Predictors of hypofibrinogenemia in blunt trauma patients on admission

Purpose

Massive bleeding usually leads to critically low levels of clotting factors, including fibrinogen. Although reduced fibrinogen levels correlate with increased mortality, predictors of hypofibrinogenemia have remained poorly understood. We investigated whether findings available on admission can be used as predictors of hypofibrinogenemia.

Methods

We retrospectively reviewed serum fibrinogen levels tested on arrival in 290 blunt trauma patients transported to a level I trauma center during a 3-year period. The primary outcome was prehospital predictors for hypofibrinogenemia. Covariates included age, sex, prehospital fluid therapy, prehospital anatomical and physiological scores, time from injury, base excess, and lactate on arrival. All variables with values of p < 0.10 in univariate analysis were included in a multivariate logistic regression model. The relationships between the variables and the 7-day mortality rate were evaluated in a Cox proportional hazards model.

Results

Patient’s age [odds ratio (OR): 0.97, p < 0.001], Triage Revised Trauma Score (T-RTS) (OR: 0.81, p = 0.003), and prehospital fluid therapy (OR: 2.54, p = 0.01) were detected as independent predictors for hypofibrinogenemia in multivariate logistic regression analysis. Serum fibrinogen level [hazard ratio (HR): 0.99, p = 0.01] and T-RTS (HR: 0.77, p < 0.01) were associated with the 7-day mortality rate.

Conclusion

T-RTS is considered to play an important role in predicting hypofibrinogenemia and 7-day mortality in blunt trauma patients.

     

Medical admission of elderly trauma patients with isolated injuries

We sought to evaluate the outcomes of trauma patients admitted to medical services rather than to the general trauma team, particularly those elderly patients with isolated injuries of a specialty nature. Over the 2-year retrospective study period, 3017 trauma patients were admitted. The trauma service directed care in 2740 (90.8%) of this group versus the 277 (9.2%) admitted to medical services (MS). The patients in each group were then classified according to age younger than 55 years or older than 55 years (elderly). Of the 277 patients admitted to the MS, 177 (63.8%) were elderly compared with only 13 per cent of the trauma service group. Smaller proportions (16.9%) of the elderly medical patients were admitted to the intensive care unit as compared with the trauma group (22.1%). There was a higher morbidity rate, 41.9 per cent, in the trauma service group as compared with the MS group, 20 per cent. No patients on the MS underwent a laparotomy for intraabdominal injuries nor were there any missed injuries of a general surgical nature. Allowing elderly trauma patients with isolated specialty injuries to be managed by the MS is not associated with increased morbidity or mortality.     

Incidence and timing of hypothermia in trauma patients undergoing operations

Hypothermia is a major problem in patients who have sustained trauma. We reviewed the cases of 100 consecutive trauma patients transferred directly to the operating room (OR) from the Emergency Department (ED) in a Level I trauma center; 26 cases could not be evaluated. Forty-two patients (57%) became hypothermic at some time between injury and leaving the OR. Fifty-five patients (74%) had a temperature (T) recorded on arrival to the ED; but only 7 (12%) were hypothermic (34.7 degrees +/- 1.5 degrees C). In contrast, 34 patients (46%) arrived in the OR hypothermic (34.8 degrees +/- 0.9 degrees C) and 26 (76%) of these left the OR hypothermic (34.8 degrees +/- 0.9 degrees C). Eight additional patients (20%) arriving in the OR with a T greater than 35.9 degrees C left the OR hypothermic (35.1 degrees +/- 0.4 degrees C). The mean T loss in the ED was significantly greater than that lost in the OR (-0.8 degrees +/- 0.7 degrees C vs. 0.0 degrees +/- 0.6 degrees C; p less than 0.0001, ANOVA). Ninety-two percent of the patients lost temperature in the ED, while 43% of the patients gained temperature in the OR. Hypothermia was associated with lower Trauma Scores, and those patients who were severely hypothermic received more intravenous fluids. However, the impact of fluid infusion was not independent from Trauma Score and did not fully explain the magnitude of the heat loss. These data suggest that hypothermia in trauma patients has a multifactoral etiology related to the magnitude of injury and that the major T loss occurs in the ED rather than in the OR.(ABSTRACT TRUNCATED AT 250 WORDS)     

The initial management of severe trauma patients at hospital admission

The initial management of trauma patient is a critical period aiming at: stabilizing the vital functions; following a rigorous injury assessment; defining a therapeutic strategy. This management has to be organized to minimize loss of time that would be deleterious for the patients outcome. Thus, before patient arrival, the trauma team alert should lead to the initiation of care procedures adapted to the announced severity of the patient. Moreover, each individual should know its role in advance and the team should be managed by only one individual (the trauma leader) to avoid conflicts of decision. A rapid trauma injury assessment aims not only at guiding resuscitation (chest drainage, pelvic contention, to define the mean arterial pressure goal) but also to decide a critical intervention in case of hemodynamic instability (laparotomy, thoracotomy, arterial embolisation). This initial assessment includes a chest and a pelvic X-ray, abdominal ultrasound (extended to the lung) and transcranial Doppler (TCD). The whole body scanner with administration of intravenous contrast material is the cornerstone of the injury assessment but can be done for patients stabilized after the initial resuscitation.     

