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Yamamoto R, Maeshima K, Funabiki T, Eastridge BJ, Cestero RF, Sasaki J. Immediate Angiography and Decreased In-Hospital Mortality of Adult Trauma Patients: A Nationwide Study. Cardiovasc Intervent Radiol 2024; 47:472-480. [PMID: 38332119 DOI: 10.1007/s00270-024-03664-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/11/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE This study aimed to elucidate whether immediate angiography within 30 min is associated with lower in-hospital mortality compared with non-immediate angiography. MATERIALS AND METHODS We conducted a retrospective cohort study using a nationwide trauma databank (2019-2020). Adult trauma patients who underwent emergency angiography within 12 h after hospital arrival were included. Patients who underwent surgery before angiography were excluded. Immediate angiography was defined as one performed within 30 min after arrival (door-to-angio time ≤ 30 min). In-hospital mortality and non-operative management (NOM) failure were compared between patients with immediate and non-immediate angiography. Inverse probability weighting with propensity scores was conducted to adjust patient demographics, injury mechanism and severity, vital signs on hospital arrival, and resuscitative procedures. A restricted cubic spline curve was drawn to reveal survival benefits by door-to-angio time. RESULTS Among 1,455 patients eligible for this study, 92 underwent immediate angiography. Angiography ≤ 30 min was associated with decreased in-hospital mortality (5.0% vs 11.1%; adjusted odds ratio [OR], 0.42 [95% CI, 0.31-0.56]; p < 0.001), as well as lower frequency of NOM failure: thoracotomy and laparotomy after angiography (0.8% vs. 1.8%; OR, 0.44 [0.22-0.89] and 2.6% vs. 6.5%; OR, 0.38 [0.26-0.56], respectively). The spline curve showed a linear association between increasing mortality and prolonged door-to-angio time in the initial 100 min after arrival. CONCLUSION In trauma patients, immediate angiography ≤ 30 min was associated with lower in-hospital mortality and fewer NOM failures. LEVEL OF EVIDENCE Level 3b, non randomized controlled cohort/follow up study.
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Affiliation(s)
- Ryo Yamamoto
- Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Katsuya Maeshima
- Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Tomohiro Funabiki
- Department of Emergency Medicine, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
| | - Ramon F Cestero
- Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
| | - Junichi Sasaki
- Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Mazzei M, Donohue JK, Schreiber M, Rowell S, Guyette FX, Cotton B, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Brown JB, Neal MD, Sperry JL. Prehospital tranexamic acid is associated with a survival benefit without an increase in complications: results of two harmonized randomized clinical trials. J Trauma Acute Care Surg 2024:01586154-990000000-00670. [PMID: 38523128 DOI: 10.1097/ta.0000000000004315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Recent randomized clinical trials have demonstrated that prehospital tranexamic acid (TXA) administration following injury is safe and improves survival. However, the effect of prehospital TXA on adverse events, transfusion requirements and any dose response relationships require further elucidation. METHODS A secondary analysis was performed using harmonized data from two large, double-blinded, randomized prehospital TXA trials. Outcomes, including 28-day mortality, pertinent adverse events and 24-hour red cell transfusion requirements were compared between TXA and placebo groups. Regression analyses were utilized to determine the independent associations of TXA after adjusting for study enrollment, injury characteristics and shock severity across a broad spectrum of injured patients. Dose response relationships were similarly characterized based upon grams of prehospital TXA administered. RESULTS A total of 1744 patients had data available for secondary analysis and were included in the current harmonized secondary analysis. The study cohort had an overall mortality of 11.2% and a median injury severity score of 16 (IQR: 5-26). TXA was independently associated with a lower risk of 28-day mortality (HR: 0.72, 95% CI 0.54, 0.96, p = 0.03). Prehospital TXA also demonstrated an independent 22% lower risk of mortality for every gram of prehospital TXA administered (HR: 0.78, 95% CI 0.63, 0.96, p = 0.02). Multivariable linear regression verified that patients who received TXA were independently associated with lower 24-hour red cell transfusion requirements (β: -0.31, 95% CI -0.61, -0.01, p = 0.04) with a dose-response relationship (β: -0.24, 95% CI -0.45, -0.02, p = 0.03). There was no independent association of prehospital TXA administration on VTE, seizure, or stroke. CONCLUSIONS In this secondary analysis of harmonized data from two large randomized interventional trials, prehospital TXA administration across a broad spectrum of injured patients is safe. Prehospital TXA is associated with a significant 28-day survival benefit, lower red cell transfusion requirements at 24 hours and demonstrates a dose-response relationship. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
| | | | - Martin Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Susan Rowell
- Department of Surgery, University of Chicago, Chicago, IL
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bryan Cotton
- Department of Surgery, University of Texas Health Houston, Houston, TX
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Donohue JK, Iyanna N, Lorence JM, Brown JB, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL. Missingness matters: a secondary analysis of thromboelastography measurements from a recent prehospital randomized tranexamic acid clinical trial. Trauma Surg Acute Care Open 2024; 9:e001346. [PMID: 38375027 PMCID: PMC10875568 DOI: 10.1136/tsaco-2023-001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Background Tranexamic acid (TXA) has been hypothesized to mitigate coagulopathy in patients after traumatic injury. Despite previous prehospital clinical trials demonstrating a TXA survival benefit, none have demonstrated correlated changes in thromboelastography (TEG) parameters. We sought to analyze if missing TEG data contributed to this paucity of findings. Methods We performed a secondary analysis of the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport Trial. We compared patients that received TEG (YES-TEG) and patients unable to be sampled (NO-TEG) to analyze subgroups in which to investigate TEG differences. TEG parameter differences across TXA intervention arms were assessed within subgroups disproportionately present in the NO-TEG relative to the YES-TEG cohort. Generalized linear models controlling for potential confounders were applied to findings with p<0.10 on univariate analysis. Results NO-TEG patients had lower prehospital systolic blood pressure (SBP) (100 (78, 140) vs 125 (88, 147), p<0.01), lower prehospital Glascow Coma Score (14 (3, 15) vs 15 (12, 15), p<0.01), greater rates of prehospital intubation (39.4% vs 24.4%, p<0.01) and greater mortality at 30 days (36.4% vs 6.8%, p<0.01). NO-TEG patients had a greater international normalized ratio relative to the YES-TEG subgroup (1.2 (1.1, 1.5) vs 1.1 (1.0, 1.2), p=0.04). Within a severe prehospital shock cohort (SBP<70), TXA was associated with a significant decrease in clot lysis at 30 min on multivariate analysis (β=-27.6, 95% CI (-51.3 to -3.9), p=0.02). Conclusions Missing data, due to the logistical challenges of sampling certain severely injured patients, may be associated with a lack of TEG parameter changes on TXA administration in the primary analysis. Previous demonstration of TXA's survival benefit in patients with severe prehospital shock in tandem with the current findings supports the notion that TXA acts at least partially by improving clot integrity. Level of evidence Level II.
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Affiliation(s)
- Jack K Donohue
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nidhi Iyanna
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John M Lorence
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Frances X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Terence O'Keeffe
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Donohue JK, Gruen DS, Iyanna N, Lorence JM, Brown JB, Guyette FX, Daley BJ, Eastridge BJ, Miller RS, Nirula R, Harbrecht BG, Claridge JA, Phelan HA, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Billiar TR, Sperry JL. Mechanism matters: mortality and endothelial cell damage marker differences between blunt and penetrating traumatic injuries across three prehospital clinical trials. Sci Rep 2024; 14:2747. [PMID: 38302619 PMCID: PMC10834504 DOI: 10.1038/s41598-024-53398-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/31/2024] [Indexed: 02/03/2024] Open
Abstract
Injury mechanism is an important consideration when conducting clinical trials in trauma. Mechanisms of injury may be associated with differences in mortality risk and immune response to injury, impacting the potential success of the trial. We sought to characterize clinical and endothelial cell damage marker differences across blunt and penetrating injured patients enrolled in three large, prehospital randomized trials which focused on hemorrhagic shock. In this secondary analysis, patients with systolic blood pressure < 70 or systolic blood pressure < 90 and heart rate > 108 were included. In addition, patients with both blunt and penetrating injuries were excluded. The primary outcome was 30-day mortality. Mortality was characterized using Kaplan-Meier and Cox proportional-hazards models. Generalized linear models were used to compare biomarkers. Chi squared tests and Wilcoxon rank-sum were used to compare secondary outcomes. We characterized data of 696 enrolled patients that met all secondary analysis inclusion criteria. Blunt injured patients had significantly greater 24-h (18.6% vs. 10.7%, log rank p = 0.048) and 30-day mortality rates (29.7% vs. 14.0%, log rank p = 0.001) relative to penetrating injured patients with a different time course. After adjusting for confounders, blunt mechanism of injury was independently predictive of mortality at 30-days (HR 1.84, 95% CI 1.06-3.20, p = 0.029), but not 24-h (HR 1.65, 95% CI 0.86-3.18, p = 0.133). Elevated admission levels of endothelial cell damage markers, VEGF, syndecan-1, TM, S100A10, suPAR and HcDNA were associated with blunt mechanism of injury. Although there was no difference in multiple organ failure (MOF) rates across injury mechanism (48.4% vs. 42.98%, p = 0.275), blunt injured patients had higher Denver MOF score (p < 0.01). The significant increase in 30-day mortality and endothelial cell damage markers in blunt injury relative to penetrating injured patients highlights the importance of considering mechanism of injury within the inclusion and exclusion criteria of future clinical trials.
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Affiliation(s)
- Jack K Donohue
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Danielle S Gruen
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nidhi Iyanna
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - John M Lorence
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | | | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Jeffrey A Claridge
- Department of Surgery, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy R Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA.
