Relationship between Obesity and Massive Transfusion Needs in Trauma Patients, and Validation of TASH Score in Obese Population: A Retrospective Study on 910 Trauma Patients

A proposed clinical coagulation score for research in trauma-induced coagulopathy

BACKGROUND

Trauma-induced coagulopathy (TIC) has been the subject of intense study for greater than a century, and it is associated with high morbidity and mortality. The Trans-Agency Consortium for Trauma-Induced Coagulopathy, funded by the National Health Heart, Lung and Blood Institute, was tasked with developing a clinical TIC score, distinguishing between injury-induced bleeding from persistent bleeding due to TIC. We hypothesized that the Trans-Agency Consortium for Trauma-Induced Coagulopathy clinical TIC score would correlate with laboratory measures of coagulation, transfusion requirements, and mortality.

METHODS

Trauma activation patients requiring a surgical procedure for hemostasis were scored in the operating room (OR) and in the first ICU day by the attending trauma surgeon. Conventional and viscoelastic (thrombelastography) coagulation assays, transfusion requirements, and mortality were correlated to the coagulation scores using the Cochran-Armitage trend test or linear regression for numerical variables.

RESULTS

Increased OR TIC scores were significantly associated with abnormal conventional and viscoelastic measurements, including hyperfibrinolysis incidence, as well as with higher mortality and more frequent requirement for massive transfusion ( p < 0.0001 for all trends). Patients with OR TIC score greater than 3 were more than 31 times more likely to have an ICU TIC score greater than 3 (relative risk, 31.6; 95% confidence interval, 12.7-78.3; p < 0.0001).

CONCLUSION

A clinically defined TIC score obtained in the OR reflected the requirement for massive transfusion and mortality in severely injured trauma patients and also correlated with abnormal coagulation assays. The OR TIC score should be validated in multicenter studies.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Factor VIII: A Dynamic Modulator of Hemostasis and Thrombosis in Trauma

A trace amount of thrombin cleaves factor VIII (FVIII) into an active form (FVIIIa), which catalyzes FIXa-mediated activation of FX on the activated platelet surface. FVIII rapidly binds to von Willebrand factor (VWF) after secretion and becomes highly concentrated via VWF-platelet interaction at a site of endothelial inflammation or injury. Circulating levels of FVIII and VWF are influenced by age, blood type (nontype O > type O), and metabolic syndromes. In the latter, hypercoagulability is associated with chronic inflammation (known as thrombo-inflammation). In acute stress including trauma, releasable pools of FVIII/VWF are secreted from the Weibel-Palade bodies in the endothelium and then augment local platelet accumulation, thrombin generation, and leukocyte recruitment. Early systemic increases of FVIII/VWF (>200% of normal) levels in trauma result in a lower sensitivity of contact-activated clotting time (activated partial thromboplastin time [aPTT] or viscoelastic coagulation test [VCT]). However, in severely injured patients, multiple serine proteases (FXa plasmin and activated protein C [APC]) are locally activated and may be systemically released. Severity of traumatic injury correlates with prolonged aPTT and elevated activation markers of FXa, plasmin, and APC, culminating in a poor prognosis. In a subset of acute trauma patients, cryoprecipitate that contains fibrinogen, FVIII/VWF, and FXIII is theoretically advantageous over purified fibrinogen concentrate to promote stable clot formation, but comparative efficacy data are lacking. In chronic inflammation or subacute phase of trauma, elevated FVIII/VWF contributes to the pathogenesis of venous thrombosis by enhancing not only thrombin generation but also augmenting inflammatory functions. Future developments in coagulation monitoring specific to trauma patients, and targeted to enhancement or inhibition of FVIII/VWF, are likely to help clinicians gain better control of hemostasis and thromboprophylaxis. The main goal of this narrative is to review the physiological functions and regulations of FVIII and implications of FVIII in coagulation monitoring and thromboembolic complications in major trauma patients.

Impact of obesity on complications and surgical outcomes after adult degenerative scoliosis spine surgery

OBJECTIVE

To compare perioperative outcomes of obese versus non-obese adult patients who underwent degenerative scoliosis spine surgery.

