scholarly journals Impact of Crystalloid to PRBC Ratio in Patients with Exsanguinating Penetrating Abdominal Injuries: The Conundrum of Resuscitation

2013 ◽  
Vol 2 (1) ◽  
pp. 52-57
Author(s):  
Marie Unruh ◽  
Marquinn Duke ◽  
Peter Meade ◽  
Norman E McSwain ◽  
Juan C Duchesne
Keyword(s):  
Logistic Regression ◽  
Trauma Center ◽  
Survival Benefit ◽  
High Ratio ◽  
Abdominal Injuries ◽  
Hemostatic Resuscitation ◽  
Level 1 ◽  
Overall Survival Benefit ◽  
The Impact ◽  
Level 1 Trauma Center

ABSTRACT Background When intraoperative hemostatic resuscitation (IHR) implements high transfusion ratios of FFP:PRBC (>1:2), there is an associated increased survival in patients with exsanguinating penetrating abdominal injuries (EPAI). The impact of crystalloids: PRBC during IHR has not been analyzed. We hypothesize that minimizing the amount of intraoperative crystalloids:PRBC in combination with high ratio FFP: PRBC will correlate with a survival benefit in patients with EPAI. Methods This was a 9-year retrospective analysis of patients with EPAI at a Level 1 Trauma Center. EPAI was defined as any patient who received >20 units of PRBC during IHR. Intraoperative ratio for FFP:PRBC was recorded, and patients were placed in three separate categories accordingly: high (>1:2), mid (1:4 - 1:2), and low ratio (<1:4) groups. Quantity of crystalloids used during each category was recorded and a ratio of crystalloids:PRBC calculated. Logistic regression model was applied to analyze impact of crystalloid:PRBC on mortality, comparing the high FFP:PRBC ratio group to the low FFP: PRBC ratio group. Results Intraoperative high ratio FFP:PRBC conveyed a 32% overall survival benefit when compared with low ratio groups. Patients that received a high ratio FFP:PRBC when compared to low ratio group, received less intraoperative crystalloids (calculated crystalloids:PRBC ratios 1:3.4 vs 1:1.1; p = 0.001). Our logistic regression demonstrated a survival benefit with a high FFP:PRBC [OR 95%;0.19 , CI (0.05-0.33), p = 0.003] and the calculated low crystalloid:PRBC [OR 95%; 0.11 CI (0.01- 0.59), p = 0.001]. Conclusion We were able to demonstrate a survival advantage in patients with EPAI that received IHR of a high ratio of FFP:PRBC and a low ratio of crystalloids:PRBC. These findings suggest that in patients with EAPI requiring massive volumes of PRBC, the ratio of intraoperative FFP:PRBC should be high and crystalloids:PRBC should be low. How to cite this article Guidry C, Unruh M, Duke M, Meade P, McSwain NE Jr, Duchesne JC. Impact of Crystalloid to PRBC Ratio in Patients with Exsanguinating Penetrating Abdominal Injuries: The Conundrum of Resuscitation. Panam J Trauma Critical Care Emerg Surg 2013;2(1):52-57.

scholarly journals Identifying trauma patients with benefit from direct transportation to Level-1 trauma centers

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Charlie A. Sewalt ◽  
Benjamin Y. Gravesteijn ◽  
Daan Nieboer ◽  
Ewout W. Steyerberg ◽  
Dennis Den Hartog ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Trauma Center ◽  
Trauma Patients ◽  
Trauma Centers ◽  
Absolute Benefit ◽  
Predicted Probability ◽  
Prehospital Triage ◽  
Level 1 ◽  
Level 1 Trauma Center ◽  
Level 2

Abstract Background Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. Methods We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. Results We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92–0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%). Conclusions Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.

scholarly journals Effect of American College of Surgeons Level 1 Trauma Center Designation on Management of Adult Severe TBI Patients

