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BACKGROUND: The Injury Severity Score (ISS) is widely used as a method for rating severity of injury. The ISS is the sum of the squares of the three worst Abbreviated Injury Scale (AIS) values from three body regions. Patients with penetrating injuries tend to have higher mortality rates for a given ISS than patients with blunt injuries. This is thought to be secondary to the increased prevalence of multiple severe injuries in the same body region in patients with penetrating injuries, which the ISS does not account for. We hypothesized that the mechanism-based difference in mortality could be attributed to certain ISS ranges and specific AIS values by body region. METHODS: Outcome and injury scoring data were obtained from transfused patients admitted to 23 Level I trauma centers. ISS values were grouped into categories, and a logistic regression model was created. Mortality for each ISS category was determined and compared with the ISS 1 to 15 group. An interaction term was added to evaluate the effect of mechanism. Additional logistic regression models were created to examine each AIS category individually. RESULTS: There were 2,292 patients in the cohort. An overall interaction between ISS and mechanism was observed (p = 0.049). Mortality rates between blunt and penetrating patients with an ISS between 25 and 40 were significantly different (23.6 vs. 36.1%; p = 0.022). Within this range, the magnitude of the difference in mortality was far higher for penetrating patients with head injuries (75% vs. 37% for blunt) than truncal injuries (26% vs. 17% for blunt). Penetrating trauma patients with an AIS head of 4 or 5, AIS abdomen of 3, or AIS extremity of 3 all had adjusted mortality rates higher than blunt trauma patients with those values. CONCLUSION: Significant differences in mortality between blunt and penetrating trauma patients exist at certain ISS and AIS category values. The mortality difference is greatest for head injured patients. Language: en

Background Significant differences in outcomes have been demonstrated between Level I trauma centers. Usually these differences are ascribed to regional or administrative differences, although the influence of variation in clinical practice is rarely considered. This study was undertaken to determine whether differences in early mortality of patients receiving a massive transfusion (MT, ≥ 10 units pf RBCs within 24 hours of admission) persist after adjustment for patient and transfusion practice differences. We hypothesized differences among centers in 24-hour mortality could predominantly be accounted for by differences in transfusion practices as well as patient characteristics. Methods Data were retrospectively collected over a 1-year period from 15 Level I centers on patients receiving an MT. A purposeful variable selection strategy was used to build the final multivariable logistic model to assess differences between centers in 24-hour mortality. Adjusted odds ratios for each center were calculated. Results : There were 550 patients evaluated, but only 443 patients had complete data for the set of variables included in the final model. Unadjusted mortality varied considerably across centers, ranging from 10% to 75%. Multivariable logistic regression identified injury severity score (ISS), abbreviated injury scale (AIS) of the chest, admission base deficit, admission heart rate, and total units of RBC transfused, as well as ratios of plasma:RBC and platelet:RBC to be associated with 24-hour mortality. After adjusting for severity of injury and transfusion, treatment variables between center differences were no longer significant. Conclusions In the defined population of patients receiving an MT, between-center differences in 24-hour mortality may be accounted for by severity of injury as well as transfusion practices.

Background: The effect of blood component ratios on the survival of patients with traumatic brain injury (TBI) has not been studied. Methods: A database of patients transfused in the first 24 hours after admission for injury from 22 Level I trauma centers over an 18-month period was queried to find patients who (1) met different definitions of massive transfusion (5 units red blood cell [RBC] in 6 hours vs. 10 units RBC in 24 hours), (2) received high or low ratios of platelets or plasma to RBC units (1:2 vs. /=1:2), and (3) had severe TBI (head abbreviated injury score /=3) (TBI+). Results: Of 2,312 total patients, 850 patients were transfused with /= 5 RBC units in 6 hours and 807 could be classified into TBi+ (n = 281) or TBI- (n = 526). Six hundred forty-three patients were transfused with /=10 RBC units in 24 hours with 622 classified into TBI+ (n = 220) and TBi- (n = 402). For both high-risk populations, a high ratio of platelets:RBCs (not plasma) was independently associated with improved 30-day survival for patients with TBI+ and a high ratio of plasma:RBCs (not platelets) was independently associated with improved 30-day survival in TBI- patients. Conclusions: High platelet ratio was associated with improved survival in TBI+ patients while a high plasma ratio was associated with improved survival in TBI- patients. Prospective studies of blood product ratios should include TBI in the analysis for determination of optimal use of ratios on outcome in injured patients.

