Early Prehospital Tranexamic Acid Following Injury Is Associated With a 30-day Survival Benefit: A Secondary Analysis of a Randomized Clinical Trial.

OBJECTIVE: We sought to characterize the timing of administration of prehospital tranexamic acid (TXA) and associated outcome benefits. BACKGROUND: TXA has been shown to be safe in the prehospital setting post-injury. METHODS: We performed a secondary analysis of a recent prehospital randomized TXA clinical trial in injured patients. Those who received prehospital TXA within 1 hour (EARLY) from time of injury were compared to those who received prehospital TXA beyond 1 hour (DELAYED). We included patients with a shock index of >0.9. Primary outcome was 30-day mortality. Kaplan-Meier and Cox Hazard regression were utilized to characterize mortality relationships. RESULTS: EARLY and DELAYED patients had similar demographics, injury characteristics, and shock severity but DELAYED patients had greater prehospital resuscitation requirements and longer prehospital times. Stratified Kaplan-Meier analysis demonstrated significant separation for EARLY patients (N = 238, log-rank chi-square test, 4.99; P = 0.03) with no separation for DELAYED patients (N = 238, log-rank chi-square test, 0.04; P = 0.83). Stratified Cox Hazard regression verified, after controlling for confounders, that EARLY TXA was associated with a 65% lower independent hazard for 30-day mortality [hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.19-0.65, P = 0.001] with no independent survival benefit found in DELAYED patients (HR 1.00, 95% CI 0.63-1.60, P = 0.999). EARLY TXA patients had lower incidence of multiple organ failure and 6-hour and 24-hour transfusion requirements compared to placebo. CONCLUSIONS: Administration of prehospital TXA within 1 hour from injury in patients at risk of hemorrhage is associated with 30-day survival benefit, lower incidence of multiple organ failure, and lower transfusion requirements.

A Case of Local Radiation Injury in the Creation of Lichtenburg Art.

Despite the fact that there may be no immediate outward signs of tissue destruction, the ultimate damage caused by radiation exposure is immediate and may be predicted based on the source, length of exposure, and type of tissue to which the radiation is exposed. Although predictable, difficulty in caring for these patients stems from the multiple sources of radiation to which people may be exposed, the various parts of the body exposed, the dose involved, the rarity of the condition, and a general lack of knowledge on the part of treating physicians. Due to these factors, there is significant variation in treatment recommendations. Additionally, knowledge about how to treat these injuries is limited and often very difficult to access, even among healthcare professionals. This report highlights the first known case of localized radiation injury secondary to the utilization of a linear accelerator to generate Lichtenberg art. In this case, an accident occurred while working with a retired accelerator and led to severe local radiation injury to this patient's bilateral hands, prompting a series of searches and inquiries as to the next best step in management. From consulting clinicians at the Centers for Disease Control and Prevention (CDC) who are experts in managing radiation injury to the eventual need for digit amputation, this case highlights the profound lack of knowledge and accessible resources for clinicians and patients facing localized radiation injury. This is a noninterventional observation case report without the requirement of ethical approval.

Missingness matters: a secondary analysis of thromboelastography measurements from a recent prehospital randomized tranexamic acid clinical trial.

