11.14 Tachycardia Is As Bad As Bradycardia In Traumatic Brain Injury

Posted on January 25, 2017

A. Azim1, P. Rhee2, K. Ibraheem1, T. O’Keeffe1, N. Kulvatunyou1, G. Vercruysse1, A. Tang1, L. Gries1, B. Joseph1  1University Of Arizona,Trauma And Surgical Critical Care/Department Of Surgery,Tucson, AZ, USA 2Grady Memorial Hospital,Trauma And Surgical Critical Care/Department Of Surgery,Atlanta, GA, USA

Introduction:
Heart rate (HR) at initial presentation is an important indicator of hemodynamic status of the patient. However, systolic blood pressure (SBP) often takes precedence over heart rate in clinical decision-making. The aim of this study was to assess the independent effect of admission HR on mortality in traumatic brain injury (TBI) patients. 

Methods:
A one-year (2011) analysis of the National Trauma Data Bank (NTDB) was performed. Patients with TBI (head abbreviated injury scale (AIS) score ≥3) were included. Transferred patients, patients dead on arrival, and those missing vitals on presentation were excluded. Patients were stratified into groups based on admission HR. Outcome of mortality was compared for different HR groups in reference to HR range of 90-100. The association of HR groups with mortality was assessed using multivariate regression analysis after controlling for age, head AIS, gender, ISS, vital parameters, admission GCS.

Results:
A total of 48,359 patients with isolated TBI were included with mean age 41 ± 37 years, median [Range] GCS score of 15 [3-15], mean (SD) SBP of 132 (40) mm of Hg, and mean HR of 88 ± 29 bpm. The overall mortality rate was 8.9% (n=4,321). Patients with HR >100 were 25% more likely to die compared to patients with HR between 90-100 (OR: [95% CI]: 1.253 [1.117-1.404], p<0.001).  Mortality in patients with heart rate <90 was 23% higher than patients with HR between 90-100 (OR: [95% CI]: 1.23 [1.103-1.371], p<0.001). Patients with HR in the range of 80-90 bpm had the lowest mortality rate among the groups (p<0.001). With every 10 bpm increase or decrease from HR range of 90-100, mortality increases.

Conclusion:
Admission heart rate is independently associated with mortality in TBI patients regardless of their presenting SBP and GCS. The results of our study demonstrate a curvilinear association towards both extremes of heart rate. Patients who are either tachycardic or bradycardic have an associated increased mortality and warrant careful evaluation.

11.13 Mortality Rates of Severe Traumatic Brain Injury Patients: Impact of Direct vs. Non-direct Transfers

Posted on January 25, 2017

K. Prabhakaran1, P. Petrone1, G. Lombardo1, C. Stoller1, A. Betancourt1, A. Policastro1, C. P. Marini1  1Westchester Medical Center University Hospital,Trauma/Surgery/New York Medical College,Valhalla, NY, USA

Introduction: Direct transport of patients with severe traumatic brain injury (STBI) to trauma centers (TCs) that can provide definitive care results in lower mortality rates. Secondary transfers are required when patients with STBI are originally transported to non-trauma centers (NTCs) lacking in neurosurgical expertise, and thus resulting in delay of care. This study investigated the impact of direct versus non-direct transfers on the mortality rates of patients with STBI.

Methods: Data on patients with TBI admitted between 1/1/2012 to 12/31/2013 to our Level I TC were obtained from the trauma registry. Data included patient age, sex, mechanism and type of injury, co-morbidities, Glasgow Coma Scale (GCS), Injury Severity scores, pre-hospital time (PHT), time to request and to transfer, time to initiation of multimodality monitoring and goal-directed therapy protocol (MM&GDTP), dwell time in the emergency department (EDT), and mortality. Data, reported in means ± SD, were analyzed with the student t-test and chi-square. Statistical significance was accepted at a p value < 0.05.

Results:

STBI Direct transfer to TC vs. transfer from NTC: Of the 1,187 patients with TBI admitted to our TC, 768 (64.7%) were directly from the scene while 419 (35.3%) were after secondary transfer. 171 (22.2%) of the direct transfers had GCS < 8 (STBI) and 92 (21.9%) of the secondary transfers had STBI.

Transfer time: Time from scene to arrival to the ED was significantly shorter for TC vs. NTCs 43 ± 14 vs. 77 ± 26 minutes, respectively (p < 0.05). ED dwell time before transfer and time from injury to arrival to TC were 4.2 ± 2.1 and 6.2 ± 8.3 hr, respectively.

MM&GDTP: Time to initiation of MM&GDTP including craniotomy for patients with STBI was 3.1 ± 1.2 vs. 12.4 ± 2.2 hr, for patients arriving from scene to TC as opposed to patients transferred from NTC (p<0.05).

