(Objectives) We analyzed the clinical features of snowboarding-related renal injuries and the predictors of the necessity of adjuvant treatment (AT), such as transcatheter arterial embolization (TAE) or blood transfusions. (Methods) The cases of 87 renal trauma patients that were treated at our hospital between January 1992 and November 2015 were investigated by comparing the cases of patients that suffered snowboarding-related injuries (SB group) with those of patients whose injuries had other causes (NSB group). In the multivariate analysis, predictors of the necessity of AT were identified by performing comparisons between the patients that did (AT group) and did not (NAT group) require AT. (Results) Of the 30 cases in the SB group and 57 cases in the NSB group, 19 (63.3%) and 22 (38.6%) involved H2 hemorrhaging according to the H factor classification of hemorrhaging severity, respectively. Of the 9 cases involving falls induced by the opposite-edge phenomenon, H2 hemorrhaging was seen in 8 (88.9%). The renal trauma classification (p=0.0347), H factor (p=0.0484), and pre-traumatic renal lesions (p=0.0490) were identified as predictors of the necessity of AT. (Conclusions) Snowboarding-related renal injuries can be severe. Considering the predictors identified in this study, we must aim to improve the quality of conservative therapy by performing TAE aggressively.
Background : One of the major aims of improvements in trauma care is to reduce preventable trauma deaths, but few studies about this topic have been conducted in Japan. Objective : The objective of this study was to analyze the preventable trauma deaths that occurred at a rural hospital in Japan. Methods : This was a single-center study examining 147 trauma deaths that occurred between 2010 and 2014 at our hospital in Hachinohe (a rural city), Japan. Unexpected deaths, which were identified using the trauma and injury severity score (TRISS), were analyzed within 30 days via a mortality peer review. The review panels were comprised of trauma surgeons from other institutions and doctors from our department. Results : Seventeen (11%) deaths were identified as unexpected based on their TRISS, and 5 (3.4%) deaths were judged to have been preventable during the peer reviews. The overall preventable death rate was 3.4%. The preventable deaths were caused by delays in treatment and prehospital undertriage. The TRISS system was found to have a number of limitations related to injury severity, age, premorbid conditions, and complications. Conclusions : This study has identified errors that contributed to preventable trauma deaths at a rural hospital in Japan. The TRISS method has many limitations. Peer review is a more effective tool for evaluating and improving the quality of trauma care.
A 52-year-old male was brought to our hospital with a blunt chest trauma. He was diagnosed with multiple right-sided rib fractures, a right open pneumothorax, a liver injury, and a suspected right-sided diaphragmatic injury. He underwent thoracostomy and chest tube placement on his right side. On the third day, bile was seen draining through the chest tube; therefore, endoscopic retrograde cholangiopancreatography was performed. Contrast agent leaked into the pleural cavity during the latter examination, and so endoscopic nasobiliary drainage (ENBD) was conducted. After this procedure, the bile discharge from the thoracic drain decreased. Unfortunately, on the 7th day after admission the patient's respiratory status worsened so he underwent thoracotomy for open drainage and to repair the diaphragmatic injury. During the procedure, we confirmed that the bile leakage into the pleural cavity had stopped. He was discharged on the 63rd day without requiring additional surgery. We concluded that ENBD was effective against the patient's traumatic thoracobiliary fistula.
Although the pathogenesis of pneumatosis intestinalis is poorly understood, and its clinical significance is also unclear, the presence of critical abdominal conditions ; i.e., bowel ischemia and necrosis, should be considered in patients that have suffered severe traumas that require critical care. We report the clinical features of 3 cases of benign pneumatosis intestinalis that were treated conservatively. All 3 patients were elderly and had been released from the intensive care unit after being treated for multiple traumas. At diagnosis, they were not hypotensive ; were not taking vasopressors ; and did not exhibit any abdominal symptoms, peritonitis, or systemic inflammatory responses. All 3 patients had preceding intractable diarrhea. The pneumatosis intestinalis was localized in the colon, and no ascites or hepatic portal gas was detected. The patients all improved under conservative treatment without specific interventions. These symptoms might represent a benign from of postintensive care pneumatosis intestinalis that arises after multiple traumas.
