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.

Outpatient follow-up does not prevent emergency department utilization by trauma patients.

BACKGROUND: Although most trauma centers have a regularly scheduled trauma clinic, research demonstrates that trauma patients do not consistently attend follow-up appointments and often use the emergency department (ED) for outpatient care. METHODS: A retrospective review of outpatient follow-up of adult patients admitted to the trauma service (January 2014-December 2014) at an urban level I trauma center was conducted (n = 2134). RESULTS: A total of 219 patients (10%) were evaluated in trauma clinic after discharge from the hospital. Twenty-one percent of patients seen in trauma clinic visited the ED within 30 d compared with 12% of those not seen in clinic (P < 0.001). A total of 104 patients were readmitted within 30 d of discharge; no difference existed in the rate of hospital readmission between patients seen in clinic and those not seen in clinic (P = 0.25). Stepwise logistic regression showed that clinic follow-up was not a significant predictor of decreased ED utilization (adjusted odds ratio [OR] 1.16 [95% confidence interval 0.78-1.72], P = 0.461) and also showed that while ED use was a significant predictor of readmission (adjusted OR 216 [93-500], P < 0.001), clinic visits were not (adjusted OR 0.74 [0.33-1.69], P = 0.48). CONCLUSIONS: Outpatient follow-up in the trauma clinic does not decrease ED utilization or hospital readmissions indicating that interventions aimed at improving access to a conventional outpatient clinic will not impact ED utilization rates. Further study is necessary to determine the best system for providing clinically appropriate and cost-effective outpatient follow-up for trauma patients.

What is the Role of Whole Blood Transfusions on Trauma Patients?

Whole blood use in trauma has historically been limited to military use, but in recent years, there has been increasing data for use in civilian trauma. Emerging clinical data demonstrate an associated survival benefit, while some authors have also identified decreased use of an overall number of blood products and decreased complications. Use of whole blood is gradually moving toward becoming the standard of care in the hemorrhaging trauma patient.

Whole Blood Resuscitation is Safe in Pediatric Trauma Patients: A Multicenter Study.

INTRODUCTION: Whole blood (WB) resuscitation has been associated with a mortality benefit in trauma patients. Several small series report the safe use of WB in the pediatric trauma population. We performed a subgroup analysis of the pediatric patients from a large prospective multicenter trial comparing patients receiving WB or blood component therapy (BCT) during trauma resuscitation. We hypothesized that WB resuscitation would be safe compared to BCT resuscitation in pediatric trauma patients. METHODS: This study included pediatric trauma patients (0-17 y), from ten level-I trauma centers, who received any blood transfusion during initial resuscitation. Patients were included in the WB group if they received at least one unit of WB during their resuscitation, and the BCT group was composed of patients receiving traditional blood product resuscitation. The primary outcome was in-hospital mortality with secondary outcomes being complications. Multivariate logistic regression was performed to assess for mortality and complications in those treated with WB vs BCT. RESULTS: Ninety patients, with both penetrating and blunt mechanisms of injury (MOI), were enrolled in the study (WB: 62 (69%), BCT: 28 (21%)). Whole blood patients were more likely to be male. There were no differences in age, MOI, shock index, or injury severity score between groups. On logistic regression, there was no difference in complications. Mortality was not different between the groups (P = .983). CONCLUSION: Our data suggest WB resuscitation is safe when compared to BCT resuscitation in the care of critically injured pediatric trauma patients.

The role of laparoscopy in small bowel obstruction after previous laparotomy for trauma: an initial report.

Presently, there are no guidelines to help predict which patients are more likely to have successful laparoscopic adhesiolysis. We attempt to define which preoperative characteristics of trauma patients who later develop small bowel obstruction are most amenable to a laparoscopic operation. We did a retrospective review of all patients with small bowel obstruction after previous laparotomy for trauma. For the patients that received an operation to relieve the obstruction, the location of transition zone via CT scan and location of the previous abdominal scar were recorded. A previous upper abdominal surgical incision and a transition zone outside of the pelvis on CT scan were preoperative predictors of a successful laparoscopic adhesiolysis. The laparoscopic group had a shorter length of stay. Laparoscopic surgery as the initial operative approach in the management of SBO after previous laparotomy for trauma is safe and effective. Characteristics that make the laparoscopic approach most favorable are CT transition point above the pelvis and previous midline incision above umbilicus.

The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study.

BACKGROUND: Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality. METHODS: Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed. RESULTS: One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care. CONCLUSION: Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research. LEVEL OF EVIDENCE: Epidemiologic, level II.

Brachial artery injuries in a rural catchment trauma center: are the upper and lower extremity the same?