Mortality: There was a statistically significant lower mortality for patients with STBI transferred directly from the scene to TCs as opposed to patients transferred from NTCs, 33/171 (19.3%) vs. 28/92 (30.4%), respectively (p<0.05).

Conclusion: To decrease TBI-related mortality, patients with suspected STBI should be taken directly to a Level I or II TC unless they require life-saving stabilization at NTCs.

 

11.12 Non-Alcoholic Fatty Liver Disease (NAFLD) Is Associated With Increased Post-Traumatic Pneumonia

Posted on January 25, 2017

J. A. Bailey1, L. Brown1, A. Y. Parikh2, R. H. Wachsberg1, A. Kunac1, B. Koneru1, D. H. Livingston1  1New Jersey Medical School,Newark, NJ, USA 2Morristown Medical Center,Morristown, NJ, USA

Introduction:  Non-alcoholic fatty liver disease (NAFLD) has become epidemic in the US and has been associated with pulmonary complications following elective surgery and liver transplantation, but has not been considered as a comorbidity after trauma. Abdominal CT scanning can detect moderate-to-severe fatty infiltration of the liver. We hypothesized that trauma patients with pulmonary complications would have an increased incidence of pre-existing NAFLD compared to the trauma population at-large. 

Methods:  Data on adult ICU trauma patients with the diagnosis of ventilator-associated pneumonia (VAP) (N=147) were extracted from a prospective ICU respiratory database. Presence of NAFLD was identified using defined metrics comparing liver-to-spleen density on their admission abdominal CT. Analysis included demographics, ventilator and ICU days, respiratory failure, recurrent pneumonia, bacteriology, and mortality. To determine the baseline prevalence of NAFLD in the trauma population, 130 additional consecutive trauma patients who underwent abdominal CT on admission were analyzed.  

Results: The prevalence of NAFLD in the general trauma population was 27%. In contrast, NAFLD was present in 50% of trauma ICU patients who went on to develop VAP (p=0.001).  Known risk factors for VAP were similar in patients with and without NAFLD:  age (43 vs 49 years), BMI (28 vs 28), emergent intubation (68% vs 65%), TBI with head AIS ≥3 (31% vs 32%), and ISS (30 vs 33).  There were no differences in bacteriology, ventilator days or ICU stay.   

Conclusion: The presence of NAFLD on admission CT was significantly higher in ICU patients with post-traumatic VAP compared to the baseline trauma population. Given other risk factors were equal, we postulate that NAFLD may represent a pre-existing inflammatory focus that may alter the immune response to injury and represent an independent risk factor for post traumatic VAP.  The mechanisms for the increase in VAP remain speculative but this novel observation requires further prospective study, which might provide potential avenues of intervention to decrease the incidence of post-traumatic VAP. 

11.11 The Role of Cardiopulmonary Resuscitation Following Traumatic Arrest

Posted on January 25, 2017

P. Hu1, R. Uhlich1, J. Kerby1, P. Bosarge1  1UAB,Acute Care Surgery/Surgery,Birmingham, AL, USA

Introduction:
Cardiac arrest following traumatic injury is almost universally fatal. Resuscitation strategies vary depending on mechanism of injury and length of arrest. While little evidence has been published to support its use following traumatic arrest, cardiopulmonary resuscitation (CPR) remains recommended as definitive therapy following injury. We sought to evaluate the outcomes of patients suffering traumatic arrest following CPR.

Methods:
All adult trauma patients that presented to an American College of Surgeons verified level I trauma center with cardiac arrest from June 1, 2014 to August 1, 2016 were identified. Patients in arrest secondary to obvious traumatic brain injury, anoxic brain injury, burn inhalation injury or any patient undergoing resuscitative thoracotomy were excluded. Data including mechanism of injury, demographics, duration of pre and in hospital CPR, initial cardiac rhythm, any identified procedures, blood product utilization, mortality data, and disposition from hospital were collected. 

Results:
183 cases of CPR following traumatic arrest were identified. Of those, 87 were identified as meeting inclusion criteria. The majority of patients were male (78.2%) and the mean age was 47.1 years. Patients suffered mainly blunt injury (75.9%) compared to penetrating trauma (24.1%). 42 patients received CPR upon arrival in the emergency department, compared to 8 patients with isolated prehospital CPR and 37 patients receiving both. Mean prehospital CPR duration was 21.9 (0-60) minutes whereas mean isolated ED CPR time was 18.0 (0-80) minutes.  Of those receiving CPR, return of spontaneous circulation (ROSC) occurred in only 8 patients (9.2%), none of whom received prehospital CPR. All underwent attempted operative intervention following ROSC. Mean CPR time was 3.6 (2-5) minutes with one lone survivor receiving 2 minutes of CPR while en route to the operating room. Overall, patients received on average 10.2 units of blood products. No patient presenting with asystole (39) and only one with PEA (35) survived to attempted operative intervention.