Background : The Committee for Future Planning of the Japanese Association for the Surgery of Trauma conducted the Japanese Observational Study for Coagulation and Thrombolysis in Early Trauma, a multicenter, retrospective observational study. The purpose of this study were to clarify the pathophysiology of trauma-associated coagulopathy, and to establish the novel hemostatic resuscitation strategy. Methods : Data were collected from trauma patients, age≥18 years and with ISS≥16, admitted between January and December 2012. Results : Fifteen institutions participated, and 796 patients were registered. A median age was 59 (38-72), male 589, and 790 were injured from blunt mechanism. A median ISS was 24 (17-27), probability of survival 0.918 (0.767-0.967). Hemostatic surgery and interventional radiology were required in 93 (11.7%), 110 (13.8%), respectively, and tranexamic acid was administered in 281 (35.3%) within 3 hr. Blood transfusion within 6 hr were required in 207 (26.0%), and 58.5% of 207 were transfused≧10units within 24 hr. 28-day mortality was 14.7%. Conclusions : This multicenter study will contribute to clarify the pathophysiology of trauma-associated coagulopathy and to establish the novel hemostatic strategy.
Introduction : Elevated D-dimer levels in trauma patients are one of indicators of hyperfibrinolysis during the early phase of trauma. We hypothesized that high D-dimer levels would predict a poor outcome in severe trauma patients regardless of fibrinogen levels on arrival. Methods : Patients with more than 10 units of red cell concentrate transfusion and/or death during the first 24 hours were classified with a poor outcome. Based on cut-off values for fibrinogen and D-dimer to differentiate the outcomes were compared. Results : In a stepwise logistic regression analysis, fibrinogen and D-dimer levels were statistically significant predictors of a poor outcome. Optimal cut-off values for fibrinogen and D-dimer of 190 mg/dL and 38 mg/L, respectively. Based on these values, patients were divided into four groups : low D-dimer/high fibrinogen, low D-dimer/low fibrinogen, high D-dimer/high fibrinogen, and high D-dimer/low fibrinogen. The survival rate in the high D-dimer/low fibrinogen group was lower than in the other three groups. Moreover, the survival rate in the high D-dimer/high fibrinogen group was statistically lower than that in the low D-dimer/high fibrinogen and low D-dimer/low fibrinogen groups. Conclusions : High D-dimer levels on arrival are a strong predictor of poor outcome in severe trauma patients, regardless of fibrinogen levels.
[Background] There have been various discussion on prehospital fluid resuscitation (PFR) for severe trauma patients. We conducted multi–center observational study on traumatic coagulopathy, and aimed to clarify the relationship between PFR and 3 end points (28–day survival rate ; massive transfusion≥10U/24hr ; and trauma–associated coagulopathy (TAC) : PT–INR≥1.2) in this study. [Patients and methods] Retrospectively collected 796 trauma patients of ISS≥16 and age≥18, in the Japanese Observational Study of Coagulation and Thrombolysis in Early Trauma (J–OCTET) data, were divided into two groups according to whether PFR was done or not. We evaluated the relationship between PFR and the 3 end points using logistic regression analysis, followed by subgroup analysis (age, gender, presence of traumatic brain injury (TBI), and hemostatic treatment including surgery and interventional radiology) was performed. [Results] No difference was observed between PFR (n=85) and non–PFR group (n=711) regarding age, gender, 28–day survival, rate of massive transfusion, and hemostatic intervention. In contrast, ISS and PT–INR were significantly higher in PFR group. Although PFR didn't affect 28 days survival and massive transfusion rate, PFR and ISS were independent risk factors for TAC (odds ratio 1.906, 95% confidence interval 1.10–3.30, P=0.021 ; 1.08, 1.06–1.10, P<0.01, respectively). Subgroup analysis revealed that PFR was an independent risk factor for TAC in the patients under 65, associated with TBI, and requiring hemostatic intervention. [Conclusion] In trauma patients with ISS≥16, PFR may not related to 28 days survival and massive transfusion rate. However, PFR may cause coagulopathy, especially those young, having TBI, requiring hemostatic intervention. Further study is needed to understand the role of PFR for severely traumatized patients.
