Injury patterns among pedestrians using assistive mobility devices.

INTRODUCTION: As the population ages, growing numbers of individuals are turning to assisted mobility devices (AMDs) to maintain independence. These devices often place users in a seated position. Like ambulatory pedestrians, pedestrians seated in an AMD are at risk for involvement in an automobile versus pedestrian crash. The purpose of this study is to compare the injury pattern and comorbidities of standing pedestrians struck by an automobile versus those of seated pedestrians. METHODS: The Arizona State Trauma Registry was queried for pedestrians struck by an automobile between 2010 and 2015. Using ICD 9 and 10 codes as well as other available documentation, seated pedestrians were identified and matched based on age and gender to standing pedestrians. Presence of co-morbidities, injury pattern, Injury Severity Score (ISS), hospital length of stay (LOS), and mortality were compared between the two groups. RESULTS: There were 70 seated pedestrians identified, matched to 140 standing pedestrians. Co-morbidities were present in 89% of seated pedestrians vs 66% of standing pedestrians (p = 0.002). Functional dependence was more prevalent in the seated pedestrians (21% vs 1%, p = 0.004). There were not significant differences in the proportion of AIS injuries by body region. However, within the thoracic region, seated pedestrians were more likely to suffer pulmonary contusions: 14% vs 4%, p = 0.05. CONCLUSIONS: The injury pattern for seated pedestrians differs slightly from that of standing pedestrians struck by an automobile. However, seated pedestrians are more likely to have co-morbid conditions that may complicate care. These findings are important when caring for the injured pedestrian and performing injury prevention outreach.

Spinal Motion Restriction in the Trauma Patient - A Joint Position Statement.

The American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) have previously offered varied guidance on the role of backboards and spinal immobilization in out-of-hospital situations. This updated consensus statement on spinal motion restriction in the trauma patient represents the collective positions of the ACS-COT, ACEP and NAEMSP. It has further been formally endorsed by a number of national stakeholder organizations. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, and nurses as they strive to improve the care of trauma victims within their respective domains.

Factors affecting mortality after penetrating cardiac injuries: 10-year experience at urban level I trauma center.

BACKGROUND: Despite the lethality of injuries to the heart, optimizing factors that impact mortality for victims that do survive to reach the hospital is critical. METHODS: From 2003 to 2012, prehospital data, injury characteristics, and clinical patient factors were analyzed for victims with penetrating cardiac injuries (PCIs) at an urban, level I trauma center. RESULTS: Over the 10-year study, 80 PCI patients survived to reach the hospital. Of the 21 factors analyzed, prehospital cardiopulmonary resuscitation (odds ratio [OR] = 30), scene time greater than 10 minutes (OR = 58), resuscitative thoracotomy (OR = 19), and massive left hemothorax (OR = 15) had the greatest impact on mortality. Cardiac tamponade physiology demonstrated a "protective" effect for survivors to the hospital (OR = .08). CONCLUSIONS: Trauma surgeons can improve mortality after PCI by minimizing time to the operating room for early control of hemorrhage. In PCI patients, tamponade may provide a physiologic advantage (lower mortality) compared to exsanguination.

Penetrating cardiac injuries: A 36-year perspective at an urban, Level I trauma center.

BACKGROUND: This study evaluates patterns of injuries and outcomes from penetrating cardiac injuries (PCIs) at Grady Memorial Hospital, an urban, Level I trauma center in Atlanta, Georgia, over 36 years. METHODS: Patients sustaining PCIs were identified from the Trauma Registry of the American College of Surgeons and the Emory Department of Surgery database; data of patients who died prior to any therapy were excluded. Demographics and outcomes were compared over three time intervals: Period 1 (1975-1985; n = 113), Period 2 (1986-1996; n = 79), and Period 3 (2000-2010; n = 79). RESULTS: Two hundred seventy-one patients (86% were male; mean age, 33 years; initial base deficit = -11.3 mEq/L) sustained cardiac stab (SW, 60%) or gunshot wounds (GSW, 40%). Emergency department thoracotomy was performed in 67 (25%) of 271 patients. Overall mortality increased in the modern era (Period 1, 27%, vs. Period 2, 22%, vs. Period 3, 42%; p = 0.03) along with GSW mechanisms (Period 1, 32%, vs. Period 2, 33%, vs. Period 3, 57%; p = 0.001), GSW mortality (Period 1, 36%, vs. Period 2, 42%, vs. Period 3, 56%; p = 0.04), and multichamber injuries (Period 1, 12%, vs. Period 2, 10%, vs. Period 3, 34%; p< 0.001). In Period 3, GSWs (n = 45) resulted in multichamber injuries in 28 patients (62%) and multicavity injuries in 19 patients (42%). Surgeon-performed ultrasound accurately identified pericardial blood in 55 of 55 patients in Period 3. CONCLUSIONS: Increased frequency of GSWs in the past decade is associated with increased overall mortality, multichamber injuries, and multicavity injuries. Ultrasound is sensitive for detection of PCI. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemioligc study, level III.

