Increased platelet:RBC ratios are associated with improved survival after massive transfusion.

BACKGROUND: Several recent military and civilian trauma studies demonstrate that improved outcomes are associated with early and increased use of plasma-based resuscitation strategies. However, outcomes associated with platelet transfusions are poorly characterized. We hypothesized that increased platelet:red blood cells (RBC) ratios would decrease hemorrhagic death and improve survival after massive transfusion (MT). METHODS: A transfusion database of patients transported from the scene to 22 Level I Trauma Centers over 12 months in 2005 to 2006 was reviewed. MT was defined as receiving ≥ 10 RBC units within 24 hours of admission. To mitigate survival bias, 25 patients who died within 60 minutes of arrival were excluded from analysis. Six random donor platelet units were considered equal to a single apheresis platelet unit. Admission and outcome data associated with the low (>1:20), medium (1:2), and high (1:1) platelet:RBC ratios were examined. These groups were based on the median value of the tertiles for the ratio of platelets:RBC units. RESULTS: Two thousand three hundred twelve patients received at least one unit of blood and 643 received an MT. Admission vital signs, INR, temperature, pH, Glasgow Coma Scale, Injury Severity Score, and age were similar between platelet ratio groups. The average admission platelet counts were lower in the patients who received the high platelet:RBC ratio versus the low ratio (192 vs. 216, p = 0.03). Patients who received MT were severely injured, with a mean (± standard deviation) Injury Severity Score of 33 ± 16 and received 22 ± 15 RBCs and 11 ± 14 platelets within 24 hours of injury. Increased platelet ratios were associated with improved survival at 24 hours and 30 days (p < 0.001 for both). Truncal hemorrhage as a cause of death was decreased (low: 67%, medium: 60%, high: 47%, p = 0.04). Multiple organ failure mortality was increased (low: 7%, medium: 16%, high: 27%, p = 0.003), but overall 30-day survival was improved (low: 52%, medium: 57%, high: 70%) in the high ratio group (medium vs. high: p = 0.008; low vs. high: p = 0.007). CONCLUSION: Similar to recently published military data, transfusion of platelet:RBC ratios of 1:1 was associated with improved early and late survival, decreased hemorrhagic death and a concomitant increase in multiple organ failure-related mortality. Based on this large retrospective study, increased and early use of platelets may be justified, pending the results of prospective randomized transfusion data.

In the wake of Hurricane Isabel: a prospective study of postevent trauma and injury control strategies.

Preventing hurricane-related injuries (HRI) has historically centered on the pre-event and event phases of the disaster. To date, no study has focused on injuries occurring during the postevent phase. We examined HRI that occurred after Hurricane Isabel struck a U.S. urban city. HRI presenting 1 week prior to the hurricane were collected from emergency department electronic records. HRI that presented to our level 1 trauma center were prospectively collected for 1 week after the hurricane. Nine hundred seventy-eight patients with possible HRI were identified. Fifty-one patients with trauma directly attributed to the hurricane were used for analysis. The number of HRI occurring before, during, and after the hurricane were 7 (14%), 3 (6%), and 41 (80%), respectively. The majority of HRI (37%) occurred on posthurricane day 1. Head, chest, upper and lower extremities accounted for 9 (18%), 8 (16%), 13 (26%), and 14 (28%) of HRI. More than one third of HRI patients were admitted to the hospital, and 12 (24%) underwent an operation. The average hospital length of stay was 4.7 days. Of our trauma alerts, 75 per cent had an Injury Severity Score (ISS) >8, and 20 per cent had an ISS >15. Tree-related injuries (TRI) accounted for 59 per cent of HRI. Males, ages 50-60, had the highest incidence of injury (63%). Significant injuries occur in the wake of a hurricane. Optimization of disaster preparation must include prevention strategies targeted to the postevent recovery phase of disasters.

Cervical vascular injuries: a trauma center experience.

