Blood transfusions in gunshot-wound-related emergency department visits and hospitalizations in the United States.

BACKGROUND: The United States (US) leads all high-income countries in gunshot wound (GSW) deaths. However, previous US studies have not evaluated the national blood transfusion utilization patterns in hospitalized GSW patients. METHODS: Data from 2016 to 2017 were analyzed from the Nationwide Emergency Department Sample (NEDS) and Nationwide Inpatient Sample (NIS), the largest all-payer emergency department (ED) and inpatient databases, respectively. Using stratified probability sampling, weights were applied to generate nationally representative estimates. Multivariable Poisson-regression models were used to estimate prevalence ratios (PR) of blood transfusion. RESULTS: There were 168,315 ED visits and 58,815 hospitalizations (age = 18-90 years) following a GSW. The majority of hospitalizations were men (88.5%), age 18-24 years (31.8%), and assault-related GSW (51.3%). Blacks had the largest proportion (48.7%) overall of all GSW hospitalizations; Whites accounted for the highest proportion of intentional self-harm injuries (72.4%). Blood transfusions occurred in 12.7% of hospitalizations (12.0% red blood cell [RBC], 4.9% plasma, and 2.5% platelet transfusions). Only 1.9% of cases were associated with transfusion of all three blood components. Hospitalizations with major/extreme severity of illness had significantly higher prevalence of transfusion versus those with mild/moderate severity [crude PR = 4.79 (95%CI:4.15-5.33, p < .001)]. Overall, 8.2% of hospitalizations with GSW died, of whom 26.8% required blood transfusions, which was significantly higher than survivors [crude PR = 2.34 (95%CI:2.10-2.61, p < .001)]. The vast majority (95%) of the transfusions among those who died were within 48 h since admission. CONCLUSIONS: Gun-related violence is a public health emergency in the US, and GSWs are a source of significant mortality, blood utilization, and health care costs.

Ten years of molecular ballistics-a review and a field guide.

Molecular ballistics combines molecular biological, forensic ballistic, and wound ballistic insights and approaches in the description, collection, objective investigation, and contextualization of the complex patterns of biological evidence that are generated by gunshots at biological targets. Setting out in 2010 with two seminal publications proving the principle that DNA from backspatter collected from inside surfaces of firearms can be retreived and successfully be analyzed, molecular ballistics covered a lot of ground until today. In this review, 10 years later, we begin with a comprehensive description and brief history of the field and lay out its intersections with other forensic disciplines like wound ballistics, forensic molecular biology, blood pattern analysis, and crime scene investigation. In an application guide section, we aim to raise consciousness to backspatter traces and the inside surfaces of firearms as sources of forensic evidence. Covering crime scene practical as well as forensic genetic aspects, we introduce operational requirements and lay out possible procedures, including forensic RNA analysis, when searching for, collecting, analyzing, and contextualizing such trace material. We discuss the intricacies and rationales of ballistic model building, employing different tissue, skin, and bone simulants and the advantages of the "triple-contrast" method in molecular ballistics and give advice on how to stage experimental shootings in molecular ballistic research. Finally, we take a look at future applications and prospects of molecular ballistics.

The Utility of Carbohydrate-Deficient Transferrin in Identifying Chronic Alcohol Users in the Injured Patient: Expanding the Toolkit.

BACKGROUND: Alcohol use remains abundant in patients with traumatic injury. Previous studies have suggested that serum carbohydrate-deficient transferrin (%dCDT) levels, relative to blood alcohol levels (BALs), may better differentiate episodic binge drinkers from sustained heavy consumers in admitted patients with traumatic injury. We characterized %dCDT levels and BAL levels to differentiate binge drinkers from sustained heavy consumers in admitted trauma patients and their associations with outcomes. METHODS: This prospective, cross-sectional, observational study assessed %dCDT and BAL levels in admitted male and female patients with traumatic injury (≥18 y) at an American College of Surgeons Committee on Trauma level-1 center from July 2014 to June 2016. We designated patients with %dCDT levels ≥1.7% (CDT+) as chronic alcohol users and dichotomized acutely intoxicated patients using three different BAL-level thresholds. Primary outcomes included in-hospital complications, along with prolonged ventilation and intensive care unit length of stay, both defined as the top decile. Secondary outcomes included rates of drug or alcohol withdrawal and all-cause mortality. Analyses were adjusted for clinical factors. RESULTS: We studied 715 patients (77.5% men, 60.6% ≤ 40 y of age, median Injury Severity Score: 14, 41.7% motor vehicle crashes, 17.9% gunshot wounds, 11.1% falls). While 31.0% were CDT+, 48.7% were BAL>0. After adjusting for CDT levels, BAL levels >0, >100, or >200 were not associated with adverse outcomes. However, CDT+ relative to patients with CDT were associated with complications (adjusted odds ratio: 1.96 [1.24-3.09]), prolonged ventilation days (3.23 [1.08-9.65]), and prolonged intensive care unit stays (2.83 [1.20-6.68]). CONCLUSIONS: In this 2-year prospective, cross-sectional, and observational study, we found that %dCDT levels, relative to BAL levels, may better stratify admitted patients with traumatic injury into acute versus chronic alcohol users, identifying those at higher risk for in-hospital complications.

