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Torres CM, Kent A, Scantling D, Joseph B, Haut ER, Sakran JV. Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers. JAMA Surg 2023; 158:532-540. [PMID: 36652255 PMCID: PMC9857728 DOI: 10.1001/jamasurg.2022.6978] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Whole-blood (WB) resuscitation has gained renewed interest among civilian trauma centers. However, there remains insufficient evidence that WB as an adjunct to component therapy-based massive transfusion protocol (WB-MTP) is associated with a survival advantage over MTP alone in adult civilian trauma patients presenting with severe hemorrhage. Objective To assess whether WB-MTP compared with MTP alone is associated with improved survival at 24 hours and 30 days among adult trauma patients presenting with severe hemorrhage. Design, Setting, and Participants This retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2017, and December 31, 2018, included adult trauma patients with a systolic blood pressure less than 90 mm Hg and a shock index greater than 1 who received at least 4 units of red blood cells within the first hour of emergency department (ED) arrival at level I and level II US and Canadian adult civilian trauma centers. Patients with burns, death within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from February 2022 to September 2022. Exposures Resuscitation with WB-MTP compared with MTP alone within 24 hours of ED presentation. Main Outcomes and Measures Primary outcomes were survival at 24 hours and 30 days. Secondary outcomes selected a priori included major complications, hospital length of stay, and intensive care unit length of stay. Results A total of 2785 patients met inclusion criteria: 432 (15.5%) in the WB-MTP group (335 male [78%]; median age, 38 years [IQR, 27-57 years]) and 2353 (84.5%) in the MTP-only group (1822 male [77%]; median age, 38 years [IQR, 27-56 years]). Both groups included severely injured patients (median injury severity score, 28 [IQR, 17-34]; median difference, 1.29 [95% CI, -0.05 to 2.64]). A survival curve demonstrated separation within 5 hours of ED presentation. WB-MTP was associated with improved survival at 24 hours, demonstrating a 37% lower risk of mortality (hazard ratio, 0.63; 95% CI, 0.41-0.96; P = .03). Similarly, the survival benefit associated with WB-MTP remained consistent at 30 days (HR, 0.53; 95% CI, 0.31-0.93; P = .02). Conclusions and Relevance In this cohort study, receipt of WB-MTP was associated with improved survival in trauma patients presenting with severe hemorrhage, with a survival benefit found early after transfusion. The findings from this study are clinically important as this is an essential first step in prioritizing the selection of WB-MTP for trauma patients presenting with severe hemorrhage.
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Affiliation(s)
- Crisanto M. Torres
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland,Division of Trauma and Acute Care Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Alistair Kent
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Dane Scantling
- Division of Trauma and Acute Care Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Bellal Joseph
- College of Medicine, Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson
| | - Elliott R. Haut
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland,Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph V. Sakran
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland,Johns Hopkins School of Medicine, Baltimore, Maryland,Johns Hopkins School of Nursing, Baltimore, Maryland,Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia
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REBOA: Expanding Applications From Traumatic Hemorrhage to Obstetrics and Cardiopulmonary Resuscitation, From the AJR Special Series on Emergency Radiology. AJR Am J Roentgenol 2023; 220:16-22. [PMID: 35920708 DOI: 10.2214/ajr.22.27932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged over the past decade as a technique to control life-threatening hemorrhage and treat hemorrhagic shock, being increasingly used to treat noncompressible traumatic torso hemorrhage. Reports during this time also support the use of a REBOA device for an expanding range of indications including nontraumatic abdominal hemorrhage, postpartum hemorrhage, placenta accreta spectrum (PAS) disorder, and cardiopulmonary resuscitation (CPR). The strongest available evidence supports REBOA as a lifesaving adjunct to definitive surgical management in trauma and as a method to help avoid hysterectomy in select patients with postpartum hemorrhage or PAS disorder. In comparison with initial descriptions of complete REBOA inflation, techniques for partial REBOA inflation have been introduced to achieve hemodynamic stability while minimizing adverse events relating to reperfusion injuries. Fluoroscopy-free REBOA has been described in various settings, including trauma, obstetrics, and out-of-hospital cardiac arrest. As the use of REBOA expands outside the trauma setting and into nontraumatic abdominal hemorrhage, obstetrics, and CPR, it is imperative for radiologists to become familiar with this technology, its proper placement, and its potential adverse sequelae.
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Zhu X, Cheng J, Yu J, Liu R, Ma H, Zhao Y. Nicotinamide mononucleotides alleviated neurological impairment via anti-neuroinflammation in traumatic brain injury. Int J Med Sci 2023; 20:307-317. [PMID: 36860678 PMCID: PMC9969499 DOI: 10.7150/ijms.80942] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023] Open
Abstract
Traumatic brain injury (TBI) is one of the main factors of death and disability in adults with a high incidence worldwide. Nervous system injury, as the most common and serious secondary injury after TBI, determines the prognosis of TBI patients. NAD+ has been confirmed to have neuroprotective effects in neurodegenerative diseases, but its role in TBI remains to be explored. In our study, nicotinamide mononucleotides (NMN), a direct precursor of NAD+, was used to explore the specific role of NAD+ in rats with TBI. Our results showed that NMN administration markedly attenuated histological damages, neuronal death, brain edema, and improved neurological and cognitive deficits in TBI rats. Moreover, NMN treatment significantly suppressed activated astrocytes and microglia after TBI, and further inhibited the expressions of inflammatory factor. Besides, RNA sequencing was used to access the differently expressed genes (DEGs) and their enriched (Kyoto Encyclopedia of Genes and Genomes) KEGG pathways between Sham, TBI, and TBI+NMN. We found that 1589 genes were significantly changed in TBI and 792 genes were reversed by NMN administration. For example, inflammatory factor CCL2, toll like receptors TLR2 and TLR4, proinflammatory cytokines IL-6, IL-11 and IL1rn which were activated after TBI and were decreased by NMN treatment. GO analysis also demonstrated that inflammatory response was the most significant biological process reversed by NMN treatment. Moreover, the reversed DEGs were typically enriched in NF-Kappa B signaling pathway, Jak-STAT signaling pathway and TNF signaling pathway. Taken together, our data showed that NMN alleviated neurological impairment via anti-neuroinflammation in traumatic brain injury and the mechanisms may involve TLR2/4-NF-κB signaling.
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Affiliation(s)
- Xiaolu Zhu
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jin Cheng
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jiangtao Yu
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ruining Liu
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Haoli Ma
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yan Zhao
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Research Center for Emergency and Resuscitation, Zhongnan Hospital of Wuhan University, Wuhan, China
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Shock-Driven Endotheliopathy in Trauma Patients Is Associated with Leucocyte Derived Extracellular Vesicles. Int J Mol Sci 2022; 23:ijms232415990. [PMID: 36555630 PMCID: PMC9782606 DOI: 10.3390/ijms232415990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/29/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
Endotheliopathy following trauma is associated with poor outcome, but the underlying mechanisms are unknown. This study hypothesized that an increased extracellular vesicle (EV) concentration is associated with endotheliopathy after trauma and that red blood cell (RBC) transfusion could further enhance endotheliopathy. In this post hoc sub study of a multicentre observational trial, 75 trauma patients were stratified into three groups based on injury severity score or shock. In patient plasma obtained at hospital admission and after transfusion of four RBC transfusions, markers for endotheliopathy were measured and EVs were labelled with anti CD41 (platelet EVs), anti CD235a (red blood cell EVs), anti CD45 (leucocyte EVs), anti CD144 (endothelial EVs) or anti CD62e (activated endothelial EVs) and EV concentrations were measured with flow cytometry. Statistical analysis was performed by a Kruskall Wallis test with Bonferroni correction or Wilcoxon rank test for paired data. In patients with shock, syndecan-1 and von Willebrand Factor (vWF) were increased compared to patients without shock. Additionally, patients with shock had increased red blood cell EV and leucocyte EV concentrations compared to patients without shock. Endotheliopathy markers correlated with leucocyte EVs (ρ = 0.263, p = 0.023), but not with EVs derived from other cells. Injury severity score had no relation with EV release. RBC transfusion increased circulating red blood cell EVs but did not impact endotheliopathy. In conclusion, shock is (weakly) associated with EVs from leucocytes, suggesting an immune driven pathway mediated (at least in part) by shock.
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Bivens MJ, Fritz CL, Burke RC, Schoenfeld DW, Pope JV. State-by-state estimates of avoidable trauma mortality with early and liberal versus delayed or restricted administration of tranexamic acid. BMC Emerg Med 2022; 22:191. [PMID: 36463125 PMCID: PMC9719138 DOI: 10.1186/s12873-022-00741-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 11/03/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Early administration of tranexamic acid (TXA) has been shown to save lives in trauma patients, and some U.S. emergency medical systems (EMS) have begun providing this therapy prehospital. Treatment protocols vary from state to state: Some offer TXA broadly to major trauma patients, others reserve it for patients meeting vital sign criteria, and still others defer TXA entirely pending a hospital evaluation. The purpose of this study is to compare the avoidable mortality achievable under each of these strategies, and to report on the various approaches used by EMS. METHODS We used the National Center for Health Statistics Underlying Cause of Death data to identify a TXA-naïve population of trauma patients who died from 2007 to 2012 due to hemorrhage. We estimated the proportion of deaths where the patient was hypotensive or tachycardic using the National Trauma Data Bank. We used avoidable mortality risk ratios from the landmark CRASH 2 study to calculate lives saved had TXA been given within one hour of injury based on a clinician's gestalt the patient was at risk for significant hemorrhage; had it been reserved only for hypotensive or tachycardic patients; or had it been given between hours one to three of injury, considered here as a surrogate for deferring the question to the receiving hospital. RESULTS Had TXA been given within 1 hour of injury, an average of 3409 deaths per year could have been averted nationally. Had TXA been given between one and three hours after injury, 2236 deaths per year could have been averted. Had TXA only been given to either tachycardic or hypotensive trauma patients, 1371 deaths per year could have been averted. Had TXA only been given to hypotensive trauma patients, 616 deaths per year could have been averted. Similar trends are seen at the individual state level. A review of EMS practices found 15 statewide protocols that allow EMS providers to administer TXA for trauma. CONCLUSION Providing early TXA to persons at risk of significant hemorrhage has the potential to prevent many deaths from trauma, yet most states do not offer it in statewide prehospital treatment protocols.
