An analysis of outcomes for pediatric trauma warm fresh whole blood recipients in Iraq and Afghanistan.

BACKGROUND: Whole blood therapy-which contains the ideal balance of components, and particularly fresh whole blood-has been shown to be beneficial in adult trauma. It remains unclear whether there is potential benefit in the pediatric population. STUDY DESIGN AND METHODS: This is a secondary analysis of previously published data analyzing pediatric casualties undergoing massive transfusion in the Department of Defense Trauma Registry. Pediatric patients with traumatic injury who were transfused at least one blood product were included in the analysis. We compared children who received component therapy exclusively to those who received any amount of warm fresh whole blood. RESULTS: Of the 3439 pediatric casualties within our dataset, 1244 were transfused at least one blood product within the first 24 h. There were 848 patients without severe head injury. Within this cohort, 23 children received warm fresh whole blood overall, 20 of whom did not have severe head injury. In an adjusted analysis, the odds ratio (95% confidence interval [CI]) for survival for warm fresh whole blood recipients was 2.86 (0.40-20.45). After removing children with severe brain injury, there was an independent association with improved survival for warm fresh whole blood recipients with an odds ratio (95% CI) of 58.63 (2.70-1272.67). DISCUSSION: Our data suggest that warm fresh whole blood may be associated with improved survival in children without severe head injury. Larger prospective studies are needed to assess the efficacy and safety of whole blood in children with severe traumatic bleeding.

Development of prehospital assessment findings associated with massive transfusion.

BACKGROUND: Massive transfusion is frequently a component of the resuscitation of combat casualties. Because blood supplies may be limited, activation of a walking blood bank and mobilization of necessary resources must occur in a timely fashion. The development of a risk prediction model to guide clinicians for early transfusion in the prehospital setting was sought. STUDY DESIGN AND METHODS: This is a secondary analysis of a previously described data set from the Department of Defense Trauma Registry from January 2007 to August 2016 focusing on casualties undergoing massive transfusion. Serious injury was defined based on an Abbreviated Injury Scale score of 3 or greater by body region. The authors constructed multiple imputations of the model for risk prediction development. Efforts were made to internally validate the model. RESULTS: Within the data set, there were 15540 patients, of which 1238 (7.9%) underwent massive transfusion. In the body region injury scale model, explosive injuries (odds ratio [OR], 3.78), serious extremity injuries (OR, 6.59), and tachycardia >120/min (OR, 5.61) were most strongly associated with receiving a massive transfusion. In the simplified model, major amputations (OR, 17.02), tourniquet application (OR, 6.66), and tachycardia >120 beats/min (OR, 8.72) were associated with massive transfusion. Both models had area under the curve receiver operating characteristic values of greater than 0.9 for the model and bootstrap forest analysis. CONCLUSION: In the body region injury scale model, explosive mechanisms, serious extremity injuries, and tachycardia were most strongly associated with massive transfusion. In the simplified model, major amputations, tourniquet application, and tachycardia were most strongly associated.

Incidence of post-traumatic seizures in children during combat operations in Afghanistan and Iraq.

OBJECTIVES: Children represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is lacking. We seek to describe the incidence of post-traumatic seizures within this population. METHODS: This is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission. RESULTS: Of the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1-4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001). CONCLUSIONS: Within our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.

An Analysis of Intracranial Hemorrhage in Wartime Pediatric Casualties.

