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Fibrinogen is the first coagulation factor to decrease after massive hemorrhage. European massive transfusion guidelines recommend early repletion of fibrinogen; however, this practice has not been widely adopted in the US. We hypothesize that hypofibrinogenemia is common at hospital arrival and is an integral component of trauma-induced coagulopathy.This study entailed review of a prospective observational database of adults meeting the highest-level activation criteria at an urban level 1 trauma center from 2014 through 2020. Resuscitation was initiated with 2:1 red blood cell (RBC) to fresh frozen plasma (FFP) ratios and continued subsequently with goal-directed thrombelastography. Hypofibrinogenemia was defined as fibrinogen below 150 mg/dL. Massive transfusion (MT) was defined as more than 10 units RBC or death after receiving at least 1 unit RBC over the first 6 hours of admission.Of 476 trauma activation patients, 70 (15%) were hypofibrinogenemic on admission, median age was 34 years, 78% were male, median New Injury Severity Score (NISS) was 25, and 72 patients died (15%). Admission fibrinogen level was an independent risk factor for MT (odds ratio [OR] 0.991, 95% CI 0.987-0.996]. After controlling for confounders, NISS (OR 1.034, 95% CI 1.017-1.052), systolic blood pressure (OR 0.991, 95% CI 0.983-0.998), thrombelastography angle (OR 0.925, 95% CI 0.896-0.954), and hyperfibrinolysis (OR 2.530, 95% CI 1.160-5.517) were associated with hypofibrinogenemia. Early cryoprecipitate administration resulted in the fastest correction of hypofibrinogenemia.Hypofibrinogenemia is common after severe injury and predicts MT. Cryoprecipitate transfusion results in the most expeditious correction. Earlier administration of cryoprecipitate should be considered in MT protocols.

Background Despite the prevalence of hypocoagulability after injury, the majority of trauma patients paradoxically present with elevated thrombin generation (TG). While several studies have examined plasma TG post-injury, this has not been assessed in whole blood. We hypothesize that whole blood TG is lower in hypocoagulopathy, and TG effectively predicts massive transfusion. Study Design Blood was collected from trauma activation patients at an urban Level-1 trauma center. Whole blood TG was performed with a prototype point-of-care device. Whole blood TG values in healthy volunteers were compared to trauma patients, and TG values were examined in trauma patients with shock and massive transfusion requirement (MT). Results Overall, 118 patients were included (Table 1). Compared to healthy volunteers, trauma patients overall presented with more robust TG; however, those arriving in shock (n=23) had a depressed TG, with significantly lower peak thrombin (88.3 versus 133.0 nM, p=0.01) and slower maximum rate of thrombin generation (27.4 versus 48.3 nM/min, p=0.04). Patients who required massive transfusion (n=26) had significantly decreased TG, with a longer lag time (median 4.8 min versus 3.9 min, p=0.04), decreased peak thrombin (median 71.4 nM versus 124.2 nM, p=0.0003), and lower maximum rate of TG (median 15.8 nM/min versus 39.4 nM/min, p=0.01). AUROC analysis revealed lag time (AUROC 0.6), peak thrombin (AUROC 0.7), and maximum rate of TG (AUROC 0.7) predict early MT. Conclusion These data challenge the prevailing bias that all trauma patients present with elevated TG and highlight that deficient thrombin contributes to the hypocoagulopathic phenotype of trauma-induced coagulopathy. Further, whole blood TG predicts massive transfusion, suggesting point of care whole blood TG may be a useful tool for diagnostic and therapeutic strategies in trauma.

The COVID-19 pandemic has introduced a global public health threat unparalleled in our history. The most severe cases are marked by ARDS attributed to microvascular thrombosis. Hypercoagulability, resulting in a profoundly prothrombotic state, is a distinct feature of COVID-19 and is accentuated by a high incidence of fibrinolysis shutdown. The aims of this review were to describe the manifestations of fibrinolysis shutdown in COVID-19 and its associated outcomes, review the molecular mechanisms of dysregulated fibrinolysis associated with COVID-19, and discuss potential implications and therapeutic targets for patients with severe COVID-19.

