60.05 Nutritional Support Disparities in Trauma ICUs in the US: An Assessment of the AAST TRIPP Database

Posted on January 31, 2019

L. TUNG1, R. Dumas1, D. N. Holena1, M. J. Seamon1, L. J. Kaplan1, A. B. Newcomb2, C. P. Michetti2, N. D. Martin1  1University Of Pennsylvania,Philadelphia, PA, USA 2Inova Fairfax Hospital,Falls Church, VA, USA

Introduction:  Adequate nutritional support during critical illness has been shown to improve outcomes. Timely initiation of any nutrition can be variable by patient population. We hypothesize that all patient types in a trauma-designated ICU would receive a similar onset of nutritional support, and that pressors would not play a role in nutrition.

Methods:  The TRIPP database is a 2-day, multicenter prevalence study of all patients present in a trauma-designated intensive care unit (ICU) on 11/2/17 and 4/10/2018. Patients were stratified as either trauma, general surgery, or medical ICU patients. The presence of any nutritional support was evaluated based on the current ICU length of stay (LOS). Differences in nutritional support over the first 7 days were determined by t-test. Differences in either enteral feeds or parenteral nutrition above or below a total pressor equivalence of norepinephrine (NE) of 0.11mcg/kg/min was determined by chi-square.

Results: 1216 patients from 49 trauma-designated ICUs contributed data. 562 (46.2%) patients were traumatically injured, 458 (37.7%) were general surgery, and 196 (16.1%) were medicine patients. On ICU day 1, 45.7%, 51.1%, 45.5% of trauma, general surgery, and medical ICU patients were receiving nutritional support, respectively. By ICU day 7, this increased to 89.3%, 78.9%, and 80.0%, respectively, with a trend toward statistical significance. There was also no significant difference between the number of patients who were receiving nutrition on NE ≥0.11 mcg/kg/min compared to those on NE ≤0.11mcg/kg/min (p=0.5).

Conclusion: After 7 days of critical illness, a significant percentage of Trauma ICU patients were not receiving nutritional support; further, disparities between ICU populations within trauma-designated ICUs also seemed to exist.  Vasopressors however, were not associated with decreased nutritional support.  Additional research into the etiologies of these findings is warranted.

 

60.04 Comparison Of Urban Off-road Vehicle And Motorcycle Injuries At A Level 1 Trauma Center

Posted on January 31, 2019

C. A. Butts1, R. Gonzalez2, J. P. Gaughan2, J. San Roman2, S. Ross2, J. Porter2, J. P. Hazelton2  1Rutgers-Robert Wood Johnson University Hospital,Acute Care Surgery,New Brunswick, NJ, USA 2Cooper University Hospital,Trauma, Surgical Critical Care, & Acute Care Surgery,Camden, NJ, USA

Introduction:
Recently, there has been an increase in the use of dirt bikes (DB) and all-terrain vehicles (ATV) in urban environments. Our previous work found that crashes involving urban off-road vehicles (UORV), defined as any ATV or DB accident which occurred on paved inner city/suburban/major roadways, resulted in different injury patterns than crashes which occurred in rural environments.  The aim of this study is to compare the injury patterns of patients involved in crashes while riding urban off-road vehicles with motorcycles (MC).

Methods:

A retrospective review (2005-2016) of patients who presented to our urban Level I trauma center as a result of any MC or UORV crash was performed. Patients who presented more than 48 hours from time of accident were excluded. A p<0.05 was considered significant.  

Results:

1556 patients were identified to have an MC or UORV crash resulting in injury [MC: n=1324 (85%); UORV: n=232 (15%)]. Patients involved in UORV accidents were younger (26.2 vs 39.6; p <0.05), less likely to be helmeted (39.6% vs 90.2%; p<0.05), but required fewer emergent trauma bay procedures (28.4% vs. 36.7%; p<0.05) and fewer operative interventions (45.9% vs 54.2%; p <0.05).  Both group of patients had a similar ISS (12.2 vs 12.6; p=0.54) and presenting GCS (13.8 vs 13.5; p=0.46). Interestingly, UORV patients had a lower mortality (0.9% vs 4.7%; p <0.05) when compared to MC crash patients despite injury patterns being similar between both groups.

Conclusion:
Our data demonstrates that UORV riders are younger and less likely to be helmeted, but have a lower mortality rate following a crash, despite having similar injury patterns to motorcyclists.  Even though our data suggests a lower mortality in this patient population, we feel that the fact that fewer than 50% of UORV patients were wearing helmets is unacceptable in this younger patient population.  This data may provide a framework for legislative intervention for helmet laws to be more strictly enforced in this population and facilitate a more aggressive community outreach focusing on increased helmet compliance.

60.03 CSF Cultures in Traumatic Brain Injury: Is It Worth It? A Two-Center Study

Posted on January 31, 2019

N. K. Dhillon1, S. Sahi2, G. Barmparas1, N. T. Linaval1, T. Lin1, S. Lahiri1, C. V. Brown2, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA 2Dell Medical School, University of Texas at Austin,Austin, TEXAS, USA

Introduction:  Patients with traumatic brain injury (TBI) frequently develop leukocytosis, fever, and tachycardia which may lead to extensive medical investigations to rule out an infectious process. Cerebral spinal fluid (CSF) is often acquired during this work-up, however the utility of this practice has not been previously studied. We hypothesized that CSF cultures would unlikely yield positive results in patients with TBI.

Methods:  A retrospective review was conducted of all TBI patients admitted to two Level 1 trauma center at an urban, academic medical center from 01/2009 to 12/2016. Data collected included patient demographics, presenting GCS, injury profile, injury severity scores (ISS), regional abbreviated injury scale (AIS), hospital and ICU length of stay (LOS), ventilator days, and culture results. For purposes of the analysis, CSF cultures with Staphylcoccus epidermidis, Staphylococcus aureus, or Candida were considered contaminated and deemed negative.

Results: There were 148 patients who had CSF cultures obtained with a median age of 40 years and 77.7% being male. The majority of patients presented following blunt trauma with median GCS of 6, head AIS of 4, and ISS of 26. These patients had prolonged median ICU and hospital stay at 14 and 22 days, respectively. Seven (4.7%) CSF cultures demonstrated growth. Four (2.7%) were deemed to be contaminants, with two growing Staphylcoccus epidermidis only, one with both Staphylcoccus epidermidis and Staphylococcus aureus, and one with Candida. Three cultures (2.0%) were positive; two had Enterobacter Cloacae and one Klebsiella Pneumoniae. Of note, all three patients with positive cultures also had instrumentation with either an external ventricular drain or a lumbar drain.

