OHSU. Blunt cerebrovascular injuries: anatomic and pathologic heterogeneity produce management uncertainties.

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Kohler Pavilion With tram station Center for Health and Healing Top ten trauma papers published in the past year Presented at St Charles Medical Center, Bend, Oregon March 13,

Blunt cerebrovascular injuries: anatomic and pathologic heterogeneity produce management uncertainties. Blunt cerebrovascular injury (BCVI) What is known 1. Rare 2.

5% of blunt trauma admissions have a BCVI (~3% in patients with ISS > 15) Two common mechanisms of injury 1.

$High risk injury patterns associated with BCVI that justify screening Cervical spine fracture Basilar cranial fracture into carotid canal of petrous bone Unexplained$ $neurological deficit & ischemic stroke Le Fort II or III facial fracture (mandible or maxilla) Traumatic brain injury with admission GCS < 6 Cervical hematoma/cervical bruit$ vessels 99 carotid 64 vertebral Fabian, J Trauma 2014 Paper #10 CT scan is the preferred screening diagnostic study. Paulus EM, Fabian TC et al. J Trauma Acute Care Surg.

vessels 99 carotid 64 vertebral Fabian, J Trauma 2014 Paper #10 CT scan is the preferred screening diagnostic study. Paulus EM, Fabian TC et al. J Trauma Acute Care Surg.

1 Kohler Pavilion With tram station Center for Health and Healing Top ten trauma papers published in the past year Presented at St Charles Medical Center, Bend, Oregon March 13, 2015 OHSU Richard J Mullins, MD, FACS Professor of Surgery Oregon Health & Science University. Blunt cerebrovascular injuries: anatomic and pathologic heterogeneity produce management uncertainties. Blunt cerebrovascular injury (BCVI) What is known 1. Rare 2. Can involve the carotid and/or vertebral arteries 2. Most are asymptomatic until cerebral stroke occurs 3. Lesions visualized with special vascular imaging 0.5% of blunt trauma admissions have a BCVI (~3% in patients with ISS > 15) Two common mechanisms of injury 1.Hyper extension of head stretches carotid artery and disrupts intima. 2.Fractured bone (cervical spine or skull base) punctures vessel. Gray s Anatomy Text Question #1: Who should have a screening vascular exam? High risk injury patterns associated with BCVI that justify screening Cervical spine fracture Basilar cranial fracture into carotid canal of petrous bone Unexplained neurological deficit & ischemic stroke Le Fort II or III facial fracture (mandible or maxilla) Traumatic brain injury with admission GCS < 6 Cervical hematoma/cervical bruit Woman are higher risk than men (BCVI in 18% screened women and 11% of screened men) Over 12 months 594 patient met screening criteria 128 patients (22%) had 163 injured vessels 99 carotid 64 vertebral Fabian, J Trauma 2014 Paper #10 CT scan is the preferred screening diagnostic study. Paulus EM, Fabian TC et al. J Trauma Acute Care Surg. 2014; 76: high risk patients were screened with 64 channel CTA and then had Digital Subtraction Angiography. CTA performance Carotid arteries Vertebral arteries Sensitivity (+/with lesion) 72% 77% Specificity ( /without lesion) 84% 86% Positive Predictive value TP/(TP + FP) 41% 40% Negative predictive value TN/(TN +FN) 95% 97% Dr. Fabian concludes: Considering complications, cost and resource demand associated with DSA, their studies suggests that 64 channel CTA should be used as primary screening test

Denver classification Grade 1 Luminal irregularity Grade 2 Dissection with intramural hematoma or raised intimal flap Grade 3 Pseudoaneurysm Grade 4 Complete arterial occlusion Grade 5 Transection

Fabian treats with IV Heparin and target PTT 40 50 seconds; however he reports Aspirin is also effective. Paper #9 Natural history of blunt cerebrovascular injuries is grade dependent Wagenaar et al.

2014; 77: 540 45 829 BCVI diagnosed over 15 years 39 presented with stroke 648 anticoagulated (heparin or aspirin) 1% had a stroke 142 had contraindications to anticoagulation 27% had a stroke (~ day

$Many BCVI strokes are embolic Carotid Carotid Recent case: Occlusion of left vertebral artery in a patient without a cervical spine fracture, involved in high speed head on crash.$ No neurologic deficits. Treated with aspirin, then 2 nd post injury day, enoxaparin added.

