Does an early, balanced resuscitation strategy reduce the incidence of hypofibrinogenemia in hemorrhagic shock?

Objectives: Some centers have recommended including concentrated fibrinogen replacement in massive transfusion protocols (MTPs). Given our center's policy of aggressive early balanced resuscitation (1:1:1), beginning prehospital, we hypothesized that our rates of hypofibrinogenemia may be lower than those previously reported. Methods: In this retrospective cohort study, patients presenting to our trauma center November 2017 to April 2021 were reviewed. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography angle <60. Univariate and multivariable analyses assessed risk factors for HYPOFIB. Inverse probability of treatment weighting analyses assessed the relationship between cryoprecipitate administration and outcomes. Results: Of 29 782 patients, 6618 level 1 activations, and 1948 patients receiving emergency release blood, <1%, 2%, and 7% were HYPOFIB. HYPOFIB patients were younger, had higher head Abbreviated Injury Scale value, and had worse coagulopathy and shock. HYPOFIB had lower survival (48% vs 82%, p<0.001), shorter time to death (median 28 (7, 50) vs 36 (14, 140) hours, p=0.012), and were more likely to die from head injury (72% vs 51%, p<0.001). Risk factors for HYPOFIB included increased age (OR (95% CI) 0.98 (0.96 to 0.99), p=0.03), head injury severity (OR 1.24 (1.06 to 1.46), p=0.009), lower arrival pH (OR 0.01 (0.001 to 0.20), p=0.002), and elevated prehospital red blood cell to platelet ratio (OR 1.20 (1.02 to 1.41), p=0.03). Among HYPOFIB patients, there was no difference in survival for those that received early cryoprecipitate (within 2 hours; 40 vs 47%; p=0.630). On inverse probability of treatment weighted analysis, early cryoprecipitate did not benefit the full cohort (OR 0.52 (0.43 to 0.65), p<0.001), nor the HYPOFIB subgroup (0.28 (0.20 to 0.39), p<0.001). Conclusions: Low rates of hypofibrinogenemia were found in our center which treats hemorrhage with early, balanced resuscitation. Previously reported higher rates may be partially due to unbalanced resuscitation and/or delay in resuscitation initiation. Routine empiric inclusion of concentrated fibrinogen replacement in MTPs is not supported by the currently available data. Level of evidence: Level III.

Disguised Among the Sea: The Implications of Artificial Islands on Casualty Care in the Indo-Pacific.

As reported in the 2022 Biden-Harris National Security Strategy, China is perceived as the primary U.S. competitor with the intent and means to become the world's greatest superpower. China's efforts, which are at odds with America's ambition to maintain its global influence, are complemented by ostensibly harmless "gray zone tactics," defined as coercive geopolitical, economic, military, and cyber activities below the use of kinetic military force. Such tactics may be utilized with seemingly innocuous intentions, but in reality, they can complicate U.S. combat casualty care in the event of an Indo-Pacific conflict. One tactic of particular impact is China's development of artificial islands throughout the South China Sea. By creating these islands, China is expanding its reach beyond its continental borders. These islands, alongside China's well-developed naval and missile capabilities, will cause disruptions to U.S. casualty care staging, medical resupply, and aeromedical evacuations. To mitigate those threats, the USA should implement a robust regional Combatant Command Trauma System, improve global health security cooperation with local partner nations, and implement irregular or guerilla trauma systems that meet medical needs in impromptu, clandestine settings. Operational recommendations based on these efforts could include pre-positioning tactical combat casualty care and damage control resuscitation supplies and developing with nearby host-nation evacuation platforms such as small boat operators. These solutions, among others, require years of training, relationship-building, and capability development to institute successfully. As a result, U.S. Military leaders should act now to incorporate these strategies into their irregular warfare, low-intensity conflict, and large-scale combat operation toolkits.

Patients with both traumatic brain injury and hemorrhagic shock benefit from resuscitation with whole blood.

