A Descriptive Analysis of Supermassive Transfusion Recipients Among US and Coalition Forces During Combat Operations in Afghanistan and Iraq

ABSTRACT Introduction Hemorrhage is the leading cause of potentially preventable death on the battlefield. Resuscitation with blood products is essential to restore circulating volume, repay the oxygen debt, and prevent coagulopathy. Massive transfusion (MT) occurs frequently after major trauma; a subset of casualties requires a supermassive transfusion (SMT), and thus, mobilization of additional resources remains unclear. Materials and Methods This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. In this analysis, we isolated U.S. and Coalition casualties that received at least 1 unit of packed red blood cells (PRBCs) or whole blood (WB). Given a lack of consensus on the definition of SMT recipients, we included those patients receiving the top quartile of PRBC and WB administered within the first 24 hours following arrival to a military treatment facility. Results We identified 25,897 adult casualties from January 1, 2007 to March 17, 2020. Within this dataset, 2,608 (9.0%) met inclusion for this analysis. The median number of total products administered within the first 24 hours was 8 units of PRBC or WB. The upper quartile was 18 units (n = 666). Compared to all other blood product recipients, patients in the SMT cohort had a higher median injury severity score (27 vs 18, P < 0.001), were most frequently injured by explosives (84.9% vs 68.6%, P < 0.001), had a higher mean emergency department (ED) pulse (128 vs 111, P < 0.001), a lower mean systolic blood pressure (122 vs 132 mm Hg, P < 0.001), and a higher mean international normalized ratio (1.68 vs 1.38, P < 0.001). SMT patients experienced lower survival to hospital discharge (85.8% vs 93.3%, P < 0.001). Conclusions Compared to all other PRBC and WB recipients, SMT patients experienced more injury by explosives, severe injury patterns, ED vital sign derangements, and mortality. These findings may help identify those casualties who may require earlier aggressive resuscitation. However, more data is needed to define this population early in their clinical course for early identification to facilitate rapid resource mobilization. Identifying casualties who are likely to die within 24 hours compared to those who are likely to survive, may assist in determining a threshold for a SMT.

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Defining the Super Massive Transfusion in US and Coalition Forces during Combat Operations in Afghanistan and Iraq

Blood ◽

10.1182/blood-2020-143199 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 5-6

Author(s):

Steven Gremel Schauer ◽

Andrew Fisher ◽

James Bynum ◽

Andrew P. Cap

Keyword(s):

Injury Severity ◽

Massive Transfusion ◽

Conflicts Of Interest ◽

Secondary Analysis ◽

International Normalized Ratio ◽

Median Number ◽

Hemorrhage Control ◽

Us Military ◽

Total Product ◽

Serious Injuries

Introduction: Hemorrhage is the leading cause of potentially preventable death on the battlefield. After hemorrhage control, the resuscitation with blood products is essential to restore circulating volume and prevent coagulopathy. While massive transfusion (MT) occurs frequently after major trauma, it remains unclear who the subset of casualties is that define a super massive transfusion which would require mobilization of additional resources. We seek to determine what defines a super MT as this would help allocate resources. Methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. In this analysis, we isolated US and Coalition casualties that received at least 1 unit of packed red cells or whole blood. To describe the super MT, we sought the top quartile of total products administered within the first 24 hours. Results: Out of the 28222 casualties within our dataset, we identified 2204 US military and 498 Coalition that met inclusion for this analysis. The median number of total products administered within the first 24 hours was 16 with 39 total product units at the 75th percentile, which included 691 casualties. Of those in the super MT group, their median injury severity score was higher (29 versus 18, p<0.001), they were most frequently injured by explosive (84% versus 69%, p<0.001), they had a higher mean emergency department pulse (116 versus 103, p<0.001), lower mean systolic 109 versus 122, p<0.001), and higher mean international normalized ratio (1.53 versus 1.28, p<0.001). They more frequently had serious injuries to the thorax (29% versus 22%, p<0.001), abdomen (32% versus 17%, p<0.001), and extremities (85% versus 64%, p<0.001). Super MT was associated with worse survival (86% versus 92%, p<0.001). Conclusions: In our dataset, we identified the top 25th percentile of total product administration within the first 24 hours at 39 total product units. More data is needed to define this population early in their clinical course to better mobile resources early when needed. Disclosures No relevant conflicts of interest to declare.

