The relationship between INR and development of hemorrhage with placement of ventriculostomy.

BACKGROUND: This study seeks to evaluate the relationship between the risk of symptomatic hemorrhage from ventriculostomy placement and International Normalized Ratio (INR) in patients who received a ventriculostomy after traumatic brain injury. METHODS: Patients who received a ventriculostomy after traumatic brain injury between June 2007 and July 2008 were identified and their medical records were abstracted for information. RESULTS: At the time of ventriculostomy placement, 32 patients had an INR<1.2, 26 patients had an INR 1.2 to 1.4, 12 patients had an INR 1.4 to 1.6, and one patient had an INR>1.6 (INR=1.61). No significant difference in the risk of hemorrhage between the groups was observed: 9.4%, 3.9%, 8.3%, and 0%, respectively (p=0.73). In a subgroup analysis of patients who received ventriculostomy in the Neurosurgical Intensive Care Unit within 24 hours of admission (n=54), the average time between admission and ventriculostomy placement in patients who did not receive fresh frozen plasma was 6.8 hours compared with 9.3 hours (p=0.03) for those who did. CONCLUSIONS: In this retrospective study, INRs between 1.2 and 1.6 appeared to be acceptable for a neurosurgeon to place an emergent ventriculostomy in a patient with traumatic brain injury.

Intubation patterns and outcomes in patients with computed tomography-verified traumatic brain injury.

BACKGROUND: Studies evaluating traumatic brain injury (TBI) patients have shown an association between prehospital (PH) intubation and worse outcomes. However, previous studies have used surrogates, e.g., Glasgow Coma Scale (GCS) score ≤8 and Abbreviated Injury Severity Scale (AIS) score ≥3, which may overestimate the true presence of TBI. This study evaluated the impact of PH intubation in patients with PH GCS score ≤8 and radiographically proven TBI. METHODS: Trauma patients routed to a Level I trauma center over a 3-year period with blunt injury and PH GCS score ≤8 were included. PH and in-hospital records were linked and head computed tomography scans were assigned a Marshall Score (MS). Patients with TBI (MS >1) were categorized into groups based on intubation status (PH, emergency department [ED], and no intubation). Comparisons were made using analysis of variance and χ statistics. Mortality differences, crude and adjusted risk ratios (RRs), and 95% confidence intervals (CIs) were calculated using proportions hazards modeling. RESULTS: Of 334 patients with PH GCS score ≤8, 149 (50%) had TBI by MS. Among the TBI patients, 42.7% of patients were PH intubated, 47.7% were ED intubated, and 9.4% were not intubated during the initial resuscitation. Intubated patients had lower ED GCS score (PH: 4.1 and ED: 5.9 vs. 14.0; p < 0.0001) compared with patients not intubated. Also PH intubated patients had higher mean Injury Severity Score (38.0 vs. 33.7 vs. 23.5, p < 0.001) when compared with ED intubated and nonintubated patients. None of the nonintubated patients had a MS >2. Mortality for TBI patients who required PH intubation was 46.9% and 41.4% among ED-intubated patients. The crude RR of mortality for PH compared with ED intubation was 1.13 (95% CI, 0.68-1.89), and remained nonsignificant (RR, 0.68; 95% CI, 0.36-1.19) when adjusted for key markers of injury severity. CONCLUSIONS: Patients with PH GCS score ≤8 and proven TBI had a high overall rate of intubation (>90%). PH intubation seems to be a marker for more severe injury and conveyed no increased risk for mortality over ED intubation.

Prospective implementation of an algorithm for bedside intravascular ultrasound-guided filter placement in critically ill patients.

