Effect of blood products transfusion on the development of postinjury multiple organ failure.

HYPOTHESIS: Transfusion of fresh frozen plasma (FFP) and platelets is independently associated with the development of multiple organ failure (MOF) in critically injured patients. DESIGN: Prospective cohort study. SETTING: Academic regional level I trauma center. PATIENTS: From 1992 to 2004, a total of 1440 critically injured patients were admitted to our surgical intensive care unit and survived at least 48 hours. Of these, 1415 had complete data on age, Injury Severity Score (ISS), and units of FFP, platelets, and packed red blood cells (PRBCs) transfused. Multiple organ failure was defined using the Denver MOF score. Multiple logistic regression analysis was used to adjust transfusion of FFP, platelets, and PRBCs for known MOF risk factors. MAIN OUTCOME MEASURE: Multiple organ failure. RESULTS: The mean (SD) ISS was 29.3 (11.3), and the mean (SD) patient age was 37.4 (16.6) years. Among 1440 patients, 346 (24.0%) developed MOF, and 118 (8.2%) died. Multiple logistic regression analysis detected a significant interaction between units of FFP and PRBCs transfused (P < .001). Regardless of the units of PRBCs transfused, FFP transfusion was independently associated with the development of MOF. However, the deleterious effect associated with FFP transfusion was more prominent among patients receiving fewer than 6 U of PRBCs. Platelet transfusion was unassociated with MOF after adjustment for age, ISS, and FFP and PRBC transfusion. CONCLUSIONS: Early transfusion of FFP is associated with an increased risk of postinjury MOF, even after adjusting for age, ISS, and PRBC transfusion. Caution is warranted in developing protocols for empirical FFP transfusion. Specifically, transfusion triggers for FFP should be reexamined, as well as the practice of delivering FFP in fixed ratios to the units of PRBCs transfused.

Postinjury coagulopathy management: goal directed resuscitation via POC thrombelastography.

Progressive postinjury coagulopathy remains the fundamental rationale for damage control surgery, but the decision to abort operative intervention must occur before laboratory confirmation of coagulopathy. Current massive transfusion protocols have embraced pre-emptive resuscitation strategies emphasizing administration of packed red blood cells, fresh frozen plasma, and platelets in ratios approximating 1:1:1 during the first 24 hours postinjury, based on US military retrospective experience and recent noncontrolled civilian data. This policy, termed "damage control resuscitation" assumes that patients presenting with life threatening hemorrhage at risk for postinjury coagulopathy should receive component therapy in rations approximating those found in whole blood during the first 24 hours. While we concur with the concept of pre-emptive coagulation factor replacement, and initially suggested this in 1982, we remain concerned for the continued unbridled administration of fresh frozen plasma and platelets without objective evidence of their specific requirement. A major limitation of current massive transfusion protocols is the lack of real time assessment of coagulation function to guide evolving blood component requirements. Existing laboratory coagulation testing was originally designed for evaluation of hemophilia and subsequently used for monitoring anticoagulation therapy. Consequently, the applicability of these tests in the trauma setting has never been proven and the time required to conduct these assays is incompatible with prompt correction of the coagulopathy in the trauma setting. This review examines the current approach to postinjury coagulopathy, including identification of patients at risk, resuscitation strategies, design and implementation of institutional massive transfusion protocols, and the potential benefits of goal-directed therapy by real time assessment of coagulation function via point of care rapid thromboelastography.

Hemolysis, elevated liver enzymes, and low platelets syndrome: when is surgical help needed?

BACKGROUND: Life-threatening hemorrhage is a rare event in hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Epidemiologic data are lacking to predict patients at risk for hemorrhage requiring surgical consultation. We sought to identify early clinical predictors of hemorrhagic complications in patients at risk for HELLP syndrome. METHODS: Patients at risk for HELLP syndrome from 1997 to 2007 were identified retrospectively. Variables evaluated in at-risk women were maternal age, gestational history, hepatic transaminase levels, and platelet count. Multiple logistic regression analysis was used to identify independent predictors of poor maternal outcomes, which were defined as hemorrhage requiring transfusion of blood products, need for surgical intervention, hepatic rupture, and death. RESULTS: A total of 109 at-risk women were identified. Adverse outcomes included transfusions (18%), hemorrhage interventions (8%), damage control laparotomy (2.8%), and hepatic rupture (2.8%). Maternal and perinatal mortality were .9% and 3.7%, respectively. Median transfusion requirements for women with hepatic rupture were 56 U of packed red blood cells, 26 U of fresh-frozen plasma, 18 U of platelets, and 6 U of cryoprecipitate. Multiple logistic regression analysis showed previous gestations (P = .002), platelet count (P = .01), and aspartate aminotransferase level increase (P = .04) were independent predictors of life-threatening hemorrhage. Previous gestations increased the risk of adverse outcome 3-fold. CONCLUSIONS: Identifiable risk factors predictive of major hemorrhage are thrombocytopenia (<100,000 cells/microL), increase of aspartate aminotransferase level greater than 70 IU/L, and previous gestations.