Background: Improvements in prehospital care and resuscitation have led to increases in the number of severely injured patients who are salvageable. Massive transfusion has been increasingly used. Patients often present with markedly abnormal physiologic and biochemical data. The purpose of this study was to identify objective data that can be used to identify clinical futility in massively transfused trauma patients to allow for early termination of resuscitative efforts. Methods: A multicenter database was used. Initial physiologic and biochemical data were obtained, and mortality was determined for patients in the 5th and 10th percentiles for each variable. Raw data from the extreme outliers for each variable were also examined to determine whether a point of excessive mortality could be identified. Injury scoring data were also analyzed. A classification tree model was used to look for variable combinations that predict clinical futility. Results: The cohort included 704 patients. Overall mortality was 40.2%. The highest mortality rates were seen in patients in the 10th percentile for lactate (77%) and pH (72%). Survivors at the extreme ends of the distribution curves for each variable were not uncommon. The classification tree analysis failed to identify any biochemical and physiologic variable combination predictive of 90% mortality. Patients older than 65 years with severe head injuries had 100% mortality. Conclusion: Consideration should be given to withholding massive transfusion for patients older than 65 years with severe head injuries. Otherwise we did not identify any objective variables that reliably predict clinical futility in individual cases. Significant survival rates can be expected even in patients with profoundly abnormal physiologic and biochemical data.

BACKGROUND Several recent military and civilian trauma studies demonstrate that improved outcomes are associated with early and increased use of plasma-based resuscitation strategies. However, outcomes associated with platelet transfusions are poorly characterized. We hypothesized that increased platelet:red blood cells (RBC) ratios would decrease hemorrhagic death and improve survival after massive transfusion (MT). METHODS A transfusion database of patients transported from the scene to 22 Level I Trauma Centers over 12 months in 2005 to 2006 was reviewed. MT was defined as receiving ≥ 10 RBC units within 24 hours of admission. To mitigate survival bias, 25 patients who died within 60 minutes of arrival were excluded from analysis. Six random donor platelet units were considered equal to a single apheresis platelet unit. Admission and outcome data associated with the low (>1:20), medium (1:2), and high (1:1) platelet:RBC ratios were examined. These groups were based on the median value of the tertiles for the ratio of platelets:RBC units. RESULTS Two thousand three hundred twelve patients received at least one unit of blood and 643 received an MT. Admission vital signs, INR, temperature, pH, Glasgow Coma Scale, Injury Severity Score, and age were similar between platelet ratio groups. The average admission platelet counts were lower in the patients who received the high platelet:RBC ratio versus the low ratio (192 vs. 216, p = 0.03). Patients who received MT were severely injured, with a mean (± standard deviation) Injury Severity Score of 33 ± 16 and received 22 ± 15 RBCs and 11 ± 14 platelets within 24 hours of injury. Increased platelet ratios were associated with improved survival at 24 hours and 30 days (p < 0.001 for both). Truncal hemorrhage as a cause of death was decreased (low: 67%, medium: 60%, high: 47%, p = 0.04). Multiple organ failure mortality was increased (low: 7%, medium: 16%, high: 27%, p = 0.003), but overall 30-day survival was improved (low: 52%, medium: 57%, high: 70%) in the high ratio group (medium vs. high: p = 0.008; low vs. high: p = 0.007). CONCLUSION Similar to recently published military data, transfusion of platelet:RBC ratios of 1:1 was associated with improved early and late survival, decreased hemorrhagic death and a concomitant increase in multiple organ failure-related mortality. Based on this large retrospective study, increased and early use of platelets may be justified, pending the results of prospective randomized transfusion data.

