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Background Although survival benefits have been shown at the population level, it remains unclear what drives the outcome benefits for helicopter emergency medical services (HEMS) in trauma. Although speed is often cited as the vital factor of HEMS, we hypothesized a survival benefit would exist in the absence of a time savings over ground emergency medical services (GEMS). The objective was to examine the association of survival with HEMS compared with GEMS transport across similar prehospital transport times. Methods We used a retrospective cohort of scene HEMS and GEMS transports in the National Trauma Databank (2007–2012). Propensity score matching was used to match HEMS and GEMS subjects on the likelihood of HEMS transport. Subjects were stratified by prehospital transport times in 5-minute increments. Conditional logistic regression determined the association of HEMS with survival across prehospital transport times strata controlling for confounders. Transport distance was estimated from prehospital transport times and average HEMS/GEMS transport speeds. Results There were 155,691 HEMS/GEMS pairs matched. HEMS had a survival benefit over GEMS for prehospital transport times between 6 and 30 minutes. This benefit ranged from a 46% increase in odds of survival between 26 and 30 minutes (adjusted odds ratio [AOR], 1.46; 95% CI, 1.11–1.93; P < .01) to an 80% increase in odds of survival between 16 and 20 minutes (AOR, 1.80; 95% CI, 1.51–2.14; P < .01). This prehospital transport times window corresponds to estimated transport distance between 14.3 and 71.3 miles for HEMS and 3.3 and 16.6 miles for GEMS. Conclusion When stratified by prehospital transport times, HEMS had a survival benefit concentrated in a window between 6 and 30 minutes. Because there was no time-savings advantage for HEMS, these findings may reflect care delivered by HEMS providers. [ABSTRACT FROM AUTHOR]

Background Many institutions now use empiric full-body computed tomography (CT) as a standard step in the initial workup of stable trauma patients. Recent data suggest that these scans may reveal unexpected injuries and improve survival in patients with polytrauma. However, patients who are unstable on presentation are often taken to the operating room (OR) without CT. Many of these patients undergo empiric full-body CTs after being stabilized in the OR, yet few data exist regarding how often early postoperative CT reveals unexpected injuries within compartments that have been explored surgically. Thus, the objective of this study was to determine if empiric abdominal/pelvic (ABD) CT after emergent trauma laparotomies are likely to reveal missed injuries requiring urgent management and improve patient management compared with clinical judgment alone. Methods We review retrospectively 496 trauma patients who required urgent exploratory laparotomy at UPMC Presbyterian Hospital from 2007 to 2011. Patients were included if they went to the OR for exploratory laparotomy directly from the emergency department within 2 hours of arrival. Patients were excluded if they received any preoperative ABD CT imaging. Patients who expired in the OR were similarly excluded. Patients were stratified into 2 groups based on whether or not they received an empiric ABD CT in the 24 hours immediately after laparotomy. Medical records were reviewed to look for differences in missed injuries, urgent reexplorations, nontherapeutic interventions, and time to urgent reexploration. Results There were 278 patients who met inclusion at exclusion criteria and constituted the study cohort. Of these patients, 124 underwent early empiric postoperative ABD CT imaging (45%). The remaining 154 patients did not undergo early ABD imaging (no CT group). The overall cohort had a 45% incidence of damage control procedures and a 9% rate of negative laparotomy. The 2 groups were statistically similar in age, presenting vitals, and abdominal Abbreviated Injury Scores. When the ABD CT group was compared with the no CT group, there was no difference in the overall rate of urgent reexplorations (7.3 vs 7.1%; P = .956), nontherapeutic urgent reexplorations (22 vs 18%; P = .822), or time to urgent reexploration (14 ± 10 vs 12 ± 10 hours; P = .686). Out of the 124 ABD CT patients, only 5 (4.0%) were diagnosed with injuries that were not identified at the time of the initial operation or caused by operative technique. When controlling for demographics, mechanism of injury, and injury severity, a logistic regression analysis revealed that early postoperative ABD CT was not associated with any differential risk of the need for further intervention (odds ratio, 0.85; 95% CI, 0.37–1.9; P = .691). Conclusion The use of ABD CT soon after trauma laparotomy did not provide meaningful improvements in patient care in the cohort studied. Further higher level research is needed to clarify what role empiric ABD CT should play in the early postoperative period. [ABSTRACT FROM AUTHOR]

