Although our data suggest that 1:1 FFP:RBC reduced coagulopathy, this did not translate into a survival benefit. Our findings indicate that the relationship between coagulopathy and mortality is more complex, and further clinical investigation is necessary before recommending routine 1:1 in the exsanguinating trauma patient.

PPP is a rapid method for controlling pelvic fracture-related hemorrhage that can supplant the need for emergent angiography. There is a significant reduction in blood product transfusion after PPP, and this approach appears to reduce mortality in this select high-risk group of patients.

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blunt trauma admissions to our level I center, of which 643 underwent screening angiography for blunt CAI on the basis of a protocol including injury patterns and symptoms. Patients without contraindications underwent anticoagulation immediately for documented lesions.Setting: A state-designated, level I urban trauma center.Patients: Of the 643 patients undergoing screening angiography, 114 (18%) had confirmed CAI.Intervention: Early angiographic diagnosis and prompt anticoagulation.Main Outcome Measures: Diagnosis, stroke rate, and complications stratified by method of intervention.Results: A CAI was identified in 114 patients during the 7-year study period; the majority were men (71%), with a mean±SD age of 34±1.3 years and a mean±SD Injury Severity Score of 29±1.5. Seventy-three patients underwent anticoagulation after diagnosis (heparin in 54, lowmolecular-weight heparin in 2, antiplatelet agents in 17); none had a stroke. Of the 41 patients who did not receive anticoagulation (because of a contraindication in 27, symptoms before diagnosis in 9, and carotid coil or stent in 5), 19 patients (46%) developed neurologic ischemia. Ischemic neurologic events occurred in 100% of patients who presented with symptoms before angiographic diagnosis and those receiving a carotid coil or stent without anticoagulation.Conclusions: Our prospective evaluation of blunt CAIs suggests that early diagnosis and prompt anticoagulation reduce ischemic neurologic events and their disability. The optimal anticoagulation regimen, however, remains to be established.

Hypothesis: Early risk factors for hepatic-related morbidity in patients undergoing initial nonoperative management of complex blunt hepatic injuries can be accurately identified.Design: Multicenter historical cohort.Setting: Seven urban level I trauma centers.Patients: Patients from January 2000 through May 2003 with complex (grades 3-5) blunt hepatic injuries not requiring laparotomy in the first 24 hours. Intervention: Nonoperative treatment of complex blunt hepatic injuries.Main Outcome Measures: Complications and treatment strategies.Results: Of 699 patients with complex blunt hepatic injuries, 453 (65%) were treated nonoperatively. Overall, 61 patients (13%) developed 87 hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary-venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), which required 86 multimodality treatments (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy, 24; and laparoscopy, 4). Hepatic complications developed in 5% (13 of 264) of patients with grade 3 injuries, 22% (36 of 166) of patients with grade 4 injuries, and 52% (12 of 23) of patients with grade 5 injuries. Univariate analysis revealed 24-hour crystalloid, total and first 24-hour packed red blood cells, fresh frozen plasma, platelet, and cryoprecipitate requirements and liver injury grade to be significant but only liver injury grade (grade 4 odds ratio, 4.439; grade 5 odds ratio, 12.001) and 24-hour transfusion requirement (odds ratio, 6.446) predicted complications by multivariable analysis.Conclusions: Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury. Screening patients with transfusion requirements and high-grade injuries may result in earlier diagnosis and treatment of hepatic-related complications.

The effect of obesity in predisposing to hypertension, cardiovascular diseases, and type 2 diabetes is serving to negate the gains in life expectancy achieved over the past decades. A meta-analysis of 40 studies involving 250,152 patients with coronary artery disease has demonstrated that low BMI (Ͻ20.0 kg/m 2 ) is associated with higher total and cardiovascular mortality than patients with normal BMI (range, 20.0-24.9 kg/m 2 ). In fact, total and cardiovascular mortality was lowest among those who are overweight but not obese, defined as a BMI between 25.0 and 29.9 kg/m 2 (Lancet 2006;368:666-78).In this study, the authors explored the relationship between BMI and cardiovascular events in patients enrolled in the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) study. CHARISMA was a multinational double-blinded, placebo-controlled, randomized, clinical trial that evaluated the efficacy of clopidogrel in patients with atherothrombotic disease or multiple risk factors for atherothrombotic disease who were also receiving aspirin. This is a subanalysis of the CHARISMA data stratified for BMI. Primary end points included cardiovascular death, myocardial infarction, or stroke as well as all-cause mortality and bleeding complications. Follow-up was for a median of 28 months. Varying the patients with the highest BMI quartile to those with the lowest BMI quartile, the primary end point, cardiovascular, and all-cause mortality all were more frequent in those in the lowest BMI quartile. The cutoff for all cause mortality and continuous BMI was 29.9 kg/m 2 .Comment: The relationship between BMI and cardiovascular outcomes is surprisingly complex. Mortality rates in the general population are highest among those who are overweight and underweight. In the Physicians' Health Study of 5010 middle-aged men, relative risk for all-cause mortality was 1.4 among those who had a BMI Ͻ22.0 kg/m 2 compared with those with BMIs between 22 and 24.9 kg/m 2 (Arch Intern Med 2004;164:2326-32). It may be that the relationship between obesity and mortality differs between individuals with and without cardiovascular disease. Certainly the data do not imply obesity is protective in patients with cardiovascular disease, but it does appear that being underweight is detrimental to those with cardiovascular disease.