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Ács N, Korte WC, von Heymann CC, Windyga J, Blatný J. Rationale for the Potential Use of Recombinant Activated Factor VII in Severe Post-Partum Hemorrhage. J Clin Med 2024; 13:2928. [PMID: 38792469 PMCID: PMC11122570 DOI: 10.3390/jcm13102928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024] Open
Abstract
Severe post-partum hemorrhage (PPH) is a major cause of maternal mortality worldwide. Recombinant activated factor VII (rFVIIa) has recently been approved by the European Medicines Agency for the treatment of severe PPH if uterotonics fail to achieve hemostasis. Although large randomized controlled trials are lacking, accumulated evidence from smaller studies and international registries supports the efficacy of rFVIIa alongside extended standard treatment to control severe PPH. Because rFVIIa neither substitutes the activity of a missing coagulation factor nor bypasses a coagulation defect in this population, it is not immediately evident how it exerts its beneficial effect. Here, we discuss possible mechanistic explanations for the efficacy of rFVIIa and the published evidence in patients with severe PPH. Recombinant FVIIa may not primarily increase systemic thrombin generation, but may promote local thrombin generation through binding to activated platelets at the site of vascular wall injury. This explanation may also address safety concerns that have been raised over the administration of a procoagulant molecule in a background of increased thromboembolic risk due to both pregnancy-related hemostatic changes and the hemorrhagic state. However, the available safety data for this and other indications are reassuring and the rates of thromboembolic events do not appear to be increased in women with severe PPH treated with rFVIIa. We recommend that the administration of rFVIIa be considered before dilutional coagulopathy develops and used to support the current standard treatment in certain patients with severe PPH.
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Affiliation(s)
- Nándor Ács
- Department of Obstetrics and Gynaecology, Semmelweis University, H-1082 Budapest, Hungary
| | - Wolfgang C. Korte
- Centre for Laboratory Medicine, Haemostasis and Haemophilia Centre, CH-9001 St. Gallen, Switzerland
| | - Christian C. von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum in Friedrichshain, DE-10249 Berlin, Germany
| | - Jerzy Windyga
- Department of Haemostasis Disorders and Internal Medicine, Laboratory of Haemostasis and Metabolic Diseases, Institute of Haematology and Transfusion Medicine, 02-776 Warsaw, Poland
| | - Jan Blatný
- Department of Paediatric Oncology, University Hospital Brno, and Masaryk University, 613 00 Brno, Czech Republic
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Buzzard L, Schreiber M. Trauma-induced coagulopathy: What you need to know. J Trauma Acute Care Surg 2024; 96:179-185. [PMID: 37828662 DOI: 10.1097/ta.0000000000004170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
ABSTRACT Trauma-induced coagulopathy (TIC) is a global inflammatory state accompanied by coagulation derangements, acidemia, and hypothermia, which occurs after traumatic injury. It occurs in approximately 25% of severely injured patients, and its incidence is directly related to injury severity. The mechanism of TIC is multifaceted; proposed contributing factors include dysregulation of activated protein C, increased tPA, systemic endothelial activation, decreased fibrinogen, clotting factor consumption, and platelet dysfunction. Effects of TIC include systemic inflammation, coagulation derangements, acidemia, and hypothermia. Trauma-induced coagulopathy may be diagnosed by conventional coagulation tests including platelet count, Clauss assay, international normalized ratio, thrombin time, prothrombin time, and activated partial thromboplastin time; viscoelastic hemostatic assays such as thrombelastography and rotational thrombelastography; or a clinical scoring system known as the Trauma Induced Coagulopathy Clinical Score. Preventing TIC begins in the prehospital phase with early hemorrhage control, blood product resuscitation, and tranexamic acid therapy. Early administration of prothrombin complex concentrate is also being studied in the prehospital environment. The mainstays of TIC treatment include hemorrhage control, blood and component transfusions, and correction of abnormalities such as hypocalcemia, acidosis, and hypothermia. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Lydia Buzzard
- From the University of Wisconsin School of Medicine and Public Health (L.B.), Madison, Wisconsin; and Department of Surgery (L.B., M.S.), Oregon Health and Science University, Portland, Oregon
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Zhao Y, Gao J, Li C, Song G, Shan Y. MILD THERAPEUTIC HYPOTHERMIA REDUCES ISCHEMIA-REPERFUSION INJURY AFTER ZONE 1 REBOA IN A SWINE HEMORRHAGIC SHOCK MODEL. Shock 2023; 60:434-442. [PMID: 37493541 PMCID: PMC10510780 DOI: 10.1097/shk.0000000000002182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 04/06/2023] [Accepted: 07/11/2023] [Indexed: 07/27/2023]
Abstract
ABSTRACT Background: Resuscitative balloon occlusion of the aorta (REBOA) is an endovascular hemostasis method used for the management of traumatic abdominal and pelvic hemorrhages. However, REBOA-associated ischemia-reperfusion injury complication limits its blocking time. We hypothesized that mild therapeutic hypothermia would relieve ischemia-reperfusion injury caused by prolonged zone 1 REBOA. Methods: Ten pigs were anesthetized, intubated, and subsequently struck with the experimental sliding-chamber ballistic gun to inflict liver damage. Animals were randomized to hypothermia (60 min of zone 1 REBOA with external cooling for 180 min, n = 5) or control (60 min of zone 1 REBOA with no external cooling, n = 5). Physiological and laboratory parameters were monitored and assessed. Distal organs were obtained for histologic analysis. Results: At 180 min, compared with the control, the hypothermia animals exhibited significantly increased pH and significantly reduced lactate, hemoglobin, and hematocrit (all P < 0.05). The change of lactate from 0 to 180 min in hypothermia animals was less than that in the control ( P = 0.02). The total bleeding in the control group was significantly less than the hypothermia ( P < 0.01). In the hypothermia group, prothrombin time at 120 and 180 min was significantly longer than that at baseline (all P < 0.05). Compared with the control, animals in the hypothermia group showed slighter pathological injury of the distal organs and significantly lower overall injury score (all P < 0.05). Conclusions: Mild therapeutic hypothermia during prolonged zone 1 REBOA offered extraordinary distal organ preservation and decreased metabolic acidosis.