Background: Thoracic surgeons are commonly consulted to provide anterior thoracic exposure for infection and malignant neoplasms involving the thoracolumbar spine. These cases can present significant technical and management challenges secondary to the underlying pathology, associated anatomic inflammation, and impaired functional status. In this study, we review the perioperative outcomes in patients undergoing anterior spinal exposure for infection and neoplasm. Methods: 130 consecutive patients (61 women, 69 men) undergoing corpectomy, debridement, or debulking for osteomyelitis (n = 50) or neoplasms (n = 80) with decompression/stabilization at a single institution were analyzed. Primary endpoints included morbidity, mortality, and perioperative neurologic outcomes. Results: The mean age was 61.1 years. A cervical/sternotomy (n = 8) approach was used for levels C7 to T2, thoracotomy (n = 79) for levels T3 to T10, and thoracoabdominal (n = 43) for T11 to L2 involvement. Primary spinal neoplasms (n = 22, 16.9 %) and metastases (n = 58, 44.6%) were treated with corpectomy and prosthetic stabilization and were associated with increased operative time (310 vs 243 minutes, p = 0.02) and blood loss (825 vs 500 mL, p = 0.002). Osteomyelitis was associated with longer hospital stays (12 vs 7 days, p < 0.001). The 30-day and 90-day mortality was 9.2% and 20.8%, respectively. The major complication rate was 27.7%. The median length of stay was 9 days. Surgical intervention resulted in significant improvement in pain, numbness, weakness, and bowel and bladder dysfunction. Conclusions: Anterior spinal exposure represents an important modality in facilitating the treatment of patients with osteomyelitis, pathologic fractures, and spinal cord compression syndromes. These procedures are associated with a significant risk of morbidity and mortality, but they are effective in achieving spinal stabilization and alleviating neurologic symptoms. [Copyright &y& Elsevier]

Introduction: Routine, whole-body computed tomography imaging (PAN-SCAN) has been shown to identify unexpected injuries and alter the management of patients presenting with blunt trauma. We sought to characterize the changes in practice over time and the utility of PAN-SCAN imaging in elderly patients who fall and require admission to a trauma center. Methods: We performed a retrospective analysis by using data derived from a Pennsylvania state-wide trauma registry (2007–2010). All hemodynamically stable patients (>65 years) who had a ground-level fall and were admitted for >24 hours were selected. Patients who underwent a combination of all three scans within 2 hours of arrival were considered to have underwent PAN-SCAN imaging. Clinical outcomes were compared across PAN-SCAN patients relative to less diagnostic imaging. Regression analysis was used to determine whether PAN-SCAN imaging was an independent determinate of mortality and resource use. Results: Over the period of study, 13,043 patients met inclusion criteria. The annual rate of PAN-SCAN imaging after ground-level falls increased over time. After we controlled for important confounders, PAN-SCAN imaging was not associated with mortality (odds ratio 0.97, P = .74, 95% confidence interval 0.80–1.18). Despite greater injury severity, PAN-SCAN imaging was independently associated with significantly lesser intensive care unit requirements, step-down days, and a lesser overall duration of stay. Conclusion: PAN-SCAN imaging has become more common over time in elderly patients having a ground-level fall. Although PAN-SCAN imaging during the initial trauma evaluation was not associated with an independent decrease in the risk of mortality, it was independently associated with lesser hospital resource use. These data suggest that whole-body computed tomography imaging may benefit trauma center resource use for patients with ground-level falls. [Copyright &y& Elsevier]

