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Gilbert S, Desmeules F, Gauvin V, Mercier E. Trauma-induced coagulopathy, could cryoprecipitates improve outcomes? CAN J EMERG MED 2024:10.1007/s43678-024-00704-5. [PMID: 38689201 DOI: 10.1007/s43678-024-00704-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Sophie Gilbert
- Département de Médecine Familiale et Médecine d'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Francis Desmeules
- Département de Médecine Familiale et Médecine d'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
- Département de Médecine d'urgence, CHU de Québec, Québec, QC, Canada
| | - Vincent Gauvin
- Département de Médecine Familiale et Médecine d'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
- Département de Médecine d'urgence, CHU de Québec, Québec, QC, Canada
| | - Eric Mercier
- Département de Médecine Familiale et Médecine d'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada.
- Département de Médecine d'urgence, CHU de Québec, Québec, QC, Canada.
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van Wyk P, Wannberg M, Gustafsson A, Yan J, Wikman A, Riddez L, Wahlgren CM. Characteristics of traumatic major haemorrhage in a tertiary trauma center. Scand J Trauma Resusc Emerg Med 2024; 32:24. [PMID: 38528572 DOI: 10.1186/s13049-024-01196-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/15/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Major traumatic haemorrhage is potentially preventable with rapid haemorrhage control and improved resuscitation techniques. Although advances in prehospital trauma management, haemorrhage is still associated with high mortality. The aim of this study was to use a recent pragmatic transfusion-based definition of major bleeding to characterize patients at risk of major bleeding and associated outcomes in this cohort after trauma. METHODS This was a retrospective cohort study including all trauma patients (n = 7020) admitted to a tertiary trauma center from January 2015 to June 2020. The major bleeding cohort (n = 145) was defined as transfusion of 4 units of any blood components (red blood cells, plasma, or platelets) within 2 h of injury. Univariate and multivariable logistic regression analyses were performed to identify risk factors for 24-hour and 30-day mortality post trauma admission. RESULTS In the major bleeding cohort (n = 145; 145/7020, 2.1% of the trauma population), there were 77% men (n = 112) and 23% women (n = 33), median age 39 years [IQR 26-53] and median Injury Severity Score (ISS) was 22 [IQR 13-34]. Blunt trauma dominated over penetrating trauma (58% vs. 42%) where high-energy fall was the most common blunt mechanism and knife injury was the most common penetrating mechanism. The major bleeding cohort was younger (OR 0.99; 95% CI 0.98 to 0.998, P = 0.012), less female gender (OR 0.66; 95% CI 0.45 to 0.98, P = 0.04), and had more penetrating trauma (OR 4.54; 95% CI 3.24 to 6.36, P = 0.001) than the rest of the trauma cohort. A prehospital (OR 2.39; 95% CI 1.34 to 4.28; P = 0.003) and emergency department (ED) (OR 6.91; 95% CI 4.49 to 10.66, P = 0.001) systolic blood pressure < 90 mmHg was associated with the major bleeding cohort as well as ED blood gas base excess < -3 (OR 7.72; 95% CI 5.37 to 11.11; P < 0.001) and INR > 1.2 (OR 3.09; 95% CI 2.16 to 4.43; P = 0.001). Emergency damage control laparotomy was performed more frequently in the major bleeding cohort (21.4% [n = 31] vs. 1.5% [n = 106]; OR 3.90; 95% CI 2.50 to 6.08; P < 0.001). There was no difference in transportation time from alarm to hospital arrival between the major bleeding cohort and the rest of the trauma cohort (47 [IQR 38;59] vs. 49 [IQR 40;62] minutes; P = 0.17). However, the major bleeding cohort had a shorter time from ED to first emergency procedure (71.5 [IQR 10.0;129.0] vs. 109.00 [IQR 54.0; 259.0] minutes, P < 0.001). In the major bleeding cohort, patients with penetrating trauma, compared to blunt trauma, had a shorter alarm to hospital arrival time (44.0 [IQR 35.5;54.0] vs. 50.0 [IQR 41.5;61.0], P = 0.013). The 24-hour mortality in the major bleeding cohort was 6.9% (10/145). All fatalities were due to blunt trauma; 40% (4/10) high energy fall, 20% (2/10) motor vehicle accident, 10% (1/10) motorcycle accident, 10% (1/10) traffic pedestrian, 10% (1/10) traffic other, and 10% (1/10) struck/hit by blunt object. In the logistic regression model, prehospital cardiac arrest (OR 83.4; 95% CI 3.37 to 2063; P = 0.007) and transportation time (OR 0.95, 95% CI 0.91 to 0.99, P = 0.02) were associated with 24-hour mortality. RESULTS Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control. The major bleeding trauma cohort is a small part of the entire trauma population, and is characterized of being younger, male gender, higher ISS, and exposed to more penetrating trauma. Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control.
