Characteristics of traumatic major haemorrhage in a tertiary trauma center.

BACKGROUND: Major traumatic haemorrhage is potentially preventable with rapid haemorrhage control and improved resuscitation techniques. Although advances in prehospital trauma management, haemorrhage is still associated with high mortality. The aim of this study was to use a recent pragmatic transfusion-based definition of major bleeding to characterize patients at risk of major bleeding and associated outcomes in this cohort after trauma. METHODS: This was a retrospective cohort study including all trauma patients (n = 7020) admitted to a tertiary trauma center from January 2015 to June 2020. The major bleeding cohort (n = 145) was defined as transfusion of 4 units of any blood components (red blood cells, plasma, or platelets) within 2 h of injury. Univariate and multivariable logistic regression analyses were performed to identify risk factors for 24-hour and 30-day mortality post trauma admission. RESULTS: In the major bleeding cohort (n = 145; 145/7020, 2.1% of the trauma population), there were 77% men (n = 112) and 23% women (n = 33), median age 39 years [IQR 26-53] and median Injury Severity Score (ISS) was 22 [IQR 13-34]. Blunt trauma dominated over penetrating trauma (58% vs. 42%) where high-energy fall was the most common blunt mechanism and knife injury was the most common penetrating mechanism. The major bleeding cohort was younger (OR 0.99; 95% CI 0.98 to 0.998, P = 0.012), less female gender (OR 0.66; 95% CI 0.45 to 0.98, P = 0.04), and had more penetrating trauma (OR 4.54; 95% CI 3.24 to 6.36, P = 0.001) than the rest of the trauma cohort. A prehospital (OR 2.39; 95% CI 1.34 to 4.28; P = 0.003) and emergency department (ED) (OR 6.91; 95% CI 4.49 to 10.66, P = 0.001) systolic blood pressure < 90 mmHg was associated with the major bleeding cohort as well as ED blood gas base excess < -3 (OR 7.72; 95% CI 5.37 to 11.11; P < 0.001) and INR > 1.2 (OR 3.09; 95% CI 2.16 to 4.43; P = 0.001). Emergency damage control laparotomy was performed more frequently in the major bleeding cohort (21.4% [n = 31] vs. 1.5% [n = 106]; OR 3.90; 95% CI 2.50 to 6.08; P < 0.001). There was no difference in transportation time from alarm to hospital arrival between the major bleeding cohort and the rest of the trauma cohort (47 [IQR 38;59] vs. 49 [IQR 40;62] minutes; P = 0.17). However, the major bleeding cohort had a shorter time from ED to first emergency procedure (71.5 [IQR 10.0;129.0] vs. 109.00 [IQR 54.0; 259.0] minutes, P < 0.001). In the major bleeding cohort, patients with penetrating trauma, compared to blunt trauma, had a shorter alarm to hospital arrival time (44.0 [IQR 35.5;54.0] vs. 50.0 [IQR 41.5;61.0], P = 0.013). The 24-hour mortality in the major bleeding cohort was 6.9% (10/145). All fatalities were due to blunt trauma; 40% (4/10) high energy fall, 20% (2/10) motor vehicle accident, 10% (1/10) motorcycle accident, 10% (1/10) traffic pedestrian, 10% (1/10) traffic other, and 10% (1/10) struck/hit by blunt object. In the logistic regression model, prehospital cardiac arrest (OR 83.4; 95% CI 3.37 to 2063; P = 0.007) and transportation time (OR 0.95, 95% CI 0.91 to 0.99, P = 0.02) were associated with 24-hour mortality. RESULTS: Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control. The major bleeding trauma cohort is a small part of the entire trauma population, and is characterized of being younger, male gender, higher ISS, and exposed to more penetrating trauma. Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition.

BACKGROUND: Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS: This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION: A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Epidemiology of firearm injuries in a Scandinavian trauma center.