Conclusion: Obtaining CSF cultures in TBI patients without instrumentation is of extremely low yield. Other sources of infectious etiologies should be considered in this patient population.

 

60.02 Time to Prothrombin Complex Conctretrate Administration Effect on Intracranial Hemorrhage Outcomes.

Posted on January 31, 2019

L. S. Kuzomunhu1, M. M. Fleming2, R. R. Jean2, K. Y. Pei2  1Yale University School Of Medicine,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Prothrombin complex concentrate (PCC) is indicated in patients sustaining traumatic intracranial hemorrhage (ICH) while taking warfarin, but the optimal timing is unknown. This study evaluates the effect of timing to PCC administration on outcomes including intracranial hemorrhage expansion and length of hospital stay.

Methods: We retrospectively reviewed patients presenting with ICH who received PCC at our tertiary care hospital between March 2013 to November 2017. Only patients on warfarin and with repeat computed tomography of head were included. Time to PCC was defined as the time from order entry to patient administration as documented contemporaneously in the electronic health record. Time was stratified as early (≤30 minutes) or late (>30 minutes). Multivariable logistic regression with stepwise selection was used to predict ICH expansion between initial and repeat cross sectional imaging. Linear regression identified predictors for increased hospital and intensive care unit length of stay.

Results: In total, 127 patients with ICH on warfarin were included for analysis. Mean time to PCC administration was 82.3 ± 43.7 minutes. The majority of patients who demonstrated expansion of ICH (31.5% of patients) had admission motor Glasgow Coma Score (GCS) less than 6 (p<0.05), a higher Charlson Comorbidity Index (CCI) (p<0.05) and higher inpatient mortality (p<0.01). On multivariable analysis, only admission motor GCS<6 was independently associated with ICH expansion (OR 3.016, 95% CI 1.158-7.858). Time to PCC (early versus late), admission INR and anticoagulation indication were not associated with ICH expansion. On linear regression admission motor GCS<6 was associated with increased length of ICU stay (β=8.261, SE 2.070, p=0.0001); however no other patient characteristics or PCC administration time was associated with hospital length of stay.

Conclusion: Timing to PCC administration was not associated with ICH expansion or mortality after traumatic ICH. Further multi-institutional studies are needed to evaluate clinical and process measures to streamline PCC administration.

60.01 Axillary Vessel Injuries: What have we Learned From an Analysis of the National Trauma Data Bank

Posted on January 31, 2019

M. A. Dale1, A. Person1, G. Mendoza1, S. Brown1, D. Keleny1, D. Rigg1, J. Dabestani1, D. Agrawal1, J. Asensio1  1Creighton University Medical Center,Department Of Surgery,Omaha, NE, USA

Introduction: Axillary vessel injuries remain uncommon even in busy urban trauma centers. Most trauma surgeon possess limited experience with these injuries. The proximity of the surrounding anatomic structures account for a large number of associated injuries and mobidity associated with such injuries.

Methods: The National Trauma Data bank was queried for pre-hospital admission data for axillary vessel injuries. Data extracted included demographics, physiologic conditioins, surgical interventions and Functional Independent Measure Score (FIM). Univariate and stepwise logistic regression analysis were used.

Results: 590 cases were identified from 1,466,887 patients in NTDB from 2001-2005. Incidence = 0.004%. Mean age 33 ±  16, mean RTS 6.8 ±  2.3, mean Glasgow Coma Score 13 ±  4.4, mean ISS 14.9 ± 10.3. Mechanism of inury: penetrating n=329 (55.6%), blunt n=259 (43.9%), and non-specified n=2 (0.34%). Mean initial SBP 119.7 ±  37.7, mean in survivors 122.8 ± 24.8, mean in non-survivors 79.7 ±  56.1. Base deficit mean -3.7 ±  10.7, in survivors -3.3 ±  8.5, non-survivors -7.3 ± 19.2. Total number of injuries n=681, of these axillary artery n=455 (67%), axillary vein n=144 (21%), axillary nerve n=68 (9.98%), unspecified n=14 (2%). Sugical procedures for axillary injuries were documented in 238 patients, these included n=54 (15.4%) suture of the artery, n=38 (8.91%) vascular shunt or bypass. Complications n=2637 associated with axillary vessel injuries: pneumonia n=22 (16.05%), wound infection n=16 (11.67%), compartment syndrome n=14 (10.21%), ARDS n=12 (8.76%). Fuctional Independent Measures: dependent n=11 (1.86%), partial help required n=13 (2.2%), independent with device n=28 (4.75%), independent n=210 (35%), not applicable (7.3%), and not documented n=285 (48.3%). Survivors n=548 (92.88%), non-survivors n=42 (7.12%).

Conclusion: Axillary vessel injuries remain an uncommon occurence in the United States as denoted by their low incidence as reported in the NTDB and literature. Initial admitting systolic blood pressure has a higher correlation with morbidity based on mechanism of inury. However, when using stepwise logitistic models, ISS, TRISS, and LOS had the highest correlation with survival. Axillary vessel repairs require complex surgical interventions. Most injuries carry an associated high morbidity, good functional outcomes, and relative low mortality.

 

59.20 Efficacy of Endovascular Approach for Pediatric Traumatic Thoracic Aorta Injuries

Posted on January 31, 2019

M. Moore1, M. B. LaPlant1, B. J. Segura1, D. J. Hess1, D. A. Saltzman1  1University Of Minnesota,Pediatric Surgery/Pediatric Surgery/Medical School,Minneapolis, MN, USA

Introduction:  Traumatic thoracic aortic injuries are relatively rare within the pediatric population, occurring in only 0.06% to 0.1% of patients. Though infrequent, these injuries contribute to 2.1% of pediatric trauma related deaths. Thoracic aortic injuries are most frequently due to high energy, blunt trauma, with motor vehicle accidents and falls being the most common mechanisms. Endovascular repair of traumatic aortic injuries has become more common in the adult population where it has demonstrated a survival benefit and decreased morbidities in comparison to an open approach. In a previous study of all types of arterial injuries in pediatric trauma patients, there was no mortality difference between endovascular and open approaches. We aim to compare outcomes between endovascular and open management of traumatic thoracic aortic injuries in pediatric patients.