METHODS

235 patients who underwent thoracolumbar adult spinal deformity (ASD) surgery (≥4 levels) were identified and categorized into two cohorts based on their body mass indices (BMI): obese (BMI ≥30 kg/m²; n = 81) and non-obese (BMI <30 kg/m²; n = 154). Preoperative (demographics, co-morbidities, American Society of Anesthesiologists (ASA) score and modified frailty indices (mFI-5 and mFI-11)), intraoperative (estimated blood loss (EBL) and anesthesia duration), and postoperative (complication rates, Oswestry Disability Index (ODI) scores, discharge destination, readmission rates, and survival) characteristics were analyzed by student's t, chi-squared, and Mann-Whitney U tests.

RESULTS

Obese patients were more likely to be Black/African-American (p < 0.05, OR:4.11, 95% CI:1.20-14.10), diabetic (p < 0.05, OR:10.18, 95% CI:4.38-23.68) and had higher ASA (p < .01) and psoas muscle indices (p < 0.0001). Furthermore, they had greater pre- and post-operative ODI scores (p < 0.05) with elevated mFI-5 (p < 0.0001) and mFI-11 (p < 0.01). Intraoperatively, obese patients were under anesthesia for longer time periods (p < 0.05) with higher EBL (p < 0.05). Postoperatively, while they were more likely to have complications (OR:1.77, 95% CI:1.01 - 3.08), had increased postop days to initiate walking (p < .05) and were less likely to be discharged home (OR:0.55, 95% CI:0.31-0.99), no differences were found in change in ODI scores or readmission rates between the two cohorts.

CONCLUSIONS

Obesity increases pre-operative risk factors including ASA, frailty and co-morbidities leading to longer operations, increased EBL, higher complications and decreased discharge to home. Pre-operative assessment and systematic measures should be taken to improve peri-operative outcomes.

Predictors of transfusion in trauma and their utility in the prehospital environment: a scoping review

Background: Hemorrhage is a leading cause of preventable mortality from trauma, necessitating resuscitation through blood product transfusions. Early and accurate identification of patients requiring transfusions in the prehospital setting may reduce delays in time to transfusion upon arrival to hospital, reducing mortality. The purpose of this study is to characterize existing literature on predictors of transfusion and analyze their utility in the prehospital context.Objectives: The objectives of this study are to characterize the existing quantity and quality of literature regarding predictor scores for transfusion in injured patients, and to analyse the utility of predictor scores for massive transfusions in the prehospital setting and identify prehospital predictor scores for future research.Methods: A search strategy was developed in consultation with information specialists. A literature search of OVID MEDLINE from 1946 to present was conducted for primary studies evaluating the predictive ability of scoring systems or single variables in predicting transfusion in all trauma settings.Results: Of the 5824 studies were identified, 5784 studies underwent title and abstract screening, 94 studies underwent full text review, and 72 studies were included in the final review. We identified 16 single variables and 52 scoring systems for predicting transfusion. Amongst single predictor variables, fluids administered and systolic blood pressure had the highest reported sensitivity (100%) and specificity (89%) for massive transfusion protocol (MTP) activation respectively. Amongst scoring systems for transfusion, the Shock Index and Modified Shock Index had the highest reported sensitivity (96%), while the Pre-arrival Model had the highest reported specificity (95%) for MTP activation. Overall, 20 scores were identified as being applicable to the prehospital setting, 25 scores were identified as being potentially applicable, and seven scores were identified as being not applicable.Conclusions: We identified an extensive list of predictive single variables, validated scoring systems, and derived models for massive transfusion, presented their properties, and identified those with potential utility in the prehospital setting. By further validating applicable scoring tools in the prehospital setting, we may begin to administer more timely transfusions in the trauma population.