BACKGROUND: There is a concern that civilian gunshot injuries in Europe are increasing but there is a lack of contemporary studies. The purpose of this study was to investigate the current epidemiology and outcome of firearm injuries. METHODS: Retrospective cohort study of all patients (n = 235) treated for firearm injuries admitted to a Scandinavian trauma center between 2005 and 2016. Local and national trauma registries were used for data collection. RESULTS: Mean age was 31.3 years (SD ± 12.9; range 16-88 years); 93.6% males; mean ISS was 14.3 (SD ± 15.9); 31.9% (75/235) had ISS > 15. There was a significant increase in penetrating trauma (P < 0.001) and firearm injuries (P < 0.001) over the years. The most common anatomical location of firearm injury was the lower extremity, (n = 138/235; 38%), followed by the abdomen (n = 69;19%), upper extremity (n = 53;15%), chest (n = 50; 14%), and head and neck (n = 50; 14%). Ninety patients (38.3%) had more than one anatomic injury location. There were in total 360 firearm injuries and 168 major surgical procedures were performed. 53% (n = 125) of patients underwent at least one surgical procedure. The most common procedures were fracture surgery 42% (n = 70/168), followed by laparotomy 30%% (n = 51), chest tube 17% (n = 29), and thoracotomy 11% (n = 18). Forty-one patients (17%) had at least one major vascular injury (n = 54). The most common vascular injury was lower extremity vessel injuries, 26/54 (48%), followed by vessels in chest and abdomen. There was a significant increase in vascular injuries during the study period (P < 0.006). The 30-day mortality was 12.8% (n = 30); 24 patients died within 24 h mainly due to injuries to the chest and the head and neck region. CONCLUSIONS: Firearm injuries cause significant morbidity and mortality and are an important medical and public health problem. In a Scandinavian trauma center there has been an increase of firearm injuries in recent years. The lower extremities followed by the abdomen are the dominating injured regions and there has been an increase in associated vascular injuries.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition.

BACKGROUND: Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS: Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Does Beta-Blockade Reduce the Risk of Depression in Patients with Isolated Severe Extracranial Injuries?

BACKGROUND: Approximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury. METHODS: Patients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score <3 and an Injury Severity Score ≥16. In-hospital deaths and patients prescribed antidepressant therapy ≤1 year prior to admission were excluded. Patients were stratified into groups based on pre-admission beta-blocker status. The primary outcome was post-traumatic depression, defined as receiving antidepressants ≤1 year following trauma. RESULTS: Five hundred and ninety-six patients met the inclusion criteria with 11.4% prescribed pre-admission beta-blockade. Patients receiving beta-blockers were significantly older (57 ± 18 vs. 42 ± 17 years, p < 0.001) with lower Glasgow Coma Scale score (12 ± 3 vs. 14 ± 2, p < 0.001). The beta-blocked cohort spent significantly longer in hospital (21 ± 20 vs. 15 ± 17 days, p < 0.01) and intensive care (4 ± 7 vs. 3 ± 5 days, p = 0.01). A forward logistic regression model was applied and predicted lack of beta-blockade to be associated with increased risk of depression (OR 2.7, 95% CI 1.1-7.2, p = 0.04). After adjusting for group differences, patients lacking beta-blockers demonstrated an increased risk of depression (AOR 3.3, 95% CI 1.2-8.6, p = 0.02). CONCLUSIONS: Pre-admission beta-blockade is associated with a significantly reduced risk of depression following severe traumatic injury. Further investigation is needed to determine the beneficial effects of beta-blockade in these instances.

Risk factors for depression following traumatic injury: An epidemiological study from a scandinavian trauma center.

INTRODUCTION: A significant proportion of patients suffer depression following traumatic injuries. Once manifested, major depression is challenging to overcome and its presence risks impairing the potential for physical rehabilitation and functional recovery. Risk stratification for early detection and intervention in these instances is important. This study aims to investigate patient and injury characteristics associated with an increased risk for depression. METHODS: All patients with traumatic injuries were recruited from the trauma registry of an urban university hospital between 2007 and 2012. Patient and injury characteristics as well as outcomes were collected for analysis. Patients under the age of eighteen, prescribed antidepressants within one year of admission, in-hospital deaths and deaths within 30days of trauma were excluded. Pre- and post-admission antidepressant data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. To isolate independent risk factors for depression a multivariable forward stepwise logistic regression model was deployed. RESULTS: A total of 5981 patients met the inclusion criteria of whom 9.2% (n=551) developed post-traumatic depression. The mean age of the cohort was 42 [standard deviation (SD) 18] years and 27.1% (n=1620) were females. The mean injury severity score was 9 (SD 9) with 18.4% (n=1100) of the patients assigned a score of at least 16. Six variables were identified as independent predictors for post-traumatic depression. Factors relating to the patient were female gender and age. Injury-specific variables were penetrating trauma and GCS score of≤8 on admission. Furthermore, intensive care admission and increasing hospital length of stay were predictors of depression. CONCLUSION: Several risk factors associated with the development of post-traumatic depression were identified. A better targeted in-hospital screening and patient-centered follow up can be offered taking these risk factors into consideration.