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Affiliation(s)
- Matthew J. Bivens
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Christie L. Fritz
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Ryan C. Burke
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - David W. Schoenfeld
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Jennifer V. Pope
- grid.413480.a0000 0004 0440 749XDepartment of Emergency Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
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Zeineddin A, Wu F, Chao W, Zhou L, Vesselinov R, Chipman A, Dong JF, Huang H, Pati S, Kozar RA. Biomarkers of endothelial cell dysfunction persist beyond resuscitation in patients with hemorrhagic shock. J Trauma Acute Care Surg 2022; 93:572-578. [PMID: 35939376 PMCID: PMC9613546 DOI: 10.1097/ta.0000000000003758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It has been shown that microRNA-19b (miR-19b) binds to and degrades syndecan-1 after hemorrhagic shock (HS) and contributes to endothelial dysfunction in vitro and in vivo. The objective of the current study was to assess longitudinal changes in miR-19b and syndecan-1 in HS patients. METHODS Blood samples from HS patients (blood pressure <90 mm Hg and ≥2 U blood) were collected upon admission, completion of hemostasis, and after 24 hours for miR-19b (quantitative reverse transcription PCR) and syndecan-1 (enzyme-linked immunosorbent assay) and compared with controls and minimally injured (Injury Severity Score, ≤9). Inflammatory cytokines were measured (Luminex [Thermo Fisher, Waltham, MA]). Correlations between syndecan-1, miR-19b, inflammatory markers, and patient outcomes were performed. Logistic regression models were developed for outcomes. RESULTS Thirty-four HS patients were studied: age, 46 (19-89) years; male, 82%; penetrating, 35%; Injury Severity Score, 24 ± 10; and blood products at 24 hours, 21 ± 19 U. MicroRNA-19b was increased upon arrival and further increased over time: 4.6 → 6.7 → 24.1-fold change compared with 0.1 and 1.2 for minimally injured patients and controls, respectively. Syndecan-1 was increased to 42.6 → 50 → 51.5 ng/mL over time compared with 14.7 and 23.5 for minimally injured and controls, respectively. Values for both biomarkers remained significantly increased through 24 hours and were associated with a persistent increase in inflammatory cytokines. Admission syndecan-1 significantly predicted mortality, coagulopathy, and massive transfusion. CONCLUSION We have shown for the first time that miR-19b and syndecan-1 were biomarkers for endothelial dysfunction independent of resuscitation. MicroRNA-19b did not demonstrate a strong correlation with syndecan-1 nor outcomes. Admission syndecan-1, however, remains a strong prognostic marker, but its elevation over time suggests a versatile role following HS that requires further investigation. LEVEL OF EVIDENCE Prognostic/Epidemiological; Level II.
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Affiliation(s)
- Ahmad Zeineddin
- Shock Trauma and Anesthesiology Research Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, Maryland
| | - Feng Wu
- Shock Trauma and Anesthesiology Research Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, Maryland
| | - Wei Chao
- Shock Trauma and Anesthesiology Research Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, Maryland
- Department of Anesthesia, University of Maryland School of Medicine, Baltimore, MD US
| | - Lin Zhou
- Shock Trauma and Anesthesiology Research Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, Maryland
- Department of Anesthesia, University of Maryland School of Medicine, Baltimore, MD US
| | - Roumen Vesselinov
- Shock Trauma and Anesthesiology Research Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda Chipman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD US
| | - Jing Fei Dong
- Bloodworks Research Institute, Seattle, WA, US
- Hematology Division, Department of Medicine, University of Washington School of Medicine, Seattle, WA, US
| | - Huang Huang
- Shock Trauma and Anesthesiology Research Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, Maryland
- Department of Anesthesia, University of Maryland School of Medicine, Baltimore, MD US
| | - Shibani Pati
- Department of Laboratory Medicine, Department of Surgery University of California San Francisco, San Francisco, CA US
| | - Rosemary A Kozar
- Shock Trauma and Anesthesiology Research Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, Maryland
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD US
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Sartini S, Spadaro M, Cutuli O, Castellani L, Sartini M, Cristina ML, Canepa P, Tognoni C, Lo A, Canata L, Rosso M, Arboscello E. Does Antithrombotic Therapy Affect Outcomes in Major Trauma Patients? A Retrospective Cohort Study from a Tertiary Trauma Centre. J Clin Med 2022; 11:jcm11195764. [PMID: 36233632 PMCID: PMC9573302 DOI: 10.3390/jcm11195764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Antithrombotic therapy may affect outcomes in major trauma but its role is not fully understood. We aimed to investigate adverse outcomes among those with and without antithrombotic treatment in major trauma. Material and methods: This is a retrospective study conducted at the Emergency Department (ED) of the University Hospital of Genoa, a tertiary trauma center, including all major trauma between January 2019 and December 2020. Adverse outcomes were reviewed among those without antithrombotic treatment (Group 0), on antiplatelet treatment (Group 1), and on anticoagulant treatment (Group 2). Results: We reviewed 349 electronic charts for full analysis. Group 0 were n = 310 (88.8%), Group 1 were n = 26 (7.4%), and Group 2 were n = 13 (3.7%). In-hospital death and ICU admission, respectively, were: n = 16 (5.6%) and n = 81 (26%) in Group 0, none and n = 6 (25%) in Group 1, and n = 2 (15.8%) and n = 4 (30.8%) in Group 2 (p = 0.123-p = 0.874). Altered INR (OR 5.2) and increasing D-dimer levels (AUC: 0.81) correlated to increased mortality. Discussion: Group 2 showed higher mortality than Group 0 and Group 1, however Group 2 had fewer active treatments. Of clotting factors, only altered INR and elevated D-dimer levels were significantly correlated to adverse outcomes. Conclusions: Anticoagulant but not antiplatelet treatment seems to produce the worst outcomes in major trauma.
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Affiliation(s)
- Stefano Sartini
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Marzia Spadaro
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Ombretta Cutuli
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Luca Castellani
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Marina Sartini
- Department of Health Sciences, University of Genova, 16128 Genoa, Italy
- Hospital Hygiene Unit, Galliera Hospital, Via Alessandro Volta 8, 16128 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genova, 16128 Genoa, Italy
- Hospital Hygiene Unit, Galliera Hospital, Via Alessandro Volta 8, 16128 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Paolo Canepa
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Chiara Tognoni
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Agnese Lo
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Lorenzo Canata
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Martina Rosso
- School of Medicine, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Eleonora Arboscello
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
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Morrow GB, Feller T, McQuilten Z, Wake E, Ariëns RAS, Winearls J, Mutch NJ, Laffan MA, Curry N. Cryoprecipitate transfusion in trauma patients attenuates hyperfibrinolysis and restores normal clot structure and stability: Results from a laboratory sub-study of the FEISTY trial. Crit Care 2022; 26:290. [PMID: 36163263 PMCID: PMC9511733 DOI: 10.1186/s13054-022-04167-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/13/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Fibrinogen is the first coagulation protein to reach critical levels during traumatic haemorrhage. This laboratory study compares paired plasma samples pre- and post-fibrinogen replacement from the Fibrinogen Early In Severe Trauma studY (FEISTY; NCT02745041). FEISTY is the first randomised controlled trial to compare the time to administration of cryoprecipitate (cryo) and fibrinogen concentrate (Fg-C; Riastap) in trauma patients. This study will determine differences in clot strength and fibrinolytic stability within individuals and between treatment arms. METHODS Clot lysis, plasmin generation, atomic force microscopy and confocal microscopy were utilised to investigate clot strength and structure in FEISTY patient plasma. RESULTS Fibrinogen concentration was significantly increased post-transfusion in both groups. The rate of plasmin generation was reduced 1.5-fold post-transfusion of cryo but remained unchanged with Fg-C transfusion. Plasminogen activator inhibitor 1 activity and antigen levels and Factor XIII antigen were increased post-treatment with cryo, but not Fg-C. Confocal microscopy analysis of fibrin clots revealed that cryo transfusion restored fibrin structure similar to those observed in control clots. In contrast, clots remained porous with stunted fibres after infusion with Fg-C. Cryo but not Fg-C treatment increased individual fibre toughness and stiffness. CONCLUSIONS In summary, our data indicate that cryo transfusion restores key fibrinolytic regulators and limits plasmin generation to form stronger clots in an ex vivo laboratory study. This is the first study to investigate differences in clot stability and structure between cryo and Fg-C and demonstrates that the additional factors in cryo allow formation of a stronger and more stable clot.
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Affiliation(s)
- Gael B Morrow
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK.
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK.
| | - Timea Feller
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Zoe McQuilten
- Transfusion Research Unit, Melbourne and Monash Health, Monash University, Melbourne, Australia
| | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, Southport, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Southport, Australia
| | - Robert A S Ariëns
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - James Winearls
- School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Southport, Australia
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Mike A Laffan
- Centre for Haematology, Imperial College London, London, UK
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Curry
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Matthay ZA, Fields AT, Nunez-Garcia B, Park JJ, Jones C, Leligdowicz A, Hendrickson CM, Callcut RA, Matthay MA, Kornblith LZ. Importance of catecholamine signaling in the development of platelet exhaustion after traumatic injury. J Thromb Haemost 2022; 20:2109-2118. [PMID: 35592998 PMCID: PMC10450647 DOI: 10.1111/jth.15763] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 04/11/2022] [Accepted: 05/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Impaired ex vivo platelet aggregation is common in trauma patients. The mechanisms driving these impairments remain incompletely understood, but functional platelet exhaustion due to excessive in vivo activation is implicated. Given platelet adrenoreceptors and known catecholamine surges after injury, impaired ex vivo platelet aggregation in trauma patients may be linked to catecholamine-induced functional platelet exhaustion. OBJECTIVE To determine the relationship of catecholamines with platelet-dependent hemostasis after injury and to model catecholamine-induced functional platelet exhaustion in healthy donor platelets. PATIENTS/METHODS Whole blood was collected from 67 trauma patients as part of a prospective cohort study. Platelet aggregometry and rotational thromboelastometry were performed, and plasma epinephrine (EPI) and norepinephrine (NE) concentrations were measured. The effect of catecholamines on healthy donor platelets was examined in a microfluidic model, with platelet aggregometry, and by flow cytometry examining surface markers of platelet activation. RESULTS In trauma patients, EPI and NE were associated with impaired platelet aggregation (both p < 0.05), and EPI was additionally associated with decreased viscoelastic clot strength, increased fibrinolysis, and mortality (all p < 0.05). In healthy donors, short duration incubation with EPI enhanced platelet aggregation, platelet adhesion under flow, and increased glycoprotein IIb/IIIa activation, while weaker effects were observed with NE. Compared with short incubation, longer incubation with EPI resulted in decreased platelet adhesion, platelet aggregation, and surface expression of glycoprotein IIb/IIIa. CONCLUSIONS These findings suggest sympathoadrenal activation in trauma patients contributes to impaired ex vivo platelet aggregation, which mechanistically may be explained by a functionally exhausted platelet phenotype under prolonged exposure to high plasma catecholamine levels.
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Affiliation(s)
- Zachary A. Matthay
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California, USA
| | - Alexander T. Fields
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California, USA
| | - Brenda Nunez-Garcia
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California, USA
| | - John J. Park
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California, USA
| | - Chayse Jones
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aleksandra Leligdowicz
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Carolyn M. Hendrickson
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rachael A. Callcut
- Department of Surgery, University of California, Davis, Sacramento, California, USA
| | - Michael A. Matthay
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Lucy Z. Kornblith
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California, USA
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Fournier J, Salou-Regis L, Pauleau G, Goin G, de La Villeon B, Goudard Y. Evaluation of follow-up and long-term outcomes of gunshot and stab wounds in a French civilian population. Chin J Traumatol 2022; 25:201-208. [PMID: 35484011 PMCID: PMC9252929 DOI: 10.1016/j.cjtee.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The data concerning long-term follow-up and outcomes of penetrating trauma are poorly detailed in the literature. The main objective of our study was to analyze the hospital and extra-hospital follow-up of penetrating trauma victims and to evaluate the late complications and long-term consequences of these traumas. METHODS This work was a retrospective longitudinal monocentric observational study conducted at Laveran Military Hospital, from January 2007 to January 2017. All patients hospitalized for gunshot wound or stab wound management during this period were identified via a retrospective systematic query in the hospital information system using the ICD-10 codes. Epidemiological data, traumatism characteristics, hospital management, follow-up and traumatism consequences (i.e., persistent disability) were analyzed. To improve evaluation of traumatism long-term consequences, extra-hospital follow-up data from general physicians (GP) were collected by phone call. During this interview, 9 closed questions were asked to the GP. The survey evaluated: the date of the last consultation related to injury with the GP, the specific follow-up carried out by the GP, traumatism consequences, and recurrence of traumatism. Descriptive, univariate and multivariate with regression analysis were used for statistical analysis. RESULTS A total number of 165 patients were included. Median (Q1, Q3) of hospital follow-up was 28 (4, 66) days. One hundred one patients (61.2%) went to their one-month consultation at hospital. GP follow-up was achieved for 76 patients (55.2%). Median (Q1, Q3) of GP follow-up was 47 (21, 75) months. Twenty-four patients (14.5%) have been totally lost to follow up. The overall follow-up identified 54 patients (32.7%) with long-term consequences, 20 being psychiatric disorders and 30 organic injuries. Organic consequences were mainly peripheral nerve damages (n = 20; 12.1%). Most of the psychiatric consequences were diagnosed during GP follow-up (n = 14; 70%). Seventeen cases (10.3%) of recurrence were found and late mortality occurred in 4 patients (2.4%). High injury severity score, older age and gunshot wound were significantly linked to long-term consequences. Data collection and analysis were carried out in accordance with MR004 reference methodology. CONCLUSION This study showed a high rate of long-term consequences among patients managed for penetrating injury. If all organic lesions are diagnosed during hospital follow-up and jointly managed by hospital and extra-hospital physicians, most socio-psychiatric consequences were detected and followed by extra-hospital workers. However, for half of the patients, the extra-hospital follow-up could not be assessed. Thus, these consequences are very probably underestimated. It appears imperative to strengthen the compliance and adherence of these patients to the care network. Awareness and involvement of medical, paramedical teams and GP role seems essential to screen and manage these consequences.