Conclusion:
For patients suffering traumatic cardiac arrest, short duration CPR may be beneficial as a bridge to immediate hemorrhage control. Prolonged periods of CPR without hemorrhage control are likely futile and unlikely to result in survival. 
 

11.10 Effects of Missed or Off-Schedule Doses of Antibiotics on Patient Outcomes

Posted on January 25, 2017

C. Patel1, M. Swartz1, J. Tomasek1, L. Vincent1, W. Hallum2, J. Holcomb1  1University Of Texas Health Science Center At Houston,Houston, TX, USA 2Memorial Hermann Hospital,Houston, TX, USA

Introduction: When delivered according to the appropriate schedule, antibiotics (Abs) improve outcomes. Missing doses of Abs is a well described but an inadequately recognized issue. We hypothesized that missing doses of Abs decreases quality of care.

Methods: A retrospective study on all patients admitted to the Shock Trauma ICU from February to June 2015 was performed. Patients prescribed a course of Abs were evaluated, those given prophylactic or one dose were excluded.  A missed Ab dose was one planned but never given (a completely missed dose) or a dose that was not given within an hour before or after the planned time (an off-schedule missed dose). Abs given ± one hour is the standard ICU guideline. There were valid and non-valid reasons for completely missing a dose. Valid examples included a change in the order, doses held by an MD, high drug levels or dosing conflict. Non-valid examples included patient off unit and unknown. Patient outcomes included a positive culture, sepsis, ventilator, ICU and hospital days and mortality. Multiple statistical methods were used as appropriate, significance was set as p<0.05.

Results: 280 patients were admitted, 200 met inclusion criteria and 8167 doses of Abs were ordered. 8% of patients (16/200) did not miss any Ab doses, 38% (77/200) had off-schedule missed doses, 43% (86/200) missed a dose for non-valid reasons and 10% (21/200) missed doses for valid reasons. The median Ab doses ordered for those who did not miss doses was 4 (3, 6), while 26 (9, 53) were ordered for those who did miss doses (p<0.0001). All demographic data (age, BMI, ISS) were similar between patients who did and did not miss doses of Abs.
8167 total doses of Abs were ordered and 25% were missed. 21% of doses (1729/8167) were off-schedule, 2.3% (189/8167) were completely missed for non-valid reasons, and 1.3% (113/8167) were completely missed for valid reasons. Among off-schedule doses (1729/8167), the median number of hours off-schedule was 2 (2, 2) for both late doses and early doses.
Unadjusted analysis showed that patients who missed Abs had a higher rate of sepsis (p=0.01), while those who missed a dose of Abs for non-valid reasons spent more days on a ventilator (p=0.03) and in the hospital (p<0.0001) than patients who did not miss any doses.
Adjusting for age, gender, BMI, ISS and doses of Abs showed that those who completely missed a dose for non-valid reasons spent 50% more days in the hospital (p=0.01) than patients who did not miss any doses of Abs, while patients who only had off-schedule missed doses spent 54% more days in the hospital (p=0.004). Sepsis, mortality, days on ventilator, and days in the STICU were not significant when adjusted for covariates.

Conclusion: Missing doses of antibiotics (both completely and off-schedule) correlated with a substantial increase in length of hospital stay. To optimize quality of care, methods to improve compliance with antibiotic dosing schedules should be investigated. 

 

11.09 Validation of a Field Spinal Motion Restriction Protocol

Posted on January 25, 2017

J. M. Tatum1, N. Melo1, A. Ko1, N. K. Dhillon1, M. W. Choi1, E. J. Smith1, D. A. Yim1, G. Barmparas1, E. J. Ley1  1Cedars-Sinai Medical Center,Division Of Trauma And Critical Care, Department Of Surgery,Los Angeles, CA, USA

Introduction: Routine spinal motion restriction after traumatic injury has been a mainstay of pre-hospital trauma care for over three decades. Recent guidelines recommend a selective approach with cervical spine clearance in the field when criteria are met.

Methods: In January, 2014 the Department of Health Services of the City of Los Angeles, California implemented revised guidelines for cervical spinal motion restriction after blunt mechanism trauma. Adult patients (≥18 years old) with an initial GCS of ≥13 presented to a single level I trauma center after blunt mechanism trauma over the following one-year period were retrospectively reviewed. Demographics, injury data, and pre-hospital data were collected. Cervical spine injury (CSI) was identified by ICD-9 codes.