BACKGROUND: Although contrast venography is the standard imaging method for inferior vena cava (IVC) filter insertion, intravascular ultrasound (IVUS) imaging is a safe and effective option that allows for bedside filter placement and is especially advantageous for immobilized critically ill patients by limiting resource use, risk of transportation, and cost. This study reviewed the effectiveness of a prospectively implemented algorithm for IVUS-guided IVC filter placement in this high-risk population. METHODS: Current evidence-based guidelines were used to create a clinical decision algorithm for IVUS-guided IVC filter placement in critically ill patients. After a defined lead-in phase to allow dissemination of techniques, the algorithm was prospectively implemented on January 1, 2008. Data were collected for 1 year using accepted reporting standards and a quality assurance review performed based on intent-to-treat at 6, 12, and 18 months. RESULTS: As defined in the prospectively implemented algorithm, 109 patients met criteria for IVUS-directed bedside IVC filter placement. Technical feasibility was 98.1%. Only 2 patients had inadequate IVUS visualization for bedside filter placement and required subsequent placement in the endovascular suite. Technical success, defined as proper deployment in an infrarenal position, was achieved in 104 of the remaining 107 patients (97.2%). The filter was permanent in 21 (19.6%) and retrievable in 86 (80.3%). The single-puncture technique was used in 101 (94.4%), with additional dual access required in 6 (5.6%). Periprocedural complications were rare but included malpositioning requiring retrieval and repositioning in three patients, filter tilt >/=15 degrees in two, and arteriovenous fistula in one. The 30-day mortality rate for the bedside group was 5.5%, with no filter-related deaths. CONCLUSIONS: Successful placement of IVC filters using IVUS-guided imaging at the bedside in critically ill patients can be established through an evidence-based prospectively implemented algorithm, thereby limiting the need for transport in this high-risk population.

Computed tomography identification of latent pseudoaneurysm after blunt splenic injury: pathology or technology?

BACKGROUND: Serial computed tomography (CT) imaging of blunt splenic injury can identify the latent formation of splenic artery pseudoaneurysms (PSAs), potentially contributing to improved success in nonoperative management. However, it remains unclear whether the delayed appearance of such PSAs is truly pathophysiologic or attributable to imaging quality and timing. The objective of this study was to evaluate the influence of recent advancements in imaging technology on the incidence of the latent PSA. METHODS: Consecutive patients with blunt splenic injury over 4.5 years were identified from our trauma registry. Follow-up CT was performed for all but low-grade injuries 24 hours to 48 hours after initial CT. Incidences of both early and latent PSA formation were reviewed and compared with respect to imaging technology (4-slice vs. >or=16-slice). RESULTS: A total of 411 patients were selected for nonoperative management of blunt splenic injury. Of these, 135 had imaging performed with 4-slice CT, and 276 had imaging performed with CTs of >=16-slice. Mean follow-up was 75 days (range, 1-1178 days) and 362 patients (88%) had follow-up beyond 7 days. Comparing 4-slice CT with >or=16-slice CT, there were no significant differences in the incidence of early PSA (3.7% vs. 4.7%; p = 0.91) or latent PSA (2.2% vs. 2.9%; p = 0.90). In both groups, latent PSAs accounted for approximately 38% of all PSAs observed. Splenic injury grade on initial CT was not associated with latent PSA (p = 0.54). Overall, the failure rate of nonoperative management was 7.3%. Overall mortality was 4.6%. No mortalities were related to splenic or other intra-abdominal injury. CONCLUSIONS: The incidences of both early and latent PSA have remained remarkably stable despite advances in CT technology. This suggests that latent PSA is not a result of imaging technique but perhaps a true pathophysiologic phenomenon. Injury grade is unhelpful concerning the prediction of latent PSA formation.

Duration of red cell storage influences mortality after trauma.