Background Hypercoagulability and malignancy have been linked since the 1860s. However, the impact of different neoplasms on multiple components of the coagulation system remains poorly understood. Thrombelastography (TEG) enables measurement of coagulation incorporating clotting through fibrinolysis. We hypothesize that specific TEG indices that are associated with hypercoagulability can be appreciated in patients with adenocarcinoma undergoing pancreatic resection. Study Design Blood samples were obtained from patients undergoing pancreatic resection before surgical incision and assayed with TEG. The 4 indices of coagulation measured by TEG included in the analysis were R time, angle, maximum amplitude, and lysis at 30 minutes. Patient tumor type, nodal disease, and mass resectability were contrasted with TEG indices. Results One hundred patients were enrolled over 18 months. The majority (63%) of patients had adenocarcinoma. Patients with adenocarcinoma had increased angle compared with other lesions (49 degrees [interquartile range {IQR} 37 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p = 0.011). When excluding patients that underwent neoadjuvant therapy, patients with adenocarcinoma had shorter R times (13 minutes [IQR 9 to 16 minutes] vs 14 minutes [IQR 12 to 18 minutes]; p = 0.051), steeper angles (49 degrees [IQR 40 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p = 0.010), and higher maximum amplitude (67 mm [IQR 61 to 69 mm] vs 62 mm [IQR 57 to 67 mm]; p = 0.017). Nodal disease was associated with a significantly increased angle (49 degrees [IQR 42 to 59 degrees] vs 40 degrees [IQR 32 to 50 degrees]; p = 0.002) and maximum amplitude (64 mm [IQR 61 to 69 mm] vs 62 mm [IQR 56 to 67 mm]; p = 0.017). Patients who underwent successful mass resection had longer R times (14 minutes [IQR 11 to 17 minutes] vs 10 minutes [IQR 9 to 15]; p = 0.033) and shorter angles (44 degrees [IQR 35 to 55 degrees] vs 58 degrees [IQR 45 to 66 degrees]; p = 0.025). Conclusions Patients with adenocarcinoma undergoing pancreatic resection have multiple TEG abnormalities consistent with hypercoagulability. These TEG outputs are associated with tumor type, nodal disease, and probability of a successful resection. The use of preoperative TEG has the potential to aid surgeon and patient discussions on anticipated disease burden and prognosis before resection.

Background Resuscitative thoracotomy (RT) is life-saving in select patients and can be accomplished through a left anterolateral (AT) or clamshell thoracotomy (CT). CT may provide additional exposure, facilitating certain operative procedures, but the added blood and heat loss and time to perform it may increase complications. No prospective multicenter comparison of techniques has yet been reported. Study Design The observational AAST Aortic Occlusion for Resuscitation in Trauma and Acute care surgery (AORTA) registry was used to compare AT and CT in RT. Results AORTA recorded 1,218 RTs at 46 trauma centers from June 2014 to January 2020. Overall survival after RT was 6.0% (AT 6.6%; [59 of 900]; CT 4.2% [13 of 296], p = 0.132). Among all RTs, 11.1% (142 of 1,278) surviving at least 24 hours were used tocompare AT (112) and CT (30). There was no difference between the 2 groups withregard to age, sex, Injury Severity Score, or mechanism of injury (Table 1). CT was significantly more likely to be used in patients needing resection of the lung or cardiac repair. CT was not associated with increased local thoracic/systemic complications, higher transfusion requirement, or greater ventilator, ICU, or hospital days compared with AT. Conclusions Clamshell thoracotomy facilitates thoracic life-saving procedures withoutincreased systemic or thoracic complications compared with AT in patients undergoing RT.

Background COVID-19 predisposes patients to a prothrombotic state with demonstrated microvascular involvement. The degree of hypercoagulability appears to correlate with outcomes; however, optimal criteria to assess for the highest-risk patients for thrombotic events remain unclear; we hypothesized that deranged thromboelastography measurements of coagulation would correlate with thromboembolic events. Study design Patients admitted to an ICU with COVID-19 diagnoses who had thromboelastography analyses performed were studied. Conventional coagulation assays, d-dimer levels, and viscoelastic measurements were analyzed using a receiver operating characteristic curve to predict thromboembolic outcomes and new-onset renal failure. Results Forty-four patients with COVID-19 were included in the analysis. Derangements in coagulation laboratory values, including elevated d-dimer, fibrinogen, prothrombin time, and partial thromboplastin time, were confirmed; viscoelastic measurements showed an elevated maximum amplitude and low lysis of clot at 30 minutes. A complete lack of lysis of clot at 30 minutes was seen in 57% of patients and predicted venous thromboembolic events with an area under the receiver operating characteristic curve of 0.742 (p = 0.021). A d-dimer cutoff of 2,600 ng/mL predicted need for dialysis with an area under the receiver operating characteristic curve of 0.779 (p = 0.005). Overall, patients with no lysis of clot at 30 minutes and a d-dimer > 2,600 ng/mL had a venous thromboembolic event rate of 50% compared with 0% for patients with neither risk factor (p = 0.008), and had a hemodialysis rate of 80% compared with 14% (p = 0.004). Conclusions Fibrinolysis shutdown, as evidenced by elevated d-dimer and complete failure of clot lysis at 30 minutes on thromboelastography predicts thromboembolic events and need for hemodialysis in critically ill patients with COVID-19. Additional clinical trials are required to ascertain the need for early therapeutic anticoagulation or fibrinolytic therapy to address this state of fibrinolysis shutdown.

