Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism.

Importance: Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events. Objective: To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE. Design, Setting, and Participants: This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days. Exposures: Investigational imaging, prophylactic measures used, and treatment of clots. Main Outcomes and Measures: The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT. Results: A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE. Conclusions and Relevance: To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.

Mechanistic determinates of the acute coagulopathy of trauma (ACoT) in patients requiring emergency surgery.

INTRODUCTION: The development of acute coagulopathy of trauma (ACoT) is associated with a significant increase in mortality. However, the contributory mechanisms behind ACoT have yet to be clearly defined. The purpose of this study was to evaluate the influence of multiple variables, including base deficit and injury severity, on development of ACoT within a subset of critically ill trauma patients. METHODS: A retrospective review of all trauma laparotomies between 01/2004-12/2009 was performed. ACoT (+) was defined as an arrival INR ≥1.5, ACoT (-) defined as INR<1.5. Univariate and multivariate analyses were performed. RESULTS: Of 1218 patients, 337 (27%) were ACoT (+) and 881 (73%) were ACoT (-) upon presentation. Groups were similar in demographics, ED fluid administration, GCS scores, and admission temperatures. Admission base deficit (8.5 vs. 4, p<0.001) and ISS (median 25 vs. 16, p<0.001) were higher in the ACoT (+) group, as were intra-operative RBC (median 4 vs. 0 U) and plasma (3 vs. 0 U) transfusions; both p<0.001. Multiple-linear regression revealed INR values were independently associated with arrival base deficit and pre-hospital fluid volumes (both p<0.001). On logistic regression, the development of ACoT (+) was associated with base deficit (OR 0.92, p=0.013) as well as ISS (OR 1.05, p<0.001). However, blunt mechanism alone was not an independent predictor of ACoT. CONCLUSION: The current study revealed that ACoT is independently associated with both shock (base deficit) and tissue injury. Additionally, tissue injury is a significant contributor to the development of early ACoT regardless of blunt or penetrating mechanism.

The use of prognostic indicators in the development of a statistical model predictive for adrenal insufficiency in trauma patients.

We performed a retrospective chart review of trauma patients admitted to Palmetto Richland Memorial Hospital and identified 63 cases of adrenal insufficiency along with 65 trauma patient controls. Two statistical models, a neural network and a multiple logistic regression, were developed to predict patients with increased risk of developing adrenal insufficiency. Each model had 11 selected independent variables, along with patient demographic data, to make a probabilistic prediction of patient outcome. The neural network model was trained with 102 patients to identify linear and nonlinear relationships that could yield a predictive capability. The neural network achieved an accuracy of 71 per cent. The logistic regression model achieved an accuracy of 82 per cent. With these models, we have shown the feasibility of a method to more accurately screen patients with an increased risk of adrenal insufficiency. This ability should allow earlier identification and treatment of patients with adrenal insufficiency. Further development with a larger database is needed to improve the accuracy of the present models.