Early Cold Stored Platelet Transfusion Following Severe Injury: A Randomized Clinical Trial.

OBJECTIVE: To determine the feasibility, efficacy, and safety of early cold stored platelet transfusion compared with standard care resuscitation in patients with hemorrhagic shock. BACKGROUND: Data demonstrating the safety and efficacy of early cold stored platelet transfusion are lacking following severe injury. METHODS: A phase 2, multicenter, randomized, open label, clinical trial was performed at 5 US trauma centers. Injured patients at risk of large volume blood transfusion and the need for hemorrhage control procedures were enrolled and randomized. The intervention was the early transfusion of a single apheresis cold stored platelet unit, stored for up to 14 days versus standard care resuscitation. The primary outcome was feasibility and the principal clinical outcome for efficacy and safety was 24-hour mortality. RESULTS: Mortality at 24 hours was 5.9% in patients who were randomized to early cold stored platelet transfusion compared with 10.2% in the standard care arm (difference, -4.3%; 95% CI, -12.8% to 3.5%; P =0.26). No significant differences were found for any of the prespecified ancillary outcomes. Rates of arterial and/or venous thromboembolism and adverse events did not differ across treatment groups. CONCLUSIONS AND RELEVANCE: In severely injured patients, early cold stored platelet transfusion is feasible, safe and did not result in a significant lower rate of 24-hour mortality. Early cold stored platelet transfusion did not result in a higher incidence of arterial and/or venous thrombotic complications or adverse events. The storage age of the cold stored platelet product was not associated with significant outcome differences. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04667468.

Female Victims of Firearm Intimate Partner Violence: Characterization and Lethality Predictors.

Objective: To characterize the sociological risk factors for firearm intimate partner violence (IPV) among women in Texas, with a focus on lethal predictors to aid in screening and intervention guidelines. Methods: A retrospective medical and forensic chart review was conducted and supplemented by news sources, public police reports, and court records on firearm cases in Houston, TX, from 2018 to 2020. IPV was defined as a cis-gendered female victim of firearm violence from a current or ex-intimate partner. Non-IPV was defined as cis-gendered female victims of firearm violence from strangers, friends/acquaintances, gang, client, or similar relationships. Numeric variables were compared using the Wilcoxon rank-sum test and reported as median [Q1, Q3]. Categorical variables were compared using Fisher's exact test and reported as count (%). Results: A total of 102 cases of IPV were identified. Nonspousal IPV was more prevalent than spousal (65.7% versus 34.3%). Lethal injuries, older age, home location, and head injuries were more prevalent in the IPV cohort. Older age, spousal perpetrator, home shooting location, and history of prior domestic abuse were associated with lethal IPV. There were 31 cases of murder-suicide. During the COVID-19 pandemic, IPV cases increased by 91.3%, with lethal cases increasing by 57.6%. Conclusion: Risk factors for overall IPV and lethal IPV are not the same; therefore, it is imperative that all women, irrespective of race, age, or relationship status, be screened for IPV and prior domestic violence to allow intervention and prevention of lethal IPV. Patients should also be screened for personal or partner access to firearms as firearm IPV is a highly lethal form of violence.

Serial CT for Nonoperatively Managed Splenic Injuries.

INTRODUCTION: The role of serial computed tomography (CT) in the nonoperative management of blunt splenic injuries (NOMSIs) remains unclear. The purpose of the study was to determine the utility of serial CT of Grade 2-5 NOMSI in the modern era. METHODS: Blunt splenic injuries were identified over a 3.5-year period, ending in 6/2020. Our institutional protocol for NOMSI mandates a repeat 24-hour CT for Grade 2-5 injuries. Patients age<18, Grade 1 injuries and patients that underwent intervention prior to repeat scan were excluded. Demographics, comorbidities, timing of events (admission, CTs, splenectomy, and angiography), injury details, procedural details, total transfusion requirements, complications, length of stay, mortality, and discharge disposition were recorded. Descriptive statistics were performed. RESULTS: 219 patients with Grade 2-5 NOMSI had both an initial and 24-hour CT after exclusions. 24-hour CT identified 14 patients with new PSA(s) and 11 (5%) went to angiography within 24 hours with 9 (4%) undergoing angioembolization and 4 (2%) had splenectomy. Two hundred and four (93%) had no intervention though eventually 12 went on to angiography and 6 went for splenectomy. The 24-hour CT rarely altered management in the absence of clinical indication or prior PSA on initial CT with 5 (2%) receiving a therapeutic embolization and 2 (1%) had a nontherapeutic angiogram. No deaths were attributable to splenic injury. CONCLUSIONS: Routine 24-hour CT for NOMSI did not impact management. Clinical status and change in exam may warrant repeat CT in select cases in the setting of a plausible alternate explanation. Prompt angioembolization or splenectomy is more appropriate in clear-cut cases of failed NOMSI.