Methods:  We selected records from the National Trauma Databank, years 2010 – 2016. Included in analysis were all patients, aged 1 to 18 years, with a thoracic aorta injury who had endovascular repair (n = 92) or open repair (n = 93). We compared hospital mortality by treatment approach using fisher’s exact test and logistic regression, adjusting for patient demographics, injury severity, injury type, facility type, and facility clustering.  

Results: Patients ranged in age from three to 17 years (mean 15; SD 2.8). Injury severity scores ranged from 16 to 75 (mean 37; SD 15.0), and 85% of injuries were blunt. The mortality rate for patients who underwent endovascular repair was 6.5%, compared to 30.1% for patients that underwent open repair (p < .001). The mortality odds remained significantly higher for open approach patients after adjusting for patient and facility characteristics (AOR 5.89; 95% CI 1.32 – 26.28; p .021). 

Conclusion: Endovascular interventions are increasingly common in the management of trauma, but require further evaluation in pediatric patients. Mortality was significantly higher for pediatric patients who underwent open repair of thoracic aortic injuries, as compared to endovascular repair. After adjusting for patient and facility characteristics, the mortality odds remained significantly higher for patients undergoing an open approach. The use of endovascular approach for thoracic aorta repair may be efficacious and beneficial in pediatric patients.  As endovascular therapy becomes widely available, it is important to characterize further the populations and types of injuries that will benefit from this approach.

 

59.19 Training Local Law Enforcement to Stop the Bleed Improved Survival from Penetrating Trauma

Posted on January 31, 2019

A. Maitland1, K. W. Sexton1, A. Bhavaraju1, W. C. Beck1, B. Davis1, M. K. Kimbrough1, R. Robertson1, K. Buckner1, J. R. Taylor1  1University Of Arkansas for Medical Sciences,Trauma Surgery,Little Rock, AR, USA

Introduction: Hemorrhage continues to be the leading cause of early death after traumatic injury. To prevent death from hemorrhage, local law enforcement officers and first responders are being trained to "Stop the Bleed". In the year 2015, and going forward, each individual was trained using these bleeding control techniques and were equipped with CAT tourniquets. We hypothesized that this would improve early survival for victims of penetrating trauma.

Methods:  Registry data were used from a level 1 trauma center for all penetrating ballistic injuries. Exclusion criteria included patients from outside the center's county, patients not arriving directly from the scene of injury, suicide or self-injury, an event of pre-hospital cardiac arrest, a maximum AIS for the Head and Neck body regions =3, and a maximum AIS for the extremity body region =2. Univariate and bivariate statistics were performed using JMP Pro 13.2.0 (SAS: Cary, NC)

Results: In a final study population of 455 patients, overall ED mortality was 4.84%. The ED mortality rate in the pre-training group was 7.00% (21/300), and 0.65% (1/155) in the post-training group, which was a significant difference (p=0.0005). A nominal logistic regression model was performed. In this model, ED systolic blood pressure >90mmHg (p<0.0001), ED pulse rate <120bpm (p=0.000329), and injury occurrence after law enforcement training (p=0.00498) were significant predictors of survival

Conclusion: Local Law Enforcement Officer and First responder hemorrhage training can improve the early survival rate of patients with a penetrating injury. Further work needs to be done to determine the full impact of this training.

 

59.18 Does Surveillance Bias Impact the Incidence of Deep Vein Thrombosis and Pulmonary Embolism?

Posted on January 31, 2019

V. Morris1, M. K. McNutt1, L. S. Kao1, B. A. Cotton1  1McGovern Medical School at UTHealth,Acute Care Surgery,Houston, TEXAS, USA

Introduction: Venous thromboembolic events (VTE), which include deep vein thrombosis (DVT) and pulmonary embolism (PE), are used by many public and private agencies as a marker for quality of care. However, studies show rates may be affected by variability in screening practices; increased screening yields higher incidence. Reported incidence rates of VTE range from 4% to 16% in US trauma centers, suggesting a surveillance bias. The purpose of this study was to evaluate the incidence of both DVT and PE at our hospital, taking into account variability in aggressiveness in screening practices for the two distinct events.   

Methods: Retrospective cohort study, examining VTE events, screening Duplex ultrasound, and screening chest CT-angiograms (CTA) in patients admitted to the trauma service. Inclusion: Highest level-trauma activations, >15 years old, and admitted 1/16-12/16. Exclusions: patients dying in the first 24 hours, those who were pregnant, and those with >20% TBSA burns. Statistical analysis was performed with continuous data presented as medians (25th-75th interquartile range, IQR) and categorical data as proportions.

Results: 1314 patients met inclusion; 60 patients deveoped a VTE, 27 (2.1%) were diagnosed with a DVT and 37 (2.8%) were diagnosed with a PE.  A total of 141 patients had a Duplex scan and there was a total of 190 Duplex scans performed. 14.2% of Duplex scans were positive. Median Duplexes in DVT patients 1 (1, 2) vs 0 (0, 0) in those without DVT; p<0.05. 100% of DVT patients had at least one Duplex vs 9% of those without DVT, while 30% of DVT patients had at least two Duplexes vs 2% of those without DVT; both p<0.001. A total of 201 patients had a CTA and a total of 451 CTAs were performed. 8.2% of CTAs were positive. The median number of CTAs in PE patients 2 (1, 3) vs 0 (0, 0) in those without; p<0.001. 100% of PE patients had at least one CTA vs 13% of those without PE, while 80% of PE patients had at least two CTAs versus 11% of those without; both p<0.001. Of the PEs, 13% main pulmonary, 36% lobar, 24%segmental, and 27% were subsegmental. The rate of DVT per Duplex obtained was 1.8%, while the rate of PE per CTA was 2.6%. Controlling for age, gender, and injury severity, each Duplex obtained increased likelihood of DVT diagnosis 4-fold, while each CTA increased PE diagnosis almost 3-fold (TABLE).

Conclusion: The rate of VTE events in trauma centers is likely dependent on the intensity of screening for these events. An adjustment should be made for intensity of screening for these significant events when assigning scores for hospital performance and for reimbursement, least government, insurance, and quality organization discourage physicians and their hospitals from searching for these morbid and sometimes fatal events.