BACKGROUND: Elevated D-dimers in injured patients with paradoxically low fibrinolysis activity measured by viscoelastic assays have been speculated to be “occult” fibrinolysis. However, an alternative explanation is that these patients have previously activated their fibrinolytic system and have shut it down by the time of blood draw, and would gain no benefit in clot strength with tranexamic acid (TXA). We hypothesize that TXA will not increase clot strength in injured patients with low fibrinolytic activity measured by thrombelastography (TEG), despite biomarkers of fibrinolysis activation. STUDY DESIGN: Three TEG assays (rapid, tissue plasminogen activator, and functional fibrinogen) were run on trauma patients. The tissue plasminogen activator TEG served as a functional assay to quantify depletion of fibrinolysis inhibitors (DFI). Patients were stratified by DFI vs non-DFI and then by rapid TEG lysis at 30 minutes phenotype cutoffs. Response to TXA was evaluated with functional fibrinogen TEG by calculating percent change in clot strength with the addition of exogenous TXA in the TEG cup. RESULTS: Six hundred and thirty patients with a median new injury severity score of 20 were analyzed. Depletion of fibrinolysis inhibitors was present in 116 (18%). The DFI patients had significantly increased D-dimer (p < 0.001) and lower fibrinogen (p < 0.001). The DFI patients had increased rates of massive transfusion (33% vs 3.3%; p < 0.001) and mortality (40% vs 6.2%; p ≤ 0.001). Among DFI patients, TXA significantly improved fibrin clot strength with hyperfibrinolysis (+19% clot strength; p < 0.001) but not with shutdown (+1.2%) or physiologic (−2.5%). CONCLUSIONS: Patients with DFI have multiple abnormalities of their coagulation system, but only DFI patients with hyperfibrinolysis have improved fibrin clot strength with TXA. (J Am Coll Surg 2019;229: 92–101.

Background Sex dimorphisms in coagulation have been recognized, but whole blood assessment of these dimorphisms and their relationship to outcomes in trauma have not been investigated. This study characterizes the viscoelastic hemostatic profile of severely injured patients by sex, and examines how sex-specific coagulation differences affect clinical outcomes, specifically, massive transfusion (MT) and death. We hypothesized that severely injured females are more hypercoagulable and therefore, have lower rates of MT and mortality. Study Design Hemostatic profiles and clinical outcomes from all trauma activation patients from 2 level I trauma centers were examined, with sex as an experimental variable. As part of a prospective study, whole blood was collected and thrombelastography (TEG) was performed. Coagulation profiles were compared between sexes, and association with MT and mortality were examined. Poisson regression with robust standard errors was performed. Results Overall, 464 patients (23% female) were included. By TEG, females had a more hypercoagulable profile, with a higher angle (clot propagation) and maximum amplitude (MA, clot strength). Females were less likely to present with hyperfibrinolysis or prolonged activating clotting time than males. In the setting of depressed clot strength (abnormal MA), female sex conferred a survival benefit, and hyperfibrinolysis was associated with higher case-fatality rate in males. Conclusions Severely injured females have a more hypercoagulable profile than males. This hypercoagulable status conferred a protective effect against mortality in the setting of diminished clot strength. The mechanism behind these dimorphisms needs to be elucidated and may have treatment implications for sex-specific trauma resuscitation.

