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oelastography (TEG). Using an electronic transducer and alament suspended in a whole blood sample, TEG mea-ures initiation of coagulation, propagation kinetics, fibrin-latelet interaction, clot strength, and fibrinolysis indepen-ent of sample temperature (7). This provides betterdentification of the deficient component of the coagula-ion cascade, potentially permitting more targeted ther-py for coagulopathy reversal (8). In a prospective ani-al study using TEG, Martini et al. demonstrated that

hypothermia inhibited clotting times and clotting rates,hereas hemorrhage impaired clot strength. The combi-ation of hypothermia with hemorrhage impaired allhese clotting parameters” (6). Similar results have beeneported in human studies (9). Further, TEG results arevailable to the emergency physician in a little over 30in. This combination of accuracy and speed potentiallyakes TEG the ideal ED bedside test for trauma-associated

oagulopathy. However, studies utilizing TEG to deviselood component-specific and goal-directed coagulopa-hy reversal are still needed (10).

Obviously, we want to provide the best outcomes forhe most patients. We should consider the potential harmrom overuse of blood component therapy. U.S. Navynvestigators have reported that in-theater blood transfu-ion is independently associated with infection and re-ource over-utilization (11). In addition to the acutedverse effects of transfusion listed by Dr. Fraga, long-erm effects such as transfusion-associated microchimer-sm and potentially increased autoimmune disease riskave been identified in military populations after trans-usion (12,13). We should strive to, first, do no harm andecond, maximize the benefit for all our patients whenesources are scarce.

As in previous wars, the medical insights gained fromperations Iraqi Freedom and Enduring Freedom will gon to benefit generations of trauma patients. However,he dust has not settled regarding the potential benefits ofurrent in-theater transfusion recommendations. We urgell emergency physicians to enter into a discussion withheir surgical colleagues before implementing any mili-arily derived transfusion practices.

John Joseph Devlin, MD

Miguel A Gutierrez, MD

Department of Emergency MedicineNaval Medical Canter Portsmouth

Portsmouth, Virginia

doi:10.1016/j.jemermed.2009.08.069

REFERENCES

1. Fraga GP, Bansai V, Coimbra R. Transfusion of blood products intrauma: an update. J Emerg Med 2010;39:253–60. (

2. Sperry JL, Ochoa JB, Gunn SR, et al. An FFP:PRBC transfusionratio � 1:1.5 is associated with a lower risk of mortality aftermassive transfusion. J Trauma 2008;65:986–93.

3. Scalea TM, Bochicchio KM, Lumpkins K, et al. Early aggressiveuse of fresh frozen plasma does not improve outcome in criticallyinjured trauma patients. Ann Surg 2008;248:578–84.

4. Snyder CW, Weinberg JA, McGwin G, et al. The relationship ofblood product to mortality: survival benefit or survival bias?J Trauma 2009;66:358–63.

5. Hess JR, Dutton RB, Holcomb JB, Scalea TM Giving plasma at a1:1 ratio with red cells in resuscitation: who might benefit? Trans-fusion 2008;48:1763–5.

6. Martini WZ, Cortez DS, Dubick MA, Park MS, Holcomb JB.Thrombelastography is better than PT, aPTT, and activated clottingtime in detecting clinically relevant clotting abnormalities afterhypothermia, hemorrhagic shock and resuscitation in pigs.J Trauma 2008;65:535–43.

7. Rugeri L, Levrat A, David JS, et al. Diagnosis of early coagulationabnormalities in trauma patients by rotation thrombelastography.J Thromb Haemost 2007;5:289–95.

8. Jeger V, Zimmerman H, Exadaktylos AK. Can RapidTEG accel-erate the search for coagulapathies in the patient with multipleinjuries? J Trauma 2009;66:1253–7.

9. Dirkmann D, Hanke AA, Görlinger K, Peters J. Hypothermia andacidosis synergistically impair coagulation in human whole blood.Anesth Analg 2008;106:1627–32.

0. Wade CE, Dubick MA, Blackbourne LH, Holcomb JB. It is timeto assess the utility of thromboelastography in the administration ofblood products to the patient with traumatic injuries. J Trauma2009;66:1258.

