Direct Trauma Center Access by Helicopter Emergency Medical Services is Associated With Improved Survival After Severe Injury.

OBJECTIVE: Evaluate the association of survival with helicopter transport directly to a trauma center compared with ground transport to a non-trauma center (NTC) and subsequent transfer. SUMMARY BACKGROUND DATA: Helicopter transport improves survival after injury. One potential mechanism is direct transport to a trauma center when the patient would otherwise be transported to an NTC for subsequent transfer. METHODS: Scene patients 16 years and above with positive physiological or anatomic triage criteria within PTOS 2000-2017 were included. Patients transported directly to level I/II trauma centers by helicopter were compared with patients initially transported to an NTC by ground with a subsequent helicopter transfer to a level I/II trauma center. Propensity score matching was used to evaluate the association between direct helicopter transport and survival. Individual triage criteria were evaluated to identify patients most likely to benefit from direct helicopter transport. RESULTS: In all, 36,830 patients were included. Direct helicopter transport was associated with a nearly 2-fold increase in odds of survival compared with NTC ground transport and subsequent transfer by helicopter (aOR 2.78; 95% CI 2.24-3.44, P <0.01). Triage criteria identifying patients with a survival benefit from direct helicopter transport included GCS≤13 (1.71; 1.22-2.41, P <0.01), hypotension (2.56; 1.39-4.71, P <0.01), abnormal respiratory rate (2.30; 1.36-3.89, P <0.01), paralysis (8.01; 2.03-31.69, P <0.01), hemothorax/pneumothorax (2.34; 1.36-4.05, P <0.01), and multisystem trauma (2.29; 1.08-4.84, P =0.03). CONCLUSIONS: Direct trauma center access is a mechanism driving the survival benefit of helicopter transport. First responders should consider helicopter transport for patients meeting these criteria who would otherwise be transported to an NTC.

Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial.

OBJECTIVE: The aim of this study was to determine whether prehospital blood products reduce 30-day mortality in patients at risk for hemorrhagic shock compared with crystalloid only resuscitation. SUMMARY OF BACKGROUND DATA: Hemorrhage is the primary cause of preventable death after injury. Large volume crystalloid resuscitation can be deleterious. The benefits of prehospital packed red blood cells (PRBCs), plasma, or transfusion of both products among trauma patients is unknown compared with crystalloid. METHODS: Secondary analysis of the multicenter PAMPer trial was performed on hypotensive injured patients from the scene. The trial randomized 27 helicopter bases to prehospital plasma or standard resuscitation. Standard resuscitation at the sites was equally divided between crystalloid and crystalloid + PRBC. This led to 4 prehospital resuscitation groups: crystalloid only; PRBC; plasma; and PRBC+plasma. Cox regression determined the association between resuscitation groups and risk-adjusted 30-day mortality. The dose effect of resuscitation fluids was also explored. RESULTS: Four hundred seven patients were included. PRBC+plasma had the greatest benefit [hazard ratio (HR) 0.38; 95% confidence interval (95% CI) 0.26-0.55, P < 0.001], followed by plasma (HR 0.57; 95% CI 0.36-0.91, P = 0.017) and PRBC (HR 0.68; 95% CI 0.49-0.95, P = 0.025) versus crystalloid only. Mortality was lower per-unit of PRBC (HR 0.69; 95% CI 0.52-0.92, p = 0.009) and plasma (HR 0.68; 95% CI 0.54-0.88, P = 0.003). Crystalloid volume was associated with increased mortality among patients receiving blood products (HR 1.65; 95% CI 1.17-2.32, P = 0.004). CONCLUSION: Patients receiving prehospital PRBC+plasma had the greatest mortality benefit. Crystalloid only had the worst survival. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably PRBC+plasma. Prehospital whole blood may be ideal in this population.

Should All Massively Transfused Patients Be Treated Equally? An Analysis of Massive Transfusion Ratios in the Nontrauma Setting.

