scholarly journals Rapid Sequence Induction Strategies Among Critically Injured U.S. Military During the Afghanistan and Iraq Conflicts

2021 ◽  
Vol 186 (Supplement_1) ◽  
pp. 316-323
Author(s):  
Alec D Emerling ◽  
William Bianchi ◽  
Michael Krzyzaniak ◽  
Travis Deaton ◽  
Darin Via ◽  
...  
Keyword(s):  
Injury Severity Score ◽  
Severity Score ◽  
Injury Severity ◽  
Significant Benefit ◽  
Combat Trauma ◽  
Induction Agent ◽  
Blood Products ◽  
Induction Dose ◽  
Rapid Sequence ◽  
Traumatic Hemorrhage

ABSTRACT Introduction Rapid sequence intubation of patients experiencing traumatic hemorrhage represents a precarious phase of care, which can be marked by hemodynamic instability and pulseless arrest. Military combat trauma guidelines recommend reduced induction dose and early blood product resuscitation. Few studies have evaluated the role of induction dose and preintubation transfusion on hemodynamic outcomes. We compared rates of postintubation systolic blood pressure (SBP) of < 70 mm Hg, > 30% drop in SBP, pulseless arrest, and mortality at 24 hours and 30 days among patients who did and did not receive blood products before intubation and then examined if induction agent and dose influenced the same outcomes. Materials and Methods A retrospective analysis was performed of battle-injured personnel presenting to surgical care facilities in Iraq and Afghanistan between 2004 and 2018. Those who received blood transfusions, underwent intubation, and had an Injury Severity Score of  ≥15 were included. Intubation for primary head, facial, or neck injury, burns, operative room intubations, or those with cardiopulmonary resuscitation in progress were excluded. Multivariable logistic regression was performed with unadjusted and adjusted odds ratios for the five study outcomes among patients who did and did not receive preintubation blood products. The same analysis was performed for patients who received full or excessive versus partial induction agent dose. Results A total of 153 patients had a mean age of 24.9 (SD 4.5), Injury Severity Score 29.7 (SD 11.2), heart rate 122.8 (SD 24), SBP 108.2 (SD 26.6). Eighty-one (53%) patients received preintubation blood products and had similar characteristics to those who did not receive transfusions. Adjusted multivariate analysis found odds ratios as follows: 30% SBP decrease 9.4 (95% CI 2.3-38.0), SBP < 70 13.0 (95% CI 3.3-51.6), pulseless arrest 18.5 (95% CI 1.2-279.3), 24-hour mortality 3.8 (95% CI 0.7-21.5), and 30-day mortality 1.3 (0.4-4.7). In analysis of induction agent choice and comparison of induction agent dose, no statistically significant benefit was seen. Conclusion Within the context of this historical cohort, the early use of blood products conferred a statistically significant benefit in reducing postintubation hypotension and pulseless arrest among combat trauma victims exposed to traumatic hemorrhage. Induction agent choice and dose did not significantly influence the hemodynamic or mortality outcomes.

scholarly journals Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial

2021 ◽  
Vol 6 (1) ◽  
pp. e000777
Author(s):  
John A Harvin ◽  
Sasha D Adams ◽  
Shah-Jahan M Dodwad ◽  
Kayla D Isbell ◽  
Claudia Pedroza ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Injury Severity Score ◽  
Severity Score ◽  
Injury Severity ◽  
Damage Control ◽  
Controlled Trial ◽  
Pilot Trial ◽  
Blood Products ◽  
Damage Control Laparotomy ◽  
Randomized Controlled