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Affiliation(s)
- Julie Fournier
- Emergency Department, Laveran Military Hospital, Boulevard Laveran, 13013, Marseille, France
| | - Laure Salou-Regis
- Visceral and Digestive Surgery Unit, Laveran Military Hospital, Boulevard Laveran, 13013, Marseille, France
| | - Ghislain Pauleau
- Visceral and Digestive Surgery Unit, Laveran Military Hospital, Boulevard Laveran, 13013, Marseille, France
| | - Géraldine Goin
- Visceral and Digestive Surgery Unit, Laveran Military Hospital, Boulevard Laveran, 13013, Marseille, France
| | - Bruno de La Villeon
- Visceral and Digestive Surgery Unit, Laveran Military Hospital, Boulevard Laveran, 13013, Marseille, France
| | - Yvain Goudard
- Visceral and Digestive Surgery Unit, Laveran Military Hospital, Boulevard Laveran, 13013, Marseille, France,Corresponding author.
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Zeineddin A, Wu F, Dong JF, Huang H, Zou L, Chao W, Dorman B, Kozar RA. TRAUMA-DERIVED EXTRACELLULAR VESICLES ARE SUFFICIENT TO INDUCE ENDOTHELIAL DYSFUNCTION AND COAGULOPATHY. Shock 2022; 58:38-44. [PMID: 35984759 PMCID: PMC9750939 DOI: 10.1097/shk.0000000000001950] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACTINTRODUCTION Although a number of studies have demonstrated increased release of extracellular vesicles (EVs) and changes in their origin differentials after trauma, the biologic significance of EVs is not well understood. We hypothesized that EVs released after trauma/hemorrhagic shock (HS) contribute to endotheliopathy and coagulopathy. To test this hypothesis, adoptive transfer experiments were performed to determine whether EVs derived from severely injured patients in shock were sufficient to induce endothelial dysfunction and coagulopathy. Methods: Total EVs were enriched from plasma of severely injured trauma/HS patients or minimally injured patients by ultracentrifugation and characterized for size and numbers. Under isoflurane anesthesia, noninjured naive C57BL/6J mice were administered EVs at varying concentrations and compared with mice receiving equal volume vehicle (phosphate-buffered saline (PBS)) or to mice receiving EVs from minimally injured patients. Thirty minutes after injection, mice were sacrificed, and blood was collected for thrombin generation (thrombin-antithrombin, thrombin-antithrombin complex [TAT] assay) and syndecan-1 by enzyme-linked immunoabsorbent assay (ELISA). Lungs were harvested for examination of histopathologic injury and costained with von Willebrand factor and fibrin to identify intravascular coagulation. Bronchial alveolar lavage fluid was aspirated from lungs for protein measurement as an indicator of the endothelial permeability. Data are presented as mean ± SD, P < 0.05 was considered significant, and t test was used. Results: An initial proof-of-concept experiment was performed in naive mice receiving EVs purified from severely injured trauma/HS patients (Injury Severity Score [ISS], 34 ± 7) at different concentrations (5 × 106 to 3.1 × 109/100 μL/mouse) and compared with PBS (control) mice. Neither TAT nor syndecan-1 levels were significantly different between groups at 30 minutes after EV infusion. However, lung vascular permeability and histopathologic injury were significantly higher in the EV group, and lung tissues demonstrated intravascular fibrin deposition. Based on these data, EVs from severely injured trauma/HS patients (ISS, 32 ± 6) or EVs from minimally injured patients (ISS, 8 ± 3) were administered to naive mice at higher concentrations (1 × 109 to 1 × 1010 EV/100 μL/mouse). Compared with mice receiving EVs from minimally injured patients, plasma TAT and syndecan-1 levels were significantly higher in the trauma/HS EV group. Similarly, bronchial alveolar lavage protein and lung histopathologic injury were higher in the trauma/HS EV group, and lung tissues demonstrated enhanced intravascular fibrin deposition. Conclusion: These data demonstrate that trauma/HS results in the systemic release of EVs, which are capable of inducing endotheliopathy as demonstrated by elevated syndecan-1 and increased permeability and coagulopathy as demonstrated by increased TAT and intravascular fibrin deposition. Targeting trauma-induced EVs may represent a novel therapeutic strategy.
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Affiliation(s)
- Ahmad Zeineddin
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD US
| | - Feng Wu
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD US
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, WA, US
- Hematology Division, Department of Medicine, University of Washington School of Medicine, Seattle, WA, US
| | - Huang Huang
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, US
| | - Lin Zou
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, US
| | - Wei Chao
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, US
| | - Brooke Dorman
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD US
| | - Rosemary A Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD US
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Pape HC, Moore EE, McKinley T, Sauaia A. Pathophysiology in patients with polytrauma. Injury 2022; 53:2400-2412. [PMID: 35577600 DOI: 10.1016/j.injury.2022.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - E E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Aurora, CO, USA.
| | - T McKinley
- Department of Orthopaedics, Indiana University, 200 Hawkins Dr, Iowa City, IA 52242, USA.
| | - A Sauaia
- Schools of Public Health and Medicine, University of Colorado, Aurora, Colorado, USA.
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The coagulopathy underlying rotational thromboelastometry derangements in trauma patients: a prospective observational multicenter study. Anesthesiology 2022; 137:232-242. [PMID: 35544678 DOI: 10.1097/aln.0000000000004268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Viscoelastic hemostatic assays such as rotational thromboelastometry (ROTEM®) are used to guide treatment of trauma induced coagulopathy. We hypothesized that ROTEM derangements reflect specific coagulation factor deficiencies after trauma. METHODS Secondary analysis of a prospective cohort study in six European trauma centers in patients presenting with full trauma team activation. Patients with dilutional coagulopathy and patients on anticoagulants were excluded. Blood was drawn on arrival for measurement of ROTEM®, coagulation factor levels and markers of fibrinolysis. ROTEM® cut-off values to define hypocoagulability were: EXTEM clotting time (CT) >80s, EXTEM clot amplitude after 5 minutes (CA5) <40mm, EXTEM lysis at 30 minutes (Li30) <85%, FIBTEM clot amplitude after 5 minutes (CA5) <10mm and FIBTEM lysis at 30 minutes (Li30) <85%. Based on these, patients were divided into 7 deranged ROTEM® profiles and compared to the reference group (ROTEM® values within reference range). The primary endpoint was coagulation factors levels and fibrinolysis. RESULTS Of 1828 patients, 40% had ROTEM® derangements 40.0%, most often consisting of a combined decrease in EXTEM and FIBTEM CA5, that was present in 217 (11.9%) patients. While an isolated EXTEM CT>80s had no impact on mortality, all other ROTEM® derangements were associated with increased mortality. Also, coagulation factor levels in this group were similar to patients with a normal ROTEM®. Of coagulation factors, decrease was most apparent for fibrinogen (with a nadir of 0.78 g/L) and for factor V levels (with a nadir of 22.8%). In addition, increased fibrinolysis can be present when LI30 is normal but EXTEM and FIBTEM CA5 is decreased. CONCLUSION Coagulation factor levels and mortality in the group with an isolated clotting time prolongation is similar to patients with a normal ROTEM ®. Other ROTEM ® derangements are associated with mortality and reflect a depletion of fibrinogen and factor V. Increased fibrinolysis can be present when lysis after 30 minutes is normal.
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Glatts J, Weissenburger J, Mullen-Fortino M, Mazzone L, Cacchione PZ. Patient Extrication Process for Urban Emergency Departments. J Emerg Nurs 2022; 48:328-338. [DOI: 10.1016/j.jen.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/15/2022] [Accepted: 01/31/2022] [Indexed: 11/28/2022]
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Weihs V, Frenzel S, Dedeyan M, Hruska F, Staats K, Hajdu S, Negrin LL, Aldrian S. 25-Year experience with adult polytraumatized patients in a European level 1 trauma center: polytrauma between 1995 and 2019. What has changed? A retrospective cohort study. Arch Orthop Trauma Surg 2022; 143:2409-2415. [PMID: 35412071 PMCID: PMC10110639 DOI: 10.1007/s00402-022-04433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/21/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To analyze the changes of the clinical characteristics, injury patterns, and mortality rates of polytraumatized patients within the past 25 years in a European Level I trauma center. METHODS 953 consecutive polytraumatized patients treated at a single-level 1 trauma center between January 1995 and December 2019 were enrolled retrospectively. Polytrauma was defined as AIS ≥ 3 points in at least two different body regions. Retrospective data analysis on changes of clinical characteristics and mortality rates over time. RESULTS A significant increase of the average age by 2 years per year of the study could be seen with a significant increase of geriatric patients over time. No changes of the median Injury Severity Score (ISS) could be seen over time, whereas the ISS significantly decreased by patient's year. The rates of concomitant severe traumatic brain injury (TBI) remained constant over time, and did not increase with rising age of the patients. Although, the mortality rate remained constant over time the relative risk of overall in-hospital mortality increased by 1.7% and the relative risk of late-phase mortality increased by 2.2% per patient's year. CONCLUSION The number of polytraumatized patients remained constant over the 25-year study period. Also, the mortality rates remained stable over time, although a significant increase of the average age of polytraumatized patients could be seen with stable injury severity scores. Severe TBI and age beyond 65 years remained independent prognostic factors on the late-phase survival of polytraumatized patients. TRIAL REGISTRATION NCT04723992. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Valerie Weihs
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Stephan Frenzel
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Michél Dedeyan
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Florian Hruska
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Kevin Staats
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Lukas Leopold Negrin
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Silke Aldrian
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Abstract
BACKGROUND Blood-based balanced resuscitation is a standard of care in massively bleeding trauma patients. No data exists as to when this therapy no longer significantly affects mortality. We sought to determine if there is a threshold beyond which further massive transfusion will not affect in-hospital mortality. METHODS The Trauma Quality Improvement database was queried for all adult patients registered between 2013 and 2017 who received at least one unit of blood (PRBC) within 4 hours of arrival. In-hospital mortality was evaluated based on the total transfusion volume (TTV) at 4 and 24 hours in the overall cohort (OC) and in a balanced transfusion cohort (BC), composed of patients who received transfusion at a ratio of 1:1-2:1 PRBC-to-plasma. A bootstrapping method in combination with multivariable Poisson regression (MVR) was used to find a cutoff after which additional transfusion no longer affected in-hospital mortality. MVR was used to control for age, sex, race, highest abbreviated injury score in each body region, comorbidities, advanced directives limiting care, and the primary surgery performed for hemorrhage control. RESULTS The OC consisted of 99,042 patients of which 28,891 and 30,768 received a balanced transfusion during the first 4 and 24 hours, respectively. The mortality rate plateaued after a TTV of 40.5 units (95% CI, 40-41) in the OC at 4 hours and after a TTV of 52.8 units (95% CI, 52-53) at 24 hours following admission. In the BC, mortality plateaued at a TTV of 39 units (95% CI, 39-39) and 53 units (95% CI, 53-53) at 4- and 24-hours following admission, respectively. CONCLUSION Transfusion thresholds exist beyond which ongoing transfusion is not associated with any clinically significant change in mortality. These TTVs can be used as markers for resuscitation timeouts in order to assess the plan of care moving forward. LEVEL OF EVIDENCE Level V, prognostic and epidemiological.
