Andrew L. Tang

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BACKGROUND: Pelvic angioembolization (AE) is a mainstay in the treatment algorithm for pelvic hemorrhage from pelvic fractures. Nonselective AE refers to embolization of the bilateral internal iliac arteries (IIAs) proximally rather than embolization of their tributaries distally. The aim of this study was to quantify the effect of nonselective pelvic AE on pelvic venous flow in a swine model. We hypothesized that internal iliac vein (IIV) flow following IIA AE is reduced by half. METHODS: Nine Yorkshire swine underwent nonselective right IIA gelfoam AE, followed by left. Pelvic arterial and venous diameter, velocity, and flow were recorded at baseline, after right IIA AE and after left IIA AE. Linear mixed-effect model and signed rank test were used to evaluate significant changes between the three time points. RESULTS: Eight swine (77.8 ± 7.1 kg) underwent successful nonselective IIA AE based on achieving arterial resistive index of 1.0. One case was aborted because of technical difficulties. Compared with baseline, right IIV flow rate dropped by 36% ± 29% (p < 0.05) and 54% ± 29% (p < 0.01) following right and left IIA AE, respectively. Right IIA AE had no initial effect on left IIV flow (0.37% ± 99%, p = 0.95). However, after left IIA AE, left IIV flow reduced by 54% ± 27% (p < 0.01). Internal iliac artery AE had no effect on the external iliac arterial or venous flow rates and no effect on inferior vena cava flow rate. CONCLUSION: The effect of unilateral and bilateral IIA AE on IIV flow appears to be additive. Despite bilateral IIA AE, pelvic venous flow is diminished but not absent. There is abundant collateral circulation between the external and internal iliac vascular systems. Arterial embolization may reduce venous flow and improve on resuscitation efforts in those with unstable pelvic fractures. LEVEL OF EVIDENCE: Prognostic, level IV.

Introduction: Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large‐bore 32–40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX.Methods: Prospective RCT comparing 14Fr PCs to 28–32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1–5 (1 = tolerable experience, 5 = worst experience). Unpaired Student's t‐test, chi‐square and Wilcoxon rank‐sum test were utilized with significance set at P < 0.05.Results: Forty‐three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375–1087; for PCs vs. 400 ml; IR, 240–700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, “I can tolerate it”; IR, 1–2) than CT patients (median, 3, “It was a bad experience”; IR, 3–4, P = 0.001).Conclusion: In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28–32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience.www.ClinicalTrials.gov Registration ID: NCT02553434

BACKGROUND: Liquid packed red blood cells (LPRBCs) have a limited shelf life and worsening quality with age. Cryopreserved packed red blood cells (CPRBCs) can be stored up to 10 years with no quality deterioration. The effect of CPRBCs on outcomes in civilian trauma is less explored. This study aims to evaluate the safety and efficacy of CPRBCs in civilian trauma patients.METHODS: We analyzed the (2015–2016) Trauma Quality Improvement Program, including adult (age, ≥18 years) patients who received a RBC transfusion within 4 hours of admission. Patients were stratified, those who received LPRBC and those who received CPRBC. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were major complications. Propensity matching was performed adjusting for demographics, vitals, blood components, injury parameters, comorbidities, and center parameters.RESULTS: A total of 39,975 patients were identified, and a matched cohort of 483 was obtained. A total of 161 received CPRBC (CPRBC, 2 [2–4]; plasma, 2 [0–5]; platelets, 1 [0–2]) and 322 received LPRBC (LPRBC, 3 [2–6]; plasma, 3 [0–6]; platelets, 1 [0–2]). The mean age was 43 ± 22 years, 62% were men, Injury Severity Score was 18 (12–27), and 65% had a blunt injury. Patients who received CPRBC had similar 24-hour mortality (1.8% vs. 2.3%;p= 0.82) and in-hospital mortality (4.9% vs. 5.2%;p= 0.88). No difference was found in terms of complications (15.3% vs. 17.2%;p= 0.21) between the two groups.CONCLUSION: Transfusion of CPRBCs may be as safe and effective as transfusion of LPRBCs in moderately injured trauma patients. Cryopreservation has the potential to expand our transfusion armamentarium in diverse settings, such as periods of increased usage, disaster scenarios, and rural areas.LEVEL OF EVIDENCE: Therapeutic study, level III.