Looking Beyond Hospital Discharge: One-Year Mortality Following Tracheostomy Creation in Traumatically Injured Older Adults.

Introduction: We aimed to evaluate long-term outcomes following tracheostomy in older trauma patients and hypothesized that 1-year survival decreases with older age.

Methods: This was a descriptive analysis of intensive care unit patients ≥65 y old who underwent tracheostomy from 2015 to 2020. The National Death Index was accessed to determine time from tracheostomy creation to death.

Pre-injury statin therapy is associated with lower VTE after traumatic brain injury.

Background: Hemorrhage progression is a potentially devastating complication after TBI, mandating delay to VTE prophylaxis in high-risk patients. Statins have endothelial stabilizing effects associated with decreased VTE in other populations.

Objective: To explore whether prehospital statin exposure is associated with decreased incidence of VTE in TBI.

Intent Versus Execution: Failure to Achieve Balanced Resuscitation in Bleeding Trauma Patients.

Objectives: To evaluate the adherence to balanced resuscitation in the first 4 hours, and how whole blood (WB) affected the achievement of these ratios.

Background: In 2014, TQIP Best Practices recommended balanced resuscitation in a 1:1:1 (RBC:FFP:PLT) ratio. A subsequent randomized trial demonstrated a reduction in mortality with 1:1:1 in hemorrhaging trauma patients.

The effect of prehospital blood products on unexpected survival: A multi-institution study.

Background: Survival prediction models use arrival vital signs, rather than prehospital (PH) vital signs to estimate expected survival of injured patients. Prehospital blood product transfusion (PHBPT) has been associated with improvement in shock index (SI) during transport. The objective of this study was to examine the effect of PHBPT on expected and observed survival.

Where does cryoprecipitate fit into balanced resuscitation? An evaluation of 2,117 hemorrhaging patients using viscoelastic-based resuscitation.

Background: Empiric cryoprecipitate administration has recently failed to show survival benefit in hemorrhaging trauma patients. However, a recent Trauma Quality Improvement Program query suggested a survival benefit in massive transfusions when administering 1 U of cryoprecipitate to every 7 to 8 U of red blood cells (RBCs). We describe transfusion ratios when cryoprecipitate was indicated by viscoelastic testing (VET) and evaluated whole blood (WB)'s impact on this ratio.

Decrease in Total Leukocyte Count is Associated with Acute Kidney Injury After Severe Burn.

Leukocytosis is common after burn injury from profound systemic inflammatory response. Total leukocyte count (TLC) often decreases 72-96 h post-injury. The incidence of early (<72 h) leukopenia has not been previously described; this analysis sought to determine if early and extreme decreases in TLC were associated with increased fluid requirements or resuscitation-related outcomes in patients after burn injury.

Joint Trauma System: Behind the Scenes.

The Joint Trauma System was created out of a crucial need for the integration of battlefield medicine. The Joint Trauma System supports the execution and advancement of combat casualty care throughout the continuum of care by medical and nonmedical providers, leaders, and commanders at all levels.

Impact of Massive Transfusion Activation on Time to Delivery of the First Cooler and Patient Survival: A Study of 4,313 Consecutive Activations.

Background: In 2012, TQIP guidelines for massive transfusion protocols (MTPs) recommended delivery of blood product coolers within 15 minutes. Subsequent work found that every minute delay in cooler arrival was associated with a 5% increased risk of mortality. We sought to assess the impact and sustainability of quality improvement (QI) interventions on time to MTP cooler delivery and their association with trauma patient survival.

The inability to predict futility in hemorrhaging trauma patients using 4-hour transfusion volumes and rates.

Background: Blood shortages and utilization stewardship have motivated the trauma community to evaluate futility cutoffs during massive transfusions (MTs). Recent single-center studies have confirmed meaningful survival in ultra-MT (≥20 U) and super-MT (≥50 U), while others advocate for earlier futility cut points. We sought to evaluate whether transfusion volume and intensity cut points could predict 100% mortality in a multicenter analysis.

DOES WHOLE BLOOD RESUSCITATION INCREASE RISK FOR VENOUS THROMBOEMBOLISM IN TRAUMA PATIENTS? A COMPARISON OF WHOLE BLOOD VERSUS COMPONENT THERAPY IN 3,468 PATIENTS.

Background: Whole blood (WB) resuscitation has been shown to provide mortality benefit. However, the impact of whole blood transfusions on the risk of venous thromboembolism (VTE) remains unclear. We sought to compare the VTE risk in patients resuscitated with WB versus component therapy (COMP).

Neurologic Complications Associated With Burn Injury and Resuscitation.

Background: Treatment for large burn injuries relies on adequate fluid resuscitation secondary to the severe systemic inflammatory response. With improved critical care and better understanding of the complications of over and under resuscitation, morbidity and mortality rates are decreasing. Neurologic complications are not often considered as an over-resuscitation complication after burn injury but may be considered an additional form of compartment syndrome-intracranial compartment syndrome; however, it has not been evaluated for a possible threshold similar to the Ivy Index for abdominal compartment syndrome.