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High Ratio Resuscitation in Patients with Systemic acquired Coagulopathy vs Endogenous Acute Coagulopathy

Panamerican Journal of Trauma, Critical Care & Emergency Surgery ◽

10.5005/jp-journals-10030-1090 ◽

2014 ◽

Vol 3 (2) ◽

pp. 68-72

Author(s):

Robert Derenbecker

Keyword(s):

Injury Severity ◽

Traumatic Injury ◽

Retrospective Chart Review ◽

International Normalized Ratio ◽

Fresh Frozen Plasma ◽

High Ratio ◽

Packed Red Blood Cells ◽

Fresh Frozen ◽

Level I ◽

Transfusion Ratio

ABSTRACT Background Two main mechanisms of coagulopathy related to trauma have been described: systemic acquired coagulopathy (SAC) and endogenous acute coagulopathy (EAC). Resuscitation with high ratios of fresh frozen plasma to packed red blood cells (FFP:PRBC) has been shown to improve patient outcomes. Systemic acquired coagulopathy is related to acidosis, hypothermia and hemodilution. Endogenous acute coagulopathy is related to severe hemorrhage and shock, with resultant effects on intrinsic clotting pathways inducing coagulopathy more rapidly than SAC. We hypothesize that high ratio resuscitation will show improved mortality outcomes for both SAC and EAC. Study Design A retrospective chart review was performed for patients at an urban level I trauma center. All patients with international normalized ratio (INR) > 1.2 during the first 6 hours after admission who received operative intervention and at least 6 units of PRBCs following traumatic injury were included. Patients with INR > 1.2 on admission were stratified to the EAC group while patients with normal admission INR with subsequent postoperative increase in INR > 1.2 were stratified into the SAC group. Transfusion ratios for FFP:PRBC were also collected for each patient. High ratio resuscitation was defined as FFP:PRBC ≥ 1:2 and low as FFP:PRBC < 1:2. Outcomes between groups were analyzed. Results Total of 95 patients met inclusion criteria. Fifty-six (59%) patients met criteria for EAC and 39 (41%) patients developed criteria for SAC during the first 6 hours of admission. The initial average base deficit was greater in EAC vs SAC patients (–6.3 vs –4.8, p = 0.03). Endogenous acute coagulopathy patients had a higher initial INR than SAC (1.4 vs 1.1, p = 0.001), and a higher average injury severity score (ISS) (27.6 vs 21.5, p = 0.03). Regarding transfusion ratios, for both EAC and SAC, a high transfusion ratio when compared to a low transfusion ratio conveyed improved mortality (EAC: 32.5 vs 81%, p = 0.01; SAC:9 vs 64.7%, p = 0.03). For high ratio resuscitation in both groups, patients with SAC showed improved mortality compared to EAC (9 vs 32.5%, p = 0.01). Conclusion For patients with EAC and SAC, a high transfusion ratio conveyed an overall improvement in mortality. However, subgroup analysis demonstrated that despite a high transfusion ratio, EAC patients continued to have a significantly higher mortality than SAC patients. Further investigations into the mechanisms involved in EAC and interventions to improve outcomes are needed. How to cite this article Duchesne J, Derenbecker R. High Ratio Resuscitation in Patients with Systemic acquired Coagulopathy vs Endogenous Acute Coagulopathy. Panam J Trauma Crit Care Emerg Surg 2014;3(2):68-72.

