Coagulation profile tests as a predictor for adult trauma patients’ mortality

Background: Coagulopathy is commonly observed in poly-traumatized patients and is a known contributor to trauma mortality. Although, the incidence of coagulopathy is strongly associated with the severity of the injury, coagulopathy itself exerts an independent factor on mortality.Methods: This is a prospective, observational study on 100 trauma patients. All patients were evaluated using the modified shock index (MSI). Coagulation profile tests including platelet count, prothrombin time (PT), partial thromboplastin time (PTT), D-dimer and fibrinogen/fibrin degradation products (FDPs) were performed for all patients on admission and at 12 hours intervals. Statistically, a logistic regression analysis was performed of coagulation profile tests to determine the incidence of trauma induced coagulopathy (TIC) and its impact on 24 hours mortality. Correlation between clinical and laboratory status was done.Results: There was a statistically significant difference between the dead and the survived patients in the coagulation profile tests and MSI. The best cut-off point of each parameter of coagulation profile tests (PLT count, PT, PTT, d-dimer, FDPs) and MSI was calculated using receiver operating characteristic curve and were <173 × 109/l, >18.7 s, >31 s, >5 mg/l, > 321.5 mg/l and 1.6 respectively. Trauma induced coagulopathy in our study was defined by more than 2 of the following: PLT <173 × 109/l, PT >18.7 s, activated partial thromboplastin time (APTT) >31 s, D-dimer >5 mg/l and FDPs>321.5 mg/l with a p value 0.001 and associated with increased mortality.Conclusions: The incidence of trauma induced coagulopathy early after trauma is high and its severity is related to the injury itself. It is independent predictor of mortality. TIC was developed with presence of more than 2 of the coagulopathy parameters.

The emergency department length of stay: Is the time running out? / 中华创伤杂志(英文版)

PURPOSE@#To examine the relationships between emergency department length of stay (EDLOS) with hospital length of stay (HLOS) and clinical outcome in hemodynamically stable trauma patients.@*METHODS@#Prospective data collected for 2 years from consecutive trauma patients admitted to the trauma resuscitation bay. Only stable blunt trauma patients with appropriate trauma triage criteria requiring trauma team activation were included in the study. EDLOS was determined short if patient spent less than 2 h in the emergency department (ER) and long for more than 2 h.@*RESULTS@#A total of 248 patients were enrolled in the study. The mean total EDLOS was 125 min (range 78-180). Injury severity score (ISS) were significantly higher in the long EDLOS group (17 ± 13 versus 11 ± 9, p < 0.001). However, when leveled according to ISS, there were no differences in mean in diagnostic workup, admission rate to intensive care unit (ICU) or HLOS between the short and long EDLOS groups.@*CONCLUSION@#EDLOS is not a significant parameter for HLOS in stable trauma patients.

Effects of heating intravenous fluid infusion and blood transfusion based on guidelines in sever trauma patients with hypothermia / 中华急诊医学杂志

Objective To explore the effects of heating intravenous fluid infusion and blood transfusion based on guidelines in severe trauma patients with hypothermia. Methods A total of 40 severe trauma patients with hypothermia admitted from July 2014 to December 2015 were enrolled as the control group treated with routine measures to maintain the body temperature at normothermia by such as electrical heating blanket; other 40 severe casualties with hypothermia admitted from January 2016 to July 2017 were recruited as the warming up group treated with heating intravenous fluid infusion and blood transfusion by hot water bath in addition to the routine measures for keeping body temperature at normothermia. The differences in core body temperature, prothrombin time, activated partial thromboplastin time, incidence of shivering and mortality rate were compared between the two groups. Results There was statistically signifi cant difference in core body temperature at 0.5 h, 1.0 h, 1.5 h, 3.0 h between the two groups (P<0.05). Though the prothrombin time and shivering were improved after warming up in both groups, and there were significant differences in prothrombin time at 3.0 h after warming up and the incidence of shivering between two groups(P<0.05).There was no signifi cant difference in mean arterial pressure at all seven intervals between two groups. Conclusion The heating intravenous fl uid infusion and blood transfusion had remarkable effects to prevent hypothermia, improves blood coagulation and reduced the incidence of shivering to provide more simple and convenient warming up intervention for clinical practice.