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Gruen DS, Brown JB, Guyette FX, Johansson PI, Stensballe J, Li SR, Leeper CM, Eastridge BJ, Nirula R, Vercruysse GA, O’Keeffe T, Joseph B, Neal MD, Sperry JL. Prehospital tranexamic acid is associated with a dose-dependent decrease in syndecan-1 after trauma: A secondary analysis of a prospective randomized trial. J Trauma Acute Care Surg 2023; 95:642-648. [PMID: 37125811 PMCID: PMC10615664 DOI: 10.1097/ta.0000000000003955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND In the Study of Tranexamic Acid During Air and Ground Prehospital Transport (STAAMP) Trial, prehospital tranexamic acid (TXA) was associated with lower mortality in specific patient subgroups. The underlying mechanisms responsible for a TXA benefit remain incompletely characterized. We hypothesized that TXA may mitigate endothelial injury and sought to assess whether TXA was associated with decreased endothelial or tissue damage markers among all patients enrolled in the STAAMP Trial. METHODS We collected blood samples from STAAMP Trial patients and measured markers of endothelial function and tissue damage including syndecan-1, soluble thrombomodulin (sTM), and platelet endothelial cell adhesion molecule-1 at hospital admission (0 hours) and 12 hours, 24 hours, and 72 hours after admission. We compared these marker values for patients in each treatment group during the first 72 hours, and modeled the relationship between TXA and marker concentration using regression analysis to control for potential confounding factors. RESULTS We analyzed samples from 766 patients: 383 placebo, 130 abbreviated dosing, 119 standard dosing, and 130 repeat dosing. Lower levels of syndecan-1, TM, and platelet endothelial cell adhesion molecule measured within the first 72 hours of hospital admission were associated with survival at 30 days ( p < 0.001). At hospital admission, syndecan-1 was lower in the TXA group (28.30 [20.05, 42.75] vs. 33.50 [23.00, 54.00] p = 0.001) even after controlling for patient, injury, and prehospital factors ( p = 0.001). For every 1 g increase in TXA administered over the first 8 hours of prehospital transport and hospital admission, there was a 4-ng/mL decrease in syndecan-1 at 12 hours controlling for patient, injury, and treatment factors ( p = 0.03). CONCLUSION Prehospital TXA was associated with decreased syndecan-1 at hospital admission. Syndecan-1 measured 12 hours after admission was inversely related to the dose of TXA received. Early prehospital and in-hospital TXA may decrease endothelial glycocalyx damage or upregulate vascular repair mechanisms in a dose-dependent fashion. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Lumbard DC, Nygaard RM, Richardson CJ, Liao LF, Stewart RM, Eastridge BJ, Nicholson SE. Burden of unintentional pediatric firearm injury: An examination of the Nationwide Readmission Database. J Trauma Acute Care Surg 2023; 95:419-425. [PMID: 37158803 DOI: 10.1097/ta.0000000000003930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Significant increases in firearm-related mortality in the US pediatric population drive an urgent need to study these injuries to drive prevention policies. The purpose of this study was (1) to characterize those with and without readmissions, (2) to identify risk factors for 90-day unplanned readmission, and (3) to examine reasons for hospital readmission. METHODS The 2016-2019 Nationwide Readmission Database of the Healthcare Cost and Utilization Project was used to identify hospital admissions with unintentional firearm injury in patients younger than 18 years. Ninety-day unplanned readmission characteristics were assessed and detailed. Multivariable regression analysis was used to assess factors associated with unplanned 90-day readmission. RESULTS Over 4 years, 1,264 unintentional firearm injury admissions resulted in 113 subsequent readmissions (8.9%). There were no significant differences in age or payor, but more women (14.7% vs. 23%) and older children (13-17 years [80.5%]) had readmissions. The mortality rate during primary hospitalization was 5.1%. Survivors of initial firearm injury were more frequently readmitted if they had a mental health diagnosis (22.1% vs. 13.8%; p = 0.017). Readmission diagnosis included complications (15%), mental health or drug/alcohol (9.7%), trauma (33.6%), a combination of the prior three (28.3%), and chronic disease (13.3%). More than a third (38.9%) of the trauma readmissions were for new traumatic injury. Female children, those with longer lengths of stay, and those with more severe injuries were more likely to have unplanned 90-day readmissions. Mental health and drug/alcohol abuse diagnoses were not an independent predictor for readmission. CONCLUSION This study provides insight into the characteristics of and risk factors for unplanned readmission in the pediatric unintentional firearm injury population. In addition to using prevention strategies, the utilization of trauma-informed care must be integrated into all aspects of care for this population to help minimize the long-term psychological impact of surviving firearm injury. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Derek C Lumbard
- From the Department of Surgery (D.C.L., R.M.N., C.J.R.), Hennepin Healthcare, Minneapolis, Minnesota. Department of Surgery (D.C.L., L.F.L., R.M.S., B.J.E., S.E.N.), UT Health San Antonio, San Antonio, Texas
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Kotwal RS, Janak JC, Howard JT, Rohrer AJ, Harcke HT, Holcomb JB, Eastridge BJ, Gurney JM, Shackelford SA, Mazuchowski EL. United States Military Fatalities During Operation Inherent Resolve and Operation Freedom's Sentinel. Mil Med 2023; 188:3045-3056. [PMID: 35544336 DOI: 10.1093/milmed/usac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/29/2022] [Accepted: 04/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts. METHODS A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%). CONCLUSIONS Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces.
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Affiliation(s)
- Russ S Kotwal
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jud C Janak
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
| | - Jeffrey T Howard
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Public Health, College for Health Community and Policy, One UTSA Circle, University of Texas, San Antonio, TX 78249, USA
| | - Andrew J Rohrer
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Armed Forces Medical Examiner System, Defense Health Agency, Dover Air Force Base, DE 19902, USA
| | - Howard T Harcke
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Armed Forces Medical Examiner System, Defense Health Agency, Dover Air Force Base, DE 19902, USA
| | - John B Holcomb
- Department of Surgery, University of Alabama, Birmingham, AL 35294, USA
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Jennifer M Gurney
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Burn Center and Research Directorate, United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
| | - Stacy A Shackelford
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Edward L Mazuchowski
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine (Kotwal), Department of Pathology (Rohrer, Mazuchowski), Department of Radiology (Harcke), Department of Surgery (Gurney, Shackelford), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Armed Forces Medical Examiner System, Defense Health Agency, Dover Air Force Base, DE 19902, USA
- Forensic Pathology Associates, HNL Lab Medicine, Allentown, PA 18109, USA
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Medrano NW, Villarreal CL, Price MA, Bixby PJ, Bulger EM, Eastridge BJ. Access to trauma center care: A statewide system-based approach. J Trauma Acute Care Surg 2023; 95:242-248. [PMID: 37158782 DOI: 10.1097/ta.0000000000004002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Timely access to specialized trauma care is a vital element in patient outcome after severe and critical injury requiring the skills of trauma teams in levels I and II trauma centers to avoid preventable mortality. We used system-based models to estimate timely access to care. METHODS Trauma system models consisted of ground emergency medical services, helicopter emergency medical services, and designated levels I to V trauma centers were constructed for five states. These models incorporated geographic information systems along with traffic data and census block group data to estimate population access to trauma care within the "golden hour." Trauma systems were further analyzed to identify the optimal location for an additional level I or II trauma center that would provide the greatest increase in access. RESULTS The population of the states studied totaled 23 million people, of which 20 million (87%) had access to a level I or II trauma center within 60 minutes. Statewide-specific access ranged from 60% to 100%. Including levels III to V trauma centers, access within 60 minutes increased to 22 million (96%), ranging from 95% to 100%. The addition of a levels I and II trauma center in an optimized location in each state would provide timely access to a higher trauma capability for an additional 1.1 million, increasing total access to approximately 21.1 million people (92%). CONCLUSION This analysis demonstrates that nearly universal access to trauma care is present in these states when including levels I to V trauma centers. However, concerning gaps remain in timely access to levels I and II trauma centers. This study provides an approach to determine more robust statewide estimates of access to care. It highlights the need for a national trauma system, one in which all components of state-managed trauma systems are assembled in a national data set to accurately identify gaps in care. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Nicolas W Medrano
- From the Coalition for National Trauma Research (N.W.M., C.L.V., M.A.P., P.J.B.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; and Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas
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Braverman MA, Schauer SG, Ciaraglia A, Brigmon E, Smith AA, Barry L, Bynum J, Cap AD, Corral H, Fisher AD, Epley E, Jonas RB, Shiels M, Waltman E, Winckler C, Eastridge BJ, Stewart RM, Nicholson SE, Jenkins DH. The impact of prehospital whole blood on hemorrhaging trauma patients: A multi-center retrospective study. J Trauma Acute Care Surg 2023; 95:191-196. [PMID: 37012617 DOI: 10.1097/ta.0000000000003908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Whole blood (WB) use has become increasingly common in trauma centers across the United States for both in-hospital and prehospital resuscitation. We hypothesize that prehospital WB (pWB) use in trauma patients with suspected hemorrhage will result in improved hemodynamic status and reduced in-hospital blood product requirements. METHODS The institutional trauma registries of two academic level I trauma centers were queried for all patients from 2015-2019 who underwent transfusion upon arrival to the trauma bay. Patients who were dead on arrival or had isolated head injuries were excluded. Demographics, injury and shock characteristics, transfusion requirements, including massive transfusion protocol (MTP) (>10 U in 24 hours) and rapid transfusion (CAT3+) and outcomes were compared between pWB and non-pWB patients. Significantly different demographic, injury characteristics and pWB were included in univariate followed by stepwise logistic regression analysis to determine the relationship with shock index (SI). Our primary objective was to determine the relationship between pWB and improved hemodynamics or reduction in blood product utilization. RESULTS A total of 171 pWB and 1391 non-pWB patients met inclusion criteria. Prehospital WB patients had a lower median Injury Severity Score (17 vs. 21, p < 0.001) but higher prehospital SI showing greater physiologic disarray. Prehospital WB was associated with improvement in SI (-0.04 vs. 0.05, p = 0.002). Mortality and (LOS) were similar. Prehospital WB patients received fewer packed red blood cells, fresh frozen plasma, and platelets units across their LOS but total units and volumes were similar. Prehospital WB patients had fewer MTPs (22.6% vs. 32.4%, p = 0.01) despite a similar requirement of CAT3+ transfusion upon arrival. CONCLUSION Prehospital WB administration is associated with a greater improvement in SI and a reduction in MTP. This study is limited by its lack of power to detect a mortality difference. Prospective randomized controlled trials will be required to determine the true impact of pWB on trauma patients. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Maxwell A Braverman
