Goal-directed platelet transfusions correct platelet dysfunction and may improve survival in patients with severe traumatic brain injury. (Newman)

Furay E, et al. Goal-directed platelet transfusions correct platelet dysfunction and may improve survival in patients with severe traumatic brain injury. J Trauma Acute Care Surg. 2018 Nov;85(5):881-887.

BACKGROUND: Platelet dysfunction, defined as adenosine diphosphate inhibition greater than 60% on thromboelastogram, is an independent predictor of increased mortality in patients with severe traumatic brain injury (TBI). We changed our practice to transfuse platelets for all patients with severe TBI and platelet dysfunction. We hypothesized that platelet transfusions would correct platelet dysfunction and improve mortality in patients with severe TBI.

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Utility of diaphragm pacing in the management of acute cervical spinal cord injury. (Dalal)

Kerwin AJ, et al. Utility of diaphragm pacing in the management of acute cervical spinal cord injury. J Trauma Acute Care Surg. 2018 Jul 5. [Epub ahead of print]

BACKGROUND: Cervical spinal cord injury (CSCI) is devastating. Respiratory failure, ventilator associated pneumonia (VAP), sepsis, and death frequently occur. Case reports of diaphragm pacing (DPS) have suggested earlier liberation from mechanical ventilation in acute CSCI patients. We hypothesized DPS implantation would decrease VAP and facilitate liberation from ventilation.

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Severely Injured Trauma Patients With Admission Hyperfibrinolysis; Is There A Role Of Tranexemic Acid? (Lima)

Khan M, et al. Severely Injured Trauma Patients With Admission Hyperfibrinolysis; Is There A Role Of Tranexemic Acid? Findings From The PROPPR Trial. J Trauma Acute Care Surg. 2018 Feb 5. [Epub ahead of print]

INTRODUCTION: Administration of tranexemic acid (TXA) in coagulopathy-of-trauma (COT) gained popularity after the CRASH-2 trial. The aim of our analysis was to analyze the role of TXA in severely injured trauma patients with admission hyperfibrinolysis.

METHODS: We reviewed the prospectively collected Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) database. We included patients with admission hyperfibrinolysis (Ly30>3%) on thromboelastography. Patients were stratified into two groups (TXA and No-TXA) and were matched in 1:2 ratio using propensity score matching for demographics, admission vitals, and injury severity. Primary outcome measures were 6h, 12h, 24hr, and 30d mortality, 24-hour transfusion requirements, time to achieve hemostasis and re-bleeding after hemostasis requiring intervention. Secondary outcome measures were thrombotic complications.

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Early Propranolol After Traumatic Brain Injury is Associated With Lower Mortality.

Ko A, et al. Early propranolol after traumatic brain injury is associated with lower mortality. J Trauma Acute Care Surg. 2016 Apr;80(4):637-42.

BACKGROUND: β-Adrenergic receptor blockers (BBs) administered after trauma blunt the cascade of immune and inflammatory changes associated with injury. BBs are associated with improved outcomes after traumatic brain injury (TBI). Propranolol may be an ideal BB because of its nonselective inhibition and ability to cross the blood-brain barrier. We determined if early administration of propranolol after TBI is associated with lower mortality.

METHODS: All adults (age ≥ 18 years) with moderate-to-severe TBI (head Abbreviated Injury Scale [AIS] score, 3-5) requiring intensive care unit (ICU) admission at a Level I trauma center from January 1, 2013, to May 31, 2015, were prospectively entered into a database. Administration of early propranolol was dosed within 24 hours of admission at 1 mg intravenous every 6 hours. Patients who received early propranolol after TBI (EPAT) were compared with those who did not (non-EPAT). Data including demographics, hospital length of stay (LOS), ICU LOS, and mortality were collected.

RESULTS: Over 29 months, 440 patients with moderate-to-severe TBI met inclusion criteria. Early propranolol was administered to 25% (109 of 440) of the patients. The EPAT cohort was younger (49.6 years vs. 60.4 years, p < 0.001), had lower Glasgow Coma Scale (GCS) score (11.7 vs. 12.4, p = 0.003), had lower head AIS score (3.6 vs. 3.9, p = 0.001), had higher admission heart rate (95.8 beats/min vs. 88.4 beats/min, p = 0.002), and required more days on the ventilator (5.9 days vs. 2.6 days, p < 0.001). Similarities were noted in sex, Injury Severity Score (ISS), admission systolic blood pressure, hospital LOS, ICU LOS, and mortality rate. Multivariate regression showed that EPAT was independently associated with lower mortality (adjusted odds ratio, 0.25; p = 0.012).

CONCLUSION: After adjusting for predictors of mortality, early administration of propranolol after TBI was associated with improved survival. Future studies are needed to identify additional benefits and optimal dosing regimens.

LEVEL OF EVIDENCE: Therapeutic study, level IV.