BackgroundAlthough widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients for whom our surgeons had equipoise and hypothesized that definitive laparotomy (DEF) would reduce major abdominal complications (MAC) or death within 30 days compared with DCL.MethodsEligible patients undergoing emergency laparotomy were randomized during surgery to DCL or DEF from July 2016 to May 2019. The primary outcome was MAC or death within 30 days. Prespecified frequentist and Bayesian analyses were performed.ResultsOf 489 eligible patients, 39 patients were randomized (DCL 18, DEF 21) and included. Groups were similar in demographics and mechanism of injury. The DEF group had a higher Injury Severity Score (DEF median 34 (IQR 20, 43) vs DCL 29 (IQR 22, 41)) and received more prerandomization blood products (DEF median red blood cells 8 units (IQR 6, 11) vs DCL 6 units (IQR 2, 11)). In unadjusted analyses, the DEF group had more MAC or death within 30 days (1.71, 95% CI 0.81 to 3.63, p=0.159) due to more deaths within 30 days (DEF 33% vs DCL 0%, p=0.010). Adjustment for Injury Severity Score and prerandomization blood products reduced the risk ratio for MAC or death within 30 days to 1.54 (95% CI 0.71 to 3.32, p=0.274). The Bayesian probability that DEF increased MAC or death within 30 days was 85% in unadjusted analyses and 66% in adjusted analyses.ConclusionThe findings of our single center pilot trial were inconclusive. Outcomes were not worse with DCL and, in fact, may have been better. A randomized clinical trial of DCL is feasible and a larger, multicenter trial is needed to compare DCL and DEF for patients with severe abdominal trauma.Level of evidenceLevel II.

Hemodynamic Effects of Propofol for Induction of Rapid Sequence Intubation in Traumatically Injured Patients

2018 ◽  
Vol 84 (9) ◽  
pp. 1504-1508 ◽  
Author(s):  
Scott K. Dietrich ◽  
Mark A. Mixon ◽  
Ryan J. Rogoszewski ◽  
Stephanie D. Delgado ◽  
Vanessa E. Knapp ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Injury Severity Score ◽  
Severity Score ◽  
Injury Severity ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Rapid Sequence Intubation ◽  
Trauma Patients ◽  
Rapid Sequence ◽  
Injured Patients

Present guidelines for emergency intubation in traumatically injured patients recommend rapid sequence intubation (RSI) as the preferred method of airway management but specific pharmacologic agents for RSI remain controversial. To evaluate hemodynamic differences between propofol and other induction agents when used for RSI in trauma patients. Single-center, retrospective review of trauma patients intubated in the emergency department. Patients were divided in two groups based on induction agent, propofol or nonpropofol. The primary outcome was incidence of hypotension within 30 minutes of intubation. Secondary outcomes included hospital length of stay and inhospital mortality. The study protocol was approved by the Institutional Review Board. Of the 744 patients identified, 83 were analyzed, 43 in the propofol group and 40 in the nonpropofol group. Groups were similar at baseline in terms of pre-RSI hemodynamics, injury mechanism, initial Glasgow Coma Score, and Injury Severity Score. On univariate analysis, although not statistically significant, postintubation hypotension was more common in patients who received propofol compared with those who did not, 39.5 per cent versus 22.5 per cent (P = 0.9). When adjusted for age, Injury Severity Score, and pre-RSI hemodynamics, the risk of hypotension among propofol-treated patients was significantly higher (OR = 3.64; 95% Confidence interval 1.16–13.24). There were no significant differences between groups in hospital length of stay or mortality. Propofol increases the odds of postintubation hypotension in traumatically injured patients. Considerable caution should be used when contemplating the use of propofol the for induction of injured patients requiring RSI because other agents possess more favorable hemodynamic profiles.

Disseminierte intravasale Gerinnung und Fibrinolyse in der Frühphase nach Polytrauma

1995 ◽  
Vol 15 (02) ◽  
pp. 79-86
Author(s):  
L. Lampl ◽  
M. Helm ◽  
M. Tisch ◽  
K. H. Bock ◽  
E. Seifried
Keyword(s):  
Injury Severity Score ◽  
Severity Score ◽  
Injury Severity ◽  
Tissue Type ◽  
Disseminierte Intravasale Gerinnung