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Affiliation(s)
- Pieter van Wyk
- Section of Acute and Trauma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Wannberg
- Department of Molecular Medicine and Surgery, Department of Vascular Surgery, Karolinska Institute, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Anna Gustafsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jane Yan
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Agneta Wikman
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Louis Riddez
- Section of Acute and Trauma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Department of Vascular Surgery, Karolinska Institute, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
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Țichil I, Țichil T, Haplea IS, Tomuleasa CI, Fodor L, Mitre I. Predictors for anaemia, blood transfusion and outcome in plastic surgery patients. J Int Med Res 2024; 52:3000605241237720. [PMID: 38506344 PMCID: PMC10956162 DOI: 10.1177/03000605241237720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/20/2024] [Indexed: 03/21/2024] Open
Abstract
OBJECTIVE In patients undergoing plastic surgery, to identify specific risk factors for anaemia and use of blood products, and assess their impact on patient outcome. METHOD For this retrospective study, data were analysed from patients who attended the Plastic Surgery Department at our hospital over a three-year period (2018 to 2020). Adult patients who presented with traumatic injuries, oncologic patients who underwent reconstructive procedures, and patients with soft tissue infections (STIs) who required plastic surgery for tissue coverage were included. Demographic and injury data, hospital admission characteristics, surgical procedures, laboratory test results, transfusion events, and in-hospital complications were extracted from patient records. RESULTS Of the 350 patients included in the study, 228 (65%) presented with trauma, 76 (22%) underwent reconstructive surgery for cancers and 46 (13%) had STIs. In total, 175 (50%) patients developed anaemia, and 37 (11%) received blood transfusions; these were 20 (54%), 5 (14%), and 12 (32%) patients in the trauma, cancer and STI groups, respectively. Associated comorbidities and upper and lower limb surgery were the most significant risk factors for anaemia, while the number of surgeries and NSTIs were identified as risk factors for blood transfusions. Direct wound closure was consistently a protective factor for both anaemia and blood transfusions. Blood transfusions were independently associated with a high risk of sepsis, wound complications, and prolonged hospital stay. CONCLUSION While transfusions are necessary and even lifesaving in surgical patients, blood is a finite resource and its use may negatively impact patient outcome. Therefore, ongoing research must focus on providing safe and restrictive clinical practices while developing sustainable and accessible alternatives.
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Affiliation(s)
- Ioana Țichil
- University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj Napoca, 8 Victor Babes Street, 400012, Cluj-Napoca, Romania
- Emergency County Hospital, 3–5 Clinicilor Street, 400006, Cluj-Napoca, Romania
- Department of Haematology “Ion Chiricuta” Institute of Oncology 34–36 Republicii Street, Cluj-Napoca, 400015, Romania
| | - Teodora Țichil
- Emergency County Hospital, 3–5 Clinicilor Street, 400006, Cluj-Napoca, Romania
- Opticlinic Med – Eye Care Center 13–15 Bucegi Street, Cluj-Napoca, 400535, Romania
| | - Ionuț Stefan Haplea
- University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj Napoca, 8 Victor Babes Street, 400012, Cluj-Napoca, Romania
| | - Ciprian Ionuț Tomuleasa
- University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj Napoca, 8 Victor Babes Street, 400012, Cluj-Napoca, Romania
- Department of Haematology “Ion Chiricuta” Institute of Oncology 34–36 Republicii Street, Cluj-Napoca, 400015, Romania
| | - Lucian Fodor
- Emergency County Hospital, 3–5 Clinicilor Street, 400006, Cluj-Napoca, Romania
| | - Ileana Mitre
- University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj Napoca, 8 Victor Babes Street, 400012, Cluj-Napoca, Romania
- Emergency County Hospital, 3–5 Clinicilor Street, 400006, Cluj-Napoca, Romania
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Gilbert S, Gauvin V, Malo C, Blanchard PG. Prehospital tranexamic acid: more than just a PATCH for trauma systems? CAN J EMERG MED 2024; 26:86-87. [PMID: 38233577 DOI: 10.1007/s43678-023-00642-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 12/27/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Sophie Gilbert
- Departement de Medecine Familiale et de Medecine d'Urgence, Faculté de Medecine, Universite Laval, Quebec, QC, Canada
| | - Vincent Gauvin
- Departement de Medecine Familiale et de Medecine d'Urgence, Faculté de Medecine, Universite Laval, Quebec, QC, Canada
| | - Christian Malo
- Departement de Medecine Familiale et de Medecine d'Urgence, Faculté de Medecine, Universite Laval, Quebec, QC, Canada
| | - Pierre-Gilles Blanchard
- Departement de Medecine Familiale et de Medecine d'Urgence, Faculté de Medecine, Universite Laval, Quebec, QC, Canada.