- From the Department of Surgery (M.A.B., A.C., E.B., E.S., A.A.S., L.B., H.C., R.B.J., B.J.E., R.M.S., S.E.N., D.H.J.), UT Health San Antonio; Department of Emergency Medicine (S.G.S.), Brooke Army Medical Center, United States Army Institute of Surgical Research (S.G.S., A.D.C., J.B.), JBSA Fort Sam Houston; Department of Surgery (A.D.F.), University of New Mexico School of Medicine, Albuquerque, New Mexico; Southwest Texas Regional Advisory Council (E.E.); Trauma Services (M.S.), University Hospital; South Texas Blood & Tissue Center (E.W.); and Department of Emergency Health Sciences (C.W.), UT Health, San Antonio, Texas
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10
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Deeb AP, Guyette FX, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Eastridge BJ, Joseph B, Nirula R, Vercruysse GA, Sperry JL, Brown JB. Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. J Trauma Acute Care Surg 2023; 94:504-512. [PMID: 36728324 PMCID: PMC10038862 DOI: 10.1097/ta.0000000000003820] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable death after injury. Others have shown that delays in massive transfusion cooler arrival increase mortality, while prehospital blood product resuscitation can reduce mortality. Our objective was to evaluate if time to resuscitation initiation impacts mortality. METHODS We combined data from the Prehospital Air Medical Plasma (PAMPer) trial in which patients received prehospital plasma or standard care and the Study of Tranexamic Acid during Air and ground Medical Prehospital transport (STAAMP) trial in which patients received prehospital tranexamic acid or placebo. We evaluated the time to early resuscitative intervention (TERI) as time from emergency medical services arrival to packed red blood cells, plasma, or tranexamic acid initiation in the field or within 90 minutes of trauma center arrival. For patients not receiving an early resuscitative intervention, the TERI was calculated based on trauma center arrival as earliest opportunity to receive a resuscitative intervention and were propensity matched to those that did to account for selection bias. Mixed-effects logistic regression assessed the association of 30-day and 24-hour mortality with TERI adjusting for confounders. We also evaluated a subgroup of only patients receiving an early resuscitative intervention as defined above. RESULTS Among the 1,504 propensity-matched patients, every 1-minute delay in TERI was associated with 2% increase in the odds of 30-day mortality (adjusted odds ratio [aOR], 1.020; 95% confidence interval [CI], 1.006-1.033; p < 0.01) and 1.5% increase in odds of 24-hour mortality (aOR, 1.015; 95% CI, 1.001-1.029; p = 0.03). Among the 799 patients receiving an early resuscitative intervention, every 1-minute increase in TERI was associated with a 2% increase in the odds of 30-day mortality (aOR, 1.021; 95% CI, 1.005-1.038; p = 0.01) and 24-hour mortality (aOR, 1.023; 95% CI, 1.005-1.042; p = 0.01). CONCLUSION Time to early resuscitative intervention is associated with morality in trauma patients with hemorrhagic shock. Bleeding patients need resuscitation initiated early, whether at the trauma center in systems with short prehospital times or in the field when prehospital time is prolonged. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Andrew-Paul Deeb
- From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., J.B.B.), and Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville, Tennessee; Department of Surgery (R.S.M.), John Peter Smith Health Network, Fort Worth, Texas; Department of Surgery (B.G.H.), University of Louisville, Louisville, Kentucky;Department of Surgery (J.A.C.), MetroHealth Medical Center/Case Western Reserve University, Cleveland, Ohio; Department of Surgery (H.A.P.), Louisiana State University Health Sciences Center-New Orleans, New Orleans, Louisiana; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (B.J., G.A.V.), University of Arizona, Tucson, Arizona; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; Division of Trauma and General Surgery, Department of Surgery (J.L.S.), University of Pittsburgh, Pittsburgh, Pennsylvania
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11
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Medrano NW, Villarreal CL, Mann NC, Price MA, Nolte KB, MacKenzie EJ, Bixby P, Eastridge BJ. Activation and On-Scene Intervals for Severe Trauma EMS Interventions: An Analysis of the NEMSIS Database. PREHOSP EMERG CARE 2023; 27:46-53. [PMID: 35363117 DOI: 10.1080/10903127.2022.2053615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective: Time to care is a determinant of trauma patient outcomes, and timely delivery of trauma care to severely injured patients is critical in reducing mortality. Numerous studies have analyzed access to care using prehospital intervals from a Carr et al. meta-analysis of studies from 1975 to 2005. Carr et al.'s research sought to determine national mean activation and on-scene intervals for trauma patients using contemporary emergency medical services (EMS) records. Since the Carr et al. meta-analysis was published, the National Highway Traffic Safety Administration (NHTSA) created and refined the National Emergency Medical Services Information System (NEMSIS) database. We sought to perform a modern analysis of prehospital intervals to establish current standards and temporal patterns.Methods: We utilized NEMSIS to analyze EMS data of trauma patients from 2016 to 2019. The dataset comprises more than 94 million EMS records, which we filtered to select for severe trauma and stratified by type of transport and rurality to calculate mean activation and on-scene intervals. Furthermore, we explored the impact of basic life support (BLS) and advanced life support (ALS) of ground units on activation and on-scene time intervals.Results: Mean activation and on-scene intervals for ground transport were statistically different when stratified by rurality. Urban, suburban, and rural ground activation intervals were 2.60 ± 3.94, 2.88 ± 3.89, and 3.33 ± 4.58 minutes, respectively. On-scene intervals were 15.50 ± 10.46, 17.56 ± 11.27, and 18.07 ± 16.13 minutes, respectively. Mean helicopter transport activation time was 13.75 ± 7.44 minutes and on-scene time was 19.42 ± 16.09 minutes. This analysis provides an empirically defined mean for activation and on-scene times for trauma patients based on transport type and rurality. Results from this analysis proved to be significantly longer than the previous analysis, except for helicopter transport on-scene time. Shorter mean intervals were seen in ALS compared to BLS for activation intervals, however ALS on-scene intervals were marginally longer than BLS.Conclusions: With the increasing sophistication of geospatial technologies employed to analyze access to care, these intervals are the most accurate and up-to-date and should be included in access to care models.
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Affiliation(s)
| | | | - N Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Kurt B Nolte
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Ellen J MacKenzie
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Pam Bixby
- Coalition for National Trauma Research, San Antonio, Texas
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12
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Deeb AP, Hoteit L, Li S, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL, Brown JB. Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage. J Trauma Acute Care Surg 2022; 93:52-58. [PMID: 35393385 PMCID: PMC9233003 DOI: 10.1097/ta.0000000000003620] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage. METHODS We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders. RESULTS A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02). CONCLUSION For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Andrew-Paul Deeb
- From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., L.H., S.L., M.D.N., J.L.S., J.B.B.), Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; and Department of Surgery (G.A.V., T.O.K., B.J.), University of Arizona, Tucson, Arizona
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13
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Ciaraglia AV, Convertino VA, Johnson MC, DeRosa M, Nicholson SE, Eastridge BJ. Compensatory reserve and pulse character: Enhanced potential to predict urgency for transfusion and other life-saving interventions after traumatic injury. Transfusion 2022; 62 Suppl 1:S130-S138. [PMID: 35748680 DOI: 10.1111/trf.16972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Field triage of trauma patients requires timely assessment of physiologic status to determine resuscitative needs. Vital signs and rudimentary assessments such as pulse character (PC) are used by first responders to guide decision making. The compensatory reserve measurement (CRM) has demonstrated utility as an easily interpretable method for assessing patient status. We hypothesized that the ability to identify injured patients requiring transfusion and other life-saving interventions (LSI) using a measurement of pulse character could be enhanced by the addition of the CRM. METHODS We performed a prospective observational study on 300 trauma patients admitted to a level I trauma center. CRM was recorded continuously after device placement on arrival. Patient demographics, field and trauma resuscitation unit vital signs, therapeutic interventions, and outcomes were collected. A field SBP <100 mmHg was utilized as a surrogate for abnormal PC as previously validated. A patient with a CRM threshold value of <60% was considered clinically compromised with a risk of onset of decompensated shock. Data were analyzed to assess the capacity of CRM and pulse character separately or in combination to predict LSI defined as need for transfusion, intubation, tube thoracostomy, or operative/ angiographic hemorrhage control. RESULTS An improvement in the predictive capability for LSI, transfusion, or a composite outcome was demonstrated by the combination of CRM and PC compared to either measure alone. CONCLUSIONS Combining PC assessment with CRM has the potential to enhance the recognition of injured patients requiring life-saving intervention thus improving sensitivity of decision support for prehospital providers.
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Affiliation(s)
- Angelo V Ciaraglia
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Victor A Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Michael C Johnson
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Mark DeRosa
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Susannah E Nicholson
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Brian J Eastridge
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
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14
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Braverman MA, Smith AA, Ciaraglia AV, Radowsky JS, Schauer SG, Sams VG, Greebon LJ, Shiels MD, Jonas RB, Ngamsuntikul S, Waltman E, Epley E, Rose T, Bynum JA, Cap AP, Eastridge BJ, Stewart RM, Jenkins DH, Nicholson SE. The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage. Transfusion 2022; 62 Suppl 1:S80-S89. [PMID: 35748675 DOI: 10.1111/trf.16964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations.
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Affiliation(s)
| | - Allison A Smith
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Jason S Radowsky
- Department of Trauma and Acute Care Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Steven G Schauer
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Valerie G Sams
- Department of Trauma and Acute Care Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Leslie J Greebon
- Department of Pathology, UT Health San Antonio, San Antonio, Texas, USA
| | | | | | | | | | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Tracee Rose
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Andre P Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Donald H Jenkins
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
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15
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Yamamoto R, Alarhayem A, Muir MT, Jenkins DH, Eastridge BJ, Shapiro ML, Cestero RF. Gaining or wasting time? Influence of time to operating room on mortality after temporary hemostasis using resuscitative endovascular balloon occlusion of the aorta. Am J Surg 2022; 224:125-130. [DOI: 10.1016/j.amjsurg.2022.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 01/24/2022] [Accepted: 03/31/2022] [Indexed: 11/01/2022]
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16
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Qasim Z, Butler FK, Holcomb JB, Kotora JG, Eastridge BJ, Brohi K, Scalea TM, Schwab CW, Drew B, Gurney J, Jansen JO, Kaplan LJ, Martin MJ, Rasmussen TE, Shackelford SA, Bank EA, Braude D, Brenner M, Guyette FX, Joseph B, Hinckley WR, Sperry JL, Duchesne J. Selective Prehospital Advanced Resuscitative Care - Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage. Shock 2022; 57:7-14. [PMID: 34033617 DOI: 10.1097/shk.0000000000001816] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemorrhage, and particularly noncompressible torso hemorrhage remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.
