Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation.

BACKGROUND: High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR. METHODS: A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3-6 L crystalloid, and >6 L crystalloid. RESULTS: There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12-19), P = 0.135; median units of FFP: 12 (IQR 7-18) versus 12 (IQR 10-18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65-42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029). CONCLUSIONS: During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results.

Damage control resuscitation: from emergency department to the operating room.

Damage control surgery emphasizes limited operations with control of bleeding and contamination. Traditional management centered upon correction of acidosis and hypotension with crystalloids. Damage control resuscitation (DCR) is permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy with fresh-frozen plasma (FFP), restricting use of crystalloids. We hypothesize a survival advantage in patients managed with DCR when compared with a historical cohort of patients. During the 2-year retrospective review, a 1-year period after institution of DCR was compared with a historical control. Resuscitation strategies were analyzed and stratified into emergency department (ED) resuscitation and intraoperative resuscitation. Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. Fifty-seven and 61 patients were managed during the NonDCR and DCR periods respectively. Baseline demographic patient characteristics and physiologic variables were similar between groups. ED DCR patients received less crystalloids: 1.1 versus 4.7 liters (P = 0.0001), more FFP: 1.8 versus 0.5 (P = 0.001). NonDCR had a lower initial systolic pressure in the operating room when compared with DCR: 81 mm Hg versus 95 mm Hg (P = 0.03). DCR patients received less intraoperative crystalloids: 5.7 versus 15.8 liters (P = 0.0001) and more FFP: 15.1 versus 6.2 (P = 0.0001). DCR conveyed a survival benefit (Odds Ratio; 95% confidence interval: 0.40 (0.18-0.90), P = 0.024). NonDCR group had 13.2 days longer hospital length of stay. Damage control resuscitation, beginning in the ED, used more packed red blood cells and FFP minimizing crystalloids. DCR was associated with a survival advantage and shorter length of stay in patients with severe hemorrhage.

Linea alba fasciotomy: a novel alternative in trauma patients with secondary abdominal compartment syndrome.

Polytrauma patients needing aggressive resuscitation can develop intra-abdominal hypertension (IAH) with subsequent secondary abdominal compartment syndrome (SACS). After patients fail medical therapy, decompressive laparotomy is the surgical last resort. In patients with severe pancreatitis SACS, the use of linea alba fasciotomy (LAF) is an effective intervention to lower IAH without the morbidity of laparotomy. A pilot study of LAF was designed to evaluate its benefit in patients with SACS polytrauma. We conducted an observational study of blunt injury polytrauma patients undergoing LAF. Variables measured before and after LAF included intra-abdominal pressure (IAP, mmHg), abdominal perfusion pressure (APP, mmHg), right ventricular end diastolic volume index (RVEDVI, mL/m2), and ejection fraction. Of the five trauma patients with SACS, the mean age was 36 +/- 17, four (80%) male with an Injury Severity Score of 27 +/- 9. Pre- and post-LAF, IAP was 20.6 +/- 4.7 and 10.6 +/- 2.7 (P < 0.0001), APP 55.2 +/- 5.5 and 77.6 +/- 7.1 (P < 0.0001), RVEDVI 86.4 +/- 9.3 and 123.6 +/- 11.9 (P < 0.0001), and EF 27.6 +/- 4.2 and 40.8 +/- 5 (P < 0.0001), respectively. One patient needed full decompression for bile ascites from unrecognized liver injury. Linea alba fasciotomy, as a first-line intervention before committing to full abdominal decompression in patients with SACS trauma, improved physiological variables without mortality. Consideration for LAF as a bridge before full abdominal decompression needs further evaluation in patients with polytrauma SACS.

Red light cameras: do they change driver behavior and reduce accidents?