ZusammenfassungGerinnungsstörungen nach einem Polytrauma werden eine große Bedeutung für die weitere Prognose der Patienten beigemessen. In einer prospektiv angelegten Studie wurden bei 20 polytraumatisierten Patienten Gerinnungsund Fibrinolyseparameter analysiert, um deren Veränderungen während der präklinischen Phase zu definieren. Die Blutentnahmen wurden zum frühestmöglichen Zeitpunkt am Unfallort und bei Klinikübergabe durchgeführt. Die gewonnenen Proben wurden mit Hilfe eines speziell konzipierten »Kleinlabors« noch vor Ort verarbeitet, um möglichst native Meßwerte zu erhalten. Die Patienten wurden dem Schweregrad der Verletzung entsprechend kategorisiert und hatten einen Verletzungsschweregrad nach NACA > IV und einen Injury Severity Score (ISS) > 20. Die Ergebnisse zeigen, daß bereits in der sehr frühen Phase nach Eintritt des Traumas schwerwiegende Veränderungen des Gerinnungsund Fibrinolysesystems eintreten. Die frühzeitige Thrombingenerierung führt zu einer Verbrauchskoagulopathie und reaktiven Hyperfibrinolyse. Zusätzlich erzeugt die Freisetzung von endothelständigem Tissue-type-Plasminogenaktivator eine primäre Hyperfibrinolyse. Die Veränderungen des Gerinnungsund Fibrinolysesystems in der frühen präklinischen Phase nach Polytrauma können zu schwerwiegenden klinischen Komplikationen wie Blutungen, thromboembolischen Komplikationen und zur Ausbildung von Schockorganen führen.

Non-Selective Thoracic Computed Tomography in Trauma Patients Results in Injury Severity Score Inflation

2021 ◽  
pp. 000313482110249
Author(s):  
Leonardo Alaniz ◽  
Omaer Muttalib ◽  
Juan Hoyos ◽  
Cesar Figueroa ◽  
Cristobal Barrios
Keyword(s):  
Computed Tomography ◽  
Injury Severity Score ◽  
Severity Score ◽  
Injury Severity ◽  
Treatment Plan ◽  
Mortality Prediction ◽  
Trauma Patients ◽  
Mortality Benefit ◽  
Severity Scores ◽  
Score Inflation

Introduction Extensive research relying on Injury Severity Scores (ISS) reports a mortality benefit from routine non-selective thoracic CTs (an integral part of pan-computed tomography (pan-CT)s). Recent research suggests this mortality benefit may be artifact. We hypothesized that the use of pan-CTs inflates ISS categorization in patients, artificially affecting admission rates and apparent mortality benefit. Methods Eight hundred and eleven patients were identified with an ISS >15 with significant findings in the chest area. Patient charts were reviewed and scores were adjusted to exclude only occult injuries that did not affect treatment plan. Pearson chi-square tests and multivariable logistic regression were used to compare adjusted cases vs non-adjusted cases. Results After adjusting for inflation, 388 (47.8%) patients remained in the same ISS category, 378 (46.6%) were reclassified into 1 lower ISS category, and 45 (5.6%) patients were reclassified into 2 lower ISS categories. Patients reclassified by 1 category had a lower rate of mortality ( P < 0.001), lower median total hospital LOS ( P < .001), ICU days ( P < .001), and ventilator days ( P = 0.008), compared to those that remained in the same ISS category. Conclusion Injury Severity Score inflation artificially increases survival rate, perpetuating the increased use of pan-CTs. This artifact has been propagated by outdated mortality prediction calculation methods. Thus, prospective evaluations of algorithms for more selective CT scanning are warranted.

INJURY SEVERITY SCORE, HEAD INJURY, AND PATIENT WAIT DAYS

1992 ◽  
Vol 33 (2) ◽  
pp. 219-220 ◽  
Author(s):  
James Andersen ◽  
William Sharkey ◽  
Michael L. Schwartz ◽  
Barry A. McLellan
Keyword(s):  
Head Injury ◽  
Injury Severity Score ◽  
Severity Score ◽  
Injury Severity

scholarly journals Schockraum- und Schwerverletztenversorgung als „Verlustgeschäft“

2020 ◽  
Author(s):  
Thomas Gross ◽  
Felix Amsler
Keyword(s):  
Injury Severity Score ◽  
Severity Score ◽  
Injury Severity ◽  
Diagnosis Related Groups ◽  
Case Mix ◽  
Multivariate Analyse ◽  
New Injury Severity Score ◽  
Case Mix Index