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Endogenous Heparinoids Detected by anti-Xa Activity are Present in Blood during Acute Variceal Bleeding in Cirrhosis. A Prospective Study

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld.2014.1121.232.cht1 ◽

2014 ◽

Vol 23 (2) ◽

pp. 187-194 ◽

Cited By ~ 4

Author(s):

Christos Triantos ◽

Emmanuel Louvros ◽

Maria Kalafateli ◽

Anne Riddell ◽

Ulrich Thalheimer ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Variceal Bleeding ◽

Blood Cells ◽

Venous Pressure ◽

White Blood Cells ◽

International Normalized Ratio ◽

Ulcer Bleeding ◽

Factor X ◽

Packed Red Blood Cells ◽

Bacterial Peritonitis

Background & Aims: Endogenous heparinoids have been detected by thromboelastography and quantified by clotting based anti-Xa activity assays in patients with cirrhosis, but their presence in variceal bleeding has not been established yet.Methods: Clotting based anti-Xa activity was measured in A) 30 cirrhotics with variceal bleeding, B) 15 noncirrhotics with peptic ulcer bleeding, C) 10 cirrhotics without infection or bleeding, and D) 10 cirrhotics with hepatocellular carcinoma (HCC).Results: Anti-Xa activity was not detected in ulcer bleeders or in cirrhotics without infection or bleedingbut was present in seven (23%) variceal bleeders (median levels: 0.03 u/mL (0.01-0.07)) and was quantifiable for 3 days in six of seven patients. Four of seven variceal bleeders with anti-Xa activity present had HCC (p=0.023). Age, creatinine, platelet count and total infections the second day from admission were significantly correlated with the presence of measureable anti-Xa levels (p=0.014, 0.032, 0.004 and 0.019, respectively). In the HCC group, anti-Xa activity was present in three patients (30%) [median levels: 0.05 u/mL (0.01-0.06)].Conclusions: In this study, variceal bleeders and 30% of the patients with HCC had endogenous heparinoids that were detected by a clotting based anti-Xa activity assay, whereas there was no anti Xa activity present in patients with cirrhosis without infection, or bleeding or HCC, nor in those with ulcer bleeding. Thus, the anti-Xa activity is likely to be a response to bacterial infection and/or presence of HCC in cirrhosis.List of abbreviations: AFP, alpha-fetoprotein; aPTT, activated partial thromboplastin time; CP, Child-Pugh; FXa, activated factor X; GAGS, glycosaminoglycans; Hb, hemoglobin; HCC, hepatocellular carcinoma; HVPG, hepatic venous pressure gradient; INR, International normalized ratio; LMWHs, low molecular weight heparins; MELD, Model for End-stage Liver Disease; PPP, platelet-poor plasma; PRBC, packed red blood cells; PT, prothrombin time; SBP, sponataneous bacterial peritonitis; TEG, thromboelastography; WBC, white blood cells.

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Establishing a Working Definition of User Experience for eHealth Interventions: A Scoping Review of Self-Reported User Experience Measures and Delphi Consultation with eHealth Researchers and Adolescents (Preprint)

10.2196/preprints.25012 ◽

2020 ◽

Author(s):

Amanda S Newton ◽

Sonja March ◽

Nicole D Gehring ◽

Arlen K Rowe ◽

Ashley D Radomski

Keyword(s):