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Abstract
BACKGROUND Fibrinogen is the first coagulation factor to decrease after massive hemorrhage. European massive transfusion guidelines recommend early repletion of fibrinogen; however, this practice has not been widely adopted in the US. We hypothesize that hypofibrinogenemia is common at hospital arrival and is an integral component of trauma-induced coagulopathy. STUDY DESIGN This study entailed review of a prospective observational database of adults meeting the highest-level activation criteria at an urban level 1 trauma center from 2014 through 2020. Resuscitation was initiated with 2:1 red blood cell (RBC) to fresh frozen plasma (FFP) ratios and continued subsequently with goal-directed thrombelastography. Hypofibrinogenemia was defined as fibrinogen below 150 mg/dL. Massive transfusion (MT) was defined as more than 10 units RBC or death after receiving at least 1 unit RBC over the first 6 hours of admission. RESULTS Of 476 trauma activation patients, 70 (15%) were hypofibrinogenemic on admission, median age was 34 years, 78% were male, median New Injury Severity Score (NISS) was 25, and 72 patients died (15%). Admission fibrinogen level was an independent risk factor for MT (odds ratio [OR] 0.991, 95% CI 0.987-0.996]. After controlling for confounders, NISS (OR 1.034, 95% CI 1.017-1.052), systolic blood pressure (OR 0.991, 95% CI 0.983-0.998), thrombelastography angle (OR 0.925, 95% CI 0.896-0.954), and hyperfibrinolysis (OR 2.530, 95% CI 1.160-5.517) were associated with hypofibrinogenemia. Early cryoprecipitate administration resulted in the fastest correction of hypofibrinogenemia. CONCLUSION Hypofibrinogenemia is common after severe injury and predicts MT. Cryoprecipitate transfusion results in the most expeditious correction. Earlier administration of cryoprecipitate should be considered in MT protocols.
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Hamada SR, Garrigue D, Nougue H, Meyer A, Boutonnet M, Meaudre E, Culver A, Gaertner E, Audibert G, Vigué B, Duranteau J, Godier A, Abback PS, Audibert G, Gauss T, Geeraerts T, Harrois A, Langeron O, Leone M, Pottecher J, Stecken L, Hanouz JL. Impact of platelet transfusion on outcomes in trauma patients. Crit Care 2022; 26:49. [PMID: 35189930 PMCID: PMC8862339 DOI: 10.1186/s13054-022-03928-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/10/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Trauma-induced coagulopathy includes thrombocytopenia and platelet dysfunction that impact patient outcome. Nevertheless, the role of platelet transfusion remains poorly defined. The aim of the study was 1/ to evaluate the impact of early platelet transfusion on 24-h all-cause mortality and 2/ to describe platelet count at admission (PCA) and its relationship with trauma severity and outcome.
Methods
Observational study carried out on a multicentre prospective trauma registry. All adult trauma patients directly admitted in participating trauma centres between May 2011 and June 2019 were included. Severe haemorrhage was defined as ≥ 4 red blood cell units within 6 h and/or death from exsanguination. The impact of PCA and early platelet transfusion (i.e. within the first 6 h) on 24-h all-cause mortality was assessed using uni- and multivariate logistic regression.
Results
Among the 19,596 included patients, PCA (229 G/L [189,271]) was associated with coagulopathy, traumatic burden, shock and bleeding severity. In a logistic regression model, 24-h all-cause mortality increased by 37% for every 50 G/L decrease in platelet count (OR 0.63 95% CI 0.57–0.70; p < 0.001). Regarding patients with severe hemorrhage, platelets were transfused early for 36% of patients. Early platelet transfusion was associated with a decrease in 24-h all-cause mortality (versus no or late platelets): OR 0.52 (95% CI 0.34–0.79; p < 0.05).
Conclusions
PCA, although mainly in normal range, was associated with trauma severity and coagulopathy and was predictive of bleeding intensity and outcome. Early platelet transfusion within 6 h was associated with a decrease in mortality in patients with severe hemorrhage. Future studies are needed to determine which doses of platelet transfusion will improve outcomes after major trauma.
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Martinaud C, Fleuriot E, Pasquier P. Implementation of Low Titer Whole Blood for French overseas operations: O positive or negative products in massive hemorrhage? Transfus Clin Biol 2022; 29:164-167. [DOI: 10.1016/j.tracli.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/20/2022] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
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Lier H, Fries D. Emergency Blood Transfusion for Trauma and Perioperative Resuscitation: Standard of Care. Transfus Med Hemother 2022; 48:366-376. [PMID: 35082568 DOI: 10.1159/000519696] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Uncontrolled and massive bleeding with derangement of coagulation is a major challenge in the management of both surgical and seriously injured patients. The underlying mechanism of trauma-induced or -associated coagulopathy is tissue injury in the presence of shock and acidosis provoking endothelial damage, activation of inflammation, and coagulation disbalancing. Furthermore, the combination of ongoing blood loss and consumption of blood components that are essential for effective coagulation worsens uncontrolled hemorrhage. Additionally, therapeutic actions, such as resuscitation with replacement fluids or allogeneic blood products, can further aggravate coagulopathy. Of the coagulation factors essential to the clotting process, fibrinogen is the first to be consumed to critical levels during acute bleeding and current evidence suggests that normalizing fibrinogen levels in bleeding patients improves clot formation and clot strength, thereby controlling hemorrhage. Three different therapeutic approaches are discussed controversially. Whole blood transfusion is used especially in the military scenario and is also becoming more and more popular in the civilian world, although it is accompanied by a strong lack of evidence and severe safety issues. Transfusion of allogeneic blood concentrates in fixed ratios without any targets has been investigated extensively with disappointing results. Individualized and target-controlled coagulation management based on point-of-care diagnostics with respect to the huge heterogeneity of massive bleeding situations is an alternative and advanced approach to managing coagulopathy associated with massive bleeding in the trauma as well as the perioperative setting.
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Affiliation(s)
- Heiko Lier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic for Anesthesiology and Intensive Care Medicine, Cologne, Germany
| | - Dietmar Fries
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Thota B, Marinica A, Oh MW, Cripps MW, Moon TS. The Use of Tranexamic Acid in Trauma. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00509-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yazdani E, Nasr-Esfahani M, Kolahdouzan M, Pourazari P. Comparing the effectiveness of bupivacaine administration through chest tube and intercostal blockage in patients with rib fractures. Adv Biomed Res 2022; 11:66. [PMID: 36325169 PMCID: PMC9621344 DOI: 10.4103/abr.abr_50_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/11/2021] [Accepted: 10/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background: There are several methods to control pain, especially in traumatic patients with rib fractures. Intrapleural analgesia (IPA) and intercostal block methods are recommended in patients with rib fractures to control pain. Here, we aimed to evaluate and compare the effects of IPA and intercostal block on patients’ clinical conditions. Materials and Methods: This is a randomized clinical trial that was performed in 2020–2021 on thirty traumatic patients with rib fractures. We collected the results of arterial blood gas in all patients before interventions including HCO3, pH, pO2, and pCO2 and also evaluated pain of patients. The first group underwent intercostal blockade with standard method with bupivacaine, and for the second group of patients, a chest tube was implanted. Patients were monitored for up to 12 h for pain intensity and need for analgesics. Results: The mean levels of HCO3 decreased in both groups after the interventions, and this decrease was more significant in patients in the intercostal blockade group (P < 0.05). The mean levels of pO2 increased in both groups after interventions, especially in patients in the intercostal blockade group (P < 0.05). The mean pCO2 levels also decreased in both groups (P < 0.05). The mean pain intensity in both groups decreased significantly after the intervention (P < 0.05) and also the mean pain intensity in the intercostal blocking group decreased significantly more than the group treated with chest tube (P < 0.05). Conclusion: Intercostal blockade through bupivacaine is more effective than chest tube administration of bupivacaine in patients with rib fractures.
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Kakimoto K, Shibahashi K, Oishio M, Sugiyama K, Hamabe Y. Mortality of hospital
walk‐in
trauma patients: a multicenter retrospective cohort study. Acute Med Surg 2022; 9:e784. [PMID: 36092465 PMCID: PMC9448715 DOI: 10.1002/ams2.784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/17/2022] [Indexed: 01/09/2023] Open
Abstract
Aim To investigate the characteristics of patients who visited the emergency department by themselves after experiencing trauma and subsequently died, and to identify the prognostic factors of mortality in such patients. Methods Adult patients with trauma visiting the emergency department by themselves between 2004 and 2019 in Japan were identified using a nationwide trauma registry (the Japan Trauma Data Bank). The characteristics of patients who died were compared with those who survived, and multivariable logistic regression analysis was used to determine the independent association of each preselected variable with in‐hospital mortality (end‐point). Results Of the 9753 patients eligible for analysis, 4369 (44.8%) were men, and the median age was 75 years. Of these patients, 130 (1.3%) died in the hospital. The following factors had a significant association with in‐hospital mortality: age, male sex, Charlson Comorbidity Index (CCI) 3–4 and ≥5 with CCI = 0 as a reference, circumstances of injury (free fall and fall at ground level), Glasgow Coma Scale score, Shock Index ≥ 0.9, severe injuries of the head, abdomen and lower extremities, and Injury Severity Score ≥ 15. Conclusions Several risk factors, including older age, male sex, higher CCI, circumstances of injury (free fall and fall at ground level), lower Glasgow Coma Scale score, higher Shock Index, and severe injuries of the head, abdomen, and lower extremities, were identified as being associated with the death of trauma patients visiting the emergency department by themselves. Early identification of patients with these risk factors and appropriate treatment may reduce mortality posttrauma.