BACKGROUND: We analyzed 76 patients with cervical vascular injuries from penetrating neck trauma (n = 528) between 1977 and 1990 at a level I trauma center to evaluate the role of angiography in diagnosis and management and to assess the course and outcome of these patients. METHODS: Patients who were hemodynamically unstable underwent immediate surgical exploration. Stable patients were subjected to diagnostic investigation. Angiography was routinely performed to diagnose vascular injury in zones I and III and zone II if the trajectory was in the vicinity of major vessels. Therapeutic embolization was performed when possible at angiography; all other vascular injuries were treated surgically. RESULTS: Thirteen patients (2.5%) died of penetrating neck trauma, in 12 of whom hemorrhage was the contributing factor (12/76; 15.8% of patients with vascular injury). In nine patients who were hemodynamically stable vascular injury was diagnosed by angiography: 5 (6.8%) of 73 in zone I and 3 (5.4%) of 56 in zone III, four of whom underwent therapeutic embolic occlusion of the injured vessel. Injuries to vertebral and subclavian arteries and subclavian and innominate veins were often multiple, causing exsanguination and death (6.8% in zone I). In three patients with no preoperative neurologic deficit, the internal carotid artery was ligated without complication; in all other patients injury to the common carotid or internal carotid artery was repaired, in six of them with polytetrafluoroethylene grafts. CONCLUSIONS: Selective management of penetrating neck trauma should include routine angiography in zones I and III. Injuries to the common and internal carotid arteries should be repaired. The internal carotid artery may be ligated in the absence of preoperative neurologic deficit. Arterial injuries in the neck can be repaired with polytetrafluoroethylene grafts.

A critical reappraisal of indications for fasciotomy after extremity vascular trauma.

OBJECTIVE: To critically reevaluate the indications for fasciotomy in vascular trauma of the extremities. DESIGN: Case-control study. SETTING: Level I trauma center. MATERIALS AND METHODS: One hundred sixty-three vascular injuries to the extremeties were analyzed. Fasciotomy as an adjunct to vascular repair was performed in 45 limbs (28%), based either on the nature of injury or measured compartment pressure of greater than 35 mm Hg. MAIN OUTCOME MEASURES: Need for fasciotomy or limb amputation. RESULTS: Fasciotomy was performed for 29.5% of isolated arterial injuries, 15.2% of isolated venous injuries, and 31.6% of combined arterial and venous injuries, and was not related to venous repair or ligation. Seven delayed fasciotomies were performed either for vascular repair failure (5 patients) or compartment syndrome (2 patients). The highest incidence was for popliteal vessel injury (arterial 57%, combined 61%). Of the 33 lower-extremity fasciotomies, 58% were for popliteal vessel injury. In 51 combined injuries of the lower extremity, only 7 (19%) of 38 patients with injury above the knee required fasciotomy, as compared with 8 (62%) of 13 with injury to the popliteal vessels (P<.001), with or without venous repair. There were 3 amputations, all resulting from vascular repair failure. CONCLUSIONS: The presence of a combined vascular injury or the need for venous ligation does not necessitate routine fasciotomy. The need for fasciotomy may be maximal for injuries to popliteal vessels.

Emergency room thoracotomy for the resuscitation of patients with "fatal" penetrating injuries of the heart.

A total of 75 patients with penetrating cardiac injuries were treated at Lincoln Medical and Mental Health Center from January, 1974, to November, 1980. Twenty-two patients (29.3%) were unconscious on arrival and had no detectable vital signs, cardiac activity, or spontaneous respirations. Their last physical movement was observed in the ambulance. Immediate resuscitation of these patients employing intercostal or sternal splitting incisions in the emergency room revealed arrested hearts and permitted relief of tamponade, finger occlusion of the cardiac wound or wounds, and temporary suturing of the defect. Restoration of cardiac function was accomplished in 16 patients (72.7%). After transfer to the operating room for more definitive cardiorrhaphy and repair of other major wounds, 8 patients (36.4%) recovered without objective neurological disability. Our experience clearly supports the value of immediate emergency room thoracotomy in this group of patients.

A prospective randomized study of end points of resuscitation after major trauma: global oxygen transport indices versus organ-specific gastric mucosal pH.