1. Dunne JR, Riddle MS, Danko J, Hayden R, Petersen K. Bloodtransfusion is associated with infection and increased resourceutilization in combat casualties. Am Surg 2006;72:619–26.

2. Dunne JR, Lee TH, Burns C, Cardo LJ, Curry K, Busch MP.Transfusion-associated microchimerism in combat casualties.J Trauma 2008;64(2 Suppl):S92–8.

3. Utter GH, Lee TH, Rivers RM, et al. Microchimerism decadesafter transfusion among combat-injured US veterans from theVietnam, Korean, and World War II conflicts. Transfusion 2008;48:1609–15.

RESPONSE

To the Editor:

e would like to thank Drs. Devlin and Gutierrez forheir interest in our review article regarding massivelood transfusion in trauma (1). The authors pointed outhat a number of scientific articles were not available athe time of our submission. We appreciate the opportu-ity to comment on important data recently published.

The transfusion strategy for the severely hemorrhag-ng trauma patient cannot be universal. In this regard,rauma surgeons and emergency physicians must be ableo differentiate between “hemorrhage requiring massiveransfusion” and “hemorrhage that will likely need trans-usion.” These scenarios have different physiologic con-equences, in particular with regard to the patient’s co-gulation profile. Unfortunately, studies that seem tohallenge the benefit of a high packed red blood cells

PRBCs):fresh frozen plasma (FFP) ratio may not be

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344 Letters to the Editor

nalyzing the appropriate patient population or patientariables, thus confusing the issue.

As our colleagues have noted, Sperry et al. did nothow a crude mortality difference in patients receivingn FFP:PRBC ratio � 1:1.5 when compared to thoseho received a ratio � 1:1.5. Importantly, and perhaps

ost in the manuscript title, is the fact that patients re-eiving a higher FFP:PRBCs ratio were ultimately trans-used 16.0 units of PRBCs compared to 22.0 units in theower ratio group 24 h after injury. In addition, thisnalysis is a secondary analysis of a prospective studyetermining the genomic response after severe injury andemorrhagic shock. Therefore, patients were not ran-omized and there was insufficient power to adequatelytudy crude mortality. The study cohorts, however, wereeverely injured, with each group having a base deficit �0.7 and an admission international normalized ratio �.75 (2). An aggressive PRBC-to-FFP strategy in theseeverely hemorrhaging patients may help prevent ongo-ng coagulopathy where an already baseline coagulopa-hy exists. In comparison, the Baltimore group showedxactly what should be avoided. It is no surprise thatear-equal transfusion of PRBCs:FFP in the non-massivelyemorrhaging patient does not improve outcomes. Their50 patients receiving varying ratios of blood and FFPere not patients suffering from massive hemorrhage

nd therefore, the physiologic profile and coagulationtatus were quite different from the Sperry study. Blindlyransfusing FFP should be avoided unless there is suffi-ient evidence that the patient is massively hemorrhagingnd likely hypocoagulable (3).

We disagree that “one of the difficulties with imple-enting early FFP involves predicting, at the time of

mergency department presentation, who will go on toequire massive transfusion.” We believe that this is nothe critical issue when attempting to resuscitate a se-erely injured, massively hemorrhaging trauma patient.he real issue is that those individuals arrive at the

rauma center already coagulopathic.The concept of initial trauma-induced coagulopathy in

atients with acute severe hemorrhage being due to di-ution of coagulation factors is wrong and outdated. Evenf this theory was valid, aggressive infusion of plasmatill offers the best chance for correction of coagulopa-hy. In this regard, Hirschberg et al., using a computer-zed model, showed that dilution of clotting factors ineverely hemorrhaging patients is generally underesti-ated, and rapid infusion of plasma is useful in prevent-

ng the dilution of coagulation factors due to aggressiveuid resuscitation (4). Several studies have clearly doc-mented that the development of early trauma-inducedoagulopathy is accompanied by high mortality rates.

ho develops early coagulopathy after injury? The an-

wer is clear: severely injured patients (high injury se- t

erity scores) presenting with acute hemorrhage andhock. When do they develop coagulopathy? The answers also clear: immediately after the injury. Most of thoseatients will be coagulopathic during transport and uponrrival to the trauma center (5–9). Waiting for laboratoryests before FFP infusion will certainly delay hemostasis.