Effects of intensive insulin therapy on the level of inflammatory factors and prognosis in severe multiple trauma patients / 临床外科杂志

Objective To observe the influence of intensive insulin therapy on inflammatory fac-tors and prognosis in severe multiple trauma patients.Methods A total of 53 cases of severe multiple trauma were randomly divided into the treatment group(n =27)and the control group(n =26).Besides basic treatment,patients in the treatment group received additional intensive insulin therapy by micro-pump.The level of blood glucose in the control group was controlled under 11.1 mmol/L.Levels of TNF-α,IL-1β,IL-6,and CRP were tested before and after treatment.Multiple organ dysfunction syndrome,noso-comial infection rate,and mortality rate were also observed.Results The levels of TNF-α,IL-1β,IL-6, and CRP in the treatment group were significantly lower than those of the control group(P <0.05 or P <0.01).The incidence of multiple organ dysfunction syndrome,nosocomial infection,and mortality rate in the treatment group was lower(P <0.05).Conclusion Intensive insulin therapy can effectively decrease the expressions of inflammatory factors in patients with severe multiple trauma,improve the prognosis,re-duce the incidence of nosocomial infection and mortality.

Investigation of the value in clinical diagnosis of two dimers (D-D), fibrinogen (Fbg) and platelet parameters (PLT, MPV, PDW) level induced by postoperative deep vein thrombosis (DVT) in patients with severe trauma / 中国医师杂志

Objective To investigate the D-in patients with severe trauma in two dimers (D-D),fibrinogen (Fbg) and platelet parameters (PLT,MPV,PDW) level induced by postoperative deep vein thrombosis (DVT) in the formation of value in clinical diagnosis.Methods Eighty cases of healthy people as control group,were compared before and after operation and level and 321 severe traumatic patients were measured before surgery,after 1 days and 3 days of D-D,Fbg and platelet parameters,trauma were divided into fracture,traumatic brain injury,multiple injuries in three groups.Results Different trauma patients with D-D,Fbg concentration and platelet index compared with the control group increased obviously significant (P ＜ 0.05),especially the brain trauma and multiple injuries in two group increased significantly (P ＜0.01),the positive rate of D-D was 22.8％,35.2％,40.9％.Postoperative 1D in addition to brain injury group,trauma group D-D levels compared with those before operation were significantly increased with significant (P ＜ 0.05),other indicators compared with preoperative changes little,the positive rate of D-D increased slightly,but without statistical significance.Levels of Fbg 3D after the trauma group decreased significantly,D-D increased significantly,decreased the number of PLT,MPV,PDW value increases,the value of preoperative has the remarkable significance (P ＜ 0.01 or P ＜ 0.05).The positive rate of D-D was increased up to 41％,59.2％,62.3％,compared with those before operation by chi-square test was significant (P ＜0.01).Conclusion The patients with severe trauma patients after two D-dimer concentration should be alert to the occurrence of DVT,contribute to the clinically as soon as possible to take measures to avoid,there is an important clinical significance in the treatment and prognosis of trauma patients.