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Affiliation(s)
- Kohei Kakimoto
- Tertiary Emergency Medical Center (Trauma and Critical Care) Tokyo Metropolitan Bokutoh Hospital Tokyo Japan
| | - Keita Shibahashi
- Tertiary Emergency Medical Center (Trauma and Critical Care) Tokyo Metropolitan Bokutoh Hospital Tokyo Japan
| | - Masato Oishio
- Tertiary Emergency Medical Center (Trauma and Critical Care) Tokyo Metropolitan Bokutoh Hospital Tokyo Japan
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center (Trauma and Critical Care) Tokyo Metropolitan Bokutoh Hospital Tokyo Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center (Trauma and Critical Care) Tokyo Metropolitan Bokutoh Hospital Tokyo Japan
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Walker SC, Richter RP, Zheng L, Ashtekar AR, Jansen JO, Kerby JD, Richter JR. Increased Plasma Hyaluronan Levels are Associated With Acute Traumatic Coagulopathy. Shock 2022; 57:113-117. [PMID: 34608101 PMCID: PMC8678307 DOI: 10.1097/shk.0000000000001867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Acute traumatic coagulopathy (ATC) is an endogenous impairment in hemostasis that often contributes to early mortality after trauma. Endothelial glycocalyx damage is associated with trauma-induced coagulation abnormalities; however, the specific relationship between hyaluronan (HA), a key glycocalyx constituent, and ATC has not been evaluated. METHODS We performed a secondary analysis of prospectively collected data from a recent study in which trauma patients (>18 years) admitted to our Level I trauma center with an ABC Score≥2 were enrolled. Partial thromboplastin time (PTT), international normalized ratio (INR), and thromboelastography (TEG) parameters were recorded at arrival. Injury characteristics and clinical outcomes were obtained. Plasma HA levels were measured in healthy controls (HC) and in trauma subjects at arrival (t = 0 h) and 12, 24, and 48 h. ATC was defined as admission INR>1.2 or PTT≥36.5 s. Comparisons of HA levels were assessed, and Spearman's correlations were performed between 0 h and 24 h HA levels, coagulation measures and clinical outcomes. P values < 0.05 were considered significant. RESULTS Forty-eight trauma patients and 22 controls were enrolled for study. Sixteen trauma subjects were coagulopathic at admission. HA levels in subjects with ATC were higher than non-coagulopathic subjects at all time points and elevated above HC levels at 24 and 48 h. At arrival, HA levels correlated with TEG R-time, PTT, and INR. HA levels at 24 h correlated with increased transfusion requirements and intensive care unit and hospital lengths of stay. CONCLUSION Shed HA is associated with early coagulation abnormalities in trauma patients, which may contribute to worse outcomes. These findings highlight the need for additional studies to evaluate the mechanistic role of HA in ATC.
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Affiliation(s)
- Shannon C Walker
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Robert P Richter
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lei Zheng
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amit R Ashtekar
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey D Kerby
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jillian R Richter
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Picetti E, Rosenstein I, Balogh ZJ, Catena F, Taccone FS, Fornaciari A, Votta D, Badenes R, Bilotta F. Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review. J Clin Med 2021; 11:18. [PMID: 35011760 PMCID: PMC8745292 DOI: 10.3390/jcm11010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 01/28/2023] Open
Abstract
Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this narrative review, we summarize the available evidence in this setting, focusing on perioperative brain protection, cardiorespiratory optimization, and preservation of the coagulative function. An overview on simultaneous multisystem surgery (SMS) is also presented.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, 43100 Parma, Italy; (E.P.); (A.F.)
| | - Israel Rosenstein
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle 2305, Australia;
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital, 47521 Cesena, Italy;
| | - Fabio S. Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Anna Fornaciari
- Department of Anesthesia and Intensive Care, Parma University Hospital, 43100 Parma, Italy; (E.P.); (A.F.)
| | - Danilo Votta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| | - Rafael Badenes
- Department of Anesthesiology and Intensive Care, Hospital Clìnico Universitario de Valencia, University of Valencia, 46010 Valencia, Spain
| | - Federico Bilotta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
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Mayer AR, Dodd AB, Rannou-Latella JG, Stephenson DD, Dodd RJ, Ling JM, Mehos CJ, Robertson-Benta CR, Pabbathi Reddy S, Kinsler RE, Vermillion MS, Gigliotti AP, Sicard V, Lloyd AL, Erhardt EB, Gill JM, Lai C, Guedes VA, Chaudry IH. 17α-Ethinyl estradiol-3-sulfate increases survival and hemodynamic functioning in a large animal model of combined traumatic brain injury and hemorrhagic shock: a randomized control trial. Crit Care 2021; 25:428. [PMID: 34915927 PMCID: PMC8675515 DOI: 10.1186/s13054-021-03844-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/26/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Traumatic brain injury (TBI) and severe blood loss resulting in hemorrhagic shock (HS) represent leading causes of trauma-induced mortality, especially when co-occurring in pre-hospital settings where standard therapies are not readily available. The primary objective of this study was to determine if 17α-ethinyl estradiol-3-sulfate (EE-3-SO4) increases survival, promotes more rapid cardiovascular recovery, or confers neuroprotection relative to Placebo following TBI + HS.
Methods
All methods were approved by required regulatory agencies prior to study initiation. In this fully randomized, blinded preclinical study, eighty (50% females) sexually mature (190.64 ± 21.04 days old; 28.18 ± 2.72 kg) Yucatan swine were used. Sixty-eight animals received a closed-head, accelerative TBI followed by removal of approximately 40% of circulating blood volume. Animals were then intravenously administered EE-3-SO4 formulated in the vehicle at 5.0 mg/mL (dosed at 0.2 mL/kg) or Placebo (0.45% sodium chloride solution) via a continuous pump (0.2 mL/kg over 5 min). Twelve swine were included as uninjured Shams to further characterize model pathology and replicate previous findings. All animals were monitored for up to 5 h in the absence of any other life-saving measures (e.g., mechanical ventilation, fluid resuscitation).
Results
A comparison of Placebo-treated relative to Sham animals indicated evidence of acidosis, decreased arterial pressure, increased heart rate, diffuse axonal injury and blood–brain barrier breach. The percentage of animals surviving to 295 min post-injury was significantly higher for the EE-3-SO4 (28/31; 90.3%) relative to Placebo (24/33; 72.7%) cohort. EE-3-SO4 also restored pulse pressure more rapidly post-drug administration, but did not confer any benefits in terms of shock index. Primary blood-based measurements of neuroinflammation and blood brain breach were also null, whereas secondary measurements of diffuse axonal injury suggested a more rapid return to baseline for the EE-3-SO4 group. Survival status was associated with biological sex (female > male), as well as evidence of increased acidosis and neurotrauma independent of EE-3-SO4 or Placebo administration.
Conclusions
EE-3-SO4 is efficacious in promoting survival and more rapidly restoring cardiovascular homeostasis following polytraumatic injuries in pre-hospital environments (rural and military) in the absence of standard therapies. Poly-therapeutic approaches targeting additional mechanisms (increased hemostasis, oxygen-carrying capacity, etc.) should be considered in future studies.
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Duchesne J, Taghavi S, Khan M, Perreira B, Cotton B, Brenner M, Ferrada P, Horer T, Kauvar D, Kirkpatrick A, Ordoñez C, Priouzram A, Roberts D. Circulatory Trauma: A Paradigm for Understanding the Role of Endovascular Therapy in Hemorrhage Control. Shock 2021; 56:22-29. [PMID: 34797785 DOI: 10.1097/shk.0000000000001513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The pathophysiology of traumatic hemorrhage is a phenomenon of vascular disruption and the symptom of bleeding represents one or more vascular injuries. In the Circulatory Trauma paradigm traumatic hemorrhage is viewed as injury to the circulatory system and suggests the underlying basis for endovascular hemorrhage control techniques. The question "Where is the patient bleeding?" is replaced by "Which blood vessels are disrupted?" and stopping bleeding becomes a matter of selective vessel access and vascular flow control. Control of traumatic hemorrhage has traditionally been performed via external access to the end organ that is bleeding followed by the application of direct pressure, packing, or clamping and repair of directly affected blood vessels. In the circulatory trauma paradigm, bleeding is seen as disruption to vessels which may be accessed internally, from within the vascular system. A variety of endovascular treatments such as balloon occlusion, embolization, or stent grafting can be used to control hemorrhage throughout the body. This narrative review presents a brief overview of the current role of endovascular therapy in the management of circulatory trauma. The authors draw on their personal experience combined with the last decade of published experiences with the use of endovascular techniques in trauma and present general recommendations for their evolving use. The focus of the review is on the use of endovascular techniques as specific vascular treatments using the circulatory trauma paradigm.
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Affiliation(s)
- Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana, USA
| | - Sharven Taghavi
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana, USA
| | - Mansoor Khan
- Department of Digestive Diseases, Brighton and Sussex University Hospitals, Brighton, UK
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Bryan Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, Texas, USA
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California, USA
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canadian Forces Health Services
| | - Carlos Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery. Fundación Valle del Lili. Universidad del Valle, Cali , Colombia
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Derek Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
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Comparison of Shock Index With the Assessment of Blood Consumption Score for Association With Massive Transfusion During Hemorrhage Control for Trauma. J Trauma Nurs 2021; 28:341-349. [PMID: 34766927 DOI: 10.1097/jtn.0000000000000613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of early mortality following trauma. A massive transfusion protocol (MTP) to guide resuscitation while bleeding is definitively controlled may improve outcomes. Prompts to initiate massive transfusion (MT) include shock index (SI) and the Assessment of Blood Consumption (ABC) score. OBJECTIVE To compare SI with the ABC score for association with transfusion requirement, need for emergency hemorrhage interventions, and early mortality. METHODS A retrospective cohort analysis of trauma MTP activations at our Level I trauma center was conducted from January 1, 2012, to December 31, 2016. The study data were obtained from the Trauma Registry and the blood bank. An SI cutoff of 1.0 was chosen for comparison with the positive ABC score. RESULTS The study cohort included 146 patients. Shock index ≥ 1 had significant association with MT requirement (p = .002) whereas a positive ABC score did not (p = .65). More patients with SI ≥ 1 required bleeding control interventions (67% surgery, 47% interventional radiology) than patients having a positive ABC score (49% surgery, 29% interventional radiology). For geriatric patients who received MT, 65% had SI ≥ 1 but only 30% had a positive ABC score. Three-hour mortality following emergency department arrival was similar (60% SI ≥ 1, 62% positive ABC score). CONCLUSION Shock index ≥ 1 outperformed a positive ABC score for association with MT requirement. Shock index is a simple tool registered nurses can independently utilize to anticipate MT.
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Zeineddin A, Hu P, Yang S, Floccare D, Lin CY, Scalea TM, Kozar RA. Prehospital continuous vital signs predict need for resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy prehospital continuous vital signs predict resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2021; 91:798-802. [PMID: 33797486 DOI: 10.1097/ta.0000000000003171] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rapid triage and intervention to control hemorrhage are key to survival following traumatic injury. Patients presenting in hemorrhagic shock may undergo resuscitative thoracotomy (RT) or resuscitative endovascular balloon occlusion of the aorta (REBOA) as adjuncts to rapidly control bleeding. We hypothesized that machine learning along with automated calculation of continuously measured vital signs in the prehospital setting would accurately predict need for REBOA/RT and inform rapid lifesaving decisions. METHODS Prehospital and admission data from 1,396 patients transported from the scene of injury to a Level I trauma center via helicopter were analyzed. Utilizing machine learning and prehospital autonomous vital signs, a Bleeding Risk Index (BRI) based on features from pulse oximetry and electrocardiography waveforms and blood pressure (BP) trends was calculated. Demographics, Injury Severity Score and BRI were compared using Mann-Whitney-Wilcox test. Area under the receiver operating characteristic curve (AUC) was calculated and AUC of different scores compared using DeLong's method. RESULTS Of the 1,396 patients, median age was 45 years and 68% were men. Patients who underwent REBOA/RT were more likely to have a penetrating injury (24% vs. 7%, p < 0.001), higher Injury Severity Score (25 vs. 10, p < 0.001) and higher mortality (44% vs. 7%, p < 0.001). Prehospital they had lower BP (96 [70-130] vs. 134 [117-152], p < 0.001) and higher heart rate (106 [82-118] vs. 90 [76-106], p < 0.001). Bleeding risk index calculated using the entire prehospital period was 10× higher in patients undergoing REBOA/RT (0.5 [0.42-0.63] vs. 0.05 [0.02-0.21], p < 0.001) with an AUC of 0.93 (95% confidence interval [95% CI], 0.90-0.97). This was similarly predictive when calculated from shorter periods of transport: BRI initial 10 minutes prehospital AUC of 0.89 (95% CI, 0.83-0.94) and initial 5 minutes AUC of 0.90 (95% CI, 0.85-0.94). CONCLUSION Automated prehospital calculations based on vital sign features and trends accurately predict the need for the emergent REBOA/RT. This information can provide essential time for team preparedness and guide trauma triage and disaster management. LEVEL OF EVIDENCE Therapeutic/care management, Level IV.