Background Early recognition of trauma patients at risk for multiple organ failure (MOF) is important to reduce the morbidity and mortality associated with MOF. The objective of the study was to externally validate the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, a 6-item instrument that includes age, intubation, hematocrit, systolic blood pressure, blood urea nitrogen, and white blood cell count, which was designed to predict the development of MOF within 7 days of hospitalization. Study Design We performed a prospective multicenter study of adult trauma patients between November, 2011 and March, 2013. The primary outcome was development of MOF within 7 days of hospitalization, assessed using the Sequential Organ Failure Assessment Score. Hierarchical logistic regression analysis was performed to determine associations between the Denver ED TOF Score and MOF. Discrimination was assessed and quantified using a receiver operating characteristics (ROC) curve. The predictive accuracy of the Denver ED TOF score was compared with attending emergency physician estimation of the likelihood of MOF. Results We included 2,072 patients with a median age of 46 years (interquartile range [IQR] 30 to 61 years); 68% were male. The median Injury Severity Score was 9 (IQR 5 to 17), and 88% of patients had blunt mechanism injury. Among participants, 1,024 patients (49%) were admitted to the ICU, and 77 (4%) died. Multiple organ failure occurred in 120 (6%; 95% CI 5% to 7%) patients and of these, 37 (31%; 95% CI 23% to 40%) died. The area under the ROC curve for the Denver ED TOF Score prediction of MOF was 0.89 (95% CI 0.86 to 0.91) and for physician estimation of the likelihood of MOF was 0.78 (95% CI 0.73 to 0.83). Conclusions The Denver ED TOF Score predicts development of MOF within 7 days of hospitalization. Its predictive accuracy outperformed attending emergency physician estimation of the risk of MOF.

Prehospital resuscitation with crystalloid exacerbates fibrinolysis, which is associated with high mortality. We hypothesized that plasma compared with crystalloid resuscitation prevents hyperfibrinolysis in a tissue plasminogen activator (tPA)-rich environment via preservation of proteins essential for regulation of fibrinolysis.Healthy individuals donated blood, which was assayed using a native (nonactivated) thrombelastography (TEG). Whole-blood was mixed with normal saline (NS) or platelet poor plasma (PPP) at progressive dilutions. Tissue plasminogen activator was added to promote a fibrinolytic environment. In a separate experiment, PPP was run through a 100 kDa filter and liquid remaining on top of the filter (TFP) and below the filter (BFP) was obtained. Whole blood was diluted by 50% with TFP, BFP, and NS and assayed with a tPA TEG challenge. The TFP and BFP were assayed for protein concentration and protein composition.Normal saline and PPP dilution of whole blood without tPA did not affect clot lysis at 30 minutes (LY30) (NS Spearman's rho 0.300, p = 0.186 and PPP 0.294, p = 0.288). When tPA was added, NS dilution of whole blood increased LY30 in a percentage-dependent manner (0.844, p0.001), but did not significantly increase with PPP dilution (0.270, p = 0.202). The difference in LY30 from whole blood to diluted whole blood with PPP (mean change, -1.05, 95% CI, -9.42 to 7.33) was similar with TFP (1.23, 95% CI, -5.20 to 7.66, p = 0.992). However, both BFP (37.65, 95% CI 24.47 to 50.82, p = 0.001) and NS (47.36, 95% CI 34.3 to 60.45, p0.001) showed large increases in fibrinolysis compared with PPP.Crystalloid and plasma dilution of whole blood does not increase fibrinolysis. However, NS dilution of whole blood increases susceptibility to tPA-mediated fibrinolysis. Plasma resuscitation, simulated by plasma dilution of whole blood, attenuates increased susceptibility to tPA-mediated fibrinolysis. The benefits of plasma resuscitation are mediated through preservation of plasma proteins.

Background The role of stenting for blunt cerebrovascular injuries (BCVI) continues to be debated, with a trend toward more endovascular stenting. With the recent intracranial stenting trial halted in favor of medical therapy, however, management of BCVI warrants reassessment. The study purpose was to determine if antithrombotic therapy, rather than stenting, was effective in post-injury patients with high-grade vascular dissections and pseudoaneurysms. Study Design In 1996, we began screening for BCVI. After the 2005 report on the risks of carotid stenting for BCVI, a virtual moratorium was placed on stenting at our institution; our primary therapy for BCVI has been antithrombotics. Patients with grade II (luminal narrowing >25%) and grade III (pseudoaneurysms) injuries were included in the analysis. Results Grade II or III BCVIs were diagnosed in 195 patients. Before 2005, 25% (21 of 86) of patients underwent stent placement, with 2 patients suffering stroke. Of patients treated with antithrombotics, 1 had a stroke. After 2005, only 2% (2 of 109) of patients with high-grade injuries had stents placed. After 2005, no patient treated with antithrombotics suffered a stroke and there was no rupture of a pseudoaneurysm. Conclusions Antithrombotic treatment for BCVI is effective for stroke prevention. Routine stenting entails increased costs and potential risk for stroke, and does not appear to provide additional benefit. Intravascular stents should be reserved for the rare patient with symptomatology or a markedly enlarging pseudoaneurysm.