59.17 Aortic Injuries in Pediatric Blunt Trauma Patients

Posted on January 31, 2019

G. Bergman1, J. Hassoun1, L. S. Burkhalter3, G. P. Wools3, J. Tweed4, L. S. Hynan2, F. G. Qureshi1,3  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Department Of Clinical Sciences,Dallas, TX, USA 3Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 4Children’s Medical Center,Trauma Services,Dallas, TX, USA

Introduction: Blunt traumatic aortic injuries are rare in children and management strategies are not well defined. These injuries can be managed expectantly, via open operation, or with endovascular techniques. We evaluated pediatric blunt aortic injuries at a level I pediatric trauma center over a ten-year period, focusing on management and outcomes between intervention and nonintervention groups.

Methods: After IRB approval, a retrospective chart review occurred. Demographics, injury mechanisms, associated injuries, injury severity score (ISS), management, and outcome data were collected and analyzed with SPSS.  Data is presented as counts and percentage, or mean and standard deviation as appropriate.  Fisher’s Exact Test was employed to test difference between groups.

Results: In a facility with an average of 1,200 trauma admission annually, 14 suffered blunt aortic injuries, 9 (65%) were males, average 9.6 (±3.2) years of age, there were 12 abdominal and two thoracic aortic injuries.  Average ISS of 30 (±12.3), in which all patients survived to hospital discharge.  All were passengers in a vehicle with restraint status including lap and shoulder belt (n=6, 43%), lap belt alone (n=5, 36%), or restrained but unspecified (n=3, 21%). Thirteen (93%) patients had documented seatbelt signs. Aortic injuries included three (21%) intimal tears, three (21%) pseudo aneurysms, three (21%) dissections, two (14%) transections, and three (21%) with a combination of injuries.  All patients had at least one associated injuries including bowel (79%), chance fractures (50%), and solid organ (36%).  Exploratory laparotomy was required in 12 (86%) patients with 10 being immediate operations.  A total of five patients required open abdominal aortic repair, three performed immediately, one on second-look laparotomy, and one in conjunction with a delayed laparotomy. Open repair methods included thrombectomy with patch (3/5, 60%) and PTFE graft (2/5, 40%). Two patients underwent endovascular repair.  The remaining seven were managed conservatively. Surgical intervention and non-surgical intervention patients were similar in demographics and ISS.  As seen in table 1, the groups did not significantly differ terms of presentation or associated injuries.

Conclusions: Blunt aortic injuries are rare in the pediatric population, but have excellent survival outcomes.  Vascular management is varied and determined by type of aortic injury and clinical findings. While sample size is small, there are no apparent differences apart from severity of aortic injury between those requiring intervention and those that do not.

59.16 Even in Death, Women Are Better at Planning Ahead

Posted on January 31, 2019

E. W. Tindal1, C. A. Adams1, S. F. Monaghan1, D. S. Heffernan1, A. H. Stephen1, W. G. Cioffi1, S. N. Lueckel1  1Rhode Island Hospital,General Surgery,Providence, RI, USA

Introduction:  As the population ages, there has been a change in focus from curing disease to improving end of life care. Patients who receive early palliative care report increased quality of life, less depression and had longer survival compared to patients with more aggressive care. Additionally, Do-Not-Resuscitate (DNR) orders have been associated with higher quality of life. In the setting of trauma, devastating injuries and an aging population with a reduced capacity to recover make the incorporation of these practices increasingly important. Here we aim to determine predictors of having an advanced directive (AD) at the time of presentation in trauma patients.

Methods:  This is a retrospective analysis of our trauma registry from 2015 to 2017. We queried our registry for adult (≥ 18 years) patients with “Advanced directive limiting care” listed as a comorbidity on admission. We performed a multivariate logistic regression including a case-matching analysis to control for age to identify significant predictors of a pre-existing AD following univariate analysis.

Results: We identified 7561 patients, 822 with an AD on admission. Those with an AD were older (80 vs 55 years, p<.001), more likely to be female (64.8 vs 39.5%, p<.001) and white (93.3 vs 82.2%, p<.001). Patients with an AD were more likely to arrive from a nursing home (NH) (23.8 vs 0.1%, p<.001), and have multiple co-morbidities including a functionally-dependent health status (FDHS) (63.0 vs 35.7%, p<.001). Regression analysis demonstrated that a pre-existing AD was independently associated with age over 65 (odds ratio (OR) 3.8, p<.001), female gender (OR 1.5, p<.001), arrival from NH (OR 178, p<.001) as well as comorbidities which include dementia (OR 2, p<.001), congestive heart failure (CHF) (OR 1.6, p<.05), hypertension (HTN) (OR 2.7, p<.001), FDHS (OR 1.2, p<.05) and chronic obstructive pulmonary disorder (COPD) (OR 2.6, p<.001). Case-control matching for age was performed given the large age discrepancy between the two groups and showed that these factors remained significant with the exception of CHF and FDHS.

Conclusion: Our findings demonstrate that, in addition to age and comorbidities, gender plays a significant role in end-of-life planning even prior to arrival at the hospital. As a result of this, those without an AD in place may experience more physical and emotional discomfort following a traumatic injury than those who present with an AD at the time of admission. Additional analysis is warranted to determine what personal and systemic factors may be driving this relationship.

 

59.15 Full Trauma Team Activation versus Partial Trauma Team Activation- Does it Really Matter?

Posted on January 31, 2019

L. M. Maloney1, E. C. Huang1, A. J. Singer1, R. C. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction: Most trauma centers have two levels of trauma team activation based on physiologic, anatomic, or mechanistic criteria: full activation (Code T), and partial activation (Trauma Alert).

Methods: A query was performed on a pre-existing, ACS verified level 1 trauma center registry for Code T or Trauma Alert patients. Inclusion criteria included: presentation between 1/1/2015 and 12/31/2017, hospital admission, age >16 years. Exclusion criteria included death in the ED and isolated burns. Univariate statistical analyses were performed to compare baseline characteristics and outcomes in patients in these two groups.