Fibrinogen level at hospital admission after multiple injury correlates with BMI and is negatively associated with the need for transfusion and early multiple organ failure

INTRODUCTION

Bleeding and coagulopathy are leading causes of morbidity and lethal outcome after multiple injuries. The pathophysiology of traumatic coagulopathy is under extensive investigations and recent results highlighted the central role of fibrinogen and the fibrin polymerisation process. Our goal was to investigate the factors influencing fibrinogen level and the consequences of hypofibrinogenaemia with clinical importance.

METHODS

We conducted a retrospective analysis enrolling adult patients admitted to the shock room of a tertiary trauma centre in Hungary. Beside coagulation values, demographic data, injury related, transfusion and outcome parameters were collected from the hospital electronic charts. Only patients with complete e-chart were involved into final analysis. Multivariate linear and proportional odds logistic regression models were used to model outcomes - admission fibrinogen and SOFA score - controlling for age, sex, BMI, ISS and lactic acidosis.

RESULTS

54 patients were enrolled in final analysis. Among the parameters analysed, BMI was positively associated with fibrinogen level at admission (+0.23 g/l for every 5 unit of increase in BMI, 95% CI: 0.09-0.37, p=0.0021). Increased risk of transfusion was observed, if fibrinogen at admission was about 1.8 g/l or lower. Beside age and ISS, fibrinogen concentration was also a determinant of early organ failures as it negatively correlated with SOFA scores within 24 hours or care (OR=2.42, 95% CI: 1.05-5.62, for 1 g/l decrease, p=0.0388).

CONCLUSIONS

In our trauma cohort BMI seems to significantly influence fibrinogen level at admission. This result draws our attention to the possible differences of haemostasis process, and consequently different diagnostic and therapeutic thresholds in the management of obese trauma patients. Moderate hypofibrinogenaemia increases transfusion risk and beside ISS might be a prognostic factor of early MOF after multiple injuries.

Systematic reviews of scores and predictors to trigger activation of massive transfusion protocols

BACKGROUND

The use of massive transfusion protocols (MTPs) in the resuscitation of hemorrhaging trauma patients ensures rapid delivery of blood products to improve outcomes, where the decision to trigger MTPs early is important. Scores and tools to predict the need for MTP activation have been developed for use to aid with clinical judgment. We performed a systematic review to assess (1) the scores and tools available to predict MTP in trauma patients, (2) their clinical value and diagnostic accuracies, and (3) additional predictors of MTP.

METHODS

MEDLINE, EMBASE, and CENTRAL were searched from inception to June 2017. All studies that utilized scores or predictors of MTP activation in adult (age, ≥18 years) trauma patients were included. Data collection for scores and tools included reported sensitivities and specificities and accuracy as defined by the area under the curve of the receiver operating characteristic.

RESULTS

Forty-five articles were eligible for analysis, with 11 validated and four unvalidated scores and tools assessed. Of four scores using clinical assessment, laboratory values, and ultrasound assessment the modified Traumatic Bleeding Severity Score had the best performance. Of those scores, the Trauma Associated Severe Hemorrhage score is most well validated and has higher area under the curve of the receiver operating characteristic than the Assessment of Blood Consumption and Prince of Wales scores. Without laboratory results, the Assessment of Blood Consumption score balances accuracy with ease of use. Without ultrasound use, the Vandromme and Schreiber scores have the highest accuracy and sensitivity respectively. The Shock Index uses clinical assessment only with fair performance. Other clinical variables, laboratory values, and use of point-of-care testing results were identified predictors of MTP activation.

CONCLUSION

The use of scores or tools to predict MTP need to be individualized to hospital resources and skill set to aid clinical judgment. Future studies for triggering nontrauma MTP activations are needed.

LEVEL OF EVIDENCE

Systematic review, level III.

Impact of pathologic body composition assessed by CT-based anthropometric measurements in adult patients with multiple trauma: a retrospective analysis

PURPOSE

In recent years, there has been mounting evidence on the clinical importance of body composition, particularly obesity and sarcopenia, in various patient populations. However, the relevance of these pathologic conditions remains controversial, especially in the field of traumatology. Computed tomography-based measurements allow clinicians to gain a prompt and thorough assessment of fat and muscle compartments in trauma patients. Our aim was to investigate whether CT-based anthropometric parameters of fat and muscle tissues show correlations with key elements of pre-hospital and clinical care in an adult population with multiple trauma.