Primary repair of civilian colon injuries is safe in the damage control scenario.

BACKGROUND: Although the safety of primary repair/anastomosis for civilian colon injuries after standard laparotomy (SL) has been established, recent civilian and military reports have questioned the advisability of this technique in the patient requiring damage control laparotomy (DL). We hypothesized that, even in the high-risk DL group, primary repair could be safely used after patient stabilization and that the open abdomen would facilitate the safety of this procedure. METHODS: All patients admitted to our level 1 trauma center with a colon injury over a 7-year period were reviewed from a prospectively collected database. Patients were categorized as having undergone either SL or DL at initial operation. Primary variables of interest were as follows: injury patterns; method of primary repair (suture repair, resection and primary anastomosis, resection and delayed anastomosis); diversion techniques (planned diversion or diversion for anastomotic dehiscence); and colon-related morbidity and mortality. High-risk status in the DL group was identified by the following physiologic variables: mean injury severity score (ISS), red blood cell (RBC) transfusions, ventilator days, and intensive care unit (ICU) duration of stay. RESULTS: During the study period, 309 patients had colonic wounds identified at laparotomy. Of these 309 patients, 280 (91%) underwent SL, of which 277 (98.9%) had primary colonic repair/anastomosis. In the SL group, 1 (0.3%) patient required diversion for subsequent leak and 2 (0.6%) patients had planned diversion The remaining 29 hemodynamically unstable patients required DL. Mean +/- standard deviation indices of injury severity in this group included: ISS = 36.2 +/- 15.8, RBC = 28.7 +/- 25.4 units, ventilator days = 20.1 +/- 16.3, ICU duration of stay = 29.5 +/- 21.6 days. Of the 29 patients in the DL group, 21 (72%) had bowel continuity successfully reestablished in 2.6 +/- 2 days after initial attempts at primary suture repair or resection/anastomosis. A total of 4 (16.6%) patients in this group developed colon-related complications, 3 of whom were treated with subsequent diversion before definitive abdominal closure. One patient developed a late leak. (day 43). Another 4 (13.8%) patients had planned diversion for injuries that were considered to be high risk for leak at subsequent reexploration. There were no colon-related deaths in either group. CONCLUSION: Primary repair of colon injuries appears safe in the majority of patients after DL. Although it is associated with a higher leak rate than SL, the open abdomen affords careful inspection of abdominal contents at reexploration to identify patients who require subsequent diversion.

Rapid thrombelastography (r-TEG) identifies hypercoagulability and predicts thromboembolic events in surgical patients.

