 (1.03-1.14). CONCLUSIONS: We found an association of both DVT and PE with early whole blood and platelets.

The effects of hypocalcemia in severely injured pediatric trauma patients.

INTRODUCTION: The role of calcium is ubiquitous in human physiology. Emerging evidence suggests that the lethal triad be revised to include hypocalcemia (hypoCa) and thus be known as the lethal diamond . There are data showing that traumatic injury may result in hypoCa independent from the mechanism of calcium chelation by citrate-based blood preservatives. Minimal literature exists analyzing the role of hypoCa in pediatric trauma patients. We hypothesize that there is an independent association of hypoCa with increased blood product requirements and mortality. METHODS: A retrospective cohort study of severely injured pediatric trauma patients was conducted. Trauma registry data were collected from January 2016 to August 2021. Ionized calcium (iCa) levels were obtained from arrival blood draws. Subjects were categorized into two groups by a threshold iCa level of 1.00 mmol/L and compared. Shock Index Pediatric Adjusted scores were used to adjust for age-specific differences in vital signs. RESULTS: A total of 142 patients were compared, of which 46.5% were hypocalcemic (iCa <1.00 mmol/L). Patients were well matched in terms of demographics and injury severity. The hypocalcemic group had lower systolic blood pressure and a higher percentage of Shock Index Pediatric Adjusted-positive patients. Weight-adjusted transfusion volumes were significantly higher in the hypocalcemic group at both the 4-hour and 24-hour time points without a difference in prehospital transfusion requirements. There was no observed difference in early or in-hospital mortality. CONCLUSION: This study contributes to the body of literature regarding the association between hypoCa and traumatic injury in the pediatric population. Hypocalcemia was associated with increased blood product requirements without a difference in prehospital transfusion requirements, suggesting a possible independent association. Further prospective studies are needed to better understand this relationship. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.