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Affiliation(s)
- Yang Zhao
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou, China
- Department of Emergency Medicine, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Jianxin Gao
- Department of Emergency Medicine, The First Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Chengcheng Li
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou, China
- Department of Emergency Medicine, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Guogeng Song
- Department of Emergency Medicine, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Yi Shan
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou, China
- Department of Emergency Medicine, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
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Weber B, Sturm R, Henrich D, Marzi I, Leppik L. CD44+ and CD31+ extracellular vesicles (EVs) are significantly reduced in polytraumatized patients with hemorrhagic shock - evaluation of their diagnostic and prognostic potential. Front Immunol 2023; 14:1196241. [PMID: 37662913 PMCID: PMC10471799 DOI: 10.3389/fimmu.2023.1196241] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/25/2023] [Indexed: 09/05/2023] Open
Abstract
Background Hemorrhagic shock (HS) is responsible for approximately 2 million deaths per year worldwide and is caused in 80% by polytrauma. These patients need a precise and quick diagnostic, which should be based on a combination of laboratory markers and radiological data. Extracellular vesicles (EVs) were described as potential new markers and mediators in trauma. The aim of the present study was to analyze, whether the surface epitopes of plasma-EVs reflect HS in polytraumatized patients and whether cell-specific EV subpopulations are useful diagnostic tools. Material and methods Plasma samples from polytraumatized patients (ISS ≥16) with HS (n=10) and without (n=15), were collected at emergency room (ER) and 24h after trauma. Plasma-EVs were isolated via size exclusion chromatography and EV-concentrations were detected by Coomassie Plus (Bradford) Assay. The EVs subpopulations were investigated by a bead-based multiplex flow cytometry measurement of surface epitopes and were compared with healthy controls (n=10). To investigate the diagnostic and prognostic potential of EVs subpopulations, results were correlated with clinical outcome parameters documented in the electronical patients' record. Results We observed a significant reduction of the total amount of plasma EVs in polytrauma patients with HS, as compared to polytrauma patients without HS and healthy controls. We found significant reduction of CD42a+ and CD41b+ (platelet-derived) EVs in all polytrauma patients, as well as a reduction of CD29+ EVs compared to healthy volunteers (*p<0.05). CD44+ and CD31+ EVs were specifically altered in patients with HS (*p<0.05). Both EV populations showed a moderate correlation (r² = 0.42) with the transfusion of erythrocyte concentrate, were associated with non-survival and the need for catecholamines (*p<0.05). Conclusion Our data reveal that polytrauma patients with a hemorrhagic shock are characterized by a reduction of CD44+ and CD31+ plasma-EVs. Both EV populations showed a moderate correlation with the need of erythrocyte transfusion, were associated with non-survival and the need for catecholamines.
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Affiliation(s)
- Birte Weber
- Department of Trauma−, Hand− and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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Chitosan-Based Hemostatic Hydrogels: The Concept, Mechanism, Application, and Prospects. Molecules 2023; 28:molecules28031473. [PMID: 36771141 PMCID: PMC9921727 DOI: 10.3390/molecules28031473] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/19/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023] Open
Abstract
The design of new hemostatic materials to mitigate uncontrolled bleeding in emergencies is challenging. Chitosan-based hemostatic hydrogels have frequently been used for hemostasis due to their unique biocompatibility, tunable mechanical properties, injectability, and ease of handling. Moreover, chitosan (CS) absorbs red blood cells and activates platelets to promote hemostasis. Benefiting from these desired properties, the hemostatic application of CS hydrogels is attracting ever-increasing research attention. This paper reviews the recent research progress of CS-based hemostatic hydrogels and their advantageous characteristics compared to traditional hemostatic materials. The effects of the hemostatic mechanism, effects of deacetylation degree, relative molecular mass, and chemical modification on the hemostatic performance of CS hydrogels are summarized. Meanwhile, some typical applications of CS hydrogels are introduced to provide references for the preparation of efficient hemostatic hydrogels. Finally, the future perspectives of CS-based hemostatic hydrogels are presented.