Implications of positive urine toxicology screening in trauma patients

BackgroundPain management in trauma patients can be difficult due to their varied injuries and presence or absence of illicit substances in their systems. Additionally, trauma patients have variable lengths of stay. Limiting length of stay to what is medically necessary and preventing long-term dependence on narcotic medications are important in trauma patient care.MethodsWe performed a retrospective review of 385 consecutive trauma activations at a Level II trauma center with urine toxicology screens from 2015. Main outcome measures recorded were urine toxicology results, average daily morphine milligram equivalents (MME), length of stay (LOS), injury severity score (ISS). We also recorded patient demographic information. Statistical analysis compared outcomes and demographics between trauma patients with positive urine toxicology screens to those with negative screens. Significance was set at p < 0.05.ResultsPositive urine toxicology screens were present in 230/385 (59.7%) patients. The median (interquartile range (IQR)) daily MME usage in the positive urine toxicology group was 25.2 (12.0-48.6) versus 12.4 (2.5-27.5) for those with a negative drug screen (p < 0.001). Median LOS was 3 (1-6) days versus 2 (1-4) days for the positive and negative groups, respectively (p = 0.004). There were no differences in age, gender distribution, or ISS between the two groups. Subgroup analysis showed urine toxicology positive for opiates, benzodiazepines, and tetrahydrocannabinol (THC) were associated with increased daily MME. Benzodiazepines and amphetamines were associated with increased LOS.ConclusionThis study identifies a positive toxicology screening as a risk factor for increased narcotic demands and longer length of stay in trauma patients. These findings may assist in developing treatment plans and setting expectations in this population. This information can also lead to proactive interventions aimed at minimizing narcotic use and shortening LOS in this population.     

Early coagulopathy in trauma patients: an on-scene and hospital admission study

PurposeAmongst trauma patients, early coagulopathy is common on hospital admission. No studies have evaluated the initial coagulation status in the pre-hospital setting. We hypothesise that the coagulopathic process begins at the time of trauma. We studied the on-scene and on hospital arrival coagulation profile of trauma patients.MethodsProspective, observational study investigating the on-scene coagulation profile and its time course. We studied 45 patients at the scene of the accident, before fluid administration, and on hospital admission and classified their coagulopathy using the International Society on Thrombosis and Haemostasis score during a 2-month period. Prothrombin time, activated partial thromboplastin time, fibrinogen concentration, factors II, V and VII activity, fibrin degradation products, antithrombin and protein C activities, platelet counts and base deficit were measured.ResultsThe median injury severity score was 25 (13–35). On-scene, coagulation status was abnormal in 56% of patients. Protein C activities were decreased in the trauma-associated coagulopathy group (p = .02). Drops in protein C activities were associated with changes in activated partial thromboplastin time, prothrombin time, fibrinogen concentration, factor V and antithrombin activities. Only factor V levels decreased significantly with the severity of the trauma. On hospital admission, coagulation status was abnormal in 60% of patients. The on-scene coagulopathy was spontaneously normalised only in 2 patients whereas others had the same or a poorer coagulopathy status. All parameters of coagulation were significantly abnormal comparing to the on-scene phase. Decreases in protein C activities were related to the coagulation status (p < .0001) and changes in other coagulation parameters. Patients with base deficit ≤?6 mmol/L had changes in antithrombin, factor V and protein C activities but no significant coagulopathy.ConclusionCoagulopathy occurs very early after injury, before fluid administration, at the site of accident. Coagulation and fibrinolytic systems are activated early. The incidence of coagulopathy is high and its severity is related to the injury and not to hypoperfusion.     

The effect of admission spontaneous hypothermia on patients with severe traumatic brain injury

Introduction

Recent information has emerged regarding the harmful effects of spontaneous hypothermia at time of admission in trauma patients. However the volume of evidence regarding the role of spontaneous hypothermia in TBI patients is inadequate.

Methods

We performed secondary data analysis of 10 years of the Pennsylvania trauma outcome study (PTOS) database. Unadjusted comparisons of the association of admission spontaneous hypothermia with mortality were performed. In addition, full assessment of the association of hypothermia with mortality was conducted using multivariable logistic regressions reporting the odds ratios (OR) with the 95% confidence intervals (CI) and P-values.