BACKGROUND: Gastric tonometry, as a method of organ-specific monitoring of the status of the splanchnic circulation, has demonstrated prognostic and therapeutic implications in critically ill patients. The experience with this method in patients with trauma has been limited. STUDY DESIGN: Fifty-seven patients were prospectively randomized into two groups: group 1, n = 30, normalization and maintenance of gastric mucosal pH (pHi) at or above 7.3 and group 2, n = 27, maintenance of oxygen delivery index of 600 or an oxygen consumption index of greater than 150. The groups had statistically similar injury severity scores, lactate levels, and base deficits. RESULTS: Of the 44 patients with pHi greater than 7.3 at 24 hours, three (6.8 percent) died of multiple organ dysfunction syndrome as compared with seven (53.9 percent) of 13 in whom pHi was not optimized, p = 0.006. Optimization times for oxygen delivery index, oxygen consumption index, lactate levels, and base excess were similar between survivors and nonsurvivors. The time for pHi optimization was significantly longer in nonsurvivors. Multiple organ dysfunction syndrome points were significantly higher in patients who did not have pHi optimized within 24 hours (6.08 compared with 2.5, p = 0.03). Optimization time for pHi was predictive of mortality on multiple regression. Persistently low pHi was frequently associated with systemic or intra-abdominal complications. It was the first finding in all the nonsurvivors at least 48 to 72 hours before death. CONCLUSIONS: Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation. Monitoring of pHi may provide early warning for systemic complications in the postresuscitation period.

Emergency department thoracotomy for trauma: a collective review.

A decade of experience with resuscitative thoracotomy for the trauma victim in extremis has been gained since the pioneering efforts of Mattox and his associates in 1974. It appears, from a review of the various reports from different trauma centers, that there is an emergence of a consensus as to the best indications for the procedure. It is generally agreed upon that ERT is fruitless in the patient with severe head trauma or when vital signs were absent at the scene of the injury. In the absence of penetrating thoracic injuries ERT yields a very poor survival in patients without vital signs on admission to the emergency center. It is widely accepted that the best results for ERT are in patients with cardiac tamponade. The prognosis is hopeless in patients without vital signs after sustaining blunt trauma.

Is limb loss avoidable in civilian vascular injuries?

Limb salvage is virtually guaranteed when arterial injury is associated with a gunshot or stab wound. In this setting, associated injury is limited, and arterial injury is uniformly suspected, deliberately sought, and expeditiously repaired. Blunt trauma and massive injuries to the soft tissue, bones, and joints of the extremities augur amputation. In a patient with blunt trauma and loss of distal pulses, liberal, early use of angiography helps to avoid amputations secondary to missed or delayed diagnosis. Deliberate local anticoagulation and effective venous drainage is recommended in the management of dual-complex popliteal injuries. Discriminate amputation merits consideration when arterial trauma is accompanied by massive soft tissue and bony injuries with extensive loss of soft tissue.

Current concepts in the use of cavitary endoscopy in the evaluation and treatment of blunt and penetrating truncal injuries.

The use of thoracoscopy in the patient with penetrating injury to the thorax is in its infancy. Although it is used mainly for diagnosis, evidence suggests that it will become a therapeutic tool during the initial management of the traumatized patient and in the postinjury period (early evacuation of retained hemothorax and the treatment of empyema). Although its role in injuries to the superior chest is clear, its role has not been established in the evaluation of the diaphragm. Both laparoscopy and thoracoscopy offer advantages in this area that must be considered when contemplating diagnosis and treatment. Further studies help define the place of these procedures for injuries in the thoracoabdominal area. The indications for cavitary endoscopy after truncal injury are summarized in Table 2. It must be remembered that experience in this field is rapidly increasing, and indications will change with new studies and new technology.

The injured heart.

Penetrating and blunt injuries to the heart, ranging from cardiac concussion to rupture, are seen more and more frequently. Prompt diagnosis because of a high index of suspicion and timely, well-executed resuscitative efforts are rewarded by remarkable survival rates, even in the patients presenting in extremis, whereas hesitancy in diagnosis and therapeutic action militates against a successful result.

Intra-abdominal hypertension and the abdominal compartment syndrome.