Texting while driving: does the new law work among healthcare providers?

INTRODUCTION: This study assessed whether Georgia Senate Bill 360, a statewide law passed in August 2010, that prohibits text messaging while driving, resulted in a decrease in this behavior among emergency medicine (EM) and general surgery (GS) healthcare providers. METHODS: Using SurveyMonkey®, we created a web-based survey containing up to 28 multiple choice and free-text questions about driving behaviors. EM and GS healthcare providers at a southeastern medical school and its affiliate county hospital received an email inviting them to complete this survey in February 2011. We conducted all analyses in SPSS (version 19.0, Chicago, IL, 2010), using chi-squared tests and logistic regression models. The primary outcome of interest was a change in participant texting or emailing while driving after passage of the texting ban in Georgia. RESULTS: Two hundred and twenty-six providers completed the entire survey (response rate 46.8%). Participants ranged in age from 23 to 71 years, with an average age of 38 (SD=10.2; median=35). Only three-quarters of providers (n=173, 76.6%) were aware of a texting ban in the state. Out of these, 60 providers (36.6%) reported never or rarely sending texts while driving (0 to 2 times per year), and 30 engaged in this behavior almost daily (18.9%). Almost two-thirds of this group reported no change in texting while driving following passage of the texting ban (n=110, 68%), while 53 respondents texted less (31.8%). Respondents younger than 40 were more than twice as likely to report no change in texting post-ban compared to older participants (OR=2.31, p=0.014). Providers who had been pulled over for speeding in the previous 5 years were about 2.5 times as likely to not change their texting-while-driving behavior following legislation passage compared to those without a history of police stops for speeding (OR=2.55, p=0.011). Each additional ticket received in the past 5 years for a moving violation lessened the odds of reporting a decrease in texting by 45%. (OR=0.553, p=0.007). CONCLUSION: EM and GS providers, particularly those who are younger, have received more tickets for moving violations, and with a history of police stops for speeding, exhibit limited compliance with distracted driving laws, despite first-hand exposure to the motor vehicle crashes caused by distracted driving.

Trauma surgery associations and societies: which organizations match your goals?

This focused summary is a multi-institutional, multi-national, and multi-generational project designed to briefly summarize current academic trauma societies for both trainees and faculty alike. The co-authorship is composed of former and/or current presidents from most major trauma organizations. It has particular relevance to trainees and/or recent graduates attempting to navigate the multitude of available trauma organizations.

An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma.

This report describes the development of an evidence-based guideline for external hemorrhage control in the prehospital setting. This project included a systematic review of the literature regarding the use of tourniquets and hemostatic agents for management of life-threatening extremity and junctional hemorrhage. Using the GRADE methodology to define the key clinical questions, an expert panel then reviewed the results of the literature review, established the quality of the evidence and made recommendations for EMS care. A clinical care guideline is proposed for adoption by EMS systems. Key words: tourniquet; hemostatic agents; external hemorrhage.

A consensus-based criterion standard for trauma center need.