Introduction: Computed tomography (CT) has become an essential tool in the assessment of the stable trauma patient. Intravenous (IV) contrast is commonly relied upon to provide superior image quality, particularly for solid-organ injury. However, a substantial proportion of injured patients have contraindications to IV contrast. Little information exists concerning the repercussions of CT imaging without IV contrast, specifically for splenic injury. Methods: We performed a retrospective analysis using data from our trauma registry and chart review as part of a quality improvement project at our institution. All patients with splenic injury, during a 3-year period (2008–2010), where a CT of the abdomen without IV contrast (DRY) early during their admission were selected. All splenic injuries had to have been verified with abdominal CT imaging with IV contrast (CONTRAST) or via intraoperative findings. DRY images were independently read by a single, blinded, radiologist and assessed for parenchymal injury or “suspicious” splenic injury findings and compared with CONTRAST imaging results or intraoperative findings. Results: During the time period of the study, 319 patients had documented splenic injury with 44 (14%) patients undergoing DRY imaging, which was also verified by CONTRAST imaging or operative findings. Splenic parenchymal injury was only visualized in 38% of patients DRY patients. “Suspicious” splenic injury radiographic findings were common. When these less-specific findings for splenic injury were incorporated in the radiographic assessment, DRY imaging had more than 93% sensitivity for detecting splenic injury. Conclusion: DRY imaging is increasingly being performed after injury and has a low sensitivity in detecting splenic parenchymal injury. However, less-specific radiographic findings suspicious for splenic injury in combination provide high sensitivity for the detection of splenic injury. These results suggest CONTRAST imaging is preferred to detect splenic injury; however, in those patients who have contraindications to IV contrast, DRY imagining may be able to select those who require close monitoring or intervention. [Copyright &y& Elsevier]

Background: Injured elderly patients experience high rates of undertriage to trauma centers (TCs) whereas debate continues regarding the age defining a geriatric trauma patient. We sought to identify when mortality risk increases in injured patients as the result of age alone to determine whether TC care was associated with improved outcomes for these patients and to estimate the added admissions burden to TCs using an age threshold for triage. Methods: We performed a retrospective cohort study of injured patients treated at TCs and non-TCs in Pennsylvania from April 1, 2001, to March 31, 2005. Patients were included if they were between 19 and 100 years of age and had sustained minimal injury (Injury Severity Score < 9). The primary outcome was in-hospital mortality. We analyzed age as a predictor of mortality by using the fractional polynomial method. Results: A total of 104,015 patients were included. Mortality risk significantly increased at 57 years (odds ratio 5.58; 95% confidence interval 1.07–29.0; P = .04) relative to 19-year-old patients. TC care was associated with a decreased mortality risk compared with non-TC care (odds ratio 0.83; 95% confidence interval 0.69–0.99; P = .04). Using an age of 70 as a threshold for mandatory triage, we estimated TCs could expect an annual increase of approximately one additional admission per day. Conclusion: Age is a significant risk factor for mortality in trauma patients, and TC care improves outcomes even in older, minimally injured patients. An age threshold should be considered as a criterion for TC triage. Use of the clinically relevant age of 70 as this threshold would not impose a substantial increase on annual TC admissions. [ABSTRACT FROM AUTHOR]