BACKGROUND: Although previous studies have identified an association between the transfusion of relatively older red blood cells (RBCs) (storage ≥ 14 days) and adverse outcomes, they are difficult to interpret because the majority of patients received a combination of old and fresh RBC units. To overcome this limitation, we compared in-hospital mortality among patients who received exclusively old versus fresh RBC units during the first 24 hours of hospitalization. METHODS: Patients admitted to a Level I trauma center between January 2000 and May 2009 who received ≥ 1 unit of exclusively old (≥ 14 days) vs. fresh (< 14 days) RBCs during the first 24 hours of hospitalization were identified. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for the association between mortality and RBC age, adjusted for patient age, Injury Severity Score, gender, receipt of fresh frozen plasma or platelets, RBC volume, brain injury, and injury mechanism (blunt or penetrating). RESULTS: One thousand six hundred forty-seven patients met the study inclusion criteria. Among patients who were transfused 1 or 2 RBC units, no difference in mortality with respect to RBC age was identified (adjusted RR, 0.97; 95% CI, 0.72-1.32). Among patients who were transfused 3 or more RBC units, receipt of old versus fresh RBCs was associated with a significantly increased risk of mortality, with an adjusted RR of 1.57 (95% CI, 1.14-2.15). No difference was observed concerning the mean number of old versus fresh units transfused to patients who received 3 or more units (6.05 vs. 5.47, respectively; p = 0.11). CONCLUSION: In trauma patients undergoing transfusion of 3 or more RBC units within 24 hour of hospital arrival, receipt of relatively older blood was associated with a significantly increased mortality risk. Reservation of relatively fresh RBC units for the acutely injured may be advisable.

Management of colon wounds in the setting of damage control laparotomy: a cautionary tale.

BACKGROUND: Although colon wounds are commonly treated in the setting of damage control laparotomy (DCL), a paucity of data exist to guide management. The purpose of this study was to evaluate our experience with the management of colonic wounds in the context of DCL, using colonic wound outcomes after routine, single laparotomy (SL) as a benchmark. METHODS: Consecutive patients during a 7-year period with full-thickness or devitalizing colon injury were identified. Early deaths (<48 hour) were excluded. Colon-related complications (abscess, suture or staple leak, and stomal ischemia) were compared between those managed in the setting of DCL versus those managed by SL, both overall and as stratified by procedure (primary repair, resection and anastomosis, and resection and colostomy). RESULTS: One hundred fifty-seven patients met study criteria: 101 had undergone SL and 56 had undergone DCL. Comparison of DCL patients with SL patients was notable for a significant difference in colon-related complications (30% vs. 12%, p < 0.005) and suture/staple leak in particular (12% vs. 3%, p < 0.05). Stratification by procedure revealed a significant difference in colon-related complications among those that underwent resection and anastomosis (DCL: 39% vs. SL: 18%, p < 0.05), whereas no differences were observed in those who underwent primary repair or resection and colostomy. CONCLUSIONS: Management of colonic wounds in the setting of DCL is associated with a relatively high incidence of complications. The excessive incidence of leak overall and morbidity particular to resection and anastomosis, however, give us pause. Although stoma construction is not without its own complications in the setting of DCL, it may be the safer alternative.

The relationship of blood product ratio to mortality: survival benefit or survival bias?

BACKGROUND: Recent studies show an apparent survival advantage associated with the administration of higher cumulative ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC). It remains unclear how temporal factors and survival bias may influence these results. The objective of this study was to evaluate the temporal relationship between blood product ratios and mortality in massively transfused trauma patients. METHODS: Patients requiring massive transfusion (>10 units of PRBC within 24 hours of admission) between 2005 and 2007 were identified (n = 134). In-hospital mortality was compared between patients receiving high (>1:2) versus low (<1:2) FFP:PRBC ratios with a regression model, using the FFP:PRBC ratio as a fixed value at 24 hours (method I) and as a time-varying covariate (method II). RESULTS: The FFP:PRBC ratio for all patients was low early and increased over time. Sixty-eight percent of total blood products were given and 54% of deaths occurred during the first 6 hours. Using method I, patients receiving a high FFP:PRBC ratio (mean, 1:1.3) by 24 hours had a 63% lower risk of death (RR, 0.37; 95% CI, 0.22-0.64) compared with those receiving a low ratio (mean, 1:3.7). However, this association was no longer statistically significant (RR, 0.84; 95% CI, 0.47-1.50) when the timing of component product transfusion was taken into account (method II). CONCLUSIONS: Similar to previous studies, an association between higher FFP:PRBC ratios at 24 hours and improved survival was observed. However, after adjustment for survival bias in the analysis, the association was no longer statistically significant. Prospective trials are necessary to evaluate whether hemostatic resuscitation is clinically beneficial.