BACKGROUND: Hemorrhagic shock in the setting of traumatic brain injury (TBI) reduces cerebral blood flow and doubles mortality. The optimal resuscitation strategy for hemorrhage in the setting of TBI is unknown. We hypothesized that, among patients presenting with concomitant hemorrhagic shock and TBI, resuscitation including whole blood (WB) is associated with decreased overall and TBI-related mortality when compared with patients receiving component (COMP) therapy alone. METHODS: An a priori subgroup of prospective, observational cohort study of injured patients receiving emergency-release blood products for hemorrhagic shock is reported. Adult trauma patients presenting November 2017 to September 2020 with TBI, defined as a Head Abbreviated Injury Scale of ≥3, were included. Whole blood group patients received any cold-store low-titer Group O WB units. The COMP group received fractionated blood components alone. Overall and TBI-related 30-day mortality, favorable discharge disposition (home or rehabilitation), and 24-hour blood product utilization were assessed. Univariate and inverse probabilities of treatment-weighted multivariable analyses were performed. RESULTS: Of 564 eligible patients, 341 received WB. Patients who received WB had a higher injury severity score (median, 34 vs. 29), lower scene blood pressure (104 vs. 118), and higher arrival lactate (4.3 vs. 3.6, all p < 0.05). Univariate analysis noted similar overall mortality between WB and COMP; however, weighted multivariable analyses found WB was associated with decreased overall mortality and TBI-related mortality. There were no differences in discharge disposition between the WB group and COMP group. CONCLUSION: In patients with concomitant hemorrhagic shock and TBI, WB transfusion was associated with decreased overall mortality and TBI-related mortality. Whole blood should be considered a first-line therapy for hemorrhage in the setting of TBI. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Mortality and outcomes by blood group in trauma patients: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Blood group O contains lower levels of factor VIII and von Willebrand factor. Higher incidence of bleeding among group O is reported in multiple contexts. Results of studies vary regarding outcomes stratified by blood group in trauma. We systematically reviewed the literature for outcomes related to blood group in trauma patients. Meta-analysis of studies evaluating mortality related to blood group was performed. MATERIALS AND METHODS: The PubMed and Embase databases were searched for studies analysing relationships between blood group and outcomes in trauma patients. Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. We synthesized outcomes data related to blood group. Meta-analysis compared mortality rates between group O and non-O patients. RESULTS: Inclusion criteria were met by 13 studies. Statistically significant differences by blood group were reported in 3 of 10 (30%) studies evaluating mortality, 2 of 3 (66.7%) evaluating mortality from haemorrhage and 2 of 9 (22.2%) evaluating transfusion requirement. Meta-analysis was performed on seven studies evaluating mortality (total n = 11,835). There was significant heterogeneity among studies (I2 = 86%, p < 0.00001). No difference was found in mortality between group O and non-O patients (relative risk = 1.21, 95% confidence interval = 0.89-1.64, p = 0.23). CONCLUSION: Existing literature does not consistently demonstrate a mortality difference between trauma patients with O and non-O blood groups. High variability in the methods and results among studies limits this conclusion, and further research is needed to delineate under what circumstances blood group may influence outcomes.

Is Low-Titer Group O Whole Blood Truly a Universal Blood Product?

BACKGROUND: Whole blood was historically transfused as a type-specific product. Given recent advocacy for low-titer group O whole blood (LTOWB) as a universal blood product, we examined outcomes after LTOWB transfusion stratified by recipient blood groups. STUDY DESIGN: Adult trauma patients receiving prehospital or in-hospital transfusion of LTOWB (November 2017 to July 2020) at a single trauma center were prospectively evaluated. The patients were divided into blood type groups (O, A, B, and AB). Major complications and survival to 30 days were compared. Univariate analyses among blood groups were followed by purposeful regression modeling, reflecting 6 variables of significance: male sex, White race, injury severity, arrival lactate, arrival systolic blood pressure, and emergency department blood products. RESULTS: Of 1,075 patients receiving any LTOWB, 539 (50.1%) were Group O, 340 (31.6%) were Group A, 150 (14.0%) were Group B, and 46 (4.3%) were Group AB. There were no statistically significant differences in demographics, injury severity, hemolysis panels, prehospital vitals, or resuscitation parameters (all p > 0.05). However, arrival systolic pressure was lower (91 vs 102, p = 0.034) and lactate was worse (5.5 vs 4.1, p = 0.048) in Group B patients compared to other groups. While survival and most major complications did not differ across recipient groups, acute kidney injury (AKI) initially appeared higher for Group B. Stepwise regression did not show a difference in AKI rates. This analysis was repeated in patients receiving only component products. Group B again showed no significantly increased risk of AKI (13%) compared to other groups (O 7%, A 7%, AB 5%; p = 0.091). CONCLUSIONS: LTOWB appears to be a safe product for universal use across all blood groups. Group B recipients arrived with worse physiologic values associated with hemorrhagic shock whether receiving LTOWB or standard component products.