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Affiliation(s)
- Zaffer Qasim
- Departments of Emergency Medicine and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank K Butler
- Uniformed Services University, Consultant in Tactical Combat Casualty Care, Joint Trauma System, San Antonio, Texas
| | - John B Holcomb
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph G Kotora
- Navy Medicine Readiness and Training Command, Naval Medical Forces Atlantic, Portsmouth, Virginia
| | - Brian J Eastridge
- Division of Trauma and Emergency General Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Karim Brohi
- Center for Trauma Sciences, Queen Mary, University of London, London, UK
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - C William Schwab
- Division of Traumatology and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendon Drew
- Joint Trauma System Committee on Tactical Combat Casualty Care, Camp Pendleton, California
| | - Jennifer Gurney
- US Army Institute of Surgical Research, Defense Committee on Trauma, Joint Trauma System, San Antonio, Texas
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lewis J Kaplan
- Division of Traumatology and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew J Martin
- Department of Surgery, Scripps Mercy Hospital, San Diego, California
| | - Todd E Rasmussen
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Stacy A Shackelford
- US Army Institute of Surgical Research, Defense Committee on Trauma, Joint Trauma System, San Antonio, Texas
| | - Eric A Bank
- Harris County Emergency Services District, Houston, Texas
| | - Darren Braude
- Division of Prehospital, Austere, and Disaster Medicine, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Megan Brenner
- Department of Surgery, University of California, Riverside, Riverside, California
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, The University of Arizona, Tucson, Arizona
| | - William R Hinckley
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jason L Sperry
- Section of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Juan Duchesne
- Division of Trauma, Acute Care, and Critical Care Surgery, Tulane University, New Orleans, Louisiana
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Zhu CS, Braverman M, Goddard S, McGinity AC, Pokorny D, Cotner-Pouncy T, Eastridge BJ, Epley S, Greebon LJ, Jonas RB, Liao L, Nicholson SE, Schaefer R, Stewart RM, Winckler CJ, Jenkins DH. Prehospital shock index and systolic blood pressure are highly specific for pediatric massive transfusion. J Trauma Acute Care Surg 2021; 91:579-583. [PMID: 33990534 DOI: 10.1097/ta.0000000000003275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While massive transfusion protocols (MTPs) are associated with decreased mortality in adult trauma patients, there is limited research on the impact of MTP on pediatric trauma patients. The purpose of this study was to compare pediatric trauma patients requiring massive transfusion with all other pediatric trauma patients to identify triggers for MTP activation in injured children. METHODS Using our level I trauma center's registry, we retrospectively identified all pediatric trauma patients from January 2015 to January 2018. Massive transfusion (MT) was defined as infusion of 40 mL/kg of blood products in the first 24 hours of admission. Patients missing prehospital vital sign data were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data, prehospital vital signs, prehospital transport times, and Injury Severity Scores. Statistical significance was determined using Mann-Whitney U test and χ2 test. p Values of less than 0.05 were considered significant. RESULTS Thirty-nine (1.9%) of the 2,035 pediatric patients met the criteria for MT. All-cause mortality in MT patients was 49% (19 of 39 patients) versus 0.01% (20 of 1996 patients) in non-MT patients. The two groups significantly differed in Injury Severity Score, prehospital vital signs, and outcome data.Both systolic blood pressure (SBP) of <100 mm Hg and shock index (SI) of >1.4 were found to be highly specific for MT with specificities of 86% and 92%, respectively. The combination of SBP of <100 mm Hg and SI of >1.4 had a specificity of 94%. The positive and negative predictive values of SBP of <100 mm Hg and SI of >1.4 in predicting MT were 18% and 98%, respectively. Based on positive likelihood ratios, patients with both SBP of <100 mm Hg and SI of >1.4 were 7.2 times more likely to require MT than patients who did not meet both of these vital sign criteria. CONCLUSION Pediatric trauma patients requiring early blood transfusion present with lower blood pressures and higher heart rates, as well as higher SIs and lower pulse pressures. We found that SI and SBP are highly specific tools with promising likelihood ratios that could be used to identify patients requiring early transfusion. LEVEL OF EVIDENCE Therapeutic/care management, level V.
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Affiliation(s)
- Caroline S Zhu
- From the Department of Trauma and Emergency Surgery (C.S.Z., M.B., S.G., A.C.M., B.J.E., R.B.J., L.L., S.E.N., R.M.S., D.H.J.), University of Texas Health Science Center, San Antonio, Texas; Trauma Surgery (D.P.), Naval Medical Center Camp Lejeune, Camp Lejeune, North Carolina; University Hospital in San Antonio (T.C.-P., S.E.), Trauma Services; Department of Pathology (L.J.G.), University of Texas Health Science Center; Southwest Texas Regional Advisory Council (R.S.); and Department of Emergency Health Sciences (C.J.W.), University of Texas Health Science Center, San Antonio, Texas
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18
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Braverman MA, Smith A, Pokorny D, Axtman B, Shahan CP, Barry L, Corral H, Jonas RB, Shiels M, Schaefer R, Epley E, Winckler C, Waltman E, Eastridge BJ, Nicholson SE, Stewart RM, Jenkins DH. Prehospital whole blood reduces early mortality in patients with hemorrhagic shock. Transfusion 2021; 61 Suppl 1:S15-S21. [PMID: 34269467 DOI: 10.1111/trf.16528] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion. STUDY DESIGN AND METHODS A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed. RESULTS A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05). DISCUSSION This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.
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Affiliation(s)
| | - Alison Smith
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Douglas Pokorny
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Benjamin Axtman
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Lauran Barry
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Hannah Corral
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Michael Shiels
- Trauma Services, University Hospital, San Antonio, Texas, USA
| | - Randall Schaefer
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Christopher Winckler
- Department of Emergency Health Services, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Donald H Jenkins
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
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Convertino VA, Johnson MC, Alarhayem A, Nicholson SE, Chung KK, DeRosa M, Eastridge BJ. Compensatory reserve detects subclinical shock with more expeditious prediction for need of life-saving interventions compared to systolic blood pressure and blood lactate. Transfusion 2021; 61 Suppl 1:S167-S173. [PMID: 34269439 DOI: 10.1111/trf.16494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/11/2021] [Accepted: 02/11/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION We conducted a prospective observational study on 205 trauma patients at a level I trauma facility to test the hypothesis that a compensatory reserve measurement (CRM) would identify higher risk for progression to shock and/or need a life-saving interventions (LSIs) earlier than systolic blood pressure (SBP) and blood lactate (LAC). METHODS A composite outcome metric included blood transfusion, procedural LSI, and mortality. Discrete measures assessed as abnormal (ab) were SBP <90 mmHg, CRM <60%, and LAC >2.0. A graded categorization of shock was defined as: no shock (normal [n] SBP [n-SBP], n-CRM, n-LAC); sub-clinical shock (ab-CRM, n-SBP, n-LAC); occult shock (n-SBP, ab-CRM, ab-LAC); or overt shock (ab-SBP, ab-CRM, ab-LAC). RESULTS Three patients displayed overt shock, 53 displayed sub-clinical shock, and 149 displayed no shock. After incorporating lactate into the analysis, 86 patients demonstrated no shock, 25 were classified as sub-clinical shock, 91 were classified as occult shock, and 3 were characterized as overt shock. Each shock subcategory revealed a graded increase requiring LSI and transfusion. Initial CRM was associated with progression to shock (odds ratio = 0.97; p < .001) at an earlier time than SBP or LAC. CONCLUSIONS Initial CRM uncovers a clinically relevant subset of patients who are not detected by SBP and LAC. Our results suggest CRM could be used to more expeditiously identify injured patients likely to deteriorate to shock, with requirements for blood transfusion or procedural LSI.
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Affiliation(s)
- Victor A Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA.,Department of Medicine and Surgery, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael C Johnson
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Abdul Alarhayem
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Susannah E Nicholson
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Kevin K Chung
- Department of Medicine and Surgery, Uniformed Services University, Bethesda, Maryland, USA
| | - Mark DeRosa
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Brian J Eastridge
- Division of Trauma and Emergency Surgery, UT Health San Antonio, San Antonio, Texas, USA
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Kotwal RS, Mazuchowski EL, Janak JC, Howard JT, Harcke HT, Holcomb JB, Eastridge BJ, Gurney JM, Shackelford SA. United States military fatalities during Operation New Dawn. J Trauma Acute Care Surg 2021; 91:375-383. [PMID: 34397956 DOI: 10.1097/ta.0000000000003268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Military operations vary by scope, purpose, and intensity, each having unique forces and actions to execute a mission. Evaluation of military operation fatalities guides current and future casualty care. METHODS A retrospective study was conducted of all US military fatalities from Operation New Dawn in Iraq, 2010 to 2011. Data were obtained from autopsies and other records. Population characteristics, manner of death, cause of death, and location of death were analyzed. All fatalities were evaluated for concomitant evidence of underlying atherosclerosis. Nonsuicide trauma fatalities were also reviewed for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS Of 74 US military Operation New Dawn fatalities (median age, 26 years; male, 98.6%; conventional forces, 100%; prehospital, 82.4%) the leading cause of death was injury (86.5%). The manner of death was primarily homicide (55.4%), followed by suicide (17.6%), natural (13.5%), and accident (9.5%). Fatalities were divided near evenly between combatants (52.7%) and support personnel (47.3%), and between battle injury (51.4%) and disease and nonbattle injury (48.6%). Natural and suicide death was higher (p < 0.01, 0.02) among support personnel who were older (p = 0.05) with more reserve/national guard personnel (p = 0.01). Total population prevalence of underlying atherosclerosis was 18.9%, with more among support personnel (64.3%). Of 46 nonsuicide trauma fatalities, most died of blast injury (67.4%) followed by gunshot wound (26.1%) and multiple/blunt force injury (6.5%). The leading mechanism of death was catastrophic tissue destruction (82.6%). Most had nonsurvivable injuries (82.6%) and nonpreventable deaths (93.5%). CONCLUSION Operation New Dawn fatalities were exclusively conventional forces divided between combatants and support personnel, the former succumbing more to battle injury and the latter to disease and nonbattle injury including self-inflicted injury. For nonsuicide trauma fatalities, none died from a survivable injury, and 17.4% died from potentially survivable injuries. Opportunities for improvement included providing earlier blood products and surgery. LEVEL OF EVIDENCE Therapeutic, level V and epidemiological, level IV.