No neurologic deficits. Treated with aspirin, then 2 nd post injury day, enoxaparin added.

2 Denver classification Grade 1 Luminal irregularity Grade 2 Dissection with intramural hematoma or raised intimal flap Grade 3 Pseudoaneurysm Grade 4 Complete arterial occlusion Grade 5 Transection and/or arteriovenous fistula. Denver classification of BCVI. J Amer Coll Surg (5): Fabian treats with IV Heparin and target PTT seconds; however he reports Aspirin is also effective. Paper #9 Natural history of blunt cerebrovascular injuries is grade dependent Wagenaar et al. (Denver Group) J Trauma Acute Care Surg. 2014; 77: BCVI diagnosed over 15 years 39 presented with stroke 648 anticoagulated (heparin or aspirin) 1% had a stroke 142 had contraindications to anticoagulation 27% had a stroke (~ day 4 post injury) Vertebral % healed Carotid % healed number number Grade I % % Grade II 48 17% 56 20% Grade III 35 14% 73 5% Grade IV 39 3% 3 none Off the street stroke Anticoagulation protective Worse case scenarios: patients who cannot be anti coagulated Grade 1 Grade 2 Grade 3 Grade 4 Hypothesis: Circle of Willis collaterals protect patients with arterial thrombosis. Many BCVI strokes are embolic Carotid Carotid Recent case: Occlusion of left vertebral artery in a patient without a cervical spine fracture, involved in high speed head on crash. No neurologic deficits. Treated with aspirin, then 2 nd post injury day, enoxaparin added. Carotid 6% 10% 17% 55% Vertebral 3% 30% 22% 18% Anatomy or arteries of vertebral circulation University of Illinois, College of Medicine Right vertebral normal Near occlusion left vertebral Post injury day 5, on aspirin. MRI angiogram looking for strokes. Short segment stenosis of proximal left vertebral artery. Three recommendations 1. Screen high risk patients for BCVI using CT angiogram (64 channel). 2. If positive CT angiogram, anticoagulate! Bleeding risk? => Aspirin 300 mg Minimal bleeding risk? => Heparin A pseudoaneurysm requires long term follow up 3. Remain vigilant for delayed stroke in first week in patients who screen negative. Open Questions regarding BCVI 1. How long should BCVI be treated? 2. What is optimal anticoagulation therapy? 3. When are endovascular stents indicated?

A 36 year old man is in a high speed head on collision with a dump truck.

As he was loaded into the ambulance, he had a PEA arrest and died.

circumferential tear of the aorta. Autopsy reveals transection of the aorta and 2.

Left subclavian Ligamentum arteriosum Blunt thoracic aorta injury Change in practice over one

J Trauma 207 patients all had open repair: Mortality 14% Paraplegia 9% 2008 Operative repair

J Trauma 193 patients 69 had TEVAR: Mortality 4% Paraplegia 1% 46 had open repair: Mortality

Old : open repair through a left thoracotomy +/ cardio aortic shunt New : TEVAR = Thoracic

diagnostic and antihypertensive therapy reduces risk of rupture. Fabian TC. Davis KA.

1998; 227:666 76 58 of 71 patients with BAI were treated with antihypertensive medications to

nitroprusside 1 Rx with nitroprusside 15 patients were treated for days with antihypertensive

9 were managed until death from associated injuries.