BACKGROUND: Despite routine prophylaxis, thromboembolic events (TEs) in surgical patients remain a substantial problem. Furthermore, the timing and incidence of hypercoagulability, which predisposes to these events is unknown, with institutional screening programs serving primarily to establish a diagnosis after an event has occurred. Emerging evidence suggests that point of care (POC) rapid thrombelastography (r-TEG) provides a real-time analysis of comprehensive thrombostatic function, which represents an analysis of both enzymatic and platelet components of thrombus formation. We hypothesized that r-TEG can be used as a screening tool to identify hypercoagulable states in surgical patients and would predict subsequent thromboembolic events. METHODS: Rapid thrombelastography r-TEG analyses were performed on 152 critically ill patients in the surgical intensive care unit (ICU) during 7 months. Hypercoagulability was defined as clot strength (G)>12.4 dynes/cm(2). Variables of interest for identifying hypercoagulability and thromboembolic events included sex, age, operating hospital service, specific injury patterns, injury severity score (ISS), transfusion within first 24 h, ICU duration of stay, ventilator days, hospital admission days, and thromboprophylaxis. Comparisons between the hypercoagulable and normal groups or between the groups with and without thromboembolic events were performed using Chi-square tests or the Fisher exact test for categorical variables and independent sample t tests or Wilcoxon rank sum tests for continuous variables. Multivariate logistic regression analysis (LR) was performed to identify independent predictors of thromboembolic events. A receiver operating characteristic curve was used to measure the performance of G for predicting the occurrence of a TE event. All tests were 2-sided with significance of P < .05. RESULTS: In all, 86 patients (67%) were hypercoagulable by r-TEG. More than 85% of patients in the hypercoagulable group and 79% in the normal group received thromboprophylaxis during the study period. The differences between hypercoagulable and normal groups by bivariate analysis included high-risk injuries (52% vs 35%; P = .03), spinal cord injury (27% vs 12%; P = .03), median ICU duration of stay (13 vs 7 days; P < .001), median ventilator days (6 vs 2; P < .001), and median hospital duration of stay (20 vs 13 days; P < .001). A total of 16 patients (19%) of the hypercoagulable group suffered a thromboembolic event, and 10 hypercoagulable patients (12%) had thromboembolic events predicted by prior r-TEG hypercoagulability. No patients with normal coagulability by r-TEG had an event (P < .001). LR analysis showed that the strongest predictor of TE after controlling for the presence of thromboprophylaxis was elevated G value (odds ratio: 1.25, 95% confidence interval [CI]: 1.12-1.39). For every 1 dyne/cm(2) increase in G, the odds of a TE increased by 25%. CONCLUSION: These results indicate that the presence of hypercoagulability identified by r-TEG is predictive of thromboembolic events in surgical patients. Subsequent study is necessary to define optimal prophylactic treatment strategies for patients with r-TEG proven hypercoagulability.

Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques.

BACKGROUND: Continuing improvements in computerized tomography scan technology and widespread acceptance of focused abdominal sonography for trauma (FAST) have prompted the suggestion that diagnostic peritoneal lavage (DPL) is obsolete. This sentiment, coupled with decreasing resident familiarity with DPL, has led to a poor understanding of the modern indications for DPL and no clear guidelines. We hypothesized that, while its indications may have changed, DPL remains essential in the rapid, effective triage of the trauma patient. METHODS: We queried our Level I trauma center's trauma registry from January 1996 through August 2006 for patients who underwent a DPL as part of their initial evaluation. Specific variables investigated were indications for or results of DPL, performance of a laparotomy in the first 24 hours, and operative findings. RESULTS: Six hundred twenty-seven patients underwent DPL (145 positive, 482 negative). Although the accuracy of DPL for predicting therapeutic laparotomy for all patients was only 77%, in the subset of hemodynamically unstable patients (of which only 46% had a positive FAST), it was 100%. Conversely, only 7% of all patients with negative DPL subsequently had a therapeutic laparotomy, with only 5% in the subset of stab wounds. CONCLUSION: DPL continues to be a vital tool in the evaluation of the trauma patient. A positive test in the hemodynamically unstable patient with potential multisystem trauma allows for expeditious intervention. A negative test in abdominal stab wounds supports observation and early subsequent discharge. Our current guidelines continue to emphasize the complimentary roles of DPL, FAST, and computerized tomography scan in the trauma bay.

Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents.