METHODS

In this retrospective analysis we searched our institutional records of the German Trauma Registry (TraumaRegister DGU^®) from January 2008 to May 2014. Included were 297 adult trauma patients with multiple trauma who underwent a whole-body CT-scan on admission and were treated in an ICU. We measured anthropometric determinants of abdominal core muscle and adipose tissue using the digital imaging software OsiriX™. Multivariate linear and logistic regression analyses were conducted to unveil potential correlations.

RESULTS

None of the obesity-linked anthropometric parameters were associated with longer pre-hospital or initial ED treatment times. Obese patients were less frequently intubated at the site of the accident. Patients with increased abdominal fat tissue received on average lower volumes during fluid resuscitation in the pre-hospital phase but were not more often in shock on admission. During ED treatment, fluid resuscitation and transfusion volumes were not affected by abdominal fat tissue, although transfusion rates were higher in the obese. Furthermore, damage control surgeries took place less frequently in patients with increased abdominal fat tissue markers. Obesity parameters did not affect the prevalence of sepsis, although increased abdominal fat was associated with higher white blood cell counts on admission. Finally, there was no statistically significant correlation between sarcopenia or obesity markers and duration of mechanical ventilation, ICU length of stay or neurologic outcome.

CONCLUSION

CT-based assessment of abdominal fat and muscle mass is a simple method in revealing pathologic body composition in trauma patients. Our study suggests that obesity influences pre-hospital and ED treatment and early immune response in multiple trauma. Nevertheless, we could not demonstrate any significant effect of abdominal fat and muscle tissue parameters on the course of treatment, in particular the duration of mechanical ventilation, ICU length of stay and neurologic outcome.

Obesity May Not be Protective in Abdominal Stab Wounds

Context:

Current protocols for the management of abdominal stab wounds were established based on retrospective data from prior decades. Few have investigated whether higher body mass index (BMI) affects outcomes after these injuries.

Aim:

The aim was to determine the effects of obesity on outcomes in abdominal stab wound patients.

Setting and Design:

This was a retrospective cohort study at a Level I university-associated trauma center in the United States.

Materials and Methods:

We reviewed medical records of 100 adult patients admitted to our trauma center with abdominal stab wounds. Demographics, types of internal organ injury, gastrointestinal (GI) resection and repair, mortality, length of hospital stay (LOS), units of blood transfused within 24 h of admission, need and indications for exploratory laparotomy, surgical site infections (SSI), and need for re-operation were compared between obese and nonobese patients.

Statistical Analysis:

Categorical and continuous outcome variables were compared between the two groups using Chi-squared and independent-samples t-tests, respectively. BMI was evaluated as a predictor of outcomes using univariate and multivariate logistic regression.

Results:

Records of 100 adult abdominal stab wound patients were reviewed. Twenty-five patients were obese. The obese group was older (38.76 vs. 31.23, P = 0.018). Rates of therapeutic laparotomy were similar between obese and nonobese patients (20 [80.00%] vs. 64 [85.33%]). Obesity was associated with longer LOS (9.6 vs. 6.5, P = 0.026). In the multivariate analysis, increasing BMI was an independent predictor of need for GI resection (odds ratio: 1.10 [1.02–1.18], P = 0.018). One patient from the obese group died.

Conclusions:

Obese patients with abdominal stab wounds have longer LOS than nonobese patients. Increasing BMI was an independent predictor of need for GI resection.