Background: Tranexamic acid (TXA) has been hypothesized to mitigate coagulopathy in patients after traumatic injury. Despite previous prehospital clinical trials demonstrating a TXA survival benefit, none have demonstrated correlated changes in thromboelastography (TEG) parameters. We sought to analyze if missing TEG data contributed to this paucity of findings. Methods: We performed a secondary analysis of the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport Trial. We compared patients that received TEG (YES-TEG) and patients unable to be sampled (NO-TEG) to analyze subgroups in which to investigate TEG differences. TEG parameter differences across TXA intervention arms were assessed within subgroups disproportionately present in the NO-TEG relative to the YES-TEG cohort. Generalized linear models controlling for potential confounders were applied to findings with p<0.10 on univariate analysis. Results: NO-TEG patients had lower prehospital systolic blood pressure (SBP) (100 (78, 140) vs 125 (88, 147), p<0.01), lower prehospital Glascow Coma Score (14 (3, 15) vs 15 (12, 15), p<0.01), greater rates of prehospital intubation (39.4% vs 24.4%, p<0.01) and greater mortality at 30 days (36.4% vs 6.8%, p<0.01). NO-TEG patients had a greater international normalized ratio relative to the YES-TEG subgroup (1.2 (1.1, 1.5) vs 1.1 (1.0, 1.2), p=0.04). Within a severe prehospital shock cohort (SBP<70), TXA was associated with a significant decrease in clot lysis at 30 min on multivariate analysis (ß=-27.6, 95% CI (-51.3 to -3.9), p=0.02). Conclusions: Missing data, due to the logistical challenges of sampling certain severely injured patients, may be associated with a lack of TEG parameter changes on TXA administration in the primary analysis. Previous demonstration of TXA's survival benefit in patients with severe prehospital shock in tandem with the current findings supports the notion that TXA acts at least partially by improving clot integrity. Level of evidence: Level II.

Prehospital tranexamic acid is associated with a survival benefit without an increase in complications: results of two harmonized randomized clinical trials.

INTRODUCTION: Recent randomized clinical trials have demonstrated that prehospital tranexamic acid (TXA) administration following injury is safe and improves survival. However, the effect of prehospital TXA on adverse events, transfusion requirements and any dose response relationships require further elucidation. METHODS: A secondary analysis was performed using harmonized data from two large, double-blinded, randomized prehospital TXA trials. Outcomes, including 28-day mortality, pertinent adverse events and 24-hour red cell transfusion requirements were compared between TXA and placebo groups. Regression analyses were utilized to determine the independent associations of TXA after adjusting for study enrollment, injury characteristics and shock severity across a broad spectrum of injured patients. Dose response relationships were similarly characterized based upon grams of prehospital TXA administered. RESULTS: A total of 1744 patients had data available for secondary analysis and were included in the current harmonized secondary analysis. The study cohort had an overall mortality of 11.2% and a median injury severity score of 16 (IQR: 5-26). TXA was independently associated with a lower risk of 28-day mortality (HR: 0.72, 95% CI 0.54, 0.96, p = 0.03). Prehospital TXA also demonstrated an independent 22% lower risk of mortality for every gram of prehospital TXA administered (HR: 0.78, 95% CI 0.63, 0.96, p = 0.02). Multivariable linear regression verified that patients who received TXA were independently associated with lower 24-hour red cell transfusion requirements (ß: -0.31, 95% CI -0.61, -0.01, p = 0.04) with a dose-response relationship (ß: -0.24, 95% CI -0.45, -0.02, p = 0.03). There was no independent association of prehospital TXA administration on VTE, seizure, or stroke. CONCLUSIONS: In this secondary analysis of harmonized data from two large randomized interventional trials, prehospital TXA administration across a broad spectrum of injured patients is safe. Prehospital TXA is associated with a significant 28-day survival benefit, lower red cell transfusion requirements at 24 hours and demonstrates a dose-response relationship. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Mechanism matters: mortality and endothelial cell damage marker differences between blunt and penetrating traumatic injuries across three prehospital clinical trials.