IAH causes multiple and profound physiologic abnormalities both within and outside the abdomen. IAP monitoring is easily performed by bladder measurements. Careful monitoring and prompt recognition and treatment of IAP are critical in patients after damage control surgery because IAH is extremely common in these patients. Use of mesh fascial prostheses at the initial celiotomy in high-risk patients may prevent the deleterious effects of IAH. IAH should be considered an earlier manifestation of ACS. Surgical intervention should be indicated by IAH and not delayed until ACS is clinically apparent.

Complex duodenal injuries.

Duodenal trauma, with early diagnosis and prompt treatment, can be managed effectively by simple surgical techniques. Severe duodenal injuries and those associated with major destruction of adjacent structures (the pancreaticobiliary complex or abdominal vessels) require a more thoughtful strategy that incorporates a careful consideration of the physiologic stability of the patient and the extent of local destruction. Figure 8 summarizes these concepts in an algorithm.

Laparoscopy in the new century.

Minimally invasive surgery already has established itself as a useful tool in the management of trauma. The future holds exciting possibilities for this field, borne and fostered by innovative developments in imaging, computer technology, and artificial intelligence. The next millennium may witness the disappearance of trauma surgery as it is known today.

Preferred route of tracheostomy--percutaneous versus open at the bedside: a randomized, prospective study in the surgical intensive care unit.

Percutaneous tracheostomy has been touted as the preferred route of tracheostomy. However, to date, no prospective randomized study comparing bedside percutaneous (BP) to bedside open (BO) tracheostomy has been performed. Surgical intensive care unit (sICU) patients were randomized to receive either a BP or a BO tracheostomy. Patients were monitored for complications. Procedure time was documented. A group of medical ICU patients had open tracheostomies in the operating room (OR) and served as contemporaneous controls. Over 11 months, there were 24 surgical ICU patients randomized to receive either BP tracheostomy or BO tracheostomy, 12 in each group. Forty-six medical ICU patients received standard open tracheostomy in the OR. The number of ventilator days before placing the tracheostomy was similar between the BP and BO groups, 9.8 and 12.4, respectively. The clinical indications for tracheostomy were similar between the two groups. The procedure time for the BP group was 14.5 minutes, whereas 25.2 minutes for the BO group. There were no postprocedure complications in the BP and BO groups. There was a trend toward more complications in the BP group, including the loss of the airway, leading to death. The procedure time and complications were similar between the BO and OR groups. These data do not support that BP tracheostomy is the preferred route of tracheostomy when compared with BO tracheostomy. These data support that experienced surgical intensivists can perform BO tracheostomies with lower risk and cost, when compared with BP tracheostomy.

Unwillingness to lie supine? a sign of pericardial tamponade.

The stable patient with an occult cardiac injury can represent a diagnostic dilemma. The trauma surgeon must maintain a high index of suspicion for cardiac injury with precordial penetrating trauma. Herein are reported two cases of stable patients with penetrating precordial trauma who refused to lie supine because of difficulty breathing, preferring to sit upright, who eventually had positive pericardial windows and sternotomies for repair of cardiac injuries. The presence of this clinical finding, unwillingness to lie supine, should make the trauma surgeon highly suspicious of a cardiac injury and to proceed quickly to echocardiography or, preferably, to subxiphoid pericardial window to rule out cardiac injury.

Should trauma surgeons render definitive vascular repair in peripheral vascular injuries?

Our hypothesis is that in an established Level I trauma center general trauma surgeons should repair peripheral vascular injuries even in stable patients when there is time for a vascular consult. We reviewed all penetrating peripheral vascular injuries in stable patients operated on by nine experienced general trauma surgeons (1993-1996). Outcome measures were amputation, nerve damage, and vascular complications. There were 43 patients with 44 peripheral vascular injuries identified. Sixty per cent were from stab wounds. There were 27 arterial injuries (carotid four, subclavian one, vertebral two, axillary three, brachial eight, ulnar one, radial two, femoral five, and anterior tibial one). There were three venous injuries (one each subclavian, axillary, and popliteal). There were 14 combined injuries (vertebral two, femoral nine, and popliteal three). There were no mortalities. Morbidity was limited to patients with lower extremity injuries. In the nine patients with combined femoral vessel injury there were three complications (nerve damage, thrombosed arterial repair, and thrombosed venous repair). In the four patients with popliteal venous injuries there were two complications, both venous thrombosis. Our early arterial patency rate was 97.6 per cent. These data support the hypothesis that general surgeons with trauma experience can provide effective treatment of peripheral vascular injuries. The significance of these findings in improving the image of trauma surgery as a career is discussed.