Progesterone in traumatic brain injury: time to move on to phase III trials.

There are several candidate neuroprotective agents that have been shown in preclinical testing to improve outcomes following traumatic brain injury (TBI). Xiao and colleagues have performed an in hospital, double blind, randomized, controlled clinical trial utilizing progesterone in the treatment of patients sustaining TBI evaluating safety and long term clinical outcomes. These data, combined with the results of the previously published ProTECT trial, show progesterone to be safe and potentially efficacious in the treatment of TBI. Larger phase III trials will be necessary to verify results prior to clinical implementation. Clinical trials networks devoted to the study of TBI are vital to the timely clinical testing of these candidate agents and need to be supported.

Closing the open abdomen: improved success with Wittmann Patch staged abdominal closure.

BACKGROUND: Although the "open abdomen" has likely contributed to improved outcomes in trauma patients, the challenge of subsequent fascial closure has emerged. Since mid 2004, we have incorporated Wittmann Patch staged abdominal closure into our management of the open abdomen. The purpose of this study was to evaluate the impact of this device on our incidence of fascial closure versus planned ventral hernia. METHODS: Patients managed by open abdomen from 2001 through 2006 were identified from the trauma registry. Fascial closure immediately after definitive repair of injuries was defined as "early fascial closure." Continuation of the open abdomen beyond the definitive repair of injuries with subsequent fascial closure was defined as "delayed fascial closure." Since April 2004, the Wittmann Patch was uniformly employed in open abdomen management. Patients managed before the use of this device ("pre-Patch") were compared with those managed in the "Patch" era. RESULTS: Fifty-six open abdomens were managed in the pre-Patch era and 103 were managed in the Patch era. In the pre-Patch era, 33 (59%) underwent early fascial closure, compared with 67 (65%) in the Patch era (p NS). For the remaining patients, the incidence of delayed fascial closure was significantly higher in those managed with the Wittmann Patch compared with those managed in the pre-Patch era (78% vs. 30%, p < 0.001). Planned ventral hernia was performed in 8 (8%) patients in the Patch era versus 16 (29%) patients in the pre-Patch era (p < 0.001). Abdominal complications were similar between groups (11% vs. 9%, p NS). CONCLUSIONS: Incorporating the Wittmann Patch into a clinical pathway for management of the open abdomen has contributed to an increased incidence of delayed fascial closure. Abdominal complications were similar in both groups, suggesting that the device is not only efficacious, but also relatively safe.

Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS).

BACKGROUND: Laboratory-based evidence of coagulopathy (LC) is observed in 25-35% of trauma patients, but clinically-evident coagulopathy (CC) is not well described. METHODS: Prospective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. RESULTS: Of 1,019 highest-risk patients, CC+ (n=41, 4%) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59% vs 12%) than CC- (n=978, 96%). The overall incidence of LC was 39%. 30-day mortality was 22% vs 9% in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95% CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95% CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95% CI 1.1-1.3), and INR >1.5 (RR 5.4, 95% CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. CONCLUSION: CC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.

Use of a fascial prosthesis for management of abdominal compartment syndrome secondary to obstetric hemorrhage.