OBJECTIVES: Although balanced resuscitation has become integrated into massive transfusion practice, there is a paucity of evidence supporting the delivery of high ratios of plasma and platelet to RBCs in the nontrauma setting. This study investigated the administration of blood component ratios in the massively transfused nontrauma demographic. DESIGN: Retrospective analysis of a prospective, observational cohort of massively bleeding patients. SETTING: Surgical and critically ill patients at a tertiary medical center between 2011 and 2015. PATIENTS: Massively transfused nontrauma patients. INTERVENTIONS: Patients receiving plasma, platelet, and RBC transfusions were categorized into high and low ratio groups and analyzed for differences in characteristics and clinical outcomes. MEASUREMENTS AND MAIN RESULTS: The primary outcome was 30-day mortality. Secondary outcomes included 48-hour mortality, hospital length of stay, ICU length of stay, and ventilator-free days. Among 601 massively transfused nontrauma patients, cardiothoracic surgery and gastrointestinal or hepato-pancreatico-biliary bleeds were the most common indications for massive transfusion. Higher fresh frozen plasma ratios (> 1:2) were not associated with increased 30-day mortality. A high platelets-to-packed RBCs ratio (> 1:2) was associated with decreased 48-hour mortality (10.5% vs 19.3%; p = 0.032), but not 30-day mortality. Fresh frozen plasma-to-packed RBCs and platelets-to-packed RBCs ratios were not associated with 30-day mortality hazard ratios after controlling for baseline characteristics and disease severity. CONCLUSIONS: The benefits of higher ratios of fresh frozen plasma-to-packed RBCs and platelets-to-packed RBCs described in trials of trauma patients were not observed in this analysis of a nontrauma, massively transfused population. These data suggest that greater than 1:2 ratio transfusion in the setting of massive hemorrhage may not be appropriate for all patients, and that further research to guide appropriate resuscitation strategies in nontrauma patients is warranted.

Impact of Volume Change Over Time on Trauma Mortality in the United States.

OBJECTIVE: To evaluate the association of trauma center volume change over time with mortality. BACKGROUND: Regionalization of trauma systems assumes a volume-outcome relationship for severe injury. Whereas this has been shown for cross-sectional volume, it is unclear whether volume changes over time translate into predictable outcome changes. METHODS: Retrospective cohort study of severely injured (injury severity score >15) patients from the National Trauma Databank 2000 to 2012. A center-level standardized mortality ratio (SMR) was constructed (ratio of observed to expected deaths). Expected mortality was obtained from multilevel logistic regression model, adjusting for demographics, mechanism, vital signs, and injury severity. Center-level percent volume change was assessed across early (2000-2006) and late (2007-2012) periods. Longitudinal panel modeling evaluated association between annual SMR change and volume change over preceding years. RESULTS: There were 839,809 patients included from 287 centers. Each 1% increase in volume was associated with 73% increased odds of improving SMR over time [odds ratio (OR) 1.73; 95% confidence interval (CI) 1.03-2.91; P = 0.03]. Each 1% decrease in volume was associated with 2-fold increase in odds of worsening SMR over time (OR 2.14; 95% CI 1.07-4.26, P = 0.03). Significant improvement in the SMR emerged after 3 or more preceding years of increasing volume (SMR change -0.008; 95% CI -0.015, -0.002; P = 0.01). This benefit occurred only in centers that were level I or II verified. CONCLUSIONS: Increasing volume was associated with improving outcomes, whereas decreasing volume was associated with worsening outcomes. High-level trauma center infrastructure seems to facilitate the volume-outcome relationship. The trauma center designation process should consider volume changes in the overall system.

Helicopter transport improves survival following injury in the absence of a time-saving advantage.

BACKGROUND: Although survival benefits have been shown at the population level, it remains unclear what drives the outcome benefits for helicopter emergency medical services (HEMS) in trauma. Although speed is often cited as the vital factor of HEMS, we hypothesized a survival benefit would exist in the absence of a time savings over ground emergency medical services (GEMS). The objective was to examine the association of survival with HEMS compared with GEMS transport across similar prehospital transport times. METHODS: We used a retrospective cohort of scene HEMS and GEMS transports in the National Trauma Databank (2007-2012). Propensity score matching was used to match HEMS and GEMS subjects on the likelihood of HEMS transport. Subjects were stratified by prehospital transport times in 5-minute increments. Conditional logistic regression determined the association of HEMS with survival across prehospital transport times strata controlling for confounders. Transport distance was estimated from prehospital transport times and average HEMS/GEMS transport speeds. RESULTS: There were 155,691 HEMS/GEMS pairs matched. HEMS had a survival benefit over GEMS for prehospital transport times between 6 and 30 minutes. This benefit ranged from a 46% increase in odds of survival between 26 and 30 minutes (adjusted odds ratio [AOR], 1.46; 95% CI, 1.11-1.93; P < .01) to an 80% increase in odds of survival between 16 and 20 minutes (AOR, 1.80; 95% CI, 1.51-2.14; P < .01). This prehospital transport times window corresponds to estimated transport distance between 14.3 and 71.3 miles for HEMS and 3.3 and 16.6 miles for GEMS. CONCLUSION: When stratified by prehospital transport times, HEMS had a survival benefit concentrated in a window between 6 and 30 minutes. Because there was no time-savings advantage for HEMS, these findings may reflect care delivered by HEMS providers.