3 A 36 year old man is in a high speed head on collision with a dump truck. When EMTs arrived he was complaining of shortness of breath and they felt a radial pulse. As he was loaded into the ambulance, he had a PEA arrest and died. Incised back wall of the aorta opens the vessel distal to left subclavian There is a complete circumferential tear of the aorta. Autopsy reveals transection of the aorta and 2.5 liters of blood in left chest. Left subclavian Ligamentum arteriosum Blunt thoracic aorta injury Change in practice over one decade 1997 Prospective study of blunt aortic injury Fabian et al. J Trauma 207 patients all had open repair: Mortality 14% Paraplegia 9% 2008 Operative repair or endovascular stent graft Demetriades et al. J Trauma 193 patients 69 had TEVAR: Mortality 4% Paraplegia 1% 46 had open repair: Mortality 24% Paraplegia 2% Management options to treat the blunt thoracic aorta injury. Old : open repair through a left thoracotomy +/ cardio aortic shunt New : TEVAR = Thoracic endovascular aortic repair Prospective study of blunt aortic injury (BAI): helical CT is diagnostic and antihypertensive therapy reduces risk of rupture. Fabian TC. Davis KA. Gavant ML et al. Ann Surg.1998; 227: of 71 patients with BAI were treated with antihypertensive medications to decrease aortic wall shear force 36 Rx with [beta] blocker 21 Rx with [beta] blocker and nitroprusside 1 Rx with nitroprusside 15 patients were treated for days with antihypertensive medication; none ruptured. 6 patients had delayed repair and survived. 9 were managed until death from associated injuries. Paper # 8 Parameters for successful nonoperative management of traumatic aortic injury. Grading of blunt aortic injury Rabin J, DuBose J, Sliker CW et al. J Thorac. Cardiovasc Surg. 2014; 147: Rabin J, DuBose J, Sliker CW et al. J Thorac Cardiovasc Surg. 2014; 147: The management of patients with blunt aortic injury is changing! Grade I: small intimal tear Grade II: small pseudoaneurysm Grade III: Large pseudoaneurysm Grade IV: rupture/transection

The added treatment of non operative management of small lesions Rabin J, DuBose J, Sliker CW et al. J Thorac Cardiovasc Surg. 2014; 147: 143 50.

categorized based on CT image Grade I Intimal flap Grade II Small pseudoaneurysm 31 = 32% 35 = 36% Grade III 24 >50% circumference = 25% pseudoaneurysm Grade IV Rupture or transection 7 = 7% 3 None

60% TEVAR 40% Non op Rx Reduce SBP < 110, TEVAR within 24 hours Grade III Large Aneurysm Reduce SBP < 110, treat primary injuries, delay TEVAR Grade IV Leaking Reduce SBP < 90, immediate thoracotomy

Plan: keep Systolic BP below 120 mm Hg, and repeat CT scan in 1week. Clinical Practice Guideline of the Society for Vascular Surgery Lee et al. J Vasc Surg.

Early rupture can be prevented with immediate control of SBP. 2. One third of patients have Grade I lesions and do not need a procedure. 3. TEVAR is the preferred procedure. 4.

4 The added treatment of non operative management of small lesions Rabin J, DuBose J, Sliker CW et al. J Thorac Cardiovasc Surg. 2014; 147: Total N = 97 TEVAR N = 45 Open surgery N = 7 Nonoperative Medical N = 45 Mortality related to aorta Guideline for treatment of patients with a blunt thoracic aortic injury Blunt aortic injury categorized based on CT image Grade I Intimal flap Grade II Small pseudoaneurysm 31 = 32% 35 = 36% Grade III 24 >50% circumference = 25% pseudoaneurysm Grade IV Rupture or transection 7 = 7% 3 None 28 With 24 Survivors 22 None 13 With 7 survivors With 0 survivors 2 4 None 5 none 1 None Grade I Intimal flap Reduce SBP < 120, repeat CT in one week Grade II Small Aneurysm Reduce SBP < % TEVAR 40% Non op Rx Reduce SBP < 110, TEVAR within 24 hours Grade III Large Aneurysm Reduce SBP < 110, treat primary injuries, delay TEVAR Grade IV Leaking Reduce SBP < 90, immediate thoracotomy or TEVAR TEVAR = Thoracic EndoVascular Aortic Repair 58 year old in high speed MVC. Assessment: Grade I lesion with a > 95% probability the lesion will be stable or resolve. Plan: keep Systolic BP below 120 mm Hg, and repeat CT scan in 1week. Clinical Practice Guideline of the Society for Vascular Surgery Lee et al. J Vasc Surg. 2011; 53: When TEVAR covers the left subclavian artery orifice, selective revascularization indicated. Intimal defect No peri aortic hematoma Lessons learned in the past 15 years: 1. Early rupture can be prevented with immediate control of SBP. 2. One third of patients have Grade I lesions and do not need a procedure. 3. TEVAR is the preferred procedure. 4. Open repair can save the life of a Grade IV patient, but few surgeons can claim extensive experience. Best Practices promulgated by ACS 1. Use Glasgow Coma Scale 2. Monitor Intracranial pressure using external ventricular drain 3. Treat aggressively increased ICP. 4. Early Craniotomy for a mass lesion 5. Start enteral nutrition within 48 hours 6. Transfusion trigger: Hgb 7 g/dl 7. Severe TBI deserves 72 hours of treatment

