Injury Severity, Arrival Physiology, Coagulopathy, and Outcomes Among the Youngest Trauma Patients.

BACKGROUND: Although physiologic differences exist between younger and older children, pediatric trauma analyses are weighted toward older patients. Trauma-induced coagulopathy, determined by rapid thrombelastography (rTEG), is a predictor of outcome in trauma patients, but the significance of rTEG values among very young trauma patients remains unknown. Our objective was to identify the prehospital or physiologic factors, including rTEG values, that were associated with mortality in trauma patients younger than 5 y old. MATERIALS AND METHODS: Patients younger than 5 y old that met the highest-level trauma activation criteria at an academic children's hospital from 2010-2016 were included. Data regarding demographics, pre-hospital management, laboratory values, injury severity, and outcome were queried. Univariate and multivariate analyses were performed comparing survivors and non-survivors. RESULTS: A total of 356 patients were included. 60% were male, and the median age was 3 y (IQR 1-4). Overall mortality was 13% (n = 45); brain injury (91%) and hemorrhage (9%) were the causes of death. Compared to survivors, rTEG values in nonsurvivors showed longer activated clotting time and slower speed of clot formation. Clot strength was also decreased in nonsurvivors. On stepwise regression modeling, rTEG values were not significant predictors of mortality. Admission base deficit, arrival temperature, and head injury severity were identified as independent predictors of mortality. CONCLUSIONS: While rTEG identified coagulopathy in trauma patients < 5 y old, it was not an independent predictor of mortality. Our findings suggest that trauma providers should pay close attention to admission base deficit, arrival temperature, and head injury severity when managing the youngest trauma patients.

Energy Drink Effects on Hemodynamics and Endothelial Function in Young Adults.

INTRODUCTION: Cardiovascular side effects associated with energy drink consumption may be related to effects on vascular endothelial function, heart rate, blood pressure, and electrocardiogram parameters. We sought to measure them following energy drink consumption. METHODS: Forty-four healthy non-smoking young volunteer medical students, at an average age of 24.7 years (range 23-27 years, 34 males), with an average BMI of 23.4, received electrocardiograms and had their heart rates and blood pressures taken. Subjects then underwent baseline testing of endothelial function using the technique of endothelium-dependent flow-mediated dilatation (FMD) with high-resolution ultrasound. The subjects then drank an energy drink (24 oz Monster Energy Drink®). Hemodynamic measurements were repeated 15 and 90 min later. FMD and the electrocardiogram were repeated 90 min later. The FMD was calculated as the ratio of the post-cuff release and the baseline diameter. RESULTS: Energy drink consumption resulted in a significantly attenuated peak FMD response (mean ± SD): baseline 5.1 ± 4.1% versus post-energy drink (2.8 ± 3.8%; p = 0.004). In addition, systolic and diastolic blood pressures and heart rate increased after 15 min. Diastolic blood pressure and heart rate remained increased 90 min following energy drink consumption. There were no significant changes in electrocardiogram parameters. CONCLUSION: Energy drink consumption was associated with an acute significant impairment in endothelial function in young healthy adults as well as with significant hemodynamic changes. As energy drinks are becoming more popular, it is important to study their effects to better determine safe consumption patterns.

Targeting resuscitation to normalization of coagulating status: Hyper and hypocoagulability after severe injury are both associated with increased mortality.

INTRODUCTION: The prevalence and impact of hypercoagulability (hypo) in severely injured patients early after injury remains unclear. We hypothesize that the predominant phenotype of postinjury coagulopathy is hypercoagulability (hyper) and it is associated with increased mortality. MATERIAL AND METHODS: Blood samples from 141 healthy volunteers assayed with thrombelastography (TEG) were used to identify thresholds of hypo and hypercoagulability (above 95th/below the 5thpercentile) in four TEG indices. These cutoffs were subsequently evaluated in severely injured trauma patients (ISS>15) from two level 1 trauma centers. RESULTS: 2540 patients with a median ISS of 25 were analyzed. Normal TEG was present in 36% of patients. Hyper was found in 38% of patients, with mixed (11%) and hypo (15%) being less common. Compared to normal coagulation patients and after controlling for age, sex, blood pressure, and injury hyper (0.013), mixed (p < 0.001) and hypo (p < 0.001) were all independent predictors of mortality. CONCLUSION: These data support the ongoing need for goal directed resuscitation in trauma patients, it appears the optimal resuscitation strategy should be targeted towards normalization of coagulation status as both early hyper and hypocoagulability are associated with increased mortality.

Prevalence and Impact of Admission Acute Traumatic Coagulopathy on Treatment Intensity, Resource Use, and Mortality: An Evaluation of 956 Severely Injured Children and Adolescents.