Finally, the group from the University of Alabama didhow that the mortality benefit from a near 1:1 ratio inassively hemorrhaging patients might be secondary to

tatistical aberrancy when a time-dependent variant wasncluded. They called it survival bias (10). However, it ismportant to note that 1:1 transfusion in their analysisas not done as part of an established protocol resusci-

ating with PRBCs and FFP evenly. Rather, the first unitf PRBC was given at a median time of 18 min, whereashe first unit of FFP was given at a median time of 93in. An established massive transfusion protocol aggres-

ively and evenly transfusing PRBCs, FFP, and plateletsay ameliorate statistical discrepancies and show a mor-

ality improvement. In fact, instead of a survival bias, byot having the state of readiness required to transfuseeverely injured patients with early trauma-induced co-gulopathy (immediate availability of thawed plasma),hey might have described what others would call a deathias instead.

Teixeira et al. showed that early and higher ratios ofFP:PRBCs decreased mortality in massively hemor-haging patients. These patients were transfused withittle lag time between PRBCs, FFP, and platelet thera-ies (11).

The ideal ratio between PRBCs, FFP, and platelets istill under investigation. The current proposed strategy ofhemostatic resuscitation” or “damage control resuscita-ion,” part of which is a high PRBCs:FFP:platetet ratio,ay be effective not only due to an “ideal” PRBCs:FFP

atio, but also due to the aggressiveness and readinessequired to have thawed plasma immediately availableor infusion concomitantly with PRBCs (12).

In a recent publication, Zink et al. addressed the issuef PRBCs:FFP:platelet ratio in a multi-institutional fash-on (13). To address the issue of “survival bias,” theyxcluded patients who died within 30 min from admis-ion to the trauma center, as it was unlikely that anyesuscitative strategy would change the final outcome.he following transfusion component ratios were stud-

ed: � 1:4, � 1:4–1:1, and � 1:1. A marked decrease in-h and in-hospital mortality was observed (37.3%, 15.2%,nd 2.0%, and 54.9%, 41.1%, 25.5%, respectively) fromFP:PRBC’s ratios as well as for platelet:PRBC’s ratios22.8%, 19.0%, 3.2%, and 43.7%, 46.8%, and 27.4%,espectively).

Drs. Devlin and Gutierrez discussed the potentialarm from use of blood component therapy. We agree

hat blood transfusion has been independently associated

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The Journal of Emergency Medicine 345

ith infection and resource overutilization. It is possiblehat blood transfusion in retrospective studies using mul-ivariate analysis was just a surrogate for severe injuriesnd prolonged shock, and therefore, the risk of infectionas increased due to ischemia and reperfusion, and over-helming inflammation. Zink et al. also examined in

heir study the potential harm of transfusion-inducedung dysfunction and Acute Respiratory Distress Syn-rome (13). They found no difference in respiratoryutcomes based on PRBCs:FFP ratios. Interestingly, re-piratory outcomes improved with higher PRBCs:plate-et ratios.

Finally, Drs. Devlin and Gutierrez mentioned the is-ue of resource utilization. O’Keeffe et al. demonstratedhat having a well-defined massive transfusion protocolecreased the overall blood product usage and cost (14).

The Iraqi and Enduring Freedom conflicts have solid-fied the paradigm that not all transfusion strategies arequal. Despite the lack of randomized, prospective civil-an trials (one is being launched soon), it is important toe cognizant that bleeding patients are also not equal.apid identification of the bleeding injured patient and

mmediate intervention to improve tissue perfusion ando correct the trauma-induced coagulopathy would cer-ainly offer the best chance for survival.