The TQIP guidelines recommend External Ventricular Drain [EVD] is preferable to a subarachnoid bolt.

Glasgow Coma Score. In clinical setting better to graph the individual scales over time.

Teasdale and Jennett, Lancet, 1974 Increasing intracranial pressure indicates a mass lesion is

Trauma Quality Improvement Project (TQIP) report is based upon the combined data of over 180,000 patients

TQIP reports how an individual trauma center s performance compares to risk adjusted benchmarks.

treatment of Traumatic Brain Injury In the US, annual rate of TBI is 1.

demonstrated progesterone following TBI reduces cerebral edema, neuronal loss and behavioral deficits and

5 The TQIP guidelines recommend External Ventricular Drain [EVD] is preferable to a subarachnoid bolt. EVDs combine the capacity to make the diagnosis and treat Glasgow Coma Scale, when summed give the Glasgow Coma Score. In clinical setting better to graph the individual scales over time. Deterioration = possible need for surgery! Teasdale and Jennett, Lancet, 1974 Increasing intracranial pressure indicates a mass lesion is increasing; the treatment is evacuation of the mass. Trauma Quality Improvement Project (TQIP) report is based upon the combined data of over 180,000 patients from 223 trauma centers. TQIP reports how an individual trauma center s performance compares to risk adjusted benchmarks. Observed Odds death Expected Odds death Poor Performance Superior Performance The search for effective treatment of Traumatic Brain Injury In the US, annual rate of TBI is 1.7 million US cost annually of TBI = $76 billion Are there new treatments that improve survival and quality of recovery from TBI? Papers # 7 A and 7 B Progesterone, a potent neurosteroid synthetized in the CNS 180 experimental studies demonstrated progesterone following TBI reduces cerebral edema, neuronal loss and behavioral deficits and has a neuroprotective effect In the United States. Very early administration of progesterone for acute traumatic brain injury. Wright DW, Yeatts SD, Silbergleit R et al for the Neurological Emergencies Treatment Trials (NETT) Investigators. N Engl J Med 2014; 371: Around the world. A clinical trial of progesterone for severe traumatic brain injury. Skolnick BE, Maas AI, Narayan RK et al and the SYNAPSE trial Investigators. N Engl J Med 2014; 371:

Blunt brain injured patients given either progesterone or placebo.

Admission GCS 3 10% 4 6 45% 7 8 45% 9 12 none More severely injured In the United States; at six months follow up Extended Glasgow

Stratified by severity of injury on hospital presentation White indicates good recovery Moderate injury: admit GCS 9 12 Moderate severe

6 hours 7 hours Severe injury: admit GCS 4 5 Around the World at six months follow up The Glasgow Outcome Scale was used to dichotomize

No benefit to patients with severe TBI from administration of progesterone. Why did the preliminary studies suggested benefit?

6 Blunt brain injured patients given either progesterone or placebo. In the United States n = 1140 Age (median) 35 Male 73% Admission GCS % % % Around the world n = % Admission GCS 3 10% % % 9 12 none More severely injured In the United States; at six months follow up Extended Glasgow Outcome Scale at six months showed no difference between progesterone vs placebo. Stratified by severity of injury on hospital presentation White indicates good recovery Moderate injury: admit GCS 9 12 Moderate severe injury: admit GCS 6 8 Black indicates dead Time to 1 st dose 3.6 hours 7 hours Severe injury: admit GCS 4 5 Around the World at six months follow up The Glasgow Outcome Scale was used to dichotomize each patient. They were categorized as having a favorable or unfavorable outcome. No benefit to patients with severe TBI from administration of progesterone. Why did the preliminary studies suggested benefit? Is there wide spread bias in preliminary studies when there is substantial professional or financial investment in a specific outcome? There is a need for a comprehensive review of the TBI translational research strategy. Following rapid sequence intubation in the trauma resuscitation bay. What can we do for TBI patients that helps? Avoid hypoxia Avoid hypotension Operate early to evacuate mass lesions that increase ICP.