Multivariate Analysis of Predictive Factors for the Severity in Stable Patients with Severe Injury Mechanism

PURPOSE: For determining the prognosis of critically injured patients, transporting patients to medical facilities capable of providing proper assessment and management, running rapid assessment and making rapid decisions, and providing aggressive resuscitation is vital. Considering the high mortality and morbidity rates in critically injured patients, various studies have been conducted in efforts to reduce those rates. However, studies related to diagnostic factors for predicting severity in critically injured patients are still lacking. Furthermore, patients showing stable vital signs and alert mental status, who are injured via a severe trauma mechanism, may be at a risk of not receiving rapid assessment and management. Thus, this study investigates diagnostic factors, including physical examination and laboratory results, that may help predict severity in trauma patients injured via a severe trauma mechanism, but showing stable vital signs. METHODS: From March 2010 to December 2011, all trauma patients who fit into a diagnostic category that activated a major trauma team in CHA Bundang Medical Center were analyzed retrospectively. The retrospective analysis was based on prospective medical records completed at the time of arrival in the emergency department and on sequential laboratory test results. PASW statistics 18(SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Patients with relatively stable vital signs and alert mental status were selected based on a revised trauma score of more than 7 points. The final diagnosis of major trauma was made based on an injury severity score of greater than 16 points. Diagnostic variables include systolic blood pressure and respiratory rate, glasgow coma scale, initial result from focused abdominal sonography for trauma, and laboratory results from blood tests and urine analyses. To confirm the true significance of the measured values, we applied the Kolmogorov-Smirnov one sample test and the Shapiro-Wilk test. When significance was confirmed, the Student's t-test was used for comparison; when significance was not confirmed, the Mann-Whitney u-test was used. The results of focused abdominal sonography for trauma (FAST) and factors of urine analysis were analyzed using the Chi-square test or Fisher's exact test. Variables with statistical significance were selected as prognostics factors, and they were analyzed using a multivariate logistics regression model. RESULTS: A total of 269 patients activated the major trauma team. Excluding 91 patients who scored a revised trauma score of less than 7 points, 178 patients were subdivided by injury severity score to determine the final major trauma patients. Twenty-one(21) patients from 106 major trauma patients and 9 patients from 72 minor trauma patients were also excluded due to missing medical records or untested blood and urine analysis. The investigated variables with p-values less than 0.05 include the glasgow coma scale, respiratory rate, white blood cell count (WBC), serum AST and ALT, serum creatinine, blood in spot urine, and protein in spot urine. These variables could, thus, be prognostic factors in major trauma patients. A multivariate logistics regression analysis on those 8 variables showed the respiratory rate (p=0.034), WBC (p=0.005) and blood in spot urine (p=0.041) to be independent prognostic factors for predicting the clinical course of major trauma patients. CONCLUSION: In trauma patients injured via a severe trauma mechanism, but showing stable vital signs and alert mental status, the respiratory rate, WBC count and blood in the urine can be used as predictable factors for severity. Using those laboratory results, rapid assessment of major trauma patients may shorten the time to diagnosis and the time for management.

Incidence and Prevention of Venous Thromboembolism in Severely Injured Patients with Lower Extremity Fracture / 대한정형외과학회잡지

PURPOSE: To compare the incidence of venous thromboembolism (VTE) in severely injured patients with lower extremity fracture in a prophylactic group with that in a non-prophylactic group during a retrospective study. MATERIALS AND METHODS: Severely injured patients with lower extremity fracture were enrolled in this study and were divided into the following two groups: Group I, non-prophylactic group, and Group II, prophylactic group using anticoagulants and mechanical prophylaxis. RESULTS: Symptomatic VTE occurred in 5 cases (16.1%) among the 31 cases in Group I; i.e., deep vein thrombosis in one case and pulmonary embolism (PE) in four cases, including life threatening PE 2 cases. There were no patients with symptomatic VTE among the 32 cases in Group II. CONCLUSION: The incidence of symptomatic VTE without the use of prophylaxis was 16.1%. This rate dramatically decreased with the use of prophylaxis. Therefore, we believe that prophylaxis with anticoagulants and mechanical device is necessary in order to prevent VTE in severely injured patients with lower extremity fracture.