HYPOTHESIS: We hypothesize that the 2 antithrombotic treatment regimens, systemic heparin sodium vs antiplatelet agents, are equivalent for the treatment of blunt cerebrovascular injuries (BCVIs) to prevent devastating injury-related strokes. DESIGN: Retrospective review of a prospective database. SETTING: Level I trauma center. PATIENTS: Patients with BCVIs from January 1, 1997, to January 1, 2007. MAIN OUTCOME MEASURES: Incidence of cerebrovascular accident (CVA), stratified by treatment. RESULTS: During the study period, 422 BCVIs were identified in 301 patients (64.8% men; mean [SEM] age, 37.0 [0.8] years; mean [SEM] injury severity score, 27.0 [0.9]). A total of 22 patients presented with neurologic ischemia, and 5 patients sustained CVAs after embolization and/or stenting of an injury. Treatment was initiated for 282 asymptomatic BCVIs (heparin, 192; aspirin, 67; aspirin and/or clopidogrel, 23); 1 patient had a CVA (0.5%). Of 107 patients with untreated, asymptomatic BCVIs, 23 (21.5%) had a CVA. For untreated patients sustaining BCVI-related CVAs, the mean (SEM) time to diagnosis was 58 (10) hours. For those who did not exhibit symptoms within 2 hours of injury, mean time to diagnosis of CVA was 75 (11) hours. Injury healing rates (heparin, 39%; aspirin, 43%; aspirin/clopidogrel, 46%) and injury progression rates (12%; 10%; 15%) were equivalent between therapeutic regimens. CONCLUSIONS: With an overall CVA risk of 21% and a documented latent period, comprehensive screening, early diagnosis, and institution of antithrombotic therapy for BCVI are clearly warranted. The type of treatment, heparin vs antiplatelet agents, does not appear to affect either stroke risk or injury healing rates.

Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial.

BACKGROUND: The optimal management of hemodynamically stable, asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe, cost-effective manner. Common evaluation strategies include local wound exploration (LWE)/diagnostic peritoneal lavage (DPL), serial clinical assessments (SCAs), and computed tomography (CT) imaging. The purpose of this multicenter study was to evaluate the clinical course of patients managed by the various strategies, to determine whether there are differences in associated nontherapeutic laparotomy (NONTHER LAP), emergency department (ED) discharge, or complication rates. METHODS: A multicenter, Institutional Review Board-approved study enrolled patients with AASWs. Management was individualized according to surgeon/institutional protocols. Data on the presentation, evaluation, and clinical course were recorded prospectively. RESULTS: Three hundred fifty-nine patients were studied. Eighty-one had indications for immediate LAP, of which 84% were therapeutic. ED D/C was facilitated by LWE, CT, and DPL in 23%, 21%, and 16% of patients, respectively. On the other hand, LAP based on abnormalities on LWE, CT, and DPL were NONTHER in 57%, 24%, and 31% of patients, respectively. Twelve percent of patients selected for SCA ultimately had LAP (33% were NONTHER); there was no apparent morbidity due to delay in intervention. CONCLUSIONS: Shock, evisceration, and peritonitis warrant immediate LAP after AASW. Patients without these findings can be safely observed for signs or symptoms of bleeding or hollow viscus injury. To limit the number of hospital admissions, we propose a uniform strategy using LWE to ascertain the depth of penetration; the patient may be safely discharged in the absence of peritoneal violation. Peritoneal penetration, absent evidence of ongoing hemorrhage or hollow viscus injury, should not be considered an indication for LAP, but rather an indication for admission for SCAs. We suggest that a prospective multicenter trial be performed to document the safety and cost-effectiveness of such an approach.

Pediatric blunt vertebral artery injury: case report and treatment plan.

Aggressive screening for blunt cerebrovascular injuries in patients with trauma has led to the identification and successful treatment of these injuries. We report the case of an 8-year-old boy who sustained a vertebral artery injury after a motor vehicle collision. Computed tomography angiogram showed an 8-mm thrombosed segment of the vertebral artery. The patient was initially anticoagulated with a heparin drip and transitioned over to treatment with enoxaparin sodium (Lovenox). With few reports in the literature of blunt cerebrovascular injuries in the pediatric population, a review of the appropriate screening parameters, treatment plans, and follow-up is helpful for the practicing physician.

Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds.

BACKGROUND: Recent guidelines do not support local wound exploration (LWE) or diagnostic peritoneal lavage (DPL) in the evaluation of patients with anterior abdominal stab wounds (AASWs), favoring computed tomography scanning or serial examinations. In patients without immediate indications for laparotomy, we hypothesized that LWE/DPL would identify patients requiring surgery while limiting unnecessary hospital admissions. METHODS: Patients sustaining penetrating trauma at our level I trauma center over a 3-year period were reviewed. RESULTS: During the study period, 139 patients with AASW followed our LWE/DPL algorithm. Fifty-six patients had LWE without fascial penetration: 46 were discharged immediately, 10 required admission. Fifty-eight patients had fascial penetration on LWE but negative DPL: 37 were observed for less than 24 hours, 19 were observed for more than 24 hours, and 2 patients developed peritonitis requiring exploration. Twenty-five patients had positive LWE/DPL: 13 had therapeutic laparotomy, 12 had nontherapeutic laparotomy. CONCLUSIONS: Only 11% of patients with AASWs without overt indication for laparotomy require surgical care. LWE remains a valid method to exclude intra-abdominal injury and to eliminate hospitalization in more than one third of AASW patients.