Impact of Incorporating Whole Blood into Hemorrhagic Shock Resuscitation: Analysis of 1,377 Consecutive Trauma Patients Receiving Emergency-Release Uncrossmatched Blood Products.

BACKGROUND: Use of whole blood (WB) for trauma resuscitation has seen a resurgence. The purpose of this study was to investigate survival benefit of WB across a diverse population of bleeding trauma patients. STUDY DESIGN: A prospective observational cohort study of injured patients receiving emergency-release blood products was performed. All adult trauma patients resuscitated between November 2017 and September 2020 were included. The WB group included patients receiving any group O WB units. The component (COMP) group received no WB units, instead relying on fractionated blood (red blood cells, plasma, and platelets). Univariate and multivariate analyses were performed. Given large observed differences in our regression model, post hoc adjustments with inverse probability of treatment were conducted and a propensity score created. Propensity scoring and Poisson regression supported these findings. RESULTS: Of 1,377 patients receiving emergency release blood products, 840 received WB and 537 remained in the COMP arm. WB patients had higher Injury Severity Score (ISS; 27 vs 20), lower field blood pressure (103 vs 114), and higher arrival lactate (4.2 vs 3.5; all p < 0.05). Postarrival transfusions and complications were similar between groups, except for sepsis, which was lower in the WB arm (25 vs 30%, p = 0.041). Although univariate analysis noted similar survival between WB and COMP (75 vs 76%), logistic regression found WB was independently associated with a 4-fold increased survival (odds ratio [OR] 4.10, p < 0.001). WB patients also had a 60% reduction in overall transfusions (OR 0.38, 95% CI 0.21-0.70). This impact on survival remained regardless of location of transfusion, ISS, or presence of head injury. CONCLUSION: In patients experiencing hemorrhagic shock, WB transfusion is associated with both improved survival and decreased overall blood utilization.

Trends in Surgical Case Volume During Pacific Partnership Missions Onboard USNS Mercy.

INTRODUCTION: Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. MATERIALS AND METHODS: Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. RESULTS: A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician-gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. CONCLUSIONS: Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.

The Role of TEG and ROTEM in Damage Control Resuscitation.

ABSTRACT: Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.

An Analysis of Essential Pediatric Surgical Cases Encountered During a Decade of Large-Scale Military Humanitarian Aid Missions.

INTRODUCTION: Disease Control Priorities, 3rd Edition (DCP3) is an evidence-based, published resource that outlines essential procedures recommended for developing health care systems. These systems must consider various populations and the incidence of certain surgical conditions that require treatment. In relation to pediatric patients, the prevalence of certain surgical conditions encountered remains unclear in several low- and middle-income countries. Over the past 15 years, the USNS Mercy, one of the U.S. Navy's large hospital ships, has led the Pacific Partnership missions, which provide large-scale humanitarian aid throughout Southeast Asia. The data collected during these missions provide an opportunity to analyze the scope of pediatric operations performed in resource-limited countries. This analysis may assist in future planning for specific needs during military humanitarian missions. MATERIALS AND METHODS: Surgical case data were prospectively collected during the six Pacific Partnership missions from 2006 to 2018. Demographic data were analyzed for all patients ≤8 years of age who underwent an operation. These data were retrospectively reviewed and all case logs were categorized by mission year, procedure-type, and host nation. Operations were classified based on 44 essential operations delineated in DCP3. Primary outcome was incidence of DCP3 essential operations. Secondary outcomes were perioperative complications. Standard statistical methods were performed for descriptive analysis. RESULTS: A total of 3,209 major and minor operations were performed during 24 port visits in nine countries. Pediatric cases represented 1,117 (38%) of these procedures. Pediatric surgeons performed 291 (26%) of these cases. Based on DCP3 criteria, 789 pediatric operations (71%) were considered essential procedures. The most common DCP3-aligned procedures were cleft lip repair (432, 57%), hernia repair (207, 27%), and hydrocelectomy (60, 8%). Operative volume for pediatric surgery was highest during the 2008 mission (522 cases), when two pediatric surgeons were deployed, and lowest during the 2018 mission (five cases), when the mission focus was on education rather than surgical procedures and lack of pediatric cases referred by the host nation. Overall complication rate for pediatric cases was 1%. CONCLUSIONS: This study represents the largest known analysis of military humanitarian assistance. Pediatric operations represented over one-third of the surgical volume during Pacific Partnership missions from 2006 to 2018. The majority of cases were DCP3-aligned and associated with a low complication rate. Future humanitarian aid missions and host nations should allocate appropriate medical and educational resources to treat DCP3 pediatric surgical diseases in low- and middle-income countries to support long-term capacity building while maintaining optimal surgical outcomes.