Injury mechanism is an important consideration when conducting clinical trials in trauma. Mechanisms of injury may be associated with differences in mortality risk and immune response to injury, impacting the potential success of the trial. We sought to characterize clinical and endothelial cell damage marker differences across blunt and penetrating injured patients enrolled in three large, prehospital randomized trials which focused on hemorrhagic shock. In this secondary analysis, patients with systolic blood pressure < 70 or systolic blood pressure < 90 and heart rate > 108 were included. In addition, patients with both blunt and penetrating injuries were excluded. The primary outcome was 30-day mortality. Mortality was characterized using Kaplan-Meier and Cox proportional-hazards models. Generalized linear models were used to compare biomarkers. Chi squared tests and Wilcoxon rank-sum were used to compare secondary outcomes. We characterized data of 696 enrolled patients that met all secondary analysis inclusion criteria. Blunt injured patients had significantly greater 24-h (18.6% vs. 10.7%, log rank p = 0.048) and 30-day mortality rates (29.7% vs. 14.0%, log rank p = 0.001) relative to penetrating injured patients with a different time course. After adjusting for confounders, blunt mechanism of injury was independently predictive of mortality at 30-days (HR 1.84, 95% CI 1.06-3.20, p = 0.029), but not 24-h (HR 1.65, 95% CI 0.86-3.18, p = 0.133). Elevated admission levels of endothelial cell damage markers, VEGF, syndecan-1, TM, S100A10, suPAR and HcDNA were associated with blunt mechanism of injury. Although there was no difference in multiple organ failure (MOF) rates across injury mechanism (48.4% vs. 42.98%, p = 0.275), blunt injured patients had higher Denver MOF score (p < 0.01). The significant increase in 30-day mortality and endothelial cell damage markers in blunt injury relative to penetrating injured patients highlights the importance of considering mechanism of injury within the inclusion and exclusion criteria of future clinical trials.

Repair of a Crossbow Bolt Injury of the Subclavian Artery Behind the Mid-clavicle.

The management of a rare midclavicular crossbow bolt injury to the subclavian artery is discussed. Important concepts include the initial clinical diagnosis, operative planning, the surgical approach to the retro-clavicular great vessels, the technical aspects of repair, and postoperative course. A discussion of the reasoning behind an operative vs. endovascular approach is also discussed.

Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage.

BACKGROUND: Hemorrhage is the leading cause of preventable death after injury. Others have shown that delays in massive transfusion cooler arrival increase mortality, while prehospital blood product resuscitation can reduce mortality. Our objective was to evaluate if time to resuscitation initiation impacts mortality. METHODS: We combined data from the Prehospital Air Medical Plasma (PAMPer) trial in which patients received prehospital plasma or standard care and the Study of Tranexamic Acid during Air and ground Medical Prehospital transport (STAAMP) trial in which patients received prehospital tranexamic acid or placebo. We evaluated the time to early resuscitative intervention (TERI) as time from emergency medical services arrival to packed red blood cells, plasma, or tranexamic acid initiation in the field or within 90 minutes of trauma center arrival. For patients not receiving an early resuscitative intervention, the TERI was calculated based on trauma center arrival as earliest opportunity to receive a resuscitative intervention and were propensity matched to those that did to account for selection bias. Mixed-effects logistic regression assessed the association of 30-day and 24-hour mortality with TERI adjusting for confounders. We also evaluated a subgroup of only patients receiving an early resuscitative intervention as defined above. RESULTS: Among the 1,504 propensity-matched patients, every 1-minute delay in TERI was associated with 2% increase in the odds of 30-day mortality (adjusted odds ratio [aOR], 1.020; 95% confidence interval [CI], 1.006-1.033; p < 0.01) and 1.5% increase in odds of 24-hour mortality (aOR, 1.015; 95% CI, 1.001-1.029; p = 0.03). Among the 799 patients receiving an early resuscitative intervention, every 1-minute increase in TERI was associated with a 2% increase in the odds of 30-day mortality (aOR, 1.021; 95% CI, 1.005-1.038; p = 0.01) and 24-hour mortality (aOR, 1.023; 95% CI, 1.005-1.042; p = 0.01). CONCLUSION: Time to early resuscitative intervention is associated with morality in trauma patients with hemorrhagic shock. Bleeding patients need resuscitation initiated early, whether at the trauma center in systems with short prehospital times or in the field when prehospital time is prolonged. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Putting Medical Boots on the Ground: Lessons from the War in Ukraine and Applications for Future Conflict with Near-Peer Adversaries.

