Trauma: Overview

Abstract
Background: Hemorrhage is a leading cause of preventable mortality in trauma. During times of blood shortages, it may be prudent to consider a transfusion threshold during massive transfusion after which additional transfusions are futile due to nonsurvivability. The main objective of this study is to examine outcomes associated with ultramassive transfusion (UMT; defined as ≥20 units of red blood cells [RBC] within 24 hours) and determine if there is a threshold beyond which additional transfusion efforts should cease.

Methods: We performed a retrospective (2016-2022) analysis of adult trauma patients (≥ 18 years old) who underwent surgery and received blood products within 24 hours of admission at 7 US Level I trauma centers. We compared patients who received UMT and patients who received <20 units RBC and evaluated the effects of various amounts of blood products on mortality, length of stay (LOS), mechanical ventilation (MV), and complications. Segmented logistic regression analysis was performed to determine if there is a "plateau" effect of increasing RBC units on mortality.

Results: Of 3248 patients included, 2913 (89.7%) received <20 RBC units within 24 hours, and 333 (10.3%) received ≥20 RBC units within 24 hours. Patients receiving UMT had increased 24-hour mortality (risk ratio [RR] 6.00, 95% confidence interval [CI], 4.79-7.52, P < .001) and index hospitalization mortality (RR 3.99 [3.34-4.75], P < .001). These patients also more often developed complications (RR 1.67 [1.44-1.94], P < .001) and multiple organ failure (RR 2.78 [2.20-3.52], P < .001). Compared to those receiving 20 to 29 RBC units, those receiving 30 to 44 RBC units had statistically similar associated risk of death (RR 1.32 [0.93-1.87], P = .12); however, those receiving ≥45 RBC units had an increased associated risk of death (RR 1.59, [1.12-2.25], P = .009), and additional transfusion beyond this point did not improve the probability of survival.

Conclusions: In this study, patients who received UMT had higher mortality and worse outcomes than those who received fewer units. However, this study did not identify a threshold beyond which all patients died and therefore cannot justify implementing a limit on the number of RBC units transfused based on these data alone.

Abstract
Objective: This study aimed to evaluate the effects of acupuncture combined with hyperbaric oxygenation (HBO) compared with HBO alone in improving the disturbance of consciousness (DOC) of people with traumatic brain injury (TBI).

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in this study. In accordance with the preestablished search strategy, all the literature was obtained from eight online databases. Following the stringent application of inclusion and exclusion criteria, two researchers conducted an independent extraction of valid data from eligible randomized controlled trials (RCTs). The risk of bias in each study was assessed using the Cochrane Risk of Bias 2.0 tool. The meta-analysis was conducted utilizing the RevMan software. Adverse events were determined based on data from each study assessing the safety of acupuncture treatment.

Results: A total of 11 RCTs with 896 participants were included in the analysis. Overall, the methodological quality of the RCTs encompassed within this meta-analysis was below standard. The pooled data demonstrated that acupuncture treatment combined with HBO was significantly superior to HBO alone, based on the Glasgow Coma Scale (GCS) scores [mean difference (MD) = 2.13, 95% confidence interval (CI): 1.64-2.62, p < 0.00001]. We also found that electroacupuncture (EA) combined with HBO improved GCS scores more than HBO alone in TBI patients (MD = 2.15, 95% CI: 1.95-2.36). The early intervention (MD = 3.09, 95% CI, 2.66-3.52) demonstrated significantly more significant improvement in GCS scores following combination therapy compared with the late intervention group (MD = 1.86, 95% CI, 1.47-2.25). Furthermore, compared with HBO alone, acupuncture combined with HBO significantly improved patients' consciousness rate (CR) (RR = 2.26, 95% CI: 1.48-3.46). Statistical analysis also revealed that acupuncture combined with HBO improved the effective rate (ER) (RR = 1.47, 95% CI: 1.27-2.69). Additionally, no studies reported any significant adverse events.

Conclusion: Compared with HBO alone, acupuncture combined with HBO has a more substantial positive effect on GCS scores, AR, and ER in patients with TBI. However, given the limited availability of high-quality evidence and the dearth of RCTs in this area, the conclusions drawn herein warrant validation through additional research endeavours.

Abstract
Background: Endotracheal intubation is essential for airway management in trauma patients but may cause hemodynamic instability and delay critical resuscitation measures. Recent studies have suggested that emergency department (ED) intubation may be linked with higher mortality compared to operating room (OR) intubation in trauma patients. However, it remains unclear if these findings apply to broader trauma populations, including both civilian and military patients. This study uses a nationwide trauma registry to test the hypothesis that ED intubation is associated with higher in-hospital mortality among major trauma patients, compared to OR intubation.

Methods: Registry-based analysis of the Israeli National Trauma Registry evaluating major trauma (Injury Severity Score [ISS] ≥16) patients requiring hemorrhage control surgery between 2016 and 2023. ED intubation was the main exposure variable with in-hospital mortality serving as the primary outcome. Multivariable logistic regression and propensity score matching were applied to adjust for confounders, including injury severity, ED vital signs, penetrating injury, and blood product administration.

Results: The study included 975 patients, 470 (48.2%) of whom were intubated in the ED. ED-intubated patients had significantly higher ISS and higher proportion of profound shock compared to those intubated in the OR. In-hospital mortality was more common among patients intubated in the ED (22.6%) as compared with those intubated in the OR (8.5%). In the unadjusted logistic regression, ED intubation was associated with higher odds of in-hospital mortality (OR: 3.13, 95% confidence interval [CI], 2.15-4.62). However, after adjusting for several potential confounders, the association became nonsignificant and was persistent across sensitivity subgroup analyses. Propensity score matching resulted in 1:1 matching of 271 patients in each group, balancing characteristics such as ISS, profound shock, Glasgow Coma Scale, and penetrating injury. After matching, the mortality rate was similar between groups (12.5% for ED intubation vs 12.2% for OR intubation). In the matched cohort, logistic regression demonstrated no significant association between ED intubation and in-hospital mortality (OR: 0.97, 95% CI, 0.58-1.61). ED intubation was associated with a greater than 2-fold increase in odds of ICU admission in adjusted and propensity score-matched analyses.

Conclusions: ED intubation was not significantly associated with increased in-hospital mortality after controlling for injury severity and shock. These findings suggest that while ED intubation may be more frequent in severely injured patients, its independent impact on mortality in patients undergoing emergent surgery remains unclear, warranting further prospective investigation.