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Affiliation(s)
- Russ S Kotwal
- From the Joint Trauma System (R.S.K., E.L.M., J.C.J., J.T.H., J.M.G., S.A.S.), Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas; Uniformed Services University (R.S.K., E.L.M., H.T.H., J.M.G., S.A.S.), Bethesda, Maryland; Texas A&M University (R.S.K.), College Station, Texas; Armed Forces Medical Examiner System (E.L.M., H.T.H.), Defense Health Agency, Dover Air Force Base, Delaware; University of Texas (J.T.H., B.J.E.), San Antonio, Texas; University of Alabama (J.B.H.), Birmingham, Alabama; and United States Army Institute of Surgical Research (J.M.G.), Joint Base San Antonio-Fort Sam Houston, Texas
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21
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Tadlock MD, Carr M, Diaz J, Rhee P, Cannon JW, Eastridge BJ, Morgan MM, Brink E, Shackelford SA, Gurney JM, Johannigman JA, Rizzo AG, Knudson MM, Galante JM. How to maintain the readiness of forward deployed caregivers. J Trauma Acute Care Surg 2021; 90:e87-e94. [PMID: 33405471 DOI: 10.1097/ta.0000000000003054] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew D Tadlock
- From the Department of Surgery (M.D.T., M.C., J.D.), Navy Medicine Readiness & Training Command, San Diego, California; Section of Trauma and Acute Care Surgery, Department of Surgery (P.R.), Westchester Medical Center-New York Medical College, Valhalla, New York; Department of Surgery (J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (M.M.M.), University of Colorado Health, Colorado Springs, Colorado; Department of Surgery (E.B.), Navy Medicine & Readiness Training Command, Camp Lejeune, North Carolina; Joint Trauma System, Defense Health Agency (S.A.S., J.M.G.), San Antonio, Texas; Department of Surgery (J.A.J.), University of Cincinnati, Cincinnati, Ohio; Inova Trauma Center (A.G.R.), Falls Church, Virginia; Military Health System Strategic Partnership with the American College of Surgeons University of California (M.M.K.); San Francisco, California; Military Health System Strategic Partnership with the American College of Surgeons (M.M.K.), Chicago, Illinois; and Department of Surgery (J.M.G.), University of California Davis Medical Center, Sacramento, California
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Riesberg JC, Gurney JM, Morgan M, Northern DM, Onifer DJ, Gephart WJ, Remley MA, Eickhoff E, Miller C, Eastridge BJ, Montgomery HR, Butler FK, Drew B. The Management of Abdominal Evisceration in Tactical Combat Casualty Care: TCCC Guideline Change 20-02. J Spec Oper Med 2021; 21:138-142. [PMID: 34969144 DOI: 10.55460/9u6s-1k7m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2021] [Indexed: 06/14/2023]
Abstract
Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration may be expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself. Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration. For abdominal evisceration injuries, the following principles of management apply: (1) Control any associated bleeding visible in the wound. (2) If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort. (3) Rinse the eviscerated bowel with clean fluid to reduce gross contamination. (4) Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available. (4) For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents. (6) If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal). (7) Do NOT FORCE contents back into abdomen or actively bleeding viscera. (8) Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself. (9) Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.
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Guyette FX, Brown JB, Zenati MS, Early-Young BJ, Adams PW, Eastridge BJ, Nirula R, Vercruysse GA, O’Keeffe T, Joseph B, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Forsythe RM, Rosengart MR, Billiar TR, Yealy DM, Peitzman AB, Sperry JL. Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial. JAMA Surg 2020; 156:2771225. [PMID: 33016996 PMCID: PMC7536625 DOI: 10.1001/jamasurg.2020.4350] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/13/2020] [Indexed: 12/14/2022]
Abstract
IMPORTANCE In-hospital administration of tranexamic acid after injury improves outcomes in patients at risk for hemorrhage. Data demonstrating the benefit and safety of the pragmatic use of tranexamic acid in the prehospital phase of care are lacking for these patients. OBJECTIVE To assess the effectiveness and safety of tranexamic acid administered before hospitalization compared with placebo in injured patients at risk for hemorrhage. DESIGN, SETTING, AND PARTICIPANTS This pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized clinical trial included injured patients with prehospital hypotension (systolic blood pressure ≤90 mm Hg) or tachycardia (heart rate ≥110/min) before arrival at 1 of 4 US level 1 trauma centers, within an estimated 2 hours of injury, from May 1, 2015, through October 31, 2019. INTERVENTIONS Patients received 1 g of tranexamic acid before hospitalization (447 patients) or placebo (456 patients) infused for 10 minutes in 100 mL of saline. The randomization scheme used prehospital and in-hospital phase assignments, and patients administered tranexamic acid were allocated to abbreviated, standard, and repeat bolus dosing regimens on trauma center arrival. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day all-cause mortality. RESULTS In all, 927 patients (mean [SD] age, 42 [18] years; 686 [74.0%] male) were eligible for prehospital enrollment (460 randomized to tranexamic acid intervention; 467 to placebo intervention). After exclusions, the intention-to-treat study cohort comprised 903 patients: 447 in the tranexamic acid arm and 456 in the placebo arm. Mortality at 30 days was 8.1% in patients receiving tranexamic acid compared with 9.9% in patients receiving placebo (difference, -1.8%; 95% CI, -5.6% to 1.9%; P = .17). Results of Cox proportional hazards regression analysis, accounting for site, verified that randomization to tranexamic acid was not associated with a significant reduction in 30-day mortality (hazard ratio, 0.81; 95% CI, 0.59-1.11, P = .18). Prespecified dosing regimens and post-hoc subgroup analyses found that prehospital tranexamic acid were associated with significantly lower 30-day mortality. When comparing tranexamic acid effect stratified by time to treatment and qualifying shock severity in a post hoc comparison, 30-day mortality was lower when tranexamic acid was administered within 1 hour of injury (4.6% vs 7.6%; difference, -3.0%; 95% CI, -5.7% to -0.3%; P < .002). Patients with severe shock (systolic blood pressure ≤70 mm Hg) who received tranexamic acid demonstrated lower 30-day mortality compared with placebo (18.5% vs 35.5%; difference, -17%; 95% CI, -25.8% to -8.1%; P < .003). CONCLUSIONS AND RELEVANCE In injured patients at risk for hemorrhage, tranexamic acid administered before hospitalization did not result in significantly lower 30-day mortality. The prehospital administration of tranexamic acid after injury did not result in a higher incidence of thrombotic complications or adverse events. Tranexamic acid given to injured patients at risk for hemorrhage in the prehospital setting is safe and associated with survival benefit in specific subgroups of patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02086500.
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Affiliation(s)
- Francis X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mazen S. Zenati
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barbara J. Early-Young
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter W. Adams
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian J. Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | | | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson
| | - Louis H. Alarcon
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Clifton W. Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew D. Neal
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raquel M. Forsythe
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew R. Rosengart
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy R. Billiar
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew B. Peitzman
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason L. Sperry
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
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Yamamoto R, Cestero RF, Muir MT, Jenkins DH, Eastridge BJ, Funabiki T, Sasaki J. Delays in Surgical Intervention and Temporary Hemostasis Using Resuscitative Endovascular Balloon Occlusion of the aorta (REBOA): Influence of Time to Operating Room on Mortality. Am J Surg 2020; 220:1485-1491. [PMID: 32739046 DOI: 10.1016/j.amjsurg.2020.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/08/2020] [Accepted: 07/16/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remain unclear. We hypothesized that patients who experience delays in surgical intervention would benefit from REBOA. METHODS Using the Japan Trauma Databank (2014-2019), patients transferred to the operating room (OR) within 3 h were identified. Patients treated with REBOA were matched with those without REBOA using propensity scores, and further divided based on the transfer time to OR: ≤ 1 h (early), 1-2 h (delayed), and >2 h (significantly-delayed). Survival to discharge was compared. RESULTS Among 5258 patients, 310 underwent REBOA. In 223 matched pairs, patients treated with REBOA had improved survival (56.5% vs. 31.8%; p < 0.01), although in-hospital mortality was reduced by REBOA only in the delayed and significantly-delayed subgroups (HR = 0.43 [0.28-0.65] and 0.42 [0.25-0.71]). CONCLUSIONS REBOA-treated trauma patients who experience delays in surgical intervention (>1 h) have improved survival.
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Affiliation(s)
- Ryo Yamamoto
- Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan; Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA.
| | - Ramon F Cestero
- Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
| | - Mark T Muir
- Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
| | - Donald H Jenkins
- Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
| | - Tomohiro Funabiki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumiku, Yokohama, Kanagawa, 230-8765, Japan
| | - Junichi Sasaki
- Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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25
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Alarhayem AQ, Rasmussen TE, Farivar B, Lim S, Braverman M, Hardy D, Jenkins DJ, Eastridge BJ, Cestero RF. Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular aortic repair era. J Vasc Surg 2020; 73:896-902. [PMID: 32682070 DOI: 10.1016/j.jvs.2020.05.079] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/20/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) is the preferred operative treatment of blunt thoracic aortic injuries (BTAIs). Its use is associated with improved outcomes compared with open surgical repair and nonoperative management. However, the optimal time from injury to repair is unknown and remains a subject of debate across different societal practice guidelines. The purpose of this study was to evaluate national trends in the management of BTAI, with a specific focus on the impact of timing of repair on outcomes. METHODS Using the National Trauma Data Bank, we identified adult patients with BTAI between 2012 and 2017. Patients with prehospital or emergency department cardiac arrest or incomplete data sets were excluded from analysis. Patients were classified according to timing of repair: group 1, <24 hours; and group 2, ≥24 hours. The primary outcome evaluated was in-hospital mortality; secondary outcomes included overall hospital and intensive care unit length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS The analysis was completed for 2821 patients who underwent TEVAR for BTAI with known operative times. The overall mortality in the patient cohort was 8.4% (238/2821); 75% of patients undergoing TEVAR were repaired within 24 hours. Mortality was more than twofold greater in group 1 compared with group 2 (9.8% [207/2118] vs 4.4% [31/703]; P = .001). This mortality benefit persisted across injury severity groups and was independent of the presence of serious extrathoracic injuries. Logistic regression analysis, adjusting for age ≥65 years, Glasgow Coma Scale score ≤8, systolic blood pressure ≤90 mm Hg at admission, and serious extrathoracic injuries, showed a higher adjusted mortality in group 1 (odds ratio, 2.54; 95% confidence interval, 1.66-3.91; P = .001). CONCLUSIONS The majority of patients with BTAI undergo endovascular repair within 24 hours of injury. Patients undergoing delayed repair have improved survival compared with those repaired within the first 24 hours of injury in spite of similar injury patterns and severity. In patients with BTAIs without signs of imminent rupture, delaying endovascular repair beyond 24 hours after injury should be considered.