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Massive Hemorrhage Protocol. Emerg Med Clin North Am 2023; 41:51-69. [DOI: 10.1016/j.emc.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Is ROTEM Diagnostic in Trauma Care Associated with Lower Mortality Rates in Bleeding Patients?—A Retrospective Analysis of 7461 Patients Derived from the TraumaRegister DGU®. J Clin Med 2022; 11:jcm11206150. [PMID: 36294471 PMCID: PMC9605144 DOI: 10.3390/jcm11206150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/08/2022] [Accepted: 10/14/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction: Death from uncontrolled trauma haemorrhage and subsequent trauma-induced coagulopathy (TIC) is potentially preventable. Point-of-care devices such as rotational thromboelastometry (ROTEM®) are advocated to detect haemostatic derangements more rapidly than conventional laboratory diagnostics. Regarding reductions in RBC transfusion, the use of ROTEM has been described as being efficient and associated with positive outcomes in several studies. Objective: The effect of ROTEM use was assessed on three different outcome variables: (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality in severely injured patients. Methods and Material: A retrospective analysis of a large data set of severely injured patients collected into the TraumaRegister DGU® between 2009 and 2016 was conducted. The data of 7461 patients corresponded to the inclusion criteria and were subdivided into ROTEM-using and ROTEM-non-using groups. Both groups were analysed regarding (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality. Results: A lower mortality rate in ROTEM-using groups was observed (p = 0.043). Furthermore, more patients received haemostatic medication when ROTEM was used. In ROTEM-using groups, there was a statistically relevant higher application of massive transfusion. Conclusions: In this retrospective study, the use of ROTEM was associated with reduced mortality and an increased application of haemostatics and RBC transfusions. Prospective evidence is needed for further evidence-based recommendations.
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Wang Y, Rao Q, Li X. Adverse transfusion reactions and what we can do. Expert Rev Hematol 2022; 15:711-726. [PMID: 35950450 DOI: 10.1080/17474086.2022.2112564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Transfusions of blood and blood components have inherent risks and the ensuing adverse reactions. It is very important to understand the adverse reactions of blood transfusion comprehensively for ensuring the safety of any future transfusions. AREAS COVERED According to the time of onset, adverse reactions of blood transfusion are divided into immediate and delayed transfusion reactions. In acute transfusion reactions, timely identification and immediate cessation of transfusion is critical. Vigilance is required to distinguish delayed responses or reactions that present non-specific signs and symptoms. In this review, we present the progress of mechanism, clinical characteristics and management of commonly encountered transfusion reactions. EXPERT OPINION The incidence of many transfusion-related adverse events is decreasing, but threats to transfusion safety are always emerging. It is particularly important for clinicians and blood transfusion staff to recognize the causes, symptoms and treatment methods of adverse blood transfusion reactions to improve the safety. In the future, at-risk patients will be better identified and can benefit from more closely matched blood components.
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Affiliation(s)
- Yajie Wang
- Department of Blood Transfusion, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Quan Rao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Xiaofei Li
- Department of Blood Transfusion, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Hu H, Luo F, Zhang Q, Xu M, Chen X, Liu Z, Xu H, Wang L, Ye F, Zhang K, Chen B, Zheng S, Jin J. Berberine coated biocomposite hemostatic film based alginate as absorbable biomaterial for wound healing. Int J Biol Macromol 2022; 209:1731-1744. [PMID: 35487376 DOI: 10.1016/j.ijbiomac.2022.04.132] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 01/08/2023]
Abstract
In wound treatment, severe bleeding and infection are always primary challenges. Therefore, it is highly desired to develop novel dressing with both hemostatic and antibacterial capability. Herein, a series of biocomposite hemostatic films (BHFs) based alginate/chitosan/collagen-berberine have been prepared and well characterized for further biofunctional study. We have demonstrated that the hemostatic and antibacterial activities were significantly enhanced by calcium/berberine dual-crosslinking system in the film. Through the synergistic effects, BHF-6B exhibited a shorter in vivo clotting and wound healing time than that of commercial dressing in rat tail amputation and full-thickness skin defect models. Additionally, BHF-6B showed excellent bacteriostatic activity with long-term effects. Moreover, hemolysis and cytotoxicity tests in vitro illustrated the prominent biocompatibility of the composite films. Notably, BHF-6B could be degraded quickly and completely in vivo. Overall, the present work indicated that the functionalized BHF-6B has great potential as an absorbable biomaterial for wound treatment.
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Affiliation(s)
- Haofeng Hu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Fulin Luo
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Qian Zhang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Ming Xu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Xin Chen
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Zhihao Liu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Haodong Xu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Lei Wang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Fei Ye
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Kui Zhang
- International Innovation Center for Forest Chemicals and Materials, College of Chemical Engineering, Nanjing Forestry University, Nanjing 210037, China
| | - Bin Chen
- Department of Orthopedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, China
| | - Song Zheng
- Department of Orthopedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, China
| | - Jia Jin
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China.