BACKGROUND: In civilian trauma care, field triage is the process applied by prehospital care providers to identify patients who are likely to have severe injuries and immediately need the resources of a trauma center. Studies of the efficacy of field triage have used various measures to define trauma center need because no "criterion standard" exists, making cross-study comparisons difficult. This study aimed to develop a consensus-based functional criterion standard definition of trauma center need. METHODS: Local and national experts were recruited for participation. Blinded key informant interviews were conducted in order of availability until no new themes emerged. Themes identified during the interviews were used to develop a Modified Delphi survey, which was electronically delivered via Survey Monkey. The trauma center need criteria were refined iteratively based on participant responses. Participants completed additional surveys until there was at least 80% agreement for each criterion. RESULTS: Fourteen experts were recruited. Five participated in key informant interviews. A Modified Delphi survey was administered five times (four modifications based on the expert's responses). After the fifth round, there was at least 82% agreement on each criterion. The final definition included 10 time-specific indicators: major surgery, advanced airway, blood products, admission for spinal cord injury, thoracotomy, pericardiocentesis, cesarean delivery, intracranial pressure monitoring, interventional radiology, and in-hospital death. CONCLUSION: We developed a consensus-based functional criterion standard definition of needing the resources of a trauma center, which may help to standardize field triage research and quality assurance in trauma systems as well as allow for cross study comparisons.

The impact of shorter prehospital transport times on outcomes in patients with abdominal vascular injuries.

BACKGROUND: Most deaths in patients with abdominal vascular injuries (ABVI) are caused by exsanguination and irreversible shock. Therefore, time to definitive hemorrhage control is an important factor affecting survival. The study goals were: (1) document current outcomes in patients with ABVI, and (2) compare outcomes to those from the era preceding improvements in an urban prehospital system. METHODS: A retrospective review of all patients with ABVI at an urban level 1 trauma center was completed. Patients injured prior to prehospital transport improvements (1991-1994) were compared to those following a reduction in transport times (1995-2004). RESULTS: Of 388 patients, 70 (18%) arrived prior to prehospital improvements (1991-1994). Patient/injury demographics were similar in both groups (age, sex, penetrating mechanism; p > 0.05). The number of patients presenting with ABVI increased (23 vs. 35 per year; p < 0.05) concurrent to a reduction in transport times (27 vs. 20 minutes; p < 0.05). Patients were more frequently unstable (63% vs. 91%; p < 0.05). Regardless of the specific vessel, mortality increased (37% vs. 67%; p < 0.05) following prehospital improvements. CONCLUSIONS: A reduction in urban transport times resulted in an increase in (1) the number of patients arriving with abdominal vascular injuries, (2) the proportion presenting in physiologic extremis, and (3) overall mortality.

Alternative dosing of prophylactic enoxaparin in the trauma patient: is more the answer?

BACKGROUND: Inadequate anti-factor Xa levels and increased venous thromboembolic events occur in trauma patients receiving standard prophylactic enoxaparin dosing. The aim of this study was to test the hypothesis that higher dosing (40 mg twice daily) would improve peak anti-Xa levels and decrease venous thromboembolism. METHODS: A retrospective review was performed of trauma patients who received prophylactic enoxaparin and peak anti-Xa levels over 27 months. Patients were divided on the basis of dose: group A received 30 mg twice daily, and group B received 40 mg twice daily. Demographics and rates of venous thromboembolism were compared between dose groups and patients with inadequate or adequate anti-Xa levels. RESULTS: One hundred twenty-four patients were included, 90 in group A and 34 in group B. Demographics were similar, except that patients in group B had a higher mean body weight. Despite this, only 9% of group B patients had inadequate anti-Xa levels, compared with 33% of those in group A (P = .01). Imaging studies were available in 69 patients and revealed 8 venous thromboembolic events (P = NS, group A vs group B) with significantly more venous thromboembolic events occurring in patients with low anti-Xa levels (P = .02). CONCLUSIONS: Although higher dosing of enoxaparin led to improved anti-Xa levels, this did not equate to a statistical decrease in venous thromboembolism.

Choice of motorcycle helmet makes a difference: a prospective observational study.