BACKGROUND: : Installation of red light cameras (RLC) at intersections associated with a high number of traffic accidents are currently in use to reduce the number of traffic collisions. The primary objective of this study was to evaluate the sustained effect of RLC on driver behavior. The secondary objective was to evaluate the number of collisions before and after RLC implementation. METHODS: : For the primary objective, an 8-month prospective observational study after installation of RLC in September 2007 was undertaken at the intersection with the highest incidence of traffic accidents in the State of Louisiana. For the secondary objective, collision occurrences were collected 10 months before and after RLC installation. The mean number of citations was calculated by month, and the statistical significance of trend was obtained from a linear regression model across the study period and by t test to compare before and after citations were issued. The number of traffic collisions was compared using chi. RESULTS: : During the initial 30 days, 2,428 violations per week were recorded, whereas in the subsequent 30 days, there were 534 citations per week issued (p < 0.001). After eight months, the number of citations was reduced to an average of 356 citations per week (p < 0.01). Mean number of citations decreased significantly during implementation of RLC. Three drivers received more than one citation. Although there was a trend in reduction of collisions from 122 to 97 before and after RLC, this did not reach statistical significance; p = 0.18. CONCLUSION: : A significant and sustained reduction in the number of citations occurred as driving behavior was modified. Despite reducing the number of cars entering this intersection during a red light, RLC do not seem to prevent traffic collisions at this monitored intersection. Alternative means of injury prevention must be investigated.

Damage control resuscitation in combination with damage control laparotomy: a survival advantage.

BACKGROUND: Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). METHODS: This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. RESULTS: One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). CONCLUSION: This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.

Disaster response. Natural disaster: Katrina.

The aftermath and response to a disaster can be divided into four phases. The importance of each depends on the length of time without resupply and the resources that are required. This in turn depends on the time span of the disaster; the area involved; the number of the population affected; the resupply available; the extent of the devastation; and the size of the evacuation. The above phases are discussed using hurricane Katrina as an example. The phases are as follows: immediate response, evacuation, backfill and resupply, and restoration. The restoration phase is usually the longest and requires the most resources. This article addresses the situation of Katrina, the mistakes that were made, the lessons that were learned, and the solutions that are needed. Appropriate training and practice are required for all participants using realistic scenarios.

Recurrent abdominal compartment syndrome: an inciting factor of the second hit phenomenon.

Intra-abdominal hypertension (IAH) after damage control laparotomy (DCL) is not unusual and because of this, patients are treated with open-abdomen techniques to prevent abdominal compartment syndrome (ACS). The occurrence of recurrent ACS (R-ACS) after abdominal wall closure under tension in patients managed with DCL can be a trigger factor for second hit syndrome. Outcomes in this subset have not been previously described. In this 1-year retrospective study of severely injured patients in a Level I trauma center managed with DCL and sequential abdominal wall closure, 26 patients were identified. After attempted abdominal wall closure, 13 (50%) patients had R-ACS and 13 (50%) non-R-ACS. R-ACS patients had a statistically significant higher incidence of multisystem organ failure, acute respiratory distress syndrome, and sepsis as well as requiring longer ventilator support and longer hospital length of stay. We concluded that failure to recognize and treat IAH with development of R-ACS after tension abdominal wall closure in patients with DCL will trigger the second hit syndrome with increased risk of morbidity. Institution of a management algorithm with intra-abdominal pressure/abdominal perfusion pressure surveillance at the time of abdominal wall closure can potentially ameliorate complications.

Open-book pelvic fractures with perineal open wounds: a significant morbid combination.

Open-book pelvic fractures (OBPF) with concomitant intra-abdominal injuries carry a high morbidity and mortality; the significance of associated perineal open wound (OBPF-POW) has not been defined. We hypothesize that the presence of perineal open wounds increases morbidity, mortality, and concomitant use of hospital resources. Patients diagnosed with OBPF over a 5-year period at a Level I trauma center were identified by trauma registry review, and were retrospectively reviewed under an Institutional Review Board-approved protocol. Patients with OBPF without a perineal open wound were compared with those with OBPF-POW. Data collected included patient demographics, injury details, management, and outcomes. A total of 1,635 patients with blunt pelvic fractures were identified, of which 177 (10.8%) had OBPF. OBPF-POW (36/177) significantly increased the use of angioembolization, occurrence of sepsis, pelvic sepsis, ARDS, and multi-organ system failure. Patients with OBPF-POW had an increase of 13 days in length of hospitalization compared with the OBPF group (P < 0.001), with cost of $120,647.30 and $62,952.72 respectively (P < 0.001). Perineal open wounds complicate open-book pelvic fractures with significant increase in hospital resource utilization. Aggressive multidisciplinary evaluation and management is appropriate to detect and prevent complications.

The changing face of trauma: New Orleans before and after Hurricane Katrina.