Prognostic Factor, for Major Trauma Patients in the Emergency Medical Service System

PURPOSE: A few studies have assessed the factors affecting the prognoses for major trauma patients and those improving the circumstances when dealing with the trauma system. In that light, we analyzed factors, such as pre-hospital factors, the time to admission, the length of stay in the emergency department (ED) and emergency operation, influencing the outcomes for trauma patients. METHODS: The patients who visited our emergency department from April 1, 2009, to February 29, 2011, due to major trauma were enrolled in the study. The inclusion criterion was a revised trauma score (RTS) or = 16. We used reviews of medical records, to analyze each step of emergency medical care with respect to patients' sex, age, visit time and visit date. Continuous variables were described as a median with an interquartile range, and we compared the variables between the survival and the mortality groups by using the Mann-Whitney U test. Fisher's exact test was used for nominal variables. Using the variables that showed statistical significance in univariate comparisons, we performed a logistic regression analysis, and we tested the model's adequacy by the using the Hosmer-Lemeshow method. RESULTS: A total of 261 patients with major trauma satisfied either the RTS score criterion or the ISS score criterion. Excluding 12 patients with missing data, 249 patients were included in this study. The overall mortality rate was 16.9%. Time to ED arrival, time to admission, time of ED stay, RTS, ISS, and visit date being a holiday showed statistically significant differences between the survival and the mortality groups in the univariate analysis. RTS, ISS, length of ED stay, and visit date being a holiday showed statistical significance in the multivariate analysis. CONCLUSION: The mortality rate did not show a significant relationship with the time to ED arrival, use of 119, on time to admission. Rather, it elicited a quite significant correlation with the trauma scoring system (RTS and ISS), the time of ED stay, and the visit date being a holiday.

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial / Efectos del ácido tranexámico sobre la mortalidad, eventos oclusivos vasculares y transfusiones de sangre en pacientes con traumatismos con hemorragias significativas (CRASH-2): estudio aleatorio, controlado con placebo

BACKGROUND: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. METHODS: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.gov NCT00375258, and South African Clinical Trial Register DOH-27-0607-1919. RESULTS: 10 096patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14-5%] tranexamic acid group vs 1613 [16-0%] placebo group; relative risk 0-91, 95% CI 0-85-0-97; p = 0-0035). The risk of death due to bleeding was significantly reduced (489 [4-9%] vs 574 [5-7%]; relative risk 0-85, 95% CI 0-76-0-96; p = 0-0077). CONCLUSION: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis ofthese results, tranexamic acid should be considered for use in bleeding trauma patients.

ANTECEDENTES: El ácido tranexámico puede reducir las hemorragias en pacientes que serán sometidos a cirugía electiva. Evaluamos los efectos de la administración anticipada de un tratamiento de corta duración con ácido tranexámico sobre la mortalidad, los eventos oclusivos vasculares y la administración de transfusiones de sangre en pacientes con traumatismos. MÉTODOS: Este estudio controlado aleatorio se realizó en 274 hospitales distribuidos en 40países. Se asignó en forma aleatoria un total de 20.211 pacientes adultos con traumatismos, con riesgos o no de tener una hemorragia significativa dentro de las 8 horas de la lesión al tratamiento con ácido tranexámico (dosis de carga 1 g durante 10 min. y luego infusión de 1 gen 8 horas) o placebo en forma similar. La distribución aleatoria se equilibró en cada centro, con una secuencia de asignaciones basada en un tamaño de bloque de ocho, generado por un generador de números aleatorios por computadora. Tanto los participantes como el personal del estudio (investigadores del centro y personal del centro que coordinaba el estudio) desconocían la asignación de los tratamientos. El principal resultado fue la mortalidad en el hospital dentro de las 4 semanas de ocurrida la lesión, que se describió con las siguientes categorías: hemorragia, oclusión vascular (infarto de miocardio, accidente cerebrovascular y embolia pulmonar), falla multiorgánica, lesión en la cabeza y otros. Todos los análisis se realizaron con intención de tratar. Este estudio está registrado como ISRCTN86750102, Clinicaltrials.gov NCT00375258, y Registro de Estudios Clínicos Sudafricano DOH-27-0607-1919. RESULTADOS: Se asignaron 10 096 pacientes al tratamiento con ácido tranexámico y 10 115 al tratamiento con placebo, de los cuales se analizaron 10 060 y 10 067, respectivamente. La mortalidad por cualquier causa se redujo significativamente con el tratamiento con ácido tranexámico (1463 [14.5%] del grupo que recibió ácido tranexámico comparados con 1613 [16.0%] del grupo que recibió placebo; riesgo relativo 0.91, 95% CI 0.85-0.97; p = 0.0035). El riesgo de muerte debido a hemorragias se redujo significativamente (489 comparado con 574; riesgo relativo 0.85, 95% CI 0.76-0.96; p = 0.0077). CONCLUSIÓN: En este estudio el ácido tranexámico redujo con seguridad el riesgo de muerte en pacientes con traumatismos hemorrágicos. En base a estos resultados, debe considerarse la utilidad del ácido tranexámico en pacientes con traumatismos hemorrágicos.