An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study.

BACKGROUND: Efforts to determine the suitability of low-grade pancreatic injuries for nonoperative management have been hindered by the inaccuracy of older computed tomography (CT) technology for detecting pancreatic injury (PI). This retrospective, multicenter American Association for the Surgery of Trauma-sponsored trial examined the sensitivity of newer 16- and 64-multidetector CT (MDCT) for detecting PI, and sensitivity/specificity for the identification of pancreatic ductal injury (PDI). METHODS: Patients who received a preoperative 16- or 64-MDCT followed by laparotomy with a documented PI were enrolled. Preoperative MDCT scans were classified as indicating the presence (+) or absence (-) of PI and PDI. Operative notes were reviewed and all patients were confirmed as PI (+), and then classified as PDI (+) or (-). As all patients had PI, an analysis of PI specificity was not possible. PI patients formed the pool for further PDI analysis. As sensitivity and specificity data were available for PDI, multivariate logistic regression was performed for PDI patients using the presence or absence of agreement between CT and operative note findings as an independent variable. Covariates were age, gender, Injury Severity Score, mechanism of injury, presence of oral contrast, presence of other abdominal injuries, performance of the scan as part of a dedicated pancreas protocol, and image thickness < or =3 mm or > or =5 mm. RESULTS: Twenty centers enrolled 206 PI patients, including 71 PDI (+) patients. Intravenous contrast was used in 203 studies; 69 studies used presence of oral contrast. Eight-nine percent were blunt mechanisms, and 96% were able to have their duct status operatively classified as PDI (+) or (-). The sensitivity of 16-MDCT for all PI was 60.1%, whereas 64-MDCT was 47.2%. For PDI, the sensitivities of 16- and 64-MDCT were 54.0% and 52.4%, respectively, with specificities of 94.8% for 16-MDCT scanners and 90.3% for 64-MDCT scanners. Logistic regression showed that no covariates were associated with an increased likelihood of detecting PDI for either 16- or 64-MDCT scanners. The area under the curve was 0.66 for the 16-MDCT PDI analysis and 0.77 for the 64-MDCT PDI analysis. CONCLUSION: Sixteen and 64-MDCT have low sensitivity for detecting PI and PDI, while exhibiting a high specificity for PDI. Their use as decision-making tools for the nonoperative management of PI are, therefore, limited.

Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures.

OBJECTIVE: To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation. METHODS: A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n=20) or early pelvic angiography (ANGIO group, n=20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded. RESULTS: The PACK group underwent operative packing at a median of 45min from admission; the median time to angiography in the ANGIO group was 130min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage. CONCLUSIONS: Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.

Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer?

BACKGROUND: Recent military experience suggests that immediate 1:1 fresh frozen plasma (FFP); red blood cells (RBC) for casualties requiring >10 units packed red blood cells (RBC) per 24 hours reduces mortality, but no clinical trials exist to address this issue. Consequently, we reviewed our massive transfusion practices during a 5-year period to test the hypothesis that 1:1 FFP:RBC within the first 6 hours reduces life threatening coagulopathy. METHODS: We queried our level I trauma center's prospective registry from 2001 to 2006 for patients undergoing massive transfusion. Logistic regression was used to evaluate the independent effect of FFP:RBC in 133 patients who received >10 units RBC in 6 hours on (1) Coagulopathy (international normalized ratio [INR] >1.5 at 6 hours), controlling for our previously described risk factors predictive of coagulopathy, as well as RBC, FFP, and platelet administration (2) Death (controlling for all variables plus age, crystalloids per 24 hours, INR >1.5 at 6 hours). RESULTS: Overall mortality was 56%; 50% died from acute blood loss in the operating room. Over 80% of the RBC transfusions were completed in the first 6 hours: (Median RBC: 18 units) Median FFP:RBC survivors, 1:2, nonsurvivors: 1:4. (p < 0.001) INR >1.5 at 6 hours occurred in 30 (23%); 81% died. Regarding mortality, logistic regression showed significant variables (p < 0.05) included: RBC per 6 hours (OR = 1.248, 95%CI: 1.957-53.255), INR at 6 hours >1.5 (OR = 10.208, 95% CI: 1.957-53.255), ED temperature <34 degrees C (OR = 15.491, 95% CI 1.376-174.396), and age >55 years (OR = 40.531, CI 5.315-309.077). The adjusted OR for FFP:RBC ratio including the quadratic term was found to follow a U-shaped association (quadratic term estimate 0.6737 +/- 0.0345, p = 0.0189). CONCLUSION: Although our data suggest that 1:1 FFP:RBC reduced coagulopathy, this did not translate into a survival benefit. Our findings indicate that the relationship between coagulopathy and mortality is more complex, and further clinical investigation is necessary before recommending routine 1:1 in the exsanguinating trauma patient.