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Affiliation(s)
- Ahmad Zeineddin
- From the Shock, Trauma and Anesthesiology Research (STAR) Center (A.Z., P.H., S.Y., C.-Y.L., R.A.K.), Shock Trauma Center (T.M.S., R.A.K.), University of Maryland School of Medicine; and Maryland Institute for Emergency Medical Services Systems (D.F.), Baltimore, Maryland
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80
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Picetti E, Bouzat P, Cattani L, Taccone FS. Perioperative management of severe brain injured patients. Minerva Anestesiol 2021; 88:380-389. [PMID: 34636222 DOI: 10.23736/s0375-9393.21.15927-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy -
| | - Pierre Bouzat
- Department of Anesthesiology and Intensive Care Medicine, Grenoble Alps Trauma Centre, Grenoble Alpes University Hospital, Grenoble, France
| | - Luca Cattani
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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81
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Soeyland T, Hollott JD, Garner A. External Aortic Compression in Noncompressible Truncal Hemorrhage and Traumatic Cardiac Arrest: A Scoping Review. Ann Emerg Med 2021; 79:297-310. [PMID: 34607742 DOI: 10.1016/j.annemergmed.2021.07.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/10/2021] [Accepted: 07/26/2021] [Indexed: 11/19/2022]
Abstract
External aortic compression has been investigated as a treatment for non-compressible truncal haemorrhage in trauma patients. We sought to systematically gather and tabulate the available evidence around external aortic compression. We were specifically interested in its ability to achieve hemostasis and aid in resuscitation of traumatic arrest and severe shock and to consider physiological changes and adverse effects. A scoping review approach was chosen due to the highly variable existing literature. We were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using the specific extension for scoping reviews. Searches were done on PubMed and Scopus databases in October 2020. We found that a range of studies have investigated external aortic compression in a variety of settings, including case reports and small case series, porcine hemorrhage models and effects on healthy volunteers. External aortic compression for postpartum hemorrhage in a single center provided some evidence of effectiveness. Overall the level of evidence is limited, however, external aortic compression does appear able to achieve cessation of distal blood flow. Furthermore, it appears to improve many relevant physiological parameters in the setting of hypovolemic shock. Application for more than 60 minutes appears to cause increasingly problematic complications. In conclusion we find that the role of external aortic compression warrants further research. The intervention may have a role as a bridge to definitive treatment of noncompressible truncal haemorrahge.
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Affiliation(s)
- Torgrim Soeyland
- Hunter Retrieval Service, John Hunter Hospital, NSW Health, New South Wales, Australia.
| | - John David Hollott
- Hunter Retrieval Service, John Hunter Hospital, NSW Health, New South Wales, Australia
| | - Alan Garner
- Nepean Clinical School, University of Sydney, Sydney, Australia; Trauma Services, Nepean Hospital, Kingswood, Sydney, Australia
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Tanaka KA, Shettar S, Vandyck K, Shea SM, Abuelkasem E. Roles of Four-Factor Prothrombin Complex Concentrate in the Management of Critical Bleeding. Transfus Med Rev 2021; 35:96-103. [PMID: 34551881 DOI: 10.1016/j.tmrv.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/27/2021] [Indexed: 12/19/2022]
Abstract
Four-factor prothrombin complex concentrate (4F-PCC) is the term used to describe a pathogen-reduced, lyophilized concentrate that contains therapeutic amounts of at least 4 coagulation factors: Factor II (FII), Factor VII (FVII), Factor IX (FIX), and Factor X (FX). 4F-PCC has proven to be an effective hemostatic agent compared to plasma transfusion in several prospective randomized trials in acute warfarin reversal. In recent years, 4F-PCC has been used in various acquired coagulopathies including post-cardiopulmonary bypass bleeding, trauma-induced coagulopathy, coagulopathy in liver failure, and major bleeding due to anti-FXa (anti-Xa) inhibitors (eg, rivaroxaban and apixaban). As transfusion of frozen plasma (FP) has not been found efficacious in the above critical bleeding scenarios, there is increasing interest in expanding the use of 4F-PCC. However, efficacy, safety, and clinical implications of expanded use of 4F-PCC have not been fully elucidated. Prothrombin time and international normalized ratio are commonly used to assess dose effects of 4F-PCC. Prothrombin time/international normalized ratio are standardly use for warfarin titration, but they are not suited for real-time monitoring of complex coagulopathies. Optimal dosing of 4F-PCC outside of the current approved use for vitamin K antagonist reversal is yet to be determined. In this review, we will discuss the use of 4F-PCC in four critical bleeding settings: cardiac surgery, major trauma, end-stage liver disease, and oral anti-Xa reversal. We will discuss recent studies in each area to explore the dosing, efficacy, and safety of 4F-PCC.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA.
| | - Shashank Shettar
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Kofi Vandyck
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Susan M Shea
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Racial and ethnic disparities in withdrawal of life-sustaining treatment after non-head injury trauma. Am J Surg 2021; 223:998-1003. [PMID: 34384589 PMCID: PMC8818056 DOI: 10.1016/j.amjsurg.2021.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/21/2021] [Accepted: 08/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about potential disparities in end-of-life care in trauma. We examined racial/ethnic differences in withdrawal of life-sustaining treatment (WLST) in non-head injury trauma. METHODS We retrospectively analyzed the National Trauma Databank (2017-2018), including patients ≥ 18 years without head injury. We performed a bivariate analysis by WLST status and used logistic regression to estimate adjusted odds of WLST by racial/ethnic group. RESULTS Of 942,914 identified, 20,052 (2.1%) died. Of those who died, WLST occurred in 29.9%. The adjusted odds of WLST were lower in Blacks (OR 0.48, 95% CI 0.41-0.57) and Hispanics (OR 0.71, 95% CI 0.57-0.89) than Whites. The predicted probability of WLST in Black patients remained lower than Whites at 30 days. CONCLUSIONS Among non-head injured dying patients, Blacks and Hispanics are less likely to utilize WLST than Whites. Further investigation into the socio-cultural norms and institutional distrust influencing these differences is imperative.
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Matthay ZA, Hellmann ZJ, Callcut RA, Matthay EC, Nunez-Garcia B, Duong W, Nahmias J, LaRiccia AK, Spalding MC, Dalavayi SS, Reynolds JK, Lesch H, Wong YM, Chipman AM, Kozar RA, Penaloza L, Mukherjee K, Taghlabi K, Guidry CA, Seng SS, Ratnasekera A, Motameni A, Udekwu P, Madden K, Moore SA, Kirsch J, Goddard J, Haan J, Lightwine K, Ontengco JB, Cullinane DC, Spitzer SA, Kubasiak JC, Gish J, Hazelton JP, Byskosh AZ, Posluszny JA, Ross EE, Park JJ, Robinson B, Abel MK, Fields AT, Esensten JH, Nambiar A, Moore J, Hardman C, Terse P, Luo-Owen X, Stiles A, Pearce B, Tann K, Abdul Jawad K, Ruiz G, Kornblith LZ. Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2021; 91:24-33. [PMID: 34144557 PMCID: PMC8243874 DOI: 10.1097/ta.0000000000003121] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Zachary A Matthay
- From the Department of Surgery at Zuckerberg San Francisco General Hospital, University of California San Francisco (Z.A.M., Z.J.H., R.A.C., B.N.-G., L.Z.K., E.E.R., J.J.P., B.R., M.K.A., A.T.F.), San Francisco, California; Department of Epidemiology and Biostatistics, University of California San Francisco (E.C.M), San Francisco, California; Department of Laboratory Medicine, University of California, San Francisco (J.H.E., A.N., J.M.), San Francisco, California; Department of Surgery, University of California Irvine (W.D., J.N.), Irvine, Orange, California; Department of Surgery, Ohio Health Grant Medical Center (A.K.L., M.C.S.), Columbus, Ohio; Department of Surgery, University of Kentucky (S.S.D., J.K.R.), Lexington, Kentucky; Department of Surgery, Miami Valley Hospital (H.L., Y.W., C.H.), Dayton, Ohio; Department of Surgery, R Adams Cowley Shock Trauma Center (A.M.C., R.A.K., P.T.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery, Loma Linda Medical Center (L.P., K.M., X.L.-O.), Loma Linda, California; Department of Surgery, University of Kansas Medical Center (K.T., C.A.G.), Kansas City, Kansas; Department of Surgery, Crozer-Chester Medical Center (S.S.S., A.R.), Upland, Pennsylvania; Department of Surgery, WakeMed Health and Hospitals (A.M., P.U., A.S., B.P., K.T.), Raleigh, North Carolina; Department of Surgery, University of New Mexico School of Medicine (K.M., S.A.M.), Albuquerque, New Mexico; Department of Surgery, Wellspan York Hospital (J.G.), York, Pennsylvania; Department of Surgery, Ascension Via Christi Hospitals St. Francis (J.K., J.H., K.L.), Wichita, Kansas; Department of Surgery, Maine Medical Center (J.B.O., D.C.C.), Portland, Maine; Department of Surgery, South Shore Hospital/Brigham and Women's Hospital (S.A.S., J.C.K.), Boston, Massachusetts; Department of Surgery, Penn State Hershey Medical Center (J.G., J.P.H.), Hershey, Pennsylvania; Department of Surgery, Northwestern University Feinberg School of Medicine (A.Z.B., J.A.P.), Chicago, Illinois; Department of Surgery, University of California (R.A.C.), UC Davis, Sacramento, California; Department of Surgery, Ryder Trauma Center (K.A.J., G.R.), University of Miami Miller School of Medicine, Miami, Florida; and Washington University School of Medicine St. Louis (J.K.), Missouri
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Björklund MK, Cruickshank M, Lendrum RA, Gillies K. Randomised controlled trials in pre-hospital trauma: a systematic mapping review. Scand J Trauma Resusc Emerg Med 2021; 29:65. [PMID: 34001219 PMCID: PMC8127177 DOI: 10.1186/s13049-021-00880-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/21/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Trauma is a leading cause of morbidity and mortality worldwide with about 5.8 million deaths globally and the leading cause of death in those aged 45 and younger. The pre-hospital phase of traumatic injury is particularly important as care received during this phase has effects on survival. The need for high quality clinical trials in this area has been recognised for several years as a key priority to improve the evidence base and, ultimately, clinical care in prehospital trauma. We aimed to systematically map the existing evidence base for pre-hospital trauma trials, to identify knowledge gaps and inform decisions about the future research agenda. METHODS A systematic mapping review was conducted first employing a search of key databases (MEDLINE, CINAHL, EMBASE, and Cochrane Library from inception to March 23rd 2020) to identify randomised controlled trials within the pre-hospital trauma and injury setting. The evidence 'map' identified and described the characteristics of included studies and compared these studies against existing priorities for research. Narrative description of studies informed by analysis of relevant data using descriptive statistics was completed. RESULTS Twenty-three eligible studies, including 10,405 participants across 14 countries, were identified and included in the systematic map. No clear temporal or geographical trends in publications were identified. Studies were categorised into six broad categories based on intervention type with evaluations of fluid therapy and analgesia making up 60% of the included trials. Overall, studies were heterogenous with regard to individual interventions within categories and outcomes reported. There was poor reporting across several studies. No studies reported patient involvement in the design or conduct of the trials. CONCLUSION This mapping review has highlighted that evidence from trials in prehospital trauma is sparse and where trials have been completed, the reporting is generally poor and study designs sub-optimal. There is a continued need, and significant scope, for improvement in a setting where high quality evidence has great potential to make a demonstrable impact on care and outcomes.