BACKGROUND: Children make up a significant cohort of patients treated at combat support hospitals. Where traumatic head injury, including intracranial hemorrhage (ICH), is well studied in military adults, such research is lacking regarding pediatric patients. We seek to describe the incidence and outcomes of ICH within this population. METHODS: This is a secondary analysis of a previously published dataset from the Department of Defense Trauma Registry for all pediatric casualties in Iraq and Afghanistan from January 2007 to January 2016. Within our dataset, we searched for casualties with an ICH. RESULTS: Of the 3439 pediatric encounters in our dataset, we identified 495 (14%) casualties that had at least 1 type of ICH. Most were between 5 and 12 years of age, male (74%), and injured by an explosive (42%). Of the casualties with ICHs, 82 had epidural (16.6%), 237 had subdural (47.9%), 153 had subarachnoid (30.9%), 157 had parenchymal bleeds (31.7%), and 239 had ICHs not otherwise specified (48.3%). In the hospital setting, the epidural group was more frequently treated with skull decompression (41%) and craniotomy with skull elevation (28%). The subdural group was more frequently treated with a craniectomy (17%) and the parenchymal group had more frequent intracranial pressure monitoring (18%). In our dataset, 22 received ketamine prehospital (4.4%) and most were discharged alive from the hospital (79%). CONCLUSIONS: Within our dataset, we identified 495 cases of ICH in pediatric patients. Most survived to hospital discharge despite less than half undergoing a decompression procedure.

Assessing Challenges with Access to Care for Patients Presenting to the Emergency Department for Non-Emergent Complaints.

INTRODUCTION: Emergency department (ED) utilization continues to climb nationwide resulting in overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients frequently choose the ED for apparent non-emergent medical issues or injuries that after-the-fact could be cared for in a primary care setting. We seek to better understand the reasons why patients choose the ED over their primary care managers. METHODS: We prospectively surveyed patients that signed into the ED at the Brooke Army Medical Center as an emergency severity index of 4 or 5 (non-emergent triage) regarding their visit. We then linked their survey data to their ED visit including interventions, diagnoses, diagnostics, and disposition by using their electronic medical record. We defined their visit to be non-urgent and more appropriate for primary care, or primary care eligible, if they were discharged home and received no computed tomography (CT) imaging, ultrasound, magnetic resonance imaging (MRI), intravenous (IV) medications, or intramuscular (IM) controlled substances. RESULTS: During the 2-month period, we collected data on 208 participants out of a total of 252 people offered a survey (82.5%). There were 92% (n=191) that were primary care eligible within our respondent pool. Most reported very good (38%) or excellent (21%) health at baseline. On survey assessing why they came, inability to get a timely appointment (n=73), and a self-reported emergency (n=58) were the most common reported reasons. Most would have utilized primary care if they had a next-morning appointment available (n=86), but many reported they would have utilized the ED regardless of primary care availability (n=77). The most common suggestion for improving access to care was more primary care appointment availability (n=96). X-rays were the most frequent study (37%) followed by laboratory studies (20%). Before coming to the ED, 38% (n=78) reported trying to contact their primary care for an appointment. Before coming to the ED, 22% (n=46) reported contacting the nurse advice line. Based on our predefined model, 92% (n=191) of our respondents were primary care eligible within our respondent pool. CONCLUSIONS: Patient perceptions of difficulty obtaining appointments appear to be a major component of the ED use for non-emergent visits. Within our dataset, most patients surveyed stated they had difficulty obtaining a timely appointment or self-reported as an emergency. Data suggests most patients surveyed could be managed in the primary care setting.

Freeze Dried Plasma Administration Within the Department of Defense Trauma Registry.

Hemorrhage is common among the combat injured, and plasma plays a vital role in blood product resuscitation. Regarding freeze dried plasma (FDP), US forces have had limited access to this product compared with other countries. In 2018, the US Food and Drug Administration provided emergency authorization for Department of Defense (DoD) use through the newly congressionally directed military use pathway. We describe the documented uses of FDP by US forces by performing a secondary analysis of two previously described datasets from the DoD Trauma Registry. In 11 identified cases, the median age was 28; cases were most frequently male, part of Operation Enduring Freedom, with US military affiliation, and injured by explosive or gunshot wound. The median injury severity score was 21; most did not receive a massive transfusion. Most survived to hospital discharge. Ongoing surveillance is warranted to optimize the implementation of FDP into military prehospital guidelines, training, and doctrine.

Validation of the age-adjusted shock index for pediatric casualties in Iraq and Afghanistan.