BACKGROUND: Although many states mandate that motorcyclists wear helmets, their laws do not indicate which type of helmet should be used. In addition, there are no prospective studies in the literature evaluating patterns of injuries as they relate to helmet type. The hypothesis in this study was that full-face helmets (FFHs) reduce craniofacial injuries associated with motorcycle collisions when compared with other helmet types. METHODS: A prospective observational study was conducted at a Level I trauma center to evaluate the efficacy of helmet types relative to craniofacial injuries. Data included patient demographics, helmet types, injuries, and outcomes. The incidences of facial fractures, skull fractures, and traumatic brain injuries (TBIs) were compared in patients wearing FFHs versus other helmet types (OH) during motorcycle crashes. RESULTS: From 2011 to 2012, 151 patients of motorcycle crashes (135 males, 16 female; mean age, 38.4 years; range, 19-74 years) whose helmet types were identified by health care providers were entered into the study. The distribution of helmets was 84 FFH and 67 OH (39 half and 28 modular). Facial fractures were present in 7% of the patients wearing FFH (95% confidence interval, 0.015-0.125) versus 27% (95% confidence interval, 0.164-0.376) of those wearing OH (p = 0.004). In addition skull fractures were present in 1% of the patients wearing FFH versus 8% in those wearing OH (p < 0.05). While there was a trend for patients wearing FFH to have a lower incidence of TBI (13% vs. 25% in those wearing OH), this was not statistically significant (p = 0.053). There were no differences in Injury Severity Score (ISS), length of stay, or mortality between the two groups. CONCLUSION: Victims of motorcycle crashes who are wearing FFH have a significant reduction in facial and skull fractures when compared with those wearing OH. Further studies will be needed to assess whether FFH will significantly decrease the incidence of TBI. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Base deficit as a marker of survival after traumatic injury: consistent across changing patient populations and resuscitation paradigms.

BACKGROUND: Damage control resuscitation (DCR) has improved outcomes in severely injured patients. In civilian centers, massive transfusion protocols (MTPs) represent the most formal application of DCR principles, ensuring early, accurate delivery of high fixed ratios of blood components. Recent data suggest that DCR may also help address early trauma-induced coagulopathy. Finally, base deficit (BD) is a long-recognized and simple early prognostic marker of survival after injury. METHODS: Outcomes of patients with admission BD data resuscitated during the DCR era (2007-2010) were compared with previously published data (1995-2003) of patients cared for before the DCR era (pre-DCR). Patients were considered to have no hypoperfusion (BD, >-6), mild (BD, -6 to -14.9), moderate (BD, -15 to -23.9), or severe hypoperfusion (BD, <-24). RESULTS: Of 6,767 patients, 4,561 were treated in the pre-DCR era and 2,206 in the DCR era. Of the latter, 218 (9.8%) represented activations of the MTP. DCR patients tended to be slightly older, more likely victims of penetrating trauma, and slightly more severely injured as measured by trauma scores and BD. Despite these differences, overall survival was unchanged in the two eras (86.4% vs. 85.7%, p = 0.67), and survival curves stratified by mechanism of injury were nearly identical. Patients with severe BD who were resuscitated using the MTP, however, experienced a substantial increase in survival compared with pre-DCR counterparts. CONCLUSION: Despite limited adoption of formal DCR, overall survival after injury, stratified by BD, is identical in the modern era. Patients with severely deranged physiology, however, experience better outcomes. BD remains a consistent predictor of mortality after traumatic injury. Predicted survival depends more on the energy level of the injury (stab wound vs. nonstab wound) than the mechanism of injury (blunt vs. penetrating).

The effects of protocolized use of recombinant factor VIIa within a massive transfusion protocol in a civilian level I trauma center.

