Letters to the Editor / Injury, Int. J. Care Injured 46 (2015) 2073–2087
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This, when the authors concede that the group of patients treated with TSP had a higher proportion of ‘more advanced level of fracture’. 2) The authors have determined whether the extent of lesser trochanter comminution could increase the risk of a lateral wall fracture. If more than 2 cm, lesser trochanter comminution is deemed present. However they have not explained what exactly have they measured. Have they measured the length of the lesser trochanter fragment or the extent of comminution as measured by Collinge et al. [1] on 2D CT scans. Our concern is that is it valid to measure either length or extent of comminution on radiographs, given the fact that the lesser trochanter fragment is often flexed, due to the pull of the iliopsoas [2,3] and its length may therefore not be correctly determined on plain radiographs . Similarly there may be comminuted fragments lying posterior to the lesser trochanter fragment and therefore not discernible on plain radiographs. This is critical as the P value has come out to be 0.056.
Conflict of interest The authors declare that they have no conflict of interest. References [1] Collinge CA, Mir H, Reddix R. Fracture morphology of high shear angle ‘‘vertical’’ femoral neck fractures in young adult patients. J Orthop Trauma 2014;28: 270–5. [2] Sharma G, Singh R, Kumar A, Sharma V, Farooque K. Acute femoral artery pseudoaneurysm due to lesser trochanter fragment: an unusual complication of an intertrochanteric fracture. Chin J Traumatol 2013;16(5):301–3. [3] Sharma G, Kumar GNK, Yadav S, Lakhotia D, Singh R, Gamanagatti S, Sharma V. Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility. Injury 2014;45(12):1950–7.
Gaurav Sharma* Vijay Sharma Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, All India Institute of Medical Sciences, India *Corresponding author. Tel.: +91 9810758543 E-mail address: [email protected] (G. Sharma).
http://dx.doi.org/10.1016/j.injury.2015.07.026
haemorrhage and a high likelihood of significant transfusion requirements. There were 176 ‘Code Red’ activations during the 30-month study period. 115 (91%) of the patients declared ‘Code Red’ in the pre-hospital phase received blood product transfusion following hospital arrival. More interestingly, considering blood product transfusion in ‘Code Red’ patients in the first 24-h, besides the 10.4 units (95% CI 8.4–12.3 units) mean packed red blood cell transfusion and the 4 units (95% CI 2.7–5.2) mean fresh frozen plasma transfusion, the mean platelet transfusion was 0 units. However, there is a growing body of evidence that early use of higher platelets ratio in massive transfusion protocol can improve outcome of severe haemorrhage trauma patients. Actually, one method to improve the outcome of rapidly bleeding patients is to deliver predetermined ratios of platelets, plasma, and red blood cells (RBCs). However, the optimal ratio of these products is unclear. In military setting, the current United States Department of Defense guideline specifies the use of 1:1:1 [2,3]. Furthermore, according to the French military guideline, since the French Military Health Service has not opted for platelet preparation on theatres of operation, platelets inputs are provided by whole blood transfusion [4]. In civilian observational studies, a large observational transfusion study of bleeding trauma patients, the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, was conducted in 10 Level I trauma centres in the US [5]. In PROMMTT, clinicians generally delivered transfusion ratios that cumulated in the range of 1:1 or 1:2. More recently, another large, pragmatic, phase 3, multisite, randomised clinical trial comparing blood product ratios and collecting serial blood samples, the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial determined the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets and red blood cells in 1:1:1 ratio (338 patients) compared with a 1:1:2 ratio (331 patients) [6,7]. Although without significant differences detected in mortality at 24 h, more patients in the 1:1:1 group achieved haemostasis than in the 1:1:2 group (86% vs. 78%, respectively. p = 0.006) and fewer experienced death due to exsanguination by 24 h. Finally, in PROPPR, platelets were transfused not only within the first pack of massive transfusion but also were transfused first. To conclude we would like to know if the authors could give more details about the implementation of a massive transfusion protocol in their Trauma Centre, with special insights into the platelets:RBC ratio applied; and if they could provide their opinion regarding these current trends in transfusion in patients with severe trauma. Conflict of interest All authors declare no conflict interest. References
Letter to the Editor Platelets in the ‘Code Red’ transfusion request policy initiated by pre-hospital physicians We read with interest the study by Weaver et al. about the implementation of a pre-hospital transfusion request policy where a pre-hospital physician can request the presence of a major transfusion pack on arrival at the destination trauma centre [1]. The authors demonstrated that three simple criteria (suspicion or evidence of active haemorrhage; systolic blood pressure (BP)
2086
This, when the authors concede that the group of patients treated with TSP had a higher proportion of ‘more advanced level of fracture’. 2) The authors have determined whether the extent of lesser trochanter comminution could increase the risk of a lateral wall fracture. If more than 2 cm, lesser trochanter comminution is deemed present. However they have not explained what exactly have they measured. Have they measured the length of the lesser trochanter fragment or the extent of comminution as measured by Collinge et al. [1] on 2D CT scans. Our concern is that is it valid to measure either length or extent of comminution on radiographs, given the fact that the lesser trochanter fragment is often flexed, due to the pull of the iliopsoas [2,3] and its length may therefore not be correctly determined on plain radiographs . Similarly there may be comminuted fragments lying posterior to the lesser trochanter fragment and therefore not discernible on plain radiographs. This is critical as the P value has come out to be 0.056.