Background: Platelet transfusion is utilized increasingly for traumatic brain injury (TBI) for the reversal of aspirin (ASA) therapy. Assessment of platelet inhibition and reversal by platelet transfusion after TBI has not been adequately characterized. Methods: A retrospective cohort analysis of TBI patients at a level I trauma center (January 2008–December 2009) was performed. The Aspirin Response Test (ART; VerifyNow) was used to assess platelet inhibition in TBI patients and guide platelet transfusion in patients with ASA-induced suppression. A follow-up ART was obtained after platelet administration. Primary endpoints were progression of intracranial hemorrhage on computed tomography, need for craniotomy, and mortality. Results: We analyzed 84 patients (median age, 78 [interquartile range, 64–86)]; 54% male). ASA use was documented in 36 (42%) patients. Initial ART indicated platelet dysfunction in 54 (64%) patients, including 42% of patients without a documented history of ASA use. Of the patients with a documented history of ASA, 2.4% had a normal ART. Of those with an initial ART of <550 ASA response units, 45 received platelets. Repeat ART demonstrated reversal of inhibition in 29 patients (64.4%). Initial responders to transfusion received a greater volume of platelets, suggesting a dose–response relationship. Logistic regression revealed a trend toward higher mortality in nonresponders to transfusion (P = .09). Receiver operating characteristic curve analysis revealed that ART results increased prediction of poor outcome compared with ASA history alone (area under the curve = 0.760 and 0.775, respectively). Conclusion: The ART should be used to better target and guide platelet transfusions in TBI patients with known or suspected ASA use history. Patients with occult platelet dysfunction can be identified, unnecessary platelet transfusions avoided, and the adequate volume of platelets administered to correct drug-induced dysfunction. A dose–response relationship between quantity of platelets transfused and reversal of ASA inhibition was observed. [Copyright &y& Elsevier]

Background: With liberal use of computed tomography in the diagnostic management of trauma patients, incidental findings are common and represent a major patient-care and medical–legal concern. Consequently, we began an initiative to capture, notify, and documentadequately incidental finding events with a dedicated incidental finding coordinator. We hypothesized a dedicated incidental finding coordinator would increase incidental finding capture and promote notification, follow-up, and documentation of incidental finding events. Methods: A quality-improvement project to record and follow-up incidental findings postinjury was initiated at our level I trauma center (April 2007–March 2008, prededicated incidental finding). Because of concerns for inadequate documentation of identified incidental finding events, we implemented a dedicated incidental finding coordinator (April 2008–March 2009, postdedicated incidental finding). The dedicated incidental finding coordinator documented incidental findings daily from trauma admission radiology final reads. Incidental findings were divided into 3 groups; category 1: attention prior to discharge; category 2: follow-up with primary doctor within 2 weeks; category 3: no specific follow-up. For category 1 incidental findings, in-hospital consultation of the appropriate service was verified. On discharge, patient notification, follow-up, and documentation of events were confirmed. Certified mail or telephone contact was used to notify either the patient or the primary doctor in those who lacked appropriate notification or documentation. Results: Admission rates and incidental finding categories were similar across the 2 time periods. Implementation of a dedicated incidental finding coordinator resulted in more than a 165% increase in incidental finding capture (n = 802 vs n = 302; P < .001). Patient notification was attempted, and appropriate documentation of events was confirmed in 99.8% of patients. Patient notification was verified, and follow-up was initiated in 95.8% of cases. Conclusion: The implementation of a dedicated incidental finding coordinator resulted in more than a 2.5-fold higher capture of incidental findings. Dedicated attention to incidental findings resulted in a near complete initiation of patient notification, follow-up, and hospital record documentation of incidental finding events. Inadequate patient notification and follow-up would delay appropriate care and potentially would result in morbidity or even mortality. A dedicated incidental finding coordinator represents a potential solution to this patient-care and medical–legal dilemma. [Copyright &y& Elsevier]