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Plasmatic coagulation profile after major traumatic injury: a prospective observational study. Eur J Trauma Emerg Surg 2022; 48:4595-4606. [PMID: 35578018 DOI: 10.1007/s00068-022-01971-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/02/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Uncontrolled hemorrhage is still the major cause of preventable death after trauma and is aggravated by trauma-induced coagulopathy (TIC). The underlying pathophysiology of TIC is still elusive, but several key effectors such as the thrombin-generation capacity, the protein C (PC) pathway, and the fibrinolytic activity could be identified. The aim of this prospective observational study was to investigate plasma coagulation markers attributed to reflect the course of TIC and to identify the mechanisms being responsible for the coagulopathy after major trauma. METHODS Seventy-three consecutive patients after major trauma and admission to a level-1-trauma unit were included to the study. During early trauma management, extended coagulation testing including the measurement of circulating thrombin markers and activated PC (APC) was performed and correlated with standard shock parameters and the patients' clinical course and outcome. RESULTS In contrast to standard coagulation parameters, thrombin markers and APC were found to be increased in correlation with injury severity. Even in patients with lower impact mechanisms, early endogenous accumulation of thrombin markers and APC (ISS < 16: 0.5 ng/ml; ISS ≥ 16-26: 1.5 ng/ml; ISS > 26: 4.1 ng/ml) were observed. Furthermore, APC showed ISS- and injury-dependent patterns while ROC curve analysis revealed that especially APC plasma levels were predictive for coagulopathy and general patient outcome. CONCLUSION Increased levels of APC and thrombin markers in patients after major trauma were positively correlated with injury severity. APC showed an ISS- and injury-dependent kinetic and might serve as candidate biomarker to identify patients at risk for developing TIC.
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Dahlquist A, Elander Degerstedt L, von Oelreich E, Brännström A, Gustavsson J, P Arborelius U, Günther M. Blast polytrauma with hemodynamic shock, hypothermia, hypoventilation and systemic inflammatory response: description of a new porcine model. Eur J Trauma Emerg Surg 2022; 48:401-409. [PMID: 32862315 PMCID: PMC7456397 DOI: 10.1007/s00068-020-01476-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 08/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE In the past decade blast injuries have become more prevalent. Blast trauma may cause extensive injuries requiring improved early resuscitation and prevention of haemorrhage. Randomized prospective trials are logistically and ethically challenging, and large animal models are important for further research efforts. Few severe blast trauma models have been described, which is why we aimed to establish a comprehensive polytrauma model in accordance with the criteria of the Berlin definition of polytrauma and with a survival time of > 2 h. Multiple blast injuries to the groin and abdomen were combined with hypoperfusion, respiratory and metabolic acidosis, hypoventilation, hypothermia and inflammatory response. The model was compared to lung contusion and haemorrhage. METHODS 16 landrace swine (mean weight 60.5 kg) were randomized to "control" (n = 5), "chest trauma/hem" by lung contusion and class II haemorrhage (n = 5), and "blast polytrauma" caused by multiple blast injuries to the groin and abdomen, class II haemorrhage, lipopolysaccharide (LPS) infusion and hypothermia 32 °C (n = 6). RESULTS The blast polytrauma group had an Injury Severity Score of 57 which resulted in haemodynamic shock, hypothermia, respiratory and metabolic acidosis and inflammatory response. The chest trauma/hem group had an Injury Severity Score of 9 and less profound physiologic effects. Physiologic parameters presented a dose-response relationship corresponding to the trauma levels. CONCLUSION A comprehensive blast polytrauma model fulfilling the Berlin polytrauma criteria, with a high trauma load and a survival time of > 2 h was established. A severe, but consistent, injury profile was accomplished enabling the addition of experimental interventions in future studies, particularly of immediate resuscitation efforts including whole blood administration, trauma packing and haemostasis.
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Affiliation(s)
- Albin Dahlquist
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Louise Elander Degerstedt
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Erik von Oelreich
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Brännström
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ulf P Arborelius
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden.
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Lu CH, Zheng ZH, Yeh TT, Yeh CC. Practice algorithm of rotational thromboelastometry-guided bleeding management in trauma and orthopedic surgery. JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/jmedsci.jmedsci_122_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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OUP accepted manuscript. Lab Med 2022; 53:349-359. [DOI: 10.1093/labmed/lmac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Influencing Factors and Prevention of Sepsis or Acute Kidney Injury in 85 Patients with Severe Trauma. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:5754114. [PMID: 34777535 PMCID: PMC8580668 DOI: 10.1155/2021/5754114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/29/2021] [Indexed: 11/18/2022]
Abstract
Severe trauma can cause systemic reactions, leading to massive bleeding, shock, asphyxia, and disturbance of consciousness. At the same time, patients with severe trauma are at high risk of sepsis and acute renal injury. The occurrence of complications will increase the difficulty of clinical treatment, improve the mortality rate, and bring heavy physical and mental burdens and economic pressure to patients and their families. It is of great clinical significance to understand the high risk factors of sepsis and AKI and actively formulate prevention and treatment measures. In this study, the clinical data of 85 patients with severe trauma were analyzed by univariate and multivariate logistic regression to identify the risk factors leading to sepsis or AKI and analyze the prevention and treatment strategies. The results showed that multiple injuries, APACHE II score on admission, SOFA score on admission, and mechanical ventilation were independent influencing factors of sepsis in patients with severe trauma, while hemorrhagic shock, APACHE II score on admission, CRRT, and sepsis were independent influencing factors of AKI in patients with severe trauma. Severe trauma patients complicated with sepsis or AKI will increase the risk of death. In the course of treatment, prevention and intervention should be given as far as possible to reduce the incidence of complications.