Results

There were 11,033 patients identified from the PTOS with severe TBI. There were 4839 deaths (43.9%). The proportion of deaths in hypothermic patients was higher than the proportion of deaths in normothermic patients (53.9% vs. 37.4% respectively; P value < 0.001). In a multivariable logistic regression model adjusted for demographics, injury characteristics, and information at admission to the trauma centre, the odds of death among patients with hypothermia were 1.70 times the odds of death among patients with normothermia (OR 1.70, 95% CI 1.50–1.93), indicating that the probability of death was significantly higher when patients arrived hypothermic at the trauma centre.

Conclusion

The presence of spontaneous hypothermia at hospital admission is associated with a significant increase in the risk of mortality in patients with severe TBI. The benefit of maintaining normothermia in severe TBI patients, the impact of prolonged re-warming in patients with established hypothermia and the introduction of prophylactic measures to complications of hypothermia are key points that require further investigation.     

Avoiding hypothermia in the trauma patient

Hypothermia may be encountered during the management of severely injured patients, and with exception of deliberate hypothermia for neuroprotection, has been associated with increased morbidity and mortality. This review examines the recent literature with regard to risk factors for developing hypothermia, significance of hypothermia, therapeutic use of hypothermia, and invasive and noninvasive methods to prevent and treat hypothermia.     

Challenges of surgical trauma emergency admission

Introduction  

Trauma still remains as one of the leading causes for mortality in Western civilization. The early clinical management of severely injured patients leads to structural and organizational challenges involving different specialties.     

Do elderly patients with hip pain following trauma require hospital admission?

A series of 123 elderly patients (mean age 77.8 years) were identified who presented to the accident and emergency department following trauma, who complained of hip pain but had a 'normal' hip radiograph. These patients were followed up by a scrutiny of hospital admissions, 'phone contact with their general practitioner or nursing home or postal questionnaire. At the time of review, which ranged from 3 to 12 months, 13 patients had died. Of the remaining patients, five had sustained a fracture but only three had sustained a hip fracture. Of patients reviewed, 20 per cent had been admitted to hospital with other problems. Hip pain following trauma may be a better predictor of morbidity and mortality than of an occult hip fracture.     

Pathophysiologic changes and effects of hypothermia on outcome in elective surgery and trauma patients

Generally, hypothermia is defined as a core temperature <35 degrees C. In elective surgery, induced hypothermia has beneficial effects. It is recommended to diminish complications attributable to ischemia reperfusion injury. Experimental studies have shown that hypothermia during hemorrhagic shock has beneficial effects on outcome. In contrast, clinical experience with hypothermia in trauma patients has shown accidental hypothermia to be a cause of posttraumatic complications. The different etiology of hypothermia might be one reason for this disparity because induced therapeutic hypothermia, with induction of poikilothermia and shivering prevention, is quite different from accidental hypothermia, which results in physiological stress. Other studies have shown evidence that this contradictory effect is related to the plasma concentration of high-energy phosphates (e.g., adenosine triphosphate [ATP]). Induced hypothermia preserves ATP storage, whereas accidental hypothermia causes depletion. Hypothermia also has an impact on the immunologic response after trauma and elective surgery by decreasing the inflammatory response. This might have a beneficial effect on outcome. Nevertheless, posttraumatic infectious complications may be higher because of an immunosuppressive profile. Further studies are needed to investigate the impact of induced hypothermia on outcome in trauma patients.     

Systemic inflammatory response syndrome score at admission independently predicts infection in blunt trauma patients

BACKGROUND: Systemic inflammatory response syndrome (SIRS) score has been demonstrated to be an accurate predictor of outcome in critical surgical illness. To our knowledge, there is a paucity of data using SIRS score as a tool to predict posttraumatic infection. Our goal was to determine whether the severity of SIRS score at admission is an accurate predictor of infection in trauma patients. METHODS: Prospective data were collected on 4,887 blunt trauma patients admitted to a primary adult resource center designated trauma center over an 18-month period. Patients were stratified by age and Injury Severity Score (ISS). SIRS score was calculated at admission. SIRS was defined as an SIRS score > or = 2. Each patient was screened for infection by an infectious disease specialist. Those at high risk for infection were then monitored daily throughout their hospitalization. Centers for Disease Control and Prevention guidelines were used to diagnose infection. RESULTS: Of the 4,887 patients, 1,850 (38%) were admitted > 24 hours and evaluated for subsequent infection (mean ISS, 16 +/- 9; mean age, 43 +/- 19, SD). Thirty-one percent (577) of the patients acquired an infection. The mean hospital length of stay (20.2 days vs. 6.5 days) and mortality (7.8% vs. 2.7%) were significantly greater in the infected group (p < 0.001). Of the four SIRS variables (temperature, heart rate, white blood cell count, and respiratory rate), hypothermia and leukocytosis were the most significant predictors of infection (p < 0.001) when adjusted for age and ISS. SIRS scores of > or = 2 were increasingly predictive of infection when analyzed by multiple logistic regression analysis. CONCLUSION: An admission SIRS score of > or = 2 is a significant independent predictor of infection and outcome in blunt trauma. Daily SIRS scores may be a meaningful method of assessing postinjury risk of infection, and may initiate earlier diagnostic intervention for determination of infection.     