Characteristics of Pediatric Patients With Retained Bullet Fragments and Need for Follow-Up Blood Lead Monitoring.

OBJECTIVES: Multiple case reports of lead toxicity related to retained bullet fragments in pediatric patients sustaining gunshot wound have been published. The purpose of the present study was to determine whether the demographic and clinical characteristics of gunshot wounds (GSWs) could be classified high/low risk and whether routine blood lead monitoring is necessary in these patients. METHODS: A single-center prospective case series of pediatric GSW patients presenting to the emergency department (ED). The data points that were collected and analyzed included age, sex, race, wound location, disposition, and baseline and follow-up lead levels within 6 months post-injury. RESULTS: Twenty patients were enrolled in the study and the median age was 7.5 years (interquartile range 5.25-10.75); 75% of the patients were African American. A total of 15 patients (75%) had injuries in either a lower or upper extremity, 9 of whom required admission. Almost all of the injuries involving the head, chest, or abdomen required admission. Of the patients, 65% were admitted and 35% were discharged. All of the patients had an initial blood lead level taken, and follow-up lead levels were determined at 6 months post-injury to be <5 µg/dL. Twelve of 20 patients were lost to follow-up. CONCLUSIONS: Pediatric GSW is common in male African Americans and these patients had baseline and follow-up lead levels below the reference level. These patients were difficult to follow up. Based on the available data, follow-up lead monitoring may not be indicated.

Bullet wipe on the uppermost textile layer of gunshot entrance sites: may it be absent due to pre-existing blood staining?

Most gunshot entrance sites on human victims are localized in clothed body regions. Except for the use of lead-free ammunition, a positive color reaction of the sodium rhodizonate test indicates a primary target hit by the bullet. Any lead residue pattern in the area around the entrance hole allows approximate conclusions as to the firing distance in close and intermediate range shots, whereas the presence of a bullet wipe denotes an entrance site. A criminal case gave rise to an experimental study to clarify whether a blood-soaked garment being shot at as a primary target may lack a bullet wipe around the entrance hole. Distant-range shots were fired with a semi-automatic pistol (Heckler & Koch, Mod. USP Compact, cal. 9-mm Luger) using cartridges with jacketed round-nose bullets and a Sinoxid primer containing lead styphnate. In fabrics saturated with fluid blood, a wide area around the bullet entrance was densely covered with rhodizonate-positive microparticles simulating gunshot residues (GSR) from a close-range shot. In shots to fabrics oversaturated with blood, a typical bullet wipe was lacking, whereas lead-containing particles were spotted in the periphery. The results are discussed with respect to the aberrant appearance of bullet entrance sites in blood-soaked fabrics.

Massive transfusion associated with a hemolytic transfusion reaction: necessary precautions for prevention.

CASE REPORT: A 45-year-old male presented in severe hypovolemic shock after a thoracoabdominal gunshot wound. The massive transfusion protocol (MTP) was activated and the patient was taken to the operating room. His major injuries included liver, small bowel, and right common iliac vein. Hemorrhage was stopped and a damage control laparotomy was completed. He received a total of 113 blood products. During his postoperative course he received a group B blood transfusion on Hospital Days 2 and 7 based on incorrect blood typing late in his massive transfusion and repeat testing on Day 4. RESULTS: He succumbed to multiple organ failure on Day 8. MTPs are standard in most trauma centers during which universal donor red blood cells are initially used. As hemorrhage is controlled, the patient undergoes a complete type and cross according to blood banking protocols. These typing results are used to continue transfusions once the MTP is no longer needed. In contacting other blood banks servicing Level I trauma centers, the policy of when to switch from universal donor blood to crossmatched blood is variable. CONCLUSION: Our case illustrates a potential blood typing problem that had a disastrous outcome. We identified changes in policy that will make MTPs safer.