Background Urinary tract infection (UTI) in trauma patients is associated with increased mortality. Whether the urinalysis (UA) is an adequate test for a urinary source of fever in the ICU trauma patient has not been demonstrated. We hypothesized that the UA is a valuable screen for UTI in the febrile, critically ill trauma patient. Study Design All trauma ICU patients in our surgical ICU who had a fever (temperature >38.0°C), urinary catheter, UA, and a urine culture between January 1, 2011 and December 13, 2011 were reviewed. A positive UA was defined as positive leukocyte esterase, positive nitrite, WBC > 10/high power field, or presence of bacteria. A positive urine culture was defined as growth of ≥10 5 colony forming units (cfu) of an organism irrespective of the UA result or ≥10 3 cfu in the setting of a positive UA. A UTI was defined as positive urine culture without an alternative cause of the fever. Results There were 232 UAs from 112 patients that met criteria. The majority (75%) of patients were men; the mean age was 40 (±16) years. Of the 232 UAs, 90 (38.7%) were positive. There were 14 UTIs. The sensitivity, specificity, positive predictive value, and negative predictive value of the UA for UTI were 100%, 65.1%, 15.5%, and 100%, respectively. Conclusions A negative UA reliably excludes a catheter-associated UTI in the febrile, trauma ICU patient with a 100% negative predictive value, and it can rapidly direct the clinician toward more likely sources of fever and reduce unnecessary urine cultures.

Variation in use of damage control (DC) surgery across trauma centers may be partially driven by surgeon uncertainty as to when it is appropriately indicated. We sought to determine opinions of practicing surgeons on the appropriateness of published indications for trauma DC surgery.We asked 384 trauma centers in the United States, Canada, and Australasia to nominate 1 to 3 surgeons at their center to participate in a survey about DC surgery. We then asked nominated surgeons their opinions on the appropriateness (benefit-to-harm ratio) of 43 literature-derived indications for use of DC surgery in adult civilian trauma patients.In total, 232 (64.8%) trauma centers nominated 366 surgeons, of whom 201 (56.0%) responded. Respondents rated 15 (78.9%) preoperative and 23 (95.8%) intraoperative indications to be appropriate. Indications respondents agreed had the greatest expected benefit included a temperature34°C, arterial pH7.2, and laboratory-confirmed (international normalized ratio/prothrombin time and/or partial thromboplastin time1.5 times normal) or clinically observed coagulopathy in the pre- or intraoperative setting; administration of10 units of packed red blood cells; requirement for a resuscitative thoracotomy in the emergency department; and identification of a juxtahepatic venous injury or devascularized or destroyed pancreas, duodenum, or pancreaticoduodenal complex during operation. Ratings were consistent across subgroups of surgeons with different training, experience, and practice settings.We identified 38 indications that practicing surgeons agreed appropriately justified the use of DC surgery. Until further studies become available, these indications constitute a consensus opinion that can be used to guide practice in the current era of changing trauma resuscitation practices.

Background Our aim was to determine the prevalence of platelet dysfunction using an end point of assembly into a stable thrombus after severe injury. Although the current debate on acute traumatic coagulopathy has focused on the consumption or inhibition of coagulation factors, the question of early platelet dysfunction in this setting remains unclear. Study Design Prospective platelet function in assembly and stability of the thrombus was determined within 30 minutes of injury using whole blood samples from trauma patients at the point of care using thrombelastography-based platelet functional analysis. Results There were 51 patients in the study. There were significant differences in the platelet response between trauma patients and healthy volunteers, such that there was impaired aggregation to these agonists. In trauma patients, the median ADP inhibition of platelet function was 86.1% (interquartile range [IQR] 38.6% to 97.7%) compared with 4.2 % (IQR 0 to 18.2%) in healthy volunteers. After trauma, the impairment of platelet function in response to arachidonic acid was 44.9% (IQR 26.6% to 59.3%) compared with 0.5% (IQR 0 to 3.02%) in volunteers (Wilcoxon nonparametric test, p Conclusions In this study, we show that platelet dysfunction is manifest after major trauma and before substantial fluid or blood administration. These data suggest a potential role for early platelet transfusion in severely injured patients at risk for postinjury coagulopathy.