User Experience ◽

Scoping Review ◽

Descriptive Analysis ◽

Intervention Development ◽

Health Condition ◽

Working Definition ◽

Perceived Impact ◽

Behavioural Factors ◽

Definition Of ◽

Ehealth Intervention

BACKGROUND Across eHealth intervention studies involving children, adolescents, and their parents, researchers have measured users’ experiences to assist with intervention development, refinement, and evaluation. To date, there are no widely agreed-on definitions or measures of ‘user experience’ to support a standardized approach for evaluation and comparison within or across interventions. OBJECTIVE We conducted a scoping review with subsequent Delphi consultation to (1) identify how user experience is defined and measured in eHealth research studies, (2) characterize the measurement tools used, and (3) establish working definitions for domains of user experience that could be used in future eHealth evaluations. METHODS We systematically searched electronic databases for published and gray literature available from January 1, 2005 to April 11, 2019. Studies assessing an eHealth intervention that targeted any health condition and was designed for use by children, adolescents, and their parents were eligible for inclusion. eHealth interventions needed to be web-, computer-, or mobile-based, mediated by the internet with some degree of interactivity. Studies were also required to report the measurement of ‘user experience’ as first-person experiences, involving cognitive and behavioural factors, reported by intervention users. Two reviewers independently screened studies for relevance and appraised the quality of user experience measures using published criteria: ‘well-established’, ‘approaching well-established’, ‘promising’, or ‘not yet established’. We conducted a descriptive analysis of how user experience was defined and measured in each study. Review findings subsequently informed the survey questions used in the Delphi consultations with eHealth researchers and adolescent users for how user experience should be defined and measured. RESULTS Of the 8,634 articles screened for eligibility, 129 and one erratum were included in the review. Thirty eHealth researchers and 27 adolescents participated in the Delphi consultations. Based on the literature and consultations, we proposed working definitions for six main user experience domains: acceptability, satisfaction, credibility, usability, user-reported adherence, and perceived impact. While most studies incorporated a study-specific measure, we identified ten well-established measures to quantify five of the six domains of user experience (all except for self-reported adherence). Our adolescent and researcher participants ranked perceived impact as one of the most important domains of user experience and usability as one of the least important domains. Rankings between adolescents and researchers diverged for other domains. CONCLUSIONS Findings highlight the various ways user experience has been defined and measured across studies and what aspects are most valued by researchers and adolescent users. We propose incorporating the working definitions and available measures of user experience to support consistent evaluation and reporting of outcomes across studies. Future studies can refine the definitions and measurement of user experience, explore how user experience relates to other eHealth outcomes, and inform the design and use of human-centred eHealth interventions.

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National temporal variation in major trauma in England, Wales and Northern Ireland

Trauma ◽

10.1177/1460408620982264 ◽

2021 ◽

pp. 146040862098226

Author(s):

Will Kieffer ◽

Daniel Michalik ◽

Jason Bernard ◽

Omar Bouamra ◽

Benedict Rogers

Keyword(s):

Northern Ireland ◽

Temporal Variation ◽

Major Trauma ◽

Injury Severity ◽

Research Network ◽

Trauma Patients ◽

Trauma Outcomes ◽

Causes Of Mortality ◽

Injured Patients ◽

Time Of Admission

Introduction Trauma is one of the leading causes of mortality worldwide, but little is known of the temporal variation in major trauma across England, Wales and Northern Ireland. Proper workforce and infrastructure planning requires identification of the caseload burden and its temporal variation. Materials and Methods The Trauma Audit Research Network (TARN) database for admissions attending Major Trauma Centres (MTCs) between 1st April 2011 and 31st March 2018 was analysed. TARN records data on all trauma patients admitted to hospital who are alive at the time of admission to hospital. Major trauma was classified as an Injury Severity Score (ISS) >15. Results A total of 158,440 cases were analysed. Case ascertainment was over 95% for 2013 onwards. There was a statistically significant variation in caseload by year (p < 0.0001), times of admissions (p < 0.0001), caseload admitted during weekends vs weekdays, 53% vs 47% (p < 0.0001), caseload by season with most patients admitted during summer (p < 0.0001). The ISS varied by time of admission with most patients admitted between 1800 and 0559 (p < 0.0001), weekend vs weekday with more severely injured patients admitted during the weekend (p < 0.0001) and by season p < 0.0001). Discussion and Conclusion: There is a significant national temporal variation in major trauma workload. The reasons are complex and there are multiple theories and confounding factors to explain it. This is the largest dataset for hospitals submitting to TARN which can help guide workforce and resource allocation to further improve trauma outcomes.

