Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial.

BACKGROUND: Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS: This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS: A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION: Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE: Diagnostic test, level III.

Wound patterns in survivors of modern firearm related civilian Mass Casualty Incidents.

BACKGROUND: Civilian mass shooting events (CMSE) are occurring with increased frequency. Unfortunately, our knowledge of how to respond to these events is largely based on military experience and medical examiner data. While this translational knowledge has improved our basic response to such events, it is critical that we have a better under-standing of the wound patterns observed and the resources utilized in civilian mass shootings. This will allow us to better prepare our systems for future events. METHODS: Patients from two consecutive CMSEs presented to the same level 1 trauma center in Fort Lauderdale, Florida. The patients received by this center were studied for their wound patterns as well as the care they received while in the hospital. This included wound patterns and severity, subspecialty interventions, and hospitalization requirements. RESULTS: Both events produced a total of 19 victims who were brought to the center as trauma activations. The events had a combined fatality rate of 55 percent. Fifty-five percent of patients also had at least one wound to an extrem-ity, two with major vascular injuries who had field tourniquets applied. Sixty-three percent required an orthopedic interven-tion and 32 percent required intensive care unit (ICU) admission, half of these with prolonged ventilator support. CONCLUSIONS: Given the number of extremity wounds in these events, we should continue the efforts championed by the stop the bleed campaign. The variety and quantity of specialties involved in the care of these patients also highlights the importance of a multidisciplinary approach to preparation and implementation of care in mass shooting events.

Accumulation of miR-155 and BIC RNA in human B cell lymphomas.

We show that the microRNA miR-155 can be processed from sequences present in BIC RNA, a spliced and polyadenylated but non-protein-coding RNA that accumulates in lymphoma cells. The precursor of miR-155 is likely a transient spliced or unspliced nuclear BIC transcript rather than accumulated BIC RNA, which is primarily cytoplasmic. By using a sensitive and quantitative assay, we find that clinical isolates of several types of B cell lymphomas, including diffuse large B cell lymphoma (DLBCL), have 10- to 30-fold higher copy numbers of miR-155 than do normal circulating B cells. Similarly, the quantities of BIC RNA are elevated in lymphoma cells, but ratios of the amounts of the two RNAs are not constant, suggesting that the level of miR-155 is controlled by transcription and processing. Significantly higher levels of miR-155 are present in DLBCLs with an activated B cell phenotype than with the germinal center phenotype. Because patients with activated B cell-type DLBCL have a poorer clinical prognosis, quantification of this microRNA may be diagnostically useful.