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Affiliation(s)
| | - Todd E Rasmussen
- Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, Md.
| | - Behzad Farivar
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sungho Lim
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Max Braverman
- University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - David Hardy
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Donald J Jenkins
- University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Brian J Eastridge
- University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Ramon F Cestero
- University of Texas Health Science Center at San Antonio, San Antonio, Tex
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Goralnick E, Ezeibe C, Chaudhary MA, McCarty J, Herrera-Escobar JP, Andriotti T, de Jager E, Ospina-Delgado D, Goolsby C, Hunt R, Weissman JS, Haider A, Jacobs L, Andrade E, Brown J, Bulger EM, Butler FK, Callaway D, Caterson EJ, Choudhry NK, Davis MR, Eastman A, Eastridge BJ, Epstein JL, Evans CL, Gausche-Hill M, Gestring ML, Goldberg SA, Hanfling D, Holcomb JB, Jonson CO, King DR, Kivlehan S, Kotwal RS, Krohmer JR, Levy-Carrick N, Levy M, Meléndez Lugo JJ, Mooney DP, Neal MD, Niskanen R, O'Neill P, Park H, Pons PT, Prytz E, Rasmussen TE, Remley MA, Riviello R, Salim A, Shackelfold S, Smith ER, Stewart RM, Swaroop M, Ward K, Uribe-Leitz T, Jarman MP, Ortega G. Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement. JAMA Netw Open 2020; 3:e209393. [PMID: 32663307 DOI: 10.1001/jamanetworkopen.2020.9393] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. OBJECTIVE To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons. EVIDENCE REVIEW The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda. FINDINGS Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy. CONCLUSIONS AND RELEVANCE The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.
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Affiliation(s)
- Eric Goralnick
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chibuike Ezeibe
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin McCarty
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Juan P Herrera-Escobar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tomas Andriotti
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Craig Goolsby
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland
- National Center for Disaster Medicine and Public Health, Rockville, Maryland
| | - Richard Hunt
- National Health Care Preparedness Program, Department of Health and Human Services, Washington, DC
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Office of the Dean, Medical School, Aga Khan University, Karachi, Pakistan
| | - Lenworth Jacobs
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | | | - Erin Andrade
- Department of Surgery, Washington University in St Louis, Missouri
| | - Jeremy Brown
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC
| | | | - Frank K Butler
- Defense Health Agency, Joint Trauma System, Joint Base San Antonio-Fort Sam Houston, Texas
| | - David Callaway
- Department of Emergency Medicine, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
| | - Edward J Caterson
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Niteesh K Choudhry
- Center for Healthcare Delivery Sciences, Harvard Medical School, Boston, Massachusetts
| | - Michael R Davis
- Combat Casualty Care Research Program Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Alex Eastman
- Countering Weapons of Mass Destruction Office Department of Homeland Security, Washington, DC
| | - Brian J Eastridge
- Department of Surgery, The University of Texas Health Science Center at San Antonio
| | - Jonathan L Epstein
- Training Services Division, American Red Cross, American Red Cross, Washington, DC
| | - Conor L Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston
| | - Marianne Gausche-Hill
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Mark L Gestring
- Department of Surgery, Rochester Medical Center, Rochester, New York
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dan Hanfling
- Forum on Medical and Public Health Preparedness for Catastrophic Events, National Academies of Science, Washington, DC
| | | | - Carl-Oscar Jonson
- Center for Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - David R King
- Department of Surgery, Massachusetts General Hospital, Boston
| | - Sean Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Russ S Kotwal
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - Jon R Krohmer
- Office of Emergency Medical Services, National Highway Traffic Safety Administration, Washington, DC
| | - Nomi Levy-Carrick
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - David P Mooney
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Habeeba Park
- Department of Surgery, University of Maryland Shock Trauma Center, Baltimore
| | - Peter T Pons
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver
| | - Erik Prytz
- Department of Computer and Information Science, Linköping University, Linköping, Sweden
| | - Todd E Rasmussen
- Department of Surgery, F. Edward Hébert School of Medicine Uniformed Services University, Bethesda, Maryland
| | - Michael A Remley
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - Robert Riviello
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stacy Shackelfold
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - E Reed Smith
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC
| | - Ronald M Stewart
- Department of Surgery, The University of Texas Health Science Center at San Antonio
| | - Mamta Swaroop
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kevin Ward
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Biomedical Engineering, University of Michigan, Ann Arbor
| | | | - Molly P Jarman
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gezzer Ortega
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Braverman MA, Smith A, Shahan CP, Axtman B, Epley E, Hitchman S, Waltman E, Winckler C, Nicholson SE, Eastridge BJ, Stewart RM, Jenkins DH. From battlefront to homefront: creation of a civilian walking blood bank. Transfusion 2020; 60 Suppl 3:S167-S172. [PMID: 32478857 DOI: 10.1111/trf.15694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/17/2020] [Accepted: 01/17/2020] [Indexed: 01/24/2023]
Abstract
Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.
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Affiliation(s)
| | - Alison Smith
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | | | - Benjamin Axtman
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas
| | - Scott Hitchman
- Southwest Texas Regional Advisory Council, San Antonio, Texas
| | | | - Christopher Winckler
- Department of Emergency Health Services, UT Health San Antonio, San Antonio, Texas
| | | | | | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | - Donald H Jenkins
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
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28
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Burmeister DM, Johnson TR, Lai Z, Scroggins S, DeRosa M, Jonas RB, Zhu C, Scherer E, Stewart RM, Schwacha MG, Jenkins DH, Eastridge BJ, Nicholson SE. The gut microbiome distinguishes mortality in trauma patients upon admission to the emergency department. J Trauma Acute Care Surg 2020; 88:579-587. [PMID: 32039976 PMCID: PMC7905995 DOI: 10.1097/ta.0000000000002612] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients. METHODS We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and β-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses. RESULTS Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission β-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). β-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05). CONCLUSION Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- David M. Burmeister
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
| | | | - Zhao Lai
- Greehey Children’s Cancer Research Institute, UT Health San Antonio, San Antonio, Texas
- Department of Molecular Medicine, UT Health San Antonio, San Antonio, Texas
| | | | - Mark DeRosa
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | | | - Caroline Zhu
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | | | | | | | | | | | - Susannah E. Nicholson
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
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29
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Thompson P, Hudson AJ, Convertino VA, Bjerkvig C, Eliassen HS, Eastridge BJ, Irvine-Smith T, Braverman MA, Hellander S, Jenkins DH, Rappold JF, Gurney JM, Glassberg E, Cap AP, Aussett S, Apelseth TO, Williams S, Ward KR, Shackelford SA, Stroberg P, Vikeness BH, Pepe PE, Winckler CJ, Woolley T, Enbuske S, De Pasquale M, Boffard KD, Austlid I, Fosse TK, Asbjornsen H, Spinella PC, Strandenes G. Risk of Harm Associated With Using Rapid Sequence Induction Intubation and Positive Pressure Ventilation in Patients With Hemorrhagic Shock. J Spec Oper Med 2020; 20:97-102. [PMID: 32969011 DOI: 10.55460/q4g3-feqr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 06/11/2023]
Abstract
Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.
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30
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Zhu CS, Pokorny DM, Eastridge BJ, Nicholson SE, Epley E, Forcum J, Long T, Miramontes D, Schaefer R, Shiels M, Stewart RM, Stringfellow M, Summers R, Winckler CJ, Jenkins DH. Give the trauma patient what they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low-titer O+ whole blood. Transfusion 2019; 59:1429-1438. [PMID: 30980748 DOI: 10.1111/trf.15264] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/23/2019] [Accepted: 02/03/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured. MATERIALS AND METHODS Our regional trauma network (Southwest Texas Regional Advisory Council) developed and implemented a multiphased approach toward facilitating remote damage control resuscitation. This approach required placing low-titer O+ whole blood (LTO+ WB) at helicopter emergency medical service bases, transitioning hospital-based trauma resuscitation from component therapy to the use of whole blood, modifying select ground-based units to carry and administer whole blood at the scene of an accident, and altering the practices of our blood bank to support our new initiative. In addition, we had to provide information and training to an entire large urban emergency medical system regarding changes in policy. RESULTS Through a thorough, structured program we were able to successfully implement point-of-injury resuscitation with LTO+ WB. Preliminary evaluation of our first 25 patients has shown a marked decrease in mortality compared to our historic rate using component therapy or crystalloid solutions. Additionally, we have had zero transfusion reactions or seroconversions. CONCLUSION Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.