Serum thiol levels and thiol/disulphide homeostasis in gunshot injuries.

BACKGROUND: Gunshot injuries result in serious traumatic tissue damage due to high velocity of the bullet, deep penetration, and ballistic effect. Trauma is known to be related with oxidative stress. Serum thiol levels and disulphide/thiol homeostasis are novel oxidative stress biomarkers. In this study, we aimed to investigate serum thiol levels and disulphide/thiol homeostasis in injury patterns of patients admitted to the emergency department with a gunshot injury. METHOD: A total of 128 participants were included in the study. The participants were divided into two groups: the patient group (Group 1; n = 73) and healthy controls (Group 2; n = 55). Native thiol, total thiol, disulphide levels, disulphide/native thiol, disulphide/total thiol, and neutrophil-to-lymphocyte ratio (NLR) were measured. The Revised Trauma Scale (RTS) and Glasgow Coma Scale (GCS) scores were calculated. RESULTS: Native thiol, total thiol, and disulphide levels were significantly lower in Group 1 (p < 0.001). Disulphide/native thiol ratio, disulphide/total thiol ratio, and NLR were significantly higher in Group 1, compared to Group 2 (p < 0.05). There was a positive correlation between thiol levels and RTS and GCS scores and NLR. Stepwise linear regression analysis showed that native thiol was an independent indicator of RTS and GCS scores. The receiver operating characteristic curve (ROC) analysis revealed that serum native thiol levels of ≤ 342.9 could predict gunshot injury with a sensitivity of 82% and a specificity of 77% (area under the curve = 0.853; 95% confidence interval 0.783-0.924). CONCLUSION: Our study results suggest that thiol-disulphide homeostasis is disrupted in patients sustaining gunshot injuries, and thiol levels decrease in correlation with the severity of trauma with a high sensitivity and specificity. As the level of native thiol is an independent predictor of the severity of trauma, reduced thiol levels may be of prognostic value in the early assessment of patients in the emergency room.

A raised serum lactate level is an independent predictor of in-hospital mortality in patients with isolated cerebral gunshot wounds.

BACKGROUND: Cerebral gunshot wounds (CGSWs) represent a highly lethal form of traumatic brain injury, and triaging these patients is difficult. The prognostic significance of the serum lactate level in the setting of CGSWs is largely unknown. OBJECTIVES: To examine the relationship between elevated serum lactate levels and mortality in patients with isolated CGSWs. METHODS: A retrospective review of the regional trauma registry was undertaken at the Pietermaritzburg Metropolitan Trauma Service, South Africa, over a 5-year period from 1 January 2010 to 31 December 2014. All patients with an isolated CGSW were included. RESULTS: A total of 102 patients with isolated CGSWs were identified. Of these, 92.2% (94/102) were male. The mean age (standard deviation) was 29 (8) years, and the in-hospital mortality rate was 21.6% (22/102). The mean serum lactate level was significantly higher among non-survivors than among survivors (6.1 mmol/L v. 1.3 mmol/L; p<0.001). Lactate levels among non-survivors were <2 mmol/L in 4.5%, 2 - 3.99 mmol/L in 9.1%, 4 - 5.99 mmol/L in 36.4% and ≥6 mmol/L in 50.0%. The odds ratio for mortality with a lactate level of 4 - 5.99 mmol/L was 67 (95% confidence interval (CI) 1.7 - 2 674.2), while for a lactate level of ≥6 mmol/L it was 1 787 (95% CI 9.0 - 354 116.1). The serum lactate level accurately predicted mortality even after adjustment for other variables. Based on a receiver operating curve analysis, an optimal cut-off of 3.3 mmol/L for serum lactate as a predictor for mortality was identified (area under the curve = 0.957). CONCLUSIONS: CGSWs are associated with significant mortality, and a raised serum lactate level appears to be an independent predictor of in-hospital mortality. It is a potentially useful adjunct in the resuscitation room for identifying patients with a very poor prognosis.

