Jenkins, Donald H.

Almost 50% of trauma‐related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma‐induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipient's ABO group. Historically, group AB plasma has been considered the “universal donor” plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma service's DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in‐hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.

AbstractBackgroundRib fracture stabilization has become a more accepted practice although stabilization of the most cephalad ribs presents a unique challenge. We present our experience with use of a 90° drill and screwdriver to bridge these difficult rib fractures.MethodsThis retrospective review included patients who underwent rib fracture stabilization from August 1, 2009, through September 30, 2012. Patients were divided into two groups: those whose procedure used the 90° device and those that did not. Data were compared using standard statistical analysis and reported as percentages and medians [interquartile ranges]. P values <0.05 were considered significant.ResultsWe identified 89 patients: 29 (33 %) had 90° devices used and 60 (67 %) did not. There were no differences between groups in age, sex, Trauma‐Related Injury Severity Score, the presence of flail chest, occurrence of pneumonia, and intensive care unit or hospital length of stay. The Injury Severity Score was higher in the 90° group (22 vs. 16; P = 0.03). The highest rib stabilized was different between the 2 groups (3 [2–5] vs. 5 [2–9]; P = 0.001), with more third rib stabilizations in the 90° group (38 vs. 20 %; P = 0.04) as well as more total number of ribs fixed (5 vs. 4; P = 0.001). There was no difference in operative time between the 2 groups.ConclusionsThe surgical reach for rib fracture stabilization has been extended with use of a 90° drill and screwdriver. High fractures under the scapula where access is technically challenging can be stabilized without prolonging operative times.

AbstractBackgroundBotulinum toxin A (BTX) confers flaccid paralysis and pain modulation when injected into a muscle. We hypothesized that long‐term paralysis of the abdominal wall musculature (i.e., chemical component paralysis, CCP) would benefit incisional hernia repair (IHR) by decreasing postoperative pain, the use of opioid analgesia, and thus opioid‐related side effects.MethodsAdult patients who underwent elective IHR with preoperative CCP (n = 22) were compared to concurrent matched controls (n = 66, 1:3 ratio) based on age (±5 years), sex, body mass index (±5 kg/m2), history of hernia recurrence (0 vs. ≥1), and type of repair (open vs. laparoscopic). BTX was injected under ultrasonographic guidance into the transversus abdominis and internal and external oblique muscles at three sites bilaterally (300 units total).ResultsPatients who underwent IHR with CCP used significantly less opioid analgesia (mean ± SD morphine equivalents) when compared to controls on hospital days (HDs) 2 and 5: HD2, 48 ± 27 versus 87 ± 41; HD5, 17 ± 16 versus 48 ± 45. Likewise, CCP patients reported significantly less pain (visual analogue scale 1–10) when compared to controls on HD2 (5.2 ± 1.5 vs. 6.8 ± 2) and HD4 (3.6 ± 1.2 vs. 5.2 ± 1.9): all p < 0.007 (Bonferroni adjusted). There was no difference in postoperative complications (surgical site, 9 vs. 14 %), opioid‐related adverse events (ileus 5 vs. 5 %), hospital stay (4 ± 3 vs. 3 ± 2 days), or hernia recurrence (18 months mean follow‐up: 9 vs. 9 %).ConclusionsDespite similar multimodality treatment of postoperative pain after IHR, patients who underwent CCP required significantly less opioid analgesia and reported less pain.

BackgroundThe rapid reversal of warfarin in the setting of traumatic brain injury (TBI) has been associated with improved outcomes. Until now, remote reversal of hypocoagulable states has not been possible in the prehospital environment. This manuscript describes the development and analysis of a prehospital plasma transfusion protocol to reverse warfarin at the earliest possible moment after TBI.Study Design and MethodsA retrospective review of all TBI patients receiving plasma transfusion(s) in the prehospital environment for warfarin reversal between February 2009 and September 2010 was conducted. Thawed plasma was carried on every air ambulance flight centered at the main campus.ResultsA total of 2836 flights carried over 2500 units of thawed plasma throughout the study period. During this time, 16 patients received prehospital plasma resuscitation, five of who were on warfarin with a concurrent TBI. The median Injury Severity Score was 17 (8.5‐27.5) with a median Glasgow Coma Score of 13 (8‐15) and a mortality rate of 40%. A median of 2 (1.5‐2.0) units of thawed plasma and 0 (0‐0) units of RBCs were transfused en route. The pretransfusion point‐of‐care international normalized ratio improved from 3.1 (2.3‐4.0) to 1.9 (1.3‐3.6) upon trauma center admission (serum sample). One hundred percent of the transported, but unused, thawed plasma underwent subsequent transfusion prior to expiration.ConclusionsRemote prehospital plasma transfusions effectively reverse anticoagulation secondary to warfarin administration in TBI patients. It is feasible to transfuse thawed plasma in the prehospital setting via remote damage control techniques without increasing waste. Prospective studies are needed to determine if this practice can improve outcomes in this population.