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Affiliation(s)
- Caroline S Zhu
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas
| | - Douglas M Pokorny
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas
| | - Brian J Eastridge
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas.,The Southwest Texas Regional Advisory Council, San Antonio, Texas
| | - Susannah E Nicholson
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas
| | - Eric Epley
- The Southwest Texas Regional Advisory Council, San Antonio, Texas
| | | | - Tasia Long
- The Southwest Texas Regional Advisory Council, San Antonio, Texas
| | - David Miramontes
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas.,The Southwest Texas Regional Advisory Council, San Antonio, Texas
| | - Randall Schaefer
- The Southwest Texas Regional Advisory Council, San Antonio, Texas
| | - Michael Shiels
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas
| | - Ronald M Stewart
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas.,The Southwest Texas Regional Advisory Council, San Antonio, Texas
| | | | - Rena Summers
- The Southwest Texas Regional Advisory Council, San Antonio, Texas
| | - Christopher J Winckler
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas.,The Southwest Texas Regional Advisory Council, San Antonio, Texas.,San Antonio Office of the Medical Director, San Antonio, Texas
| | - Donald H Jenkins
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas.,The Southwest Texas Regional Advisory Council, San Antonio, Texas.,San Antonio Office of the Medical Director, San Antonio, Texas
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31
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Pokorny DM, Braverman MA, Edmundson PM, Bittenbinder DM, Zhu CS, Winckler CJ, Schaefer R, McGinity AC, Epley E, Eastridge BJ, Nicholson SE, Stewart RM, Jenkins DH. The use of prehospital blood products in the resuscitation of trauma patients: a review of prehospital transfusion practices and a description of our regional whole blood program in San Antonio,
TX. ACTA ACUST UNITED AC 2019. [DOI: 10.1111/voxs.12498] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Douglas M. Pokorny
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
| | - Maxwell A. Braverman
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
| | - Philip M. Edmundson
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
| | - David M. Bittenbinder
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
| | - Caroline S. Zhu
- The University of Texas Health Science Center San Antonio TX USA
| | - Christopher J. Winckler
- The University of Texas Health Science Center San Antonio TX USA
- Department of Emergency Health Sciences The University of Texas Health Science Center San AntonioTX USA
- Department of Emergency Medicine The University of Texas Health Science Center, San AntonioTX USA
- Southwest Texas Regional Advisory Council San AntonioTX USA
| | - Randall Schaefer
- Department of Emergency Medicine The University of Texas Health Science Center, San AntonioTX USA
| | - Ashley C. McGinity
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
| | - Eric Epley
- Southwest Texas Regional Advisory Council San AntonioTX USA
| | - Brian J. Eastridge
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
- Southwest Texas Regional Advisory Council San AntonioTX USA
| | - Susannah E. Nicholson
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
| | - Ronald M. Stewart
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
- Southwest Texas Regional Advisory Council San AntonioTX USA
| | - Donald H. Jenkins
- The University of Texas Health Science Center San Antonio TX USA
- Department of Surgery The University of Texas Health Science Center San Antonio TX USA
- Southwest Texas Regional Advisory Council San AntonioTX USA
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32
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Zhu CS, Cobb D, Jonas RB, Pokorny D, Rani M, Cotner-Pouncy T, Oliver J, Cap A, Cestero R, Nicholson SE, Eastridge BJ, Jenkins DH. Shock index and pulse pressure as triggers for massive transfusion. J Trauma Acute Care Surg 2019; 87:S159-S164. [PMID: 31246921 DOI: 10.1097/ta.0000000000002333] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Hemorrhage is the most common cause of preventable death in trauma patients. These mortalities might be prevented with prehospital transfusion. We sought to characterize injured patients requiring massive transfusion to determine the potential impact of a prehospital whole blood transfusion program. The primary goal of this analysis was to determine a method to identify patients at risk of massive transfusion in the prehospital environment. Many of the existing predictive models require laboratory values and/or sonographic evaluation of the patient after arrival at the hospital. Development of an algorithm to predict massive transfusion protocol (MTP) activation could lead to an easy-to-use tool for prehospital personnel to determine when a patient needs blood transfusion. METHODS Using our Level I trauma center's registry, we retrospectively identified all adult trauma patients from January 2015 to August 2017 requiring activation of the MTP. Patients who were younger than 18 years, older than 89 years, prisoners, pregnant women, and/or with nontraumatic hemorrhage were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data (survival, length of stay, intensive care unit days, ventilator days), prehospital vital signs, prehospital transport times, and Injury Severity Score. The independent-samples t test and χ test were used to compare the group who died to the group who survived. p < 0.05 was considered significant. Based on age and mechanism of injury, relative risk of death was calculated. Graphs were generated using Microsoft Excel software to plot patient variables. RESULTS Our study population of 102 MTP patients had an average age of 42 years and average Injury Severity Score of 29, consisted of 80% males (82/102), and was 66% blunt trauma (67/102). The all-cause mortality was 67% (68/102). The positive predictive value of death for patients with pulse pressure of less than 45 and shock index of greater than 1 was 0.78 for all patients, but was 0.79 and 0.92 for blunt injury and elderly patients, respectively. CONCLUSIONS Our data demonstrate a high mortality rate in trauma patients who require MTP despite short transport times, indicating the need for early intervention in the prehospital environment. Given our understanding that the most severely injured patients in hemorrhagic shock require blood resuscitation, this study demonstrates that this subset of trauma patients requiring massive transfusion can be identified in the prehospital setting. We recommend using Emergency Medical Services pulse pressure in combination with shock index to serve as a trigger for initiation of prehospital whole blood transfusion. LEVEL OF EVIDENCE Therapeutic/care management, level V.
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Affiliation(s)
- Caroline S Zhu
- From the Department of Trauma and Emergency Surgery (C.S.Z., R.B.J., D.P., R.C., S.E.N., B.J.E., D.H.J.), University of Texas Health Science Center, San Antonio, Texas; Department of Surgery (D.C.), Louisiana State University School of Medicine, Baton Rouge, Louisiana; Department of Transplant Surgery (M.R.), University of Texas Health Science Center, San Antonio, Texas; Trauma Services (T.C.-P., J.O.), University Hospital in San Antonio, San Antonio, Texas; and US Army Institute of Surgical Research (A.C.), San Antonio, Texas
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33
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Butler FK, Holcomb JB, Shackelford SA, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis MS, DeLellis SM, Dorlac WC, DuBose JJ, Eastridge BJ, Fisher AD, Glasser JJ, Gurney JM, Jenkins DA, Johannigman J, King DR, Kotwal RS, Littlejohn LF, Mabry RL, Martin MJ, Miles EA, Montgomery HR, Northern DM, O'Connor KC, Rasmussen TE, Riesberg JC, Spinella PC, Stockinger Z, Strandenes G, Via DK, Weber MA. Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018. J Spec Oper Med 2019; 18:37-55. [PMID: 30566723 DOI: 10.55460/yjb8-zc0y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2018] [Indexed: 11/09/2022]
Abstract
TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.
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34
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Cap AP, Pidcoke HF, Spinella P, Strandenes G, Borgman MA, Schreiber M, Holcomb J, Tien HCN, Beckett AN, Doughty H, Woolley T, Rappold J, Ward K, Reade M, Prat N, Ausset S, Kheirabadi B, Benov A, Griffin EP, Corley JB, Simon CD, Fahie R, Jenkins D, Eastridge BJ, Stockinger Z. Damage Control Resuscitation. Mil Med 2019; 183:36-43. [PMID: 30189070 DOI: 10.1093/milmed/usy112] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Indexed: 11/14/2022] Open
Abstract
Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.
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Affiliation(s)
- Andrew P Cap
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Heather F Pidcoke
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Philip Spinella
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Geir Strandenes
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew A Borgman
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Martin Schreiber
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - John Holcomb
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Homer Chin-Nan Tien
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Andrew N Beckett
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Heidi Doughty
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Tom Woolley
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Joseph Rappold
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Kevin Ward
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Michael Reade
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Nicolas Prat
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Sylvain Ausset
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Bijan Kheirabadi
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Avi Benov
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Edward P Griffin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jason B Corley
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Clayton D Simon
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Roland Fahie
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Donald Jenkins
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Brian J Eastridge
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Eastridge BJ, Holcomb JB, Shackelford S. Outcomes of traumatic hemorrhagic shock and the epidemiology of preventable death from injury. Transfusion 2019; 59:1423-1428. [DOI: 10.1111/trf.15161] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 12/26/2022]
Affiliation(s)
| | | | - Stacy Shackelford
- Joint Trauma SystemU.S. Army Institute of Surgical Research Fort Sam Houston Texas
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Medrano NW, Villarreal CL, Price MA, MacKenzie E, Nolte KB, Phillips MJ, Stewart RM, Eastridge BJ. Multi-Institutional Multidisciplinary Injury Mortality Investigation in the Civilian Pre-Hospital Environment (MIMIC): a methodology for reliably measuring prehospital time and distance to definitive care. Trauma Surg Acute Care Open 2019; 4:e000309. [PMID: 31058244 PMCID: PMC6461208 DOI: 10.1136/tsaco-2019-000309] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/25/2019] [Indexed: 11/04/2022] Open
Abstract
The detailed study of prehospital injury death is critical to advancing trauma and emergency care, as circumstance and causality have significant implications for the development of mitigation strategies. Though there is no true 'Golden Hour,' the time from injury to care is a critical element in the analysis matrix, particularly in patients with severe injury. Currently, there is no standard method for the assessment of time to definitive care after injury among prehospital deaths. This article describes a methodology to estimate total prehospital time and distance for trauma patients transported via ground emergency medical services and helicopter emergency medical services using a geographic information system. Data generated using this method, along with medical examiner and field investigation reports, will be used to estimate the potential survivability of prehospital trauma deaths occurring in five US states and the District of Columbia as part of the Multi-Institutional Multidisciplinary Injury Mortality Investigation in the Civilian Pre-Hospital Environment study. One goal of this work is to develop standard metrics for the assessment of total prehospital time and distance, which can be used in the future for more complex spatial analyses to gain a deeper understanding of trauma center access. Results will be used to identify high priority areas for research and development in injury prevention, trauma system performance improvement, and public health.
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Affiliation(s)
| | | | | | - Ellen MacKenzie
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kurt B Nolte
- Office of the Medical Investigator, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
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Nicholson SE, Merrill D, Zhu C, Burmeister DM, Zou Y, Lai Z, Darlington DN, Lewis AM, Newton L, Scroggins S, Eastridge BJ, Schwacha MG. Polytrauma independent of therapeutic intervention alters the gastrointestinal microbiome. Am J Surg 2018; 216:699-705. [PMID: 30100050 DOI: 10.1016/j.amjsurg.2018.07.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/01/2018] [Accepted: 07/17/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study characterizes the gastrointestinal (GI) microbiome in a pre-clinical polytrauma hemorrhage model. METHODS Rats (n = 6) were anesthetized, hemorrhaged 20% of their blood volume, and subjected to a femur fracture and crush injuries to the small intestine, liver, and limb skeletal muscle without resuscitation. Fecal samples were collected pre-injury and 2 h post-injury. Purified DNA from the samples underwent 16s rRNA sequencing for microbial quantification. Bacterial diversity analysis and taxonomic classification were performed. RESULTS Following injury, the gut microbial composition was altered with a shift in beta diversity and significant differences in the relative abundance of taxa. The relative abundance of the families Lachnospiraceae and Mogibacteriaceae was increased at 2 h, while Barnesiellaceae and Bacteroidaceae were decreased. Alpha diversity was unchanged. CONCLUSIONS The GI microbiome is altered in rats subjected to a polytrauma hemorrhage model at 2 h post-injury in the absence of antibiotics or therapeutic interventions.
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Affiliation(s)
- Susannah E Nicholson
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
| | - Daniel Merrill
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
| | - Caroline Zhu
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
| | - David M Burmeister
- The United State Army Institute of Surgical Research, Institute of Surgical Research, 3698 Chambers Pass STE B, JBSA Ft Sam Houston TX 78234-7767, USA.
| | - Yi Zou
- Greehey Children's Cancer Research Institute UT Health San Antonio at San Antonio, 8403 Floyd Curl Dr., San Antonio, TX 78229, USA.
| | - Zhao Lai
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
| | - Daniel N Darlington
- The United State Army Institute of Surgical Research, Institute of Surgical Research, 3698 Chambers Pass STE B, JBSA Ft Sam Houston TX 78234-7767, USA.
| | - Aaron M Lewis
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
| | - Larry Newton
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
| | - Shannon Scroggins
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
| | - Brian J Eastridge
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
| | - Martin G Schwacha
- The University of Texas Health Science Center at San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229-3900, USA.