Triple diagnostics for early detection of ambivalent necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis is an uncommon, rapidly progressive and potential lethal condition. Over the last decade time to surgery decreased and outcome improved, most likely due to increased awareness and more timely referral. Early recognition is key to improve mortality and morbidity. However, early referral frequently makes it a challenge to recognize this heterogeneous disease in its initial stages. Signs and symptoms might be misleading or absent, while the most prominent skin marks might be in discrepancy with the position of the fascial necrosis. Gram staining and especially fresh frozen section histology might be a useful adjunct. METHODS: Retrospective analysis of 3 year period. Non-transferred patients who presented with suspected necrotizing fasciitis are included. ASA classification was determined. Mortality was documented. RESULTS: In total, 21 patients are included. Most patients suffered from severe comorbidities. In 11 patients, diagnoses was confirmed based on intra-operative macroscopic findings. Histology and/or microbiotic findings resulted in 6/10 remaining patients in a change in treatment strategy. In total, 17 patients proved to suffer necrotizing fasciitis. In the cohort series 2 patients died due to necrotizing fasciitis. CONCLUSION: In the early phases of necrotizing fasciitis, clinical presentation can be ambivalent. In the present cohort, triple diagnostics consisting of an incisional biopsy with macroscopic, histologic and microbiotic findings was helpful in timely identification of necrotizing fasciitis.

Digital rectal examination for initial assessment of the multi-injured patient: Can we depend on it?

BACKGROUND: Digital rectal examination (DRE) is part of the assessment of trauma patients as recommended by ATLS(®). The theory behind is to aid early diagnosis of potential lower intestinal, urethral and spinal cord injuries. Previous studies suggest that test characteristics of DRE are far from reliable. This study examines the correlation between DRE findings and diagnosis and whether DRE findings affect subsequent management. MATERIALS AND METHODS: Patients with ICD-10 codes for spinal cord, urethral and lower intestinal injuries were identified from the trauma registry at an urban university hospital between 2007 and 2011. A retrospective review of electronic medical records was carried out to analyse DRE findings and subsequent management. RESULTS: 253 patients met the inclusion criteria with a mean age of 44 ± 20 years and mean ISS of 26 ± 16. 160 patients had detailed DRE documentation with abnormal findings in 48%. Sensitivity rate was 0.47. Correlational analysis between examination findings and diagnosis gave a kappa of 0.12. Subsequent management was not altered in any case due to DRE findings. CONCLUSION: DRE in trauma settings has low sensitivity and does not change subsequent management. Excluding or postponing this examination should therefore be considered.

Positive blood alcohol level in severe traumatic brain injury is associated with better long-term functional outcome.

OBJECTIVE: To investigate the association between positive blood alcohol level (BAL) and functional outcome in patients suffering severe traumatic brain injury. STUDY DESIGN: The brain trauma registry of an academic trauma centre was queried for patients admitted between January 2007 and December 2011. All patients (≥ 18 years) with a neurosurgical intensive care length of stay beyond 2 days were included. Patient demographics, clinical characteristics, injury profile, laboratory test and outcomes were abstracted for analysis. Primary outcome was unfavourable functional outcome defined as Glasgow Outcome Score (GOS) ≤ 3. Multivariable regression models were used for analysis. RESULTS: Of the 352 patients, 39% were BAL (+) at admission. Patients with (+) BAL were significantly younger with less co-morbidities. The cohorts exhibited no significant difference in the severity of the intra-cranial injury and the use of intra-cranial monitoring or surgical interventions. Further, the groups presented no difference in in-hospital mortality (p = 0.1) or 1-year mortality (p = 0.5). There was a worse long-term functional outcome in (-) BAL patients compared to their BAL (+) counterparts after adjustment for confounders (GOS ≤ 3: AOR = 2.0, 95% CI = 1.1-3.5, p = 0.02). CONCLUSION: Positive BAL on admission is associated with a better long-term functional outcome in patients suffering severe traumatic brain injury.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition.

