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Background: Pulmonary thromboembolism (PTE) is a dangerous complication of traumatic injury, with varied risk profiles and treatment options. This review aims to describe reported incidence and variables associated with PTE among severely injured patients.Methods: Searches were conducted using PubMed, Cochrane and MEDLINE. Relevant studies were identified by two independent reviewers based on predetermined inclusion criteria. Incidence of PTE was the primary outcome measure. Variables associated with PTE was the secondary outcome measure. The Newcastle-Ottawa Scale was used to assess quality of included studies.Results: There were eight studies that satisfied inclusion criteria. The diagnosed incidence of PTE in these populations ranged from 0.35 to 24%. The most common variables associated with PTE were pelvic or lower limb injury, chest injury, higher total Injury Severity Score, male sex and age. Variables that were less commonly associated with PTE were previous warfarin use, head injury, high serum lactate, soft tissue injury, more than one operation, more than three days on a ventilator, presence of a subclavian central venous catheter, need for a blood transfusion, systolic blood pressure <90mmHg, abdominal injury, presence of a deep venous thrombosis, inferior vena cava filter placement and isolated liver spleen or spinal injuries.Conclusions: The reported incidence of PTE after major trauma is variable and dependent on inclusion criteria, diagnostic criteria and study design. Identified variables differed to those reported for venous thromboembolism in other populations. It is difficult to predict populations at risk of clinically significant PTE following injury using available evidence. Further studies linked to patient-specific variables will assist in more precise risk-stratification and interventions. [ABSTRACT FROM AUTHOR]

Background Detecting occult bleeding can be challenging and may delay resuscitation. The Shock Index (SI) defined as heart rate divided by systolic blood pressure has attracted attention. Prediction models using combinations of pre-hospital SI (phSI) and the trauma centre SI (tcSI) values may be effective in identifying patients requiring massive blood transfusions (MT). Aim To explore whether combinations of the phSI and the tcSI augment MT prediction. Methods The scores were retrospectively developed using all major trauma patients that presented to The Alfred Hospital between 2006 and 2012. The first PH and TC observations were used. To avoid exclusion of the ‘sickest’ patients, the SI was imputed to 2 where SBP was missing, but HR was present. We developed 4 models. (i) ‘Dichotomised’, defined as positive when both phSI and tcSI were ≥1. (ii) ‘Formulaic’, defined by logistic regression analysis. (iii) ‘Combination’, defined pragmatically based on the logistic regression. (iv) ‘Trending’, defined as: tcSI minus phSI. Results There were 6990 major trauma patients and 360 (5.2%) received MT. There were 1371 cases with either phSI or tcSI missing and were thus excluded from the analysis. The ‘Dichotomised’ had higher positive predictive value than the tcSI with a further 5 per 100 patients identified. The ‘Formulaic’ model, defined as: log Odds (MT) = 2.16 × tcSI + 0.89 × phSI − 5.42, and the ‘Combination’ model, defined as: phSI × 0.5 + tcSI, performed equally (AUROC 0.83 versus 0.83, χ 2 = 0.86, p = 0.35). The ‘Formulaic’ performed marginally, but statistically significantly, more accurate than the tcSI alone (AUROC 0.83 versus 0.82, χ 2 = 6.89, p < 0.01). An ‘Upward Trending’ SI was observed in 1758 patients, revealing a 4.6-fold univariate association with MT (OR 4.55; 95%CI 2.64–7.83), and an AUROC of 0.79 (95%CI 0.74–0.83). The ‘Downward Trending’ SI was protective against MT (OR 0.44; 95%CI 0.34–0.57). Conclusion The initial pre-hospital SI is associated with MT. However, this relationship did not clinically augment MT decision when combined with the in-hospital SI. The simplicity of the SI makes it a favourable option to explore further. Computer-assisted technology in data capturing, analysis and prognostication presents avenues for further research. [ABSTRACT FROM AUTHOR]