[Preoperative risk and perioperative management of obese patients]

The obese patient is at an increased risk of perioperative complications. Most importantly, these include difficult access to the airways (intubation, difficult or impossible ventilation), and post-extubation respiratory distress secondary to the development of atelectasis or obstruction of the airways, sometimes associated with the use of morphine derivatives. The association of obstructive sleep apnea syndrome (OSA) with obesity is very common, and induces a high risk of peri- and postoperative complications. Preoperative OSA screening is crucial in the obese patient, as well as its specific management: use of continuous positive pre, per and postoperative pressure. For any obese patient, the implementation of protocols for mask ventilation and/or difficult intubation and the use of protective ventilation, morphine-sparing strategies and a semi-seated positioning throughout the care, is recommended, combined with close monitoring postoperatively. The dosage of anesthetic drugs should be based on the theoretical ideal weight and then titrated, rather than dosed to the total weight. Monitoring of neuromuscular blocking should be used where appropriate, as well as monitoring of the depth of anesthesia. The occurrence of intraoperative recall is indeed more frequent in the obese patient than in the non-obese patient. Appropriate prophylaxis against venous thromboembolic disease and early mobilization are recommended, as thromboembolic disease is increased in the obese patient. The use of non-invasive ventilation to prevent the occurrence of acute post-operative respiratory failure and for its treatment is particularly effective in obese patients. In case of admission to ICU, an individualized ventilatory management based on pathophysiology and careful monitoring should be initiated.

Shock parameters and shock index during severe post-partum haemorrhage and implications for management: a clinical study

The aim of this study was to report the association between shock severity, laboratory parameters and treatment in patients with severe post-partum haemorrhage (PPH) requiring the transfusion of ≥4 blood unit. Patients were divided into two groups: (1) conservative therapy and (2) emergency post-partum hysterectomy. The aggressive decision was always shared by two consultants. Out of 26,094 deliveries, severe PPH occurred in 34 (0.13%) women, emergency post-partum hysterectomy was required in 13 (0.05%), while 21 (0.08%) were treated conservatively. Grade of shock, shock index (SI) and the number of blood units transfused were significantly higher in the hysterectomy group. No statistically significant difference among the two groups was observed for haemoglobin and coagulation results. The severity of shock was associated with the therapeutic choice in the treatment of severe PPH. Therefore, grade of shock and SI should be taken into consideration by the leading obstetrician in the decision making process toward the emergency hysterectomy.Impact StatementWhat is already known on this subject? Primary post-partum haemorrhage (PPH) is the leading cause of maternal death in developing and industrialised countries. Emergency post-partum hysterectomy is considered a life-saving procedure performed when the women is experiencing a life-threatening haemorrhage.What the results of this study add? Therapeutic dichotomy between conservative and aggressive approach in severe PPH has not been defined, in particular emergency post-partum hysterectomy timing. Shock index (SI) has been proposed as an indicator of adverse maternal outcome. However, the association between shock parameters and advanced treatment modalities has not yet been reported. In our study, grade of shock, SI and the number of blood units transfused were significantly higher in the patients which needed hysterectomy suggesting that it may have a role in the decision making among conservative and aggressive treatment. No statistically significant difference was observed for haemoglobin and coagulation results.What the implications are of these findings for clinical practice and/or further research? Grade of shock and SI should be taken into consideration in the decision making process toward the emergency hysterectomy in severe PPH. The choice between conservative and aggressive treatment should be based on hemodynamic parameters that may represent, in more accurate way, the severity of blood loss. Nevertheless, these data need further confirmation in a larger study.

Application of a recursive partitioning decision tree algorithm for the prediction of massive transfusion in civilian trauma: the MTPitt prediction tool

BACKGROUND

A supervised machine learning algorithm was used to generate decision trees for the prediction of massive transfusion at a Level 1 trauma center.

METHODS

Trauma patients who received at least one unit of RBCs and/or low-titer group O whole blood between January 1, 2015, and December 31, 2017, were included. Massive transfusion was defined as the transfusion of 10 or more units of RBCs and/or low-titer group O whole blood in the first 24 hours of admission. A recursive partitioning algorithm was used to generate two decision trees for prediction of massive transfusion using a training data set (n = 550): the first, MTPitt, was based on demographic and clinical parameters, and the second, MTPitt+Labs, also included laboratory data. Decision tree performance was compared with the Assessment of Blood Consumption score and the Trauma Associated Severe Hemorrhage score.