TQIP proclaimed goals of treatment in the ICU of patients with asevere TBI If ICP > 20, reduce with three tiered approach Tier 1 HOB elevated 30 degrees PaCO2 30 35 mm Hg Sedation Tier 2 If

Tier 3 Neuromuscular paralysis 2 twitches on nerve stim Propofol coma trial Intracranial pressure monitoring in severe traumatic brain injury: Results from the American College of Surgeons

Frequent ICP users The 155 trauma centers reporting to TQIP 10,628 adult patients with severe TBI, Hospitals divided into four quartiles based on % who had a intracranial pressure monitor.

Within a group of collegiate football athletes, there was a significant inverse relationship between concussion and years of football played with hippocampal volume.

Young D, Harrison DA, Cuthbertson, MD, Rowan K D Phil. JAMA 2012; 309: 2121 2129 This randomized control trial conducted in 72 ICUs in England.

7 TQIP proclaimed goals of treatment in the ICU of patients with asevere TBI If ICP > 20, reduce with three tiered approach Tier 1 HOB elevated 30 degrees PaCO mm Hg Sedation Tier 2 If ICP > 25 mm Hg: Hyperosmolar Rx EVD (ventriculostomy) Test for loss of autoregulation (ICP increases as MAP increases). Tier 3 Neuromuscular paralysis 2 twitches on nerve stim Propofol coma trial Intracranial pressure monitoring in severe traumatic brain injury: Results from the American College of Surgeons Trauma Quality Improvement Program. Alali et al. J Neurotrauma 2013; 30: Frequent ICP users The 155 trauma centers reporting to TQIP 10,628 adult patients with severe TBI, Hospitals divided into four quartiles based on % who had a intracranial pressure monitor. Paper #6 Relationship of collegiate football experience and concussion with hippocampal volume and cognitive outcomes. Singh R, Meier T, Kuplicki R et al. JAMA 2014; 311: Within a group of collegiate football athletes, there was a significant inverse relationship between concussion and years of football played with hippocampal volume. To trach or not to trach, that is the question. Martin Droeshout, portrait, Effect of early vs late tracheostomy placement in survival of patients receiving mechanical ventilation. Young D, Harrison DA, Cuthbertson, MD, Rowan K D Phil. JAMA 2012; 309: This randomized control trial conducted in 72 ICUs in England. A pragmatic trial, meaning included a wide spectrum of patients Patients who had four days of mechanical ventilation, and whom medical providers guessed would likely need 7 more days of mechanical ventilation were randomized. Early n= % had tracheostomy Age 64 Surgery patients: 20% Primary Dx: Respiratory failure 60% Late n = % had tracheostomy Age 64 Surgery patients: 21% Primary Dx: Respiratory failure 59% 90% of the tracheostomies were percutaneous and at the bedside.

Outcome: no difference in survival Early Tracheostomy Mortality 30 Day 30.8% 1 year 45.9% 2 year 51.0% Ventilated days 13.6 Late Tracheostomy Mortality 30 Day 31.5% 1 year 49.0% 2 year 53.

) The authors comment: A modest reduction in sedative use was seen in patients randomized to early tracheostomy. Median = 5 days. Median = 8 days. Kaplan Meier Survival Curve; P =.

JAMA 2012; 309: 2121 2129 Conclusions Early tracheostomy did not provide survival benefit or reduce ICU length of stay.