Charity Hospital (CH) was devastated by Hurricane Katrina and remains closed. Design and staffing of a new, temporary dedicated trauma hospital relied on data from prior experience at CH, updated census information, and a changed trauma demographic. The study objective was to analyze the new trauma program and evaluate changes in demographics, injury patterns, and outcomes between pre- (PK) and post-Katrina (POK) trauma populations. A retrospective review of trauma patients' demographics, anatomical variables, and physiological variables 6 months PK and POK was performed under an approved Institutional Review Board protocol. Trauma activation triage criteria between study periods were also analyzed. Continuous data comparisons between the two time periods were made with Student's t test. Dichotomous data were analyzed using chi2 test. The demographic of trauma patients is different in the POK interval, reflecting changes in the New Orleans population. Modification of triage criteria by the exclusion of mechanism as an activation criterion resulted in an increase of patients with higher acuity and Injury Severity Score, lower initial Glasgow Coma Score, and a higher proportion of penetrating mechanism. Outcome measures reflect longer length of stay (4.4 vs. 6.8 days, P < 0.0001) without a significant difference in mortality (6.0 vs 7.5, P = 0.227). Hospital data demonstrates that the POK trauma system was stressed by the increased acuity, penetrating injury, and number of procedures per patient (1.7 vs. 3.4). Resources should be directed toward patients requiring multidisciplinary care by increasing intensive care unit beds and operating room capacity. Future resource planning in the recovery phases of large-scale natural disasters should take into account these observations.

Impact of obesity in damage control laparotomy patients.

BACKGROUND: Obesity is an independent predictor of increased morbidity and mortality in critically injured trauma patients. We hypothesized that obese patients in need of damage control laparotomy (DCL) will encounter an increase incidence of postsurgical complications with a concomitant increase mortality when compared with a cohort of nonobese patients. METHODS: All adult trauma patients who underwent DCL during a 4-year period at a Level I Trauma Center were retrospectively reviewed. Patients were categorized into nonobese (body mass index [BMI] < or = 29 kg/m), obese (BMI 30-39 kg/m), and severely obese (BMI > or = 40 kg/m) groups. Outcome measures included the occurrence of postoperative infectious complications, failure of primary abdominal wall fascial closure, acute respiratory distress syndrome, acute renal insufficiency, multiple system organ failure, days of ventilator support, hospital length of stay, and death. RESULTS: During a 4-year period, 12,759 adult trauma patients were admitted to our Level I Trauma Center of which 1,812 (14.2%) underwent emergent laparotomy. Of these, 104 (5.7%) were treated with DCL: nonobese, n = 51 (49%); obese, n = 38 (37%); and severely obese, n = 15 (14%). In a multivariate adjusted model, multiple system organ failure was 1.82 times more likely in severely obese (95% CI: 1.14-2.90) and 1.74 times more likely in the obese patients (95% CI: 1.14-2.66) when compared with patients with normal BMI after DCL (p < 0.01). In the severely obese patients undergoing DCL, significantly elevated prevalence ratios (PR) for development of postoperative infectious complications, acute renal insufficiency, and failure of primary abdominal wall fascial closure were 1.75, 3.07, and 2.62, respectively. Days of ventilator support, length of stay, and mortality rates were significantly higher in severely obese patients (24 days, 27 days, and 60%) compared with obese (14 days, 14 days, and 21%) and nonobese (9.8 days, 14 days, and 28%) patients. CONCLUSION: Severe obesity was significantly associated with adverse outcomes and increased resource utilization in trauma patients treated with DCL. Measures to improve outcomes in this vulnerable patient population must be directed at multiple levels of health care.

Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy.