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Jones AR, Miller JL, Jansen JO, Wang HE. Whole Blood for Resuscitation of Traumatic Hemorrhagic Shock in Adults. Adv Emerg Nurs J 2021; 43:344-354. [PMID: 34699424 PMCID: PMC8555430 DOI: 10.1097/tme.0000000000000376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Injured patients with traumatic hemorrhagic shock often require resuscitation with transfusion of red blood cells, plasma, and platelets. Resuscitation with whole blood (WB) has been used in military settings, and its use is increasingly common in civilian practice. We provide an overview of the benefits and challenges, guidelines, and unanswered questions related to the use of WB in the treatment of civilian trauma-related hemorrhage. Implications for advanced practice nurses and nursing staff are also discussed.
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Affiliation(s)
- Allison R Jones
- School of Nursing (Drs Jones and Miller), and Division of Trauma and Acute Care Surgery & Center for Injury Science (Dr Jansen), University of Alabama at Birmingham; The Ohio State University (Dr Wang)
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Jamal L, Saini A, Quencer K, Altun I, Albadawi H, Khurana A, Naidu S, Patel I, Alzubaidi S, Oklu R. Emerging approaches to pre-hospital hemorrhage control: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1192. [PMID: 34430633 PMCID: PMC8350651 DOI: 10.21037/atm-20-5452] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/18/2021] [Indexed: 12/18/2022]
Abstract
In the United States, trauma claims the lives of over 150,000 civilians each year. In military settings, trauma and exsanguination result in 50% of combat related deaths. The majority of these deaths result from uncontrolled non-compressible hemorrhage. Non-compressible hemorrhage often results from deep vascular injuries within the torso, however can also occur secondary to penetrating injuries that involve the extremities. Given the high mortality rates for non-compressible hemorrhage, rapid and effective management of patients suffering from hemorrhage is essential to good patient outcomes. Consequently, there has been increasing interest in solutions for point-of-injury hemorrhage control in trauma and military medicine. Undoubtedly there is a great need for prehospital hemostatic interventions that can be deployed by trained and untrained personnel. Since 2001, various hemostatic agents have been developed, each with its advantages based upon the type and severity of injury, wound size, wound location, accessibility to injury site, and the coagulation status of the patient. These agents are often used in the military setting as a temporizing measure prior to definitive therapy and include techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and bioengineered agents including ResQFoam, RevMedx’s XSTAT, Tranexamic acid (TXA), and QuikClot Combat Gauze (QCG). Here, we review the indications, composition, technique, efficacy, and outcomes of these hemostatic agents.
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Affiliation(s)
- Leila Jamal
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aman Saini
- Department of Radiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Keith Quencer
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - Izzet Altun
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aditya Khurana
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Sailendra Naidu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Indravadan Patel
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Sadeer Alzubaidi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
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Resuscitation of the Traumatically Injured Patient. Crit Care Nurs Clin North Am 2021; 33:245-261. [PMID: 34340788 DOI: 10.1016/j.cnc.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Trauma is a leading cause of death. Optimal outcomes depend on a coordinated effort. Providers must be prepared to act in an organized and methodical manner. Recognizing and immediately treating causes of shock after trauma offer the best chance of survival to the patient. Incorporating evidence-based knowledge and resuscitation techniques learned from the military, the trauma victim experiencing acute hypovolemia has better outcomes because of advances in the clinical management of blood loss than ever before. Treatment focuses primarily on stopping the bleeding, providing damage control resuscitation, and monitoring and treating the patient for signs of shock. If the patient can be stabilized and avoid the lethal trauma triad, definitive surgical care can be achieved.
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Roman P, Rodriguez-Alvarez A, Bertini-Perez D, Ropero-Padilla C, Martin-Ibañez L, Rodriguez-Arrastia M. Tourniquets as a haemorrhage control measure in military and civilian care settings: An integrative review. J Clin Nurs 2021. [PMID: 33969561 DOI: 10.1111/jocn.15834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The aim of review was to describe and synthesise the evidence on the use of tourniquets to control haemorrhages, summarising both civilian and military use. BACKGROUND Trauma-related haemorrhage constitutes one of the most preventable deaths among injured patients, particularly in multi-casualty incidents and disasters. In this context, safe instruments such as tourniquets are essential to help healthcare professionals to minimise loss of life and maximise patient recovery. DESIGN AND METHODS An integrative review was conducted in Medline, Nursing & Allied Health Premium, and Health & Medical Collection, using published data until March 2021 and following the PRISMA guidelines. RESULTS A total of 25 articles were included. Evidence has been synthesised to understand the use of different types of tourniquets, environment of application, indication for their placement and potential complications associated with tourniquet placement. CONCLUSIONS Commercial tourniquets such as Combat Application Tourniquet or Emergency Tourniquet models are a valuable and safe instrument for haemorrhage control in both military and civilian out-of-hospital care settings. Nurses, as part of emergency teams, and other professionals should be aware that there is a possibility of adverse complications, but they are directly proportional to the time of tourniquet placement and generally temporary. In addition, national and international guidelines ensure the need for all civilian emergency services to be equipped with these devices, as well as for the training of healthcare professionals and first responders in their use. RELEVANCE TO CLINICAL PRACTICE Despite the lack of complications in the use of tourniquets in these cases, their use has been a matter of debate for decades. In this sense, this review yields up-to-date guidelines in the use of tourniquets, their recommendations and their significance among professionals to manage complicated situations.