In the past 20 years of the Global War on Terror, the US has seen substantial improvements in its system of medical delivery in combat. However, throughout that conflict, enemy forces did not have parity with the weaponry, capability, or personnel of the US and allied forces. War against countries like China and Russia, who are considered near-peer adversaries in terms of capabilities, will challenge battlefield medical care in many different ways. This article reviews the experience of a medical team, Global Surgical and Medical Support Group, that has been providing assistance, training, medical support, and surgical support to Ukraine since the Russian invasion began in February 2022. The team has extensive experience in medicine, surgery, austere environments, conflict zones, and building partner nation capacities. This article compares and contrasts the healthcare systems of this war against the systems used during the Global War on Terror. The lessons learned here could help the US anticipate challenges and successfully plan for the provision of medical care in a future conflict against an adversary with capabilities close to its own.

Prehospital tranexamic acid is associated with a dose-dependent decrease in syndecan-1 after trauma: A secondary analysis of a prospective randomized trial.

BACKGROUND: In the Study of Tranexamic Acid During Air and Ground Prehospital Transport (STAAMP) Trial, prehospital tranexamic acid (TXA) was associated with lower mortality in specific patient subgroups. The underlying mechanisms responsible for a TXA benefit remain incompletely characterized. We hypothesized that TXA may mitigate endothelial injury and sought to assess whether TXA was associated with decreased endothelial or tissue damage markers among all patients enrolled in the STAAMP Trial. METHODS: We collected blood samples from STAAMP Trial patients and measured markers of endothelial function and tissue damage including syndecan-1, soluble thrombomodulin (sTM), and platelet endothelial cell adhesion molecule-1 at hospital admission (0 hours) and 12 hours, 24 hours, and 72 hours after admission. We compared these marker values for patients in each treatment group during the first 72 hours, and modeled the relationship between TXA and marker concentration using regression analysis to control for potential confounding factors. RESULTS: We analyzed samples from 766 patients: 383 placebo, 130 abbreviated dosing, 119 standard dosing, and 130 repeat dosing. Lower levels of syndecan-1, TM, and platelet endothelial cell adhesion molecule measured within the first 72 hours of hospital admission were associated with survival at 30 days ( p < 0.001). At hospital admission, syndecan-1 was lower in the TXA group (28.30 [20.05, 42.75] vs. 33.50 [23.00, 54.00] p = 0.001) even after controlling for patient, injury, and prehospital factors ( p = 0.001). For every 1 g increase in TXA administered over the first 8 hours of prehospital transport and hospital admission, there was a 4-ng/mL decrease in syndecan-1 at 12 hours controlling for patient, injury, and treatment factors ( p = 0.03). CONCLUSION: Prehospital TXA was associated with decreased syndecan-1 at hospital admission. Syndecan-1 measured 12 hours after admission was inversely related to the dose of TXA received. Early prehospital and in-hospital TXA may decrease endothelial glycocalyx damage or upregulate vascular repair mechanisms in a dose-dependent fashion. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Evaluation of critical care burden following traumatic injury from two randomized controlled trials.

Trauma resuscitation practices have continued to improve with new advances targeting prehospital interventions. The critical care burden associated with severely injured patients at risk of hemorrhage has been poorly characterized. We aim to describe the individual and additive effects of multiorgan failure (MOF) and nosocomial infection (NI) on delayed mortality and resource utilization. A secondary analysis of harmonized data from two large prehospital randomized controlled trials (Prehospital Air Medical Plasma (PAMPer) Trial and Study of Tranexamic Acid during Air and Ground Medical Prehospital Transport (STAAMP) Trial) was conducted. Only those patients who survived beyond the first 24 hours post-injury and spent at least one day in the ICU were included. Patients were stratified by development of MOF only, NI only, both, or neither and diagnosis of early (≤ 3 days) versus late MOF (> 3 days). Risk factors of NI and MOF, time course of these ICU complications, associated mortality, and hospital resource utilization were evaluated. Of the 869 patients who were enrolled in PAMPer and STAAMP and who met study criteria, 27.4% developed MOF only (n = 238), 10.9% developed NI only (n = 95), and 15.3% were diagnosed with both MOF and NI (n = 133). Patients developing NI and/or MOF compared to those who had an uncomplicated ICU course had greater injury severity, lower GCS, and greater shock indexes. Early MOF occurred in isolation, while late MOF more often followed NI. MOF was associated with 65% higher independent risk of 30-day mortality when adjusting for cofounders (OR 1.65; 95% CI 1.04-2.6; p = 0.03), however NI did not significantly affect odds of mortality. NI was individually associated with longer mechanical ventilation, ICU stay, hospital stay, and rehabilitation requirements, and the addition of MOF further increased the burden of inpatient and post-discharge care. MOF and NI remain common complications for those who survive traumatic injury. MOF is a robust independent predictor of mortality following injury in this cohort, and NI is associated with higher resource utilization. Timing of these ICU complications may reveal differences in pathophysiology and offer targets for continued advancements in treatment.

Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage.

BACKGROUND: Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage. METHODS: We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders. RESULTS: A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02). CONCLUSION: For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Shocked Though the Heart and YouTube Is to Blame-The Rising Incidence of Accidental Trans-cardiac Electrocution From Do-It-Yourself Fractal Wood Art, and a Call to Action.

In the past year, we have become aware of a new mechanism of severe electrical injury ascribed to fractal wood art. This type of art has become increasingly popular and deadly due to exponential popularity in the use of Youtube type video teaching. This manuscript is one of the initial descriptions of the injury mode, presentation, treatment, and outcomes from four such cases treated at our institution. Additionally, we elicit a call for action in preventing further similar unnecessary injuries and deaths.

Early predictors of massive transfusion in patients sustaining torso gunshot wounds in a civilian level I trauma center.

BACKGROUND: Early prediction of the need for massive transfusion (MT) remains difficult. We hypothesized that MT protocol (MTP) utilization would improve by identifying markers for MT (>10 units packed red blood cell [PRBC] in 24 hours) in torso gunshot wounds (GSW) requiring early transfusion and operation. METHODS: Data from all MTPs were collected prospectively from February 1, 2007, to January 31, 2009. Demographic, transfusion, anatomic, and operative data were analyzed for MT predictors. RESULTS: Of the 216 MTP activations, 78 (36%) patients sustained torso GSW requiring early transfusion and operation. Five were moribund and died before receiving MT. Of 73 early survivors, 56 received MT (76%, mean 19 units PRBC) and 17 had early bleeding control (EBC), (24%, mean 5 units PRBC). Twelve transpelvic and 13 multicavitary wounds all received MT regardless of initial hemodynamic status (mean systolic blood pressure: 96 mm Hg; range, 50-169). Of 31 MT patients with low-risk trajectories (LRT), 18 (58%) had a systolic blood pressure <90 mm Hg compared with 3 of 17 (17%) in the EBC group (p < 0.01). In these same groups, a base deficit of <-10 was present in 27 of 31 (92%) MT patients versus 4 of 17 (23%) EBC patients (p < 0.01). The presence of both markers identified 97% of patients with LRT who requiring MT and their absence would have potentially eliminated 16 of 17 EBC patients from MTP activation. CONCLUSIONS: In patients requiring early operation and transfusion after torso GSW: (1) early initiation of MTP is reasonable for transpelvic and multicavitary trajectories regardless of initial hemodynamic status as multiple or difficult to control bleeding sources are likely and (2) early initiation of MTP in patients with LRT may be guided by a combination of hypotension and acidosis, indicating massive blood loss.

Occult pneumothoraces in patients with penetrating trauma: Does mechanism matter?

