No abstract

: III.

A significant portion of patients sustaining traumatic brain injury (TBI) take antiplatelet medications (aspirin or clopidogrel), which have been associated with increased morbidity and mortality. In an attempt to alleviate the risk of increased bleeding, platelet transfusion has become standard practice in some institutions. This study was designed to determine if platelet transfusion reduces mortality in patients with TBI on antiplatelet medications. Databases from two Level I trauma centers were reviewed. Patients with TBI 50 years of age or older with documented preinjury use of clopidogrel or aspirin were included in our cohort. Patients who received platelet transfusions were compared with those who did not to assess outcome differences between them. Demographics and other patient characteristics abstracted included Injury Severity Score, Glasgow Coma Scale, hospital length of stay, and warfarin use. Three hundred twenty-eight patients comprised the study group. Of these patients, 166 received platelet transfusion and 162 patients did not. Patients who received platelets had a mortality rate of 17.5 per cent (29 of 166), whereas those who did not receive platelets had a mortality rate of 16.7 per cent (27 of 162) ( P = 0.85). Transfusion of platelets in patients with TBI using antiplatelet therapy did not reduce mortality.

Injury grade is a predictor of ARM among patients with BTAIs. Aggressive use of the current Society for Vascular Surgery Clinical Practice Guidelines at a busy level I trauma center resulted in low rates of ARM. In this setting, identification of additional physiologic and radiographic criteria indicating the need for emergency (vs urgent) repair of aortic pseudoaneurysms remains elusive.

In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among military personnel with combat-related injuries. Our analysis expands on a prior 6-month evaluation and assesses CPG adherence with respect to antimicrobial prophylaxis for U.S. combat casualties medically evacuated to Landstuhl Regional Medical Center over a 1-year period (June 2009 through May 2010), with an eventual goal of continuously monitoring CPG adherence and measuring outcomes as a function of compliance. We classified adherence to the CPG as receipt of recommended antimicrobials within 48 hours of injury. A total of 1106 military personnel eligible for CPG assessment were identified and 74% received antimicrobial prophylaxis. Overall, CPG compliance within 48 hours of injury was 75%. Lack of antimicrobial prophylaxis contributed 2 to 22% to noncompliance varying by injury category, whereas receipt of antibiotics other than preferred was 11 to 30%. For extremity injuries, antimicrobial prophylaxis adherence was 60 to 83%, whereas it was 80% for closed injuries and 68% for penetrating abdominal injuries. Overall, the results of our analysis suggest an ongoing need to improve adherence, monitor CPG compliance, and assess effectiveness.

Objective Rational development of technology for rapid control of non-compressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) versus open (OPEN) management. Methods Retrospective study of adult trauma patients with NCTH admitted to 4 urban level 1 trauma centers in the Houston and San Antonio metropolitan areas in 2008–2012. Inclusion criteria: named axial torso vessel disruption, AIS chest or abdomen ≥3 with shock (base excess <−4) or truncal operation in ≤90 minutes, or pelvic fracture with ring disruption. Exclusion criteria: isolated hip fractures, falls from standing, or prehospital CPR. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, ISS, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients. Results 543 patients with NCTH underwent ENDO (n=166, 31%), OPEN (n=309, 57%), or RT (n=68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, while OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs 34% vs 32%); severe injuries (median ISS 34 vs 27 vs 21), and increased time to intervention (median 298 vs 92 vs 51 min), compared to OPEN and RT. Mortality was 15% vs 20% vs 79%. ENDO was associated with decreased mortality compared to OPEN (RR 0.58, 95% CI 0.46–0.73). Conclusion Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding. Level of Evidence Level V (Prognostic and Epidemiologic)

Prognostic/epidemiologic study, level III; therapeutic/care management study, level IV.

Epidemiologic study, level III.