Results: Of 5023 trauma admissions, 314 were after a Code T, and 571 after a Trauma Alert. No large differences existed in sex (75% vs 73% male), median age (41[IQR 25-58] vs 45[IQR 26-73] years), or percentage of patients with ?1 comorbidity (59% vs 60%, p=.769). Trauma Alerts most often had ?5 comorbidities (3% vs 0%, p=.003), and were more likely to have diabetes (9% vs 3%, p=.003), dementia (4% vs 0.6%, p=.009), and a pre-admission DNR (2% vs 0%, p=.009). The most common mechanism of injury was motor vehicle/motorcycle collisions in both groups (43% Code T vs 48% Trauma Alert, p=0.15). Code T patients were more likely to sustain penetrating injuries (16% vs 2%, p<0.001), while Trauma Alert patients were more likely to sustain a fall (25% vs 16%, p=.004). Code T patients more often had major injuries (AIS>3) to the head (31% vs 16%, P<0.001), c-spine (7% vs 3%, p=.008), chest (45% vs 22%, p<0.001), and abdomen (17% vs 8%, p<0.001). Code T patients had a median ISS of 19 (IQR 9-33), compared to a median ISS of Trauma Alert patients of 10 (IQR 5-17, p<.001). The median ED GCS was 14 (IQR 3-15) for Code T patients and 15 (IQR 15-15, p<.001) for Trauma Alert patients. Disposition following evaluation in the ED was more often to the ICU in Code T patients (35% vs 25%, p=.003), and to the Operating Room (46% vs 25%, p<.001). Code T patients more often received blood within 4 hours of arrival (34% vs 7%, p<.001). Code T patients more often had complications (20% vs 10%, p<.001), with the most likely being a PE/DVT (5% vs 2%, p=.042) or ulcers (3% vs 0.7%, p=.01), with similar percentages of pneumonia, AMI, sepsis, respiratory or failure, stroke, and unplanned ICU time. The final disposition at hospital discharge of Trauma Alert patient was more frequently home than Code T patients (66% vs 48%, p<.001). Code T patients had a higher mortality rate (14% vs 2%, p<.001).

Conclusions: The data demonstrate the principles of trauma triage recommended by the ACS effectively identified high-risk patients at the only level 1 trauma center in a large suburban county

59.14 Diagnosis of Pancreatic Injuries in Abdominal Trauma Patients with Negative Initial CT Scans

Posted on January 31, 2019

S. Rabinowitz1,2, J. Wycech2,3, A. Tymchak1,2,3,4, M. Crawford2, M. Gomez3, A. A. Fokin2, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
There are several challenges of detecting pancreatic injury within the first hours post trauma, as clinical presentation is often delayed, imaging may be obscured, and enzyme analysis is unreliable. The aim of this study was to evaluate characteristics of patients with pancreatic injuries who had a negative initial computed tomography (CT) scan to determine indicators that can be used in detecting pancreatic injury.

Methods:
This IRB approved retrospective cohort study included 23 patients, ages 17-94, diagnosed with pancreatic injuries at a Level 1 trauma center between 01/2012 and 06/2018. Studied variables included: injury severity score (ISS), incidence of hemoperitoneum, contrast CT imaging, operative vs. non-operative management (NOM), enzyme levels, organ injury score (OIS), co-injuries, intensive care unit length of stay (ICULOS), hospital LOS (HLOS), complications and mortality.

Results:
Of the 23 patients, 9 (39.1%) had negative initial CT for pancreatic injury within the first 12 hours post trauma and were the subject of analysis. In this cohort, the mean ISS was 29.4. CT scans for all 9 patients were positive for hemoperitoneum.  Although initial contrast CT scans were negative for pancreatic injuries, they showed other abdominal organ trauma. As a result, 8 patients underwent urgent laparotomy during which injuries to the pancreas were diagnosed, and in 4 patients (44.4%) pancreas was immediately operated on. Only 1 of the 9 patients had attempted NOM, which failed, and pancreatic injury was discovered during laparotomy. Elevated amylase and lipase levels were seen in only 1 patient. Pancreas injuries categorized by region were: 7 patients had injuries to the pancreatic tail and 2 to the pancreatic head/neck. There were no injuries to the pancreatic duct. The mean pancreas OIS was 1.6. All 9 patients had additional solid organ injuries (SOI) and/or hollow viscus injuries (HVI):  4 patients had other SOI without HVI, 3 had other SOI with HVI, and 2 had pancreas injuries with HVI only. The most common SOI in association with pancreas was spleen (66.7%, n=6). All spleen injuries were categorized as severe (mean spleen OIS 4.3) and resulted in splenectomy. In patients with pancreatic injuries with two other SOI, the most common combination was spleen and left kidney injuries (33.3%, n=3). There was also incidence of lumbar trauma involving L1-L2 fractures in 2 patients: one had spleen and kidney co-injuries, while the other had spleen and left colon trauma. Mean ICULOS was 9.5 days and HLOS was 17.3 days. Complications, such as peritonitis and blood loss anemia developed in 4 patients, however no mortality was recorded.

Conclusion:
Early CT scans can be less sensitive for the detection of pancreatic injuries in patients with multiple abdominal organ injuries. High grade spleen injuries, especially when combined with left kidney, left colon or lumbar vertebrae trauma, should be considered risk factors for possible pancreatic damage.
 

59.13 Non Therapeutic Laparotomy Challenges the Conventional Indications for Laparotomy in Abdominal Trauma.

Posted on January 31, 2019

R. R. Chakraborty1, A. A. Maruf1, T. Benzir1, R. R. Chakraborty1  1Chittagong Medical College Hospital,Department Of Casualty,Chittagong, Bangladesh

Introduction:  

Trauma is the leading cause of death in the active people under the age 45 years. There is definite protocol for conservative management of Blunt Abdominal Trauma (BAT) but much lower threshold for exploratory laparotomy in Penetrating Abdominal Trauma (PAT). Though some specific presenting features and investigation findings are crucial in decision making, still the rate of Non Therapeutic Laparotomy (NTL) varies center to center from 12% – 40% in both blunt and penetrating abdominal trauma.

Methods:
A prospective study was conducted from July 2017 to June 2018 to evaluate the characteristics of cases that lead to NTL. The study was conducted in casualty department of a tertiary level hospital in Bangladesh. All patients with abdominal injury underwent exploratory laparotomy were included in this study. Only those cases which were found NTL were analyzed to see the presenting features that lead to exploratory laparotomy. 

Results:
During the study period 114 patients with abdominal trauma underwent exploratory laparotomy of which 42(36.8%) for blunt injury and 72(63.2%) for penetrating injury. Total NTL cases were 38 (33.33%). Analysis of NTL cases reveals that NTL for BAT were 8 (21.1%) and NTL in case of PAT were 30(78.9%). Indications for laparotomy in NTL cases of BAT were peritonitis 6(15.8%), Hemodynamic instability 4(10.5%), abdominal distension with significant peritoneal collection 8(21.1%)and average peritoneal collection was 2075 ml. Indications for laparotomy of NTL in PAT were peritonitis 20(52.6%), Evisceration of gut and omentum 8(21.1%), Hemodynamic instability 12(31.6%), dangerous mechanism of injury 6(15.8%), abdominal distension with significant peritoneal collection 14(36.8%) and average peritoneal collection was 226ml.

