Which injured patients with moderate fibrinogen deficit need fibrinogen supplementation?

Abstract Background In severely injured patients, fibrinogen supplementation is recommended when fibrinogenemia is < 1.5 g L−1, but some teams have suggested to use higher thresholds (fibrinogenemia < 2.0 g L−1 or FIBTEM clot amplitude at 5 min (A5) values < 11 mm). The goal of this study was to specify in patients with a moderate fibrinogen deficit (MFD) whether some admission characteristics would be associated with fibrinogen administration at 24 h. Methods Prospective analysis of retrospectively collected data from a trauma registry (01/2011–12/2019). MFD-C was defined by a fibrinogenemia 1.51–1.99 g L−1 or the corresponding FIBTEM-A5 values (MFD-A5) that were determined from linear regression and ROC curve analysis. Administration of fibrinogen were described according to the following admission parameters: shock index (SI) > 1, hemoglobin level < 110 g L−1 (HemoCue®), and base deficit > 5 mEq L−1. Data are expressed as count (%), median [IQR]. Results 1076 patients were included in the study and 266 (27%) had MFD-C, among them, 122/266 (46%) received fibrinogen. Patients with MFD-C who received fibrinogen were more severely injured (ISS: 27 [19–36] vs. 24 [17–29]) and had more impaired vital signs (base deficit: 5.4 [3.6–7.8] vs. 3.8 [2.0–6.0]). Linear regression analysis found a positive correlation between fibrinogen level and FIBTEM-A5 (r: 0.805). For a fibrinogen level < 1.5 g L−1 and < 2.0 g L−1, FIBTEM-A5 thresholds were 6 mm (sensitivity 85%, specificity 83%, AUC: 0.934) and 9 mm (sensitivity 84%, specificity 69%, AUC: 0.874), respectively. MFD-A5 values (185 (27%) patients) were defined as a FIBTEM-A5 between 7 and 9 mm. More than 50% of MFD-C patients presenting a SI > 1, a hemoglobin level < 110 g L−1, or a base deficit > 5.0 mEq L−1 received fibrinogen. The relative risk [95% CI] for fibrinogen administration (SI > 1) were 1.39 [1.06–1.82] for MFD-C, and 2.17 [1.48–3.19] for MFD-A5. Results were not modified after adjustment on the ISS. Conclusions We have shown in this study an association between shock parameters and fibrinogen administration. Further studies are needed to determine how these parameters may be used to guide fibrinogen administration in trauma patients with MFD.

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Trauma in pregnancy: A review of the Pennsylvania Trauma Systems Foundation database

Trauma ◽

10.1177/1460408617703677 ◽

2017 ◽

Vol 20 (1) ◽

pp. 30-37 ◽

Cited By ~ 3

Author(s):

Meike Schuster ◽

Natasha Becker ◽

Amanda Young ◽

Michael J Paglia ◽

A Dhanya Mackeen

Keyword(s):

Blunt Trauma ◽

Motor Vehicle ◽

Penetrating Trauma ◽

Blunt Injury ◽

Trauma Patients ◽

Severely Injured ◽

Trauma Systems ◽

Severely Injured Patients ◽

Vaginal Deliveries ◽

Injured Patients

Objective The goal of this study is to determine if injury severity score (ISS) of ≥9 and systolic blood pressure (SBP) predict poor maternal/pregnancy outcomes in blunt and penetrating trauma, respectively. Methods The Pennsylvania Trauma Systems Foundation database was used to identify pregnant trauma patients. Blunt trauma patients were analyzed with regard to ISS, while penetrating trauma patients were analyzed to determine whether SBP < 90 mmHg was predictive of poor maternal outcome. Results Patients with severe blunt injury (ISS ≥ 9) due to motor vehicle accident were less likely to wear seatbelts (51% vs. 63%, p = 0.005), and delivery was required in 17% of these patients as compared to 6% of the less severely injured, and only 6% of those were vaginal deliveries. Severely injured patients were discharged home 68% of the time and 6% died compared to less severely injured patients of which 83% were discharged home and <1% died; all other patients required discharge to a rehabilitation facility. Patients with penetrating trauma and SBP < 90 mmHg on arrival were more likely to require delivery (35% vs. 5%, p < 0.001) and were 14 times more likely to die (58% vs. 4%, p < 0.001) when compared to the normotensive group. Conclusion ISS ≥ 9 and SBP < 90 mmHg are predictors for poor outcomes after trauma during pregnancy. Severely injured blunt trauma patients often require surgery and delivery. Patients who present with SBP < 90 after penetrating trauma are more likely to deliver and are 14 times more likely to die.

