Article 1
Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce health care resource utilization. Gallagher SP, Capacio BA, Rooney AS, Schaffer KB, Calvo RY, Sise B, Krzyzaniak A, Sise MJ, Bansal V, Biffl WL, Martin MJ. J Trauma Acute Care Surg. 2024 Feb 1;96(2):240-246.
Traumatic brain injury is a significantly morbid and resource intensive disease, with health care resources used in imaging, ICU utilization, and neurosurgery consultations. The Brain Injury Guidelines (BIG) are an innovative and independently verified protocol that allow for decreased health care utilization without compromising patient outcomes. Within the BIG, anticoagulant and antiplatelet use automatically places patients within the highest tier (category 3) requiring the most resources. This retrospective cohort study evaluated 221 patients over the age of 55 on anticoagulation or antiplatelet therapy with traumatic brain injury (TBI) without significant multisystem injury. Modified BIG were used to re-stratify patients by removing anticoagulation as a parameter but adding worsening head CT, worsening GCS, and neurosurgical intervention. Tracked outcomes included TBI progression, neurosurgical intervention, and mortality. Overall, none of the patients initially stratified to BIG 1/2 groups had neurosurgical intervention or mortality despite higher rates of TBI progression in all groups compared to patients not on anticoagulation.
This study challenges the current BIG, suggesting that with BIG 1/2 injuries, even with anticoagulation the risk of major morbidity or neurosurgical intervention is essentially nonexistent; even if TBI worsens on imaging the clinical outcome appears unchanged suggesting that anticoagulation itself does not need to be included in the criteria. Limitations of the study are that it is a retrospective observational study, and the study is limited to two urban trauma centers. Further, elucidating how much of an impact anticoagulation reversal had on outcomes is not clear: further work needs to be done to develop guidelines on when anticoagulation reversal is appropriate. Finally, there is no long-term outcome data to evaluate whether any morbidity occurred outside of the initial hospitalization. This study represents an important step in refining the BIG to continue to streamline TBI management and reduce resource utilization.
Article 2
Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. Deeb A, Guyette FX, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Eastridge BJ, Joseph B, Nirula R, Vercruysse GA, Sperry JL, Brown JB. J Trauma Acute Care Surg. 2023 Apr 1;94(4):504-512.
Trauma and hemorrhage are synonymous; hemorrhage is the leading cause of death in trauma and time to hemorrhage control is clearly established as directly correlating with morbidity and mortality. Damage control resuscitation techniques have also changed the way we manage these patients shifting away from crystalloid and hemodilution to early blood product administration in ratios that more closely resemble whole blood, if whole blood resuscitation itself is not available. The authors of this trial performed a secondary analysis of the PAMPer and STAAMP trials – both multicenter randomized trails analyzing use of early blood products and TXA respectively – to evaluate how the overall time to early resuscitative intervention affected mortality in the hypotensive bleeding trauma patient. Propensity matching was used to address selection bias, and a total of 1187 patients were analyzed. The authors found that increased time to early resuscitative intervention led to increased mortality at both 24 hours and 30 days.
It intuitively it makes sense that early blood product administration would improve 24-hour mortality. That early resuscitation reduces 30-day mortality in this propensity matched group shows that it is not important just in the immediate “golden hour” when trying to achieve hemorrhage control, but also in how it alters the physiology of the shock state during course of the patient’s hospitalization. Limitations of this study include that it is a secondary analysis of two different studies that were analyzing different treatments; furthermore, there is no clear resuscitative threshold evident in the data to guide clinical practice. This study supports the need for highly efficient trauma systems that allow early administration of blood either by prehospital personnel, or through early and quick transport to a trauma center.
Article 3
Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery. Dunton Z, Seamon MJ, Subramanian M, Jopling J, Manukyan M, Kent A, Sakran JV, Stevens K, Haut E, Bryne JP. J Trauma Acute Care Surg. 2023 Jul 1;95(1):69-77.
Background:
Uncontrolled hemorrhage is a common cause of preventable death following trauma. It is essential to the function of a trauma center of to be able to urgently control hemorrhage. Early processes like time to transfusion and definitive control impact survival. The first letter in the trauma ABCs is A for airway. Airway management can present a clinical challenge in acutely bleeding patients. The first instinct of many is to immediately control the airway, but in acutely hemorrhaging patients, intubation can exacerbate shock and rapidly cause extremis in the patient. This retrospective study evaluated the association between emergency department (ED) intubation vs. (OR intubation) and mortality for patients undergoing urgent hemorrhage control surgery at trauma centers in the US and Canada.
Study Design:
This was a retrospective cohort study of patients 16 years and older who underwent hemorrhage control surgery at level 1 or 2 trauma centers in the National Trauma Data Bank from 2017-2019. For inclusion, patients who were moved to the OR within 60 minutes of arrival and received at least 1 unit of blood. Patients who underwent ED thoracotomy, non-survivable injuries, dead on arrival, pre-hospital cardiac arrest, severe head and neck trauma, or GCS<8 were excluded. Outcome measures were in-hospital mortality, total ED dwell time, units of blood transfused in the first four hours, and major complications (including: in-hospital cardiac arrest, acute kidney injury, acute respiratory distress syndrome, ventilator-associated pneumonia, and severe sepsis). During the study period, 9,667 patients underwent hemorrhage control surgery at 253 level 1 and 2 trauma centers. Intubation in the emergency department was performed in 1,972 patients (20%) with 877 (9%) dying.
Findings:
Patients were most likely to be young men (83% with median age of 33) who suffered penetrating injuries (51% firearm, 21% stabbing). Average GCS on arrival was 15. Patients most commonly underwent laparotomy (68%). Patients who suffered blunt trauma were more likely to be intubated in the ED (34% vs. 27%) with higher injury severity scores (22 vs. 17). The most common injuries in ED intubation patients was lung, thoracic vascular, cardiac, liver, and abdominal vascular injuries. Vital signs between the groups varied significantly statistically but not clinically. There were significant differences in unadjusted outcomes between ED and OR intubation groups. Patients intubated in the ED were significantly more likely to die (17%vs. 7%). ED intubation was also associated with longer dwell time in the ED, more blood transfusions in the first 4 hours, and higher risks of major complications. This trend remained after adjusting for patient baseline and injury characteristics. ED intubation was associated with increased risk of in-hospital cardiac arrest, acute kidney injury, and acute respiratory distress syndrome. When comparing hospitals, 26% of hospitals were high outliers with a significantly higher than average tendency for ED intubation. Twenty percent of hospitals were low outliers with lower-than-average intubation in ED (ED intubation rate of 40% vs. 8%). Patients treated at high outlier for ED intubation were significantly more likely to suffer in-hospital cardiac arrest compared to the low outliers. Hospitals with the lowest number of ED intubations were more likely to be level 1 trauma centers with high volumes of hemorrhage control surgeries.
Limitations:
Limitations of this study included confounding due to unmeasured factors (including reason for intubation), timing of major complications was unknown, hospital level observations likely reflect multiple factors in patient care, and the database used was not designed for the purpose of this study.
Conclusion:
Intubation in the OR has clear advantages compared to ED intubation in select patients undergoing hemorrhage control surgery at trauma centers. ED intubation was associated with increased odds of mortality and major complications. There was significant variability between hospitals in rates of ED intubation vs. OR intubation. Patients treated in centers with higher rates of ED intubation had increased risk of in-hospital cardiac arrest. This study suggests that, when feasible, intubation should be deferred until arrival in the OR with prioritization of rapid resuscitation with blood products and transport to the OR.