Conclusion:
In this study we found a high rate of NTL where we made the decision of exploratory laparotomy in abdominal trauma cases based on certain clinical features, abdominal Ultrasonography and in some cases on abdominal CT-Scan. More over higher rate of NTL in penetrating Abdominal trauma was due to very low threshold for exploratory laparotomy in these cases due to protocol obligation and medico-legal issue. So it seems that traditional way of decision making for exploratory laparotomy should be challenged and much scope to think in this issue.
 

59.12 Does Admission TEG Predict the Need for Dose Adjustment of Venous Thromboembolism Chemoprophylaxis?

Posted on January 31, 2019

H. V. Lewis1, C. Furnish2, C. A. Droege3,4, M. E. Droege3,4, N. E. Ernst3,4, M. D. Goodman1  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2University Of Colorado Denver,Skaggs School Of Pharmacy And Pharmaceutical Sciences,Aurora, CO, USA 3University Of Cincinnati,Department Of Pharmacy Services,Cincinnati, OH, USA 4University Of Cincinnati,Division Of Pharmacy Practice And Administrative Sciences, University Of Cincinnati James L. Winkle College Of Pharmacy,Cincinnati, OH, USA

Introduction:  Venous thromboembolism (VTE) contributes to significant morbidity and mortality in trauma patients, with enoxaparin chemoprophylaxis preferred in high risk patients. Early thrombelastography (TEG) following injury has been shown to predict the incidence of posttraumatic VTE; however, TEG-adjusted enoxaparin dosing has not adequately guided chemoprophylaxis as reliably as serum anti-factor Xa (aXa) concentrations. We hypothesized that the TEG obtained during initial trauma evaluation could facilitate earlier identification of the need for enoxaparin dose adjustment based on subprophylactic aXa.

Methods:  This single-center, retrospective chart review evaluated patients admitted to an urban level I trauma center over a nine month period. Patients were included if they underwent rapid TEG testing upon emergency department arrival and received a dose of enoxaparin with at least one serum trough anti-Xa concentration drawn during admission. Patients were stratified into dose adjusted (DAE) or single dose (SDE) groups based upon final enoxaparin dose received. Demographics including injury, VTE incidence, and chemoprophylaxis dosing and timing were analyzed. The primary aim was to compare TEG parameters between SDE and DAE groups. Secondary aims included VTE incidence and time to chemoprophylaxis initiation. Multivariate logistic regression analyses were performed to identify laboratory-associated and injury-specific independent risk factors for enoxaparin dose adjustment.

Results: 204 patients were included in the analysis with the majority (n=140, 69%) receiving dose-adjusted enoxaparin. Baseline differences between groups included age (SDE, 48.5 [29.3-72] vs. DAE, 38.5 [25-55.7] years; p=0.005), admission creatinine clearance (SDE, 92.9 [67.4-113.4] vs. DAE, 102.1 [83.8-129.2] mL/min; ­p=0.02), and time to VTE prophylaxis initiation (SDE, 23.8 [11.2-36.4] vs. DAE, 34.5 [18.3-52.7] hours; p<0.005). There was no difference in any TEG parameter, including MA:R ratio (SDE, 1.59 [1.18-1.87] vs. DAE, 1.43 [1.06-1.80]; p=0.13), or VTE incidence (SDE, 17.2% vs DAE, 11.4%; p=0.37) between groups. No independent laboratory value risk factors for enoxaparin dose adjustment were identified. Risk Assessment Profile score above 10 was an independent risk factor for VTE development.

Conclusion: Admission TEG did not predict the need for subsequent enoxaparin dose adjustment in trauma patients. Multicenter trials are needed to further explore the utility of TEG in guiding enoxaparin chemoprophylaxis in trauma patients.

 

59.11 Analysis of Patient Outcomes Receiving a REBOA in the First 18 Months at a Level 1 Trauma Center

Posted on January 31, 2019

T. W. Wolff1,3, E. A. Naber1, M. L. Moorman1,2, M. C. Spalding1,2  1OhioHealth Grant Medical Center,Division Of Trauma And Acute Care Surgery,Columbus, OHIO, USA 2Ohio University Heritage College of Osteopathic Medicine,Athens, OHIO, USA 3OhioHealth Doctors Hospital,Department Of Surgery,Columbus, OHIO, USA

Introduction:  Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an emerging tool for trauma surgeons that serves as an alternative to open aortic occlusion in the acute resuscitation of patients in shock. Although placement is a team effort, program implementation is often surgeon-centric. We report our preparation and initial experience of a team-based REBOA program at an urban Level 1 trauma center in hopes to provide comparisons for similar centers initiating such programs.

Methods:  Two trauma surgeons attended the Basic Endovascular Skills in Trauma course and subsequently trained the remaining trauma surgeons, residents, advanced practice providers, nurses, emergency physicians, pharmacists, and medics. A nurse educator liaised with the emergency department (ED), operating room (OR), and intensive care unit (ICU) nursing staff. Training involved didactics, high-fidelity simulation, and structured debriefing in all three settings.

Results: Six trauma surgeons placed 27 REBOA catheters (mean ISS-36, GCS-6, HR-82, SBP-52) for penetrating (5, 19%) and blunt mechanisms (22, 82%). Patient physiology, indication, common femoral artery (CFA) access, and outcome differed significantly between months 1-9 and 10-18 (see Figure). REBOA was performed in the ED (22, 81.5%), ICU (1, 3.7%), OR (3, 11.1%), and interventional radiology (1, 3.7%). In-hospital mortality (55.6%) was significantly different between the first and second 9-month periods (75% vs. 40%, p<0.05). Complications consisted of inability to obtain arterial access in four cases and a CFA pseudoaneurysm that resolved with manual pressure.

Conclusion: We successfully implemented a REBOA program with little external assistance and placed 27 catheters in 18 months with no complications requiring intervention. During the 18-month initiation period, the patient selection differed significantly over time, more percutaneous access was acheieved, and survival was significantly different. This can assist newly established REBOA programs in predicting early outcomes, patient selection, and likely complications.