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Wigginton O, Johnson S, Jervis B, Joshi A, Steere M, Ferguson I. Prehospital Blood Transfusion: A Cross-Sectional Study of Prehospital and Retrieval Medicine Services across Australia & Aotearoa-New Zealand. PREHOSP EMERG CARE 2024:1-5. [PMID: 38241180 DOI: 10.1080/10903127.2024.2306249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND The frequency and type of prehospital blood product delivery across Australia and Aotearoa-New Zealand is unknown. This study aims to describe transfusion practice across different services in the two nations, as well as identifying potential barriers to the carriage of blood products. METHODOLOGY Prehospital and retrieval medicine services operating teams of doctors, specialist paramedics, and/or flight nurses out of specialty bases across Australia and Aotearoa-New Zealand were sent a standardized questionnaire regarding their base characteristics and their current blood transfusion practice. Bases that only performed inter-hospital transfers or search & rescue operations were excluded. Bases were queried on personnel, equipment, transport times, type and volume of blood products carried, frequency of use, and barriers to implementation for those without prehospital blood transfusion programs. RESULTS 64 bases were identified and contacted, of which 5 were excluded and 45 of the remaining 59 (76.3%) responded. 62% (28/45) of respondents routinely carry prehospital blood products. 78.6% (22/28) carried packed red blood cells (PRBC) only, 14.3% (4/28) carried both PRBC and plasma, and 1 service (3.6%) carried whole blood. The mean number of units of blood product carried was 3.3 (SD 0.82). 2 bases (7.1%) carried fibrinogen concentrate. All services carried tranexamic acid and calcium. 734 patients received a blood transfusion in 2021, with trauma being the most common indication (552, 75.2%). Base characteristics varied significantly in staffing, vehicle platform and transfer times. The median transfer time from scene to hospital was 65 min (IQR of 40-92). Services without access to prehospital blood products identified multiple barriers to implementation, including training and supply chain. CONCLUSION Approximately two-thirds of prehospital services operating advanced teams across Australia and Aotearoa-New Zealand carried blood products and there was wide variation both in the type and number of blood products carried by each base. Multiple barriers to the carriage of blood by all bases were reported, which have implications for service equity. Transfer times are generally long in Australia and Aotearoa-New Zealand, which may impact the generalizability of overseas research performed in prehospital systems with significantly shorter transfer times to services operating in Australia and Aotearoa-New Zealand.
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Affiliation(s)
- Oscar Wigginton
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Sue Johnson
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- Auckland Rescue Helicopter Trust (ARHT), Auckland, Aotearoa-New Zealand
| | - Bethan Jervis
- CareFlight Australia, Northmead, New South Wales, Australia
| | - Anil Joshi
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- Auckland Rescue Helicopter Trust (ARHT), Auckland, Aotearoa-New Zealand
| | - Mardi Steere
- Royal Flying Doctor Service, RFDS Central Operations, Adelaide, South Australia, Australia
| | - Ian Ferguson
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
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Brede JR, Rehn M. The end of balloons? Our take on the UK-REBOA trial. Scand J Trauma Resusc Emerg Med 2023; 31:69. [PMID: 37908007 PMCID: PMC10619299 DOI: 10.1186/s13049-023-01142-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used. The recently published UK-REBOA trial aimed to investigate patients suffering haemorrhagic shock and randomized to standard care alone or REBOA as adjunct to standard care and concludes that REBOA may increase the mortality. MAIN BODY In this commentary we try to balance the discussion on use of REBOA and address limitations in the UK-REBOA trial that may have influenced the outcome of the study. CONCLUSION The situation is complex, and the patients are in extremis. In summary, we do not think this is the end of balloons.
