Seeking a Relevant Description of Major Trauma Bleeding: Comparison of Four Major Bleeding Definitions.

BACKGROUND: The traditional definition of massive transfusion is 10 red blood cell units transfused within 24 hr. This definition has been faulted for excluding patients who die early from exsanguination. Alternative major bleeding definitions in the trauma literature include time-based (e.g., Resuscitation Intensity) and event based (e.g., Sharpe) transfusion thresholds. OBJECTIVE: The study objective was to compare four definitions of major bleeding, including a modification to the Sharpe definition, on clinically relevant processes and outcomes. METHODS: This is a retrospective cohort study of adult trauma patients admitted from the field to a Level I trauma center from 2014 to 2019. Data sources were the trauma registry, blood bank, and electronic medical records. Transfusion thresholds were defined as follows: Resuscitation Intensity-4 units of any combination of crystalloids, colloids, or blood products within the first 30 min of arrival; Sharpe-10 red blood cell units from trauma bay presentation to inpatient admission (a proxy for the interval of hemorrhage control); Modified Sharpe-10 units of any combination of blood products during the same interval. The study analysis consisted of descriptive statistics. RESULTS: The cohort contained 187 subjects. Of 39 deaths, 28 (72%) occurred within 6 hr following arrival. Modified Sharpe captured 27 (96%) of these 28 subjects, whereas Resuscitation Intensity captured 20 (71%). Sharpe and the traditional definition each captured 22 subjects (79%). Modified Sharpe captured 17%-25% of deaths missed by the other definitions. CONCLUSION: Modified Sharpe may optimally indicate major bleeding during trauma resuscitation.

Comparison of Shock Index With the Assessment of Blood Consumption Score for Association With Massive Transfusion During Hemorrhage Control for Trauma.

BACKGROUND: Hemorrhage is a leading cause of early mortality following trauma. A massive transfusion protocol (MTP) to guide resuscitation while bleeding is definitively controlled may improve outcomes. Prompts to initiate massive transfusion (MT) include shock index (SI) and the Assessment of Blood Consumption (ABC) score. OBJECTIVE: To compare SI with the ABC score for association with transfusion requirement, need for emergency hemorrhage interventions, and early mortality. METHODS: A retrospective cohort analysis of trauma MTP activations at our Level I trauma center was conducted from January 1, 2012, to December 31, 2016. The study data were obtained from the Trauma Registry and the blood bank. An SI cutoff of 1.0 was chosen for comparison with the positive ABC score. RESULTS: The study cohort included 146 patients. Shock index ≥ 1 had significant association with MT requirement (p = .002) whereas a positive ABC score did not (p = .65). More patients with SI ≥ 1 required bleeding control interventions (67% surgery, 47% interventional radiology) than patients having a positive ABC score (49% surgery, 29% interventional radiology). For geriatric patients who received MT, 65% had SI ≥ 1 but only 30% had a positive ABC score. Three-hour mortality following emergency department arrival was similar (60% SI ≥ 1, 62% positive ABC score). CONCLUSION: Shock index ≥ 1 outperformed a positive ABC score for association with MT requirement. Shock index is a simple tool registered nurses can independently utilize to anticipate MT.

Correlation of Nasal Cannula End-Tidal Carbon Dioxide Concentration With Need for Critical Resources for Blunt Trauma Patients Triaged to Lower-Tier Trauma Activation.

Patients assigned lower-tier trauma activation may be undertriaged. Delayed recognition and intervention may adversely affect outcome. For critically injured intubated patients, research shows that abnormally low end-tidal carbon dioxide (EtCO2) values correlate with need for blood transfusion, surgery, and mortality. The purpose of this study was to evaluate EtCO2 monitoring for patients triaged to lower-tier trauma activation. EtCO2 monitoring may aid in the recognition of patients who have greater needs than anticipated. This is a prospective observational study conducted at a Level I trauma center. Potential subjects presenting from the field were identified by lower-tier trauma activation for blunt mechanism. EtCO2 measurements acquired using nasal cannula sidestream technology were prospectively recorded in the trauma bay during the initial assessment. The medical record and trauma registry were queried for demographics, injury data, mortality, and critical resource data defined as intubation, blood transfusion, surgery, intensive care unit admission, and vasoactive medication infusion. EtCO2 data were obtained for 682 subjects during a 10.5-month period. Following exclusions, 262 patients were enrolled for data collection. EtCO2 values less than 30 mmHg were significantly associated with blood transfusion (p = .03) but not with other critical resources or mortality. Although capnography had limited utility for patients triaged to lower-tier trauma activation, EtCO2 values less than 30 mmHg correlated with blood transfusion, consistent with previous studies of critically injured intubated patients. EtCO2 monitoring is noninvasive and may serve as a simple prompt for earlier initiation of blood transfusion, a resource-intensive intervention.

Evaluation of Dwell Time for Peripheral Intravenous Catheters Started in the Field for Geriatric Blunt Trauma Patients.

Replacement time for peripheral intravenous (PIV) catheters started in the field is unclear. The purpose of this study was to compare field-start PIV catheter dwell time of 2 days or less versus field-start PIV catheter dwell time of more than 2 days for the development of indicators of infection for geriatric blunt trauma patients. A retrospective case series was conducted at the state-designated trauma referral center. Activated trauma team patients with blunt injury were included if 65 years or older and if admitted from the field for 7 days or more with a PIV catheter placed prehospital. Presence of fever, abnormal white blood cell (WBC) count, and a positive Quick Sequential Organ Failure Assessment (qSOFA) score as recommended by the Surviving Sepsis Campaign were used to describe potential infection and were analyzed in relation to PIV catheter dwell time with statistical significance set at p < .05. Forty-two patients (28%) had PIV catheter dwell time of 2 days or less, and 108 (72%) had PIV catheter dwell time of more than 2 days. At dwell time of more than 2 days, a statistically significant smaller percentage of patients demonstrated positive qSOFA score (p = .005) and fever (p = .003) and approached statistical significance for abnormal WBC count (p = .05). Dwell time of more than 2 days for field-start PIV catheters did not lead to an increase in fevers, abnormal WBC count, or positive qSOFA scores. These data support consideration of longer dwell time for PIV catheters initiated in the field for geriatric blunt trauma patients. Further studies are needed.

Association of Prehospital Shock Index and Trauma Bay Uncrossmatched Red Blood Cell Transfusion With Multiple Transfusion.

Early resuscitation of bleeding trauma patients with multiple blood products improves outcome, yet transfusion initiation is not standardized. Shock index (heart rate/systolic blood pressure) and trauma bay uncrossmatched red blood cell (RBC) transfusion were evaluated for association with multiple transfusions, defined as 6 or more RBCs during the first 6 hrs of hospital presentation. A prehospital shock index of 1 was significantly associated with multiple transfusions (p = .02). Subjects receiving uncrossmatched RBCs required more RBCs during the first 6 hrs (10.3 units, p < .01). Consideration of these simple variables may help trauma nurses anticipate the potentially bleeding patient.