Preperitoneal pelvic packing/external fixation (PPP/EF) for controlling life-threatening hemorrhage from pelvic fractures is used widely in Europe but has not been adopted in North America. We hypothesized that PPP/EF arrests hemorrhage rapidly, facilitates emergent operative procedures, and ensures efficient use of angioembolization (AE).In 2004 we initiated a PPP/EF guideline for pelvic fracture patients with refractory shock requiring ongoing blood transfusion at our regional trauma center.Among 1,245 patients admitted with pelvic fractures, 75 consecutive patients underwent PPP/EF (age 42 ± 2 years and injury severity score 52 ± 1.5). Emergency department systolic blood pressure was 76 ± 2 mmHg and heart rate 119 ± 2 beats/min. Time to operation was 66 ± 7 minutes, and 65 patients (87%) underwent 3 ± 0.3 additional procedures. Blood transfusion before PPP/EF compared with the first postoperative 24 hours was 10 ± 0.8 units versus 4 ± 0.5 units (p0.05). The fresh frozen plasma-red blood cell ratio was 1:2. After PPP/EF, 10 patients (13%) underwent angioembolization with a documented blush; time to angioembolization was 10.6 ± 2.4 hours (range 1 to 38 hours). Mortality for all pelvic fractures was 8%, with 21% mortality in this high-risk group. There were no deaths due to acute hemorrhage.PPP/EF was effective in controlling hemorrhage from unstable pelvic fractures. None of these high-risk patients died due to pelvic bleeding. Secondary angioembolization was needed in a minority, permitting selective use of this resource-demanding intervention. Additionally, PPP/EF temporizes arterial hemorrhage, providing valuable transfer time for facilities without angiography. With other urgent operative interventions required in85% of patients, combining these procedures with PPP/EF for operative pelvic hemorrhage control appears to optimize patient care.

Background Bedside percutaneous tracheostomy (BPT) is a cost-effective alternative to open tracheostomy. Small series have consistently documented minimal morbidity, but BPT has yet to be embraced as the standard of care. Because this has been our preferred technique in the surgical ICU for more than 20 years, we reviewed our experience to ascertain its safety. We hypothesize that BPT has acceptably minimal morbidity, even in high-risk patients. Study Design Patients undergoing BPT from January 1998 to June 2008 were reviewed. High-risk patients were defined as those with cervical collar or halo, cervical spine injuries, systemic heparinization, positive end-expiratory pressure >10 cm H 2 O or fraction of inspired oxygen > 50%. Results During the study period, 1,000 patients underwent BPT (74% men; mean ± SEM age 46 ± 0.6 years; 70% trauma). BPT was performed 8.9 ± 0.2 days (mean ± SEM) after admission. Patients remained ventilator dependent for an additional 9.7 ± 0.4 days (mean ± SEM). There were 482 (48%) patients undergoing BPT who were considered high-risk: 1 risk category, 273 patients; 2 risk categories, 139 patients; 3 risk categories, 56 patients; 4 risk categories, 12 patients; 5 risk categories, 2 patients. Complications occurred in 14 (1.4%) patients. Early complications included tracheostomy tube misplacement requiring revision (n = 4), bleeding requiring intervention (n = 2), infection (n = 1), and procedure failure requiring cricothyroidotomy (n = 1). Late complications included persistent stoma requiring operative closure (n = 4) and subglottic stenosis (n = 2). There were 6 complications (1.2%) in normal risk and 8 complications (1.7%) in high-risk patients. There were no deaths related to BPT. Conclusions BPT in the surgical intensive care unit is a safe procedure, even in high-risk patients. We believe BPT is the new gold standard for patients requiring tracheostomy for mechanical ventilation.

An unprecedented wave of terror has captivated world attention, highlighted by events of increasing magnitude. 1-8 Terror represents extremists’ persistent efforts to invoke fear to force their philosophies on the world population. Not unlike disease outbreaks in world history, the current terror epidemic knows no borders and strikes innocent civilians during their most productive years of life. The objective of terrorists is to kill and maim as many citizens as possible and to incite fear and chaos, so dense population centers and locations where the public congregates are prime targets. Traditionally, key factors emphasized in epidemiologicstudieshaveincludedthemagnitudeoftheproblem, populations affected, and patterns of injury. Based on such reviews, interventional efforts have been tailored for specific injury prevention. Although politicians worldwide debate negotiated solutions, the medical community must respond to the immediate needs of the population, dealing with the devastating effects after such mass casualty events. The management of mass casualty events demands strict adherence to established protocols and coordinated mobilization of available manpower and medical resources, which are stressed to the maximum. Lessons learned from regions of the world that have encountered terrorist attacks reinforce the concept that the sheer volume of injured patients encountered in such events may challenge even the most mature trauma system and the most experienced individual institution. 9-13 Accordingly, as greater experience