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Outcomes of major trauma among patients with chronic kidney disease and receiving dialysis in Nova Scotia: a retrospective analysis

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000672 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000672

Author(s):

Ryan Pratt ◽

Mete Erdogan ◽

Robert Green ◽

David Clark ◽

Amanda Vinson ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Nova Scotia ◽

Kidney Disease ◽

Hospital Mortality ◽

Major Trauma ◽

Injury Severity ◽

Cox Regression ◽

Trauma Patients ◽

Risk Of Death ◽

Increased Risk

BackgroundThe risk of death and complications after major trauma in patients with chronic kidney disease (CKD) is higher than in the general population, but whether this association holds true among Canadian trauma patients is unknown.ObjectivesTo characterize patients with CKD/receiving dialysis within a regional major trauma cohort and compare their outcomes with patients without CKD.MethodsAll major traumas requiring hospitalization between 2006 and 2017 were identified from a provincial trauma registry in Nova Scotia, Canada. Trauma patients with stage ≥3 CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2) or receiving dialysis were identified by cross-referencing two regional databases for nephrology clinics and dialysis treatments. The primary outcome was in-hospital mortality; secondary outcomes included hospital/intensive care unit (ICU) length of stay (LOS) and ventilator-days. Cox regression was used to adjust for the effects of patient characteristics on in-hospital mortality.ResultsIn total, 6237 trauma patients were identified, of whom 4997 lived within the regional nephrology catchment area. CKD/dialysis trauma patients (n=101; 28 on dialysis) were older than patients without CKD (n=4896), with higher rates of hypertension, diabetes, and cardiovascular disease, and had increased risk of in-hospital mortality (31% vs 11%, p<0.001). No differences were observed in injury severity, ICU LOS, or ventilator-days. After adjustment for age, sex, and injury severity, the HR for in-hospital mortality was 1.90 (95% CI 1.33 to 2.70) for CKD/dialysis compared with patients without CKD.ConclusionIndependent of injury severity, patients without CKD/dialysis have significantly increased risk of in-hospital mortality after major trauma.

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A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

European Geriatric Medicine ◽

10.1007/s41999-021-00546-9 ◽

2021 ◽

Author(s):

Y. Kalbas ◽

M. Lempert ◽

F. Ziegenhain ◽

J. Scherer ◽

V. Neuhaus ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Descriptive Analysis ◽

Patient Characteristics ◽

Severe Trauma ◽

Diagnostic Tools ◽

Trauma Patients ◽

Treatment Algorithms ◽

Injured Patients ◽

Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

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Life Cycles in Social Science History

Social Science History ◽

10.1017/s0145553200021830 ◽

1999 ◽

Vol 23 (4) ◽

pp. 481-489

Author(s):

Andrew Abbott

Keyword(s):

Social Science ◽

Descriptive Analysis ◽

Life Cycles ◽

Science History ◽

The Past ◽

Social Science History ◽

The Social ◽

Definition Of

When one is asked to speak on the past, present, and future of social science history, one is less overwhelmed by the size of the task than confused by its indexicality. Whose definition of social science history? Which past? Or, put another way, whose past? Indeed, which and whose present? Moreover, should the task be taken as one of description, prescription, or analysis? Many of us might agree on, say, a descriptive analysis of the past of the Social Science History Association. But about the past of social science history as a general rather than purely associational phenomenon, we might differ considerably. The problem of description versus prescription only increases this obscurity.

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Abstract 31: Penumbra Consumption Rates Based on T Max Delay and Reperfusion Status: A Post-Hoc Analysis of the Defuse-3 Trial

Stroke ◽

10.1161/str.52.suppl_1.31 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Shadi Yaghi ◽

Eytan Raz ◽

Seena Dehkharghani ◽

Howard Riina ◽

Ryan McTaggart ◽

...

