Background Observational studies have demonstrated improved outcomes in TBI patients receiving in-hospital betablockers. The aim of this study is to conduct a randomized controlled trial examining the effect of beta-blockers on outcomes in TBI patients. Methods Adult patients with severe TBI (intracranial AIS C 3) were included in the study. Hemodynamically stable patients at 24 h after injury were randomized to receive either 20 mg propranolol orally every 12 h up to 10 days or until discharge (BB?) or no propranolol (BB-). Outcomes of interest were in-hospital mortality and Glasgow Outcome Scale-Extended (GOS-E) score on discharge and at 6-month follow-up. Subgroup analysis including only isolated severe TBI (intracranial AIS C 3 with extracranial AIS B 2) was carried out. Poisson regression models were used. Results Two hundred nineteen randomized patients of whom 45% received BB were analyzed. There were no significant demographic or clinical differences between BB ? and BBcohorts. No significant difference in inhospital mortality (adj. IRR 0.6 [95% CI 0.3-1.4], p = 0.2) or long-term functional outcome was measured between the cohorts (p = 0.3). One hundred fifty-four patients suffered isolated severe TBI of whom 44% received BB. The BB ? group had significantly lower mortality relative to the BBgroup (18.6% vs. 4.4%, p = 0.012). On regression analysis, propranolol had a significant protective effect on in-hospital mortality (adj. IRR 0.32, p = 0.04) and functional outcome at 6-month follow-up (GOS-E C 5 adj. IRR 1.2, p = 0.02). Conclusion Propranolol decreases in-hospital mortality and improves long-term functional outcome in isolated severe TBI. This randomized trial speaks in favor of routine administration of beta-blocker therapy as part of a standardized neurointensive care protocol. Level of evidence Level II; therapeutic.

INTRODUCTION Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients. METHODS We analyzed the (2015–2016) Trauma Quality Improvement Program. We included adult (age, ≥18 years) trauma patients presenting with hemorrhagic shock and requiring at least 1 U of packed red blood cells (pRBCs) within 4 hours. Patients were stratified into WB-CT versus CT only. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were hospital length of stay and major complications. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS A total of 8,494 patients were identified, of which 280 received WB-CT (WB, 1 [1–1]; pRBC, 16 [10–23]; FFP, 9 [6–16]; platelets, 3 [2–5]) and 8,214 received CT only (pRBC, 15 [10–24]; FFP, 10 [6–16]; platelets, 2 [1–4]). Mean ± SD age was 34 ± 16 years, 79% were male, Injury Severity Score was 33 (24–43), and 63% had penetrating injuries. Patients who received WB-CT had a lower 24-hour mortality (17% vs. 25%; p = 0.002), in-hospital mortality (29% vs. 40%; p < 0.001), major complications (29% vs. 41%; p < 0.001), and a shorter length of stay (9 [7–12] vs. 15 [10–21]; p = 0.011). On regression analysis, WB was independently associated with reduced 24-hour mortality (odds ratio [OR], 0.78 [0.59–0.89]; p = 0.006), in-hospital mortality (OR, 0.88 [0.81–0.90]; p = 0.011), and major complications (OR, 0.92 [0.87–0.96]; p = 0.013). CONCLUSION The use of WB as an adjunct to CT is associated with improved outcomes in resuscitation of severely injured civilian trauma patients. Further studies are required to evaluate the role of adding WB to massive transfusion protocols. LEVEL OF EVIDENCE Therapeutic, level IV.

Objectives: Examine the effect of different types of firearms on readmission due to acute stress disorder (ASD) and/or post-traumatic stress disorder (PTSD) in firearm-injury victims. Background: Survivors of firearm-related injuries suffer long-term sequelae such as disability, work loss, and deterioration in the quality of life. There is a paucity of data describing the long-term mental health outcomes in these patients. Methods: We performed a 5-year (2011–2015) analysis of the Nationwide Readmission Database. All adult patients with firearm injuries were stratified into 3 groups by firearm type: handgun, shotgun, and semiautomatic rifle. Outcome measures were the incidence and predictors of ASD/PTSD. Results: A total of 100,704 victims of firearm-related injuries were identified, of which 13.3% (n = 13,393) were readmitted within 6 months of index hospitalization, 6.7% (n = 8970) of these due to ASD/PTSD. Mean age was 34 ± 14 years, 88% were men. Of those readmitted due to ASD/PTSD, 24% (n = 2153) sustained a handgun-related injury on index hospitalization, 12% (n = 1076) shotgun, and 64% (n = 5741) semiautomatic gun (P = 0.039). On regression analysis, semiautomatic gun and shotgun victims had higher odds of developing ASD/PTSD upon readmission [odds ratio (OR): 2.05 (1.10–4.12) and OR: 1.41 (1.08–2.11)] compared to handgun. Female sex [OR: 1.79 (1.05–3.05)] and younger age representing those younger than 25 years [OR: 4.66 (1.12–6.74)] were also independently associated with higher odds of ASD/PTSD. Conclusions: Apart from the lives lost, survivors of semiautomatic rifle- and shotgun-related injuries suffer long-term mental health sequalae. These secondary and debilitating mental health outcomes are important considerations for capturing the overall burden of the disease.

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, B. (2019). Is early chemical thromboprophylaxis in patients with solid organ injury a solid decision?.