Cryoprecipitate use during massive transfusion: A propensity score analysis.

INTRODUCTION: Cryoprecipitate is frequently administered as an adjunct to balanced transfusion in the setting of traumatic hemorrhage. However, civilian studies have not demonstrated a clear survival advantage, and prior observational studies noted selection bias when analyzing cryoprecipitate use. Additionally, due to the logistics involved in cryoprecipitate administration, it is inconsistently implemented alongside standardized massive transfusion protocols. This study aims to evaluate the effects of early cryoprecipitate administration on inpatient mortality in the setting of massive transfusion for exsanguinating trauma and to use propensity score analysis to minimize selection bias. METHODS: The registry of an urban level 1 trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 h of presentation. Univariate analysis, multiple logistic regression, and propensity score matching were performed. RESULTS: 562 patients were identified. Patients with lower median RTS (6.86 (IQR 4.09-7.84) vs 7.6 (IQR 5.97-7.84), P<0.01), decreased Glasgow coma scale (12 (IQR 4-15) vs 15 (IQR 10-15), P<0.01), and increased lactate (7.5 (IQR 4.3-10.2) vs 4.9 (IQR 3.1-7.2), P<0.01) were more commonly administered cryoprecipitate. Mortality was greater among those who received cryoprecipitate (40.2% vs 23.7%, p<0.01) on univariate analysis. Neither multiple logistic regression (OR 0.917; 95% confidence interval 0.462-1.822; p = 0.805) nor propensity score matching (average treatment effect on the treated 2.3%, p = 0.77) revealed that cryoprecipitate administration was associated with a difference in inpatient mortality. CONCLUSIONS: Patients receiving cryoprecipitate within 4 h of presentation were more severely injured at presentation and had increased inpatient mortality. Multivariable logistic regression and propensity score analysis failed to show that early administration of cryoprecipitate was associated with survival benefit for exsanguinating trauma patients. The prospect of definitively assessing the utility of cryoprecipitate in exsanguinating hemorrhage warrants prospective investigation.

Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score.

PURPOSE: Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma. METHODS: All patients with a discharge diagnosis of bowel and/or mesenteric injury after blunt trauma were identified over a 5-year period. Admission CT scans were reviewed to identify potential predictors of bowel and/or mesenteric injury. Patients were then stratified by operative intervention [therapeutic laparotomy (TL) vs. non-therapeutic laparotomy (NTL)] and compared. All potential predictors included in the initial regression model were assigned one point and a score based on the number of predictors was calculated: the radiographic predictors of therapeutic operative intervention (RAPTOR) score. RESULTS: 151 patients were identified. 114 (76%) patients underwent operative intervention. Of these, 75 patients (66%) underwent TL. Multifocal hematoma, acute arterial extravasation, bowel wall hematoma, bowel devascularization, fecalization, pneumoperitoneum and fat pad injury, identified as potential predictors on univariable analysis, were included in the initial regression model and comprised the RAPTOR score. The optimal RAPTOR score was identified as ≥ 3, with a sensitivity, specificity and positive predictive value of 67%, 85% and 86%, respectively. Acute arterial extravasation (OR 3.8; 95% CI 1.2-4.3), bowel devascularization (OR 14.5; 95% CI 11.8-18.4) and fat pad injury (OR 4.5 95% CI 1.6-6.2) were identified as independent predictors of TL (AUC 0.91). CONCLUSIONS: CT imaging remains vital in assessing for potential bowel and/or mesenteric injuries following blunt abdominal trauma. The RAPTOR score provides a simplified approach to predict the need for early therapeutic operative intervention.