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Affiliation(s)
- Pablo Roman
- Faculty of Health Sciences, Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, Almeria, Spain
- Research Group CTS-451 Health Sciences, University of Almeria, Almeria, Spain
- Health Research Centre, University of Almeria, Almeria, Spain
| | | | | | - Carmen Ropero-Padilla
- Faculty of Health Sciences, Pre-Department of Nursing, Jaume I University, Castellon de la Plana, Spain
- Research Group CYS, Faculty of Health Sciences, Jaume I University, Castello de la Plana, Spain
| | - Luis Martin-Ibañez
- Field Artillery Group, Light Infantry Brigade "King Alfonso XIII" II of the Legion, Almeria, Spain
| | - Miguel Rodriguez-Arrastia
- Faculty of Health Sciences, Pre-Department of Nursing, Jaume I University, Castellon de la Plana, Spain
- Research Group CYS, Faculty of Health Sciences, Jaume I University, Castello de la Plana, Spain
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Böhm JK, Schäfer N, Maegele M, Stümpges B, Bauerfeind U, Caspers M. Plasmatic and cell-based enhancement by microparticles originated from platelets and endothelial cells under simulated in vitro conditions of a dilutional coagulopathy. Scand J Trauma Resusc Emerg Med 2021; 29:38. [PMID: 33622398 PMCID: PMC7901091 DOI: 10.1186/s13049-021-00847-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 02/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aggressive fluid management and other external factors may lead to hypothermia, acidosis and hemodilution (defined as Lethal Triad, LT) contributing to a trauma-induced coagulopathy (TIC) that worsens patients' outcomes. Procoagulant microparticles (MP) are crucial players at the interface of cellular and plasmatic coagulation. However, their functions remain largely unexplored. This study aimed to characterize effects of MP subtypes and concentrations on functional coagulation under in vitro simulated conditions. METHODS Blood from eleven volunteers were collected to simulate in vitro conditions of hemodilution (HD) and LT, respectively. HD was induced by replacing a blood volume of 33% by crystalloids and for LT, samples were further processed by reducing the temperature to 32 °C and lowering the pH to 6.8. MP were obtained either from platelet concentrates (platelet-derived MP, PDMP) or from cell culture (ECV304 cells for endothelial-derived MP, EDMP) by targeted stimulation. After introducing MP to in vitro conditions, we measured their concentration-dependent effects (1.000, 10.000 and 15.000 MP/μl blood) on coagulation compared to whole blood (WB). For each condition, coagulation was characterized by flow cytometric platelet activation and by quantification of fibrin clot propagation using Thrombodynamics® technology. RESULTS MP originated from platelets and endothelial cells affected blood coagulation in a concentration-dependent manner. Particularly, high PDMP quantities (10.000 and 15.000 PDMP/μl blood) significantly induced platelet activation and fibrin clot growth and size in HD conditions. In LT conditions as well, only high PDMP concentration induced platelet activation, clot growth and size. In contrast, EDMP did not induce platelet activation, but resulted in enhanced formation of spontaneous clots, irrespective of simulated condition. With increasing EDMP concentration, the time until the onset of spontaneous clotting decreased in both HD and LT conditions. DISCUSSION The study demonstrates an essential role of MP within the coagulation process under simulated coagulopathic conditions. PDMP affected platelets promoting clot formation likely by providing a surface enlargement. EDMP presumably affected clotting factors of the plasmatic coagulation resulting in an increased formation of spontaneous clots. CONCLUSION Under simulated conditions of a dilutional coagulopathy, MP from different cellular origin indicate a divergent but both procoagulant mechanism within the coagulation process.
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Affiliation(s)
- Julia K Böhm
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Nadine Schäfer
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Marc Maegele
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Straße 200, 51109, Cologne, Germany
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany
| | - Birgit Stümpges
- Department of Haematology and Transfusion Medicine, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany
| | - Ursula Bauerfeind
- Department of Haematology and Transfusion Medicine, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany
| | - Michael Caspers
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Straße 200, 51109, Cologne, Germany.