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Matthew Helton ◽  
Austin Porter ◽  
Kevin Thomas ◽  
Jeffrey C Henson ◽  
Mason Sifford ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Patient Outcomes ◽  
Trauma Center ◽  
Trauma Centers ◽  
Cranial Surgery ◽  
American College Of Surgeons ◽  
Severe Tbi ◽  
Level 1 ◽  
The Impact ◽  
Level 1 Trauma Center

Abstract INTRODUCTION Severe traumatic brain injury (TBI) remains a leading cause of morbidity and mortality. There is a wide variability in treatment paradigm for patients with severe TBI. American College of Surgeons (ACS) level 1 trauma centers have access to 24 h neurosurgical coverage. In this study, we use the National Trauma Database (NTDB) to evaluate if ACS trauma center designation correlates with the management and outcomes of severe TBI in adults. METHODS Adult patients (<65 yr) with a severe isolated nonpenetrating TBI were identified in the NTDB from years 2007 to 2014. ICD-9 procedure codes were used to identify primary treatment approaches: intracranial pressure monitoring and cranial surgery. Multivariate logistic regression was used to determine the impact of ACS designation on procedures and patient outcomes. Patient and injury characteristics were included in the analysis. RESULTS A total of 54 769 TBI patients were identified. Among those, 22 316 (42%) were treated at an ACS level 1 trauma center and 31 835 (58%) were treated elsewhere. Level 1 designated patients had significantly more intracranial pressure (ICP) monitors placed (12.3% vs10.8%; P < .0001) and more cranial surgeries performed (17.7% vs 15.7%; P < .0001). A greater percentage of patients were admitted to the intensive care unit (ICU; 89.9% vs 83.9%; P < .0001) and had a longer hospital stay (16.1 vs 15.2; P < .0001) at ACS level 1 trauma centers. In a regression analysis, patients at level 1 centers were associated with a 14% and 17% increased odds of obtaining a cranial surgery or ICP monitor, respectively. Patients treated at a level 1 center were associated with a 6% decrease in odds of mortality (P = .01). CONCLUSION ACS level 1 designation did correlate with increased rates of neurosurgical intervention and ICU admissions. This translated into patient outcomes as those treated at level 1 facilities were associated with lower rates of mortality.

scholarly journals (P2-74) Does Implementation of Protocols Improve the Red Area Disposition Time of Emergency Department at a Level-1 Trauma Center?

2011 ◽  
Vol 26 (S1) ◽  
pp. s160-s160
Author(s):  
R. Kumar ◽  
K. Shyamla ◽  
S. Bhoi ◽  
T.P. Sinha ◽  
S. Chauhan ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Emergency Department ◽  
Trauma Center ◽  
Safety Issues ◽  
Ed Visits ◽  
Level 1 ◽  
The Impact ◽  
Level 1 Trauma Center ◽  
Final Disposition ◽  
Disposition Time

BackgroundAcute care addresses immediate resuscitation and early disposition to definitive care. Delay in final disposition from the emergency department (ED) affects outcomes in terms of morbidity and mortality. An audit was performed to assess the impact of protocols on red area disposition time.MethodsAn audit of red (resuscitation) area disposition time was performed among patients with compromised airway, breathing, and circulation. The red area disposition time was defined as the time from ED arrival to red area disposition. Pre-protocol data from nursing report books were reviewed for ED to operating room (OR), ED to intensive care unit (ICU), and overall disposition time between September 2007 and January 2008. Similar outcomes were documented after implementation of protocols during February to December 2008.ResultsIn the pre-protocol period, 992 red area patients were enrolled out of 10,000 ED visits. Out of which 527 (53.1%) were shifted to the OR and 222 (22.3%) to ICU. The average ED disposition time was 3.5 hours (range 2–5). Similarly, 1797 red area patients were enrolled in the post-protocol period out of 25,928. Of these, 453 (25.2%) patients were shifted to the OR, and 423 (23.7%) were shifted to the ICU. The average ED disposition time was 1.5 hours (range 10 minutes–3 hours).ConclusionsImplementation of protocols improves the red area disposition time of the ED. Auditing is an important tool to address patient safety issues.