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Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences

The American Surgeon ◽

10.1177/000313481408001130 ◽

2014 ◽

Vol 80 (11) ◽

pp. 1132-1135 ◽

Cited By ~ 4

Author(s):

Peter E. Fischer ◽

Paul D. Colavita ◽

Gregory P. Fleming ◽

Toan T. Huynh ◽

A. Britton Christmas ◽

...

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Local Trauma ◽

Level 1 ◽

Poor Outcomes ◽

Injured Patients ◽

Level 1 Trauma Center

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

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Vasopressor Use during Emergency Trauma Surgery

The American Surgeon ◽

10.1177/000313481408000518 ◽

2014 ◽

Vol 80 (5) ◽

pp. 472-478 ◽

Cited By ~ 5

Author(s):

Robert M. Van Haren ◽

Chad M. Thorson ◽

Evan J. Valle ◽

Gerardo A. Guarch ◽

Jassin M. Jouria ◽

...

Keyword(s):

Cardiac Arrest ◽

Mortality Rate ◽

Odds Ratio ◽

Injury Severity ◽

Trauma Surgery ◽

Vital Signs ◽

Severely Injured ◽

Severely Injured Patients ◽

Vasopressor Use ◽

Injured Patients

Most evidence suggests early vasopressor use is associated with death after trauma, but no previous study has focused on patients requiring emergency operative intervention (OR). We test the hypothesis that vasopressors are harmful in this population. Records from 746 patients requiring OR from July 2009 to March 2013 were retrospectively reviewed and stratified based on vasopressor use (epinephrine [EPI], phenylephrine, ephedrine, norepinephrine, dobutamine, vasopressin) or no vasopressor use. Vasopressors were administered to 225 patients (30%) during OR; 59 patients (8%) received multiple vasopressors. Patients who received vasopressors were older, more severely injured, had worse vital signs, and increased mortality rate (all P < 0.001). EPI was independently associated with mortality (odds ratio, 6.88; P = 0.001). If patients who received EPI were excluded, there was no difference in mortality between those who received vasopressors alone or in combination and those that did not (5 vs 6%, P = 0.523), although multiple markers of injury severity were worse. We conclude that vasopressor use is relatively common in the most severely injured patients requiring OR and is associated with mortality. EPI is most often used for cardiac arrest, whereas other vasopressors are used for their vasoconstrictive properties. This suggests that, except for EPI, vasopressors during OR are not independently associated with mortality.

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Loss of GPVI and GPIbα contributes to trauma-induced platelet dysfunction in severely injured patients

Blood Advances ◽

10.1182/bloodadvances.2020001776 ◽

2020 ◽

Vol 4 (12) ◽

pp. 2623-2630 ◽

Cited By ~ 1

Author(s):

Paul Vulliamy ◽

Samantha J. Montague ◽

Scarlett Gillespie ◽

Melissa V. Chan ◽

Lucy A. Coupland ◽

...

Keyword(s):