BACKGROUND: Although hemostatic resuscitation with a 1:1 ratio of fresh-frozen plasma (FFP) to packed red blood cells (PRBC) after severe hemorrhage has been shown to improve survival, its benefit in patients with traumatic-induced coagulopathy (TIC) after >10 units of PRBC during operation has not been elucidated. We hypothesized that a survival benefit would occur when early hemostatic resuscitation was used intraoperatively after injury in patients with TIC. METHODS: A 7-year retrospective study of patients with emergency department diagnosis of TIC after transfusion of >10 units of PRBC in the operating room. TIC was defined as initial emergency department international normalized ratio > 1.2, prothrombin time > 16 seconds, and partial thromboplastin time > 50 seconds. Patients were divided into FFP:PRBC ratios of 1:1, 1:2, 1:3, and 1:4. Patients with diagnosis of TIC who received transfusion of both FFP and PRBC during surgery were included. Other variables evaluated included age, gender, mechanism of injury, initial base deficit, mean operative time, trauma intensive care unit length of stay (TICU LOS) and Injury Severity Score. The primary outcome measure evaluated was the impact of the early FFP:PRBC ratio on mortality. RESULTS: Four hundred thirty-five patients underwent emergency operations postinjury and received FFP with >10 units of PRBC in the operating room; 135 (31.0%) of these patients had TIC and 53 died (39.5% mortality). Mean operative time was 137 minutes (SD +/- 49). There were no differences with regard to age, gender, mechanism of injury, initial base deficit, or Injury Severity Score among all groups. A significant difference in mortality was found in patients who received >10 units of PRBC when FFP:PRBC ratio was 1:1 versus 1:4 (28.2% vs. 51.1%, p = 0.03). Intermediate mortality rates were noted in patients with 1:2 and 1:3 ratios (38% and 40%, respectively). From a linear regression model, 13 days of increased TICU LOS was observed among 1:4 group compared with 1:1 group (p < 0.01). CONCLUSION: TIC is common after severe injury and is associated with a high mortality in patients transfused with >10 units of PRBC during surgery. Early hemostatic resuscitation during first hours after injury improves survival with shorter TICU LOS in patients with TIC.

Current evidence based guidelines for factor VIIa use in trauma: the good, the bad, and the ugly.

Recombinant factor VII (rFVIIa) has arisen as an option for the control of life-threatening traumatic bleeding unresponsive to other means. The timing of administration, dosage, mortality, units of blood transfusion saved, risk of thrombotic events, and risk/benefits ratio are presently poorly defined. A Medline search from 1995 through March 2008 was conducted. All English language articles containing the terms "trauma" and "factor VII" or its variants were retrieved. Letters to the editor, animal studies, and general reviews were excluded. A total of 19 articles met inclusion criteria. These articles were then reviewed and stratified into three classes of evidence according to the quality assessment instrument developed by the Brain and Trauma Foundation. Levels of recommendation were developed. A total of 118 articles were identified. Only one Class I study was identified. This study demonstrated that three doses of rFVIIa given in blunt traumatic hemorrhage yielded a significant reduction of 2.6 of red blood cells used. These findings were not statistically significant for penetrating trauma patients. There was no reduction in mortality and no increase in thromboembolic events. Four Class II studies were identified; three showed a significant decrease of blood product usage and one demonstrated significant reductions in 24-hour and 30 day death from hemorrhage in patients receiving rFVIIa. The remaining 14 studies were Class III reviews of databases, registries, case series, and case reports. No identified study specifically addressed the cost/benefit analysis of rFVIIa usage in trauma hemorrhage. Utility of rFVIIa in trauma-associated hemorrhage remains controversial. There is Level I supporting the use of rFVIIa for blunt trauma patients only. There is no Class I evidence supporting decreased mortality or differences in thromboembolic events. Minimal effective dosing regimens and cost/benefit analyses have not yet been examined.

Impact of telemedicine upon rural trauma care.