Background The clinical sequel of ischemia and reperfusion remains a challenge in several clinical areas. Overexpression of heme oxygenase-1 (HO-1), using viral vectors, endotoxemia, and hypoxia, provides protection against ischemia and reperfusion injury. To date, however, no clinically viable therapy exists to safely induce HO-1. We have recently observed that administration of a hemoglobin-based oxygen carrier (HBOC) attenuates postinjury systemic inflammation. We have further demonstrated that an HBOC can induce HO-1 in vitro. We now explore the tissue-specific induction of heme oxygenase-1 after administration of an HBOC. Study Design Rats were infused with doses of HBOC or saline through femoral vein injection (n=5 per group). Animals were sacrificed and organs were flushed. Heart, lung, and brain samples were taken for evaluation of total organ levels of HO-1 induction and for histologic localization of the cellular expression of the HO-1. Heat shock protein 72 levels were also analyzed to determine whether HO-1 induction was a generalized stress response. Results Both the heart and lung demonstrated a dose-dependent induction of total organ HO-1. Interestingly, brain tissue did not have any significant amount of HO-1, either at baseline or after HBOC therapy. The cellular localization of HO-1 between organs was also specific, predominantly occurring in the cardiac myocyte and alveolar macrophages. Heat shock protein 72 levels were not significantly changed in any group examined, suggesting the induction of HO-1 is specific. Conclusions This study demonstrates that a clinically accessible product, HBOC, can specifically and selectively induce the expression of the protective enzyme HO-1 in vivo. These findings begin to characterize which organ systems may benefit by preischemic treatments with HBOC and further expand potential clinical applications of HBOCs.

Background Damage-control laparotomy has become increasingly common after operative resuscitation of severe hemorrhagic shock after injury. Despite increased use, uncertainty exists about the safety and timing of enteral nutrition. The purpose of this study was to determine the safety and effect of immediate enteral nutrition. Study Design Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in adults with hemorrhagic shock after injury and were limited to patients with an open abdomen and no hollow viscus injury. The immediate enteral nutrition cohort was defined as initiation of enteral feeds within 36 hours after acute resuscitation completion. Multivariate stepwise logistic regression was used to evaluate factors associated with immediate enteral nutrition. Results One hundred subjects met inclusion criteria; 32 immediate enteral nutrition and 68 nonimmediate enteral nutrition. Nearly all patients underwent fascial closure (93.8% immediate enteral nutrition versus 94.1% nonimmediate enteral nutrition), with an average closure day of 6.47 ± 0.83 with immediate enteral nutrition and 8.55 ± 0.85 with nonimmediate enteral nutrition (p = 0.129). No significant difference in multiorgan dyfunction syndrome, length of ventilator days, ICU days, hospital days, or mortality was seen between groups. The rate of pneumonia was significantly different: 14 (43.8%) in immediate enteral nutrition and 49 (72.1%) in nonimmediate enteral nutrition (p = 0.008). Immediate enteral nutrition remained independently associated with a reduction in pneumonia within our stepwise regression (odds ratio=0.32; 95% CI, 0.13 to 0.79). Conclusions Immediate enteral nutrition after damage control appears safe, with no effect on abdominal closure rate. In addition, the reduction in pneumonia associated with immediate enteral nutrition suggests a tangible benefit. Immediate enteral nutrition should be considered in patients with open abdomens after severe trauma.

BACKGROUND: Obesity is an independent risk factor for a variety of diseases, including postinjury morbidity and mortality. Obesity is associated with a proinflammatory state that could affect the postinjury inflammatory response and increase risk of organ dysfunction. The purpose of this study was to determine the relationship between obesity and postinjury multiple organ failure (MOF). STUDY DESIGN: A prospective observational study of patients at risk for postinjury MOF. Inclusion criteria were age older than 15 years, Injury Severity Score > 15, ICU admission within 24 hours of injury, and survival longer than 48 hours after injury. Isolated head injuries were excluded. Organ dysfunction was assessed using the Denver multiple organ failure score. RESULTS: Data were collected on 716 severely injured patients, 70% were men and 83% were victims of blunt trauma. There was no relationship between body mass index and injury severity or the amount of blood transfused within 12 hours of injury. Postinjury MOF was observed in 123 of 564 (22%) nonobese patients and 56 of 152 (37%) obese patients. Obesity was independently associated with MOF (odds ratio, 1.8; 95% CI, 1.2-2.7) after adjusting for patient age, injury severity, and amount of blood transfused during resuscitation. In this study population, obesity was also associated with increased length of ICU and hospital stay but not death. CONCLUSIONS: Obese patients are at increased risk of postinjury MOF. Study of the obesity-related inflammatory profile could provide additional insight into the pathogenesis of organ dysfunction and identify therapeutic targets for both obese and nonobese patients. Increased morbidity and length of stay in obese trauma patients implies greater resource allocation for this population.