The U.S. trauma surgeon's current scope of practice: can we deliver acute care surgery?

BACKGROUND: The evolving discipline of acute care surgery as an expansion of trauma surgery is undergoing intense critique. As we envision this new paradigm of surgical practice, an evaluation of our current status across the nation's trauma centers is an essential step. The purpose of this study is to determine the practice patterns of trauma surgeons at major trauma centers throughout the United States. METHODS: A survey was sent to the trauma directors of the 1,288 designated trauma centers in the United States, as listed by the American Trauma Society. As proposed, acute care surgery would encompass performing emergent abdominal, vascular, and thoracic trauma procedures as well as providing critical care. The addition of simple orthopedic and neurosurgical procedures has been considered. RESULTS: The survey response rate was 72% among the Level I/II/III centers (n = 515) with 92% of Level I, 72% of Level II, and 59% of Level III centers responding. Of the 169 Level I centers, 31 (18%) reported their trauma surgeons perform the full complement of thoracic, vascular, and abdominal cases. Trauma surgeons managed the full range of injuries at 11 (6%) of the 187 Level II centers and 7 (4%) of the 159 Level III centers. At these 49 centers, only 41% of surgeons perform elective thoracic and vascular cases. The remaining 466 centers enlist a combination of vascular and thoracic surgeons to manage trauma patients. Finally, trauma surgeons performed cranial burr holes at eight trauma centers, placement of ICP monitors at four, and open fracture washout at three trauma centers. CONCLUSIONS: The model of the acute care surgeon is attractive and timely, but only a limited number of trauma surgeons currently practice this proposed range of operative procedures; even fewer surgeons have an elective surgical practice to maintain key operative skills. Fellowship training programs need to incorporate vascular and thoracic procedures to enable the specialty of acute care surgery.

Outcomes in surgical versus medical patients with the secondary abdominal compartment syndrome.

BACKGROUND: Secondary abdominal compartment syndrome (SACS) is a well-recognized sequelae of massive fluid resuscitation in surgical patients, but has only anecdotally been reported in the medical patient population. The purpose of this study was to compare the clinical scenarios, physiologic indices, and outcomes of patients with SACS due to medical versus trauma etiologies. METHODS: Patients undergoing decompression for SACS from January 1999 to January 2006 were identified using our computerized operative records. RESULTS: During the 7-year study period, 54 patients developed SACS (41 postinjury patients and 13 medical patients). There were no significant differences in demographics, physiologic indices, or fluid resuscitation between the medical and postinjury groups: age (46.6 +/- 4.7 vs 40.6 +/- 2.3), bladder pressure (33.5 +/- 1.1 vs 32.8 +/- 1.8), peak airway pressures (45.9 +/- 2.4 vs 49.3 +/- 2.1), base deficit (14.6 +/- 1.4 vs 13.6 +/- 1.1), and fluids (18.5 +/- 1.8 vs 16.0 +/- 1.5 liters). Patients with a medical cause of SACS had a significantly longer time to decompression (21 +/- 3.6 versus 6.5 +/- 1.9 hours), significantly higher incidence of MOF (62% v 27%), and trend toward greater mortality (54% versus 34%). CONCLUSIONS: Patients with diverse disease processes may develop SACS. Despite similar age and physiologic indices, the MOF and mortality rates associated with medical SACS are markedly higher. These findings highlight the need for routine monitoring in at-risk patients, prevention of pathologic intra-abdominal hypertension, and a low threshold for decompression.