8 Outcome: no difference in survival Early Tracheostomy Mortality 30 Day 30.8% 1 year 45.9% 2 year 51.0% Ventilated days 13.6 Late Tracheostomy Mortality 30 Day 31.5% 1 year 49.0% 2 year 53.7% Ventilated days 15.2 P=.06 The early tracheostomy group needed fewer days of sedation (P <.001.) The authors comment: A modest reduction in sedative use was seen in patients randomized to early tracheostomy. Median = 5 days. Median = 8 days. Kaplan Meier Survival Curve; P =.45 Effect of early vs late tracheostomy placement in survival of patients receiving mechanical ventilation. Young D, Harrison DA, Cuthbertson, MD, Rowan K D Phil. JAMA 2012; 309: Conclusions Early tracheostomy did not provide survival benefit or reduce ICU length of stay. The medical teams were wrong 50% of they times they predicted patients will likely need > 7 more days of ventilation. Early tracheostomy is not justified. Paper #4 Tracheostomy timing in traumatic brain injury: a propensity matched cohort study. Alali AS, Scales DC, Fowler RA et al. J Trauma Acute Care Surg 2014; 76: Avoid the secondary insult of hypoxia! Studied patients in TQIP data base with TBI and who had a tracheostomy Early tracheostomy Trach in < 8 days n=873 Age 49 Admit GCS (median) 4 Head AIS 3 9% 4 46% 5 46% Late tracheostomy Trach in > 8 days. n=938 Age 53 Admit GCS (median) 7 Head AIS 3 6% 4 30% 5 44% Patients who had early tracheostomy did not have a lower odds of death ET 8.4% versus LT 6.8% Tracheostomy shortened ventilator days and ICU days

To trach or not to trach? Two tactics: preemptive trach versus wait and see. Conclusion Data supports the wait and see about 10 days.

Safety of bedside percutaneous tracheostomy in the critically ill: evaluation of more than 3,000 procedures Dennis BM, Eckert MJ Gunter OL et al.

bleeding, tube occlusion 5 cases of tracheal stenosis 2 Deaths tube dislodgement 16% had a body mass index > 35 Conclusions: The percutaneous

exclusively performed by a team who follow a protocol.

9 To trach or not to trach? Two tactics: preemptive trach versus wait and see. Conclusion Data supports the wait and see about 10 days. Medicare pays more to hospitals for patients whose DRG indicates the patient had > 96 hours of mechanical ventilation through a tracheostomy. Safety of bedside percutaneous tracheostomy in the critically ill: evaluation of more than 3,000 procedures Dennis BM, Eckert MJ Gunter OL et al. J Am Coll Surg 2013; 216, ,162 percutaneous dilational tracheostomies Complications and deaths 12 immediate complications airway loss, bleeding, tube occlusion 5 cases of tracheal stenosis 2 Deaths tube dislodgement 16% had a body mass index > 35 Conclusions: The percutaneous tracheostomy is safe, even in patients with a BMI > 35 Low complications and very low death rates can be achieved by having the procedure exclusively performed by a team who follow a protocol. Motorcycle rider collides with a wire, presents with stridor, severe agitation and inability to phonate. Lateral C spine shows suspected larynx injury. An immediate tracheostomy using local anesthesia was completed within 25 minutes of the patient s arrival.

What should be done to treat the anemia of ICU patients? Simplistic concept: Red blood cells are like box cars, and if you want to deliver more oxygen increase the number of box cars.

10 What should be done to treat the anemia of ICU patients? Simplistic concept: Red blood cells are like box cars, and if you want to deliver more oxygen increase the number of box cars. We trod the hard road of trial and error. A landmark study A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care Hebert PC, Wells G, Blajchman MA et al. Canadian Critical Care Trials Group. 1999; N Engl J Med. 340: Comparison of liberal and restrictive transfusion practices leads to conclusion: Fewer transfusions and lower hemoglobin (~ 8 g/dl) provides superior results. Two strategies: Transfuse red cell units to keep hemoglobin between either 7 to 9 g/dl or 10 to 12 g/dl Restrictive strategy (n=418) Liberal strategy (n=420) P value Hemoglobin entering 8 +/ 1 g/dl 8 +/ 1 g/dl study > 1 organs failing 74% 77% Vasoactive drugs 37% 37% Hemoglobin during 8 +/ 1 g/dl 11 +/ 1 g/dl P < 0.01 study Red cell units 2.6 +/ / 5.3 P < 0.01 transfused Hospital death % 22.2% 28.1% P = 0.05 > 1 organs failing 76% 80.5% NS Hebert et al. N Engl J Med. 340: Kaplan Meier survival curves were similar Hebert et al. N Engl J Med. 340: Kaplan Meier survival curves revealed patients under the age of 55 were more likely to die if transfused to Hgb > 10 g/dl Hebert et al. N Engl J Med. 340:

Page #3 Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial.