Gustavo Fraga, MD, PHD, FACS

Vishal Bansal, MD

Raul Coimbra, MD, PHD, FACS

Division of Trauma, Surgical Critical Care, and Burnsniversity of California San Diego School of Medicine

San Diego, California

doi:10.1016/j.jemermed.2010.03.001

REFERENCES

1. Fraga GP, Bansal V, Coimbra R. Transfusion of blood products intrauma: an update. J Emerg Med 2010;39:253–60.

2. Sperry JL, Ochoa JB, Gunn SR, et al. An FF:PRBC transfusionratio �1:1.5 is associated with a lower risk of mortality aftermassive transfusion. J Trauma 2008;65:986–93.

3. Scalea TM, Bochicchio KM, Lumpkins K, et al. Early aggressiveuse of fresh frozen plasma does not improve outcomes in criticallyinjured trauma patients. Ann Surg 2008;248:578–84.

4. Hirshberg A, Dugas M, Banez EI, et al. Minimizing dilutionalcoagulopathy in exsanguinating hemorrhage: a computer simula-tion. J Trauma 2003;54:454–63.

5. MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathypredicts mortality in trauma. J Trauma 2003;55:39–44.

6. Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy.J Trauma 2003;54:1127–30.

7. Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh frozen plasmashould be given earlier to patients requiring massive transfusion.J Trauma 2007;62:112–9.

8. Duchesne JC, Islam TM, Stuke L, et al. Hemostatic resuscitationduring surgery improves survival in patients with traumatic-

induced coagulopathy. J Trauma 2009;67:33–9.

9. Niles SE, McLaughlin DF, Perkins JG, et al. Increased mortality b

associated with the early coagulopathy of trauma in combatcasualties. J Trauma 2008;64:1459–63.

0. Snyder CW, Weinberg JA, McGwin G, et al. The relationship ofblood product to mortality: survival benefit or survival bias?J Trauma 2009;66:358–63.

1. Teixeira PGR, Inaba K, Shulman I, et al. Impact of plasma trans-fusion in massively transfused trauma patients. J Trauma 2009;66:693–7.

2. Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion protocols:the role of aggressive resuscitation versus product ratio in mortalityreduction. J Am Coll Surg 2009;209:198–205.

3. Zink KA, Sambasivan CH, Holcomb JB, et al. A high ratio ofplasma and platelets to packed red blood cells in the first 6 hoursof massive transfusion improves outcomes in a large multicenterstudy. Am J Surg 2009;197:565–70.

4. O’Keeffe T, Refaai M, Tchorz K, et al. A massive transfusionprotocolto decrease blood component use and costs. Arch Surg2008;143:686–91.

ROCURONIUM VS. SUCCINYLCHOLINEEVISITED

To the Editor:

read with interest the review by Mallon et al. about thehoice between rocuronium and succinylcholine for rapidequence intubation (RSI) in the emergency departmentED) (1). I commend the authors on their review and assess-ent of the literature addressing this controversial topic.With respect to safety, succinylcholine has a long history

f use in the ED and its track record cannot be impugned.n the other hand, succinylcholine has a number of abso-

ute contraindications, some of which relate to pre-existingonditions that may not be known to providers at the timef intubation. Furthermore, cardiac arrest immediately afterntubation is not a rare event, and this is often attributed tohe circumstances that necessitated intubation in the firstlace; it is likely that succinylcholine-induced hyperkalemias a cause or contributor in these cases would not beecognized. These concerns are theoretical and would nothallenge the use of succinylcholine if an agent withoutontraindications were not available.

With respect to efficacy, the data suggest that when bothrugs are given at ideal doses, no clinically consequentialifference in intubation conditions exists. Dr. Walls’ com-entary after the review endorses this position.My primary concern is with the notion that “. . . the long

uration of non-depolarizing drugs can be a problem ifntubation is difficult because prolonged bag-valve-maskentilation will be required,” an assertion that seems to beupported by the conclusion of the cited Cochrane review:We found no statistical difference in intubation conditionshen succinylcholine was compared to 1.2 mg/kg rocuro-ium; however, succinylcholine was clinically superior as itas a shorter duration of action.”

The shorter duration of action of succinylcholine has

een touted as an advantage for a number of reasons. The