B-17 The impact of a hospital-based air ambulance program on a level 1 trauma center

1987 ◽  
Vol 2 (5) ◽  
pp. 36
Author(s):  
Kevin Fitzpatrick ◽  
Joseph A. Moylan ◽  
Gregory Georgiade ◽  
Rita Weber
Keyword(s):  
Trauma Center ◽  
Air Ambulance ◽  
Level 1 ◽  
The Impact ◽  
Level 1 Trauma Center

Early Prognostication after Traumatic Brain Injury: Specific Validation of the IMPACT Prognostic Calculator in a Level 1 Trauma Center

2019 ◽  
Vol 80 (06) ◽  
pp. 423-429
Author(s):  
Anna Jung ◽  
Felix Arlt ◽  
Maciej Rosolowski ◽  
Jürgen Meixensberger
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Trauma Center ◽  
Roc Analysis ◽  
Time Frame ◽  
Extended Model ◽  
Severe Tbi ◽  
Level 1 ◽  
The Impact ◽  
Level 1 Trauma Center

AbstractThe present study evaluated the usefulness of the IMPACT prognostic calculator (IPC) for patients receiving acute neurointensive care at a level 1 trauma center in Germany. A total of 139 patients with traumatic brain injury (TBI) were assessed. One day after trauma, the extended model of the IPC was found to provide the most valid prediction of 6-month mortality/unfavorable outcome. Different time frames within the first day could be determined by analyzing mild, moderate, and severe TBI cohorts. The CORE + CT model at time frame Z2 (<6 h from the point of first documentation) for mild TBI exhibited the highest values in the receiver operating characteristic (ROC) analysis (area under the curve [AUC], 0.9; sensitivity, 1; specificity, 0.7). For patients with moderate head injury at time frame Z2/3 (<6–12 h from point of first documentation), the extended model fit best. For patients with severe TBI, the extended model at time frame Z6 (48–72 h from point of first documentation) best predicted 6-month mortality and unfavorable outcome (ROC analysis: AUC, 0.542/0.445; sensitivity, 0.167/0.364; specificity, 0.575/0.444). Center-specific validation demonstrated the validity of the IPC in the early phase after TBI. These findings support the usefulness of the IPC for predicting the prognosis of patients with TBI. However, further prospective validation using a larger TBI cohort is needed.

scholarly journals The impact of the “Weekend Effect” on emergency exploratory laparotomy surgeries outcomes at an urban level 1 trauma center

2020 ◽  
Vol 13 (3) ◽  
pp. 232
Author(s):  
Adel Elkbuli ◽  
Sarah Zajd ◽  
Brianna Dowd ◽  
Shaikh Hai ◽  
Dessy Boneva ◽  
...  
Keyword(s):  
Trauma Center ◽  
Exploratory Laparotomy ◽  
Weekend Effect ◽  
Urban Level ◽  
Level 1 ◽  
The Impact ◽  
Level 1 Trauma Center

scholarly journals Minor change in initial PEEP setting decreases rates of ventilator-associated events in mechanically ventilated trauma patients

2020 ◽  
Vol 5 (1) ◽  
pp. e000455
Author(s):  
Ethan Ferrel ◽  
Kristina M Chapple ◽  
Liviu Gabriel Calugaru ◽  
Jennifer Maxwell ◽  
Jessica A Johnson ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Injury Severity ◽  
Trauma Patients ◽  
Trauma Centers ◽  
Level Of Evidence ◽  
Mechanically Ventilated ◽  
Change In Practice ◽  
Level 1 ◽  
The Impact ◽  
Level 1 Trauma Center