Keyword(s):

Infarct Volume ◽

Secondary Analysis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Consumption Rates ◽

Definition Of ◽

Post Hoc ◽

New Generation

Introduction: In patients with acute large vessel occlusion, the definition of penumbral tissue based on T max delay perfusion imaging is not well established in relation to late-window endovascular thrombectomy (EVT). In this study, we sought to evaluate penumbra consumption rates for T max delays in patients treated between 6 and 16 hours from last known normal. Methods: This is a secondary analysis of the DEFUSE-3 trial, which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is percentage penumbra consumption defined as (24 hour infarct volume-core infarct volume)/(Tmax volume-baseline core volume). We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates. Results: We included 143 patients, of which 66 were untreated, 16 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, a median (IQR) of 48% (21% - 85%) of penumbral tissue was consumed based on Tmax6 as opposed to 160.6% (51% - 455.2%) of penumbral tissue based on Tmax10. On the contrary, in patients achieving TICI 3 reperfusion, a median (IQR) of 5.3% (1.1% - 14.6%) of penumbral tissue was consumed based on Tmax6 and 25.7% (3.2% - 72.1%) of penumbral tissue based on Tmax10. Conclusion: Contrary to prior studies, we show that at least 75% of penumbral tissue with Tmax > 10 sec delay can be salvaged with successful reperfusion and new generation devices. In untreated patients, since infarct expansion can occur beyond 24 hours, future studies with delayed brain imaging are needed to determine the optimal T max delay threshold that defines penumbral tissue in patients with proximal anterior circulation large vessel occlusion.

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Predictors of blunt diaphragm injury in Australia

Trauma ◽

10.1177/14604086211041857 ◽

2021 ◽

pp. 146040862110418

Author(s):

Annelise M Cocco ◽

Vignesh Ratnaraj ◽

Benjamin PT Loveday ◽

Kellie Gumm ◽

Phillip Antippa ◽

...

Keyword(s):

Injury Severity Score ◽

Severity Score ◽

Major Trauma ◽

Injury Severity ◽

Rib Fractures ◽

Organ Injury ◽

Trauma Patients ◽

Missed Injury ◽

Diaphragm Injury ◽

Trauma Service

Introduction Blunt diaphragm injury (BDI) is an uncommon, potentially fatal consequence of blunt torso injury. While associations between BDI and other factors such as mechanism of injury or other injuries have been described elsewhere, little recent research has been done in Australia into BDI. The aims of this study were to determine the incidence rate of BDI in our centre, identify how it was diagnosed, determine rates of missed injury and identify predictive factors for BDI. The hypothesis was that patients with BDI would significantly differ to those without BDI. Methods All major trauma patients with blunt torso injuries at our Level 1 major trauma service from 2010 to 2018 were included. Data for patient demographics, other injuries, diagnosis and treatment of BDI were extracted. Patients with BDI were compared with patients without BDI in order to identify differences that could be used to predict BDI in future patients. Results Of 5190 patients with a blunt torso injury, 51 (0.98%) had a BDI at a mean age of 53 ± 19.6 years, and median Injury Severity Score (ISS) of 27(IQR 21–38.5) compared with 5139 patients with a mean age of 48.2 ± 20.7 years and median ISS of 21.9(IQR 14–26) who did not have a BDI. The diagnosis of BDI was made at CT ( n = 35), surgery ( n = 14) or autopsy ( n = 2). Blunt diaphragm injury was missed on index imaging for 11 of 43 patients (25.6%). On multivariate analysis, each point increase in ISS (OR 1.03, p = 0.02); rib fractures (OR 4.65, p = 0.004); splenic injury (OR 2.60, p = 0.004); and liver injury (OR 2.78, p = 0.003) were independently associated with BDI. Conclusion Injury Severity Score, rib fractures and solid abdominal organ injury increase the likelihood of BDI. In patients with these injuries, BDI should be considered even in the presence of normal CT findings.

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