BACKGROUND: Supine anteroposterior (AP) chest radiography is an insensitive test for detecting posttraumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) not diagnosed by chest radiography. All previous literature describes the epidemiology of OPTX in patients with blunt polytrauma. Our goal was to identify the frequency of OPTXs in patients with penetrating trauma. METHODS: All patients with penetrating trauma admitted over a 10-year period to Grady Memorial Hospital with a PTX were identified. We reviewed patients' thoracoabdominal CT scans and corresponding chest radiographs. RESULTS: Records for 1121 (20%) patients with a PTX (penetrating mechanism) were audited; CT imaging was available for 146 (13%) patients. Of these, 127 (87%) had undergone upright chest radiography. The remainder (19 patients) had a supine AP chest radiograph. Fifteen (79%) of the PTXs detected on supine AP chest radiographs were occult. Only 10 (8%) were occult when an upright chest radiograph was used (p < 0.001). Posttraumatic PTXs were occult on chest radiographs in 17% (25/146) of patients. Fourteen (56%) patients with OPTXs underwent tube thoracostomy, compared with 95% (115/121) of patients with overt PTXs (p < 0.001). CONCLUSION: Up to 17% of all PTXs in patients injured by penetrating mechanisms will be missed by standard trauma chest radiographs. This increases to nearly 80% with supine AP chest radiographs. Upright chest radiography detects 92% of all PTXs and is available to most patients without spinal trauma. The frequency of tube thoracostomy use in patients with overt PTXs is significantly higher than for OPTXs in blunt and penetrating trauma.

Overutilization of Helicopter Transport in the Minimally Burned-A Healthcare System Problem That Should Be Corrected.

Eighty-eight percent of all patients burned in North America suffer burns of less than 20% TBSA. These patients may need care at a burn center, but barring any inhalation injury or polytrauma, these patients do not require helicopter transport (HEMS). We sought to identify a cohort of patients suffering smaller burns who do not benefit from HEMS to establish significant health care system savings. A 5-year retrospective analysis of data collected from our trauma registry was performed. Patients were separated into two groups: HEMS and ground transport (EMS). A subanalysis was performed between those with smaller burns (<20% TBSA and no ICU/OR requirement). ED disposition, hospital length of stay, distance transported, and cost was analyzed. Of 616 burn patients presenting to our center, 13% were transported by HEMS, 46% by ambulance, and 61% by private vehicle. Of those transported via HEMS, 38% had been evaluated and treated at an outside hospital before transfer. Patients transported via HEMS had larger burns (13 vs 9 %TBSA; P = .002) and deeper burns (P < .001), longer hospital stays (P = .003), higher ICU admission rates (P < .001), and mortality rates (P = .003) compared with those transported by EMS. Transport distance was a mean 5.5 times greater (88 vs 16 mi) in the HEMS group (P < .001). Within this cohort, 53% of patients transported via HEMS suffered smaller burns, compared with 73% transported by EMS. A subanalysis of the smaller burns cohort showed increased distances of transport via HEMS (91 vs 18 mi; P < .001) and increased rates of admission from the ED in the EMS group (93% vs 68% by HEMS; P = .005), yet no difference in length of stay, or rates of early discharge, defined as <24-hour hospital stay. Fully 1/4 of those transported via HEMS with smaller burns were discharged from the ED after burn consultation, debridement, and dressing. Mortality in both was nil. Average cost per helicopter transport was US$29K. Accurate triage and burn center consultation before scene transport or hospital transfer could help identify patients not benefiting from HEMS yet safely transferrable by ground, or better served by early clinic follow-up, which would reduce cost without compromising care in this cohort. Annual patient savings approximating US$444K could be multiplied were non-HEMS transport universally adopted for smaller burns.

Updating the Burn Center Referral Criteria: Results From the 2018 eDelphi Consensus Study.

