Contact isolation is a risk factor for venous thromboembolism in trauma patients.

expanded upon through review of 51 papers to propose recommendations regarding the type of femoral shaft fracture stabilization after blunt trauma, external fixation versus definitive internal fixation. The clinical parameters encompass areas of shock, coagulation, temperature, and soft tissue injury to provide a broad range of options for assessment of the patient at hand. As stated throughout our paper, the CGS was modified because several parameters were not measured or available. In their work, Pape et al. propose a large series of clinical and laboratory criteria useful to clinicians in determining stability for surgery. Some are redundant, and others’ objective values permit overlap. As the authors state, and as is implied, ‘‘patients may be categorized into one of four different classes if they meet the criteria in three of four categories, while individual variations exist. ’’ We included patients with chest Abbreviated Injury Scale (AIS) scores of 0 through 5, since they met the other inclusion criteria of multiple-system trauma and fractures as previously mentioned; for example, many of our patients with pelvis class C and/or abdominal grade III injuries had no chest injury. Our patients with chest AIS scores of 1 and 2 were classified as stable, and AIS score greater than 2 as borderline or unstable, which is within their recommendations. The CGS does not state that patients without chest injury be excluded. The Thoracic Trauma Score is not part of our standard trauma registry but can be calculated from additional clinical and radiographic parameters; we determined the CGS grade to be the same, whether based on the Thoracic Trauma Score or the chest AIS score for 20 patients with an AIS score of 2 or 3 in our study group, thus providing validity to the strategy that either one may be feasible when using the CGS. Factors II and V, fibrinogen, and D-dimer levels were never obtained on presentation. The ATLS classification for shock (based on vital signs and estimated blood loss), was not determined because retrospective assessment of in-field hemorrhage was not accurate. Emergency department measurement of urine output was also not possible, in that most patients were in the emergency department for less than 60minutes. The shock categorywas addressed via blood pressure, transfusions, lactate, and base deficit. Lastly, the PaO2:FiO2 ratio was also not used, as too fewpatients hadmechanical ventilation data on arrival. We have no basis to make recommendations regarding the use of these additional criteria, since we have not studied them. However, our large number of patients (n=1,196), all with multiple parameters, promotes accurate application inclusive of the four categories of pathology: shock, coagulopathy, hypothermia, and soft tissue injury. The available data seem reflective of a large urban trauma center. The EAC protocol identified 96% of multiple trauma patients were adequately resuscitated to safely undergo early definitive fracture care, resulting in lower complication rates than with delayed fixation. With the CGS, 85% of borderline patients were also treated with early definitive fixation without a complication. Unlike prior published guidelines to determine the adequacy of resuscitation and the readiness for definitive fracture care, the EAC protocol was developed with data from 1,443 patients with femoral, pelvic, acetabular, or spine fractures and incorporation of logistical predictive models, which analyzed patients’ age, ISS, vital signs, hematocrit, platelets, INR, lactate, pH, base excess, age, associated injury severity (head, chest, and abdomen), number and type of fractures, and timing of fixation. Time-based predictive models also assessed laboratory parameters for magnitude and rate of change over time. Incorporating all of these elements defined the predicted probability of pulmonary and other complications to be related to presence and severity of chest injury, magnitude of metabolic acidosis, and timing of definitive fixation. The EAC parameters with pH, base excess, or lactate were selected to build a probability model to decrease pulmonary complications from our prior level. This is consistent with a growing body of literature denoting the severity and duration of metabolic acidosis to be associated with complications and mortality. Prospective use of EAC has decreased complications, length of stay, and costs when resuscitated patients undergo definitive fixation within 36 hours after injury. Since we have implemented EAC, all patients surviving the injury event have achieved adequate resuscitation levels within the day of injury. The EAC recommendations are safe for most multiply injured patients. They are simple and widely applicable. However, unique circumstances occur infrequently, such as severe head injury with reduced cerebral perfusion pressure or critical medical conditions, like evolving myocardial infarction, and preclude definitive fracture care (G1% of our patients). Current grading systems have not accounted for these variations. We applaud Dr. Pape and his colleagues for their long-standing commitment to excellent care and research of the multiple trauma patient. We likewise commit and look forward to improvements in our multidisciplinary approach over time.