Are trauma centers penalized for improved prehospital resuscitation?: The effect of prehospital transfusion on arrival vitals and predicted mortality.

Background: Prediction models for survival in trauma rely on arrival vital signs to generate survival probabilities. Hospitals are benchmarked on expected and observed outcomes. Prehospital blood (PB) transfusion has been shown to improve mortality, which may affect survival prediction modeling.

The thin red line: Blood planning factors and the enduring need for a robust military blood system to support combat operations.

Battlefield lessons learned are forgotten; the current name for this is the Walker Dip. Blood transfusion and the need for a Department of Defense Blood Program are lessons that have cycled through being learned during wartime, forgotten, and then relearned during the next war. The military will always need a blood program to support combat and contingency operations.

A Joint Trauma System Clinical Practice Guideline: Traumatic Brain Injury Management and Basic Neurosurgery in the Deployed Environment.

Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. These challenges are magnified while forward deployed in austere or hostile environments. This Joint Trauma System Clinical Practice Guideline provides recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources, and follow-on care are limited.

'Door-to-prophylaxis' as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury.

Objective: Venous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis would be the strongest modifiable risk for VTE, even after adjusting for competing risk factors.

Methods: A prospectively maintained trauma registry was queried for patients admitted July 2017-October 2021 who were 18 years and older and received emergency release blood products.

Exposure to statin therapy decreases the incidence of venous thromboembolism after trauma.

Introduction: Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in trauma patients, despite chemoprophylaxis. Statins have been shown capable of acting upon the endothelium. We hypothesized that statin therapy in the pre- or in-hospital settings leads to a decreased incidence of VTE.

Resuscitation and Care in the Trauma Bay.

Start balanced resuscitation early (pre-hospital if possible), either in the form of whole blood or 1:1:1 ratio. Minimize resuscitation with crystalloid to minimize patient morbidity and mortality. Trauma-induced coagulopathy can be largely avoided with the use of balanced resuscitation, permissive hypotension, and minimized time to hemostasis.

Empiric Cryoprecipitate Transfusion in Patients with Severe Hemorrhage: Results from the US Experience in the International CRYOSTAT-2 Trial.

Background: Hypofibrinogenemia has been shown to predict massive transfusion and is associated with higher mortality in severely injured patients. However, the role of empiric fibrinogen replacement in bleeding trauma patients remains controversial. We sought to determine the effect of empiric cryoprecipitate as an adjunct to a balanced transfusion strategy (1:1:1).

Hypofibrinogenemia following injury in 186 children and adolescents: identification of the phenotype, current outcomes, and potential for intervention.

Objectives: Recent studies evaluating fibrinogen replacement in trauma, along with newly available fibrinogen-based products, has led to an increase in debate on where products such as cryoprecipitate belong in our resuscitation strategies. We set out to define the phenotype and outcomes of those with hypofibrinogenemia and evaluate whether fibrinogen replacement should have a role in the initial administration of massive transfusion.

Methods: All patients <18 years of age presenting to our trauma center 11/17-4/21 were reviewed.

Use of Low-Titer O-Positive Whole Blood in Female Trauma Patients: A Literature Review, Qualitative Multidisciplinary Analysis of Risk/Benefit, and Guidelines for Its Use as a Universal Product in Hemorrhagic Shock.

Background: Whole blood transfusion is associated with benefits including improved survival, coagulopathy, and decreased transfusion requirements. The majority of whole blood transfusion is in the form of low-titer O-positive whole blood (LTOWB). Practice at many trauma centers withholds the use of LTOWB in women of childbearing potential due to concerns of alloimmunization.

When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial.

Background: The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice.

The reports of my death are greatly exaggerated: An evaluation of futility cut points in massive transfusion.

Background: Following COVID and the subsequent blood shortage, several investigators evaluated futility cut points in massive transfusion. We hypothesized that early aggressive use of damage-control resuscitation, including whole blood (WB), would demonstrate that these cut points of futility were significantly underestimating potential survival among patients receiving >50 U of blood in the first 4 hours.

Methods: Adult trauma patients admitted from November 2017 to October 2021 who received emergency-release blood products in prehospital or emergency department setting were included.

Mortality and outcomes by blood group in trauma patients: A systematic review and meta-analysis.

Background And Objectives: Blood group O contains lower levels of factor VIII and von Willebrand factor. Higher incidence of bleeding among group O is reported in multiple contexts. Results of studies vary regarding outcomes stratified by blood group in trauma.

Power of mentorship for civilian and military acute care surgeons: identifying and leveraging opportunities for longitudinal professional development.

Across disciplines, mentorship has been recognized as a key to success. Acute care surgeons, focused on the care of trauma surgery, emergency general surgery and surgical critical care, practice in a wide variety of settings and have unique mentorship needs across all phases of their career. Recognizing the need for robust mentorship and professional development, the American Association for the Surgery of Trauma (AAST) convened an expert panel entitled 'The Power of Mentorship' at the 81st annual meeting in September 2022 (Chicago, Illinois).