BACKGROUND: Massive obstetric hemorrhage can be catastrophic, with considerable maternal morbidity and mortality. CASE: A 41-year-old term gravida experienced massive postpartum hemorrhage attributed to an amniotic fluid embolism with rapid development of disseminated intravascular coagulation and resultant abdominal compartment syndrome. In this critically ill patient, a fascial prosthesis used for abdominal wall closure was placed to expedite multiple abdominal explorations and packing. Additionally, this device facilitated fascial closure once the abdominal compartment syndrome was resolved. CONCLUSION: Abdominal compartment syndrome resulting from overwhelming obstetric hemorrhage may necessitate emergent decompressive laparotomy to alleviate increased intra-abdominal pressure and end-organ dysfunction. The fascial prosthesis allows a staged abdominal wall closure to be performed once the abdominal compartment syndrome is resolved.

Age-related gender differential in outcome after blunt or penetrating trauma.

Although laboratory studies indicate that female rodents better tolerate the deleterious consequences of trauma and have higher survival rates than male rodents, it remains unclear whether a similar gender dimorphic pattern is evident in humans. In view of this, the association between gender and mortality in trauma patients admitted to a University Level I Trauma Center was assessed. All adult patients admitted to the University of Alabama at Birmingham Trauma Center with blunt or penetrating injury between July 1996 and March 2001 were selected for analysis. Patients were categorized by mechanism (blunt or penetrating), and odds ratios (ORs) were used to compare the risk of death among males compared with females. The ORs were stratified according to age and were adjusted for demographic, medical, and injury characteristics. Male blunt trauma patients <50 years old had a 2.5 times (95% CI 1.3-4.9) higher risk of death than females; however, for those > or = 50 years old, a smaller, nonstatistically significant difference was apparent (OR 1.4, 95% CI 0.8-2.3). Conversely, for penetrating trauma, males <50 years old exhibited an increased yet nonsignificant risk of death (OR 1.8, 95% CI 0.6-5.4), whereas those > or = 50 years old had a survival advantage (OR 0.1, 95% CI 0.02-0.5). Laboratory studies have demonstrated that estrogens are salutary and androgens are detrimental for survival following trauma-hemorrhage. The results of this study suggest that the physiologic pattern of premenopausal adult female sex hormones may provide a survival advantage in blunt trauma patients; however, the converse pattern prevails for the penetrating trauma patients.

Risk factors for conversion to permanent ventricular shunt in patients receiving therapeutic ventriculostomy for traumatic brain injury.

BACKGROUND: Intracranial pressure is routinely monitored in patients with severe traumatic brain injury (TBI). Patients with TBI sometimes develop hydrocephalus, requiring permanent cerebrospinal fluid (CSF) diversion. OBJECTIVE: To quantify the need for permanent CSF diversion in patients with TBI. METHODS: Patients who received a ventriculostomy after TBI between June 2007 and July 2008 were identified, and their medical records were abstracted to a database. RESULTS: Sixteen of 71 patients (22.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. The average number of days between ventriculostomy and shunt was 18.3. Characteristics that predispose these patients to require permanent CSF diversion include the need for craniotomy within 48 hours of admission (odds ratio, 5.20; 95% confidence interval, 1.48-18.35) and history of culture-positive CSF (odds ratio, 5.52; 95% confidence interval, 1.19-25.52). Length of stay was increased in patients receiving permanent CSF diversion (average length of stay, 61 vs 31 days; P = .04). Patient discharge disposition was similar between shunted and nonshunted patients. CONCLUSION: In this retrospective study, 22% of TBI patients who required a ventriculostomy eventually needed permanent CSF diversion. Patients with TBI should be assessed for the need for permanent CSF diversion before discharge from the hospital. Care must be taken to prevent ventriculitis. Future studies are needed to evaluate more thoroughly the risk factors for the need for permanent CSF diversion in this patient population.

Motor vehicle crash-related mortality is associated with prehospital and hospital-based resource availability.

