Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. Robertson CS, Hannay HJ, Yamal JM, Gopinath S, Goodman JC, Tilley BC; Epo Severe TBI Trial Investigators, Baldwin A, Rivera Lara L, Saucedo-Crespo H, Ahmed O, Sadasivan S, Ponce L, Cruz-Navarro J, Shahin H, Aisiku IP, Doshi P, Valadka A, Neipert L, Waguspack JM, Rubin ML, Benoit JS, Swank P. JAMA. 2014 Jul 2;312(1):36-47.
Patients with closed head injury who were unable to follow commands after their initial trauma resuscitation were enrolled into a randomized clinical trial at two Level-I trauma centers. Investigators evaluated the effects of both erythropoietin administration and adherence to differing transfusion triggers (7 and 10 g/dL) on neurologic outcomes 6 months after TBI. While study drug administration (EPO vs. placebo) was blinded, transfusion threshold assignments were not. The primary outcome measure was Glasgow Outcome Scale assessed 6 months following injury. Of 895 patients assessed, 200 were enrolled and randomized into 1 of 4 groups (threshold 7g/dL + EPO, threshold 7g/dL + placebo, threshold 10g/dL + EPO, threshold 10g/dL + placebo). While RBC transfusion has been shown to improve cerebral oxygenation in prior reports, this randomized clinical trial has determined that neither erythropoietin administration nor utilizing a transfusion threshold of 10g/dL improved neurologic recovery 6 months following closed head injury.
Compliance with recommended care at trauma centers: association with patient outcomes. Shafi S, Barnes SA, Rayan N, Kudyakov R, Foreman M, Cryer HG, Alam HB, Hoff W, Holcomb J. J Am Coll Surg. 2014 Aug;219(2):189-98.
State health departments and the American College of Surgeons have focused on available resources when verifying Trauma Centers. The investigators of this multicenter study went beyond resource availability and measured compliance with 22 commonly recommended clinical practices and correlated them with hospital mortality. Of 9633 patients who met inclusion/exclusion criteria, 3867 were randomly selected and a compliance score calculated. Recommended practice compliance was associated with outcomes by including compliance scores as both a continuous and binary (optimal care compliance score =100%, suboptimal less than 100%) variable in risk-adjustment models. The overall median compliance score was suboptimal at 83% but varied by center (range, 67 to 100) and individual process (13% to 94%). After adjusting for demographics and injury severity, the authors found that each 10% increase in compliance score was associated with a 14% reduction in risk of death with a small increase in hospital LOS. Further analysis revealed mortality would be reduced 41% (6.7% vs. 11.3%) by providing optimal care.
Endovascular stenting is rarely necessary for the management of blunt cerebrovascular injuries. Burlew CC, Biffl WL, Moore EE, Pieracci FM, Beauchamp KM, Stovall R, Wagenaar AE, Jurkovich GJ. J Am Coll Surg. 2014 May; 218:1012-7.
While screening criteria for BCVI have expanded, proper treatment of BCVI remains controversial. A retrospective review of all patients found to have grade II (>25% luminal narrowing) or III (pseudoaneurysm) lesions was undertaken. Outcomes were compared with respect to therapy (stenting before 2005 vs. anticoagulation or antiplatelet therapy after 2005). Patients presenting with neurologic symptoms or other injury grades were excluded. Prior to 2005, 86 patients sustained grade II or III BCVI injuries, of which 21 were stented and 2 suffered a stroke. Since 2005, 109 patients were found to have grade II or III BCVI injuries—97 of these patients were treated with antithrombotics and none suffered a stroke. While 21% of these 109 asymptomatic patients had progression of their BCVI on repeat imaging, no patients suffered a stroke or had a rupture of their pseudoaneurysm. Although compliance with specific aspects of the antithrombotic therapy were not presented, the authors do provide their treatment protocol (heparin 15 U/kg/h without loading dose, goal PTT 40-50, followed by aspirin 325mg/d and/or clopidogrel 75mg/d upon hospital discharge until repeat imaging 3-6 months following injury).
"Permissive hypoventilation" in a swine model of hemorrhagic shock. Taghavi S, Jayarajan SN, Ferrer LM, Vora H, McKee C, Milner RE, Gaughan JP, Dujon J, Sjoholm LO, Pathak A, Rappold JF, Santora TA, Houser SR, Goldberg AJ. J Trauma Acute Care Surg. 2014 Jul;77(1):14-9.
To mimic the prehospital care of penetrating trauma victims, 19 Yorkshire pigs underwent either endotracheal intubation with manual positive pressure ventilation (n=6), positive pressure ventilation by bag-valve-mask with ambu-bag (n=7), or passive ventilation with oxygen via facemask (n=6). Baseline and serial vital signs, hemodynamic parameters and laboratories were obtained as the animals were exsanguinated via a 14 gauge carotid artery catheter until death utilizing a documented hemorrhagic shock model. Although no difference in survival time between study groups was detected, swine treated with passive oxygen delivery via facemask were less hypothermic and had greater cardiac output during all measured time-points than those who underwent positive pressure ventilation by either endotracheal intubation or bag-valve-mask. Importantly, animals treated with passive oxygen delivery by facemask, despite a profound respiratory acidosis, had less evidence of end-organ malperfusion (measured by serum lactate and creatinine) than positive pressure ventilation study groups.
Self-expanding foam improves survival following a lethal, exsanguinating iliac artery injury. Rago A, Duggan MJ, Marini J, Beagle J, Velmahos G, De Moya MA, Sharma U, Hwabejire J, King DR. J Trauma Acute Care Surg. 2014 Jul;77(1):73-7.
The investigators sought to determine the efficacy of self-expanding polyurethane foam in a swine model of massive, non-compressible, lethal arterial hemorrhage. The external iliac artery was exposed through the retroperitoneum and encircled with a cutting wire 1cm from the aortic bifurcation, the wire was then exteriorized and abdomen closed. Animals treated with damage control resuscitation fluid alone (n=14), 100mL (n=12), or120mL (n=13) of foam injected into the abdomen were compared with respect to baseline and serial vital signs, hemodynamic parameters and laboratories for 3hrs or until death. When compared to fluid resuscitation only control swine, foam administration decreased rates of hemorrhage (control, 1.4g/kg; 100mL, 0.23g/kg; 120mL, 0.27g/kg), increased median survival time (control, 32min; 100mL, 175min; 120mL, 135min) and improved survival after 3hrs (control, 0%; 100mL, 50%; 120mL, 39%. These results support the hypothesis of the investigators—that self-expanding foam administration may temporize and slow hemorrhage to non-lethal rates.