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Transfusion of fresh frozen plasma (FFP) and platelets is independently associated with the development of multiple organ failure (MOF) in critically injured patients.Prospective cohort study.Academic regional level I trauma center.From 1992 to 2004, a total of 1440 critically injured patients were admitted to our surgical intensive care unit and survived at least 48 hours. Of these, 1415 had complete data on age, Injury Severity Score (ISS), and units of FFP, platelets, and packed red blood cells (PRBCs) transfused. Multiple organ failure was defined using the Denver MOF score. Multiple logistic regression analysis was used to adjust transfusion of FFP, platelets, and PRBCs for known MOF risk factors.Multiple organ failure.The mean (SD) ISS was 29.3 (11.3), and the mean (SD) patient age was 37.4 (16.6) years. Among 1440 patients, 346 (24.0%) developed MOF, and 118 (8.2%) died. Multiple logistic regression analysis detected a significant interaction between units of FFP and PRBCs transfused (P.001). Regardless of the units of PRBCs transfused, FFP transfusion was independently associated with the development of MOF. However, the deleterious effect associated with FFP transfusion was more prominent among patients receiving fewer than 6 U of PRBCs. Platelet transfusion was unassociated with MOF after adjustment for age, ISS, and FFP and PRBC transfusion.Early transfusion of FFP is associated with an increased risk of postinjury MOF, even after adjusting for age, ISS, and PRBC transfusion. Caution is warranted in developing protocols for empirical FFP transfusion. Specifically, transfusion triggers for FFP should be reexamined, as well as the practice of delivering FFP in fixed ratios to the units of PRBCs transfused.

Hypothesis We hypothesize that the 2 antithrombotic treatment regimens, systemic heparin sodium vs antiplatelet agents, are equivalent for the treatment of blunt cerebrovascular injuries (BCVIs) to prevent devastating injury-related strokes. Design Retrospective review of a prospective database. Setting Level I trauma center. Patients Patients with BCVIs from January 1, 1997, to January 1, 2007. Main Outcome Measures Incidence of cerebrovascular accident (CVA), stratified by treatment. Results During the study period, 422 BCVIs were identified in 301 patients (64.8% men; mean [SEM] age, 37.0 [0.8] years; mean [SEM] injury severity score, 27.0 [0.9]). A total of 22 patients presented with neurologic ischemia, and 5 patients sustained CVAs after embolization and/or stenting of an injury. Treatment was initiated for 282 asymptomatic BCVIs (heparin, 192; aspirin, 67; aspirin and/or clopidogrel, 23); 1 patient had a CVA (0.5%). Of 107 patients with untreated, asymptomatic BCVIs, 23 (21.5%) had a CVA. For untreated patients sustaining BCVI-related CVAs, the mean (SEM) time to diagnosis was 58 (10) hours. For those who did not exhibit symptoms within 2 hours of injury, mean time to diagnosis of CVA was 75 (11) hours. Injury healing rates (heparin, 39%; aspirin, 43%; aspirin/clopidogrel, 46%) and injury progression rates (12%; 10%; 15%) were equivalent between therapeutic regimens. Conclusions With an overall CVA risk of 21% and a documented latent period, comprehensive screening, early diagnosis, and institution of antithrombotic therapy for BCVI are clearly warranted. The type of treatment, heparin vs antiplatelet agents, does not appear to affect either stroke risk or injury healing rates.