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Johnson MC, Eastridge BJ, Liao L. Characterization of Pediatric Traumatic Diaphragm Injury. Am Surg 2018; 84:e91-e93. [PMID: 30454419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
MESH Headings
- Adolescent
- Child
- Child, Preschool
- Diaphragm/diagnostic imaging
- Diaphragm/injuries
- Female
- Hernia, Diaphragmatic, Traumatic/diagnosis
- Hernia, Diaphragmatic, Traumatic/epidemiology
- Hernia, Diaphragmatic, Traumatic/etiology
- Humans
- Incidence
- Infant
- Male
- Retrospective Studies
- Rupture
- Survival Rate/trends
- Thoracic Injuries/complications
- Thoracic Injuries/diagnosis
- Trauma Severity Indices
- United States/epidemiology
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/epidemiology
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Affiliation(s)
- Michael C Johnson
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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Affiliation(s)
- Michael C. Johnson
- University of Texas Health Science Center at San Antonio San Antonio, Texas
| | - Brian J. Eastridge
- University of Texas Health Science Center at San Antonio San Antonio, Texas
| | - Lillian Liao
- University of Texas Health Science Center at San Antonio San Antonio, Texas
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Carroll ND, Restrepo CS, Eastridge BJ, Stasik CN. Left atrial thrombi following tranexamic acid in a bleeding trauma patient-A word of caution. J Card Surg 2018; 33:83-85. [PMID: 29385649 DOI: 10.1111/jocs.13521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe the case of a bleeding trauma patient who received tranexamic acid (TXA) during air transport who subsequently developed multiple intra-cardiac thrombi. The administration of TXA during transport may be associated with this unusual presentation.
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Affiliation(s)
- Nels Davis Carroll
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Carlos S Restrepo
- Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Brian J Eastridge
- Department of Trauma Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Chad N Stasik
- Department of Cardiothoracic Surgery, Cape Thoracic & Cardiovascular Surgery, Cape Girardeau, Missouri
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41
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Johnson MC, Eastridge BJ. Discussion of: “Redefining the abdominal seatbelt sign: Enhanced CT imaging metrics improve injury prediction”. Am J Surg 2017; 214:1180-1181. [DOI: 10.1016/j.amjsurg.2017.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Johnson MC, Eastridge BJ. Redefining the abdominal seatbelt sign: Enhanced CT imaging metrics improve injury prediction. Am J Surg 2017; 214:1175-1179. [DOI: 10.1016/j.amjsurg.2017.08.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 08/11/2017] [Accepted: 08/27/2017] [Indexed: 11/26/2022]
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Buehner MF, Eastridge BJ, Aden JK, DuBose JJ, Blackbourne LH, Cestero RF. Combat Casualties and Severe Shock: Risk Factors for Death at Role 3 Military Facilities. Mil Med 2017; 182:e1922-e1928. [PMID: 28885956 DOI: 10.7205/milmed-d-16-00392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Although significant research has been conducted on combat casualties receiving blood products, there is limited data for the subpopulation presenting in shock. The purpose of this study was to evaluate combat casualties arriving to a role 3 facility with an initial systolic blood pressure (SBP) ≤ 90 in order to identify clinical characteristics and associations between presentation, transfusion therapy, and mortality outcomes. METHODS The Department of Defense Trauma Registry was queried from 2001 to 2010 for trauma-related casualties who arrived at a role 3 combat surgical facility with a SBP ≤ 90. Transfers from role 2 facilities were excluded. Data captured included demographics, admission vital signs, laboratory values, blood products, and mortality. Relationships between admission physiology, blood product utilization, and mortality were developed. Independent associations between variables were determined by logistic regression analysis. RESULTS 1,703 patients were identified who met our inclusion criteria and composite mortality was 23%. Mortality in those receiving a balanced transfusion ratio was 18% versus 27% (p < 0.0001). Hypotensive casualties who survived were significantly more likely to have a higher presenting Glasgow Coma Score (GCS), temperature, SBP, shock index, and pH. In addition, this group was also more likely to have a lower international normalized ratio, pCO2, and base deficit (p < 0.001). Age, heart rate, and pulse pressure were not significantly different between groups. Independent predictors of mortality included Injury Severity Score, presentation GCS, and initial pH value (p < 0.0001). In contrast, independent predictors of survival included those with above-knee amputation and a balanced transfusion (p < 0.0001). CONCLUSIONS Combat casualties hypotensive on arrival to surgical facilities have a significant expected mortality. Those receiving balanced transfusions demonstrated improved survival. Of the five independent risk factors, pH, GCS, and the presence of above-knee amputation are typically available during initial evaluation. These factors may be helpful in determining resource allocation and mortality risk, especially in triage or mass casualty settings.
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Affiliation(s)
- Michelle F Buehner
- General Surgery Department, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA FSH, TX 770234
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229
| | - James K Aden
- Department of Statistics, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA FSH, TX 770234
| | - Joseph J DuBose
- Department of Surgery, Travis Air Force Base, 690 Airman Drive, CA 94535
| | - Lorne H Blackbourne
- General Surgery Department, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA FSH, TX 770234
| | - Ramon F Cestero
- Department of Surgery, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229
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Alarhayem AQ, Cohn SM, Muir MT, Myers JG, Fuqua J, Eastridge BJ. Organ Donation, an Unexpected Benefit of Aggressive Resuscitation of Trauma Patients Presenting Dead on Arrival. J Am Coll Surg 2017; 224:926-932. [PMID: 28263857 DOI: 10.1016/j.jamcollsurg.2017.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND We sought to determine whether aggressive resuscitation in trauma patients presenting without vital signs, or "dead on arrival," was futile. We also sought to determine whether organ donation was an unexpected benefit of aggressive resuscitation. STUDY DESIGN We conducted a review of adults presenting to our Level I trauma center with no signs of life (pulse = 0 beats/min; systolic blood pressure = 0 mmHg; and no evidence of neurologic activity, Glasgow Coma Scale score = 3). Primary end point was survival to hospital discharge or major organ donation (ie heart, lung, kidney, liver, or pancreas were harvested). We compared our survival rates with those of the National Trauma Data Bank in 2012. Patient demographics, emergency department vital signs, and outcomes were analyzed. RESULTS Three hundred and forty patients presented with no signs of life to our emergency department after injury (median Injury Severity Score = 40). There were 7 survivors to discharge, but only 5 (1.5%) were functionally independent (4 were victims of penetrating trauma). Of the 333 nonsurvivors, 12 patients (3.6%) donated major organs (16 kidneys, 2 hearts, 4 livers, and 2 lungs). An analysis of the National Trauma Data Bank yielded a comparable survival rate for those presenting dead on arrival, with an overall survival rate of 1.8% (100 of 5,384); 2.3% for blunt trauma and 1.4% for penetrating trauma. CONCLUSIONS Trauma patients presenting dead on arrival rarely (1.5%) achieve functional independence. However, organ donation appears to be an under-recognized outcomes benefit (3.6%) of the resuscitation of injury victims arriving without vital signs.
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Affiliation(s)
- Abdul Q Alarhayem
- University of Texas Health Science Center at San Antonio, San Antonio, TX.
| | | | - Mark T Muir
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - John G Myers
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - James Fuqua
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Brian J Eastridge
- University of Texas Health Science Center at San Antonio, San Antonio, TX
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Eastridge BJ. Injuries to the Abdomen from Explosion. Curr Trauma Rep 2017. [DOI: 10.1007/s40719-017-0079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sordo S, Holloway TL, Woodard RL, Conway BE, Liao LF, Eastridge BJ, Myers JG, Stewart RM, Dent DL. Small Bowel Perforations by Metallic Grill Brush Bristles: Clinical Presentations and Opportunity for Prevention. Am Surg 2016; 82:412-5. [DOI: 10.1177/000313481608200515] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Increasing reports on the incidental ingestion of metallic bristles from barbeque grill cleaning brushes have been reported. We sought to describe the clinical presentation and grilling habits of patients presenting after ingesting metallic bristles in an attempt to identify risk factors. We performed a chart review of six patients with documented enteric injury from metallic bristles. Subjects were contacted and administered a survey focused on the events surrounding the bristle ingestion. We arranged for in-home visits to inspect the grill and grill brush whenever possible. Of the six subjects identified, three (50%) were male, five (83%) were white, and they ranged in age from 18 to 65 years (mean 42.5). All complained of abdominal pain. All bristles were identified by CT scan. Three patients underwent laparoscopic enterorrhaphy, and two underwent laparotomy. The remaining patients did not require intervention. None had replaced their grill brush in at least two years. Surgeon's awareness of this unusual injury is important to identify and manage this problem. Alternative methods to clean the grill should be sought and grill brushes should be replaced at least every two years.
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Affiliation(s)
- Salvador Sordo
- Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, Texas
| | - Travis L. Holloway
- Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, Texas
| | - Russell L. Woodard
- General Surgical Associates, Methodist Health Care Ministries, San Antonio, Texas
| | - Bruce E. Conway
- General Surgical Associates, Methodist Health Care Ministries, San Antonio, Texas
| | - Lillian F. Liao
- Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, Texas
| | - Brian J. Eastridge
- Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, Texas
| | - John G. Myers
- Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, Texas
| | - Ronald M. Stewart
- Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, Texas
| | - Daniel L. Dent
- Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, Texas
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Alarhayem AQ, Myers JG, Dent D, Lamus D, Lopera J, Liao L, Cestero R, Stewart R, Eastridge BJ. “Blush at first sight”: significance of computed tomographic and angiographic discrepancy in patients with blunt abdominal trauma. Am J Surg 2015; 210:1104-10; discussion 1110-1. [DOI: 10.1016/j.amjsurg.2015.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/20/2015] [Accepted: 08/25/2015] [Indexed: 12/12/2022]
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Alarhayem AQ, Cohn SM, Eastridge BJ, Rubalcava NS, Myers JG. Natural History of Trauma Patients Presenting “Dead on Arrival”: Should We Resuscitate? J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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50
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Gross KR, Rickard RF, Eastridge BJ, Curtis RA, Witte SM, Shackelford SA, Bailey JA, Kuncir EJ, Paix B, Riley KD, Burrell E, Smith MP, Soliz BA, Remick KN. Review of the Fifth Annual Joint Theater Trauma System Trauma Conference. J Trauma Acute Care Surg 2015; 79:S70-4. [DOI: 10.1097/ta.0000000000000669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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