OBJECTIVES: Only preliminary reports have evaluated the impact of telemedicine in trauma care. This study will analyze outcomes before (pre-TM) and after (post-TM) implementation of telemedicine in the management of rural trauma patients initially treated at local community hospitals (LCH) before trauma center (TC) transfer. METHODS: Seven rural hospital emergency departments in Mississippi were equipped with dual video cameras with remote control capability. All trauma patients initially treated at these LCH with TC consultation were reviewed. Data included patient demographics, Injury Severity Score, institutional volume of patients, mode of transportation, length of stay in LCH, transfer time (TT), mortality, and hospital cost. Patients were grouped in the pre-TM and post-TM periods. Statistical testing was with two-sample Student's t test or chi analysis as appropriate. RESULTS: During 5 years, 814 traumatically injured patients (pre-TM, n = 351; post-TM, n = 463) presented to the LCH. In the pre-TM period, 351 patients were transferred directly from the LCH for definitive management to the TC. In the post-TM period, 463 virtual consults were received, of which 51 patients were triaged to the TC. There were no differences in patient age, sex, or mode of transportation. When comparing post-TM with pre-TM era, patients had a higher Injury Severity Score (18 vs. 10, p < 0.001); less incidence of blunt trauma 35 (68%) versus 290 (82%), p < 0.05; a decrease in length of stay at LCH 1.5 hours versus 47 hours, p < 0.001; as well as TT LCH to TC 1.7 hours versus 13 hours, p < 0.001. After arrival to TC during the post-TM era patients received more units of packed red bed cell 13 units versus 5 units, p < 0.001 but without difference in mortality 4 (7.8%) versus 17 (4.8%), when compared with pre-TM era. Of statistical significance there was a dramatic decrease in hospital cost when comparing post-TM and pre-TM eras ($1,126,683 vs. $7,632,624, p < 0.001). CONCLUSION: Telemedicine significantly improved rural LCH evaluation and management of trauma patients. More severely injured trauma patients were identified and more rapidly transferred to the TC. Total TC hospital costs were significantly decreased without significant changes in TC mortality. Introduction of telemedicine consultation to rural LCH emergency departments expanded LCH trauma capabilities and conserved TC resources, which were directed to more severely injured patients.

Proximal splenic angioembolization does not improve outcomes in treating blunt splenic injuries compared with splenectomy: a cohort analysis.

BACKGROUND: Although splenic angioembolization (SAE) has been introduced and adopted in many trauma centers, the appropriate selection for and utility of SAE in trauma patients remains under debate. This study examined the outcomes of proximal SAE as part of a management algorithm for adult traumatic splenic injury compared with splenectomy. METHODS: A retrospective cohort analysis was performed on all hemodynamically stable (HDS) blunt trauma patients with isolated splenic injury and computed tomographic (CT) evidence of active contrast extravasation that presented to a level 1 Trauma Center over a period of 5 years. The cohorts were defined by two separate 30 month periods and included 78 patients seen before (group I) and 76 patients seen after (group II) the introduction of an institutional SAE protocol. Demographics, splenic injury grade, and outcomes of the two groups were compared using Student's t test, or chi2 test. Analysis was by intention-to-treat. RESULTS: Six hundred eighty-two patients with blunt splenic injury were identified; 154 patients (29%) were HDS with CT evidence of active contrast extravasation. Group I (n = 78) was treated with splenectomy and group II (n = 76) was treated with proximal SAE. There was no difference in age (33 +/- 14 vs. 37 +/- 17 years), Injury Severity Score (31 +/- 13 vs. 29 +/- 11), or mortality (18% vs. 15%) between the two groups. However, the incidence of Adult Respiratory Distress Syndrome (ARDS) was 4-fold higher in those patients that underwent proximal SAE compared with those that underwent splenectomy (22% vs. 5%, p = 0.002). Twenty two patients failed nonoperative management (NOM) after SAE. This failure appeared to be directly related to the grade of splenic organ injury (grade I and II: 0%; grade III: 24%; grade IV: 53%; and grade V: 100%). CONCLUSION: Introduction of proximal SAE in NOM of HDS splenic trauma patients with active extravasation did not alter mortality rates at a Level 1 Trauma Center. Increased incidence of ARDS and association of failure of NOM with higher splenic organ injury score identify areas for cautionary application of proximal SAE in the more severely injured trauma patient population. Better patient selection guidelines for proximal SAE are needed. Without these guidelines, outcomes from SAE will still lack transparency.

Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years?