Secondary injuries in brain trauma: effects of hypothermia

Hypothermia has been shown to be cerebroprotective in traumatized brains. Although a large number of traumatic brain injury (TBI) studies in animals have shown that hypothermia is effective in suppressing a variety of damaging mechanisms, clinical investigations have shown less consistent results. The complexity of damaging mechanisms in human TBI may contribute to these discrepancies. In particular, secondary injuries such as hypotension and hypoxemia may promote poor outcome. However, few experimental TBI studies have employed complex models that included such secondary injuries to clarify the efficacy of hypothermia. This review discusses the effects of hypothermia in various TBI models addressing primary and acute secondary injuries. Included are recently published clinical data using hypothermia as a therapeutic tool for preventing or reducing the detrimental posttraumatic secondary injuries and neurobehavioral deficits. Also discussed are recent successful applications of hypothermia from outside the TBI realm. Based on all available data, some general considerations for the application of hypothermia in TBI patients are given.     

Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients

Background

The early diagnosis of pelvic arterial haemorrhage is challenging for initiating treatment by transcatheter arterial embolization (TAE) in multiple trauma patients. We use an institutional algorithm focusing on haemodynamic status on admission and on a whole-body CT scan in stabilized patients to screen patients requiring TAE. This study aimed to assess the effectiveness of this approach.

Methods

This retrospective cohort study included 106 multiple trauma patients admitted to the emergency room with serious pelvic fracture [pelvic abbreviated injury scale (AIS) score of 3 or more].

Results

Of the 106 patients, 27 (25%) underwent pelvic angiography leading to TAE for active arterial haemorrhage in 24. The TAE procedure was successful within 3 h of arrival in 18 patients. In accordance with the algorithm, 10 patients were directly admitted to the angiography unit (n = 8) and/or operating room (n = 2) for uncontrolled haemorrhagic shock on admission. Of the remaining 96 stabilized patients, 20 had contrast media extravasation on pelvic CT scan that prompted pelvic angiography in 16 patients leading to TAE in 14. One patient underwent a pelvic angiography despite showing no contrast media extravasation on pelvic CT scan. All 17 stabilized patients who underwent pelvic angiography presented a more severely compromised haemodynamic status on admission, and they required more blood products during their initial management than the 79 patients who did not undergo pelvic angiography. The incidence of unstable pelvic fractures was however comparable between the two groups. Overall, haemodynamic instability and contrast media extravasation on the CT-scan identified 26 out of the 27 patients who required subsequent pelvic angiography leading to TAE in 24.

Conclusions

An algorithm focusing on haemodynamic status on arrival and on the whole-body CT scan in stabilized patients may be effective at triaging multiple trauma patients with serious pelvic fractures.     

Invasive and non-invasive physiological monitoring of blunt trauma patients in the early period after emergency admission

Pulmonary artery catheterization is usually not available to critically injured patients before admission to the intensive care unit, where action to correct values derived from such monitoring may be too late. Methods allowing hemodynamic monitoring during the early stages after trauma need to be explored. We used non-invasive monitoring systems (bioimpedance cardiac output monitoring, pulse oximetry and transcutaneous oximetry) to evaluate early temporal hemodynamic patterns after blunt trauma, and compared these to invasive PA monitoring. We included prospectively 134 patients monitored shortly after admission to the emergency department. The non-invasive impedance cardiac output estimations under extenuating emergency conditions approximated those of the thermodilution method: r = 0.83, r2 = 0.69, P<0.001; bias and precision were -0.02+/-0.78 l/min/m2. In the intensive care unit, these values improved further to: r = 0.91, r2 = 0.83, P<0.001; bias and precision = 0.36+/-0.59 l/min/m2. Monitoring revealed episodes of hypotension, low cardiac index, arterial hemoglobin desaturation, low transcutaneous oxygen and high transcutaneous carbon dioxide tensions, and low oxygen consumption during initial resuscitation. Low flow and poor tissue perfusion were more pronounced in non-survivors by both methods. Multicomponent non-invasive monitoring systems give continuous on-line, real-time displays of physiological data that allow early recognition of circulatory dysfunction. Such systems provide information similar to that provided by the invasive thermodilution method, and are easier and safer to use.