key: cord-0061461-k503yih4
authors: Painter, Matthew D.; Fadeyi, Emmanuel; Bouldin, Bethany; Kayser, Philip; Nakase, Taishi C.; Hoth, James J.; Miller, Preston R.; Nunn, Andrew M.
title: Whole Blood Based Resuscitation in Trauma is Associated with a Decreased Incidence of Acute Respiratory Distress Syndrome
date: 2020-10-02
journal: J Am Coll Surg
DOI: 10.1016/j.jamcollsurg.2020.08.155
sha: 52d2e0eec4f4b5ab99ed56a701f1687463b28b00
doc_id: 61461
cord_uid: k503yih4

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described by the Chest Wall Injury Society (CWIS). Elderly patients with rib fracture have high rate of morbidity due to pain with breathing. We hypothesize that SSRF will decrease pain during the period of fracture healing in the elderly.

METHODS: This is a post hoc subset analysis of the CWIS NON-FLAIL study. We compared SSRF within 72 hours with nonoperative management in patients 60 years of age without flail chest. The primary end-point was Numeric Pain Score (NPS) at 2 week follow-up. Secondary end points were NPS, narcotic consumption, spirometry at 4 and 8 weeks mortality, ICU length of stay (LOS), and hospital LOS (HLOS). Baseline parameters and outcomes of interest were compared between operative and nonoperative cohorts. Parametric and non-parametric tests were used where appropriate. Results are reported as median (25, 75 IQ).

A total of 45 patients 60 years of age were identified, 22 (48.9%) in the operative group and 23 (51.1%) in the nonoperative group. There were no statistical differences between the groups. There was a significantly lower NPS in the operative group at 2-week (2 [0,3] vs 4 [2.5,5.5] p ¼ 0.021) and 4-week (0 [0,2] vs 3 [2,4] p ¼ 0.012)) follow-up. There were no differences in HLOS, ICU LOS, and mortality. The pelvic x-ray (PXR) remains an important adjunct during the initial assessment in trauma. Its primary role is to identify potentially life-threatening pelvic fracture that may change management or provide necessary information if the patients were to suddenly deteriorate. We sought to evaluate the accuracy of PXR in detecting these fractures.

Patients directly admitted to a Level I trauma center (January 2010 to May 2019) with a severe blunt pelvic fracture (Abbreviated Injury Score [AIS] 3) were extracted from the registry. Patients with PXR before CT scan were analyzed. All PXRs were randomly combined with a control group of normal PXRs and then reviewed by a blinded attending trauma radiologist. PXR findings and CT scan reports were compared according to the specific pelvic fracture location, and severity.

Overall, an abnormal PXR was detected in 252/285 patients with pelvic fracture (sensitivity 88.4%) and in 3/97 in the control group (specificity 96.9%). In patients with AIS 3, 29/184 (15.8%) the PXR was read as normal compared with 4/ 101 (4.0%) in the AIS 4/5 group (p ¼ 0.003). Fracture patterns for which PXR had the lowest sensitivity were ischial (10.7%), iliac (28.7%), acetabular (42.4%), and sacral fracture (49.1%). PXR was best for detecting symphysis diastasis (89.8%).

CONCLUSION: PXR may be useful in identifying severe pubic symphysis diastasis in the acute setting. However, it misses or underestimates a significant number of fractures. CT evaluation should be performed in patients with a suspicious mechanism or clinical suspicion of pelvic fracture. Military data has demonstrated improved outcomes with fresh warm whole blood which generated enthusiasm for use of cold-stored whole blood (WB) in civilians. Trauma patients requiring blood at our institution are given up to 2 units of WB followed by component therapy. We compared our outcomes to conventional component-only (COMP) resuscitation.

METHODS: Blunt trauma patients admitted to our ACS verified Level 1 Trauma Center who received blood were included. Patients that were pulseless on arrival, had severe traumatic brain injury defined by Head AIS 3, or that received only 1 unit of blood were excluded. WB and COMP patients were compared. Categorical data were compared with chi-square or Fisher's Exact Test and continuous data with Mann-Whitney U test. A p value < 0.05 was considered statistically significant.

Compared with 86 COMP patients, WB patients were older (48.3 vs 56 years, p ¼ 0.044) but otherwise similar in regards to sex, Injury Severity Score, vitals at presentation, lactate, base deficit and shock index