Development and Validation of the Air Medical Prehospital Triage Score for Helicopter Transport of Trauma Patients.

OBJECTIVE: The aim of this study was to develop and internally validate a triage score that can identify trauma patients at the scene who would potentially benefit from helicopter emergency medical services (HEMS). SUMMARY BACKGROUND DATA: Although survival benefits have been shown at the population level, identification of patients most likely to benefit from HEMS transport is imperative to justify the risks and cost of this intervention. METHODS: Retrospective cohort study of subjects undergoing scene HEMS or ground emergency medical services (GEMS) in the National Trauma Databank (2007-2012). Data were split into training and validation sets. Subjects were grouped by triage criteria in the training set and regression used to determine which criteria had a survival benefit associated with HEMS. Points were assigned to these criteria to develop the Air Medical Prehospital Triage (AMPT) score. The score was applied in the validation set to determine whether subjects triaged to HEMS had a survival benefit when actually transported by helicopter. RESULTS: There were 2,086,137 subjects included. Criteria identified for inclusion in the AMPT score included GCS <14, respiratory rate <10 or >29, flail chest, hemo/pneumothorax, paralysis, and multisystem trauma. The optimal cutoff for triage to HEMS was ≥2 points. In subjects triaged to HEMS, actual transport by HEMS was associated with an increased odds of survival (AOR 1.28; 95% confidence interval [CI] 1.21-1.36, P < 0.01). In subjects triaged to GEMS, actual transport mode was not associated with survival (AOR 1.04; 95% CI 0.97-1.11, P = 0.20). CONCLUSIONS: The AMPT score identifies patients with improved survival following HEMS transport and should be considered in air medical triage protocols.

Pre-trauma center red blood cell transfusion is associated with improved early outcomes in air medical trauma patients.

BACKGROUND: Hemorrhage is the leading cause of survivable death in trauma and resuscitation strategies including early RBC transfusion have reduced this. Pre-trauma center (PTC) RBC transfusion is growing and preliminary evidence suggests improved outcomes. The study objective was to evaluate the association of PTC RBC transfusion with outcomes in air medical trauma patients. STUDY DESIGN: We conducted a retrospective cohort study of trauma patients transported by helicopter to a Level I trauma center from 2007 to 2012. Patients receiving PTC RBC transfusion were matched to control patients (receiving no PTC RBC transfusion during transport) in a 1:2 ratio using a propensity score based on prehospital variables. Conditional logistic regression and mixed-effects linear regression were used to determine the association of PTC RBC transfusion with outcomes. Subgroup analysis was performed for scene transport patients. RESULTS: Two-hundred and forty treatment patients were matched to 480 control patients receiving no PTC RBC transfusion. Pre-trauma center RBC transfusion was associated with increased odds of 24-hour survival (adjusted odds ratio [AOR] = 4.92; 95% CI, 1.51-16.04; p = 0.01), lower odds of shock (AOR = 0.28; 95% CI, 0.09-0.85; p = 0.03), and lower 24-hour RBC requirement (Coefficient -3.6 RBC units; 95% CI, -7.0 to -0.2; p = 0.04). Among matched scene patients, PTC RBC was also associated with increased odds of 24-hour survival (AOR = 6.31; 95% CI, 1.88-21.14; p < 0.01), lower odds of shock (AOR = 0.24; 95% CI, 0.07-0.80; p = 0.02), and lower 24-hour RBC requirement (Coefficient -4.5 RBC units; 95% CI, -8.3 to -0.7; p = 0.02). CONCLUSIONS: Pre-trauma center RBC was associated with an increased probability of 24-hour survival, decreased risk of shock, and lower 24-hour RBC requirement. Pre-trauma center RBC appears beneficial in severely injured air medical trauma patients and prospective study is warranted as PTC RBC transfusion becomes more readily available.

Variation in the BDNF gene interacts with age to predict mortality in a prospective, longitudinal cohort with severe TBI.