Despite conflicting data regarding its effectiveness, many massive transfusion protocols (MTPs) include recombinant Factor VIIa (rFVIIa) as an adjunct to hemorrhage control. Over a 3-year period, outcome data for massively transfused patients was compared based on administration of rFVIIa as part of a mature MTP. Of 228 MTP activations, 117 patients were candidates for rFVIIa, and, of these, 39 patients received rFVIIa under the MTP. Comparing patients who received rFVIIa with those who did not based on initial packed red blood cell (PRBC) transfusion requirements, there was no difference in mortality for transfusions ≤ 20 units (25 vs 24%, 24-hour; 25 vs 42%, 30-day) or 21 to 30 units (33 vs 47%, 24-hour; 55 vs 50%, 30-day). For initial requirement ≥ 30 units of PRBCs, 24-hour mortality (26 vs 64%, P = 0.02) was significantly decreased in patients that received rFVIIa (n = 19) compared with those who did not (n = 17). These mortality differences were not maintained at 30 days (68 vs 71%). rFVIIa had minimal clinical impact on outcomes for patients requiring less than 30 units of PRBCs. For patients transfused more than 30 units of PRBCs, differences in 24-hour and 30-day mortality suggest that rFVIIa converted early deaths from exsanguination to late deaths from multiorgan failure.

Uncrossmatched blood transfusions for trauma patients in the emergency department: incidence, outcomes and recommendations.

BACKGROUND: Early transfusion of blood products for severely injured patients can improve volume depletion, acidosis, dilution and coagulopathy. There is concern that some patients are unnecessarily exposed to the risks of emergent transfusion with uncrossmatched red blood cell products (URBC) in the emergency department (ED). The goal of this study was to evaluate the transfusion practices in our ED among all patients who received URBC. METHODS: We analyzed all injured patients transfused at least 1 URBC in the ED at a level-1 trauma centre between Jan. 15, 2007, and Jan. 14, 2008. Demographics, injuries and outcomes were reported. We used standard statistical methodology. RESULTS: At least 1 URBC product was transfused into 153 patients (5% of all patients, mean 2.6 products) in the ED (median Injury Severity Score [ISS] 28; hemodynamic instability 94%). Sixty-four percent of patients proceeded to an emergent operation and 17% required massive transfusion. The overall mortality rate was 45%, which increased to 52% and 100% in patients who received 4 and 5 or more URBC products, respectively. Nonsurvivors had a higher median ISS (p=0.017), received more URBC in the ED (p=0.006) and possessed more major vascular injuries (p<0.001). Among nonsurvivors, 67% died of uncontrollable hemorrhage. Unnecessary URBC transfusions in the ED occurred in 7% of patients. CONCLUSION: Overtransfusion was minimal based on clinical acumen triggers. Early transfer of patients receiving URBC products in the ED to the operating room, intensive care unit or angiography suite for ongoing resuscitation and definitive hemorrhage control must be strongly considered.

The impact of country and culture on end-of-life care for injured patients: results from an international survey.

BACKGROUND: Up to 20% of all trauma patients admitted to an intensive care unit die from their injuries. End-of-life decision making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms, and clinician experience. The goal of this study was to better understand end-of-life processes after major injury by comparing clinician viewpoints from various countries and cultures. METHODS: A clinician-based, 38-question international survey was used to characterize the impacts of medical, religious, social, and system factors on end-of-life care after trauma. RESULTS: A total of 419 clinicians from the United States (49%), Canada (19%), South Africa (11%), Europe (9%), Asia (8%), and Australasia (4%) completed the survey. In America, the admitting surgeon guided most end-of-life decisions (51%), when compared with all other countries (0-27%). The practice structure of American respondents also varied from other regions. Formal medical futility laws are rarely available (14-38%). Ethical consultation services are often accessible (29-98%), but rarely used (0-29%), and typically unhelpful (<30%). End-of-life decision making for patients with traumatic brain injuries varied extensively across regions with regard to the impact of patient age, Glasgow Coma Scale score, and clinician philosophy. Similar differences were observed for spinal cord injuries (age and functional level). The availability and use of "donation after cardiac death" also varied substantially between countries. CONCLUSIONS: In this unique study, geographic differences in religion, practice composition, decision-maker viewpoint, and institutional resources resulted in significant variation in end-of-life care after injury. These disparities reflect competing concepts (patient autonomy, distributive justice, and religion).

Occult pneumothoraces in patients with penetrating trauma: Does mechanism matter?