BACKGROUND: Pediatric casualties account for a notable proportion of encounters in the deployed setting based on the humanitarian medical care mission. Previously published data demonstrates that an age-adjust shock index may be a useful tool in predicting massive transfusion and death in children. We seek to determine if those previous findings are applicable to the deployed, combat trauma setting. METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties seeking to validate previously published data using the shock index, pediatric age-adjusted. We then used previously published thresholds to determine patients outcome for validation by age grouping, 1-3 years (1.2), 4-6 years (1.2), 7-12 years (1.0), 13-17 years (0.9). RESULTS: From January 2007 through January 2016 there were 3439 pediatric casualties of which 3145 had a documented heart rate and systolic pressure. Of those 502 (16.0%) underwent massive transfusion and 226 (7.2%) died prior to hospital discharge. Receiver operating characteristic (ROC) thresholds were inconsistent across age groups ranging from 1.0 to 1.9 with generally limited area under the curve (AUC) values for both massive transfusion and death prediction characteristics. Using the previously defined thresholds for validation, we report sensitivity and specificity for the massive transfusion by age-group: 1-3 (0.73, 0.35), 4-6 (0.63, 0.60), 7-12 (0.80, 0.57), 13-17 (0.77, 0.62). For death, 1-3 (0.75, 0.34), 4-6 (0.66-0.59), 7-12 (0.64, 0.52), 13-17 (0.70, 0.57). However, negative predictive values (NPV) were generally high with all greater than 0.87. CONCLUSIONS: Within the combat setting, the age-adjusted pediatric shock index had moderate sensitivity and relatively poor specificity for predicting massive transfusion and death. Better scoring systems are needed to predict resource needs prior to arrival, that perhaps include other physiologic metrics. We were unable to validate the previously published findings within the combat trauma population.

Validating clinical threshold values for a dashboard view of the compensatory reserve measurement for hemorrhage detection.

BACKGROUND: Compensatory reserve measurement (CRM) is a novel noninvasive monitoring technology designed to assess physiologic reserve using feature interrogation of arterial pulse waveforms. This study was conducted to validate clinically relevant CRM values with a simplified color-coded dashboard view. METHODS: We performed a prospective observational study of 300 injured patients admitted to a level I trauma center. Compensatory reserve measurement was recorded upon emergency department admission. Data collected to complement the analysis included patient demographics, vital signs, lifesaving interventions, Injury Severity Score (ISS), and outcomes. Threshold values of CRM were analyzed for predictive capability of hemorrhage. RESULTS: A total of 285 patients met the inclusion criteria. Mean age of the population was 47 years, and 67% were male. Hemorrhage was present in 32 (11%), and lifesaving intervention was performed in 40 (14%) patients. Transfusion of packed red blood cells was administered in 33 (11.6%) patients, and 21 (7.4%) were taken to the operating room for surgical or endovascular control of hemorrhage. Statistical analyses were performed to identify optimal threshold values for three zones of CRM to predict hemorrhage. Optimal levels for red, yellow, and green areas of the dashboard view were stratified as follows: red if CRM was less than 30%, yellow if CRM was 30% to 59%, and green if CRM was 60% or greater. Odds of hemorrhage increased by 12-fold (odds ratio, 12.2; 95% confidence interval, 3.8-38.9) with CRM less than 30% (red) and 6.5-fold (odds ratio, 6.5; 95% confidence interval, 2.7-15.9) with CRM of equal to 30% to 59% (yellow) when compared with patients with CRM of 60% or greater. The area under the receiver operating characteristic curve for three-zone CRM was similar to that of continuous CRM (0.77 vs. 0.79) but further increased the ability to predict hemorrhage after adjusting for ISS (area under the receiver operating characteristic curve, 0.87). CONCLUSION: A three-zone CRM could be a potentially useful predictor of hemorrhage in trauma patients with added capabilities of continuous monitoring and a real-time ISS assessment. These data substantiate easily interpretable threshold dashboard values for triage with potential to improve injury outcomes. LEVEL OF EVIDENCE: Diagnostic, level II.