Extra-Articular Retained Missiles; Is Surveillance of Lead Levels Needed?

Background: Although gunshot wounds are relatively common, lead toxicity associated with extra-articular retained missiles (EARMs) is an uncommon, yet potentially devastating, complication. Although the risk of lead toxicity with intra-articular retained missiles is well known, EARMs are routinely left in situ or only removed in selected circumstances secondary to the relatively rare occurrence of complications. Methods: We first describe a patient with systemic lead poisoning associated with retained lead fragments after a gunshot-induced left femoral shaft fracture. We then performed a systematic review of the literature to answer the following questions: (1) In the setting of retained extra-articular bullets and/or bullet fragments, is regular monitoring and/or surveillance of lead levels in the blood routinely indicated? and, if so, (2) what are the selected factors that portend an increased risk for elevations in blood lead levels in the setting of retained extra-articular bullets and/or bullet fragments? The systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines, of the English language literature utilizing Medline (PubMed), EMBASE, Cochrane, and CINAHL on the topic of lead poisoning, retained bullet, and gunshot wound, and then searched for additional references by manually searching of bibliographies of the included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the accepted levels of evidence. Findings: Routine monitoring or surveillance of lead levels in blood is recommended in all cases of EARM at the time of hospital admission and again at discharge, followed by monthly intervals until 3 mo post-injury and then again at 1 yr post-injury. The studies identified demonstrated significant risk factors for elevated blood lead levels in the setting of EARM, which included the number of retained missiles and concomitant fracture. Discussion: Recommendations for routine monitoring and surveillance of blood lead levels in all cases of EARM are conflicting, but such monitoring appears to be warranted given that the potential risks and morbidity associated with systemic lead poisoning are outweighed by any potential harm of short-term, blood lead level monitoring. Outside of concomitant fracture, the evidence for making further clinical recommendations regarding selected risk factors that portend an increased risk for elevated blood lead levels after gunshot injury is weak. Larger level II and III studies are needed to determine the indications for and frequency of lead toxicity screening after retained EARM.

Large area imaging of forensic evidence with MA-XRF.

This study introduces the use of macroscopic X-ray fluorescence (MA-XRF) for the detection, classification and imaging of forensic traces over large object areas such as entire pieces of clothing and wall paneling. MA-XRF was sufficiently sensitive and selective to detect human biological traces like blood, semen, saliva, sweat and urine on fabric on the basis of Fe, Zn, K, Cl and Ca elemental signatures. With MA-XRF a new chemical contrast is introduced for human stain detection and this can provide a valuable alternative when the evidence item is challenging for conventional techniques. MA-XRF was also successfully employed for the chemical imaging and classification of gunshot residues (GSR). The full and non-invasive elemental mapping (Pb, Ba, Sr, K and Cl) of intact pieces of clothing allows for a detailed shooting incident reconstruction linking firearms and ammunition to point of impact and providing information on the shooting angle. In high resolution mode MA-XRF can even be used to provide information on the shooting order of different ammunition types. Finally, by using the surface penetration of X-rays we demonstrate that the lead signature of a bullet impact can be easily detected even if covered by multiple layers of wall paint or human blood.

High-Precision (MC-ICPMS) Isotope Ratio Analysis Reveals Contrasting Sources of Elevated Blood Lead Levels of an Adult with Retained Bullet Fragments, and of His Child, in Milwaukee, Wisconsin.

Exposure to the neurotoxic element lead (Pb) continues to be a major human health concern, particularly for children in US urban settings, and the need for robust tools for assessment of exposure sources has never been greater. The latest generation of multicollector inductively coupled plasma mass spectrometry (MC-ICPMS) instrumentation offers the capability of using Pb isotopic signatures as a tool for environmental source tracking in public health. We present a case where MC-ICPMS was applied to isotopically resolve Pb sources in human clinical samples. An adult male and his child residing in Milwaukee, Wisconsin, presented to care in August 2015 with elevated blood lead levels (BLLs) (>200 µg/dL for the adult and 10 µg/dL for the child). The adult subject is a gunshot victim who had multiple bullet fragments embedded in soft tissue of his thigh for approximately 10 years. This study compared the high-precision isotopic fingerprints (<1 ‰ 2σ external precision) of Pb in the adult's and child's whole blood (WB) to the following possible Pb sources: a surgically extracted bullet fragment, household paint samples and tap water, and a Pb water-distribution pipe removed from servicing a house in the same neighborhood. Pb in the bullet and adult WB were nearly isotopically indistinguishable (matching within 0.05-0.56 ‰), indicating that bullet fragments embedded in soft tissue could be the cause of both acute and chronic elevated blood Pb levels. Among other sources investigated, no single source dominated the child's exposure profile as reflected in the elevated BLL.