Background: Administration of high transfusion ratios in patients not requiring massive transfusion might be harmful. We aimed to determine the effect of high ratios of fresh frozen plasma (FFP) and platelets (PLT) to packed red blood cells (PRBC) in nonmassively transfused patients. Methods: Records of 1,788 transfused trauma patients who received 10 units of PRBC in 24 hours at 23 United States Level I trauma centers were reviewed. The relationship between ratio category (low and high) and in-hospital mortality was assessed with propensity-adjusted multivariate proportional hazards models. Results: At baseline, patients transfused with a high FFP:PRBC ratio were younger, had a lower Glasgow Coma Scale score, and a higher Injury Severity Score. Those receiving a high PLT:PRBC ratio were older. The risk of in-hospital mortality did not vary significantly with FFP:PRBC ratio category. Intensive care unit (ICU)-free days, hospital-free days, and ventilator-free days did not vary significantly with FFP:PRBC ratio category. ICU-free days and ventilator-free days were significantly decreased among patients in the high (1:1) PLT:PRBC category, and hospital-free days did not vary significantly with PLT:PRBC ratio category. The analysis was repeated using 1:2 as the cutoff for high and low ratios. Using this cutoff, there was still no difference in mortality with either FFP:PRBC ratios or platelet:PRBC ratios. However, patients receiving a 1:2 ratio of FFP: PRBCs or a 1:2 ratio PLT:PRBCs had significantly decreased ICU-free days and ventilator-free days. Conclusions: FFP:PRBC and PLT:PRBC ratios were not associated with in-hospital mortality. Depending on the threshold analyzed, a high ratio of FFP:PRBC and PLT:PRBC transfusion was associated with fewer ICU-free days and fewer ventilator-free days, suggesting that the damage control infusion of FFP and PLT may cause increased morbidity in nonmassively transfused patients and should be rapidly terminated when it becomes clear that a massive transfusion will not be required.

To evaluate the role of nonoperative management in the treatment of blunt liver trauma we examined all victims of blunt hepatic trauma admitted to our institution during a 36-month period under a protocol of nonoperative management. One hundred twenty-six patients had the diagnosis of blunt hepatic injury confirmed by abdominal computed tomographic (CT) scanning, surgical exploration, or autopsy. Twenty-four patients went to the operating room without CT scanning because of hemodynamic instability (16), peritoneal signs (two), or positive results on DPL (six). Ten other patients died of extra-abdominal trauma before reaching the operating room. The remaining 92 patients had CT scans of the abdomen. Of these 92 patients, 20 required surgery. The indications for surgery were hemodynamic instability (seven), peritoneal signs (six), nonhepatic injuries requiring surgery (five), and massive hemoperitoneum (two). Seventy-two patients were intentionally managed nonoperatively (55% of total liver injuries, 78% of scanned patients). Seventy (97%) of these patients were managed successfully without surgery. Of these 72 liver injuries, 11 were grade I, 28 were grade II, 16 were grade III, ten were grade IV, and five were grade V. The transfusion requirement in the first 24 hours for the nonoperative group was significantly lower than that for the group undergoing surgery (1.2 +/- 1.7 vs. 12.2 +/- 14 units). There were no instances of hemobilia, intrahepatic bile collections, or abdominal abscess in the nonoperative group. The grade of hepatic injury as diagnosed by CT scan does not predict the need for surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal CT, which routinely includes the lower thorax, is an important adjunct to supine chest radiography in detecting chest injury in patients with blunt abdominal trauma. In 1,086 consecutive patients with blunt abdominal trauma, 223 of whom had both supine chest radiography and abdominal CT, 49 patients examined with both techniques had pneumothoraces, 28 of them occult (seen only on CT). To help guide management, we established three categories of occult pneumothorax, based on size and location: (a) minuscule (1 cm in greatest thickness, seen on four or fewer images); (b) anterior (1 cm in greatest thickness, but not extending beyond the midcoronal line); (c) anterolateral (extending beyond the midcoronal line). In our study four of six patients with minuscule pneumothorax, including one who required mechanical ventilation, were observed without complications; two of six patients had chest tube placement. Seven of 14 cases with anterior pneumothorax were observed and resolved without complication; seven had chest tube placement. All eight patients with anterolateral pneumothoraces underwent percutaneous tube thoracostomy, regardless of proposed management.