BACKGROUND: Mortality predictions following traumatic brain injury (TBI), and our understanding of TBI pathology, may be improved by including genetic risk in addition to traditional prognostic variables. One promising target is the gene coding for brain-derived neurotrophic factor (BDNF), a ubiquitous neurotrophin important for neuronal survival and neurogenesis. OBJECTIVE: We hypothesized the addition of BDNF genetic variation would improve mortality prediction models and that BDNF Met-carriers (rs6265) and C-carriers (rs7124442) would have the highest mortality rates post-TBI. METHODS: This study examined BDNF functional single nucleotide polymorphisms rs6265 (val66met) and rs7124442 (T>C) in relation to mortality in a prospective, longitudinal cohort with severe TBI. We examined 315 individuals receiving care for a closed head injury within the University of Pittsburgh Medical Center, aged 16 to 74 years. Mortality was examined acutely (0-7 days postinjury) and postacutely (8-365 days postinjury). A gene risk score (GRS) was developed to examine both BDNF loci. Cox proportional hazards models were used to calculate hazard ratios for survivability post-TBI while controlling for covariates. RESULTS: BDNF GRS was significantly associated with acute mortality, regardless of age. Interestingly, subjects in the hypothesized no-risk allele group had the lowest survival probability. Postacutely, BDNF-GRS interacted with age such that younger participants in the no-risk group had the highest survival probability, while older participants in the hypothesized no-risk group had the lowest probability of survival. CONCLUSIONS: These data suggest complex relationships between BDNF and TBI mortality that interact with age to influence survival predictions beyond clinical variables alone. Evidence supporting dynamic, temporal balances of pro-survival/pro-apoptotic target receptors may explain injury and age-related gene associations.

The importance of empiric abdominal computed tomography after urgent laparotomy for trauma: do they reveal unexpected injuries?

BACKGROUND: Many institutions now use empiric full-body computed tomography (CT) as a standard step in the initial workup of stable trauma patients. Recent data suggest that these scans may reveal unexpected injuries and improve survival in patients with polytrauma. However, patients who are unstable on presentation are often taken to the operating room (OR) without CT. Many of these patients undergo empiric full-body CTs after being stabilized in the OR, yet few data exist regarding how often early postoperative CT reveals unexpected injuries within compartments that have been explored surgically. Thus, the objective of this study was to determine if empiric abdominal/pelvic (ABD) CT after emergent trauma laparotomies are likely to reveal missed injuries requiring urgent management and improve patient management compared with clinical judgment alone. METHODS: We review retrospectively 496 trauma patients who required urgent exploratory laparotomy at UPMC Presbyterian Hospital from 2007 to 2011. Patients were included if they went to the OR for exploratory laparotomy directly from the emergency department within 2 hours of arrival. Patients were excluded if they received any preoperative ABD CT imaging. Patients who expired in the OR were similarly excluded. Patients were stratified into 2 groups based on whether or not they received an empiric ABD CT in the 24 hours immediately after laparotomy. Medical records were reviewed to look for differences in missed injuries, urgent reexplorations, nontherapeutic interventions, and time to urgent reexploration. RESULTS: There were 278 patients who met inclusion at exclusion criteria and constituted the study cohort. Of these patients, 124 underwent early empiric postoperative ABD CT imaging (45%). The remaining 154 patients did not undergo early ABD imaging (no CT group). The overall cohort had a 45% incidence of damage control procedures and a 9% rate of negative laparotomy. The 2 groups were statistically similar in age, presenting vitals, and abdominal Abbreviated Injury Scores. When the ABD CT group was compared with the no CT group, there was no difference in the overall rate of urgent reexplorations (7.3 vs 7.1%; P = .956), nontherapeutic urgent reexplorations (22 vs 18%; P = .822), or time to urgent reexploration (14 ± 10 vs 12 ± 10 hours; P = .686). Out of the 124 ABD CT patients, only 5 (4.0%) were diagnosed with injuries that were not identified at the time of the initial operation or caused by operative technique. When controlling for demographics, mechanism of injury, and injury severity, a logistic regression analysis revealed that early postoperative ABD CT was not associated with any differential risk of the need for further intervention (odds ratio, 0.85; 95% CI, 0.37-1.9; P = .691). CONCLUSION: The use of ABD CT soon after trauma laparotomy did not provide meaningful improvements in patient care in the cohort studied. Further higher level research is needed to clarify what role empiric ABD CT should play in the early postoperative period.

X chromosome-linked IRAK-1 polymorphism is a strong predictor of multiple organ failure and mortality postinjury.