Zusammenfassung Hintergrund Es galt herauszufinden, wie kostendeckend die Versorgung potenziell Schwerverletzter in einem Schweizer Traumazentrum ist, und inwieweit Spitalgewinne bzw. -verluste mit patientenbezogenen Unfall‑, Behandlungs- oder Outcome-Daten korrelieren. Methodik Analyse aller 2018 im Schockraum (SR) bzw. mit Verletzungsschwere New Injury Severity Score (NISS) ≥8 notfallmäßig stationär behandelter Patienten eines Schwerverletztenzentrums der Schweiz (uni- und multivariate Analyse; p < 0,05). Ergebnisse Für das Studienkollektiv (n = 513; Ø NISS = 18) resultierte gemäß Spitalkostenträgerrechnung ein Defizit von 1,8 Mio. CHF. Bei einem Gesamtdeckungsgrad von 86 % waren 66 % aller Fälle defizitär (71 % der Allgemein- vs. 42 % der Zusatzversicherten; p < 0,001). Im Mittel betrug das Defizit 3493.- pro Patient (allg. Versicherte, Verlust 4545.-, Zusatzversicherte, Gewinn 1318.-; p < 0,001). Auch „in“- und „underlier“ waren in 63 % defizitär. SR-Fälle machten häufiger Verlust als Nicht-SR-Fälle (73 vs. 58 %; p = 0,002) wie auch Traumatologie- vs. Neurochirurgiefälle (72 vs. 55 %; p < 0,001). In der multivariaten Analyse ließen sich 43 % der Varianz erhaltener Erlöse mit den untersuchten Variablen erklären. Hingegen war der ermittelte Deckungsgrad nur zu 11 % (korr. R2) durch die Variablen SR, chirurgisches Fachgebiet, Intensivaufenthalt, Thoraxverletzungsstärke und Spitalletalität zu beschreiben. Case-Mix-Index gemäß aktuellen Diagnosis Related Groups (DRG) und Versicherungsklasse addierten weitere 13 % zu insgesamt 24 % erklärter Varianz. Diskussion Die notfallmäßige Versorgung potenziell Schwerverletzter an einem Schweizer Traumazentrum erweist sich nur in einem Drittel der Fälle als zumindest kostendeckend, dies v. a. bei Zusatzversicherten, Patienten mit einem hohen Case-Mix-Index oder einer IPS- bzw. kombinierten Polytrauma- und Schädel-Hirn-Trauma-DRG-Abrechnungsmöglichkeit.

scholarly journals Factors influencing the injury severity score and the probability of survival in patients who fell from height

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Masashi Fujii ◽  
Tsutomu Shirakawa ◽  
Mami Nakamura ◽  
Mineko Baba ◽  
Masahito Hitosugi
Keyword(s):  
Regression Analysis ◽  
Mortality Rate ◽  
Confidence Interval ◽  
Injury Severity Score ◽  
Survival Probability ◽  
Severity Score ◽  
Hospital Care ◽  
Injury Severity ◽  
Body Position ◽  
Fall Height

AbstractIn Japan, falls from height result in the second highest trauma mortality rate after traffic motor vehicle collisions and the highest trauma-related mortality rate amongst young people. We aimed to identify factors that worsen injury severity and lower survival probability of patients who fell from height and to contribute to the improvement of their prehospital and in-hospital care. This retrospective analysis retrieved hospital records of 179 patients aged ≥ 15 years who were transported to our hospital after a fall from height during April 2014–March 2020. On multiple regression analysis, fall height ≥ 5 m more significantly resulted in higher the injury severity score. Logistic regression analysis revealed that fall height ≥ 5 m with the reference of 2–3 m significantly resulted in lower the survival probability with odds ratio (95% confidence interval) of 0.10 (0.02–0.55). Using ‘feet-first’ as the reference body position, the odds ratios (95% confidence interval) of survival for those who impacted the surface on the lateral or dorsal regions were 0.11 (0.02–0.64) and 0.17 (0.03–0.99), respectively. Collecting information on the abovementioned factors at pre-hospitalisation may facilitate prompt diagnosis and treatment. These results may help improve prehospital and in-hospital care, avoiding preventable trauma deaths.

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