Penetrating injury to the cardiac box.

BACKGROUND: A penetrating injury to the "cardiac box" is thought to be predictive of an injury to the heart; however, there is very little evidence available to support this association. This study aims to evaluate the relationship between penetrating trauma to the cardiac box and a clinically significant injury. METHODS: All patients presenting to a Level I trauma center from January 2009 to June 2015 who sustained a penetrating injury isolated to the thorax were retrospectively identified. Patients were categorized according to the location of injury: within or outside the historical cardiac box. Patients with concurrent injuries both inside and outside the cardiac box were excluded. Clinical demographics, injuries, procedures, and outcomes were compared. RESULTS: During this 7-year period, 330 patients (92% male; median age, 28 years) sustained penetrating injuries isolated to the thorax: 138 (42%) within the cardiac box and 192 (58%) outside the cardiac box. By mechanism, 105 (76%) were stab wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125 (65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or sternotomy (35/138 [25.4%] vs. 15/192 [7.8%], p < 0.001) and the incidence of cardiac injury (18/138 [13%] vs. 5/192 [2.6%], p < 0.001) were significantly higher in patients with penetrating trauma within the cardiac box. This was, however, dependent on mechanism with SW demonstrating a higher incidence of cardiac injury (15/105 [14.3%] vs. 3/125 [2.4%], p = 0.001) and GSW showing no significant difference (3/33 [9.1%] vs. 2/67 [3%], p = 0.328]. There was no difference in overall mortality (9/138 [6.5%] vs. 6/192 [3.1%], p = 0.144). CONCLUSION: The role of the cardiac box in the clinical evaluation of a patient with a penetrating injury to the thorax has remained unclear. In this analysis, mechanism is important. Stab wounds to the cardiac box were associated with a higher risk of cardiac injury. However, for GSW, injury to the cardiac box was not associated with a higher incidence of injury. The diagnostic interaction between clinical examination and ultrasound, for the diagnosis of clinically significant cardiac injuries, warrants further investigation. LEVEL OF EVIDENCE: Prognostic study, Level IV, Therapeutic V.

Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study.

BACKGROUND: Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers. METHODS: The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration. RESULTS: From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003). CONCLUSION: Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Supermassive Transfusion: A 15-Year Single Center Experience and Outcomes.

The objective of this study was to determine the survival outcome associated with large-volume blood transfusion after trauma. This was a retrospective study at a Level I trauma center from January 2000 to December 2014 that included trauma patients who received ≥25 units packed red blood cell (pRBC) within the first 24 hours of hospital admission. Univariate and multivariable logistic regressions identified risk factors for mortality. Receiver operating characteristic curve analysis evaluated the ability of pRBC volume to predict mortality. Among 74,065 adults (≥18 years old), 178 patients (0.24%) received ≥25 units of pRBC in the first 24 hours, of which 142 (79.8%) received 25 to 49 units, 28 (15.7%) received 50 to 74 units, and 8 (4.5%) received ≥75 units. Overall, 92.2 per cent were male, mean age 33.9 (±14.0), mean Injury Severity Score 28.9 (±14.3), and median Glasgow Coma Scale score 12 (3-15). The overall mortality was 65.2 per cent and 64.1 per cent for those receiving 25 to 49 units, 64.3 per cent for 50 to 74 units, and 87.5 per cent for ≥75 units. In univariate analysis, female gender was associated with lower mortality [odds ratio (OR) 0.24, P = 0.025]. Decreasing Glasgow Coma Scale (OR 0.82, P < 0.001), increasing Injury Severity Score (OR 1.07, P < 0.001), and thoracotomy (OR 3.91, P < 0.001) were associated with higher mortality. There was no transfusion cutoff that was significantly associated with higher mortality.