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
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Brännström A, von Oelreich E, Degerstedt LE, Dahlquist A, Hånell A, Gustavsson J, Günther M. The swine as a vehicle for research in trauma-induced coagulopathy: Introducing principal component analysis for viscoelastic coagulation tests. J Trauma Acute Care Surg 2021; 90:360-368. [PMID: 33093294 DOI: 10.1097/ta.0000000000002997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Uncontrolled bleeding is the leading cause of potentially preventable deaths among trauma patients. Tissue injury and shock result in trauma-induced coagulopathy (TIC). There are still uncertainties regarding detection methods and best practice management for TIC, and a deeper understanding of the pathophysiology requires robust animal models. The applicability of swine in coagulation studies, particularly after trauma has not been sufficiently elucidated. We, therefore, evaluated the swine as a vehicle for TIC research in a selection of trauma modalities. METHODS Twenty-six landrace swine (3 females/23 males) (mean weight, 60.0 kg) were anesthetized and randomized to negative controls, receiving no manipulation (n = 5), positive controls by hemodilution (n = 5), pulmonary contusion without hemorrhage (n = 5), pulmonary contusion with hemorrhage (n = 5), and blast polytrauma with hypothermia, hypoperfusion, hypoventilation, and systemic inflammation (n = 6). A comprehensive coagulation panel was analyzed at baseline, 20 minutes and 120 minutes after trauma. RESULTS PT(INR), aPTT, thrombocytes, and fibrinogen did not change after trauma. D-dimer increased (p < 0.0001), prothrombin decreased (p < 0.05) and aPC decreased (p < 0.01) after polytrauma. PAI-1 decreased after pulmonary contusion with hemorrhage (p < 0.05). Positive controls displayed changes in PT(INR), thrombocytes, fibrinogen, prothrombin, aPC (p < 0.05). Principal Component Analysis of rotational thromboelastometry presented pathologic coagulation profiles in both polytrauma and positive control groups with vectors extending outside the 95% confidence interval, which were not detected in negative controls. CONCLUSION Coagulopathy was induced after severe porcine blast polytrauma, specifically detected in rotational thromboelastometry. A novel method for principal component analysis of viscoelastic tests was introduced which may increase the detection sensitivity and differentiation of TIC phenotypes and should be further investigated in trauma populations.
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Affiliation(s)
- Andreas Brännström
- From the Department of Clinical Science and Education (A.B., L.E.D., A.D., M.G.), Department of Physiology and Pharmacology (E.v.O.), and Department of Neuroscience (A.H., J.G.), Karolinska Institutet, Stockholm, Sweden
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Increased crystalloid fluid requirements during zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) versus Abdominal Aortic and Junctional Tourniquet (AAJT) after class II hemorrhage in swine. Eur J Trauma Emerg Surg 2021; 48:335-344. [PMID: 33515048 PMCID: PMC7846491 DOI: 10.1007/s00068-020-01592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022]
Abstract
Purpose Pelvic and lower junctional hemorrhage result in a significant amount of trauma related deaths in military and rural civilian environments. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infra-renal (zone 3) Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are two options for resuscitation of patients with life threatening blood loss from and distal to the pelvis. Evidence suggest differences in the hemodynamic response between AAJT and zone 3 REBOA, but fluid management during resuscitation with the devices has not been fully elucidated. We compared crystalloid fluid requirements (Ringer’s acetate) between these devices to maintain a carotid mean arterial pressure (MAP) > 60 mmHg. Methods 60 kg anesthetized and mechanically ventilated male pigs were subjected to a mean 1030 (range 900–1246) mL (25% of estimated total blood volume, class II) haemorrhage. AAJT (n = 6) or zone 3 REBOA (n = 6) were then applied for 240 min. Crystalloid fluids were administered to maintain carotid MAP. The animals were monitored for 30 min after reperfusion. Results Cumulative resuscitative fluid requirements increased 7.2 times (mean difference 2079 mL; 95% CI 627–3530 mL) in zone 3 REBOA (mean 2412; range 800–4871 mL) compared to AAJT (mean 333; range 0–1000 mL) to maintain target carotid MAP. Release of the AAJT required vasopressor support with norepinephrine infusion for a mean 9.6 min (0.1 µg/kg/min), while REBOA release required no vasopressor support. Conclusion Zone 3 REBOA required 7.2 times more crystalloids to maintain the targeted MAP. The AAJT may therefore be considered in a situation of hemorrhagic shock to limit the need for crystalloid infusions, although removal of the AAJT caused more severe hemodynamic and metabolic effects which required vasopressor support.
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Napolitano LM. Hemostatic defects in massive transfusion: an update and treatment recommendations. Expert Rev Hematol 2021; 14:219-239. [PMID: 33267678 DOI: 10.1080/17474086.2021.1858788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Acute hemorrhage is a global healthcare issue, and remains the leading preventable cause of death in trauma. Acute severe hemorrhage can be related to traumatic, peripartum, gastrointestinal, and procedural causes. Hemostatic defects occur early in patients requiring massive transfusion. Early recognition and treatment of hemorrhage and hemostatic defects are required to save lives and to achieve optimal patient outcomes. AREAS COVERED This review discusses current evidence and trials aimed at identifying the optimal treatment for hemostatic defects in hemorrhage and massive transfusion. Literature search included PubMed and Embase. EXPERT OPINION Patients with acute hemorrhage requiring massive transfusion commonly develop coagulopathy due to specific hemostatic defects, and accurate diagnosis and prompt correction are required for definitive hemorrhage control. Damage control resuscitation and massive transfusion protocols are optimal initial treatment strategies, followed by goal-directed individualized resuscitation using real-time coagulation monitoring. Distinct phenotypes exist in trauma-induced coagulopathy, including 'Bleeding' or 'Thrombotic' phenotypes, and hyperfibrinolysis vs. fibrinolysis shutdown. The trauma 'lethal triad' (hypothermia, coagulopathy, acidosis) has been updated to the 'lethal diamond' (including hypocalcemia). A number of controversies in optimal management exist, including whole blood vs. component therapy, use of factor concentrates vs. blood products, optimal use of tranexamic acid, and prehospital plasma and tranexamic acid administration.