The Effect of Six Sigma Activity in Major Trauma Patients on the Time Spent in the Emergency Department

PURPOSE: This study was conducted to shorten the time spent at each stage of treatment and to reduce the total amount of time patients spend in the emergency department (ED) by applying Six Sigma in the treatment of major trauma patients. METHODS: This is a comparative study encompassing 60 patients presenting to the ED of Bundang CHA Hospital from January 2008 to December 2008 and from July 2009 to March 2010. The stages of treatment for major trauma patients were divided into six categories (T1: total emergency department staying time, T2: duration of visit-radiologic evaluation time, T3: duration of visit-consult to department of admission, T4: duration of consultation-issue of hospital admissions time, T5: duration of visit-issue of hospital admissions time, T6: duration of issue of hospital admission-emergency department discharge time) and the total time patients spent in the ED was compared and analyzed for periods; before and after the application of Six Sigma. RESULTS: After the application of Six Sigma, the numerical values in four of the six categories were significantly reduced; T2, T3, T4, and T5. However, the average of the total time patients spent in the ED did not show any remarkable change because the T6 increased highly. The level of Six Sigma increased 0.17sigma. CONCLUSION: The application of Six Sigma for major trauma patients in the ED resulted in a significant improvement in the error rate for the total time patients spent in the ED. The Six Sigma activity has shown great potential. Therefore, the project is expected to bring better results in every stage of treatment if the levels of the hospital facilities are improved.

Secondary Lung Infection in Patients of Postoperative Cranio-cerebral Trauma: A Clinical Study / 中华医院感染学杂志

OBJECTIVE To probe the risk factors of the secondary lung infection in patients of postoperative(cranio)-(cerebral) trauma as well as the ways to control them.METHODS A prospective and review study was carried out in 718 cases with cranio-cerebral trauma admitted in our hospital for operation from Jan 2002 to Dec 2004.RESULTS Among 718 cases,39(5.43%) developed lung(infection),occupied 65% of the total number of the hospital(infection) in the neurosurgery.After an integrated(total and systemic) treatment,the cure rate was(69.23%(27 cases);) effective: 15.3%(6);improved: 7.7%(3); died: 7.7%(3).CONCLUSIONS Oxygen(inhalation,) nasal(feeding),sputum drawing out,(cannular) tracheotomy,and use of respirator after operation are the causes of the lung infection and it can be controlled effectively if keeping the surroundings clean,keeping strict ness in disinfection-isolation institution,improving the mangement of respiratory tract and the care of oral cavity,proper use of antibiotics,and improving immunity.