[Background] We evaluated whether coagulation/fibrinolysis markers can be a predictor for massive transfusion (MT) in patients with severe blunt trauma. [Methods] This study included blunt trauma patients based on the J–OCTET database. Patients were divided into MT (transfusion of 10 or more units of packed red blood cells in the first 24 hours after admission) and non–MT groups. We evaluated MT predictors (age, sex, vital signs, Glasgow Coma Scale, hemoglobin, platelet count, lactate, PT–INR, D–dimer, and fibrinogen levels on admission) using stepwise multiple logistic analysis. We evaluated MT prediction accuracy by receiver operating characteristic curve, and optimal cut–off value were calculated using Youden index. [Results] Heart rate (HR) (per 10 bpm), body temperature (BT), and fibrinogen (per 10 mg/dL) were independent predictors of MT [Odds ratio (OR), 1.72, p<0.001, OR, 0.70, p=0.013, and OR, 0.89, p<0.001, respectively] . The area under the curve values for MT were 0.81 in HR, 0.60 in BT, and 0.75 in fibrinogen. Optimal cut–off values for HR, BT, and fibrinogen were 96 bpm (sensitivity 73.7%, specificity 76.6%), 36.3°C (66.7%, 48.7%), and 190 mg/dL (61.4%, 80.2%), respectively. [Conclusions] Decreased levels of fibrinogen may be one of the independent predictor of MT, with higher specificity in comparison with HR, BT.
Introduction : Disseminated intravascular coagulation (DIC) is often complicated in patients with traumatic brain injury (TBI), and one of the main determination factor of poor prognosis. We tried to clarify the effects of systemic tissue hypoperfusion on the pathogenesis of DIC in patients with isolated TBI and those with extra–cranial blunt trauma without TBI. Methods : In the JOCTET, a multicenter, retrospective observational study, data were collected from trauma patients, age≧18 years and with ISS≧16. From the database, we selected patients with isolated TBI (TBI group) as patients with head abbreviated injury score (AIS) ≥4 and extra–cranial AIS<2, and extra–cranial trauma patients (non–TBI group) as patients with extra–cranial AIS≥3 and head AIS<2. Results : TBI group and non–TBI group included 160, and 186 patients, respectively. No correlations were observed between lactate levels on arrival, as a marker of systemic hypoperfusion, and hemostatic variables in TBI group. However, in the non–TBI group, lactate levels correlated with coagulation variables. Stepwise logistic regression analysis showed that lactate level was independent predictor of DIC in non–TBI group. In contrast, no relationship was observed between lactate level and DIC in TBI group. Conclusions : DIC may be complicated in patients with isolated TBI independent with systemic tissue hypoperfusion.
[Objectives] To elucidate the clinical features of severe trauma in the oldest old, as well as the kinetics of coagulation and fibrinolysis during the acute phase following an injury. [Subjects and methods] 796 patients who were hospitalized between January and December 2012 were enrolled and divided into two groups : the oldest old group (age≥85 years) and the non–oldest old group (age<85 years). A comparative study was performed based on various attribute data and indicators of coagulation and fibrinolysis kinetics. [Results] In the oldest old group, the rate of oral anticoagulant/antiplatelet agent use was significantly greater than the non–oldest old group (6.9% vs 20.0%, p<0.01). The odds ratio of in–hospital death, and death within 24 hours of admission in the oldest old group were 5.53 (p<0.001) and 4.83 (p<0.001) respectively. PT–INR levels showed no significant difference between the two groups, but tended to be prolonged in the oldest old group. The DIC scores showed no significant difference between the two groups. [Conclusions] In the oldest old population, the rate of oral anticoagulant/antiplatelet agent use is high and they are likely to cause coagulopathy. In severe trauma with an ISS 16 or over, age 85 and older independently predicts bad prognosis.