Abstract: Objectives: Incidental findings found on computed tomography (CT) scan during the Emergency Department evaluation of trauma patients are often benign, but their presence must always be communicated to patients, who should be referred for follow-up care. Our objective was to quantify the frequency of these incidental CT findings in trauma patients. A secondary goal was to determine how often these lesions were communicated to patients and how often patients were referred for follow-up. Methods: We performed a retrospective chart review of 500 consecutive patients presenting as trauma activations. Subjects received head, chest, or abdomen/pelvis CT scans at our hospital. Patients were identified using our trauma registry. Final CT reports were examined and discharge summaries were reviewed for basic demographics. Scans with incidental findings prompted detailed secondary review of discharge summaries to determine follow-up. Investigators reviewed incidental findings and classified them into three groups by clinical importance, using predetermined criteria. Results: Of the 500 patient charts identified for review, 480 (96%) were available, yielding 1930 CT reports for analysis. Incidental findings were noted in 211 of 480 (43%) patients and on 285 (15%) of the 1930 CT studies performed for the 480 patients. Of available patient records, only 27% of patient charts had mention of the finding in the discharge summary, had documentation of an in-hospital workup, or had documentation of a referral for follow-up. Most-concerning lesions, such as suspected malignancies or aortic aneurysms, accounted for 15% of all incidental findings and were referred for follow-up in only 49% of cases. Conclusions: Incidental findings were noted in 15% of trauma CT scans. Follow-up was poor, even for potentially serious findings. Further studies should examine the long-term outcome of patients with these findings. [Copyright &y& Elsevier]

Background: In the trauma population, the use of retrievable inferior vena cava filters (RIVCF) is rapidly gaining acceptance in patients at high risk for venous thromboembolism. This study reports the impact of an institutional protocol on retrieval rates of RIVCF at a level I trauma center. Methods: A review of an institutional Trauma Registry identified 94 consecutive patients who received RIVCF between January 2004 and February 2007 (group I) before the protocol was instituted. Under the protocol, 61 consecutive trauma patients received RIVCF between August 2007 and July 2008 (group II) and were prospectively followed. Results: Filter retrieval eligibility criteria were met in 81% (76/94) of patients in group I and in 61% (37/61) of patients in group II. Of those eligible, retrieval-attempt rates were 42% (32/76) in group I versus 95% (35/37) in group II (P < .001). Clinician oversight of the filter accounted for 89% (39/44) of failure of retrieval attempts; patient noncompliance accounted for the rest in group I. In group II, the latter accounted for all such failures. Retrieval was successful in 37% (28/76) and in 84% (31/37) of the eligible patients in groups I and II, respectively (P < .001). No retrieval procedure-related complications occurred. Conclusion: An institutional protocol for prospective monitoring of RIVCF significantly increases filter retrieval rate. [Copyright &y& Elsevier]

Background: Thoracic surgeons are frequently called upon to provide exposure to the anterior cervicothoracic, thoracic, and proximal lumbar spine. We reviewed our surgical experience and the perioperative outcomes of these spinal approaches. Relevant technical and anatomic considerations of each procedure are highlighted. Methods: A total of 213 patients (116 female, 97 male) undergoing anterior thoracic spinal exposures over an 11-year period at a single institution were analyzed. Primary endpoints include morbidity, mortality, and perioperative outcomes. Results: Mean age was 53.7 years. Surgical approaches were determined based on the location and length of spinal involvement, and included cervicothoracic (5), thoracotomy (117), and thoracoabdominal (91) techniques. Malignant etiologies were associated with the highest perioperative mortality (6.7%, p = 0.08). Procedures for infection were associated with a significantly higher complication rate (p = 0.041) and length of stay (p = 0.033). Correction of scoliosis required longer operative times (p < 0.001) and resulted in a trend toward higher blood loss (p = 0.16). Thoracoabdominal approaches were associated with increased operative times (386 vs 316 minutes) and length of stay (8 vs 6 days) compared with thoracotomy. Conclusions: The increased use of anterior approaches to spinal pathology necessitates greater involvement by thoracic surgeons. Familiarity with the anatomic and technical features of the anterior spinal exposure is required by thoracic surgeons to optimize surgical outcomes. [Copyright &y& Elsevier]