Background Our clinical trials using a polymerized hemoglobin solution (PolyHb) as a red cell substitute in severely injured patients suggested that this hemoglobin-based oxygen carrier has a systemic antiinflammatory effect. Heme oxygenase-1 (HO-1) has recently been shown to be cytoprotective, and is known to be induced by heme moieties. We investigated the effects of this hemoglobin-based oxygen carrier on HO-1 induction and proinflammatory activation of pulmonary endothelium. Study design Human lung microvascular endothelial cells were grown to confluence and preincubated with either cell media (control) or with an equal volume mixture of polymerized hemoglobin/cell media (experimental). The cell cultures were subsequently stimulated with lipopolysaccharide. HO-1 expression was detected by protein immunoblot and further quantified by ELISA; intercellular adhesion molecule-1 protein expression was measured by flow cytometry. Results Polymerized hemoglobin induced synthesis of HO-1 protein in human lung microvascular endothelial cells and, concurrently, inhibited lipopolysaccharide-induced intercellular adhesion molecule-1 protein cell surface expression. Conclusions Polymerized hemoglobin attenuates lipopolysaccharide-stimulated expression of intercellular adhesion molecule-1 protein, which is associated with upregulation of the cytoprotective protein HO-1 in human pulmonary endothelial cells. This antiinflammatory effect offers a novel mechanism by which hemoglobin-based oxygen carrier solutions may be exploited therapeutically as resuscitative fluids.

Background Documented prehospital asystole justifies termination of resuscitation, but recently it has been proposed to extend this policy to patients in the field with pulseless electrical activity. Consequently, we questioned whether resuscitative thoracotomy is warranted in the critically injured patient who fails to respond to prehospital CPR. Study design A prospective database of all emergency department resuscitative thoracotomies (EDT) performed at our Level I trauma center has been maintained since January 1977. These registry data were augmented by a review of prehospital paramedic records for all survivors of EDT to verify length of CPR. Results During the 26-year study period, 959 patients underwent EDT. Of the 62 patients who survived to leave the hospital, 26 (42%) required prehospital CPR. The injury mechanism in these 26 patients was stab wounds in 18 (69%), gunshot wounds in 4 (15%), and blunt trauma in 4 (15%). The duration of prehospital CPR ranged from 3 to 15 minutes and in 7 patients CPR exceeded 10 minutes. Five survivors had asystole documented at the time of EDT; four of these patients had good functional outcomes at discharge. Each of these patients had pericardial tamponade from ventricular stab wounds. Patients with blunt trauma had uniformly dismal neurologic outcomes. Conclusions EDT after prehospital CPR can be used to salvage select critically injured patients. Based on these data, we propose that resuscitative thoracotomy is futile care in patients with blunt trauma requiring prehospital CPR longer than 5 minutes, and in patients with penetrating trauma with more than 15 minutes of prehospital CPR. EDT is warranted in those patients with penetrating trauma with less than 15 minutes of prehospital CPR, and should be performed despite documented asystole on arrival if pericardial tamponade is the proximate event.

p d The Inpatient Prospective Payment System stipulates that hospitals must report rates of colon surgical site infection (SSI) to the National Healthcare Safety Network (NHSN) beginning in 2012, and colon SSI rates will be linked to reimbursement beginning in 2014. For the last decade, the se of pay-for-performance has been promoted in the belief hat economic incentives and penalties can accelerate imrovements in the quality and outcomes of care. Without n appropriate risk-stratification model, surgeons and hositals would be penalized for performing operations on atients at higher risk for SSI developing, including those ith more severe surgical disease or comorbid conditions. herefore, pay-for-performance can result in unintended utcomes, such as the exclusion of severely ill patients from are. NHSN used logistic regression to develop procedurespecific risk-adjustment models; this replaces the older National Nosocomial Infection Surveillance risk index system. This new tool is based largely on nonmodifiable patient and procedure factors and predicts the expected rate of SSI after various surgical procedures. The procedures and variables included in the model-building process were voluntarily reported from 2006 to 2008 in emergent, urgent, and elective settings. Formal assessment of data accuracy was not performed. Eight risk factors were found