 

59.10 Contrast Induced Nephropathy in Patients with Kidney Trauma

Posted on January 31, 2019

J. Saluck1,2, A. A. Fokin2, J. Wycech2,3, A. Tymchak1,2,3, M. Gomez3, M. Crawford2, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Incidence of contrast-induced nephropathy (CIN) has been reported in 1.9%-9.8% among different subgroups of trauma patients. However, the consequences of serial administration of contrast medium during angiography and repeat contrast computed tomography (CT) in patients with kidney trauma (KT) have not been sufficiently studied. The purpose of this study was to evaluate the incidence and predictors of contrast induced nephropathy (CIN) in patients with KT and to assess the effect of CIN on clinical outcomes.

Methods:

This IRB approved retrospective cohort study included adult patients, admitted to a level 1 trauma center between 2012 and 2017 who received contrast, 86 patients with a KT, and 224 with abdominal organ injuries (AOI), other than the kidney.

In the KT cohort, 10 (11.6%) developed CIN (CIN KT Group), while 76 (88.4%) did not (No-CIN KT Group). In our AOI cohort, 21 (9.4%) developed CIN and 203 (91.6%) did not. CIN was defined as relative (≥25%) or absolute (≥0.5 mg/dL) increase in serum creatinine within 72 hours of contrast administration. Age, Injury Severity Score (ISS), Kidney Organ Injury Scale (KOIS) Grade, rates of transfusion of blood products, angiography, embolization, repeat abdominal CT, hemoperitoneum, intensive care unit length of stay (ICULOS), hospital LOS (HLOS) and mortality were compared between CIN KT and No-CIN KT Groups.

Results:

Of the patients who developed CIN in KT cohort, 60.0% had an absolute increase in serum creatinine within 72 hours of contrast administration and 40.0% had a relative increase.

CIN KT and No-CIN KT Groups showed no significant difference in age (50.0 vs 44.8 years. p=0.6), ISS (27.4 vs 21.4, p=0.4), and KOIS Grade (2.4 vs 2.1, p=0.2). Both Groups, also had comparable rates of angiography (20.0% vs 17.1%, p=0.8), embolization (10.0% vs 3.9%, p=0.4), and repeat CT (40.0% vs 39.5%, p=1.0). With 100.0% of patients in CIN KT Group and 68.4% in No-CIN KT Group requiring a stay in the ICU, the difference in ICULOS between the two Groups did not reached statistical difference (9.8 vs 6.6 days, p=0.05).

CIN KT compared to No-CIN KT Group, had statistically higher rate of blood product transfusions (80.0% vs 46.1%, p=0.04) and detection of hemoperitoneum on CT (100.0% vs 55.3%, p=0.007). CIN KT patients had a statistically longer HLOS (14.2 vs 9.6 days, p=0.04), but mortality was not statistically different (20.0% vs 10.5%, p=0.4).

Conclusion:

Low grade kidney trauma did not increase incidence of CIN in patients with abdominal injuries. Higher rates of blood transfusions and hemoperitoneum detected on CT were risk factors associated with the occurrence of CIN in patients with kidney injury. Patients that developed CIN had longer HLOS, but not higher mortality.

59.09 Safety and Efficacy of Angioembolization in Combined Traumatic Brain Injury/Blunt Splenic Injury

Posted on January 31, 2019

B. Choi1, E. Warnack1, C. DiMaggio1, S. Frangos1, M. Bukur1, H. L. Pachter1, M. Klein1  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA

Introduction: There is limited data regarding the safety and efficacy of nonoperative management for blunt splenic injury (BSI) with concomitant traumatic brain injury (TBI) despite its increased use over time. We studied trends in the treatment of combined TBI/BSI, hypothesizing that angioembolization would not lead to increased mortality.

Methods:  Data were obtained from NIS-HCUP for 2004 to 2011, using ICD-9 codes to identify BSI, TBI, and treatment. Injury severity was assessed using International Classification of Injury Severity Scores (ICISS). In-hospital mortality for splenectomy and embolization groups was analyzed using logistic regression after controlling for year, age, gender, hospital teaching status, Charlson score, ICISS, and hypotension or shock at the time of presentation.

Results: Of 179,446 patients with BSI, 13,247 patients had associated TBI. The US population-based rate of TBI/BSI decreased by 0.02 injuries per 100,000 per year (P=0.09). 12.3% of TBI/BSI patients required splenectomy, while 6.1% underwent angioembolization. The rate of splenectomy decreased over the study period, from 16.6% to 8.0% (P<0.05) while the rate of embolization increased from 3.9% to 7.2% (P=0.22). Overall mortality in TBI/BSI patients was 17.1%, and did not change significantly over the study period (P=0.28). Mortality rate was lower in embolized patients (15.9%) than splenectomized patients (40.7%). Splenectomized patients had 2.75 times higher odds of death than all other TBI/BSI patients (95% CI 2.02-3.75, P<0.01), while embolized patients had no increased odds of death (OR 0.70, 95% CI 0.46-1.08, P=0.46).

Conclusion: Patients with combined BSI/TBI undergoing splenectomy carry a high mortality. For select patients, angioembolization has proven to be a safe and effective treatment option.

 

59.08 Skin Closure Techniques Following Trauma Laparotomy: Is Secondary Closure as Beneficial as We Think?

Posted on January 31, 2019

C. A. Fitzgerald1, B. C. Morse1, R. N. Smith1, J. Nguyen2, O. Danner2, R. B. Gelbard1  1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2Morehouse School of Medicine,Surgery,Atlanta, GA, USA

Introduction:

Trauma laparotomy incisions are often left open in the setting of enteric injuries to reduce the risk of wound infection, but there are limited data to support this practice. The purpose of this study was to determine if primary or delayed skin closure after trauma laparotomy is associated with an increased incidence of surgical site infections (SSI) and other wound complications.  

Methods:

Retrospective review of all patients who underwent a trauma laparotomy at a Level I trauma center from 2015-2017. Patients were separated into three groups: Group 1: fascia and skin both closed, Group 2: fascia closed, skin open for secondary closure, Group 3: delayed primary skin closure.

Results:

A total of 819 patients were included. Most patients were male (81.8%) and had penetrating injuries (66.4%). There were 556 (67.9%) patients in Group 1, 244 (29.8%) in Group 2 and 19 (2.3%) in Group 3. The incidence of hollow viscus injury (HVI) was 256 (46%), 222 (90.9%) and 18 (94.7%) in Groups 1, 2 and 3, respectively. There were 25 (4.5%) damage control laparotomies in Group 1, 57 (23.4%) in Group 2, and 1 (5.2%) in Group 3. Group 2 had longer ICU and hospital lengths of stay (10.4±14.8 vs. 5.8±9.3 vs. 6.2±12.0, p<0.001, and 25.1±24.1 vs. 15.2±14.5 vs. 17.8±12.2, p<0.001). Group 2 had a higher rate of organ space infections compared to Groups 1 and 3 (40/244, 16.4% vs. 35/556, 6.3%, vs. 1/19, 5.2%, p=0.0003) while Group 3 was associated with a significantly higher rate of fascial dehiscence and enterocutaneous fistula (ECF) among patients with HVI. There was no difference in the incidence of superficial or deep SSI or overall mortality between groups (Table 1).