Detection of blood aspiration in deadly head gunshots comparing postmortem computed tomography (PMCT) and autopsy.

BACKGROUND: The aim of our study was to analyze the reliability of postmortem computed tomography (PMCT) versus autopsy in detecting signs of blood aspiration in a distinct group of patients following deadly head, mouth or floor of mouth gunshot injuries. METHODS: In this study, in 41 cases PMCT was compared to autopsy reports, the gold standard of postmortem exams, regarding detection of blood aspiration. PMCT was evaluated for the presence and level of typical signs of blood aspiration in the major airways and lung using a semi-quantitative scale ranging from level 0 (no aspiration) to 3 (significant aspiration) also taking density values of the described potential aspiratory changes into account. RESULTS: Overall, in 29 (70.7%) of 41 enrolled cases PMCT and autopsy revealed the same level of aspiration. A difference of one level between PMCT and autopsy resulted for 5 (12.2%) of the remaining 12 cases. More than one level difference between both methods resulted for 7 cases (17.2%). Autopsy described no signs of aspiration in 10 cases, compared to 31 cases with reported blood aspiration. In contrast, PMCT revealed no signs of blood aspiration in 15 cases whereas 26 cases were rated as positive for signs of aspiration in the major airways. In 18 of these 26 cases considered positive for blood aspiration by autopsy and PMCT, clear signs of aspiration signs were also described bilaterally by both methods. CONCLUSIONS: The presented study provides evidence for the assumption that PMCT seems to be helpful in the detection of blood aspiration in cases of deadly head gunshots. In conclusion, it seems reasonable to suggest performing PMCT additionally to traditional postmortem exams in cases of suspected aspiration to rule out false-negative cases and to possibly allow for a more detailed and rather evidence based examination reconnoitering the cause of death. However, the adequate use of PMCT in this context needs further evaluation and the definition of an objective scale for aspiration detection on PMCT needs to be established in future studies.

Probable transfusion-transmission of Anaplasma phagocytophilum by leukoreduced platelets.

BACKGROUND: Anaplasma phagocytophilum (AP), a tick-borne obligate intracellular bacterium, causes human granulocytic anaplasmosis (HGA) and has been implicated in seven transfusion-transmitted (TT)-HGA cases associated with red blood cells (RBCs). Here we report the first probable case of TT-HGA involving leukoreduced platelets (PLTs). CASE REPORT: A hospitalized male received 25 blood components (November 2012) before his death from trauma. Hospital testing confirmed HGA by peripheral blood smears; samples were also sent to IMUGEN, Inc. (Norwood, MA), for AP-polymerase chain reaction (PCR) and AP-immunoglobulin (Ig)M and IgG enzyme immunoassay. All 12 potentially transmitting donors provided follow-up samples. RESULTS: Recipient smears progressed from negative to predominantly positive 16 days posttransfusion; hospital-performed AP-PCR was positive on Day 22. IMUGEN sample testing was PCR positive and IgM and IgG negative 14 to 23 days posttransfusion. The recipient had no known AP risk factors. One of 12 donors of RBCs or PLTs (leukoreduced 5-day-old PLTs) provided six follow-up samples; all were strongly IgG positive and IgM negative; one was PCR-positive. The IgG-positive donor was a 52-year-old female from Hudson Valley, New York, an area endemic for AP. She reported tick bites in September to October 2012 with no travel outside New York. The donor remained asymptomatic and received no treatment. The cocomponent PLT unit was transfused to a 78-year-old male who died of causes unrelated to AP. CONCLUSIONS: This eighth case of probable TT-HGA indicates that leukoreduced PLTs may be infectious. An antibody- and PCR-positive donor having prior tick exposure living in an endemic area was identified. PCR positivity and elevated IgG levels, which continue to exceed the assay's detectible range even in the absence of IgM, indicate active donor infection.