OBJECTIVE(S): Clinical research characterizing the mechanisms responsible for sex-based outcome differences postinjury remain conflicting. We sought to characterize an X chromosome-linked IRAK-1 (IL-1 receptor-associated kinase) polymorphism as an alternative mechanism responsible for sex differences postinjury. IRAK-1 is key intermediate in the toll-like receptor (TLR) pathway thought to drive inflammation postinjury. METHODS: A prospective cohort study was performed over a 24-month period. Bluntly injured patients requiring intensive care unit admission were enrolled, whereas patients with isolated brain and spinal cord injuries were excluded. Outcomes of interest included multiple organ failure (MOF, Marshall MOD score > 5) and mortality. Logistic regression was utilized to determine the independent risk of poor outcome associated with the IRAK-1 variant after controlling for important differences. RESULTS: In an enrolled cohort of 321 patients, the IRAK-1 variant was common (12.5%). Patients with and without the variant were similar in age, injury severity, and 24hr blood transfusion. After controlling for important confounders, the IRAK1 variant was independently associated with more than eightfold (OR = 8.4, P = 0.005, 95% CI: 1.9-37.1) and 11-fold (OR = 11.8, P = 0.037, 95% CI: 1.1-121) greater risk of MOF and mortality, respectively. These differences were most prominent in men, whereas women heterozygous for the variant demonstrated worse outcome in a dose-dependent fashion. CONCLUSIONS: The IRAK1 polymorphism is a strong independent predictor of MOF and mortality postinjury and represents a common variant with prognostic potential. These data demonstrate the importance of TLR signaling postinjury and supports that a genetic mechanism may drive sex outcome differences postinjury.

Radiographic assessment of ground-level falls in elderly patients: Is the "PAN-SCAN" overdoing it?

INTRODUCTION: Routine, whole-body computed tomography imaging (PAN-SCAN) has been shown to identify unexpected injuries and alter the management of patients presenting with blunt trauma. We sought to characterize the changes in practice over time and the utility of PAN-SCAN imaging in elderly patients who fall and require admission to a trauma center. METHODS: We performed a retrospective analysis by using data derived from a Pennsylvania state-wide trauma registry (2007-2010). All hemodynamically stable patients (>65 years) who had a ground-level fall and were admitted for >24 hours were selected. Patients who underwent a combination of all three scans within 2 hours of arrival were considered to have underwent PAN-SCAN imaging. Clinical outcomes were compared across PAN-SCAN patients relative to less diagnostic imaging. Regression analysis was used to determine whether PAN-SCAN imaging was an independent determinate of mortality and resource use. RESULTS: Over the period of study, 13,043 patients met inclusion criteria. The annual rate of PAN-SCAN imaging after ground-level falls increased over time. After we controlled for important confounders, PAN-SCAN imaging was not associated with mortality (odds ratio 0.97, P = .74, 95% confidence interval 0.80-1.18). Despite greater injury severity, PAN-SCAN imaging was independently associated with significantly lesser intensive care unit requirements, step-down days, and a lesser overall duration of stay. CONCLUSION: PAN-SCAN imaging has become more common over time in elderly patients having a ground-level fall. Although PAN-SCAN imaging during the initial trauma evaluation was not associated with an independent decrease in the risk of mortality, it was independently associated with lesser hospital resource use. These data suggest that whole-body computed tomography imaging may benefit trauma center resource use for patients with ground-level falls.

Improving mortality predictions in trauma patients undergoing damage control strategies.

The increased use of damage control surgery in complex trauma patients requires accurate prognostic indicators. We compared the discriminatory capacity of commonly used trauma and intensive care unit (ICU) scores, including revised trauma score, injury severity scores, trauma score-injury severity scores, acute physiology and chronic health evaluations II, and clinical and laboratory parameters, on 83 consecutive trauma patients admitted to the ICU, undergoing damage control. Logistic regressions were built for mortality prediction within 30 days. Performances of the models were assessed in terms of discrimination and calibration. Areas under the receiver operating characteristic curve from the models were compared. Overall mortality was 38.5 per cent. A "clinical" model was constructed including ICU admission pH and hypothermia (≤ 35 C °) and the number of packed red blood cells during the first 24 hours. This model was adjusted for age and demonstrated better discrimination for mortality prediction (areas under the receiver operating characteristic curve = 0.8054) than injury severity score (P value = 0.049), abdominal trauma index (P value = 0.049), and acute physiology and chronic health evaluations II (P value = 0.001). There was no statistically significant difference in discrimination for mortality prediction between the "clinical" model and revised trauma score (P value = 0.4) and trauma score-injury severity score (P value = 0.4). We concluded that the combination of ICU admission pH and hypothermia and blood transfusions during 24 hours provided an excellent discriminatory capacity for mortality prediction in this complex patient population.

WSES SM (World Society of Emergency Surgery Summer Meeting) highlights: emergency surgery around the world (Brazil, Finland, USA).

Emergency surgery is performed in every hospital with a A and E unit all around the world. However it is organized in different ways with different results.Aim of this paper is to present history, current scope, current training program and new politics for training national program of 3 countries of different continents.Brazil, Finland and US emergency surgery models are presented discussing all criticisms showed during the WSES Summer Meeting 2008.