BACKGROUND: To date, attempts to assess the relationship between motor vehicle collision (MVC)-related mortality and medical resources availability have largely been unsuccessful. METHODS: Information regarding sociodemographic characteristics, prehospital resources, and hospital-based resources for each county (n = 67) in the state of Alabama was obtained. MVC-related mortality rates (deaths per 1,000 collisions) by county were calculated and compared according to prehospital and hospital-based resource availability within each county after correcting for sociodemographic factors. RESULTS: Counties with 24-hour availability of a general surgeon, orthopedic surgeon, neurosurgeon, computed tomographic scanner, and operating room were shown to have decreased MVC-related mortality (relative risk [RR], 0.88). The same was true for those counties with hospitals classified as Level I-II (RR, 0.71) and Level III-IV (RR, 0.83) trauma centers compared with counties with no trauma centers. CONCLUSION: Appropriate, readily available hospital-based resources are associated with lower MVC-related mortality rates. This information may be useful in trauma system planning and development.

Specific occupant and collision characteristics are associated with motor vehicle collision-related blunt cerebrovascular artery injury.

BACKGROUND: Blunt cerebrovascular artery injury (BCI) remains difficult to diagnose but is recognized with increasing frequency after motor vehicle collisions (MVCs). Failure to detect this injury in a timely fashion can be devastating. Criteria that can be used to heighten the suspicion of this injury have been suggested; however, more encompassing screening has been recommended. To address this need, we sought to describe occupant, vehicle, and collision characteristics among MVC occupants who sustained a BCI. METHODS: All cases of BCI identified in the National Automotive Sampling System Crashworthiness Data System, a national probability sample of passenger vehicles involved in police-reported tow-away MVCs, between 1993 and 2001 were selected. Information on occupant (e.g., demographics, seating position, and restraint use), collision (e.g., collision type and severity), and vehicle characteristics were obtained and summarized using descriptive statistics. RESULTS: Nine-hundred forty individuals with BCI were identified in the Crashworthiness Data System data files. Over half were belted (57.4%) and 82.3% had airbag deployment; 16.2% were partially or completely ejected from the vehicle. Head and thoracic injuries were common (44.4% and 40.8%, respectively); 27.8% sustained a cervical spine fracture and 21.0% sustained a soft-tissue injury to the neck. The mean Injury Severity Score was 33.6. The case fatality rate was 44.5%. The majority of BCI occupants were drivers (76.0%). Among belted occupants, the lap/shoulder was the most commonly attributed as the injury source (61.4%). Among unbelted occupants, frequent injury sources included air bags (15.0%), windshield (13.7%), and other interior objects. With respect to collision characteristics, the average change in velocity (Delta V) was 43.3 km/h. The majority of collisions were frontal (76.2%). CONCLUSION: This study indicates that BCI is both a rare and lethal injury typified by specific occupant and collision characteristics. These characteristics provide insight as to the cause of this injury that may aid in the evaluation and management of the blunt trauma patient at risk for BCI.

The evolution of chest computed tomography for the definitive diagnosis of blunt aortic injury: a single-center experience.

BACKGROUND: Chest computed tomography (CT) is an excellent screening tool for blunt aortic injuries (BAIs). Aortography is considered the "gold standard" for diagnosis. Recent evidence suggests that new-generation, multislice, helical CT technology can accurately diagnose BAI. METHODS: A retrospective review of aortograms performed to evaluate for BAI was compared with the results of CT and operative findings. BAIs definitively diagnosed by CT alone were also studied. RESULTS: Between July 1, 1996, and June 30, 2002, 113 aortograms were obtained, with 28 BAI cases confirmed. Of these, 27 were congruently diagnosed by CT. Only one computed tomographic scan diagnostic for BAI had a subsequent negative aortogram. Seventeen BAIs were diagnosed with CT alone. Ten were confirmed operatively and seven were treated nonoperatively because of age, comorbid conditions, severity of injury, or the presence of small intimal defects. CONCLUSION: CT technology has evolved to allow for the definitive diagnosis and treatment of BAI. Aortography should still be used where new-generation CT is not available.