Existing burn center referral criteria were developed several years ago, and subsequent innovations in burn care have occurred. Coupled with frequent errors in the estimation of extent of burn injury and depth by referring providers, patients are both over and under-triaged when the existing criteria are used to support patient care decisions. In the absence of compelling clinical trial data on appropriate burn patient triage, we convened a multidisciplinary panel of experts to execute an iterative eDelphi consensus process to facilitate a revision. The eDelphi process panel consisted of n = 61 burn stakeholders and experts and progressed through four rounds before reaching consensus on key clinical domains. The major findings are that 1) burn center consultation is strongly recommended for all patients with deep partial-thickness or deeper burns ≥ 10% TBSA burned, for full-thickness burns ≥ 5% TBSA burned, for children and older adults with specific dressing and medical needs, and for special burn circumstances including electrical, chemical, and radiation injuries; 2) smaller burns are ideally followed in burn center outpatient settings as soon as possible after injury, preferably without delays of a week or more; 3) frostbite, Stevens-Johnson syndrome/TENS, and necrotizing soft-tissue infection patients benefit from burn center treatment; and 4) telemedicine and technological solutions are of likely benefit in achieving this standard. Unlike the original criteria, the revised consensus-based guidelines create a framework promoting communication so that triage and treatment are specifically tailored to individual patient characteristics, injury severity, geography, and the capabilities of referring institutions.

Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial.

IMPORTANCE: In-hospital administration of tranexamic acid after injury improves outcomes in patients at risk for hemorrhage. Data demonstrating the benefit and safety of the pragmatic use of tranexamic acid in the prehospital phase of care are lacking for these patients. OBJECTIVE: To assess the effectiveness and safety of tranexamic acid administered before hospitalization compared with placebo in injured patients at risk for hemorrhage. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized clinical trial included injured patients with prehospital hypotension (systolic blood pressure ≤90 mm Hg) or tachycardia (heart rate ≥110/min) before arrival at 1 of 4 US level 1 trauma centers, within an estimated 2 hours of injury, from May 1, 2015, through October 31, 2019. INTERVENTIONS: Patients received 1 g of tranexamic acid before hospitalization (447 patients) or placebo (456 patients) infused for 10 minutes in 100 mL of saline. The randomization scheme used prehospital and in-hospital phase assignments, and patients administered tranexamic acid were allocated to abbreviated, standard, and repeat bolus dosing regimens on trauma center arrival. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day all-cause mortality. RESULTS: In all, 927 patients (mean [SD] age, 42 [18] years; 686 [74.0%] male) were eligible for prehospital enrollment (460 randomized to tranexamic acid intervention; 467 to placebo intervention). After exclusions, the intention-to-treat study cohort comprised 903 patients: 447 in the tranexamic acid arm and 456 in the placebo arm. Mortality at 30 days was 8.1% in patients receiving tranexamic acid compared with 9.9% in patients receiving placebo (difference, -1.8%; 95% CI, -5.6% to 1.9%; P = .17). Results of Cox proportional hazards regression analysis, accounting for site, verified that randomization to tranexamic acid was not associated with a significant reduction in 30-day mortality (hazard ratio, 0.81; 95% CI, 0.59-1.11, P = .18). Prespecified dosing regimens and post-hoc subgroup analyses found that prehospital tranexamic acid were associated with significantly lower 30-day mortality. When comparing tranexamic acid effect stratified by time to treatment and qualifying shock severity in a post hoc comparison, 30-day mortality was lower when tranexamic acid was administered within 1 hour of injury (4.6% vs 7.6%; difference, -3.0%; 95% CI, -5.7% to -0.3%; P < .002). Patients with severe shock (systolic blood pressure ≤70 mm Hg) who received tranexamic acid demonstrated lower 30-day mortality compared with placebo (18.5% vs 35.5%; difference, -17%; 95% CI, -25.8% to -8.1%; P < .003). CONCLUSIONS AND RELEVANCE: In injured patients at risk for hemorrhage, tranexamic acid administered before hospitalization did not result in significantly lower 30-day mortality. The prehospital administration of tranexamic acid after injury did not result in a higher incidence of thrombotic complications or adverse events. Tranexamic acid given to injured patients at risk for hemorrhage in the prehospital setting is safe and associated with survival benefit in specific subgroups of patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02086500.

Vasopressin in hemorrhagic shock: review article.

