J Trauma
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Randomized Controlled Trial Multicenter Study Comparative Study
Global differences in causes, management, and survival after severe trauma: the recombinant activated factor VII phase 3 trauma trial.
Little is known about international variation in mortality after severe trauma. This study examines variation in mortality, injury severity, and case management among countries from a recent prospective multinational trauma trial. ⋯ Considering international variation in mortality when designing or interpreting results from multinational trauma studies is important. Significant differences in mortality persisted between patients from different countries after case mix and case management adjustment. Adherence to clinical guidelines was associated with improved survival. Stratification, case mix adjustment, and use of guidelines on damage control surgery, transfusion, and ventilation may mitigate country-driven variation in mortality.
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It remains to be determined whether spine-targeted computed tomography (thoracolumbar spine computed tomography [TLS-CT]) images and visceral organ-targeted CT (abdominopelvic [AP]-CT) images are comparable for the evaluation of thoracolumbar spinal fractures using 16-channel multidetector row CT. The elimination of an additional spine-targeted CT protocol would substantially reduce time, the storage burden, and potential patient radiation exposure. ⋯ Sixteen-channel multidetector row CT images reconstructed using a soft algorithm and a wide display FOV that cover the entire abdomen using a visceral organ-targeted protocol with 1.5-mm collimation are sufficient for the evaluation of spine fractures in trauma patients, given that multiplanar-reformatted images are provided.
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Previous studies have demonstrated that the transfusion of older blood is independently associated with higher rates of infectious complications, multiple organ failure, and mortality. Putative mechanisms implicate leukocytes in stored blood that generate immunomodulatory mediators as the stored blood ages. The purpose of this retrospective cohort study was to describe the effect of prestorage leukoreduction (PS-LR) on the detrimental clinical effects of increasing age on blood products used in trauma patients. ⋯ Our data suggest that the deleterious effects of aging on banked blood are ameliorated by PS-LR. We are currently conducting a prospective observational study in an effort to duplicate the findings of this retrospective investigation.
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Long-duration blasts are an increasing threat with the expanded use of thermobaric and other novel explosives. Other potential long-duration threats include large explosions from improvised explosive devices, weapons caches, and other explosives including nuclear explosives. However, there are very few long-duration pulmonary blast injury assessments, and use of short-duration exposure injury metrics is inappropriate as the injury mechanism for long-duration exposures is likely different from that of short-duration exposures. ⋯ New injury risk assessment curves were determined for both incident and reflected pressure conditions for reflecting surface and free-field exposures. Position dependent injury risk curves were also determined. The resulting curves are an improvement to existing assessments, because they use actual data to demonstrate theoretical assumptions on the injury risk.
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Two prospective randomized trauma trials have shown recombinant factor VIIa (rFVIIa) to be safe and to decrease transfusion requirements. rFVIIa is presently used in 22% of massively transfused civilian trauma patients. The US Military has used rFVIIa in combat trauma patients for five years, and two small studies of massively transfused patients described an association with improved outcomes. This study was undertaken to assess how deployed physicians are using rFVIIa and its impact on casualty outcomes. ⋯ In military casualties, rFVIIa is used in the most severely injured patients based on physician selection rather than on guideline criteria. Use of rFVIIa is not associated with an improvement in survival or an increase in complications. The undetected bias of physician selection of patients for treatment with rFVIIa, likely, has an impact on case matching to achieve equivalence similar to that of randomized control studies. This inability to match populations, thus, prevents definitive interpretation of this study and others studies of similar design. This problem emphasizes the need to develop entry criteria to identify patients who could potentially benefit from use of rFVIIa and the need to subsequently perform efficacy studies.