Correlations of the Serum Lactate and the Base Deficit levels to Injury Severity in Trauma Patients

PURPOSE: Although the Injury Severity Score (ISS) has certain predictive limitations and difficulties in calculation, the ISS has been widely used as a predictor of serious injury. The objective of this study was to determine the correlations of the serum lactate and base deficit levels to injury severity and to determine the value of using serum lactate and base deficit measurements as prognostic tools in the emergency department. METHODS: This study was a retrospective analysis of data collected from March 2001 to February 2002, and two hundred seventeen trauma patients who were admitted to the Emergency Department (ED) of Kyungpook National University Hospital during that period were included in this study. Patients who received a transfusion, bicarbonate, or vasopressor or who had no ISS score were excluded from this study. RESULTS: The serum lactate and the base deficit, as well as the ISS, showed a significant value for predicting the seriousness of injury in trauma patients. Because gamma(Pearson's correlation coefficient) between ISS and serum lactate levels is 0.890, it showed strong association. Especially, in multiple injury patients, the serum lactate level had predictive value in revealing hidden injuries that could lead to possible death. Logistic regression showed a strong association between the serum lactate and base deficit levels and mortality rate. CONCLUSION: The serum lactate and the base deficit levels at admission to the ED are useful tools in predicting the outcome in severe trauma patients, and they can be used adjunct to previous injury scoring systems.

Prognostic Value of Base Deficit in Severe Trauma Patients

BACKGROUND: This study's objective was to determine the prognostic value of the base deficit measured in the emergency department(ED) and to determine whether base deficit can provide information not provided by advanced injury scoring system. METHODS: This study was a retrospective analysis of data collected for two years. Thirty-two severe trauma patients who were admitted to the Emergency Department of Korea University Hospital were included in this study. The patients were divided into two groups: the normal base deficit group(-3 mmol/L to 3 mmol/L) and the elevated base deficit group(>3 mmol/L). The base-deficit value, age, sex, head injury, organ failure rate, and survival were considered, and the also Revised Trauma Score(RTS), Acute Physiology And Chronic Health Evaluation(APACHE II), and Injury Severity Score(ISS) were measured. RESULT: The elevated base-deficit group showed a lower survival rate and a higher organ failure rate compared to the normal base deficit group. Logistic Regression showed a strong association between base deficit and mortality rate. Among the previous injury scoring Systems(RTS, APACHE II, ISS), base deficit had the strongest correlation with RTS. By using base deficit value and the RTS together, we obtained a higher positive predictive value than that obtained by using base deficit or RTS alone. CONCLUSION: The admission value of the base deficit in the ED is a useful tool in predicting the outcome in severe trauma patients, and it can be an adjunct to previous injury scoring systems. As an advanced injury scoring System is developed in the future, the base deficit may have some significant role.

Measurement of Intra-abdomonal Pressutre (IAP) inn trauma patients.

To study the measurement of intra-abdominal pressure by urinary catheter, we use Y glass tube connected with Foley catheter. The bladder and catheter was filled with 70 ml. NSS. The height of NSS from pubic symphysis was interpreted as intra-abdominal pressure (IAP). We measured IAP of 20 trauma patients with normal abdominal condition. The average IAP was 3.9 cm H2O. The clinical consequences of elevated IAP will be in the future study.

Epidemiological aspect of trauma patients admitted to Siriraj Hospital, 1988.

There were 33,256 new patients being treated for various injuries in the Devision of Traumatology, Department of Surgery, Siriraj Hospital in 1988. The males to females ratio was 2:1. The ages ranged from seven days to ninety-nine years, with the most frequent range encountered between 21-30 years (30.30%). The most common injuries was household accident (45.36%) followed by traffic accident (29.82%). The patients with traffic accidents and more severe injury than the household ones. Over one-half of the traffic injuries (63.03%) were from motorcycle. Among patients with severe injuries, 131 died on arrival at the emergency room, 1,512 were admitted for further treatment while 325 being transferred to other hospitals due to limited number of beds. Those with traffic accidents occupied almost one-half of the admission beds.