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Affiliation(s)
- Matilda K Björklund
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Moira Cruickshank
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Robbie A Lendrum
- NHS Lothian, Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.,Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, UK.,London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, UK
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK.
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86
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Daskal Y, Hershkovitz Y, Peleg K, Dubose JJ, Kessel B, Jeroukhimov I, Givon A, Dudkiewicz M. Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry. ANZ J Surg 2021; 90:477-480. [PMID: 32339421 DOI: 10.1111/ans.15771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/30/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival. METHODS Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected. RESULTS Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room. CONCLUSION Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.
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Affiliation(s)
- Yaakov Daskal
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Yehuda Hershkovitz
- Department of Surgery, Shamir Medical Center, Zerifin, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Joseph J Dubose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, USA
| | - Boris Kessel
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Igor Jeroukhimov
- Department of Surgery, Shamir Medical Center, Zerifin, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Mickey Dudkiewicz
- Hospital Administration, Hillel Yaffe Medical Center, Hadera, Israel
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87
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Pritts TA. Trauma, Metabolomics, Outcomes, and Secrets of the Sphinx. J Am Coll Surg 2021; 232:797-798. [PMID: 33896480 DOI: 10.1016/j.jamcollsurg.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/21/2022]
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88
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Willers A, Swol J, Kowalewski M, Raffa GM, Meani P, Jiritano F, Matteucci M, Fina D, Heuts S, Bidar E, Natour E, Sels JW, Delnoij T, Lorusso R. Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review. ASAIO J 2021; 67:476-484. [PMID: 32657828 DOI: 10.1097/mat.0000000000001216] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Extracorporeal life support (ECLS) is indicated in refractory acute respiratory or cardiac failure. According to the need for anticoagulation, bleeding conditions (e.g., in trauma, pulmonary bleeding) have been considered a contraindication for the use of ECLS. However, there is increasing evidence for improved outcomes after ECLS support in hemorrhagic patients based on the benefits of hemodynamic support outweighing the increased risk of bleeding. We conducted a systematic literature search according to the PRISMA guidelines and reviewed publications describing ECLS support in hemorrhagic conditions. Seventy-four case reports, four case series, seven retrospective database observational studies, and one preliminary result of an ongoing study were reviewed. In total, 181 patients were identified in total of 86 manuscripts. The reports included patients suffering from bleeding caused by pulmonary hemorrhage (n = 53), trauma (n = 96), postpulmonary endarterectomy (n = 13), tracheal bleeding (n = 1), postpartum or cesarean delivery (n = 11), and intracranial hemorrhage (n = 7). Lower targeted titration of heparin infusion, heparin-free ECLS until coagulation is normalized, clamping of the endotracheal tube, and other ad hoc possibilities represent potential beneficial maneuvers in such conditions. Once the patient is cannulated and circulation restored, bleeding control surgery is performed for stabilization if indicated. The use of ECLS for temporary circulatory or respiratory support in critical patients with refractory hemorrhagic shock appears feasible considering tailored ECMO management strategies. Further investigation is needed to better elucidate the patient selection and ECLS management approaches.
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Affiliation(s)
- Anne Willers
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Justyna Swol
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Mariusz Kowalewski
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Paolo Meani
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Federica Jiritano
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Matteo Matteucci
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dario Fina
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Samuel Heuts
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Elham Bidar
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ehsan Natour
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem Sels
- Cardiology Department, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Intensive Care Department, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Thijs Delnoij
- Cardiology Department, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Intensive Care Department, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Roberto Lorusso
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, Schöchl H, Hunt BJ, Sauaia A. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7:30. [PMID: 33927200 PMCID: PMC9107773 DOI: 10.1038/s41572-021-00264-3] [Citation(s) in RCA: 298] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/12/2022]
Abstract
Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.
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Affiliation(s)
- Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA.
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Lucy Z Kornblith
- Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Maureane Hoffman
- Duke University School of Medicine, Transfusion Service, Durham VA Medical Center, Durham, NC, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg and Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | | | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
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90
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Evolving role for extracorporeal membrane oxygenation (ECMO) in trauma patients. Int Anesthesiol Clin 2021; 59:31-39. [PMID: 33710001 DOI: 10.1097/aia.0000000000000313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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91
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Dynamic effects of calcium on in vivo and ex vivo platelet behavior after trauma. J Trauma Acute Care Surg 2021; 89:871-879. [PMID: 32852184 DOI: 10.1097/ta.0000000000002820] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mobilization of intra and extracellular calcium is required for platelet activation, aggregation, and degranulation. However, the importance of alterations in the calcium-platelet axis after injury is unknown. We hypothesized that in injured patients, in vivo initial calcium concentrations (pretransfusion) predict ex vivo platelet activation and aggregation, viscoelastic clot strength, and transfusion of blood products. We additionally hypothesized that increasing calcium concentrations ex vivo increases the expression of platelet activation surface receptors and platelet aggregation responses to agonist stimulation in healthy donor blood. METHODS Blood samples were collected from 538 trauma patients on arrival to the emergency department. Standard assays (including calcium), platelet aggregometry (PA) and thromboelastometry (ROTEM) were performed. In PA, platelet activation (prestimulation impedance [Ω]) and aggregation responses to agonist stimulation (area under the aggregation curve [AUC]) with adenosine diphosphate (ADP), thrombin receptor-activating peptide, arachidonic acid (AA), and collagen (COL) were measured. Multivariable regression tested the associations of calcium with PA, ROTEM, and transfusions. To further examine the calcium-platelet axis, calcium was titrated in healthy blood. Platelet aggregometry and ROTEM were performed, and expression of platelet glycoprotein IIb/IIIa and P-selectin was measured by flow cytometry. RESULTS The patients were moderately injured with normal calcium and platelet counts. Higher calcium on arrival (pretransfusion) was independently associated with increased platelet activation (prestimulation, Ω; p < 0.001), aggregation (ADP-stimulated, AUC; p = 0.002; thrombin receptor-activating peptide-stimulated, AUC; p = 0.038), and clot strength (ROTEM max clot firmness; p < 0.001), and inversely associated with 24-hour transfusions of blood, plasma, and platelets (all p < 0.005). Up-titrating calcium in healthy blood increased platelet activation (prestimulation, Ω; p < 0.001), aggregation (ADP, AA, COL-stimulated AUCs; p < 0.050), and expression of P-selectin (p = 0.003). CONCLUSION Initial calcium concentrations (pretransfusion) are independently associated with platelet activation, aggregation, clot-strength, and transfusions after injury. These changes may be mediated by calcium driven expression of surface receptors necessary for platelet activation and aggregation. However, the therapeutic benefit of early, empiric calcium repletion in trauma patients remains undefined. LEVEL OF EVIDENCE Prognostic, level V.
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92
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Fields AT, Matthay ZA, Nunez-Garcia B, Matthay EC, Bainton RJ, Callcut RA, Kornblith LZ. Good Platelets Gone Bad: The Effects of Trauma Patient Plasma on Healthy Platelet Aggregation. Shock 2021; 55:189-197. [PMID: 32694397 PMCID: PMC8547718 DOI: 10.1097/shk.0000000000001622] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Altered postinjury platelet behavior is recognized in the pathophysiology of trauma-induced coagulopathy (TIC), but the mechanisms remain largely undefined. Studies suggest that soluble factors released by injury may inhibit signaling pathways and induce structural changes in circulating platelets. Given this, we sought to examine the impact of treating healthy platelets with plasma from injured patients. We hypothesized that healthy platelets treated ex-vivo with plasma from injured patients with shock would impair platelet aggregation, while treatment with plasma from injured patients with significant injury burden, but without shock, would enhance platelet aggregation. METHODS Plasma samples were isolated from injured patients (pretransfusion) and healthy donors at a Level I trauma center and stored at -80°C. Plasma samples from four separate patients in each of the following stratified clinical groups were used: mild injury/no shock (injury severity score [ISS] 2-15, base excess [BE]>-6), mild injury/with shock (ISS 2-15, BE≤-6), severe injury/no shock (ISS>25, BE>-6), severe injury/with shock (ISS>25, BE≤-6), minimal injury (ISS 0/1, BE>-6), and healthy. Platelets were isolated from three healthy adult males and were treated with plasma for 30 min. Aggregation was stimulated with a thrombin receptor agonist and measured via multiple-electrode platelet aggregometry. Data were normalized to HEPES Tyrode's (HT) buffer-only treated platelets. Associations of plasma treatment groups with platelet aggregation measures were tested with Mann-Whitney U tests. RESULTS Platelets treated with plasma from patients with shock (regardless of degree of injury) had significantly impaired thrombin-stimulated aggregation compared with platelets treated with plasma from patients without shock (P = 0.002). Conversely, platelets treated with plasma from patients with severe injury, but without shock, had amplified thrombin-stimulated aggregation (P = 0.030). CONCLUSION Shock-mediated soluble factors impair platelet aggregation, and tissue injury-mediated soluble factors amplify platelet aggregation. Future characterization of these soluble factors will support development of novel treatments of TIC.
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Affiliation(s)
| | | | | | - Ellicott C. Matthay
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Roland J. Bainton
- Department of Anesthesia and Perioperative Care, University of California, San Francisco
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93
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Dynamic impact of transfusion ratios on outcomes in severely injured patients: Targeted machine learning analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios randomized clinical trial. J Trauma Acute Care Surg 2021; 89:505-513. [PMID: 32520897 DOI: 10.1097/ta.0000000000002819] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Massive transfusion protocols to treat postinjury hemorrhage are based on predefined blood product transfusion ratios followed by goal-directed transfusion based on patient's clinical evolution. However, it remains unclear how these transfusion ratios impact patient outcomes over time from injury. METHODS The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) is a phase 3, randomized controlled trial, across 12 Level I trauma centers in North America. From 2012 to 2013, 680 severely injured patients required massive transfusion. We used semiparametric machine learning techniques and causal inference methods to augment the intent-to-treat analysis of PROPPR, estimating the dynamic relationship between transfusion ratios and outcomes: mortality and hemostasis at different timepoints during the first 24 hours after admission. RESULTS In the intention-to-treat analysis, the 1:1:1 group tended to have decreased mortality, but with no statistical significance. For patients in whom hemostasis took longer than 2 hours, the 1:1:1 ratio was associated with a higher probability of hemostasis, statistically significant from the 4 hour on. In the per-protocol, actual-transfusion-ratios-received analysis, during four successive time intervals, no significant association was found between the actual ratios and mortality. When comparing patient groups who received both high plasma/PRBC and high platelet/PRBC ratios to the group of low ratios in both, the relative risk of achieving hemostasis was 2.49 (95% confidence interval, 1.19-5.22) during the third hour after admission, suggesting a significant beneficial impact of higher transfusion ratios of plasma and platelets on hemostasis. CONCLUSION Our results suggest that the impact of transfusion ratios on hemostasis is dynamic. Overall, the transfusion ratios had no significant impact on mortality over time. However, receiving higher ratios of platelets and plasma relative to red blood cells hastens hemostasis in subjects who have yet to achieve hemostasis within 3 hours after hospital admission. LEVEL OF EVIDENCE Therapeutic IV.