Background: The management of splenic injuries has evolved with a greater emphasis on nonoperative management. Although several institutions have demonstrated that nonoperative management of splenic injuries can be performed with an increasing degree of success, the impact of this treatment shift on outcome for all patients with splenic injuries remains unknown. We hypothesized that outcomes for patients with splenic injuries have improved as the paradigm for splenic injury treatment has shifted. Methods: Consecutive patients from 1987 to 2001 with splenic injuries who were entered into a state trauma registry were reviewed. Demographic variables, injury characteristics, and outcome data were collected. Results: The number of patients who were diagnosed with splenic injuries increased from 1987 through 2001, despite a stable number of institutions submitting data to the registry. The number of minor injuries and severe splenic injuries remained stable, and the number of moderately severe injuries significantly increased over time. Overall mortality rate improved but primarily reflected the decreased mortality rates of moderately severe injuries; the mortality rate for severe splenic injuries was unchanged. Conclusion: Trauma centers are seeing increasing numbers of splenic injuries that are less severe in magnitude, although the number of the most severe splenic injuries is stable. The increased proportion of patients with less severe splenic injuries who are being admitted to trauma centers is a significant factor in the increased use and success rate of nonoperative management. [Copyright &y& Elsevier]

Background: The Eastern Association for the Surgery of Trauma Multiinstitutional Workgroup reported a failure rate for nonoperative management of blunt splenic injury in adults of 10.8%. Sixty percent of the failures occurred within 24hours of admission. The purpose of this multiinstitutional study by the Eastern Association for the Surgery of Trauma was to determine common variables in failure of nonoperative management of blunt splenic injury in adults. Study design: Medical records were reviewed in a blinded fashion on 78 patients in whom nonoperative management failed. Statistical analysis was performed with ANOVA, extended chi-square, and Fisher’s exact test; statistical significance was p&#60;0.05. Results: The 78 patients were categorized based on hemodynamic status. Forty-four percent were stable; 31% had transient hypotension or tachycardia that resolved with fluid infusion (responders); and 25% were unstable. Two-thirds of the unstable patients required laparotomy within 12hours of admission; all had laparotomy within 72hours. Mortality was significantly different when comparing the unstable to the stable and responder groups: stable (3%), responders (8%), and unstable (37%), despite similar age and only modest differences in Injury Severity Score. Eight CT scans were misinterpreted initially. Of 26 Focused Abdominal Sonography for Trauma (FAST) studies, 11 (42.3%) were false negative. Abnormal abdominal findings were noted in 67.7% of patients on admission. Ten patients died (12.8%). Sixty percent of the deaths were caused largely by delayed treatment of splenic or other abdominal injuries; one patient died in the responder group and five unstable patients died. Conclusions: Thirty percent to 40% of the patients who had unsuccessful nonoperative management in this study were selected inappropriately, with hemodynamic instability or initial misinterpretation of diagnostic studies. As a consequence, the majority of the deaths were from delayed treatment of intraabdominal injuries. This article suggests that written protocols, better adherence to sound clinical judgment, and experienced and timely interpretation of radiologic studies would reduce the incidence of failure of nonoperative management of blunt splenic injury in adults. [Copyright &y& Elsevier]

Background: Admission physiology predicts mortality after injury, but may be improved by resuscitation before transfer. This phenomenon, which has been termed lead-time bias, may lead to underprediction of mortality in transferred patients and inaccurate benchmarking in centers receiving large numbers of transfer patients. We sought to determine the impact of using vital signs on arrival at the referring center vs on arrival at the trauma center in mortality prediction models for transferred trauma patients.Study Design: We performed a retrospective cohort study using a state-wide trauma registry including all patients age 16 years or older, with Abbreviated Injury Scale scores ≥ 3, admitted to level I and II trauma centers in Pennsylvania, from 2011 to 2014. The primary outcomes measure was the risk-adjusted association between mortality and interhospital transfer (IHT) when adjusting for physiology (as measured by Revised Trauma Score [RTS]) using the referring hospital arrival vital signs (model 1) compared with trauma center arrival vital signs (model 2).Results: After adjusting for patient and injury factors, IHT was associated with reduced mortality (odds ratio [OR] 0.85; 95% CI 0.77 to 0.93) using the RTS from trauma center admission, but with increased mortality (OR 1.15; 95% CI 1.05 to 1.27) using RTS from the referring hospital. The greater the number of transfer patients seen by a center, the greater the difference in center-level mortality predicted by the 2 models (β -0.044; 95% CI -0.044 to -0.0043; p ≤ 0.001).Conclusions: Trauma center vital signs underestimate mortality in transfer patients and may lead to incorrect estimates of expected mortality. Where possible, benchmarking efforts should use referring hospital vital signs to risk-adjust IHT patients. [ABSTRACT FROM AUTHOR]