Plasma-to-red cell ratio and mechanism of injury in massively transfused combat casualties.

STUDY DESIGN: A retrospective review of 930 combat casualties from March 2003 to September 2009 who received a massive transfusion. Mechanism was categorized as explosion (EXPL) (712), gunshot wound (GSW) (190), and blunt trauma (28). Cohorts were also categorized by fresh frozen plasma (FFP) to red blood cell (RBC) ratio: low, ≤1:1.5 and high, >1:1.5. Patient characteristics and in-hospital mortality rates were compared among groups. Propensity matching was used to control for confounding variables. RESULTS: Cohorts were similar in demographics, admission vital signs, and laboratory values. Median injury severity score was higher in EXPL compared to GSW. High FFP:RBC ratio was associated with improved survival compared to low ratio in the EXPL group (p < 0.01). The GSW group had similar survival in the high and low FFP:RBC ratio groups (p = 0.06). After propensity matching, a high FFP:RBC ratio was associated with improved survival compared to low ratio in both the EXPL (p < 0.01) and GSW groups (p = 0.05). CONCLUSIONS: High FFP:RBC ratios are associated with improved survival in combat casualties regardless of injury mechanism.

[Gunshot wounds: should projectiles and fragments always be removed?]. / Schussverletzungen: Müssen Projektile und Fragmente immer entfernt werden?

BACKGROUND: Projectiles or metal fragments can remain lodged in the body of victims of gunshot injuries. This also applies to projectiles which do not tend to deform or fragment on impact. When a projectile fragments on penetration, jacket or lead core particles are likely to remain lodged in the affected region even if the projectile has exited the body. AIM OF THE STUDY: A frequently asked question in the surgical management of such injuries is whether there are medical indications for the surgical removal of projectiles or fragments. MATERIAL AND METHODS: This article presents some typical cases of patients who have received treatment at our institution and reviews the pertinent literature to show general recommendations in special cases concerning the removal of projectiles or fragments and when additional surgical trauma is justified. Parameters for decision making are presented in an algorithm. RESULTS: From our own patients, 5 with remaining fragments in the soft tissue were invited for a clinical follow up. Serum probes and 24 h urine output was analysed for serum lead levels and urinary aminolevulinic acid levels. 74 months (max. 128 - min. 42 months) after injury we documented not elevated serum lead levels of 8.25 µg/ml and urinary aminolevulinic acid levels of 4.8 mg/24 h. DISCUSSION: When lead-containing projectiles or fragments remain lodged in the body, monitoring is required and includes the measurement of serum lead levels and urinary aminolevulinic acid levels. The most important clinical symptoms of lead poisoning are gastrointestinal and neurological in nature. The treatment of choice for lead poisoning is the administration of chelating agents and removal of the lead source by surgical intervention.

Lead toxicity and management of gunshot wounds in the lumbar spine.

INTRODUCTION: Gunshot wounds are one of the commonest causes of spinal injury. Management of these patients differs from other blunt trauma injuries to the spine. We present a case of a gunshot wound to the lumbar spine that occurred in 1985 which was treated non-operatively. METHODS: In the last 10 years, the patient was admitted multiple times for confusion and lead toxicity with blood levels over 100 µg/dl. Inpatient chelation therapy was implemented. After multiple recommendations for surgery, the patient agreed to have as much of the bullet removed as possible. The patient successfully underwent decompression and fusion from both anterior and posterior approaches. Lead levels subsequently declined. CONCLUSION: The purpose of this paper is to show a case of a gunshot wound to the spine that ultimately caused plumbism and required surgery. Technical aspects of the surgery are described as well as pre- and post-procedural imaging. Recommendations for the general management of spine gunshot wounds are also described.

Life, limb or off-label recombinant VIIa use in the setting of limited blood assets: a case study.

Due to the lack of adequate controlled trials, the off-label use of recombinant factor VIIa (rFVIIa) to control hemorrhage in trauma patients remains controversial. The decision regarding when to initiate rFVIIa therapy is particularly problematic. Whereas most reports and trials have delayed use until significant bleeding has occurred, there is some evidence that coagulopathy develops early in some trauma patients, raising the possibility that early rFVIIa use may be more clinically efficacious. Herein, we report the case of a hemodynamically unstable patient with massive blood loss from multiple gunshot wounds and who had a potentially salvageable upper extremity. Rapid hemorrhage despite efforts to surgically control the bleeding resulted in virtual exhaustion of the facilities' limited blood component supply. Hemorrhage was controlled when rFVIIa was added to hypotensive resuscitation allowing salvage of the arm and significant conservation of blood products. This case raises the question as to whether earlier off-label use of this agent should be considered when amputation for hemorrhage control is being considered and/or conservation of limited blood assets is needed.