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Affiliation(s)
- Jostein Rødseth Brede
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's University Hospital, Prinsesse Kristinas Gate 3, 7006, Trondheim, Norway.
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.
| | - Marius Rehn
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Staribacher D, Rauner MS, Niessner H. Hospital Resource Planning for Mass Casualty Incidents: Limitations for Coping with Multiple Injured Patients. Healthcare (Basel) 2023; 11:2713. [PMID: 37893787 PMCID: PMC10606697 DOI: 10.3390/healthcare11202713] [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: 07/10/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Using a discrete-event simulation (DES) model, the current disaster plan regarding the allocation of multiple injured patients from a mass casualty incident was evaluated for an acute specialty hospital in Vienna, Austria. With the current resources available, the results showed that the number of severely injured patients currently assigned might have to wait longer than the medically justifiable limit for lifesaving surgery. Furthermore, policy scenarios of increasing staff and/or equipment did not lead to a sufficient improvement of this outcome measure. However, the mean target waiting time for critical treatment of moderately injured patients could be met under all policy scenarios. Using simulation-optimization, an optimal staff-mix could be found for an illustrative policy scenario. In addition, a multiple regression model of simulated staff-mix policy scenarios identified staff categories (number of radiologists and rotation physicians) with the highest impact on waiting time and survival. In the short term, the current hospital disaster plan should consider reducing the number of severely injured patients to be treated. In the long term, we would recommend expanding hospital capacity-in terms of both structural and human resources as well as improving regional disaster planning. Policymakers should also consider the limitations of this study when applying these insights to different areas or circumstances.
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Affiliation(s)
- Daniel Staribacher
- Medical University Vienna, Spitalgasse 23, A-1090 Vienna, Austria;
- Clinic for Neurosurgery, Sozialstiftung Bamberg, Buger Straße 80, D-96049 Bamberg, Germany
| | - Marion Sabine Rauner
- Department of Business Decisions and Analytics, Faculty of Business, Economics, and Statistics, University of Vienna, Oskar-Morgen-Stern-Platz 1, A-1090 Vienna, Austria
| | - Helmut Niessner
- SimPlan Optimizations e. U., Ilse-Arlt-Straße 12/161, A-1220 Vienna, Austria;
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Kwon J, Lee M, Jung K. National Assessment of Opportunities for Improvement in Preventable Trauma Deaths: A Mixed-Methods Study. Healthcare (Basel) 2023; 11:2291. [PMID: 37628489 PMCID: PMC10454732 DOI: 10.3390/healthcare11162291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Trauma is a significant public health issue worldwide, particularly affecting economically active age groups. Quality management of trauma care at the national level is crucial to improve outcomes of major trauma. In Korea, a biennial nationwide survey on preventable trauma death rate is conducted. Based on the survey results, we analyzed opportunities for improving the trauma treatment process. Expert panels reviewed records of 8282 and 8482 trauma-related deaths in 2017 and 2019, respectively, identifying 258 and 160 cases in each year as preventable deaths. Opportunities for improvement were categorized into prehospital, interhospital, and hospital stages. Hemorrhage was the primary cause of death, followed by sepsis/multiorgan failure and central nervous system injury. Delayed hemostatic procedures and transfusions were common areas for improvement in hospital stage. Interhospital transfers experienced significant delays in arrival time. This study emphasizes the need to enhance trauma care by refining treatment techniques, centralizing patients in specialized facilities, and implementing comprehensive reviews and performance improvements throughout the patient transfer system. The findings offer valuable insights for addressing trauma care improvement from both clinical and systemic perspectives.
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Affiliation(s)
- Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea;
| | - Myeonggyun Lee
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA;
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea;
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