BACKGROUND: The predictors of amputation for patients with lower extremity vascular trauma are well described in the literature, but the predictors of amputation in the upper extremity are not so well defined. We hypothesize that the predictors of amputation in the lower extremity are much different when compared with the upper extremity. METHODS: Retrospective chart review of all brachial artery traumatic injuries presenting to a rural-state university trauma center. RESULTS: In a 6-year period, 41 patients presented with brachial artery injuries. Operative management was performed in 38 (93%) patients which included 23 reversed saphenous vein grafts, 13 primary repairs, and 2 synthetic grafts. There were four deaths (9.8%) and four (9.8%) amputations. Comparing the amputation and limb salvage groups, the Injury Severity Score (ISS) was 32 versus 12, whereas the Mangled Extremity Severity Score (MESS) was 7 versus 4.3. Five patients had a MESS score greater than 7; four of whom had an amputation or died. Amputation was performed in only 4 of 23 patients with neurologic deficits. Limb salvage was successful in 24 of 28 patients without a palpable pulse on arrival. CONCLUSIONS: Predictors of amputation in brachial artery injuries differ from lower extremity vascular injuries. Delayed presentation greater than 6 hours, MESS, open fracture, nerve deficits, and diminished capillary refill were not predictive of amputation for patients with brachial artery injuries. These data suggest that the vast majority of upper extremity injuries should have attempted salvage regardless of the severity scoring systems.

Surgeon reimbursement for trauma care.

BACKGROUND: Trauma care is a well-known financial burden for hospitals, yet reimbursement for the surgeon has not been reported. METHODS: For 1999, the percent of the surgeons' bills reimbursed for general surgery services (gPR) was compared with that for trauma services (tPR). Mean tPR for various groups were compared. Factors predictive of tPR lower than gPR were identified. RESULTS: The gPR was 49%, and, for 371 trauma patients, tPR was 45% (P = 0.03). The mean tPR for injury severity score (ISS) < or =10 was 48%, and for ISS > or =11, 57% (P = 0.03). Patients transferred from outside facilities did not have a significantly lower mean tPR. Penetrating trauma (odds ratio 3.7, P = 0.008) was predictive of tPR lower than gPR. CONCLUSIONS: Surgeon reimbursements for trauma care was significantly, yet only slightly less than for all general surgery care. Surgeons should not be reluctant to take trauma call based on perceptions of low reimbursement.

Homocysteine and arterial disease. Experimental mechanisms.

Hyperhomocysteinemia (hH(e)) in the general population is associated with incidence and progression of arterial occlusive disease, although the underlying mechanisms are not well defined. Current research supports a role for homocysteine (H(e))-mediated endothelial damage and endothelial dysfunction. This mechanism appears to be a key factor in subsequent impaired endothelial-dependent vasoreactivity and decreased endothelium thromboresistance. These consequences may predispose hyperhomocysteinemic vessels to the development of increased atherogenesis. Additional mechanisms of H(e)-mediated vascular pathology, including protein homocysteinylation and vascular smooth muscle cell proliferation may also play a role. Continued investigation into the mechanisms contributing to H(e) toxicity will provide further insight into the processes by which hH(e) may increase atherosclerosis.

Compartment syndrome in multiple uninjured extremities: a case report.

Compartment syndrome is a common problem in trauma patients. It can occur within any space bound by a dense fascial layer, such as the extremities or abdomen. It exists when increased tissue pressure within the limited anatomic space compromises perfusion. Failure to decompress the compartment leads to a self-perpetuating ischemia-edema process and resultant irreversible tissue damage. In the extremities, it typically arises from a vascular injury in that same extremity. Herein is reported a case of the unexpected development of compartment syndrome in multiple uninjured extremities in a trauma patient with hypotension requiring systemic vasopressors.

The cost of trauma.

Trauma is a financial burden. For the 2634 trauma patients seen in 1999, the percentage of their hospital bill reimbursed and cost coverage (CC), whether that reimbursement covered their hospital costs, were analyzed. Student t tests to compare the mean percentage reimbursements (mPR) and logistic regression with CC (yes/no) as dependent variable with results as odds ratio (OR) were done. The overall mPR was 36 per cent. Among the 947 patients admitted (36%), there was no association between injury severity and mPR. For penetrating trauma, the mPR (25%) was lower than for blunt trauma (37%, P = 0.05). The assault mPR (21%) was lower than for motor vehicle crash (39%, P < 0.001). The mPR for patients transferred in (26%) was lower than for all others (37%, P < 0.001). Male sex (OR = 0.76), Hispanic ethnicity (OR = 0.46), admission (OR = 0.69), severe brain injury (OR = 0.58), abdominal injury (OR = 0.65), and extremity injury (OR = 0.69) were significant predictors for no CC. Reimbursement is better for blunt trauma. That transfers had a significantly lower mPR may represent "dumping" of patients. There is an association between anatomic regions injured and CC. No reimbursement was obtained for 26 per cent of the patients, and in 56 per cent the reimbursement did not cover costs. A change in financing for trauma is needed.