Results: 1,111 patients were presented to the trauma center by emergency medical services after sustaining blunt mechanism trauma. Patients were excluded if they refused c-collar placement or if documentation was incomplete. A total of 997 patients with a documented evaluation were included in our analysis. Spinal motion restrictions were not implemented in 172 (17.2%) in accordance with the protocol. The rate of spinal cord injury among all patients was 2.2% (22/997) and 1.2% (2/172) in patients without spinal motion restrictions. The sensitivity and specificity of the protocol is 90.9% (95% CI: 69.4-98.4) and 17.4% (95% CI: 15.1-20.0), respectively, for cervical spine injury. Two patients with CSI (9.1%) arrived without immobilization, having met field clearance guidelines. Both were managed non-operatively and had no neurological compromise.

Conclusion: New guidelines for cervical spinal motion restriction have high sensitivity and low specificity to identify CSI. When patients with injuries were not placed on motion restrictions there were no negative clinical outcomes. A pre-hospital selective approach to implementing cervical spinal motion restriction is safe.

11.08 Institutional Experience with Suspected Non-Accidental Trauma

Posted on January 25, 2017

C. N. Litz1, P. D. Danielson1, N. M. Chandler1  1Johns Hopkins All Children’s Hospital,Division Of Pediatric Surgery,St. Petersburg, FL, USA

Introduction: Suspected non-accidental trauma (NAT) victims comprise a significant portion of the pediatric trauma population. There is no gold standard method of confirming NAT; instead, the diagnosis is made after a comprehensive evaluation by a child protective services (CPS) team. The purpose of this study was to compare the clinical and social outcomes between patients with suspected NAT (SUSP) and confirmed NAT (CONF).

Methods: Following IRB approval (No. 00082930), our institutional trauma registry was retrospectively reviewed for patients aged 0-18 years presenting from 2007 to 2012. Patients with traumatic injuries suspicious for NAT were included. NAT was diagnosed after evaluation by our CPS team. Patients with suspected and confirmed NAT were compared. General admission and outcome data were collected and analyzed.

Results: There were 281 patients with traumatic injuries suspicious for NAT; 170 were CONF and 111 SUSP. The groups did not differ in age (CONF 0.9 ± 1.1 vs SUSP 1.2 ± 2 years, p=0.16). CONF patients presented with a higher heart rate (142 ± 27 vs 128 ± 23 bpm, p<0.0001), lower systolic blood pressure (100 ± 18 vs 105 ± 16 mm Hg, p < 0.05), lower Glasgow Coma Score (12 ± 4 vs 15 ± 1, p <0.0001), and a higher Injury Severity Score (15 ± 11 vs 9 ± 5, p<0.0001). A significantly greater percentage of CONF patients were admitted to the intensive care unit (42% vs 8%, p<0.0001). CONF patients had significantly higher mortality (8.2% vs 0%, p<0.0001). CONF patients had a significantly longer overall length of stay (LOS) (7.8 ± 9.8 vs 1.6 ± 1.3 days, p <0.001), as well as a longer LOS after being medically cleared for discharge (1.2 ± 1.7 vs 0.2 ± 0.4 days, p<0.0001). Significantly fewer CONF patients were discharged with parents or other family members (54% vs 100%, P<0.0001) (Table 1).

Conclusion: Patients with a confirmed diagnosis of NAT present with more severe injuries and arrive less hemodynamically stable compared to patients in whom NAT is suspected and ruled out. In addition, patients with confirmed NAT require increased hospital resources and are less likely to be discharged to the care of parents or family members. This study emphasizes the fact that NAT patients are a high-risk subset of the pediatric trauma population, and suggests that providers should have an increased suspicion for true non-accidental trauma in patients being evaluated for possible NAT who present with more severe injuries.

11.07 EARLY POSITIVE PRESSURE VENTILATION IN TRAUMA PATIENTS WITH FACIAL AND SKULL BASE FRACTURES

Posted on January 25, 2017

M. C. Spalding1,2, D. E. Leshikar1,3, C. Hester1, C. T. Minshall1  1Parkland, UT Southwestern,Burn/Trauma/Critical Care Surgery,Dallas, TEXAS, USA 2Grant Medical Center, Ohio University College Of Osteopathic Medicine,Trauma And Acute Care Surgery,Columbus, OHIO, USA 3UC Davis,Trauma, Acute Care Surgery And Surgical Critical Care,Sacramento, CA, USA