BACKGROUND: Acute coagulopathy of trauma in children is of potential importance to clinical outcomes, but knowledge is limited and has only been investigated using conventional coagulation testing. The purpose of this study was to assess the prevalence and impact of arrival coagulopathy, determined by viscoelastic hemostatic testing, in severely injured children. STUDY DESIGN: Pediatric patients (younger than 17 years of age) who were admitted January 2010 to May 2016 and met highest-level trauma activation were included. Patients were divided into 2 groups (coagulopathy and controls) based on arrival rapid thrombelastography values. Coagulopathy was defined as the presence of any of the following on rapid thrombelastography: activated clotting time ≥128 seconds, α-angle ≤65 degrees, maximum amplitude ≤55 mm, and lysis at 30 minutes from 20-mm amplitude ≥3%. Logistic regression was used to adjust for age, sex, blood pressure, mechanism, and injury severity. RESULTS: Nine hundred and fifty-six patients met inclusion; 507 (57%) were coagulopathic and 449 (43%) were not (noncoagulopathic and control cohort). Coagulopathic patients were younger (median 14 vs 15 years) and more likely to be male (68% vs 60%) and Hispanic (38% vs 31%) (all p < 0.05). Coagulopathic patients received more RBC and plasma transfusions and had fewer ICU and ventilator-free days and higher mortality (12% vs 3%; all p < 0.05). Of these 956, 197 (21%) sustained severe brain injury-123 (62%) were coagulopathic and 74 (38%) were noncoagulopathic. The mortality difference was even greater for coagulopathic head injuries (31% vs 10%; p = 0.002). Adjusting for confounders, admission coagulopathy was an independent predictor of death, with an odds ratio of 3.67 (95% CI 1.768 to 7.632; p < 0.001). CONCLUSIONS: Almost 60% of severely injured children and adolescents arrive with evidence of acute traumatic coagulopathy. The presence of admission coagulopathy is associated with high mortality in children, especially among those with head injuries.

Mycobacterium fortuitum infection of the scalp after a skin graft.

Mycobacterium fortuitum is a non-tuberculous mycobacterium found in the soil and water of most regions of the world, and it can cause disease in immunocompetent and immunocompromised hosts. We present a 52-year-old man who developed a scalp abscess under a free flap for cranium coverage after a motor vehicle accident. Culture of material drained from the abscess grew M. fortuitum.

Acute Fibrinolysis Shutdown after Injury Occurs Frequently and Increases Mortality: A Multicenter Evaluation of 2,540 Severely Injured Patients.

BACKGROUND: Fibrinolysis is a physiologic process that maintains microvascular patency by breaking down excessive fibrin clot. Hyperfibrinolysis is associated with a doubling of mortality. Fibrinolysis shutdown, an acute impairment of fibrinolysis, has been recognized as a risk factor for increased mortality. The purpose of this study was to assess the incidence and outcomes of fibrinolysis phenotypes in 2 urban trauma centers. STUDY DESIGN: Injured patients included in the analysis were admitted between 2010 and 2013, were 18 years of age or older, and had an Injury Severity Score (ISS) > 15. Admission fibrinolysis phenotypes were determined by the clot lysis at 30 minutes (LY30): shutdown ≤ 0.8%, physiologic 0.9% to 2.9%, and hyperfibrinolysis ≥ 3%. Logistic regression was used to adjust for age, arrival blood pressure, ISS, mechanism, and facility. RESULTS: There were 2,540 patients who met inclusion criteria. Median age was 39 years (interquartile range [IQR] 26 to 55 years) and median ISS was 25 (IQR 20 to 33), with a mortality rate of 21%. Fibrinolysis shutdown was the most common phenotype (46%) followed by physiologic (36%) and hyperfibrinolysis (18%). Hyperfibrinolysis was associated with the highest death rate (34%), followed by shutdown (22%), and physiologic (14%, p < 0.001). The risk of mortality remained increased for hyperfibrinolysis (odds ratio [OR] 3.3, 95% CI 2.4 to 4.6, p < 0.0001) and shutdown (OR 1.6, 95% CI 1.3 to 2.1, p = 0.0003) compared with physiologic when adjusting for age, ISS, mechanism, head injury, and blood pressure (area under the receiver operating characteristics curve 0.82, 95% CI 0.80 to 0.84). CONCLUSIONS: Fibrinolysis shutdown is the most common phenotype on admission and is associated with increased mortality. These data provide additional evidence of distinct phenotypes of coagulation impairment and that individualized hemostatic therapy may be required.

When children become adults and adults become most hypercoagulable after trauma: An assessment of admission hypercoagulability by rapid thrombelastography and venous thromboembolic risk.

