Faculty Bibliography

BACKGROUND: The purpose of this study was to determine the incidence and identify clinical predictors for the need for tracheostomy after cervical spinal cord injury (CSCI). METHODS: The National Trauma Databank version 7.0 (2002-2006) was used to identify all patients who sustained a CSCI. Patients with severe traumatic brain injury (TBI) were excluded. Demographics, clinical data, and outcomes were abstracted. Patients requiring tracheostomy were compared with those who did not require tracheostomy. Logistic regression analysis was used to identify independent predictors for the need of tracheostomy. RESULTS: There were 5,265 eligible patients. Of these, 1,082 (20.6%) required tracheostomy and 4,174 (79.4%) did not. The majority patients were men and blunt trauma predominated. Patients requiring tracheostomy had a higher Injury Severity Score (ISS) (33.5+/-17.7 vs. 24.4+/-16.2, p<0.001) and required intubation more frequently on scene and Emergency Department (ED) (4.2 vs. 1.4%, p<0.001 and 31.1 vs. 7.9%, p<0.001, respectively). Patients requiring tracheostomy had higher rates of complete CSCI at C1-C4 (18.2 vs. 8.4%, p<0.001) and C5-C7 levels (37.8 vs. 16.9%, p<0.001). Patients requiring tracheostomy had more ventilation days, longer intensive care unit and hospital lengths of stay, but lower mortality. Intubation on scene or ED, complete CSCI at C1-C4 or C5-C7 levels, ISS>/=16, facial fracture, and thoracic trauma were identified as independent predictors for the need of tracheostomy. CONCLUSION: After CSCI, a fifth of patients will require tracheostomy. Intubation on scene or ED, complete CSCI at C1-C4 or C5-C7 levels, ISS>/=16, facial fracture, and thoracic trauma were independently associated with the need for tracheostomy.

INTRODUCTION: Early prediction of massive transfusion (MT) is critical in the management of severely injured trauma patients. Variables available early after injury including physiologic, laboratory, and rotation thromboelastometric (ROTEM) parameters were evaluated as predictors for the need of MT. METHODS: After Institutional Review Board approval, we retrospectively reviewed a cohort of severely injured trauma patients (Injury Severity Score >/= 16) admitted to a Level I trauma center with available ROTEM measurements on hospital admission during a 1-year study period. Patients with isolated head injury (Abbreviated Injury Scale head >/= 3 and Abbreviated Injury Scale chest, abdomen, and extremity < 3) and patients with a penetrating mechanism of injury were excluded. Patients who received a MT (>/= 10 units packed red blood cell within 24 hours of admission) were compared with patients who did not. Variables independently associated with MT were identified using stepwise logistic regression. RESULTS: A total of 53 patients met inclusion criteria. Of these, 18 patients (34.0%) received a MT and 35 patients (66.0%) did not. Massively transfused patients had significantly lower baseline hemoglobin values (7.9 g/dL +/- 0.4 g/dL vs. 11.4 g/dL +/- 0.4 g/dL; p < 0.001) and a trend toward higher lactate (4.8 mmol/L +/- 0.8 mmol/L vs. 3.0 mmol/L +/- 0.3 mmol/L; p = 0.056) and base deficit values (5.9 mmol/L +/- 1.1 mmol/L vs. 3.6 mmol/L +/- 0.6 mmol/L; p = 0.052). Mean international normalized ratio (1.46 +/- 0.07 vs. 1.22 +/- 0.05; p = 0.001) and partial thromboplastin times (42.4 seconds +/- 5.0 seconds vs. 29.7 seconds +/- 1.8 seconds; p < 0.001) were significantly higher in MT patients. Patients receiving a MT had significantly altered ROTEM values on admission compared with non-MT patients. An increase in the clot formation time (471.3 seconds +/- 169.9 seconds vs. 178.1 seconds +/- 19.9 seconds; p = 0.001), a shortening of the maximum clot firmness (37.5 mm +/- 2.9 mm vs. 50.7 mm +/- 1.4 mm; p < 0.001), and a shortening of the clot amplitude at all time points (10/20/30 minutes) were observed in massively transfused trauma patients. Variables independently associated with MT included a hemoglobin level