RESULTS

The incidence of massive transfusion in the validation data set (n = 199) was 7.5%. The MTPitt decision tree had a higher balanced accuracy (81.4%) and sensitivity (86.7%) compared to an Assessment of Blood Consumption Score of 2 or higher (77.9% and 66.7%, respectively) and a Trauma Associated Severe Hemorrhage score of 9 or higher (75.0% and 73.3%, respectively), although the 95% confidence intervals overlapped. Addition of laboratory data to the MTPitt decision tree (MTPitt+Labs) resulted in a higher specificity and balanced accuracy compared to MTPitt without an increase in sensitivity.

CONCLUSIONS

The MTPitt decisions trees are highly sensitive tools for identifying patients who received a massive transfusion and do not require computational resources to be implemented in the trauma setting.

Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases

PURPOSE

The relation between driving pressure (plateau pressure-positive end-expiratory pressure) and mortality has never been studied in obese ARDS patients. The main objective of this study was to evaluate the relationship between 90-day mortality and driving pressure in an ARDS population ventilated in the intensive care unit (ICU) according to obesity status.

METHODS

We conducted a retrospective single-center study of prospectively collected data of all ARDS patients admitted consecutively to a mixed medical-surgical adult ICU from January 2009 to May 2017. Plateau pressure, compliance of the respiratory system (Crs) and driving pressure of the respiratory system within 24 h of ARDS diagnosis were compared between survivors and non-survivors at day 90 and between obese (body mass index ≥ 30 kg/m²) and non-obese patients. Cox proportional hazard modeling was used for mortality at day 90.

RESULTS

Three hundred sixty-two ARDS patients were included, 262 (72%) non-obese and 100 (28%) obese patients. Mortality rate at day 90 was respectively 47% (95% CI, 40-53) in the non-obese and 46% (95% CI, 36-56) in the obese patients. Driving pressure at day 1 in the non-obese patients was significantly lower in survivors at day 90 (11.9 ± 4.2 cmH₂O) than in non-survivors (15.2 ± 5.2 cmH₂O, p < 0.001). Contrarily, in obese patients, driving pressure at day 1 was not significantly different between survivors (13.7 ± 4.5 cmH₂O) and non-survivors (13.2 ± 5.1 cmH₂O, p = 0.41) at day 90. After three multivariate Cox analyses, plateau pressure [HR = 1.04 (95% CI 1.01-1.07) for each point of increase], Crs [HR = 0.97 (95% CI 0.96-0.99) for each point of increase] and driving pressure [HR = 1.07 (95% CI 1.04-1.10) for each point of increase], respectively, were independently associated with 90-day mortality in non-obese patients, but not in obese patients.

CONCLUSIONS

Contrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.

Diagnostic performance of prothrombin time point-of-care to detect acute traumatic coagulopathy on admission: experience of 522 cases in trauma center

BACKGROUND

Early identification of acute traumatic coagulopathy is a key challenge during initial management to determine whether to initiate early hemostatic support. We assessed the performance of prothrombin time (PT) at point-of-care in trauma patients to detect moderate and severe coagulopathy on admission.

STUDY DESIGN AND METHODS

All admitted consecutive trauma patients were analyzed retrospectively between April 2014 and July 2015. PT was measured on admission with both a PT point-of-care device (PTr-CGK) and a standard coagulation test (PTr-STD). The results for PTr-CGK and PTr-STD were compared using analysis of agreement, precision, and accuracy. The diagnostic performance of PTr-CGK to predict coagulopathy was established by analysis of receiver operating characteristic curves. The predictive performance of different thresholds and risk factors for misclassification were also studied.