In a 2 X 2 factorial design, 200 patients with TBI (exclude GCS 3, fixed dilated) Average Hemoglobin levels Day 9 Day 16 GOS at 6 months = moderate to good Erythropoietin 10.7 10.8 43% Placebo 10.

11 Page #3 Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. Robertson CS, Hannay J, Yamal J et al 2014; JAMA; 312: A randomized control trial: neither transfusion to keep Hgb > 10 g/dl nor erythropoietin improved neurological outcome at 6 months. In a 2 X 2 factorial design, 200 patients with TBI (exclude GCS 3, fixed dilated) Average Hemoglobin levels Day 9 Day 16 GOS at 6 months = moderate to good Erythropoietin % Placebo % Transfusion trigger 7 g/dl Transfusion Trigger 10 g/dl % % No difference in survival in the two groups. Administration of Epo and transfusion trigger of 10 g/dl did not lead to superior outcome. Erythropoietin or placebo No difference No difference Caution: transfusion to a keep Hgb > 10 g/dl increased prevalence of thromboembolic events. Transfusion trigger 7 or 10 Paper #2 A multicenter, randomized clinical trial of IV Iron Supplementation for anemia of traumatic critical illness. Pieracci FM, Stovall RT, Jaouen B et al. 2014; Crit Care Med 42: Iron loading did not push up the erythropoiesis. Adult patient in an ICU with a hemoglobin < 12 g/dl were randomized to be given IV infusion of 100 mg of iron sucrose thrice weekly Adult patient in an ICU with a hemoglobin < 12 g/dl had no measurable benefit from IV infusion of 100 mg of iron sucrose thrice weekly Iron sucrose infusions Placebo P value RBC per study day ICU Length of stay Antibiotics days days 16 days NS NS No difference In hemoglobin Mortality 9.3% 2.7% 0.09 Pieracci et al. Crit Care Med, 2014

What is best treatment for the anemic patients in an ICU?

of patients and benefit them. Implied old blood (on the shelf more than 28 days) is bad blood when you are critically ill.

Begin resuscitation with intravenous infusion of universal donor red blood cells.

For every unit of RBC give one unit of FFP and one unit of platelets. The 1:1:1 goal!

Damage control resuscitation is required by ~ 10% of Combat Casualties Colonel John Holcomb, MC, USA Surgical Consultant, Iraq.

A failed damage control resuscitation: 16 RBC 6 FFP 1(=6U) apheresis platelets The ABC of civilian practice is substituted for CAB in military practice.

12 What is best treatment for the anemic patients in an ICU? Transfuse to keep Hgb > 7 g/dl Jungle Operating Room Howard Baer: 1944 The most recent evidence refutes earlier reports that erythropoietin can boost the hemoglobin of patients and benefit them. Implied old blood (on the shelf more than 28 days) is bad blood when you are critically ill. The axioms of damage control resuscitation On ED arrival identify a patient likely to need a massive transfusion. Begin resuscitation with intravenous infusion of universal donor red blood cells. Aim to achieve a SBP of 90 mmhg, and then move promptly to OR/angiography suite and control hemorrhage. For every unit of RBC give one unit of FFP and one unit of platelets. The 1:1:1 goal! Surgeons should rely upon damage control methods: Prompt hemostasis Abbreviated surgery Stop the vicious downward cycle of hypothermia, acidemia and coagulopathy Damage control resuscitation is required by ~ 10% of Combat Casualties Colonel John Holcomb, MC, USA Surgical Consultant, Iraq. Notified a seriously injured patient was coming to our FST, the nurse and anesthesia provider set up the Belmont rapid infusion device. A failed damage control resuscitation: 16 RBC 6 FFP 1(=6U) apheresis platelets The ABC of civilian practice is substituted for CAB in military practice. Paper #1 The PROPPR Randomized Controlled Trial Transfusion of plasma, platelets and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma. Holcomb and > 25 investigators JAMA 2015; 313: Adult injured patients transported to 12 Level I trauma centers Patients whom the trauma surgeon predicted would likely need a massive transfusion were recruited within 60 minutes of ED arrival. 1:1: (1 unit RBC) Group (n = 338) Median Age: 34 Male 78% Admit SBP < 90 mmhg: 38% Admit Hgb 12 g/dl Admit Base Excess 8 meq/l Blunt Trauma 55% 1:1: (2 unit RBC) Group (n = 342) 34 83% 39% 12 g/dl 9 meq/l 51% Achieved goal of 1 FFP to 1RBC VS 1FFP to 2RBC