The prevalence of chronic deep venous thrombosis in trauma: Implications for hospitals and patients.

INTRODUCTION: Deep venous thrombosis (DVT) is considered a preventable complication in trauma patients. Hospitals risk financial penalties for DVT rates above accepted benchmarks. These penalties do not apply to chronic DVT, which develops before admission. Lower-extremity duplex ultrasound (LEDUS) can detect characteristics of thrombus chronicity, allowing differentiation of chronic from acute DVT. The objective of this study was to determine the prevalence of chronic DVT in hospitalized trauma patients. METHODS: We performed a retrospective review of trauma patients admitted to our Level I trauma center between July 1, 2006 and October 31, 2016 who had a DVT on initial screening LEDUS. Our center utilizes screening and surveillance LEDUS for patients admitted more than 48 hours. Definitions for chronic and acute DVT were extracted from existing literature. Patients with DVT on initial LEDUS underwent review of that LEDUS to assess clot chronicity and were classified as having acute DVT, chronic DVT, or DVT of indeterminate age. Demographic data, medical history, and injury characteristics were collected. Patients with acute DVT and those with chronic DVT were compared. RESULTS: The prevalence of chronic DVT among patients with a DVT on initial LEDUS was 29.9%. Chronic DVT occurred in patients who were older and less severely injured. An above-knee component was significantly more common in chronic DVT (65%). Only 34 (41%) of those with chronic DVT reported a history of DVT. Among the patients with chronic DVT, 44 (53%) had a subsequent LEDUS, of whom 4 (9%) showed thrombus progression and 6 (14%) formed a new DVT. CONCLUSION: Lower-extremity duplex ultrasound can identify chronic DVT, which represents nearly 30% of all DVT found on initial screening LEDUS in trauma patients. Those with chronic DVT should receive pharmacologic and mechanical prophylaxis because of the incidence of progression and new acute DVT. They should also be counseled regarding the possibilities of recurrence and chronic venous insufficiency. LEVEL OF EVIDENCE: Diagnostic study, level III.

Hereditary thrombophilia in trauma patients with venous thromboembolism: Is routine screening necessary?

BACKGROUND: Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), remains a common complication following trauma. The role of hereditary thrombophilia (HT) in posttraumatic VTE is unknown. In the general population with a first-time DVT, Factor V Leiden (FVL) and prothrombin G20210A mutation (PGM) are the most common types of HT with an incidence of 20% to 25% and 6% to 18%, respectively. The objective of this study was to identify the incidence of FVL and PGM in posttraumatic VTE to determine whether routine screening for HT in trauma should be performed. METHODS: We conducted a prospective observational study at our Level I trauma center from 2013 to 2016 when 70 patients with posttraumatic DVT and PE were screened for FVL and PGM. Demographics, injury characteristics, and established risk factors for VTE were collected for each patient. Statistical analysis was performed to compare patients with and without HT. RESULTS: The incidence of FVL and PGM in posttraumatic VTE was 1.4% and 5.7%, respectively. All HT-positive patients had a DVT and one had an associated PE. Both the individual risk factors and the total number of risk factors for VTE were similar between the HT-positive group and the HT-negative group. CONCLUSION: There was a lower incidence of FVL and PGM in patients with posttraumatic DVT than in patients with a first-time DVT in the general population. HT does not appear to significantly contribute to posttraumatic VTE in our trauma population. Further research is warranted to determine whether routine screening for HT in trauma should be performed. LEVEL OF EVIDENCE: Epidemiological study, level III; Care management/therapeutic study, level IV.