Introduction: There are over 1.7 million traumatic brain injuries annually. Thirty percent of these patients present with associated skull fractures and maxillofacial fractures (SMXFX). Despite a paucity of evidence, consulting services ENT, OMFS, Plastic Surgery and Neurosurgery will restrict pulmonary recruitment techniques: incentive spirometer or bi-level positive airway pressure (BiPAP) secondary to the alleged risk of post-traumatic meningitis. These imposed limitations are not evidence-based and are potentially dangerous in patients with marginal pulmonary effort. We initiated an aggressive noninvasive respiratory protocol (NRP) to improve pulmonary recruitment for all patients with SMXFX and minimal pulmonary reserve. We prospectively evaluated the effect of therapy on the incidence of meningitis, pneumothorax, pneumocephalus or need for re-intubation on patients with SMXFX.

Methods: This is a prospective evaluation of all trauma patients with SMXFX admitted to the SICU of a Level I Trauma Center from 1/2015 to 12/2015. Patients with SMXFX were required to perform incentive spirometer (IS) every 4hrs under direction of respiratory therapy after 48 hours from time of injury. Patients that were not capable of achieving > 30% of predicted volume (PV) using IS were also started on BiPAP treatment every 4 hrs. Liberation from BiPAP therapy occurred when patients achieved > 50% PV on IS for two consecutive treatment sessions.  We tracked the incidence of new or worsening pneumocephalus, worsening pulmonary failure, pneumothorax, SICU readmission, meningitis, and deviations from protocol.

Results:Seventy five patients with complex SMXFX were admitted to the SICU during the study period. Eighty two percent of these patients received IS therapy every 4 hours with a mean start time of 48 hours from admission. The mean inspiratory capacity for patients who progressed to BIPAP was 32% of PV. The average number of BIPAP treatments per patient in this group was 39 and these treatments achieved a mean volume of 1345 ml. One patient was intubated after initiation of the NRP for progressive respiratory failure. There were no cases of meningitis, pneumothorax, need for re-intubation or pneumocephalus

Conclusion:Early implementation of the proposed NRP is safe for patients with complex SMXFX within 48 hour injury or closure of a CSF leak. Since these results we have advanced our volume recruitment strategies for complex SMXFX patients to be implemented in the first 24 hours after admission for those without a cerebral spinal fluid (CSF) leak, or 24 hours after documented closure of the CSF leak.

 

11.06 State Trauma Alert Criteria Versus Paramedic Judgment: A Comparative Analysis

Posted on January 25, 2017

T. Husty1, M. Crandall1, D. Chesire1, D. Ebler1  1University Of Florida,Surgery,Jacksonville, FL, USA

Introduction: The State of Florida Adult Trauma Triage Criteria defines specific parameters that prompt paramedics to initiate a trauma alert, including injury mechanism and vital signs. In addition to these predefined criteria, paramedics may initiate an alert based on their own judgment. This activation is known as an alert based on Paramedic Discretion (PD). Our aim was to identify predictors of PD activations and to compare the outcomes of trauma patients who met objective alert criteria versus PD. 

Methods:  This is a retrospective observational study which included all trauma patients 18 years and older evaluated in our trauma center from January 1, 2007 to December 31, 2014. Demographic and injury severity variables were obtained from our trauma registry and outcomes were compared between patients who met state alert criteria and those who were brought by PD.  We performed bivariate and multivariate statistics using SPSS and STATA.

Results: There were 13,305 patients who met state alert criteria and 1,188 alerted due to PD during the study period. Patients who were activated by state criteria had lower mean Glasgow Coma Scores [12 vs 14, p<0.001] and systolic blood pressures [126 vs 133, p<0.001].  On initial evaluation, 822 (6.4%) who met alert criteria and 14 (1.2%) activated via PD died [OR 3.7, 95% CI 2.5-5.5, p<0.001].  Admission rates were similar for both groups, as were lengths of stay.  Regression modeling was unable to find independent or combinations of vital signs or demographics that would predict PD alerts [OR 1.4, 95% CI 0.74-2.62, p=0.31].  On multivariate modeling, PD was not an independent predictor of mortality or length of stay after controlling for injury severity and demographics.

Conclusion: As expected in an established trauma triage protocol, the mortality was higher for patients who met TA criteria but crude admission and discharge rates were similar. Though regression analysis could not elucidate predictors of PD, these results suggest PD may identify a subset of patients that benefit from trauma center evaluation.  However, PD itself does not appear to be an independent predictor of mortality or length of stay after controlling for injury severity.  In summary, PD remains a reasonable adjunct to state activation criteria, but further research into PD would help refine and codify these criteria.