Overcrowded motor vehicle trauma from the smuggling of illegal immigrants in the desert of the Southwest.

Overcrowded motor vehicle crashes caused by the very active criminal enterprise of smuggling illegal immigrants in the desert of the Southwest is a recent and under-recognized trauma etiology. A computerized database search from 1990 through 2003 of local newspaper reports of overcrowded motor vehicle crashes along the 281 miles of Arizona's border with Mexico was conducted. This area was covered by two level I trauma centers, but since July 2003 is now served only by the University Medical Center. Each of these crashes involved a single motor vehicle in poor mechanical shape packed with illegal immigrants. Speeding out of control on bad tires, high-speed rollovers result in ejection of most passengers. Since 1999, there have been 38 crashes involving 663 passengers (an average of 17 per vehicle) with an injury rate of 49 per cent and a mortality rate of 9 per cent. This relatively recent phenomenon (no reports from before 1998) of trauma resulting from human smuggling is lethal and demonstrates the smugglers' wanton disregard for human life, particularly when facing apprehension. Even a few innocent bystanders have been killed. These crashes overwhelm a region's trauma resources and must be recognized when planning the distribution of trauma resources to border states.

Carotid surgery following previous carotid endarterectomy is safe and effective.

With the perceived high risk of repeat carotid surgery, carotid angioplasty and stenting have been advocated recently as the preferred treatment of recurrent carotid disease following carotid endarterectomy. An experience with the operative treatment of recurrent carotid disease to document the risks and benefits of this procedure is presented. A review of a prospectively acquired vascular registry over a 10-year period (Jan. 1990-Jan. 2000) was undertaken to identify patients undergoing repeat carotid surgery following previous carotid endarterectomy. All patients were treated with repeat carotid endarterectomy, carotid interposition graft, or subclavian-carotid bypass. The perioperative stroke and death rate, operative complications, life-table freedom from stroke, and rates of recurrent stenosis were documented. During the study period 56 patients underwent repeat carotid surgery, comprising 6% of all carotid operations during this period. The indication for operation was symptomatic disease recurrence in 41 cases (73%) and asymptomatic recurrent stenosis >/=80% in 15 cases (27%). The average interval from the prior carotid endarterectomy to the repeat operation was 78 months (range 3 weeks-297 months). The operations performed included repeat carotid endarterectomy with patch angioplasty in 31 cases (55%), interposition grafts in 19 cases (34%), and subclavian-carotid bypass in 6 cases (11%). There were three perioperative strokes with one resulting in death for a perioperative stroke and death rate of 5.4%. One minor transient cranial nerve (CN IX) injury occurred. Mean follow-up was 29 months (range, 1-116 months). Life-table freedom from stroke was 95% at 1 year and 90% at 5 years. Recurrent stenosis (>/=80%) developed in three patients (5.4%) during follow-up, including one internal carotid artery occlusion. Two patients (3.6%) underwent repeat surgery. Repeat surgery for recurrent cerebrovascular disease following carotid endarterectomy is safe and provides durable freedom from stroke. Most patients are candidates for repeat endarterectomy with patching, but interposition grafting is often required. These results strongly support the continued role of repeat carotid surgery in the treatment of recurrent carotid disease.

Telepresence and telemedicine in trauma and emergency care management.

The use of telemedicine is long-standing, but only recently has been applied to the specialties of trauma, emergency care, and surgery. Subsequently the concepts of teletrauma, telepresence, and telesurgery have evolved and are being integrated into modern care of trauma and surgical patients. This chapter will review the current applications and future endeavors of telemedicine and telepresence to trauma and emergency care as the new frontiers of telemedicine application.

Same-day restoration of mandibular single-stage implants.

The Novum system by Nobel Biocare is a unique approach that delivers a full arch definitive restoration in one day on three implants. The pre-operative evaluation, surgical protocol, and prosthetic protocol are described, and contraindications for this system are discussed. This system of immediately loaded implants placed in a single-stage surgery has success rates that compare favorably with the classic two-stage approach.

Helmet use is associated with a decrease in intracranial hemorrhage following all-terrain vehicle crashes.