The rate of deep vein thrombosis doubles in trauma patients with hypercoagulable thromboelastography.

BACKGROUND: Venous thromboembolism (VTE) in trauma can occur in patients at low risk. Conventional coagulation tests do not predict VTE. Studies investigating thromboelastography (TEG) for VTE risk are conflicting and have not included routine surveillance to detect deep vein thrombosis (DVT). We undertook a prospective study of TEG to evaluate its utility in predicting VTE. METHODS: We conducted a prospective cohort study on all adult trauma patients admitted to our Level I trauma center from 2013 to 2015. TEG was performed immediately on arrival to the trauma bay. Hypercoagulable TEG was defined as reaction time (R) below, angle (α) above, or maximum amplitude (MA) above reference ranges. All patients received mechanical and/or pharmacologic prophylaxis and were followed up for DVT with our ultrasound surveillance protocol. The primary outcome was lower-extremity DVT. After bivariate analysis of variables related to DVT, those with p values of 0.100 or less were included for multivariate logistic regression. RESULTS: A total of 983 patients were evaluated with TEG on admission; of these, 684 (69.6%) received at least one surveillance ultrasound during the index admission. Lower-extremity DVT was diagnosed in 99 (14.5%) patients. Hypercoagulability based on admission TEG occurred in 582 (85.1%) patients. The lower-extremity DVT rate was higher in patients with hypercoagulable TEG than in those without hypercoagulable TEG (15.6% vs. 8%; p = 0.039). Multivariate analysis showed hypercoagulable TEG remained associated with DVT after adjustment for relevant covariates available at admission, with an odds ratio of 2.41 (95% confidence interval, 1.11-5.24; p = 0.026). CONCLUSION: Most trauma patients were hypercoagulable at admission and remained at risk of developing DVT. The rate of DVT doubled in patients with hypercoagulable TEG indices despite prophylaxis. Beyond its current clinical roles, TEG is useful for assessing DVT risk, particularly in patients otherwise perceived to be at low risk. LEVEL OF EVIDENCE: Prognostic study, level II.

"Delay to operating room" fails to identify adverse outcomes at a Level I trauma center.

BACKGROUND: The American College of Surgeons Committee on Trauma devised process audit filters to identify opportunities for improvement (OFI), prevent adverse outcomes, and improve quality. Delay to the operating room for primary trauma laparotomy is a process audit filter that has not been definitively associated with improved outcomes. We sought to evaluate the effectiveness of delay to the operating room of greater than 2 hours (DOR) to independently identify an adverse outcome or an OFI at our Level I trauma center. METHODS: Trauma patients who underwent primary exploratory laparotomy from July 2006 to March 2015 were reviewed. Those with DOR were identified and compared with those without DOR. To analyze the ability of DOR to independently identify an adverse outcome or an OFI, DOR patients were further divided into those with isolated DOR and those with DOR in conjunction with one or more other process audit filter. Primary outcome was the presence of a complication. Secondary outcome was an identified OFI. Medical records of patients with either outcome were reviewed to determine if the outcome resulted directly from DOR. RESULTS: Of 472 patients, 109 (23%) had DOR and 363 (77%) did not. There were no significant differences in age, sex, or injury severity between the two groups. The rates of complications among DOR patients and those without DOR were not significantly different (35% vs. 38%, p = 0.59). The DOR was the only process audit filter flagged in 31(28%) patients in the DOR group. This subgroup had no identified complications but incurred two OFIs; neither OFI was associated with an adverse outcome. CONCLUSION: In trauma patients undergoing primary exploratory laparotomy, DOR fails to independently identify adverse outcomes. These findings suggest that DOR, as a routinely collected process audit filter, is not an effective indicator of suboptimal care or adverse outcomes at a Level I trauma center. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.