Patient Characteristics ◽

Surface Expression ◽

Trauma Patients ◽

Severely Injured ◽

Platelet Dysfunction ◽

Severely Injured Patients ◽

Severe Injuries ◽

Glycoprotein Vi ◽

Active Hemorrhage ◽

Injured Patients

Abstract Trauma-induced coagulopathy (TIC) is a complex, multifactorial failure of hemostasis that occurs in 25% of severely injured patients and results in a fourfold higher mortality. However, the role of platelets in this state remains poorly understood. We set out to identify molecular changes that may underpin platelet dysfunction after major injury and to determine how they relate to coagulopathy and outcome. We performed a range of hemostatic and platelet-specific studies in blood samples obtained from critically injured patients within 2 hours of injury and collected prospective data on patient characteristics and clinical outcomes. We observed that, although platelet counts were preserved above critical levels, circulating platelets sampled from trauma patients exhibited a profoundly reduced response to both collagen and the selective glycoprotein VI (GPVI) agonist collagen-related peptide, compared with those from healthy volunteers. These responses correlated closely with overall clot strength and mortality. Surface expression of the collagen receptors GPIbα and GPVI was reduced on circulating platelets in trauma patients, with increased levels of the shed ectodomain fragment of GPVI detectable in plasma. Levels of shed GPVI were highest in patients with more severe injuries and TIC. Collectively, these observations demonstrate that platelets experience a loss of GPVI and GPIbα after severe injury and translate into a reduction in the responsiveness of platelets during active hemorrhage. In turn, they are associated with reduced hemostatic competence and increased mortality. Targeting proteolytic shedding of platelet receptors is a potential therapeutic strategy for maintaining hemostatic competence in bleeding and improving the efficacy of platelet transfusions.

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Influence of late fluid management on the outcomes of severe trauma patients: A retrospective analysis of 294 severely-injured patients

Injury ◽

10.1016/j.injury.2017.06.005 ◽

2017 ◽

Vol 48 (9) ◽

pp. 1964-1971 ◽

Cited By ~ 4

Author(s):

Mehdi Mezidi ◽

Mehdi Ould-Chikh ◽

Pauline Deras ◽

Camille Maury ◽

Orianne Martinez ◽

...

Keyword(s):

Retrospective Analysis ◽

Fluid Management ◽

Severe Trauma ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Injured Patients

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Emergency angiography for trauma patients and potential association with acute kidney injury

World Journal of Emergency Surgery ◽

10.1186/s13017-021-00400-0 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Ryo Yamamoto ◽

Ramon F. Cestero ◽

Jo Yoshizawa ◽

Katsuya Maeshima ◽

Junichi Sasaki

Keyword(s):

Acute Kidney Injury ◽

Propensity Score ◽

Propensity Score Matching ◽

Injury Severity ◽

Vital Signs ◽

Kidney Injury ◽

Trauma Patients ◽

Potential Association ◽

Trauma Surgeons ◽

Injured Patients

Abstract Background Angiography has been conducted as a hemostatic procedure for trauma patients. While several complications, such as tissue necrosis after embolization, have been reported, little is known regarding subsequent acute kidney injury (AKI) due to contrast media. To elucidate whether emergency angiography would introduce kidney dysfunction in trauma victims, we compared the incidence of AKI between patients who underwent emergency angiography and those who did not. Methods A retrospective cohort study was conducted using a nationwide trauma database (2004–2019), and adult trauma patients were included. The indication of emergency angiography was determined by both trauma surgeons and radiologists, and AKI was diagnosed by treating physicians based on a rise in serum creatinine and/or fall in urine output according to any published standard criteria. Incidence of AKI was compared between patients who underwent emergency angiography and those who did not. Propensity score matching was conducted to adjust baseline characteristics including age, comorbidities, mechanism of injury, vital signs on admission, Injury Severity Scale (ISS), degree of traumatic kidney injury, surgical procedures, and surgery on the kidney, such as nephrectomy and nephrorrhaphy. Results Among 230,776 patients eligible for the study, 14,180 underwent emergency angiography. The abdomen/pelvis was major site for angiography (10,624 [83.5%]). Embolization was performed in 5,541 (43.5%). Propensity score matching selected 12,724 pairs of severely injured patients (median age, 59; median ISS, 25). While the incidence of AKI was rare, it was higher among patients who underwent emergency angiography than in those who did not (140 [1.1%] vs. 67 [0.5%]; odds ratio = 2.10 [1.57–2.82]; p < 0.01). The association between emergency angiography and subsequent AKI was observed regardless of vasopressor usage or injury severity in subgroup analyses. Conclusions Emergency angiography in trauma patients was probably associated with increased incidence of AKI. The results should be validated in future studies.