BACKGROUND: With the recent increase in size and horsepower of all-terrain vehicles (ATVs), it is imperative that preventable injuries be identified to protect the large population using ATVs. Currently, many states have no laws regulating ATV or helmet use. By identifying preventable injuries, the legislature can design appropriate laws to protect both children and adults. METHODS: A retrospective review of all patients with ATV injuries presenting between the years 2005 and 2010 was conducted. The data were grouped in several ways for analysis. This included age less than 9 years, weight less than 30 kg, crash at night, substance abuse, and presence of a helmet. RESULTS: There were 481 patients included in the study. Only 28 (8%) were using a helmet at the time of the crash. Helmet use was associated with less intracranial hemorrhage (3% vs. 22%, p = 0.01) and a decreased incidence of loss of consciousness (14% vs. 35%, p = 0.01). Patients testing positive for alcohol intoxication with or without drugs were significantly more likely to have intracranial hemorrhage, to crash at night, to have facial fracture, to have rib fracture, to arrive intubated, and to have a higher Injury Severity Score (ISS) (p < 0.01 for all). CONCLUSION: With the recent increase in size and horsepower of ATVs, it is imperative that preventable injuries be identified to help protect a growing population of ATV operators. This study reveals a high rate of intracranial hemorrhage following an ATV crash in operators who do not use a helmet. Legislative efforts to implement strict helmet laws for ATV operators may be warranted. LEVEL OF EVIDENCE: Prognostic study, level III.

Characterization of the spectrum of hemodynamic profiles in trauma patients with acute neurogenic shock.

OBJECTIVE: Neurogenic shock considered a distributive type of shock secondary to loss of sympathetic outflow to the peripheral vasculature. In this study, we examine the hemodynamic profiles of a series of trauma patients with a diagnosis of neurogenic shock. METHODS: Hemodynamic data were collected on a series of trauma patients determined to have spinal cord injuries with neurogenic shock. A well-established integrated computer model of human physiology was used to analyze and categorize the hemodynamic profiles from a system analysis perspective. A differentiation between these categories was presented as the percent of total patients. RESULTS: Of the 9 patients with traumatic neurogenic shock, the etiology of shock was decrease in peripheral vascular resistance (PVR) in 3 (33%; 95% confidence interval, 12%-65%), loss of vascular capacitance in 2 (22%; 6%-55%) and mixed peripheral resistance and capacitance responsible in 3 (33%; 12%-65%), and purely cardiac in 1 (11%; 3%-48%). The markers of sympathetic outflow had no correlation to any of the elements in the patients' hemodynamic profiles. CONCLUSIONS: Results from this study suggest that hypotension of neurogenic shock can have multiple mechanistic etiologies and represents a spectrum of hemodynamic profiles. This understanding is important for the treatment decisions in managing these patients.

The weight of obesity in patients with lower extremity vascular injuries.

OBJECTIVE: Clinical obesity is an epidemic problem in the United States. The impact of this disease upon traumatic lower extremity vascular injuries (LEVI) is as yet undefined. We hypothesized that clinical obesity adversely affects outcome in patients with traumatic LEVI. METHODS: All adult patients admitted over a 5-year period with a traumatic LEVI were identified. Clinical obesity was defined as body mass index (BMI)>30. Obese and non-obese patient groups were compared for surgical management and outcome. RESULTS: A total of 145 patients were identified. BMI data were available for 115 (79.3%) of these patients (obese n=47; non-obese n=68). Obese and non-obese groups were similar. Obese patients underwent more vascular repairs but the amputation rate and mortality were not significantly different. CONCLUSIONS: While obese body habitus can increase the complexity of evaluation and management of patients with LEVI, we have demonstrated that equivalent outcomes to the non-obese population can be achieved for the clinically obese patient with a BMI>30. However, patients with a BMI>40 did reveal a significantly higher chance of amputation and death after LEVI. Due to the small number of patients in this subset, one should use caution when interpreting this data.

Management of traumatic vascular injuries to the neck: a 7-year experience at a Level I trauma center.

Injury to the carotid artery results in significant mortality and morbidity. The general consensus is to repair all injuries to the common and internal carotid arteries. Ligation is usually reserved for neurologic or hemodynamic instability. We report our experience at a Level I trauma center with vascular injuries to the neck. Retrospective chart review of all patients with vascular injuries in the neck resulting from either blunt or penetrating trauma treated at a Level I trauma center between January 2000 and February 2007. Demographics and outcomes were collected from a chart review. Twenty-five patients with vascular injuries to the neck were identified. There were 13 carotid artery injuries (CAI), five internal jugular vein (IJV) injuries, and 13 external jugular vein (EJV) injuries. Of the carotid artery injuries, six (50%) underwent operative repair (4 primary repairs and 2 bypasses), five (38%) were managed nonoperatively, and one was treated using endovascular techniques. No patient had a postoperative decrease in Glasgow Coma Scale score. There were five isolated IJV injuries (3 primary repair and 2 ligations). Four of the venous injuries (all internal jugular veins) were repaired and the remaining 13 were ligated. Vascular injuries to the neck have significant mortality and morbidity. Treatment of these injuries must be individualized. All CAI in noncomatose patients should be repaired if hemodynamically stable. All IJV injuries should be repaired but may be ligated if hemodynamically unstable. All EJV injuries can be ligated without reservation regardless of neurological status.