BackgroundSurveillance of ventilator-associated events (VAEs) as defined by the National Healthcare Safety Network (NHSN) is performed at many US trauma centers and considered a measure of healthcare quality. The surveillance algorithm relies in part on increases in positive end-expiratory pressure (PEEP) to identify VAEs. The purpose of this cohort study was to evaluate the effect of initiating mechanically ventilated trauma patients at marginally higher PEEP on incidence of VAEs.MethodsAnalysis of level-1 trauma center patients mechanically ventilated 2+ days from 2017 to 2018 was performed after an institutional ventilation protocol increased initial PEEP setting from 5 (2017) to 6 (2018)cm H2O. Incidence of VAEs per 1000 vent days was compared between PEEP groups. Logistic regression modelling was performed to evaluate the impact of the PEEP setting change adjusted to account for age, ventilator days, injury mechanism and injury severity.Results519 patients met study criteria (274 PEEP 5 and 245 PEEP 6). Rates of VAEs were significantly reduced among patients with initial PEEP 5 versus 6 (14.61 per 1000 vent days vs. 7.13 per 1000 vent days; p=0.039). Logistic regression demonstrated that initial PEEP 6 was associated with 62% reduction in VAEs.ConclusionsOur data suggest that an incrementally increased baseline PEEP setting was associated with a significantly decreased incidence of VAEs among trauma patients. This minor change in practice may have a major impact on a trauma center’s quality metrics.Level of evidenceIV.

scholarly journals Patterns, Management, and Outcome of Traumatic Femur Fracture: Exploring the Experience of the Only Level 1 Trauma Center in Qatar

2021 ◽  
Vol 18 (11) ◽  
pp. 5916
Author(s):  
Syed Imran Ghouri ◽  
Mohammad Asim ◽  
Fuad Mustafa ◽  
Ahad Kanbar ◽  
Mohamed Ellabib ◽  
...  
Keyword(s):  
Intramedullary Nailing ◽  
Trauma Center ◽  
Femur Fracture ◽  
Femoral Shaft ◽  
Femoral Shaft Fractures ◽  
Shaft Fractures ◽  
Level 1 ◽  
The Impact ◽  
Complications And Mortality ◽  
Level 1 Trauma Center

Background: Femur is the most fractured long bone in the body that often necessitates surgical fixation; however, data on the impact of the mechanism of injury (MOI), age, and timing of intervention are lacking in our region of the Arab Middle East. We aimed to describe the patterns, management, and outcome of traumatic femoral shaft fractures. Methods: A retrospective descriptive observational study was conducted for all trauma patients admitted with femoral shaft fractures between January 2012 and December 2015 at the only level 1 trauma center and tertiary hospital in the country. Data were analyzed and compared according to the time to intervention (intramedullary nailing; IMN), MOI, and age groups. Main outcomes included in-hospital complications and mortality. Results: A total of 605 hospitalized cases with femur fractures were reviewed. The mean age was 30.7 ± 16.2 years. The majority of fractures were unilateral (96.7%) and 91% were closed fractures. Three-fourths of fractures were treated by reamed intramedullary nailing (rIMN), antegrade in 80%. The pyriform fossa nails were used in 71.6% while trochanteric entry nails were used in 28.4%. Forty-five (8.9%) fractures were treated with an external fixator, 37 (6.1%) had conservative management. Traffic-related injuries occurred more in patients aged 14–30 years, whereas fall-related injuries were significantly higher in patients aged 31–59. Thirty-one patients (7.8%) had rIMN in less than 6 h post-injury, 106 (25.5%) had rIMN after 6–12 h and 267 (66.8%) had rIMN after more than 12 h. The implant type, duration of surgery, DVT prophylaxis, in-hospital complications, and mortality were comparable among the three treatment groups. Conclusions: In our center, the frequency of femoral fracture was 11%, and it mainly affected severely injured young males due to traffic-related collisions or falls. Further multicenter studies are needed to set a consensus for an appropriate management of femur fracture based on the MOI, location, and timing of injury.

Sign in / Sign up

Export Citation Format

Share Document