The use of crossover immunoelectrophoresis to detect human blood protein in soil from an ambush scene in Kosovo.

This study examines the survivability of human blood proteins in soils from a year and a half old ambush scene in Kosovo. A total of 72 soil samples were collected, a number of which were directly associated with bone fragments or bullet projectiles. The samples were examined using crossover immunoelectrophoresis (CIEP) to determine the presence of blood protein and species affiliation. Human blood proteins were identified in 44 of the 72 samples (61%) with the majority of the positive observations (29 of 44) found 0.0-4.5 cm below ground surface (65%). Chi-squared and two-sample difference of proportions tests confirmed significant differences between samples with and without associated physical evidence and the presence and depth of human blood proteins. While DNA has largely replaced immunological analysis in forensic analyses, our results suggest that in particular situations, CIEP may still be a valuable tool in criminology.

Serum neutrophil gelatinase-associated lipocalin in ballistic injuries: a comparison between blast injuries and gunshot wounds.

UNLABELLED: Neutrophil gelatinase-associated lipocalin (NGAL) is part of a functionally diverse family of proteins that generally bind small, hydrophobic ligands. Neutrophil gelatinase-associated lipocalin is expressed in a number of human tissues including gastrointestinal, respiratory, and urinary tracts and tends to rise in response to inflammation. For this reason, we hypothesized that levels of NGAL might be expressed at higher levels after blast injury compared with other ballistic injury. PURPOSE: The purpose of this study is to test the hypothesis that NGAL may be a marker of injury severity in blast injury. MATERIALS: Twenty-three combat casualties (13 blast, 10 gunshot wounds) admitted to the multinational role 3 facility in Helmand province were studied. Serum NGAL was measured using a Biosite Triage point-of-care monitor at 5 time points after injury. RESULTS: Neutrophil gelatinase-associated lipocalin rose in both groups of casualties and was significantly predictive of death or renal failure at intensive care unit admission, 12 and 24 hours after injury. CONCLUSIONS: Neutrophil gelatinase-associated lipocalin is not a specific marker of blast injury but is predictive of both renal failure and poor outcome.

[Preoperative leukocytosis as a predictor of intrabdominal injury in penetrating abdominal trauma]. / Leucocitosis prequirúrgica como factor predictivo de lesión a órgano intrabdominal en trauma penetrante abdominal.

BACKGROUND: in Mexico, the management of abdominal penetrating trauma doesn't follow the algorithms of Trauma Center level I, because of our limitations, and laparotomies are inevitable in this context. Is possible use some grade of leukocytosis suspect in-trabdominal lesion? METHODS: study retrospective, descriptive and analytic that inclu-ded patients with abdominal penetrating trauma that suffered exploratory laparotomy. We excluded patients' whit severe damage to soft tissues in extremities, thoracic affection, fractures, or da-mage in nervous system. We divided the patients into 2 groups: group I (therapeutic laparotomy) and group II (non-therapeutic laparotomy). Dependent variables were; age, gender, type of injury, number of lesions, peripheral lesions, time between injury and, from a laboaratory blood sample, leukocytosis mean, percentage of neutrophils, leukocytosis ≥ 12,500 /mm(3), and hemoperitoneum. We compared variables between two groups and use Pearson's χ(2) test and T-Student, and percentages as summary of measures. RESULTS: we included 231 patients, group I with 159 patients and group II with 72 patients. Leukocytosis global was 13.2 mil/mm(3) and neutrophil range of 70.3%. 26% of patients did not have leukocytosis at arrival and evaluation, however they were laparotomized because of present peritoneal irritation. Leukocytosis ≥ 12.5 mil/mm(3) was statistically significant in patients with intrabdominal lesions (74.2% vs 27.7%, p < 0.001). CONCLUSIONS: leukocytosis ≥ 12.5 mil/mm(3) could be an early serum marker abdominal penetrating trauma.