Routine neurosurgical consultation is not necessary in mild blunt traumatic brain injury.

BACKGROUND: The Brain Trauma Foundation guidelines provide indications for neurosurgical intervention in traumatic brain injury (TBI) with moderate or severe intracranial hemorrhage (ICH). In TBI patients with less severe ICH, the utility of neurosurgical consultation remains unclear. We sought to determine if routine neurosurgical consultation is necessary for mild blunt TBI patients with ICH. METHODS: A retrospective cohort study was conducted on 500 consecutive blunt TBI patients aged 15 years or older with Glasgow Coma Scale score of ≥13 and ICH on initial head computed tomography admitted to a Level I trauma center over 28 months. Outcomes were neurosurgical intervention (craniotomy, craniectomy, ventriculostomy, or intracranial pressure monitor placement) and in-hospital mortality. Statistical significance was assessed at a p < 0.05. RESULTS: Of 500 patients, 49 (9.8%) underwent neurosurgical intervention. Neurosurgical intervention was more frequent in male patients (75.5% vs. 61.2%, p = 0.049), patients with higher head Abbreviated Injury Scale score (4.7 vs. 3.8, p < 0.0001), patients with an abnormal initial neurological examination (30.6% vs. 12.6%, p = 0.001), or patients with skull fracture (28.6% vs. 16.0%, p = 0.026) and was associated with higher mortality (8.2% vs. 2.0%, p = 0.010). Neurosurgical intervention was not associated with intoxication, preinjury antiplatelet/anticoagulation agents, or progression of ICH on second head computed tomography. Neurosurgical consultation was documented in 466 patients (93.2%). For patients without neurosurgical intervention, consultation did not change management. CONCLUSION: Routine neurosurgical consultation for blunt TBI with ICH seems unnecessary, regardless of intoxication or preinjury antiplatelet or anticoagulation therapy. A more selective approach is warranted to decrease hospital charges and optimize use of neurosurgical consultation. LEVEL OF EVIDENCE: Care management study, level IV.

Sarcopenia as a predictor of mortality in elderly blunt trauma patients: Comparing the masseter to the psoas using computed tomography.

BACKGROUND: Sarcopenia, or age-related loss of muscle mass, is measurable by computed tomography (CT). In elderly trauma patients, increased mortality is associated with decreased psoas muscle cross-sectional area (P-Area) on abdominal CT. Fall is the leading cause of injury in the elderly, and head CT is more often obtained. Masseter muscle cross-sectional area (M-Area) is readily measured on head CT. Hypothesizing that M-Area is a satisfactory surrogate for P-Area, we compared the two as markers of sarcopenia and increased mortality in elderly trauma patients. METHODS: All blunt-injured patients aged 65 years or older admitted to our trauma center during 2010 were included. Two-year postdischarge mortality was identified by matching records to county, state, and national death indices. Bilateral M-Area was measured on admission head CT at 2 cm below the zygomatic arch. Bilateral P-Area was measured on abdominal CT at the fourth vertebral body. Average M-Area and P-Area values were calculated for each patient. Cox proportional hazards models evaluated the relationship of M-Area and P-Area with mortality. Model predictive performance was calculated using concordance statistics. RESULTS: Among 487 patients, 357 with M-Area and 226 with P-Area were identified. Females had smaller M-Area (3.43 cm vs 4.18 cm; p < 0.050) and P-Area (6.50 cm vs 10.9 cm; p < 0.050) than males. Masseter muscle cross-sectional area correlated with P-Area (rho, 0.38; p < 0.001). Adjusted Cox regression models revealed decreased survival associated with declining M-Area (hazard ratio, 0.76; 95% confidence interval, 0.60-0.96) and P-Area (hazard ratio, 0.68; 95% confidence interval, 0.46-1.00). Masseter muscle cross-sectional area and P-Area discriminated equally well in best-fit models. CONCLUSIONS: In elderly trauma patients, M-Area is an equally valid and more readily available marker of sarcopenia and 2-year mortality than P-Area. Future study should validate M-Area as a metric to identify at-risk patients who may benefit from early intervention. LEVEL OF EVIDENCE: Prognostic study, level III.

