788
Determination [AFFORD] study). The AFFORD nomogram is
based on 17 predictors, including age, systolic blood pressure,
respiratory rate, oxygen saturation, temperature, creatinine,
brain natriuretic peptide, hemoglobin, 2-h heart rate, history
of heart failure, home sotalol use, supplemental oxygen, prior
percutaneous coronary intervention, prior cardiac ablation, prior
electrical cardioversion, chest radiograph results, and frequency
of AF symptoms. Adverse events measured at 30 days included
AF-related ED return, AF-related unscheduled hospitalization,
acute decompensated heart failure, acute coronary syndrome,
and AF-related death, among others. A total of 497 patients
were enrolled over 3 years, of which 326 of the visits were for
primary AF. Eighty-two patients were considered safe to
discharge home based on the AFFORD clinical decision aid,
of whom 73 (89%) had no 30-day adverse events. Of the 415 pa-
tients hospitalized, 291 (70%) experienced no adverse events.
The decision aid’s c-statistic for prediction of any adverse event
was 0.7 (95% confidence interval 0.65–0.76). The authors
concluded that the AFFORD clinical decision aid is the first ev-
idence-based decision tool to identify AF patients at low risk for
adverse events within 30 days who may be potential candidates
for safe discharge to home.
[Skylar Johnson, MD
Denver Health Medical Center, Denver, CO]
Comments: Clinical decision tools can be especially helpful
to emergency care providers to guide admission decisions and
inform patients about potential risks. External validation of
the AFFORD clinical decision instrument is necessary prior to
widespread utilization. The fact that 10% of patients who
were discharged using AFFORD had an adverse event, vs.
30% for those admitted, makes the tool useful for determining
higher-risk patients. However, 10% is still a high percentage,
and though that figure incorporates less serious events, such as
return to the ED, it also demonstrates that AF patients are at
high risk for adverse events in general, and though this decision
tool may be helpful, careful scrutiny of patients that might be
discharged with complaints related primarily to AF is necessary
to reduce morbidity and mortality.
, TRANEXAMIC ACID ADMINIS-
TRATION TO PEDIATRIC TRAUMA
PATIENTS IN A COMBAT SETTING:
THE PEDIATRIC TRAUMA AND TRA-
NEXAMIC ACID ATUDY (PED-TRAX).
Eckert MJ, Wertin TM, Tyner SD, et al. J
Trauma Acute Care Surg 2014;77:852–8.
Early administration of tranexamic acid (TXA) in adult
trauma patients has been associated with decreased mortality
and blood product administration. Limited data are available
on the use of TXA in pediatric trauma. The goal of this study
was to evaluate the use and efficacy of TXA in pediatric combat
patients. The authors conducted a retrospective cohort study of
all pediatric trauma admissions to the North Atlantic Treaty Or-
ganization Role 3 hospital, Camp Bastion, Afghanistan, from
Abstracts
2008 to 2012. All pediatric trauma patients < 18 years of age
were included. The primary outcome for the study was mortal-
ity. Secondary outcomes included factors associated with TXA
use and complications of TXA use. TXA administration was
used at adult dosing, with a single fixed bolus dose of 1 g
TXA administered within 3 h of injury. In total, 766 admitted
pediatric trauma patients were included in the study, of which
10% received TXA. Overall injury severity score (ISS) for those
treated with TXA was significantly higher than average (15 vs.
10, p < 0.05). Significant independent predictors of TXA admin-
istration were severe abdominal or extremity injury and severe
metabolic acidosis, with base deficit > 5. However, the propen-
sity analysis model showed significant unexplained variance in
the decision to administer TXA with an R-squared value of .47.
Unadjusted mortality was higher in patients who received TXA
(15% vs. 9%), but this difference was not statistically significant
(P = 0.06). After controlling for confounding factors including
mechanism, injury severity, base deficit, hypotension, and Glas-
gow Coma Scale score, TXA administration was associated
with reduced mortality (P = 0.03). There were nonstatistically
significant trends toward improved survival in those patients
receiving TXA in subpopulation analysis of those who received
transfusions and those severely injured, with an ISS > 15.
Analysis of additional outcomes besides mortality studied in
propensity-matched groups of TXA vs. no TXA administration
demonstrated advantage to the TXA group, with significantly
improved neurologic status at the time of discharge or transfer,
a higher likelihood of a near-normal GCS score, fewer patients
with severe brain injury, and a lower likelihood of requiring me-
chanical ventilation at the time of discharge or transfer. There
were no adverse outcomes associated with the administration
of TXA. The authors concluded that the same favorable associ-
ation of survival advantage and safety profile as seen in the adult
trauma population held true in a pediatric trauma population,
and furthermore, there may be added benefit of improved neuro-
logic and pulmonary outcomes in patients treated with TXA.
Limitations acknowledged by the authors included the retro-
spective nature of the study, and no information on blood loss
or coagulation/thromboelastometry data, which limits the
ability to directly measure the effects of TXA on blood loss or
coagulation; and lack of data on timing of TXA administration
of subsequent dosing. Another limitation noted was that the
relatively small population might significantly limit safety
conclusions.
[Skylar Johnson, MD
Denver Health Medical Center, Denver, CO]
Comments: Though limited by its retrospective nature and
possible generalizability of combat trauma to noncombat popu-
lations, this study demonstrates that there may be benefits of the
use of TXA in pediatric populations with few adverse events.
Although further investigations are indicated to fully evaluate
the safety of TXA in the pediatric population, these data suggest
that TXA should be considered in critically ill pediatric trauma
patients.