Conflict of interest The authors declare that they have no conflict of interest. References [1] Collinge CA, Mir H, Reddix R. Fracture morphology of high shear angle ‘‘vertical’’ femoral neck fractures in young adult patients. J Orthop Trauma 2014;28: 270–5. [2] Sharma G, Singh R, Kumar A, Sharma V, Farooque K. Acute femoral artery pseudoaneurysm due to lesser trochanter fragment: an unusual complication of an intertrochanteric fracture. Chin J Traumatol 2013;16(5):301–3. [3] Sharma G, Kumar GNK, Yadav S, Lakhotia D, Singh R, Gamanagatti S, Sharma V. Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility. Injury 2014;45(12):1950–7.
Gaurav Sharma* Vijay Sharma Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, All India Institute of Medical Sciences, India *Corresponding author. Tel.: +91 9810758543 E-mail address: [email protected] (G. Sharma).
http://dx.doi.org/10.1016/j.injury.2015.07.026
haemorrhage and a high likelihood of significant transfusion requirements. There were 176 ‘Code Red’ activations during the 30-month study period. 115 (91%) of the patients declared ‘Code Red’ in the pre-hospital phase received blood product transfusion following hospital arrival. More interestingly, considering blood product transfusion in ‘Code Red’ patients in the first 24-h, besides the 10.4 units (95% CI 8.4–12.3 units) mean packed red blood cell transfusion and the 4 units (95% CI 2.7–5.2) mean fresh frozen plasma transfusion, the mean platelet transfusion was 0 units. However, there is a growing body of evidence that early use of higher platelets ratio in massive transfusion protocol can improve outcome of severe haemorrhage trauma patients. Actually, one method to improve the outcome of rapidly bleeding patients is to deliver predetermined ratios of platelets, plasma, and red blood cells (RBCs). However, the optimal ratio of these products is unclear. In military setting, the current United States Department of Defense guideline specifies the use of 1:1:1 [2,3]. Furthermore, according to the French military guideline, since the French Military Health Service has not opted for platelet preparation on theatres of operation, platelets inputs are provided by whole blood transfusion [4]. In civilian observational studies, a large observational transfusion study of bleeding trauma patients, the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, was conducted in 10 Level I trauma centres in the US [5]. In PROMMTT, clinicians generally delivered transfusion ratios that cumulated in the range of 1:1 or 1:2. More recently, another large, pragmatic, phase 3, multisite, randomised clinical trial comparing blood product ratios and collecting serial blood samples, the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial determined the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets and red blood cells in 1:1:1 ratio (338 patients) compared with a 1:1:2 ratio (331 patients) [6,7]. Although without significant differences detected in mortality at 24 h, more patients in the 1:1:1 group achieved haemostasis than in the 1:1:2 group (86% vs. 78%, respectively. p = 0.006) and fewer experienced death due to exsanguination by 24 h. Finally, in PROPPR, platelets were transfused not only within the first pack of massive transfusion but also were transfused first. To conclude we would like to know if the authors could give more details about the implementation of a massive transfusion protocol in their Trauma Centre, with special insights into the platelets:RBC ratio applied; and if they could provide their opinion regarding these current trends in transfusion in patients with severe trauma. Conflict of interest All authors declare no conflict interest. References
Letter to the Editor Platelets in the ‘Code Red’ transfusion request policy initiated by pre-hospital physicians We read with interest the study by Weaver et al. about the implementation of a pre-hospital transfusion request policy where a pre-hospital physician can request the presence of a major transfusion pack on arrival at the destination trauma centre [1]. The authors demonstrated that three simple criteria (suspicion or evidence of active haemorrhage; systolic blood pressure (BP)