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Mortality Risk Stratification in Elderly Trauma Patients Based on Initial Arterial Lactate and Base Deficit Levels

The American Surgeon ◽

10.1177/000313481107701014 ◽

2011 ◽

Vol 77 (10) ◽

pp. 1337-1341 ◽

Cited By ~ 20

Author(s):

Angela L. Neville ◽

Denis Nemtsev ◽

Raed Manasrah ◽

Scott D. Bricker ◽

Brant A. Putnam

Keyword(s):

Blood Pressure ◽

Risk Stratification ◽

Systolic Blood Pressure ◽

Vital Signs ◽

Base Deficit ◽

Trauma Patients ◽

Arterial Lactate ◽

Urban Level ◽

Level I ◽

Elderly Trauma Patients

Elderly trauma patients have worse outcomes than their younger counterparts. Early risk stratification remains difficult, particularly because traditional vital signs are less reliable. We hypothesized that arrival lactate and base deficit (BD) could be used to predict mortality in elderly trauma patients with a normal admission blood pressure. We retrospectively evaluated the prospectively collected trauma registry at our urban Level I trauma center between 2003 and 2009. Patients sustaining blunt trauma, age 55 years or older, with a systolic blood pressure 90 mmHg or higher, and who had arterial lactate and/or BD measured within 4 hours of arrival comprised the study group. Primary outcomes were in-hospital and 24-hour mortality. There were 364 patients with a lactate and 324 with a BD drawn. Patients with a lactate 2.5 mmol or greater were 3.7 times more likely to die than those with a lactate less than 2.5 mmol (95% CI, 1.6 to 8.2; P = 0.0018). The OR for mortality was 5.2 (95% CI, 2.5 to 11.2; P < 0.0001) in patients with a BD -4 or less. Elevated lactate and BD were even stronger predictors of early mortality (within first 24 hours). After increasing the hypotension threshold to a systolic blood pressure 110 mmHg or greater, lactate and BD remained highly predictive of in-hospital and 24-hour mortality.

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Correlation Between ROTEM FIBTEM Maximum Clot Firmness and Fibrinogen Levels in Pediatric Cardiac Surgery Patients

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029618816382 ◽

2018 ◽

Vol 25 ◽

pp. 107602961881638 ◽

Cited By ~ 1

Author(s):

Christopher F. Tirotta ◽

Richard G. Lagueruela ◽

Danielle Madril ◽

Daria Salyakina ◽

Weize Wang ◽

...

Keyword(s):

Cardiac Surgery ◽

Linear Regression ◽

Linear Relationship ◽

Fibrinogen Level ◽

Linear Regression Analysis ◽

Plasma Fibrinogen ◽

Patient Specific ◽

Plasma Fibrinogen Level ◽

Positive Linear Relationship ◽

Maximum Clot Firmness

This study evaluated whether rotational thromboelastometry (ROTEM; Tem International GmbH, Munich, Germany) FIBTEM maximum clot firmness (MCF) can be used to predict plasma fibrinogen level in pediatric patients undergoing cardiac surgery. Linear regression was conducted to predict plasma fibrinogen level using FIBTEM MCF (0.05 level of significance). Scatter plot with the regression line for the model fit was created. Fifty charts were retrospectively reviewed, and 87 independent measurements of FIBTEM MCF paired with plasma fibrinogen levels were identified for analysis. Linear regression analysis suggested a significant positive linear relationship ( P < .0001) between plasma fibrinogen levels and MCF. Both MCF intercept and slope were significantly correlated with fibrinogen level ( P < .0001). The estimated regression equation (predicted fibrinogen = 78.6 + 12.4 × MCF) indicates that a 1-mm increase in MCF raises plasma fibrinogen level by an average of 12.4 mg/dL. The statistically significant positive linear relationship observed between MCF and fibrinogen levels ( P < .001) suggests that MCF can be used as a surrogate for fibrinogen level. This relationship is of clinical relevance in the calculation of patient-specific dosing of fibrinogen supplementation in this setting.