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Affiliation(s)
- Lena M Napolitano
- Department of Surgery, University of Michigan Health System, University Hospital, Ann Arbor, Michigan, USA
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Variations and obstacles in the use of coagulation factor concentrates for major trauma bleeding across Europe: outcomes from a European expert meeting. Eur J Trauma Emerg Surg 2021; 48:763-774. [PMID: 33399876 PMCID: PMC7782571 DOI: 10.1007/s00068-020-01563-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/19/2020] [Indexed: 12/24/2022]
Abstract
Purpose Trauma is a leading cause of mortality, with major bleeding and trauma-induced coagulopathy (TIC) contributing to negative patient outcomes. Treatments for TIC include tranexamic acid (TXA), fresh frozen plasma (FFP), and coagulation factor concentrates (CFCs, e.g. prothrombin complex concentrates [PCCs] and fibrinogen concentrate [FCH]). Guidelines for TIC management vary across Europe and a clear definition of TIC is still lacking. Methods An advisory board involving European trauma experts was held on 02 February 2019, to discuss clinical experience in the management of trauma-related bleeding and recommendations from European guidelines, focusing on CFC use (mainly FCH). This review summarises the discussions, including TIC definitions, gaps in the guidelines that affect their implementation, and barriers to use of CFCs, with suggested solutions. Results A definition of TIC, which incorporates clinical (e.g. severe bleeding) and laboratory parameters (e.g. low fibrinogen) is suggested. TIC should be treated immediately with TXA and FCH/red blood cells; subsequently, if fibrinogen ≤ 1.5 g/L (or equivalent by viscoelastic testing), treatment with FCH, then PCC (if bleeding continues) is suggested. Fibrinogen concentrate, and not FFP, should be administered as first-line therapy for TIC. Several initiatives may improve TIC management, with improved medical education of major importance; generation of new and stronger data, simplified clinical practice guidance, and improved access to viscoelastic testing are also critical factors. Conclusions Management of TIC is challenging. A standard definition of TIC, together with initiatives to facilitate effective CFC administration, may contribute to improved patient care and outcomes.
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Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
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Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
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Point-of-Care diagnostics of coagulation in the management of bleeding and transfusion in trauma patients. Curr Opin Anaesthesiol 2020; 33:246-252. [PMID: 32022729 DOI: 10.1097/aco.0000000000000836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Trauma-associated bleeding and coagulopathy require timely identification, prevention, and effective treatment. The present review summarizes the recent literature around point-of-care (POC) coagulation tests, their usefulness in the management of trauma-induced coagulopathy (TIC), their impact on trauma patient outcomes, and the requirement of quality assurance. RECENT FINDINGS Best practice algorithms to manage TIC have been compiled in the 2019 European Guideline on the management of major bleeding and coagulopathy after trauma. Evidence supports the use of goal-directed approaches to manage TIC. POC coagulation tests can accelerate and tailor individualized therapies. Recent findings emphasize: the time sparing of POC tests in prehospital settings and the validity of POC measurements in extreme environments; the potential scalability of POC-guided TIC algorithms in burn injuries and the pediatric population; the need for careful considerations of strategies to monitor and reverse the effects of direct oral anticoagulants in major trauma. SUMMARY In contrast to an abundance of reviews and practical approaches to POC coagulation management in trauma patients, there is a scarcity of research in the field and large-scale clinical trials are urgently needed. The paneuropean multicenter trial Implementing Treatment Algorithms for the Correction of Trauma Induced Coagulopathy (iTACTIC) will inform on the potential of viscoelastic tests to augment transfusion protocols for better patient outcomes.
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Kashani P, Saberinia A. Management of multiple traumas in emergency medicine department: A review. J Family Med Prim Care 2019; 8:3789-3797. [PMID: 31879615 PMCID: PMC6924209 DOI: 10.4103/jfmpc.jfmpc_774_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/16/2019] [Accepted: 10/09/2019] [Indexed: 11/04/2022] Open
Abstract
One of the main causes of adults' disability during their working age is multiple trauma. The process of medical care of patients who are injured seriously is still a challenging job. The primary treatment of these patients in the emergency medicine departments is the most required choice after the wilderness first aid and also would be very required before definitive care in the hospital. The main aim of emergency medicine departments is quick recognition and treatment of injuries which pose severe threat to patients' life in appropriate order of priority. The procedure of primary evaluation in emergency medicine department with the help of medical routine examination and ultrasonography is based on the concept of focused assessment with sonography in trauma (FAST) for identifying spontaneous intraperitoneal hemorrhage. Emergency patients who suffer from massive hematothorax, serious lung and heart traumas, and penetrating traumas to the chest would undergo thoracotomy and patients who have few symptoms of perforated hollow viscous will undergo emergency laparotomy. Based on the trauma severity, emergency treatment could be the way to fast recovery of the structure of injured organ and its function. The subsequent goal, in the acute phase, will concentrate on preventing and stopping bleeding and secondary injuries like painful compartment syndrome or intra-abdominal infections (IAIs). However, the main aim of emergency medicine department in taking care of severely injured patients is the management of airway, protecting circulation and breathing, identification of neurologic problems, and whole body clinical examination with the help of healthcare providers.
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Affiliation(s)
- Parvin Kashani
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Loghman Hakim Hospital, Tehran, Iran
| | - Amin Saberinia
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 663] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
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