〔Background〕The purpose of this study was to determine whether pre–injury use of anticoagulant and antiplatelet (antithrombotic) agents is related with hemostatic interventions. 〔Methods〕A retrospective review of 312 trauma patients without brain injury from J–OCTET database was performed. Patients were divided into pre–injury medication group and non–medication group. The impact of pre–injury antithrombotic medication on the composite outcome, defined as administration of fresh frozen plasma≧10 units and/or hemostatic treatments within 24h, was analyzed as primary outcome. 〔Results〕Pre–injury medication group was consisted with 20 patients (6.4%). Survival time was not different in two groups (P=0.361 in log–rank test). Logistic regression analysis using age, gender, injury severity score, and pre–injury antithrombotic medication as explanatory variables showed that pre–injury medication was one of the independent risk factors for the composite outcome [odds ratio ; 3.16, 95% confidential interval ; 1.08–9.10, P<0.05] . 〔Conclusions〕Pre–injury antithrombotic medication in severe trauma patients without brain injury may be associated with higher risk of hemostatic interventions.
Background : Earlier transfusion strategy has been associated with improved outcomes in trauma patients requiring massive transfusion ; however, the importance of transfusion strategy in patients requiring transfusion in the early phase has not been evaluated. Objective : To determine the predictors for patients requiring transfusion within 6hr, and evaluate the effective strategy. Design and patients : In the JOCTET, a multicenter, retrospective observational study, data were collected from trauma patients, age≧18 years and with ISS≧16. Results : Ten or more units of red blood cell (RBC) transfusion were performed in 121 of 207 patients (58.5%) requiring transfusion within 6hr. For prediction of massive transfusion, the specificity of abdominal AIS≧3 was 95.4%, and negative predictive value of heart rate≧90/min and/or lactate≧2.5 mmol/L was more than 90%. In a logistic regression analysis, plasma/RBC≧1 within 6hr was independently associated with decreased 28–day mortality (odds ratio 0.285, P=.016). In a Cox regression model using inverse probability of treatment weighting, plasma/RBC≧1 within 6hr was associated with hospital mortality (hazard ratio 0.51, P<.001). Conclusions : Plasma/RBC≧1 within 6hr was associated with decreased mortality in patients requiring transfusion in the early phase. First order of blood transfusion for severe trauma patients is RBC and plasma by each 10 unitis.
Background : This study investigated to the effect of high ratio of FFP to RBC within the first 6 h and 24 h after admission on mortality in patients with severe trauma (ISS≥16), mostly consisted with blunt trauma patients. Methods : This retrospective observational study included 207 (97 % blunt trauma) trauma patients with ISS≥16 requiring transfusion of RBCs within the first 24 h. Receiver operating characteristic (ROC) curve analysis was performed to calculate cut–off values for the FFP/RBC ratio at the first 6 h as an independent variable for outcome at discharge as a response variable. Thereafter, the patients were divided into two groups according to the FFP/RBC ratio cut–off value. These two groups were matched by caliper propensity score matching (PSM). Differences in the survival time between the two groups were compared by the log–rank test. Results : The area under the curve (AUC) was 0.56, and the FFP/RBC ratio was 1.0 at maximum sensitivity (0.59) and specificity (0.67). Based on this value of the ratio, all patients were divided into two groups, with an FFP/RBC ratio≥1 or with an FFP/RBC ratio<1, and analyzed using Propensity Score Matching (PSM) and Inverse Probability of Treatment Weighting (IPTW). The unadjusted hazard ratio was 0.44, and the hazard ratio after adjustment was 0.32. The hazard ratio was 0.38 by PSM and 0.41 by IPTW. The survival rate was significantly higher in patients with an FFP/RBC ratio≥1 within the first 6 h. Conclusion : Patients transfused with an FFP/RBC ratio≥1 within the first 6 h had a hazard ratio of about 0.4. In other words, their risk of death was reduced by about 60%. Even in the population in which a distribution ratio of patients with blunt trauma was very high, the transfusion of an FFP/RBC ratio≥1 within the first 6 h could improve the outcome of blunt trauma patients who have ISS≥16 and need a transfusion within 24 h.