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Prophylactic Inferior Vena Cava Filters

The American Surgeon ◽

10.1177/0003134820950297 ◽

2020 ◽

pp. 000313482095029

Author(s):

Adel Elkbuli ◽

John D. Ehrhardt ◽

Kyle Kinslow ◽

Mark McKenney

Keyword(s):

Inferior Vena Cava ◽

Hospital Mortality ◽

Inferior Vena ◽

Head Injuries ◽

Vena Cava ◽

Trauma Patients ◽

Severely Injured ◽

Icu Length Of Stay ◽

Vena Cava Filters ◽

Injured Patients

Background Patients with major trauma and contraindications to anticoagulation are often considered candidates for a prophylactic inferior vena cava filter (IVCF). Prophylactic IVCFs are controversial in trauma and backed by varying levels of evidence. This study aims to analyze outcomes in severely injured patients who receive IVCFs. Methods A retrospective review of trauma patients aged ≥ 16 years with ISS ≥ 15 admitted to our level 1 trauma center from years 2013 through 2018. Patients were divided into 2 groups: prophylactic IVCF versus VTE chemoprophylaxis. The analysis evaluated demographics, stratified by ISS (15-24, 25-34, ≥35), and subgrouped those with AIS-Head ≥3. Adjusted outcome measures included DVT, PE, mortality, and ICU length-of-stay (ICU-LOS). Results The study sample included 413 patients with prophylactic IVCFs and 2487 on VTE chemoprophylaxis. IVCF placement was associated with higher severity injuries: ISS 28 versus 25 and lower GCS 10.0 versus 11.8, TBI prevalence 83% versus 68% ( P < .001). Patients with IVCFs had increased ICU-LOS (23.2 days vs 12.2 days), DVT (14.8% vs 4.3%), and PE (5.8% vs 1.6%) for patients with ISS <35 ( P < .001). ISS ≥35 was not associated with intergroup DVT or PE rate differences ( P = .81 and .43). No intergroup mortality differences were observed, including after ISS stratification. Among patients with AIS-Head ≥3, prophylactic IVCF was associated with lower in-hospital mortality (8.4% vs 15.7%, P = .001). Conclusions Prophylactic IVCF placement was associated with higher rates of DVT and nonfatal PE, and prolonged ICU-LOS. Prophylactic IVCF placement was not associated with increased in-hospital mortality for severely injured trauma patients. Among patients with concomitant critical head injuries (AIS-Head ≥3), prophylactic IVCF placement was associated with lower in-hospital mortality than VTE chemoprophylaxis.

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Malnutrition and its effects in severely injured trauma patients

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-020-01304-5 ◽

2020 ◽

Vol 46 (5) ◽

pp. 993-1004 ◽

Cited By ~ 2

Author(s):

Suzan Dijkink ◽

Karien Meier ◽

Pieta Krijnen ◽

D. Dante Yeh ◽

George C. Velmahos ◽

...

Keyword(s):

Nutritional Status ◽

Adverse Outcomes ◽

Hospital Length Of Stay ◽

Geriatric Trauma ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Trauma Population ◽

Injured Patients

Abstract Purpose In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to review the current knowledge about the pathophysiology, prevalence, and effects of malnutrition in severely injured patients. Methods A systematic literature review in PubMed and Embase was conducted according to PRISMA-guidelines. Results Nine review articles discussed the hypermetabolic state in severely injured patients in relation to malnutrition. In these patients, malnutrition negatively influenced the metabolic response, and vice versa, thereby rendering them susceptible to adverse outcomes and further deterioration of nutritional status. Thirteen cohort studies reported on prevalences of malnutrition in severely injured patients; ten reported clinical outcomes. In severely injured patients, the prevalence of malnutrition ranged from 7 to 76%, depending upon setting, population, and nutritional assessment tool used. In the geriatric trauma population, 7–62.5% were malnourished at admission and 35.6–60% were at risk for malnutrition. Malnutrition was an independent risk factor for complications, mortality, prolonged hospital length of stay, and declined quality of life. Conclusions Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, frequently of low-quality, and outdated. Based on the malnutrition-associated adverse outcomes, the nutritional status of trauma patients should be routinely and carefully monitored. Trials are required to better define the optimal nutritional treatment of trauma patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results.

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