BACKGROUND: Supine anteroposterior (AP) chest radiography is an insensitive test for detecting posttraumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) not diagnosed by chest radiography. All previous literature describes the epidemiology of OPTX in patients with blunt polytrauma. Our goal was to identify the frequency of OPTXs in patients with penetrating trauma. METHODS: All patients with penetrating trauma admitted over a 10-year period to Grady Memorial Hospital with a PTX were identified. We reviewed patients' thoracoabdominal CT scans and corresponding chest radiographs. RESULTS: Records for 1121 (20%) patients with a PTX (penetrating mechanism) were audited; CT imaging was available for 146 (13%) patients. Of these, 127 (87%) had undergone upright chest radiography. The remainder (19 patients) had a supine AP chest radiograph. Fifteen (79%) of the PTXs detected on supine AP chest radiographs were occult. Only 10 (8%) were occult when an upright chest radiograph was used (p < 0.001). Posttraumatic PTXs were occult on chest radiographs in 17% (25/146) of patients. Fourteen (56%) patients with OPTXs underwent tube thoracostomy, compared with 95% (115/121) of patients with overt PTXs (p < 0.001). CONCLUSION: Up to 17% of all PTXs in patients injured by penetrating mechanisms will be missed by standard trauma chest radiographs. This increases to nearly 80% with supine AP chest radiographs. Upright chest radiography detects 92% of all PTXs and is available to most patients without spinal trauma. The frequency of tube thoracostomy use in patients with overt PTXs is significantly higher than for OPTXs in blunt and penetrating trauma.

Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length.

BACKGROUND: Tension pneumothorax requires emergent decompression. Unfortunately, some needle thoracostomies (NTs) are unsuccessful because of insufficient catheter length. All previous studies have used thickness of the chest wall (based on cadaver studies, ultrasonography or computed tomography [CT]) to extrapolate probable catheter effectiveness. The objective of this clinical study was to identify the frequency of NT failure with various catheter lengths. METHODS: We evaluated the records of all patients with severe blunt injury who had a prehospital NT before arrival at a level-1 trauma centre over a 48-month period. Patients were divided into 2 groups: helicopter (4.5-cm catheter sheath) and ground ambulance (3.2 cm) transport. Success of the NT was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography and CT. RESULTS: Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001). CONCLUSION: Tension pneumothorax decompression using a 3.2-cm catheter was unsuccessful in up to 65% of cases. When a larger 4.5-cm catheter was used, fewer procedures (4%) failed. Thoracic ultrasonography can be used to confirm NT placement.

Early predictors of massive transfusion in patients sustaining torso gunshot wounds in a civilian level I trauma center.

BACKGROUND: Early prediction of the need for massive transfusion (MT) remains difficult. We hypothesized that MT protocol (MTP) utilization would improve by identifying markers for MT (>10 units packed red blood cell [PRBC] in 24 hours) in torso gunshot wounds (GSW) requiring early transfusion and operation. METHODS: Data from all MTPs were collected prospectively from February 1, 2007, to January 31, 2009. Demographic, transfusion, anatomic, and operative data were analyzed for MT predictors. RESULTS: Of the 216 MTP activations, 78 (36%) patients sustained torso GSW requiring early transfusion and operation. Five were moribund and died before receiving MT. Of 73 early survivors, 56 received MT (76%, mean 19 units PRBC) and 17 had early bleeding control (EBC), (24%, mean 5 units PRBC). Twelve transpelvic and 13 multicavitary wounds all received MT regardless of initial hemodynamic status (mean systolic blood pressure: 96 mm Hg; range, 50-169). Of 31 MT patients with low-risk trajectories (LRT), 18 (58%) had a systolic blood pressure <90 mm Hg compared with 3 of 17 (17%) in the EBC group (p < 0.01). In these same groups, a base deficit of <-10 was present in 27 of 31 (92%) MT patients versus 4 of 17 (23%) EBC patients (p < 0.01). The presence of both markers identified 97% of patients with LRT who requiring MT and their absence would have potentially eliminated 16 of 17 EBC patients from MTP activation. CONCLUSIONS: In patients requiring early operation and transfusion after torso GSW: (1) early initiation of MTP is reasonable for transpelvic and multicavitary trajectories regardless of initial hemodynamic status as multiple or difficult to control bleeding sources are likely and (2) early initiation of MTP in patients with LRT may be guided by a combination of hypotension and acidosis, indicating massive blood loss.