BACKGROUND: Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS: The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Impaired quality of life after bicycle trauma.

INTRODUCTION: Bicycle crashes often affect individuals in working age, and can impair quality of life (QoL) as a consequence. The aim of this study was to investigate QoL in bicycle trauma patients and to identify those at risk of impaired QoL. PATIENTS AND METHODS: 173 bicycle trauma patients who attended a level I trauma centre from 2010 to 2012 received Hadorn's QoL questionnaire six months after their crash. Medical data was collected from the patient's records. Univariate ordinal logistic regression was used to investigate the association between QoL and other factors. RESULTS: 148 patients returned the questionnaire (85.5%). The majority had only mild or minor injuries (85.1%; n=126). However, 72.1% (n=106) still suffered from pain or other physical symptoms more than six months after their bicycle crash. Patients with a Glasgow Coma Scale (GCS) ≤13 or an Injury Severity Score (ISS) >15 experienced impaired emotions/outlook on life (p-values 0.003 and 0.045, respectively). Physical suffering was reported by patients with a GCS ≤13 and in those with injuries to the cervical spine (p-values 0.02 and 0.025, respectively). Patients with an ISS >15 or facial fractures experienced limitations in daily activities (p-values 0.031 and 0.025, respectively). CONCLUSIONS: More than 70% of bicycle trauma patients suffered physically more than six months after their crash, even though only 15% were severely injured. Risk factors for an impaired QoL were cervical spine injuries or facial fractures, a GCS ≤13 and an ISS >15.

The Effect of ß-blockade on Survival After Isolated Severe Traumatic Brain Injury.

BACKGROUND: Several North American studies have observed survival benefit in patients exposed to ß-blockers following traumatic brain injury (TBI). The purpose of this study was to evaluate the effect of ß-blockade on mortality in a Swedish cohort of isolated severe TBI patients. METHODS: The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between 1/2007 and 12/2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS)≥3 excluding extra-cranial injuries AIS≥3. Multivariable logistic regression analysis was used to determine the effect of ß-blocker exposure on mortality. Also, a subgroup analysis was performed to investigate the risk of mortality in patients on pre-admission ß-blocker versus not and the effect of specific type of ß-blocker on the overall outcome. RESULTS: Overall, 874 patients met the study criteria. Of these, 33% (n=287) were exposed to ß-blockers during their hospital admission. The exposed patients were older (62±16 years vs. 49±21 years, p<0.001), and more severely injured based on their admission GCS, ISS, and head AIS scores (GCS≤8: 32% vs. 28%, p=0.007; ISS≥16: 71% vs. 59%, p=0.001; head AIS≥4: 60% vs. 45%, p<0.001). The crude mortality was higher in patients who did not receive ß-blockers (17% vs. 11%, p=0.007) during their admission. After adjustment for significant confounders, the patients not exposed to ß-blockers had a 5-fold increased risk of in-hospital mortality (AOR 5.0, CI 95% 2.7-8.5, p=0.001). No difference in survival was noted in regards to the type of ß-blocker used. Subgroup analysis revealed a higher risk of mortality in patients naive to ß-blockers compared to those on pre-admission ß-blocker therapy (AOR 3.0 CI 95% 1.2-7.1, p=0.015). CONCLUSIONS: ß-blocker exposure after isolated severe traumatic brain injury is associated with significantly improved survival. We also noted decreased mortality in patients on pre-admission ß-blocker therapy compared to patients naive to such treatment. Further prospective studies are warranted.

Clinical review is essential to evaluate 30-day mortality after trauma.