 

11.05 Tranexamic Acid is Associated with Increased Mortality in Patients with Physiologic Levels of Fibrinolysis

Posted on January 25, 2017

H. B. Moore1, B. Huebner1, T. L. Nydam1, G. Settler1, G. Nunns1, C. C. Silliman1, A. Sauaia1, E. E. Moore1  1University Of Colorado Denver,Surgery,Aurora, CO, USA

Introduction: Utilization of tranexamic acid (TXA) in trauma remains debated.  While European guidelines recommend empiric TXA in hypotensive trauma patients, many trauma centers in the United States question this practice.  Recent appreciation of the spectrum of fibrinolysis acutely after injury has identified an associated protective effect of a moderate level of fibrinolysis.  There are concerns that TXA may harm this patient population.  TXA administration at our trauma center is goal directed on rapid thrombelastography (rTEG) LY30 results, although clinicians can empirically administer TXA if they believe it is indicated.   We hypothesize that this is a futile intervention and poses the risk of increased mortality in patients with physiologic fibrinolysis levels.

 

Methods: Trauma activations from 2015-2016 with blood samples obtained in the ambulance or emergency department were analyzed with rTEG.  Patients included in the analysis had an LY30 between 0.8 and 2.9 (previously defined as physiologic fibrinolysis).  Demographics, clinical variables, and blood product utilization were collected by prospectively by trained research assistants.  The primary outcome of interest was in hospital mortality contrasted between patients who received TXA and no TXA. Confounders(age, NISS, systolic blood pressure(SBP), Glasgow Coma Score(GCS), RBC transfusion in the first 2 hours from injury) were adjusted with multivariate logistic regression and cox regression analysis.

 

Results:  Fourtny nine percent of patients (141/291) were identified to have physiologic levels of fibrinolysis  The median NISS was 27 and mortality rate was 6% (significantly less than hyperfibrinolysis 20% and shutdown 16% p=0.004). Patients with physiologic phenotype were given TXA 5% of the time and delayed delivery(>3 hours) occurred in 38% of patients. NISS was higher but not significant in patients given TXA (48 vs 27p=0.334), while SBP (108 vs 118 p=0.325) and GCS were similar (15 vs 15 p=0.779). TXA patients received more RBC units at hour 1 and 2 during resuscitation (1 vs 0 p<0.001 and 2 vs 0 p=0.001). Mortality was significantly higher in the TXA group 38% vs 4% (p=0.004). After adjusting for confounders TXA was significantly associated with increased mortality in logistic regression analysis (p=0.024) and cox regression (HR 14.5 p=0.042). In patients with hyperfibrinolysis there was no differnce in survival with TXA use before (p=0.521) and after adjustment (p=0.531).

 

Conclusion:Patient's with physiologic levels of fibrinolysis that receive TXA have increased mortality compared to patients who did not receive this medication.  While the TXA patients had an overall higher requirement of blood products and were given this medication based on clinician gestalt, there was no observed benefit. These data support the continued concerns of empiric utilization of TXA, and has identified a potential danger of giving this medication to patients who present to the hospital with physiologic levels of fibrinolysis. 

 

11.04 Early Thromboprophylaxis With Low Molecular Weight Heparin In Patients With Pelvic Fractures Is Safe

Posted on January 25, 2017

F. Jehan1, K. Ibraheem1, A. Azim1, A. Tang1, T. O’Keeffe1, N. Kulvatunyou1, L. Gries1, G. Vercruysse1, R. Friese1, B. Joseph1  1University Of Arizona,Trauma,critical Care, Burn And Emergency Surgery/Department Of Surgery,Tucson, AZ, USA

Introduction:
Early initiation of thromboprophylaxis is highly desired in patients with pelvic fractures but it is often delayed due to fears of re-bleeding and hemorrhage. The aim of our study was to assess the safety profile of early initiation of venous thromboprophylaxis in patients with pelvic trauma.

Methods:
Three year (2010-2012) retrospective study of trauma patients with pelvic fractures presenting at single level-I trauma center was performed. Patients who received thromboprophylaxis with low molecular weight heparin (LMWH) during their hospital stay were included. Patients were stratified in two groups based on timing of initiation of prophylaxis; early (initiation within first 24 hours) and late (initiation after 24 hours) initiation. Signs of bleeding or hemorrhage were defined as presence of pelvic hematoma, free fluid, or blush on CT scan. Decrease in hemoglobin (Hb) was defined as difference between admission Hb level and lowest post-prophylaxis Hb level. Our primary outcome measures were decrease in Hb levels, pRBC units transfused, and need for hemorrhage control (operative or angioembolization) after initiation of prophylaxis. Secondary outcome measures were hospital and ICU length of stay. Multivariate regression analysis was performed.