Background : A randomized controlled trial suggested that tranexamic acid for bleeding trauma patients reduce mortality, however, many criticisms aroused. The study objective was to assess effects of tranexamic acid on mortality and amounts of blood transfusion based on actual trauma practice in Japan. Methods : From registered trauma subjects in J-OCTET, a propensity score matching analysis selected baseline-characteristics adjusted subjects with or without tranexamic acid administration within 3 hours from injury. Intergroup comparison estimated difference in 28-day mortality and amount of blood transfusion. Results : Out of a total of 796 subjects registered in J-OCTET, propensity score matching selected 242 and 242 subjects with or without tranexamic acid administration, respectively. Twenty-eight-day mortality was lower in subjects with tranexamic acid (12.7% versus 20.6%, mean difference of -7.9% 95% confident interval [-14.2, -1.6]). No significant differences were observed in mean amount of packed red blood cell transfusion within 24 hours (4.2 units versus 3.8 units, mean difference of 0.4 units, 95% confident interval [-1.1, 2.1]) or fresh frozen plasma (4.3 units versus 3.4 units, mean difference of 0.9 units, 95% confident interval [-0.4, 3.1]). Conclusion : This observational study reproducibly demonstrated an association of decreased 28-day mortality and tranexamic acid administration within 3 hours from injury.
Background : The effect of tranexamic acid (TXA) on survival in patients with brain injury is still unknown. The aim of this study is to clarify the effect of TXA on survial in patients with severe isolated traumatic brain injury. Materials and methods : Data were collected from J-OCTET database and the missing values were complemented with multiple imputation method, thus creating 101 data sets. Severe isolated traumatic brain injury was defined as follows : AIS score of head and neck with 4, 5 or 6, and injury to other parts of the body with AIS score of less than 2. A total of 230 patients were collected. We compared survival as outcome between patients with and without administration of TXA within 3 hours after injury. Results : Administration of TXA has significantly improved survival (P=0.033). In subgourp analysis, improved survival was significant in patients with initial levels of D-dimer 40μg/ml or more. Conclusion : Early administration of TXA significantly improved survival in patients with severe isolated traumatic brain injury. The effect of TXA is evident in the patients with hyperfibrinolysis.
Purpose : The purpose of this study was to determine optimal cut–off values associated with mortality of hemoglobin, platelet count and fibrinogen at 24 hours after injury in patients with severe trauma. Methods : We performed a retrospective analysis of patients survived over 24 hours after injury from J–OCTET database. Multivariable logistic regression models were developed to determine optimal cut–off values of hemoglobin, platelet count and fibrinogen at 24 hours after injury. We also validated the models internally with bootstrapping to assess potential overfitting. Results : There were 722 trauma patients included, with median age of 57 years, median injury severity score of 22, median revised trauma score of 7.84, and an overall hospital mortality of 6.5%. The optimal models associated with hospital mortality were hemoglobin<10.0g/dL (c–statistic 0.77, 95%CI 0.69–0.85), platelet count<10.0×104/μL (0.80, 0.72–0.87), fibrinogen<200mg/dL (0.82, 0.72–0.92). After 200 cycles of bootstrapping, the average optimisms were 0.03, 0.03, and 0.01, respectively. Conclusions : A hemoglobin<10.0g/dL, platelet count<10.0×104/μL, and fibrinogen<200mg/dL at 24 hours after injury were associated with mortality. The impact of these values as target values for resusucitation warrants further validation.
Objective : To evaluate the utility of the conventional lethal triad as the indicator for damage control strategy and to develop a novel criteria in patients with severe trauma. Design : A retrospective multicenter observational study. Patients : A total of 796 trauma patients with an ISS≥16 in a year of 2012 were enrolled. Results : The sensitivity to predict 28–day mortality of conventional criteria (PT–INR>1.5, pH<7.2, body temperature<35°C) was low and the specificity was remarkably high. Taking accuracy to predict outcome, adequate cut off value, and impact on the outcome of each parameters within the flame of triad into account, we developed the novel criteria defined by fibrinolytic disorder (FDP>90μg/ml) as major criterion, and acidosis (BE<–3mEq/L) and hypothermia (Body temperature<36°C) as minor criteria. When a patient met a major criterion or two minor criteria, the sensitivity and specificity to predict 28–day mortality were 81% and 67%, respectively. Conclusion : The conventional criteria was not suitable as a therapeutic indicator for damage control strategy in current clinical practice. The novel criteria improved sensitivity, while maintaining specificity, and assumed to have the potential to be the objective indicator to activate damage control strategy in early phase of trauma management.