BACKGROUND: Recent military experience reported casualties who receive > 10 units of packed red blood cells (PRBC) in 24 hours have 20% versus 65% mortality when the fresh-frozen plasma (FFP) to PRBC ratio was 1:1 versus 1:4, respectively. We hypothesize a similar improvement in mortality in civilian trauma patients that require massive transfusion and are treated with a FFP to PRBC ratio closer to 1:1. METHODS: Four-year retrospective study of all trauma patients who underwent emergency surgery in an urban Level I Trauma Center. Patients were divided into two groups; those that received < or = 10 units or > 10 units of PRBC during and after initial surgical intervention. Only patients who received transfusion of both FFP and PRBC were included in the analysis. The primary research question was the impact of initial FFP:PRBC ratio on mortality. Other variables for analysis included patient age, gender, mechanism, and Injury Severity Scale score. Both univariate and multivariate analysis were used to assess the relationship between outcome and predictors. RESULTS: A total of 2,746 patients underwent surgical intervention of which 1,985 (72.2%) received no transfusion. Of those that received transfusion, 626 (22.8%) received < or = 10 units of PRBC and 135 (4.9%) > 10 units of PRBC. Out of the 626 patients that received < or = 10 units of PRBC, 250 (39.9%) received FFP and 376 (60.1%) received no FFP. All the patients that received > 10 units PRBC received FFP. In univariate analysis, a significant difference in mortality was found in patients who received > 10 units of PRBC (26% vs. 87.5%) when FFP:PRBC ratio was 1:1 versus 1:4 (p = 0.0001). Multivariate analysis in the group of patients that received > 10 units of PRBC showed a FFP:PRBC ratio of 1:4 was consistent with increased risk of mortality (relative risk, 18.88; 95% CI, 6.32-56.36; p = 0.001), when compared with a ratio of 1:1. Patients who received < or = 10 units of PRBC had a trend toward increased mortality (21.2% vs.11.8%) when the FFP:PRBC ratio was 1:4 versus 1:1 (p: 0.06). CONCLUSION: An FFP to PRBC ratio close to 1:1 confers a survival advantage in patients requiring massive transfusion.

Analysis of disaster response plans and the aftermath of Hurricane Katrina: lessons learned from a level I trauma center.

BACKGROUND: The purpose of this study was to compare disaster preparedness of a Level I Trauma Center with performance in an actual disaster. Previous disaster response evaluations have shown that the key to succeeding in responding to a catastrophic event is to anticipate the event, plan the response, and practice the plan. The Emergency Management Team had identified natural disaster as the hospital's highest threat. The hospital also served as the regional hospital for the Louisiana Health Resources and Service Administration Bioterrorism Hospital Preparedness Program. METHODS: The hospital master disaster plan, including the Code Gray annex, was retrospectively reviewed and compared with the actual events that occurred after Hurricane Katrina. Vital support areas were evaluated for adequacy using a systematic approach. In addition, a survey of 10 key personnel from trauma and emergency medicine present during Hurricane Katrina was conducted. The survey of vital support areas were scored as adequate (3 pts), partially adequate (2 pts), or inadequate (1 pt). RESULTS: Ninety-three percent of the line items on the Code Gray Checklist were accomplished before landfall of the storm. The results of the survey of vital support areas were water-3.0, food-2.4, sanitation-1.5, communication-1.4, and power-1.5. CONCLUSION: Despite identifying the threat of a major hurricane, preparing a response plan, and exercising the plan, a major medical center can be overwhelmed by a catastrophic disaster like Hurricane Katrina. We offer our lessons-learned as an aid for other medical centers that are developing and exercising their plans.

Tactical combat casualty care 2007: evolving concepts and battlefield experience.

The Tactical Combat Casualty Care (TCCC) project begun by the Naval Special Warfare Command and continued by the U.S. Special Operations Command developed a set of tactically appropriate battlefield trauma care guidelines that were initially published in 1996. Transition of these guidelines into use throughout the Department of Defense has been ongoing since that time. The need for updates to the TCCC guidelines was recognized early on and has been carried out by the Committee on Tactical Combat Casualty Care established and operated by the Naval Operational Medicine Institute. The evolution of these guidelines from the 1996 recommendations to the present is described. Numerous reports in the medical literature and collected from combat first responders have documented that TCCC is saving lives on the battlefield and improving the tactical flow of missions on which casualties have occurred. Present challenges to the optimized implementation of TCCC in U.S. combat units include the need to expedite transition of new TCCC techniques and technologies to deploying units, to provide TCCC training for all U.S. combatants, and to ensure adequate funding for the Committee on TCCC.

Embolization of an acute renal arteriovenous fistula following a stab wound: case report and review of the literature.

Surgery has traditionally been the definitive form of invasive management for renal vascular injuries. There is a growing trend in the use of endovascular techniques as an alternative to surgery in the trauma setting. We present the case of a 24-year-old woman with an acute renal arteriovenous fistula caused by a stab wound in the left flank, which was successfully managed with selective arterial embolization. This represents only the second reported case of such an approach in the acute setting.