BACKGROUND: Thrombelastography (TEG) maximal amplitude (mA) has also been shown to reflect hypercoagulability and increased venous thromboembolism (VTE) risk in adult trauma patients. Based on these previous works, we sought to identify when children become adults with respect to TEG mA values and whether this correlated with VTE risk. METHODS: We evaluated all trauma patients admitted from January 2010 to December 2013 who were highest-level activations. Age was evaluated as a continuous variable, followed by a categorical evaluation. TEG mA values were evaluated as continuous and dichotomous (hypercoagulable, mA ≥ 65 mm). Logistic regression was then constructed controlling for age categories, sex, and injury severity to assess the association with TEG mA values and VTE risk. RESULTS: A total of 7,194 Level 1 trauma patients were admitted during this time frame (819 were <18 years of age). The likelihood of mA equal to or greater than 65 mm remained at 35% to 37% through age 30 years with significant increases observed at ages 31 years to 35 years (45%) and 46 years to 50 years (49%), both p < 0.01. When controlling for injury severity, race, and sex, logistic regression demonstrated that every 5-year increase in age (after age 30 years) was associated with a 16% increased likelihood of hypercoagulability at admission. Beginning with age 1 year, VTE risk remained at 1.5% or less until age 13 years where it increased to 2.3%, increasing again at age 15 years to 5.1%. Two additional significant increases were identified between ages 31 years and 35 years (5.5%) as well as 46 years and 50 years (7.6%), both p < 0.001. Logistic regression demonstrated a 3.4-fold increased risk for VTE among those aged 31 years to 50 years compared with those who are younger than 30 years. The same model noted a 2.3-fold increased risk compared with those who are older than 50 years. CONCLUSION: Beginning at age 13 years, children transition toward adult hypercoagulability, as evidenced by elevated TEG mA values and VTE risk. However, the greatest VTE risk (and highest likelihood of hypercoagulable mA) is among those adults 31 years to 50 years of age. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Prevalence and impact of admission hyperfibrinolysis in severely injured pediatric trauma patients.

INTRODUCTION: Hyperfibrinolysis (HF) on admission is associated with increased mortality in adult patients with trauma. Several studies have demonstrated that 9% of severely injured adults present to the emergency department (ED) with HF. Our aim was to (1) define HF in pediatric patients and develop a relevant cut-point for therapeutic intervention (if any); (2) identify the prevalence of HF in severely injured pediatric patients; and (3) determine whether HF on admission is as lethal a phenomenon as it is in adults. METHODS: After approval from the institutional review board (Committee for the Protection of Human Subjects), we identified all pediatric trauma admissions (patients ≤17 years old) who met highest-level trauma activation criteria between January 2010 and December 2013. Fibrinolysis rates were determined with LY-30 by rapid thrombelastography, which represents the percent decrease of the maximal clot amplitude (fibrinolysis) 30 minutes after such amplitude is achieved. HF was defined a priori as an initial LY-30 inflection point that translated to a doubling of mortality. Two previous studies in adults demonstrated an inflection point of ≥3% where mortality doubled from 9 to 20%. We began by identifying a relevant inflection point to define HF and its prevalence, followed by univariate analysis to compare HF and non-HF patients. Finally, a purposeful logistic regression model was developed to evaluate clinically relevant predictors of mortality in severely injured pediatric patients. RESULTS: A total of 819 patients met study criteria. LY-30 values were plotted against mortality. A distinct inflection point was noted at ≥3%, where mortality doubled from 6 to 14%. Of note, mortality continued to increase as the amount of lysis increased, with a 100% mortality demonstrated at a LY-30 ≥30% (compared with 77% in adults). Using LY-30 ≥3%, we stratified patients into HF (n = 197) and non-HF (n = 622) groups, with prevalence on admission of 24%. With the exception of HF patients being younger (median age 11 vs 15 years; P < .001), there were no differences in demographics, scene vitals, or Injury Severity Scores between the groups. On arrival to the ED, HF patients had a lesser systolic blood pressure (median 118 vs 124 mm Hg) and lesser hemoglobin (median 12.2 vs 12.7 g/dL); both P < .001). Controlling for age, arrival vital signs, admission hemoglobin, and Injury Severity Score, we found that logistic regression identified admission LY30 ≥3% (odds ratio 6.2, 95% confidence interval 2.47-16.27) as an independent predictor of mortality. CONCLUSION: Similar to adults, admission HF appears to reach a critical threshold at a LY30 ≥3% in pediatric patients. Admission HF in pediatric patients occurs more frequently than in adults (24 vs 9%) but is associated similarly with a substantial increase in mortality (6-14%). When controlling for additional factors, we found that admission LY-30 ≥3% has an odds ratio of 6.2 (P < .001) for mortality among severely injured pediatric patients. HF on admission may serve to identify rapidly those injured children and adolescents likely to benefit from hemostatic resuscitation efforts and to guide antifibrinolytic therapy.