Blood component ratios in massively transfused, blunt trauma patients--a time-dependent covariate analysis.

BACKGROUND: This study evaluated critical thresholds for fresh frozen plasma (FFP) and platelet (PLT) to packed red blood cell (PRBC) ratios and determined the impact of high FFP:PRBC and PLT:PRBC ratios on outcomes in patients requiring massive transfusion (MT). METHODS: Retrospective review of a cohort of massively transfused blunt trauma patients admitted to a Level I trauma center. MT was defined as transfusion of ≥10 units of PRBC within 24 hours of admission. Critical thresholds for FFP:PRBC and PLT:PRBC ratios associated with mortality were identified using Cox regression with time-dependent variables. Impacts of high blood component ratios on 12-hour and 24-hour survival were evaluated. RESULTS: During the 10-year study period, a total of 229 blunt trauma patients required a MT. At 12 hours and 24 hours after admission, a FFP:PRBC ratio threshold of 1:1.5 was found to have the strongest association with mortality. At 12 hours, 58 patients (25.4%) received a low (<1:1.5) and 171 patients (74.6%) a high (≥1:1.5) FFP:PRBC ratio. Patients in the low ratio group had a significantly higher mortality compared with those in the high ratio group (51.7% vs. 9.4%; adjusted hazard ratio [95% confidence interval] = 1.18 [1.04-1.34]; adjusted p = 0.008). A similar statistically significant difference was found at 24 hours after admission. For PLTs, a PLT:PRBC ratio of 1:3 was identified as the best cut-off associated with both 12-hour and 24-hour survival. At 12 hours, 79 patients (34.5%) received a low (<1:3) and 150 patients (65.5%) a high (≥1:3) PLT:PRBC ratio. After adjusting for differences between the ratio groups, no statistically significant survival advantage associated with a high PLT:PRBC ratio was found (40.5% vs. 9.3%; adjusted hazard ratio [95% confidence interval] = 1.11 [0.99-1.26]; adjusted p = 0.082). CONCLUSION: For massively transfused blunt trauma patients, a plasma to PRBC ratio of ≥1:1.5 was associated with improved survival at 12 hours and 24 hours after hospital admission. However, for PLTs, no statistically significant survival benefit with increasing ratio was observed. The results of this analysis highlight the need for prospective studies to evaluate the clinical significance of high blood component ratios on outcome.

Damage control in severely injured trauma patients - A ten-year experience.

BACKGROUND: This study reviews our 10-year institutional experience with damage control management and investigates risk factors for early mortality. MATERIALS AND METHODS: The trauma registry of our level I trauma centre was utilized to identify all patients from 01/96 through 12/05 who underwent initial damage control procedures. Demographics, clinical and physiological parameters, and outcomes were abstracted. Patients were categorized as either early survivors (surviving the first 72 hours after admission) or early deaths. RESULTS: During the study period, 319 patients underwent damage control management. Overall, 52 patients (16.3%) died (early deaths) and 267 patients (83.7%) survived the first 72 hours (early survivors). Early deaths showed significantly deranged serum lactate (5.81±0.55 vs. 3.46±0.13 mmol/L; P<0.001), base deficit (10.10±0.95 vs. 4.90±0.28 mmol/L; P<0.001) and pH (7.16±0.03 vs. 7.29±0.01; P<0.001) levels compared to early survivors on hospital admission. An International Normalized Ratio >1.2, base deficit >3 mmol/L, head Abbreviated Injury Scale ≥3, body temperature <35°C, serum lactate >6 mmol/L, and hemoglobin <7 g/dL proved to be independent risk factors for early mortality on hospital admission. CONCLUSIONS: Several risk factors for early mortality such as severe head injury and the lethal triad (coagulopathy, acidosis and hypothermia) in patients undergoing damage control procedures were identified and should trigger the trauma surgeon to maintain aggressive resuscitation in the intensive care unit.

Using the Violence Risk Appraisal Guide (VRAG) to predict in-prison aggressive behavior in a Swiss offender population.

The present study is a first-time evaluation of the Violence Risk Appraisal Guide's (VRAG) predictive quality for institutional violence in a German-speaking country. The VRAG was assessed for 106 violent and sexual offenders based on their files. Violent infractions during imprisonment were evaluated using the files of the state penitentiary. Results show in accordance with previous studies only a moderate effect between VRAG scores and institutional misconduct. However, these findings were only significant for participants with a sex crime as index offense. In the study, the VRAG was unable to predict verbal and physical violence by violent offenders. The implications of these findings for institutional risk management and the future development of intramural detection of participants at risk in the German-speaking part of Europe are discussed.