Introduction Older age and blood transfusion have both been independently associated with higher mortality post trauma and the combination is expected to be associated with catastrophic outcomes. Among patients who received a massive transfusion post trauma, we aimed to investigate mortality at hospital discharge of patients =65 years old and explore variables associated with poor outcomes. Methods A retrospective review of registry data on all major trauma patients presenting to a level I trauma centre between 2006 and 2011 was conducted. Mortality at hospital discharge among patients =65 years old was compared to the younger cohort. A multivariable logistic regression model was constructed to determine independent risk-factors for mortality among older patients. Results There were 51 (16.4%) patients of age =65 years who received a massive transfusion. There were 20 (39.2%) deaths, a proportion significantly higher than 55 (21.1%) deaths among younger patients ( p < 0.01). Pre-hospital GCS, the presence of acute traumatic coagulopathy and higher systolic blood pressure on presentation were independently associated with higher mortality. Age and volume of red cells transfused were not significantly associated with higher mortality. Conclusions Survival to hospital discharge was demonstrated in elderly patients receiving massive transfusions post trauma, even in the presence of multiple risk factors for mortality. Restrictive resuscitation or transfusion on the basis of age alone cannot be supported. Early aggressive resuscitation of elderly trauma patients along specific guidelines directed at the geriatric population is justified and may further improve outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Introduction and aims: Acute traumatic coagulopathy is observed in 10–25% of patients post major trauma and its management forms an integral part of haemostatic resuscitation. The identification and treatment of this coagulopathy is difficult and there is uncertainty regarding optimal therapeutic guidelines during the early phases of trauma resuscitation. This study aimed to examine the association between acute coagulopathy and early deaths post major trauma. Methods: A retrospective review of data over a 5 year period was performed to determine the associations between variables considered to contribute to mortality for adult major trauma patients (Injury Severity Score (ISS)>15) receiving blood transfusions as part of their initial resuscitation. Early death, defined as death in ED, or death in the operating theatre (OT), Intensive Care Unit (ICU) or wards within 24h of admission was the primary end-point. Patients with non-survivable head injury on initial imaging were excluded. Univariate associations were calculated and multivariable logistic regression analysis was used to determine independent associations with mortality. Results: There were 772 patients included in this study with a median ISS of 29 (19–41), with 91.7% blunt trauma. All-cause in-hospital mortality was 17.5%, while 77 (9.7%) patients died early. Increasing age (OR 1.04), a GCS of 3–8 (OR 5.05), and the presence of acute coagulopathy (OR 8.77) were significant independent variables associated with early death. Conclusions: Acute traumatic coagulopathy, independent of injury severity, transfusion practice or other physiological markers for haemorrhage, was associated with early death in major trauma patients requiring a blood transfusion. Early recognition and management of coagulopathy, independent of massive transfusion guidelines, may improve outcome from trauma resuscitation. Further studies are required for the early recognition of acute traumatic coagulopathy to enable the development of an evidence base for management. [Copyright &y& Elsevier]

Abstract: Introduction: Recent retrospective studies have found high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratios during trauma resuscitation to be associated with improved mortality. Whilst this association may be related to a mortality bias present in these studies, there has been an overall tendency towards a 1:1 FFP:PRBC ratio in massive transfusion guidelines worldwide. The aim of this study was to retrospectively review the administration of FFP in patients undergoing massive transfusion during trauma resuscitation, to add to the evidence base for massive transfusion guidelines. Materials and methods: Multi-trauma patients who were administered blood transfusions of 5units or more of packed red blood cells (PRBCs) in the first 4h were included in this study. Mortality was the primary endpoint with length of hospital stay, ICU hours and mechanically ventilated hours secondary endpoints. Results: There were 331 patients included in this study with a median Injury Severity Score (ISS) of 36 (25–50) and a mortality of 29.9%. There was little change in the ratio of FFP:PRBC transfused per patient from 2005 to 2008. A low FFP:PRBC ratio in the first 4h of resuscitation, older age, low initial GCS and coagulopathy on presentation were significant independent factors associated with mortality. When deaths in the first 24h were excluded, the FFP:PRBC ratio had no association with mortality. Discussion: This study has shown increased initial survival in association with higher FFP:PRBC ratios during massive transfusion in a population with a high proportion of blunt injuries. The association is difficult to interpret because of an inherent survival bias. The optimal ratio of FFP:PRBC during massive transfusion may be different to 1:1 and further prospective research is required. There is now an increasing need for well designed randomised controlled trials to determine the best FFP:PRBC ratio for the resuscitation of blunt multi-trauma patients. [Copyright &y& Elsevier]

Summary: Aims: To review the massive transfusion practice at a Level I adult Trauma Centre during initial trauma reception and resuscitation. Methods: All trauma patients presenting to The Alfred Emergency & Trauma Centre and receiving a transfusion of five units or more of packed red blood cells within 4h of presentation over a 26-month period were included in this study. Patient demographics, clinical characteristics, injuries, surgical management and volume of blood transfused were analysed with mortality as the primary endpoint. Initial clinical features and injuries predictive of massive transfusion were also analysed. Results: There were 119 patients who received a transfusion of five units or more of packed red blood cells (PRBCs) within 4h of presentation. The median Injury Severity Score of this group of patients was 34.0 (IQR 26–48) and mortality was 27.7%. The median number of packed red blood cell transfused was 8.0 (IQR 6–14) in the 1st 4h. Initial clinical features and injuries independently associated with a larger volume of blood transfused were initial hypotension, fractures of the pelvis, kidney injuries, initial acidaemia, and thrombocytopaenia. The Injury Severity Score, initial coagulopathy measured by APTT and the presence of head injuries were the independent predictors of mortality. Conclusions: The volume of blood transfused during trauma resuscitation was not found to be an independent predictor of mortality. Prospective studies into transfusion practice and clinical features of patients during the trauma resuscitation phase requiring massive transfusion are needed to establish evidence-based guidelines for massive transfusion. [Copyright &y& Elsevier]