Conclusion:
Leaving skin incisions open following trauma laparotomy appears to be associated with higher morbidity without reducing the rate of surgical site infections. Closing skin at the time of initial laparotomy should be considered to reduce hospital stays and lower the risk of fascial dehiscence and ECF.
 

59.07 High Rate of Fibrinolytic Shutdown and Venous Thromboembolism in Severely Injured Pelvic Fracture Patients.

Posted on January 31, 2019

J. T. Nelson1, J. R. Coleman2, H. Carmichael2, C. Mauffrey3, D. Rojas Vintimilla3, J. M. Samuels2, C. C. Silliman4, A. Banerjee2, A. Sauaia2, E. E. Moore5  1Rosalind Franklin University of Medicine and Science,Chicago Medical School,North Chicago, IL, USA 2University Of Colorado Denver,Surgery,Aurora, CO, USA 3Denver Health Medical Center,Orthopedics,Aurora, CO, USA 4Children’s Hospital Colorado,Hematology,Aurora, CO, USA 5Denver Health Medical Center,Surgery,Aurora, CO, USA

Introduction:   Trauma patients with severe pelvic fractures have a uniquely high rate of venous thromboembolic events (VTE), ranging from 3.5-8.8% in the orthopedic trauma literature.  The reason for this high morbidity risk is unknown.  In other trauma patients fibrinolytic shutdown (SD) is strongly associated with VTE. Thus, we hypothesize that the observed increase in VTE in patients with severe pelvic fractures is due to their state of fibrinolysis, specifically shutdown.

Methods:   Data was solicitated from the trauma registry of a single, urban, Level-1 trauma center for all trauma patients who presented with pelvic fracture from 2007-2017. The inclusion criteria were severely injured patients (injury severity score [ISS] > 15) with a severe pelvic fracture (abbreviated injury score [AIS] > 2) who presented after blunt mechanism and had an initial citrated rapid thrombelastography (CR-TEG). Fibrinolytic phenotypes were examined and defined as fibrinolytic shutdown (LY30 [lysis 30 minutes after maximum amplitude on CR-TEG] < 0.9%), physiologic lysis (0.9-2.9%) and hyperfibrinolysis (≥ 3.0%).  Outcomes including surgical fixation and VTE were also examined.  Chi-square tests were used for proportional comparisons, and Mann-Whitney U-test was used for comparison of non-normally distributed continuous variables.

Results:  This study included 210 patients with a median age was 44.0 years and the majority (64%) were male.  The median ISS was 34.0.  The majority of patients (59%, n=123) presented in fibrinolytic shutdown (SD) compared to 21% (n=45) in physiologic fibrinolysis (PL) and 20% (n=42) in hyperfibrinolysis (HF).  The VTE incidence was 11.0% (n=23).  The median LY30 in VTE patients was 0.5% versus 0.0% in non-VTE patients (p=0.38).  There was also no difference in injury severity, degree of shock (systolic blood pressure), traumatic brain injury, concomitant orthopedic injuries, other TEG measurements or fibrinolytic phenotypes of patients who developed a VTE compared to those who did not (Table 1).  Patients with VTE had longer length of stay (19 days vs. 16 days, p=0.02) and intensive care unit days (11.39 vs. 5.44, p=0.001). Patients who underwent pelvic fixation had a trend toward higher rate of VTE (15.8% versus 6.0% in patients who didn’t undergo fixation, p=0.08).

Conclusion:  In this population severely injured pelvic fracture patients had a high rate of VTE at 11.0%, higher than what has been described for these patients, and the majority (59%) presented in fibrinolytic shutdown.  However, in this prospective study, we were unable to identify unique factors predictive of VTE in severe pelvic fractures.  This supports the concept of implementing VTE chemoprophylaxis measures as soon as hemostasis is achieved.  

59.06 Platelet Dysfunction Not Corrected by Platelet Transfusion in Traumatic Brain Injury Patients

Posted on January 31, 2019

R. D. Rodriguez1, B. W. Carr1, A. L. Patterson1, S. A. Savage1  1Indiana University,General Surgery,Indianapolis, IN, USA

Introduction:  Platelet dysfunction is common in traumatic brain injury. While platelet transfusion is used to reverse dysfunction, there is not an established dose-response to measure effectiveness. Thromboelastogram Platelet Mapping (TEG-PM) quantifies dysfunction in the arachidonic acid (AA) and adenosine diphosphate (ADP) pathways. The purpose of this study was to examine the effect of platelet transfusion on TEG-PM in TBI patients on antiplatelet agents.

Methods:  This retrospective observational study included trauma patients admitted to a Level 1 Trauma Center with TBI from 2014 through 2017. Inclusion criteria was transfusion of at least one unit of platelets, use of antiplatelet agent prior to admission, and TEG-PM measured before and after transfusion. Repeated measures analysis of variance (ANOVA) was used to define change in ADP and AA inhibition over time in light of platelet transfusions.

Results:  Twenty-eight patients met screening criteria. Mean age was 74.6 with a median ISS of 25.  26 patients were on ASA, 12 on Plavix, 3 on ticargrelor, and 1 on dipyramidole. The median initial ADP inhibition was 66.6% and AA inhibition was 83.3%. Units of platelets transfused ranged from 1 to 6 with median 2. The change in inhibition over time, controlling for units of platelets transfused, was not statistically significant for ADP (p = 0.76) or AA (p = 0.09), see Table 1. Nine patients had expansion of hemorrhage, with 3 requiring operative intervention and 3 transitioned to hospice.

Conclusion:  Transfusion of platelets to restore platelet function was not effective for patients on antiplatelet agents as measured by TEG-PM, potentially exposing patients to unnecessary risk. This may be attributed to insufficient transfusion dosing or dysfunction in stored platelets. Further work is ongoing to identify the best way to define dysfunction, determine if correction of dysfunction is possible with platelet transfusion, and establish effective dosing.

 

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