Background Hemorrhage is the leading cause of survivable death in trauma and resuscitation strategies including early RBC transfusion have reduced this. Pre-trauma center (PTC) RBC transfusion is growing and preliminary evidence suggests improved outcomes. The study objective was to evaluate the association of PTC RBC transfusion with outcomes in air medical trauma patients. Study Design We conducted a retrospective cohort study of trauma patients transported by helicopter to a Level I trauma center from 2007 to 2012. Patients receiving PTC RBC transfusion were matched to control patients (receiving no PTC RBC transfusion during transport) in a 1:2 ratio using a propensity score based on prehospital variables. Conditional logistic regression and mixed-effects linear regression were used to determine the association of PTC RBC transfusion with outcomes. Subgroup analysis was performed for scene transport patients. Results Two-hundred and forty treatment patients were matched to 480 control patients receiving no PTC RBC transfusion. Pre-trauma center RBC transfusion was associated with increased odds of 24-hour survival (adjusted odds ratio [AOR] = 4.92; 95% CI, 1.51–16.04; p = 0.01), lower odds of shock (AOR = 0.28; 95% CI, 0.09–0.85; p = 0.03), and lower 24-hour RBC requirement (Coefficient −3.6 RBC units; 95% CI, −7.0 to −0.2; p = 0.04). Among matched scene patients, PTC RBC was also associated with increased odds of 24-hour survival (AOR = 6.31; 95% CI, 1.88–21.14; p < 0.01), lower odds of shock (AOR = 0.24; 95% CI, 0.07–0.80; p = 0.02), and lower 24-hour RBC requirement (Coefficient −4.5 RBC units; 95% CI, −8.3 to −0.7; p = 0.02). Conclusions Pre-trauma center RBC was associated with an increased probability of 24-hour survival, decreased risk of shock, and lower 24-hour RBC requirement. Pre-trauma center RBC appears beneficial in severely injured air medical trauma patients and prospective study is warranted as PTC RBC transfusion becomes more readily available. [ABSTRACT FROM AUTHOR]

Background: Recently, concern has been raised that the use of massive transfusion protocols (MTPs) in nontrauma (ie, general medical/surgical [GMS]) patients might be inefficient due to protocol overactivation (activation in patients who do not ultimately receive massive transfusion). The current study was designed to investigate whether an MTP could be used effectively in GMS patients without detrimentally impacting resource allocation. Study Design: A retrospective analysis was performed using institutional blood bank records from 2011. Trauma and GMS patients who had ≥10 U packed RBC issued to them in a single release were identified and categorized into MTP and no MTP (nMTP) cohorts. Results: The protocol was overactivated in 53.8% of GMS patients. Activation of the MTP accelerated the delivery of component products for all patients. In GMS MTP patients, fresh frozen plasma units were issued a median of 7 minutes earlier than in GMS nMTP patients (MTP: median 1.0 minute; interquartile range [IQR] 0.0 to 2.0 minutes vs nMTP: median 8.0 minutes; IQR 0.0 to 37.5 minutes; p = 0.009), and platelet units were issued 17 minutes earlier (MTP: median 7.0 minutes; IQR 0.0 to 15.0 minutes vs nMTP: median 24.0 minutes; IQR 9.0 to 96.0 minutes; p = 0.010). In GMS MTP patients, there was a statistically significant increase in the percentage of platelet units wasted (MTP 12.8% vs nMTP 8.1%; p = 0.046). This increase was also seen in trauma MTP patients (MTP 12.2% vs nMTP 4.0%; p < 0.001). Conclusions: Despite finding that our MTP is overactivated in GMS patients, we could identify no unique disadvantages to its use with respect to resource allocation. In fact, a potential advantage to MTP activation exists, as products are issued more quickly with less variability. Our findings of increased platelet waste were not unique to GMS patients and should be used as a metric for quality improvement. [ABSTRACT FROM AUTHOR]