BACKGROUND: Securing high-quality mortality statistics requires systematic evaluation of all trauma deaths. We examined the proportion of trauma patients dying within 30 days from causes not related to the injury and the impact of exclusion of patients dead on arrival on 30-day trauma mortality. We also defined the demographics, injury characteristics, cause of death and time to death in patients admitted to our trauma center who died within 30 days, between 2007-2011. METHODS: Demographics, injury characteristics, status alive/dead on arrival, cause of death and time to death of all patients were reviewed. Deaths were analyzed based on injury mechanism (penetrating, blunt trauma and low energy blunt trauma) and cause of death (traumatic brain injury (TBI), hemorrhage, organ dysfunction and other/unknown). RESULTS: Of the 7422 admissions, 343 deaths were identified of which 36 (10.5%) involved causes not related to the injury. The overall age was 71 years, Injury Severity Score (ISS) 29 and time to death 24 hours (all medians). Fifty-four patients (17.6%) were dead on arrival. Exclusion of patients dead on arrival reduced the overall mortality rate (P < 0.05) and median ISS (P < 0.05) and increased median age (P < 0.01) and time to death (P < 0.001). Injury mechanism was penetrating trauma in 7.5%, blunt trauma in 56.0%, and low energy blunt trauma in 36.5%. TBI accounted for 58.6%; hemorrhage 16.3%, organ dysfunction 15.0%, and other/unknown for 10.1% of the deaths. Patients who died after low energy blunt trauma were older, had lower ISS and longer time to death compared to those who died after penetrating and blunt trauma (all P < 0.01). CONCLUSIONS: Clinical review of all trauma deaths was essential to interpret mortality. Thirty-day trauma mortality included 10.5% deaths not directly related to the injury and the exclusion of patients dead on arrival significantly affected the unadjusted mortality rate, ISS, median age and time to death.

Preinjury ß-blockade is protective in isolated severe traumatic brain injury.

BACKGROUND: The purpose of this study was to investigate the effect of preinjury ß-blockade in patients experiencing isolated severe traumatic brain injury (TBI). We hypothesized that ß-blockade before TBI is associated with improved survival. METHODS: The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between January 2007 and December 2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS) score of 3 or greater excluding all extracranial injuries AIS score of 3 or greater. Patient demographics, clinical characteristics on admission, injury profile, Injury Severity Score (ISS), AIS score, in-hospital morbidity, and ß-blocker exposure were abstracted for analysis. The primary outcome evaluated was in-hospital mortality stratified by preinjury ß-blockade exposure. RESULTS: Overall, a total of 662 patients met the study criteria. Of these, 25% (n = 159) were exposed to ß-blockade before their traumatic insult. When comparing the demographics and injury characteristics between the groups, the sole difference was age, with the ß-blocked group being older (69 [12] years vs. 63 [13] years, p < 0.001). ß-blocked patients had a higher rate of infectious complications (30% vs. 19%, p = 0.04), with no difference in cardiac or pulmonary complications between the cohorts. Patients exposed to ß-blockade versus no ß-blockade experienced 13% and 22% mortality, respectively (p = 0.01). Stepwise logistic regression predicted the absence of ß-blockade exposure as a risk factor for mortality (odds ratio, 2.7; 95% confidence interval, 1.5-4.8; p = 0.002). After adjustment for significant differences between the groups, patients not exposed to ß-blockade experienced twofold increased risk of mortality (adjusted odds ratio, 2.2; 95% confidence interval, 1.3-3.7; p = 0.004). CONCLUSION: Preinjury ß-blockade improves survival following isolated severe TBI. The role of prophylactic ß-blockade and the timing of initiation of such therapy after TBI warrant further investigations. LEVEL OF EVIDENCE: Therapeutic study, level III; prognostic study, level II.

The STOP the Bleeding Campaign.

According to the World Health Organization, traumatic injuries worldwide are responsible for over 5 million deaths annually. Post-traumatic bleeding caused by traumatic injury-associated coagulopathy is the leading cause of potentially preventable death among trauma patients. Despite these facts, awareness of this problem is insufficient and treatment options are often unclear. The STOP the Bleeding Campaign therefore aims to increase awareness of the phenomenon of post-traumatic coagulopathy and its appropriate management by publishing European guidelines for the management of the bleeding trauma patient, by promoting and monitoring the implementation of these guidelines and by preparing promotional and educational material, organising activities and developing health quality management tools. The campaign aims to reduce the number of patients who die within 24 hours after arrival in the hospital due to exsanguination by a minimum of 20% within the next 5 years.

Management of bleeding and coagulopathy following major trauma: an updated European guideline.

INTRODUCTION: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved. METHODS: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS: Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.