Results:
 

255 patients were included (158 in early and 97 in late group). Mean±SD age was 48.2±23.3 years, 50.6% were male, and mean±SD number of pRBC units was 0.62±1.59. After adjusting for confounders, there was no difference in the decrease in Hb levels (b= 0.087, 95% [CI]=[-0.253 – 1.025], p=0.23) or pRBC units transfused (b= -0.005, 95% [CI]= [-0.366 – 0.364]; p=0.75) between the two groups. Only one patient required hemorrhage control after initiation of thromboprophylaxis and belonged to the late group. There was no difference in the hospital LOS (b=0.120, 95% [CI]= -0.165 – 4.929; p=0.67). ICU length of stay was significantly shorter in early prophylaxis group (b= 0.206, 95% [CI]= 0.206 – 4.762; p=0.03).

On sub-analysis of patients with signs of bleeding or hemorrhage (n=52), there was no difference in decrease in Hb levels (b= 0.131, 95% [CI]= -1.411 – 2.586; p=0.55) or pRBC units transfused (b= -0.007, 95% [CI]= -1.588 – 1.518; p=0.96) between the two groups

Conclusion:
Our study shows no difference in pRBC transfusion requirements, drop in hemoglobin levels, or need for hemorrhage control between early and late initiation of thromboprophylaxis. We conclude that fear of hemorrhage with early thromboprophylaxis is not substantiated in patients with pelvic fractures

11.03 Early Versus Delayed Prophylactic Anticoagulation In Adult Trauma Patients With Pulmonary Contusions

Posted on January 25, 2017

M. B. Linskey1, A. B. Podany1, A. S. Kulaylat1, A. L. Lauria1, S. R. Allen1,2, J. D. Chandler1,2, R. M. Staszak1,2, S. B. Armen1,2  1Penn State University College Of Medicine,Department Of Surgery,Hershey, PA, USA 2Penn State University College Of Medicine,Division Of Trauma, Acute Care & Critical Care Surgery,Hershey, PA, USA

Introduction: Pulmonary contusions (PC) lead to morbidity and mortality in trauma patients, placing them at increased risk for mechanical ventilation, acute respiratory distress syndrome, and pneumonia. Tissue injury and hemorrhage in PC result in inflammation, edema, atelectasis, and intrapulmonary shunting even in the uninjured lung. We hypothesized that early prophylactic anticoagulation (pAC) would be associated with worsened respiratory outcomes in patients with PC.

Methods: A retrospective cohort study identified patients with PC from a rural Level I trauma center’s institutional registry. Patients with severe traumatic brain injury, prior use of therapeutic anticoagulation or antiplatelet therapy, and those who did not receive pAC were excluded. The cohort was stratified into those receiving early or delayed pAC, within or after 48 hours of admission, respectively. Outcomes including 30-day mortality, 30-day venous thromboembolism (VTE) rate, retained hemothorax, and pneumonia were modeled using multivariable logistic regression to control for patient and injury characteristics. Propensity score matching was then used to isolate two groups with similar comorbidities and injuries. Univariate statistics were performed to compare nadir oxygen saturation levels and supplemental oxygen requirements between the two groups before and after administration of pAC.

Results: 356 patients met inclusion criteria; 195 in the early and 161 in the delayed groups. The groups did not differ with respect to age, sex, race, mechanism, pulmonary comorbidities, number of rib fractures, or proportion with flail chest. The group receiving delayed pAC had lower admission GCS scores (12.0 vs 14.1, p<0.001) and higher injury severity scores (27.7 vs 20.0, p<0.001), and was significantly more likely to have bilateral PC (41.3% vs 28.4%, p<0.05), concomitant solid organ injury (42.2% vs 12.8%, p<0.001), intracranial or spinal hematoma (35.4% vs 5.64%, p<0.001), or other organ space hematoma (28.0% vs 14.9%, p<0.01). After controlling for differences between the groups, initiation of pAC within 48 hours of injury in patients with PC did not significantly increase the odds of 30-day mortality. Similarly, early pAC was not significantly associated with retained hemothorax or pneumonia. Delayed pAC was also not associated with VTE. Of the propensity score-matched groups, those with early pAC had a decrease between their pre- and post-pAC nadir oxygen saturation levels while those with delayed pAC had a slight increase (93.2% to 90.1% among early vs 90.9 to 92.1% among delayed, p<0.001). Changes in oxygen requirements before and after pAC, however, did not differ between the two groups (37% to 28% among early vs 36% to 25% among delayed, p=0.401).

Conclusion: In this study, early vs delayed pAC did not significantly impact outcomes in patients with PC, suggesting that other clinical factors should guide timing of pAC in adult trauma patients.