Antioxidant therapy in the prevention of organ dysfunction syndrome and infectious complications after trauma: early results of a prospective randomized study.

Reactive oxygen species have been implicated in the etiology of multiorgan dysfunction syndrome and infectious complications in trauma patients by either direct cellular toxicity and/or the activation of intracellular signaling pathways. Studies have shown that the antioxidant defenses of the body are decreased in trauma patients; these include glutathione, for which N-acetylcysteine is a precursor, and selenium, which is a cofactor for glutathione. Eighteen trauma patients were prospectively randomized to a control or antioxidant group where they received N-acetylcysteine, selenium, and vitamins C and E for 7 days. As compared with the controls, the antioxidant group showed fewer infectious complications (8 versus 18) and fewer organs dysfunctioning (0 versus 9). There were no deaths in either group. We conclude that these preliminary data may support a role for the use of this antioxidant mixture to decrease the incidence of multiorgan dysfunction syndrome and infectious complications in the severely injured patient. This remains to be confirmed in larger trials.

The surgical intensive care unit as a cost-efficient substitute for an operating room at a Level I trauma center.

Critically ill patients in the surgical intensive care unit (SICU) continue to require operative procedures. Traditionally, this has meant the transport of these critically ill patients out of the safe, monitored confines of the SICU to the operating room (OR). This can be hazardous to the patient, as well as expensive. Performing the procedures in the OR can avoid both the dangers of transport and the expense of the OR. Herein is a descriptive study of 80 procedures performed on 36 patients in the SICU. We believe that these data show that the SICU can be a cost-effective alternative to the OR in a trauma center in critically ill patients. Significant cost savings may be realized without increasing the iatrogenic or infectious complications.

Penetrating pancreatic injuries. Analysis of 103 consecutive cases.

The optimal management of penetrating pancreatic injuries continues to be a matter of debate and controversy. The present study analyzes 103 consecutive patients with these wounds treated at a level I Trauma Center in a 14-year period (1975-1988). Twenty-seven patients died within 48 hours from extensive associated trauma (Abdominal Trauma Index [ATI] 46.7). The majority of the remaining 76 patients were treated by debridement and drainage. Nineteen patients with grade III injuries had distal pancreatectomy. Six patients with extensive combined pancreatoduodenal injuries had pancreatoduodenectomy. Pancreatoenteric anastomoses or duodenal diversion procedures rarely were used. Pancreatic complications included major fistulas in four patients (5%) and pancreatic abscess in nine patients (11%). Only one of the fistulas required subsequent fistulojejunostomy. Intra-abdominal abscesses occurred in 18 patients (23.6%), mostly in patients with associated colon injury (P less than 0.001). It is concluded that a conservative approach to penetrating pancreatic injuries yields optimal results and that associated colon injury is an important predeterminant for abscess formation.

Open management of the posttraumatic septic abdomen.

Thirteen patients with abdominal trauma who developed abdominal sepsis resistant to conventional methods of reexploration and drainage were managed by an open method. Eleven of these patients had multiorgan failure. The extent of anatomic and physiologic injury was defined by Abdominal Trauma Index and Acute Physiology and Chronic Health Evaluation (APACHE) scores, respectively. Ten of the 13 patients (76.9%) survived, a significantly improved survival as compared with that predicted by APACHE (50%). Complications attributable to the open technique (enteric fistula and a subphrenic abscess) occurred in two of the ten survivors. It is concluded that the open method of management of abdominal sepsis is effective and feasible. It should be considered in patients with necrotizing wound infections, multiorgan failure, and ongoing abdominal sepsis uncontrolled by conventional methods. Larger, controlled series employing such systems as the APACHE are needed for a better definition of patient selection for the open method.