Background: Controversy exists about the mechanisms responsible for sex-based outcomes differences post-injury. X-chromosome–linked immune response pathway polymorphisms represent a potential mechanism resulting in sex-based outcomes differences post-injury. The prevalence of these variants is known to differ across race. We sought to characterize racial differences and the strength of any sex-based dimorphism post-injury. Study Design: A retrospective analysis was performed using data derived from the National Trauma Data Bank 7.1 (2002−2006). Blunt-injured adult (older than 15 years) patients, surviving >24 hours and with an Injury Severity Score >16 were analyzed (n = 244,371). Patients were stratified by race (Caucasian, black, Hispanic, Asian) and multivariable regression analysis was used to characterize the risk of mortality and the strength of protection associated with sex (female vs male). Results: When stratified by race, multivariable models demonstrated Caucasian females had an 8.5% lower adjusted risk of mortality (odds ratio [OR] = 0.91; 95% CI, 0.88−0.95; p < 0.001) relative to Caucasian males, with no significant association found for Hispanics or blacks. An exaggerated survival benefit was afforded to Asian females relative to Asian males, having a >40% lower adjusted risk of mortality (OR = 0.59; 95% CI, 0.44−78; p < 0.001). Asian males had a >75% higher adjusted risk of mortality relative to non-Asian males (OR = 1.77; 95% CI, 1.5−2.0; p < 0.001), and no significant difference in the mortality risk was found for Asian females relative to non-Asian females. Conclusions: These results suggest that Asian race is associated with sex-based outcomes differences that are exaggerated, resulting from worse outcomes for Asian males. These racial disparities suggest a negative male X-chromosome–linked effect as the mechanism responsible for these sex-based outcomes differences. [ABSTRACT FROM AUTHOR]

: BackgroundThe factors important in determining outcome when managing adult blunt splenic injuries continue to be debated. Whether trauma center level designation (Level I versus Level II) affects patient management has not been evaluated.: Study designWe conducted a retrospective analysis of prospectively gathered data from the Pennsylvania Trauma Outcome Study database that collected information from 27 statewide trauma centers (Level I [15], Level II [17]). Adult patients (ages ≥ 16 years) with blunt splenic injuries (ICD-9-CM 865) were evaluated. Demographic data, injury data, and trauma center level designation were collected, and patient management, length of stay, and mortality were analyzed.: ResultsThere were 2,138 adult patients who suffered blunt splenic injuries during the study period (1998–2000). Patients treated at Level II trauma centers (n = 772) had a higher rate of operative treatment (38.2% versus 30.7%) (p < 0.001), but a shorter mean length of stay (10.1 ± 0.4 versus 12.0 ± 0.4 days) (p < 0.01) compared with patients in Level I trauma centers (n = 1,366). The rate of failure of nonoperative treatment was lower at Level II trauma centers (13.0% versus 17.6%) (p < 0.05), but the mortality for patients managed nonoperatively was higher (8.4% versus 4.5%) (p < 0.05). Splenorrhaphy was performed more frequently in Level I trauma centers.: ConclusionsManagement differences exist in the treatment of adult blunt splenic injuries between institutions of different trauma center level designation. Multicenter studies should account for this finding in design and implementation. [Copyright &y& Elsevier]