Trauma with resultant hypovolemic shock remains both prevalent and difficult to treat. Standard strategies using volume resuscitation and catecholamine support have historically yielded poor results. Vasopressin has emerged as a possible pharmacologic adjunct, particularly in patients with shock refractory to the administration of fluids and catecholamines. Much of the data regarding vasopressin is extrapolated from its usefulness in cases of nonhypovolemic human shock, which are supported by convincing animal studies. It is true that humans show a deficiency in vasopressin minutes after significant hemorrhage that can respond to administration of exogenous vasopressin. When given in physiological dosing regimens, vasopressin appears to be a safe adjunct to other therapy. Definite recommendations regarding indications for use, recommended dose, and long-term outcome in patients with hemorrhagic shock await a much needed prospective, randomized, controlled trial.

Temporary intravascular shunts: when are we really using them according to the NTDB?

Temporary intravascular shunts (TIVS) are synthetic intraluminal conduits that maintain arterial and/or venous blood flow. This technique can be used for: 1) replantation; 2) open extremity fractures with extensive soft tissue and arterial injuries; or 3) damage control (extremity/truncal). The literature defining TIVS is composed exclusively of small case series (primarily penetrating injuries). Our goal was to identify the injured population who actually undergoes TIVS using the National Trauma Data Bank (2001 to 2005). TIVS were placed in 395 patients (mean Injury Severity Score = 26; initial hemodynamic instability = 24%; mean based deficit = -7.2; mortality = 14%). Blunt mechanisms caused 64 per cent (251 of 395) of cases. Penetrating injuries were primarily gunshot wounds (97%). Concurrent severe extremity fractures and/or soft tissue defects were present in 185 (74%) blunt-injured patients. Only six of 111 centers performing TIVS used this technique five or more times. Only three centers used TIVS more than 10 times. The volume of TIVS use was similar across the study period (P > 0.05). TIVS is primarily used in blunt motor vehicle collision trauma with concurrent severe extremity fractures and soft tissue injuries. This provides distal perfusion while surgeons assess/fixate the limb. TIVS are placed relatively uncommonly by a large number of trauma centers with a few hospitals using them much more frequently for penetrating injuries.

Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center.

INTRODUCTION: Transfusion practices across the country are changing with aggressive use of plasma (fresh-frozen plasma [FFP]) and platelets during massive transfusion with current military recommendations to use component therapy at a 1:1:1 ratio of packed red blood cells to FFP to platelets. METHODS: A massive transfusion protocol (MTP) was designed to achieve a packed red blood cell:FFP:platelet ratio of 1:1:1 We prospectively gathered demographic, transfusion, and patient outcome data during the first year of the MTP and compared this with a similar cohort of injured patients (pre-MTP) receiving > or = 10 red blood cell (RBC) in the first 24 hours of hospitalization before instituting the MTP. RESULTS: One hundred sixteen MTP activations occurred. Twelve non-trauma patients and 31 who did not receive 10 RBC (15 deaths, 16 early bleeding controls) were excluded. Seventy-three MTP patients were compared with 84 patients with pre-MTP who had similar demographics and injury severity score (29 vs. 29, p = 0.99). MTP patients received an average of 23.7 RBC and 15.6 FFP transfusions compared with 22.8 RBC (p = 0.67) and 7.6 FFP (p < 0.001) transfusions in pre-MTP patients. Early crystalloid usage dropped from 9.4 L (pre-MTP) to 6.9 L (MTP) (p = 0.006). Overall patient mortality was markedly improved at 24 hours, from 36% in the pre-MTP group to 17% in the MTP group (p = 0.008) and at 30 days (34% mortality MTP group vs. 55% mortality in pre-MTP group, p = 0.04). Blunt trauma survival improvements were more marked and more sustained than victims of penetrating trauma. Early deaths from coagulopathic bleeding occurred in 4 of 13 patients in the MTP group vs. 21 of 31 patients in the pre-MTP group (p = 0.023). CONCLUSIONS: In the civilian setting, aggressive use of FFP and platelets drastically reduces 24-hour mortality and early coagulopathy in patients with trauma. Reduction in 30 day mortality was only seen after blunt trauma in this small subset.