Hypothesis The incidence and severity of postinjury multiple organ failure (MOF) has decreased over the last decade. Design A prospective 12-year inception cohort study ending December 31, 2003. Setting Regional academic level I trauma center. Patients One thousand three hundred forty-four trauma patients at risk for postinjury MOF. Inclusion criteria were aged older than 15 years, admission to the trauma intensive care unit, an Injury Severity Score higher than 15, and survival for more than 48 hours after injury. Isolated head injuries were excluded from this study. Previously identified risk factors for postinjury MOF were age, Injury Severity Score, and receiving a blood transfusion within 12 hours of injury. Main Outcome Measures Multiple organ failure was defined by a Denver MOF score of 4 or more for longer than 48 hours after injury. Multiple organ failure severity was defined by the maximum daily MOF score and the number of MOF free days within the first 28 postinjury days. Results Multiple organ failure was diagnosed in 339 (25%) of 1244 patients. The mean age and Injury Severity Scores increased and the use of blood transfusion during resuscitation decreased over the 12-year study period. After adjusting for age, injury severity, and amount of blood transfused during resuscitation, there was a decreased incidence of MOF over the study period. Of the patients who developed MOF, there was a decrease in disease severity and duration as measured by the maximum daily MOF score and the MOF free days. Although the overall mortality rate remained constant, the MOF-specific mortality decreased. Conclusions The incidence, severity, and attendant mortality of postinjury MOF decreased over the last 12 years despite an increased MOF risk. Improvements in MOF outcomes can be attributed to improvements in trauma and critical care and are associated with decreased use of blood transfusion during resuscitation.

Background Carotid stenting has been advocated in patients with grade III blunt carotid artery injuries (hereafter referred to as “blunt CAIs”) because of the persistence of the pseudoaneurysm and concern for subsequent embolization or rupture. Hypothesis Carotid stenting is safe and effective for blunt CAIs. Design Analysis of a prospective database of all patients with blunt CAIs. Setting A state-designated, level I, urban trauma center. Patients and Methods In January 1, 1996, we initiated comprehensive screening for blunt CAIs with angiography based on injury patterns. Patients without contraindications receive anticoagulation therapy immediately for documented lesions. Patients with persistent pseudoaneurysms on a second angiography at 7 to 10 days after injury are candidates for stent placement. Results During the study period (January 1, 1996, to May 1, 2004), 46 patients sustained blunt carotid pseudoaneurysms; 23 (50%) underwent carotid stent placement. There were 4 complications in patients undergoing carotid stent placement: 3 strokes and 1 subclavian dissection. Follow-up angiography was performed in 38 patients (18 patients with stents who received antithrombotic agents, 20 patients who received antithrombotic agents alone); 8 patients had poststent carotid occlusion despite having received concurrent anticoagulation therapy. Carotid occlusion rates were significantly different (45% in patients with stents vs 5% in those who received antithrombotic agents alone). In the patients not undergoing stent placement, the only complication was a middle cerebral artery stroke in a patient not treated with antithrombotic therapy. Conclusions Patients who have carotid stents placed for blunt carotid pseudoaneurysms have a 21% complication rate and a documented occlusion rate of 45%. In contrast, patients treated with antithrombotic agents alone had an occlusion rate of 5%; no asymptomatic patient treated with antithrombotic agents for their injury had a stroke. Antithrombotic therapy remains the recommended therapy for blunt CAIs, but the role of intraluminal stents remains to be defined.

Hypothesis Multiple organ dysfunction (MOD) within 48 hours of injury is a reversible physiologic response to tissue injury and resuscitation. Design A prospective 10-year inception cohort study ending September 2003. Setting Regional academic level I trauma center. Patients One thousand two hundred seventy-seven consecutive trauma patients at risk for postinjury multiple organ failure (MOF). Inclusion criteria were being 16 years and older, being admitted to the trauma intensive care unit, having an Injury Severity Score higher than 15, and surviving more than 48 hours after injury. Isolated head injuries were excluded. Interventions None. Main Outcome Measures Development of postinjury MOD as defined by a Denver MOF score of 4 or higher within 48 hours of injury and MOF as defined by a Denver MOF score of 4 or higher more than 48 hours after injury. Results Postinjury MOD and MOF were diagnosed in 209 (16%) and 300 (23%) patients, respectively. Age, Injury Severity Score, and 12-hour blood transfusion requirements were significantly higher among patients who developed MOD and MOF. Of the 209 patients who developed MOD, 134 (64%) progressively developed MOF while 75 (36%) had MOD resolve within 48 hours. Conclusion Multiple organ dysfunction during resuscitation is a reversible response to severe injury and often resolves during the resuscitation period.