11.02 Putting the Pieces Together: A Principal Component Analysis of Acute Traumatic Coagulopathy in Kids

Posted on January 25, 2017

C. M. Leeper1,2, M. D. Neal2, C. McKenna1, T. Billiar2, B. A. Gaines1  1Children’s Hospital Of Pittsburgh Of UPMC,Pediatric Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh Medical Center,General Surgery,Pittsburgh, PA, USA

Introduction:
Injured children commonly present with acute traumatic coagulopathy (ATC) defined by elevated international normalized ratio (INR). ATC is associated with poor outcome, though these patients usually are not clinically coagulopathic. INR, therefore, is not always a therapeutic target but rather a marker of complex systemic dysregulation. Our goal is to evaluate multiple coagulation parameters that encompass the broader hemostatic system and identify patterns after injury that may be associated with clinical outcomes.

Methods:
We performed principal components analysis (PCA) on prospectively collected data from children with highest trauma activation in our pediatric center from June 2015-June 2016. Admission labs included INR, platelet count and thromboelastography (TEG) parameters (clotting factors (ACT), fibrinogen (K), platelet function (MA) and fibrinolysis (LY30)). Variables were reduced to principal components (PC) and PC scores were generated for each subject for use in logistic regression. Outcomes included mortality, disability (based on functional independence measure score or discharge to rehabilitation facility), venous thromboembolism (VTE; screening ultrasound for high-risk or symptomatic patients), and blood transfusion in the first 24 hours.

Results:
133 subjects were included with median(IQR) age =10(5-13), median(IQR) ISS =17(9-25), 73.5% male, 70.8% blunt trauma. The rate of mortality was 5.6% (n=7), disability was 23.9% (n=28), early blood transfusion was 26.3%(n=35) and VTE was 10.3%(n=11). PCA identified 3 significant PCs accounting for 75.0% of overall variance. PC1 identified clot strength (platelets and fibrinogen); PC2 identified abnormal fibrinolysis, both hyperfibrinolysis and fibrinolysis shutdown (LY30 and INR); and PC3 identified global clotting factor depletion (INR and K). PC1 score was associated with increased mortality (odds ratio [OR] =1.63; p<0.001) and early transfusion (OR 1.36; p=0.002). PC2 score was correlated with ISS (rho 0.4; p<0.001) and associated with VTE (OR 1.84; p=0.034), functional disability (OR 1.66; p=0.017), increased mortality (OR 2.07; p=0.003) and early blood transfusion (OR 2.79; p<0.001). PC3 score was associated with increased mortality (OR 1.92; p=0.007) and early transfusion (OR 1.25; p=0.075).

Conclusion:
PCA detects three distinct patterns of coagulation dysregulation using widely available laboratory parameters: 1) abnormalities in clot strength; 2) abnormalities in fibrinolysis, and 3) clotting factor depletion. All were associated with poor outcomes; however, fibrinolytic dysregulation is associated with more severely injured patients and portends particularly poor outcome including increased mortality, DVT, disability and need for transfusion.
 

11.01 Massive Transfusion Protocol is Associated with Higher Rate of Venous Thromboembolism

Posted on January 25, 2017

N. K. Dhillon1, E. J. Smith1, A. Ko1, M. Y. Harada1, K. Patel1, M. Scheipe1, G. Barmparas1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  Massive Transfusion Protocol (MTP) is often initiated in patients who are unstable secondary to hemorrhagic shock. Thrombotic events have been associated with MTP, however the risk factors for the development of venous thromboembolism (VTE) within this patient population is unknown.

Methods:  A retrospective review was conducted by examining the electronic medical records of all trauma patients admitted to a Level I trauma center who had MTP initiated from 2011 to 2015. Data was collected on patient demographics, mechanism of injury, injury severity scores, quantity of packed red blood cells (PRBC) transfused during MTP activation, incidence of VTE, ICU length of stay (LOS), hospital LOS, and ventilator days.

Results: Of the 63 patients identified who had MTP activated, 11 (17.5%) developed a VTE during their hospital admission. One patient was diagnosed with a pulmonary embolus. Patients who developed VTE were compared to those who did not. Age (40 (22-62) vs. 42.5 (25.5-54) years, p=0.94), sex (46% vs. 73% male, p=0.09), and mechanism of injury (59% vs. 64% blunt, p=1.0) were similar. ICU LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE (Table 1). Multivariable analysis revealed an increase in the odds for developing a VTE with each unit of PRBC transfused (AOR=1.17, p=0.011).

Conclusion: Patients who received PRBC after MTP activation were at higher risk for developing VTE. Clinicians may need a higher suspicion for the presence of VTE within this patient population.

 

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