= massive transfusion Outcome: no difference in mortality Blood product units Median FFP/RBC = 1 Median FFP/RBC = 0.5 24 Hour Mortality 1:1:1 = 12.7% 1:1:2 = 17.0% P =.

1% P =.26 Hazard ratio = 0.83; not significant Fewer patients in the 1:1:1 group experienced death by 24 hours.

03 After 30 days Deaths 1:1:1 75/338 1:1:2 89/342 Cause of death was Exsanguination: 1:1:1 36/338 = 10.6% 1:1:2 50/342 = 14.

13 = massive transfusion Outcome: no difference in mortality Blood product units Median FFP/RBC = 1 Median FFP/RBC = Hour Mortality 1:1:1 = 12.7% 1:1:2 = 17.0% P =.12 Blood products (median) received during first 24 hours: 1:1:1 Group 9 u RBC, 7 u FFP and 12 u Platelets 1:1:2 Group 9 u RBC, 5 u FFP and 6 u Platelets 30 day Mortality 1:1:1 = 22.4% 1:1:2 = 26.1% P =.26 Hazard ratio = 0.83; not significant Fewer patients in the 1:1:1 group experienced death by 24 hours. First 24 hours Deaths 1:1:1 43/338 1:1:2 58/342 Cause of death was Exsanguination: 1:1:1 31/338 = 9.2% 1:1:2 50/342 = 14.6% Fewer deaths from exsanguination in 1:1:1. p = 0.03 After 30 days Deaths 1:1:1 75/338 1:1:2 89/342 Cause of death was Exsanguination: 1:1:1 36/338 = 10.6% 1:1:2 50/342 = 14.6% The 1:1:1 tactic is effective and was not associated with increased risk of complications Conclusions: Trauma centers can achieve 1:1:1 transfusion scheme by having pre thawed plasma. An injured patient who had bled into shock needs Type O blood transfusion and universal donor FFP (Group A and B). Early coagulation factor infusion reduced risk of death from exsanguination. Massive blood loss Mandates a box of blood Romeo and Juliet 1968 Directed by Franco Zeffirelli William Shakespeare [ ] On needing a surgeon MERCUTIO: Go villain, fetch a surgeon. ROMEO: Courage, man. The hurt cannot be much. MERCUTIO: No, tis not so deep as a well, nor so wide as a church door; but tis enough twill serve. Ask for me tomorrow, and you shall find me a grave man. Romeo and Juliet III, i 97 Summary of Top Ten Trauma papers BCVI is rare, but early diagnosis and anticoagulation reduces risk of stroke Blunt Aortic Injuries: most treated with TEVAR or observation combined with BP control. but 30% heal. TBI: Best to avoid brain injury. Neurosurgeons should promptly drain mass lesions. Treating a TBI patient, the ICU team must avoid hypoxia, hypotension. Wait about 10 days before tracheostomy in ICU ventilated patients The transfusion trigger is ~ 7 g/dl; avoid old blood. In patients needing a massive transfusion, 1:1:1 is the ideal tactic for reducing risk of exsanguination.

14 Thank you!

TEVAR for trauma is here to stay: Advances in the Treatment of Blunt Thoracic Aortic Injury

TEVAR for trauma is here to stay: Advances in the Treatment of Blunt Thoracic Aortic Injury Megan Brenner MD MS RPVI FACS Associate Professor of Surgery Division of Trauma/Surgical Critical Care, RA Cowley