6 research outputs found
Close to zero preventable in-hospital deaths in pediatric trauma patients – An observational study from a major Scandinavian trauma center
Get PDFBackground: In line with international trends, initial treatment of trauma patients has changed substantially over the last two decades. Although trauma is the leading cause of death and disability in children
globally, in-hospital pediatric trauma related mortality is expected to be low in a mature trauma system.
To evaluate the performance of a major Scandinavian trauma center we assessed treatment strategies and
outcomes in all pediatric trauma patients over a 16-year period.
Methods: A retrospective cohort study of all trauma patients under the age of 18 years admitted to a
single institution from 1st of January 2003 to 31st of December 2018. Outcomes for two time periods
were compared, 2003–2009 (Period 1; P1) and 2010–2018 (Period 2; P2). Deaths were further analyzed
for preventability by the institutional trauma Mortality and Morbidity panel.
Results: The study cohort consisted of 3939 patients. A total of 57 patients died resulting in a crude
mortality of 1.4%, nearly one quarter of the study cohort (22.6%) was severely injured (Injury Severity
Score > 15) and mortality in this group decreased from 9.7% in P1 to 4.1% in P2 (p<0.001). The main
cause of death was brain injury in both periods, and 55 of 57 deaths were deemed non-preventable. The
rate of emergency surgical procedures performed in the emergency department (ED) decreased during
the study period. None of the 11 ED thoracotomies in non-survivors were performed after 2013.
Conclusion: A dedicated multidisciplinary trauma service with ongoing quality improvement efforts secured a low in-hospital mortality among severely injured children and a decrease in futile care. Deaths
were shown to be almost exclusively non-preventable, pointing to the necessity of prioritizing prevention
strategies to further decrease pediatric trauma related mortality
Thrombelastography (TEG® 6s) early amplitudes predict maximum amplitude in severely injured trauma patients
No full textSeverely injured trauma patients are often coagulopathic and early hemostatic resuscitation is essential. Previous studies have revealed linear relationships between thrombelastography (TEG®) five- and ten-min amplitudes (A5 and A10), and maximum amplitude (MA), using TEG® 5000 technology. We aimed to investigate the performance of A5 and A10 in predicting low MA in severely injured trauma patients and identify optimal cut-off values for hemostatic intervention based on early amplitudes, using the cartridge-based TEG® 6s technology. Adult trauma patients with hemorrhagic shock were included in the iTACTIC randomized controlled trial at six European Level I trauma centers between 2016 and 2018. After admission, patients were randomized to hemostatic therapy guided by conventional coagulation tests (CCT) or viscoelastic hemostatic assays (VHA). Patients with available admission-TEG® 6s data were included in the analysis, regardless of treatment allocation. Low MA was defined as <55 mm for Kaolin TEG® and RapidTEG®, and <17 mm for TEG® functional fibrinogen (FF). One hundred eighty-seven patients were included. Median time to MA was 20 (Kaolin TEG®), 21 (RapidTEG®) and 12 (TEG® FF) min. For Kaolin TEG®, the optimal Youden index (YI) was at A5 < 36 mm (100/93% sensitivity/specificity) and A10 < 47 mm (100/96% sensitivity/specificity). RapidTEG® optimal YI was at A5 < 34 mm (98/92% sensitivity/specificity) and A10 < 45 mm (96/95% sensitivity/specificity). TEG® FF optimal YI was at A5 < 12 mm (97/93% sensitivity/specificity) and A10 < 15 mm (97/99% sensitivity/specificity). In summary, we found that TEG® 6s early amplitudes were sensitive and specific predictors of MA in severely injured trauma patients. Intervening on early amplitudes can save valuable time in hemostatic resuscitation
Data-driven Development of ROTEM and TEG Algorithms for the Management of Trauma Hemorrhage:A Prospective Observational Multicenter Study
No full textOBJECTIVE: Developing pragmatic data-driven algorithms for management of trauma induced coagulopathy (TIC) during trauma hemorrhage for viscoelastic hemostatic assays (VHAs). BACKGROUND: Admission data from conventional coagulation tests (CCT), rotational thrombelastometry (ROTEM) and thrombelastography (TEG) were collected prospectively at 6 European trauma centers during 2008 to 2013. METHODS: To identify significant VHA parameters capable of detecting TIC (defined as INR > 1.2), hypofibrinogenemia (< 2.0 g/L), and thrombocytopenia (< 100 x10/L), univariate regression models were constructed. Area under the curve (AUC) was calculated, and threshold values for TEG and ROTEM parameters with 70% sensitivity were included in the algorithms. RESULTS: A total of, 2287 adult trauma patients (ROTEM: 2019 and TEG: 968) were enrolled. FIBTEM clot amplitude at 5 minutes (CA5) had the largest AUC and 10 mm detected hypofibrinogenemia with 70% sensitivity. The corresponding value for functional fibrinogen (FF) TEG maximum amplitude (MA) was 19 mm. Thrombocytopenia was similarly detected using the calculated threshold EXTEM-FIBTEM CA5 30 mm. The corresponding rTEG-FF TEG MA was 46 mm. TIC was identified by EXTEM CA5 41 mm, rTEG MA 64 mm (80% sensitivity). For hyperfibrinolysis, we examined the relationship between viscoelastic lysis parameters and clinical outcomes, with resulting threshold values of 85% for EXTEM Li30 and 10% for rTEG Ly30.Based on these analyses, we constructed algorithms for ROTEM, TEG, and CCTs to be used in addition to ratio driven transfusion and tranexamic acid. CONCLUSIONS: We describe a systematic approach to define threshold parameters for ROTEM and TEG. These parameters were incorporated into algorithms to support data-driven adjustments of resuscitation with therapeutics, to optimize damage control resuscitation practice in trauma