Epidemiology of urban trauma deaths: a comprehensive reassessment 10 years later.

BACKGROUND: We conducted a comprehensive analysis of the epidemiology of trauma deaths in our urban county during a one-year period a decade ago. In the interim we have implemented a statewide trauma system, initiated a number of injury-prevention programs, and have had a major public effort to reduce drug traffic and related gangs. Consequently, we have reassessed the regional trauma mortality to ascertain the impact of these measures and to search for new injury patterns. METHODS: Trauma deaths occurring within our urban county from January 1 through December 31, 2002 were reviewed for mechanism, demographics, and cause of fatal injury; cases were identified using death certificates from the Colorado Department of Public Health. We compared these data to the trauma fatalities occurring during 1992. RESULTS: During the 2002 study period, there were 420 injury-related deaths. Most of the patients were men (296 patients, 70%), with a mean age of 47.3 years (median age, 42 years). The three predominant mechanisms of fatal injury were transport-related (180 patients, 43%), intentional (99 patients, 24%), and falls (86 patients, 20%). Comparison between 1992 and 2002 showed significant increases in the percentage of transport-related and fall-related deaths, and a significant reduction in intentional fatal injuries. There was also a shift in the percentage of deaths occurring in the first 24 h to delayed times. The death rate per capita in Denver County declined from 0.081 in 1992 to 0.060 in 2002. CONCLUSIONS: Along with a decrease in the per capita death rate, the major mechanisms of patient's deaths changed substantively over the decade 1992-2002; there was a shift from intentional injuries to transport-related deaths as the predominant etiology of trauma related deaths. Recognition of such injury patterns will direct future injury-prevention efforts and coordination of citywide trauma care.

Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift.

BACKGROUND: The current management of pelvic fracture patients who are hemodynamically unstable in the United States consists of aggressive resuscitation, mechanical stabilization, and angioembolization. Despite this multidisciplinary approach, our recent analysis confirms an alarming 40% mortality in these high-risk patients. Therefore, we pursued alternate therapies to improve patient outcomes. European trauma groups have suggested the technique of pelvic packing via laparotomy to directly address the venous bleeding that comprises 85% of pelvic fracture hemorrhage. We hypothesized that a modified technique of direct preperitoneal pelvic packing (PPP) would reduce the need for angiography, decrease blood transfusion requirements, and lower mortality. METHODS: Since September 2004, all patients at our ACS-verified level I trauma center with hemodynamic instability and pelvic fractures underwent PPP/external fixation, according to our protocol. Statistics are reported as mean +/- SEM and analyzed using Student's t test. RESULTS: During the study period, 28 consecutive patients underwent PPP. There was one protocol deviation of prePPP angiography to evaluate an extremity vascular injury. The majority were men (68%) with a mean age of 40 +/- 3.9 years and a mean injury severity score of 55 +/- 3.0. The mean emergency department (ED) systolic blood pressure was 77 +/- 3.0 mm Hg, heart rate was 120 +/- 4.3 bpm, and base deficit 13 +/- 0.8 mmol/L. Pelvic fracture classifications included lateral compression (LC) II (9), anteroposterior compression (APC) III (8), LC I (3), vertical shear (3), LC III (3), and APC II (2). Patients required 4 +/- 1.2 units of packed red blood cells (PRBCs) during 82 +/- 13 minutes in the ED. Blood transfusion requirements before postoperative surgical intensive care unit (SICU) admission compared with the subsequent 24 postoperative hours were significantly different (12 +/- 2.0 versus 6 +/- 1.1; p = 0.006). The first 4 patients underwent routine angiography postPPP, with 1 undergoing therapeutic embolization; 4 of the subsequent 24 patients underwent angioembolization with clinical concern of ongoing pelvic hemorrhage. Seven (25%) patients died from multiple organ failure (2), postinjury myocardial infarction/pulseless electrical activity (PEA) arrest (2), invasive mucormycosis (1), withdrawal of care (1), and closed head injury (1); there were no deaths as a result of acute blood loss. CONCLUSIONS: PPP is a rapid method for controlling pelvic fracture-related hemorrhage that can supplant the need for emergent angiography. There is a significant reduction in blood product transfusion after PPP, and this approach appears to reduce mortality in this select high-risk group of patients.