RESULTS

Over a 16-month period, 522 patients were included. PTr-CGK estimated PTr-STD with a bias of 0.00 (95% confidence interval [CI], -0.48 to 0.50) and a precision of 0.25. The optimal threshold was 1.4 to predict severe coagulopathy (sensitivity 81% [95% CI, 68%-94%], negative predictive value 98% [95% CI, 97%-99%]), and 1.2 for moderate coagulopathy (sensitivity 80% [95% CI, 72%-88%], negative predictive value 94% [95% CI, 91%-96%]). A low PTr-CGK in the presence of severity criteria (Injury Severity Score ≥ 16, Trauma Associated Severe Hemorrhage score ≥ 12, hemoglobin level < 7 g/dL, fibrinogen level < 2 g/L, base deficit ≥ 6 mmol/L) was strongly associated with a false-negative risk.

CONCLUSIONS

The PT point-of-care device is reliable and accurate for the early identification of coagulopathic trauma patients.

Viscoelastic Tissue Plasminogen Activator Challenge Predicts Massive Transfusion in 15 Minutes

BACKGROUND

Coagulopathy is associated with massive transfusion in trauma, yet most clinical scores to predict this end point do not incorporate coagulation assays. Previous work has identified that shock increases circulating tissue plasminogen activator (tPA). When tPA levels saturate endogenous inhibitors, systemic hyperfibrinolysis can occur. Therefore, the addition of tPA to a patient's blood sample could stratify a patients underlying degree of shock and early coagulation changes to predict progression to massive transfusion. We hypothesized that a modified thrombelastography (TEG) assay with exogenous tPA would unmask patients' impending risk for massive transfusion.

STUDY DESIGN

Trauma activations were analyzed using rapid TEG and a modified TEG assay with a low and high dose of tPA. Clinical scores (shock index, assessment of blood consumption, and trauma-associated severe hemorrhage) were compared with TEG measurements to predict the need for massive transfusion using areas under the receiver operating characteristic curves.

RESULTS

Three hundred and twenty-four patients were analyzed, 17% required massive transfusion. Massive transfusion patients had a median shock index of 1.2, assessment of blood consumption score of 1, and trauma-associated severe hemorrhage score of 12. Rapid TEG and tPA TEG parameters were significantly different in all massive transfusion patients compared with non-massive transfusion patients (all p < 0.02). The low-dose tPA lysis at 30 minutes had the largest the area under the receiver operating characteristic curve (0.86; 95% CI 0.79 to 0.93) for prediction of massive transfusion, similar to international normalized ratio of prothrombin time of 0.86 (95% CI 0.81 to 0.91), followed by trauma-associated severe hemorrhage score (0.83; 95% CI 0.77 to 0.89). Combing trauma-associated severe hemorrhage and tPA-TEG variables results in a positive prediction of massive transfusion in 49% of patients with a 98% negative predictive value.

CONCLUSIONS

The tPA-TEG identifies trauma patients who require massive transfusion efficiently in a single assay that can be completed in a shorter time than other scoring systems, which has improved performance when combined with international normalized ratio. This new method is consistent with our understanding of the molecular events responsible for trauma-induced coagulopathy.

Demand for specialised training for the obese trauma patient: National ATLS expert group survey results

BACKGROUND

The growing incidence of obesity in Western populations continues to place new stressors on health systems. Obese trauma patients present particular challenges across the entirety of the patient care pathway, and are at risk of higher lengths of stay, morbidity, and mortality. This study sought to assess a national group of trauma experts' opinions and knowledge regarding the management of obese trauma.

METHODS

A questionnaire was circulated to a trauma training providers and national steering committee members at a UK national Advance Trauma Life Support meeting. Demographic, knowledge, and opinion data was collected and collated for analysis.

RESULTS

109 questionnaires were returned (73% response rate). Broad agreement was reached that obese trauma patients were more challenging to manage (96.2% agreement) and suffered worse outcomes (89.9%). Only 22.2% felt their hospitals possessed appropriate resources to facilitate management. Up to a third of respondents had personally witnesses errors in care due to patient obesity. 90% believed specialist training for obese trauma could improve care.

DISCUSSION

There is broad consensus amongst UK trauma providers that obese trauma patients are at risk of poorer outcomes and errors in care. Knowledge and preparedness of centres to manage these patients is variable. There was broad consensus that specialist training for the management of obese trauma patients may improve outcomes.