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94
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Evans CCD, Li W, Seitz D. Injury-related deaths in the Ontario provincial trauma system: a retrospective population-based cohort analysis. CMAJ Open 2021; 9:E208-E214. [PMID: 33688029 PMCID: PMC8034298 DOI: 10.9778/cmajo.20200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although Ontario has an established trauma system, it experiences a substantial burden of morbidity and mortality from injury. Our objective was to describe patterns of fatal injury in Ontario, with a focus on location of death (out of hospital, trauma or non-trauma centre) and receipt of surgical intervention before death. METHODS We conducted a retrospective population-based cohort study using linked administrative data on fatal injuries in children and adults (no age restrictions) in Ontario between 2000 and 2016. We identified injury-related deaths in the Ontario Registrar General Death database. We developed descriptive statistics for injury characteristics and causes of death. We calculated the fatal injury incidence rate for each year of the study. The primary outcome was cause of death; the secondary outcome was receipt of surgical intervention. RESULTS The analysis included 19 408 people. The mean annual incidence of fatal injury averaged 8.7 (95% confidence interval 7.7-9.6) per 100 000. The most common mechanisms of injury were motor vehicle collisions (12 065, 62.2%), followed by gunshot wounds (3134, 16.1%) and falls (2387, 12.3%). Deaths frequently occurred out of hospital (72.6%), rather than at a trauma centre (14.2%) or non-trauma centre (13.2%). Patients treated at trauma centres were significantly more likely to receive a surgical intervention (standardized difference 0.6) than those treated at non-trauma centres. INTERPRETATION Most injury deaths in Ontario occur in the out-of-hospital setting or are managed at non-trauma centres; many patients receive no surgical intervention before death. There are likely opportunities to improve access to specialized injury care in Ontario's trauma system.
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Affiliation(s)
- Christopher C D Evans
- Department of Emergency Medicine (Evans), Queen's University; ICES Queen's (Evans, Li), Kingston, Ont.; Department of Psychiatry (Seitz), University of Calgary, Calgary, Alta.
| | - Wenbin Li
- Department of Emergency Medicine (Evans), Queen's University; ICES Queen's (Evans, Li), Kingston, Ont.; Department of Psychiatry (Seitz), University of Calgary, Calgary, Alta
| | - Dallas Seitz
- Department of Emergency Medicine (Evans), Queen's University; ICES Queen's (Evans, Li), Kingston, Ont.; Department of Psychiatry (Seitz), University of Calgary, Calgary, Alta
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A journey upstream: Fluctuating platelet-specific genes in cell-free plasma as proof-of-concept for using ribonucleic acid sequencing to improve understanding of postinjury platelet biology. J Trauma Acute Care Surg 2020; 88:742-751. [PMID: 32195992 DOI: 10.1097/ta.0000000000002681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The mechanisms of aberrant circulating platelet behavior following injury remain unclear. Platelets retain megakaryocyte immature ribonucleic acid (RNA) splicing and protein synthesis machinery to alter their functions based on physiologic signals. We sought to identify fluctuating platelet-specific RNA transcripts in cell-free plasma (CFP) from traumatic brain injury (TBI) patients as proof-of-concept for using RNA sequencing to improve our understanding of postinjury platelet behavior. We hypothesized that we could identify differential expression of activated platelet-specific spliced RNA transcripts from CFP of patients with isolated severe fatal TBI (fTBI) compared with minimally injured trauma controls (t-controls), filtered by healthy control (h-control) data sets. METHODS High-read depth RNA sequencing was applied to CFP from 10 patients with fTBI (Abbreviated Injury Scale [AIS] for head ≥3, AIS for all other categories <3, and expired) and five t-controls (Injury Severity Score ≤1, and survived). A publicly available CFP RNA sequencing data set from 23 h-controls was used to determine the relative steady state of splice-form RNA transcripts discoverable in CFP. Activated platelet-specific spliced RNA transcripts were derived from studies of ex vivo platelet activation and identified by splice junction presence greater than 1.5-fold or less than 0.67-fold ex vivo nonactivated platelet-specific RNA transcripts. RESULTS Forty-two differentially spliced activated platelet-specific RNA transcripts in 34 genes were altered in CFP from fTBI patients (both upregulated and downregulated). CONCLUSION We have discovered differentially expressed activated platelet-specific spliced RNA transcripts present in CFP from isolated severe fTBI patients that are upregulated or downregulated compared with minimally injured trauma controls. This proof-of-concept suggests that a pool of immature platelet RNAs undergo splicing events after injury for presumed modulation of platelet protein products involved in platelet function. This validates our exploration of injury-induced platelet RNA transcript modulation as an upstream "liquid biopsy" to identify novel postinjury platelet biology and treatment targets for aberrant platelet behavior. LEVEL OF EVIDENCE Diagnostic tests, level V.
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Hanley C, Callum J, Jerath A. Tranexamic acid and trauma coagulopathy: where are we now? Br J Anaesth 2020; 126:12-17. [PMID: 33069339 DOI: 10.1016/j.bja.2020.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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97
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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98
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Lee ZX, Lim XT, Ang E, Hajibandeh S, Hajibandeh S. The effect of preinjury anticoagulation on mortality in trauma patients: A systematic review and meta-analysis. Injury 2020; 51:1705-1713. [PMID: 32576378 DOI: 10.1016/j.injury.2020.06.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the effect of preinjury anticoagulation on mortality in trauma patients. METHODS A search of electronic information sources was conducted to identify all observational studies comparing preinjury anticoagulation with no preinjury anticoagulation in trauma patients. The primary outcome measure was overall mortality (overall mortality, in-hospital mortality and 30-day mortality). The secondary outcome measures included the length of hospital stay, length of intensive care unit (ICU) stay, incidence of intracranial haemorrhage (ICH), and need for operation. Fixed effect or random effects modelling was applied as appropriate to calculate pooled outcome data. RESULTS Nineteen comparative studies enrolling a total of 1,365,446 patients were included. Preinjury anticoagulation was associated with higher risk of overall mortality (OR 2.12, 95%CI 1.79 - 2.51, p < 0.00001), in-hospital mortality (OR 2.04, 95%CI 1.66 - 2.52, p < 0.00001), ICH (OD 1.99, 95%CI 1.61 - 2.45, p < 0.00001), and shorter length of hospital stay (MD 0.50, 95%CI 0.03 - 0.97, p = 0.04) in comparison to no preinjury anticoagulation. We found no difference between the two groups in 30-day mortality (OR 1.61, 95%CI 0.91 - 2.85, p = 0.10), length of ICU stay (MD 0.62, 95%CI -0.13 - 1.36, p = 0.11), and need for operation (OR 1.73, 95%CI 0.71 - 4.20, p = 0.23). The quality of the available evidence was moderate. CONCLUSION Preinjury anticoagulation is a significant predictor of mortality in trauma patients. Future studies should focus on strategies required to reduce such a significant risk of mortality in these high-risk patients. This may include adaptation of primary, secondary and tertiary trauma surveys for patients on preinjury anticoagulation.
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Affiliation(s)
- Zong Xuan Lee
- Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Croesnewydd Road, Wrexham, LL13 7TD, United Kingdom.
| | - Xin Tian Lim
- Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Croesnewydd Road, Wrexham, LL13 7TD, United Kingdom
| | - Eshen Ang
- Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Croesnewydd Road, Wrexham, LL13 7TD, United Kingdom
| | - Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
| | - Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Rhyl, United Kingdom
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99
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Harrois A, Anstey JR, Deane AM, Craig S, Udy AA, McNamara R, Bellomo R. Effects of Routine Position Changes and Tracheal Suctioning on Intracranial Pressure in Traumatic Brain Injury Patients. J Neurotrauma 2020; 37:2227-2233. [PMID: 32403976 DOI: 10.1089/neu.2019.6873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Patient position change and tracheal suctioning are routine interventions in mechanically ventilated traumatic brain injury (TBI) patients. We sought to better understand the impact of these interventions on intracranial pressure (ICP) and cerebral hemodynamics. We conducted a prospective study in TBI patients requiring ICP monitoring. The timing of position changes and suctioning episodes were recorded with concurrent blood pressure and ICP measurements. We collected data on 460 patient position changes and 204 suctioning episodes over 2404 h in 18 ventilated patients (mean age 34 [13] years, median Glasgow Coma Score 4 [3-7]). We recorded 24 (20-31) positioning and 11 (6-18) suctioning episodes per patient, with 54% and 39% of position changes associated with ICP ≥22 mm Hg and cerebral perfusion pressure (CPP) <60 mm Hg, respectively, and 22% and 27% of suctioning episodes associated with an ICP ≥22 mm Hg and CPP <60 mm Hg. The median change in ICP was 11 (6-16) mm Hg after position changes and 3 (1-9) mm Hg after suctioning. Reduction in CPP to <60 mm Hg lasted ≥10 min in 17% of positioning and 11% of suctioning episodes. The baseline ICP and its amplitude were both predictive of a rise in ICP ≥22 mm Hg after positioning and suctioning episodes, whereas cerebral autoregulation was not. Baseline CPP was predictive of a decrease in CPP <60 mm Hg after both interventions. Increases in ICP and reductions in CPP are common following patient positioning and tracheal suctioning episodes. Frequently, these changes are substantial and sustained.
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Affiliation(s)
- Anatole Harrois
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Anesthesia and Surgical Intensive Care, Paris Sud University, Orsay, France
| | - James R Anstey
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Adam M Deane
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Center for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Sally Craig
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, the Alfred Hospital, Melbourne, Victoria, Australia
| | - Robert McNamara
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Center for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
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100
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O'Connor JV, Moran B, Galvagno SM, Deane M, Feliciano DV, Scalea TM. Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma. J Am Coll Surg 2020; 230:494-500. [PMID: 32007533 DOI: 10.1016/j.jamcollsurg.2019.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Approximately 15% of patients with penetrating thoracic trauma require an emergency center or operating room thoracotomy, usually for hemodynamic instability or persistent hemorrhage. The hypothesis in this study was that admission physiology, not vital signs, predicts the need for operating room thoracotomy. STUDY DESIGN We conducted a trauma registry review, 2002 to 2017, of adult patients undergoing operating room thoracotomy within 6 hours of admission (emergency department thoracotomies excluded). Demographics, injuries, admission physiology, time to operating room (OR), operations, and outcomes were reviewed. Data are reported as mean (SD) or median (IQR). RESULTS Of the 301 consecutive patients in this 15-year review, 75.6% were male, mean age was 31.1 years (11.5), and 41.5% had gunshot wounds. The median Injury Severity Score was 25 (range 16 to 29), time to operating room was 38 minutes (interquartile range [IQR] 19 to 105 minutes), and 21.9% had a thoracic damage control operation. Mean admission systolic blood pressure was 115 mmHg (SD 37 mmHg), with only 23.9% <90 mmHg; however, admission pH 7.22 (SD 0.14), base deficit 7.6 (SD 6.1), and lactate 7.2 (SD 4.5) were markedly abnormal. Overall, there were 136 (45.2%) patients with significant pulmonary injuries treated with 112 major nonanatomic resections, 17 lobectomies, and 7 pneumonectomies; respective mortalities were 2.7%, 11.8%, and 42.9%. There were 100 (33.2%) cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19%) combined thoracic injuries. Mortalities for cardiac, great vessel, and aerodigestive injuries were 7%, 0%, and 14.3%, respectively. Overall mortality was 6.6%, 15.2% after damage control, and 4.3% for all others. CONCLUSIONS Shock characterized by acidosis, but not hypotension, is the most common presentation in patients who will need operating room thoracotomy after penetrating thoracic trauma. Survival rates are excellent unless a pneumonectomy or damage control thoracotomy is required.
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Affiliation(s)
- James V O'Connor
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
| | - Benjamin Moran
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Samuel M Galvagno
- Department of Anesthesia, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Molly Deane
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - David V Feliciano
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas M Scalea
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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