In some populations, intensive care unit (ICU) mobility has been shown to be safe and beneficial. We gathered data on 50 nonintubated surgical patients in a 10-bed surgical ICU (SICU) who met physiologic inclusion criteria beginning in May 2008 (A group). In January 2009, we began mandatory entry of computerized mobility orders as part of a standardized ICU order set. We also created a mobility protocol for nurses in this ICU. We then collected data on 50 patients in this postintervention cohort (B group). Both groups had similar baseline characteristics. A group patients had some form of mobility orders entered in 29 patients (58%) versus 47 patients (82%) in the B group, P0.05. In the A group, 11 patients (22%) were mobilized; in the B group, 40 patients (80%) were mobilized, P0.05. In our SICU patient population, mandatory entry of computerized mobility orders as part of a standard SICU order set and establishment of an ICU mobility nursing protocol was associated with an increase in number of mobility orders entered as well as an increase in SICU patient activity. Further studies should focus on measurement of the effect of mobility interventions on patient outcomes.

Early enteral nutrition may preserve gut function and prevent bacterial translocation after trauma. Standard enteral nutrition uses products which contain intact protein and require digestion for absorption. Peptide-based enteral nutritional products are better absorbed and stimulate the release of gut trophic hormones. This study was performed to determine whether a peptide-based (PEP) product (Reabilan HN) was better tolerated and/or produced better hepatic protein responses in patients after trauma when compared to an intact-protein (PRO) formula (Osmolite HN). Eighteen trauma patients were prospectively randomized to PEP (n = 9) or PRO (n = 9) enteral diets administered via nasoduodenal tubes (within 1-2 days of injury). Visceral protein synthesis was assessed by measuring baseline and 1 week pre-albumin and transferrin levels. Diarrhea was defined as greater than 300 gm/day of stool. Groups were similar in age, Injury Severity Score (ISS), caloric intake, and protein intake. Protein levels increased significantly faster in PEP patients despite similar urea nitrogen excretion. Diarrhea developed in four (44%) PRO patients and none of the PEP patients. Three of the PRO patients were switched to PEP after one week and diarrhea subsided in all three patients. Peptide-based enteral diets are associated with better hepatic protein responses and less diarrhea compared to intact-protein diets.

Polytetrafluoroethylene (PTFE) grafts, 1 mm in internal diameter, were interpositioned in the infrarenal aortas of 20 adult Sprague-Dawley rats with either continuous or interrupted sutures. The interrupted-suture (I-S) technique was used in ten rats, the continuous-suture (C-S) technique in the other ten. After followup of 90 days, the overall patency rate for the 20 rats was 95% (19/20); all grafts in the C-S group were patent; one graft in the I-S group had occluded on the day of operation. Since excellent patency rates were obtainable with these minute PTFE grafts placed in the rat aorta by either technique, the speed with which the C-S technique can be accomplished appears to make it preferable.

The simultaneous admission of nine youths to our institution following their ingestion of concentrated sodium hydroxide (which had been mistaken for wine) provided us with a unique opportunity to manage corrosive esophageal injuries ranging in severity from second-degree oral mucosal injury alone to full-thickness hypopharyngeal, esophageal, and gastric injury. The severity of injury was graded first on the basis of symptoms and physical examination of the mouth, and then in the operating room by rigid esophagoscopy. This procedure provided a logical approach to management. Three patients with second-degree oral burns required no surgery. Six patients required laparotomy with gastrostomy and/or chimney feeding jejunostomy, one required immediate esophagogastrectomy, and three required immediate total or subtotal gastrectomy. There were no deaths. Three patients have subsequently required esophageal replacement and three others have required repeated dilatations. At 2-year followup, all nine maintain their nutritional status orally, and all except for the previously mute patient can phonate. Ingestion of liquid lye requires a much more aggressive diagnostic and therapeutic approach than is currently recommended for ingestion of caustics in general. On the basis of our experience with these nine patients, we suggest the following for esophageal liquid lye injury: 1) early evaluation of the esophagus by esophagoscopy; 2) with esophageal burns, urgent laparotomy to assess gastric damage and gastrostomy to pass a string for subsequent retrograde dilatations; 3) adequate resection of stomach for gastric burns; 4) with deep esophageal burns, early esophagectomy.