Aspirin as added prophylaxis for deep vein thrombosis in trauma: A retrospective case-control study.

BACKGROUND: Current prophylaxis does not completely prevent deep vein thrombosis (DVT) in trauma patients. Recent data suggest that platelets may be a major contributor to hypercoagulability after trauma, indicating a potential role for antiplatelet medications in prophylaxis for DVT. We sought to determine if preinjury aspirin use was associated with a reduced incidence of lower extremity DVT in trauma patients. METHODS: Using a retrospective case-control design, we matched 110 cases of posttrauma lower extremity DVT one-to-one with controls using seven covariates: age, admission date, probability of death, number of DVT risk factors, sex, mechanism of injury, and presence of head injury. Data collected included 26 risk factors for DVT, prehospital medications, and in-hospital prophylaxis. Logistic regression models were created to examine the relationship between prehospital aspirin use and posttrauma DVT. RESULTS: Preinjury aspirin was used by 7.3% of cases (patients diagnosed with in-hospital DVT) compared with 13.6% of controls (p = 0.1). Aspirin was associated with a significant protective effect in multivariate analysis, with an odds ratio of 0.17 (95% confidence interval, 0.04-0.68; p = 0.012) in the most complete model. When stratified by other antithrombotic use, aspirin showed a significant effect only when used in combination with heparinoid prophylaxis (odds ratio, 0.35; 95% confidence interval, 0.13-0.93; p = 0.036). CONCLUSION: Preinjury aspirin use seems to significantly lower DVT rate following injury. This association is strongest when heparinoid prophylaxis is prescribed after patients on preinjury aspirin therapy are admitted. Aspirin as added prophylaxis for DVT in trauma patients needs to be further evaluated. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

A Case of an Epithelioid Hemangioendothelioma Arising from the Innominate Vein Mimicking Cervical Metastatic Lymphadenopathy.

Background. Epithelioid hemangioendothelioma (EHE) is a rare tumor usually presenting in soft tissue. EHE is a vascular malignancy of intermediate clinical behavior, with a histologic appearance of endothelial cells growing in nests or cords. Although EHE often originates from a vessel, it is relatively rare for a primary vascular EHE to originate from a large vein or artery. Occurrence in the mediastinum is exceptionally rare. There are no known associations with other malignancies. Case Presentation. We present a case of mediastinal invasive EHE in a 39-year-old female with concurrent papillary thyroid cancer. She initially presented with a thyroid mass found by her primary care provider, with preoperative imaging concerning for extension into the superior mediastinum. Operative exploration revealed a mediastinal mass distinct from her thyroid carcinoma with invasion into the great vessels, requiring off-pump interposition graft bypass for en bloc resection. Final pathology confirmed pT3N1b multifocal papillary thyroid carcinoma with a separate grade 1 pT1b EHE. Review of the literature describes the demographics, updated pathologic outcomes, histologic findings, and reported incidence of EHE. Conclusions. This is the first reported case of thyroid malignancy with separate and concurrent EHE. Surgeons should remain aware of this entity given its variable behavior. Although initially described as an indolent neoplasm, tumors with poor prognostic factors have been shown to be locally aggressive.

Long-term outcomes with transfascial sutures versus tacks in laparoscopic ventral hernia repair: a review.

Although most surgeons report using both transfascial sutures and laparoscopically placed tacks to secure prostheses in laparoscopic ventral hernia repair, a significant minority have reported large series in which sutures were omitted. A systematic review of the available literature was conducted for large case series and controlled trials documenting long-term follow-up. Forty-three articles were identified, including 6015 patients whose prostheses were secured with transfascial sutures (with or without tacks), and 2450 patients receiving tacks or staples alone. The mean follow-up time reported was 30.1 months. No significant difference was found in rates of hernia recurrence, mesh removal, prolonged postoperative pain, patient body mass index, or hernia defect size between the two groups. The suture group did experience a significantly higher rate of surgical site infection. Although suture tensile strength is greater than that of tacks, and despite numerous anecdotal reports of hernia recurrence secondary to suture failure or omission, the existing literature does not show superiority of one mesh fixation technique over the other for recurrence, whereas infection rates increase when transfascial suture is used.