Guidelines in trauma-related bleeding and coagulopathy: an update

PURPOSE OF REVIEW

The diagnosis and treatment of patients with severe traumatic bleeding and subsequent trauma-induced coagulopathy (TIC) is still inconsistent, although the implementation of standardized algorithms/treatment pathways was repeatedly linked to improved outcome. Various evidence-based guidelines for these patients now exist, three of which have recently been updated.

RECENT FINDINGS

A synopsis of the three recently updated guidelines for diagnosis and treatment of seriously bleeding trauma patients with TIC is presented: (i) AWMF S3 guideline 'Polytrauma/Seriously Injured Patient Treatment' under the auspices of the German Society for Trauma Surgery; (ii) guideline of the European Society of Anesthesiology and Intensive Care (ESAIC) on the management of perioperative bleeding; and (iii) European guideline on the management of major bleeding and coagulopathy after trauma in its 6th edition (EU-Trauma).

SUMMARY

Treatment of trauma-related bleeding begins at the scene with local compression, use of tourniquets and pelvic binders and rapid transport to a certified trauma centre. After arrival at the hospital, measures to record, monitor and support coagulation function should be initiated immediately. Surgical bleeding control is carried out according to 'damage control' principles. Modern coagulation management includes individualized treatment based on target values derived from point-of-care viscoelastic test procedures.

Massive Transfusion Protocol Adherence: Relationship to Trauma Patient Outcomes

BACKGROUND

Ongoing evaluation of massive transfusion protocol adherence is critical to ensure better trauma patient outcomes.

OBJECTIVE

This quality improvement initiative aimed to determine provider adherence to a recently revised massive transfusion protocol and its relationship to clinical outcomes among trauma patients requiring massive transfusion.

METHODS

A retrospective, descriptive, correlational design was used to determine the association between provider adherence to a recently revised massive transfusion protocol and clinical outcomes in trauma patients with hemorrhage treated at a Level I trauma center from November 2018 to October 2020. Patient characteristics, provider massive transfusion protocol adherence, and patient outcomes were assessed. Patient characteristics and massive transfusion protocol adherence associations with 24-hr survival and survival to discharge were determined using bivariate statistical methods.

RESULTS

A total of 95 trauma patients with massive transfusion protocol activation were evaluated. Of the 95, 71 (75%) survived the initial 24 hr following massive transfusion protocol activation and 65 (68%) survived to discharge. Based on protocol applicable items, the median massive transfusion protocol overall adherence rate per patient was 75% (IQR = 57.1-85.7) for the 65 survivors and 25% (IQR = 12.5-50.0) for the 21 nonsurvivors to discharge whose death occurred at least 1 hr after massive transfusion protocol activation (p < .001).

CONCLUSION

Findings indicate the importance of ongoing evaluations of adherence to massive transfusion protocols in hospital trauma settings to target areas for improvement.

Massive blood transfusion following older adult trauma: The effect of blood ratios on mortality

BACKGROUND

Massive blood transfusion (MBT) following older adult trauma poses unique challenges. Despite extensive evidence on optimal resuscitative strategies in the younger adult patients, there is limited research in the older adult population.

METHODS

We used the Trauma Quality Improvement Program (TQIP) database from 2013 to 2017 to identify all patients over 65 years old who received a MBT. We stratified our population into six fresh-frozen plasma:packed red blood cell (FFP:pRBC) ratio cohorts (1:1, 1:2, 1:3, 1:4, 1:5, 1:6+). Our primary outcomes were 24-h and 30-day mortality. We constructed multivariable regression models with 1:1 group as the baseline and adjusted for confounders to estimate the independent effect of blood ratios on mortality.

RESULTS

A total of 3134 patients met our inclusion criteria (median age 73 ± 7.6 years, 65% male). On risk-adjusted multivariable analysis, 1:1 FFP:pRBC ratio was independently associated with lowest 24-h mortality (1:2 odds ratio [OR] 1.60, 95% confidence interval [CI] 1.25-2.06, p < 0.001) and 30-day mortality (1:2 OR 1.44, 95% CI 1.15-1.80, p = 0.002).

CONCLUSIONS

Compared to all other ratios, the 1:1 FFP:pRBC ratio had the lowest 24-h and 30-day mortality following older adult trauma consistent with findings in the younger adult population.

Infrastructure, logistics and clinical practice management of acute trauma hemorrhage and coagulopathy: a survey across German trauma centers

PURPOSE

Early detection and management of acute trauma hemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructure, logistics and clinical strategies may differ.

METHODS

To assess local differences in infrastructure, logistics and clinical management of acute trauma hemorrhage and coagulopathy we have conducted a web-based survey amongst clinicians working in DGU^®-certified supraregional, regional and local trauma centers.

RESULTS

137/1875 respondents completed the questionnaire yielding a response rate of 7.3%. The majority specified to work as head of department or senior consultant (95%) in trauma/orthopedic surgery (80%) of supraregional (38%), regional (34%) or local (27%) trauma centers. Conventional coagulation assays are most frequently used to monitor bleeding trauma patients. Only half of the respondents (53%) rely on extended coagulation tests, e.g. viscoelastic hemostatic assays. Tests to assess preinjury use of direct oral anticoagulants and platelet inhibitors are still not widely available and vary according to level of care. Conventional blood products are widely available but there remain differences between trauma centers of different level of care to access other hemostatic therapies, e.g. coagulation factor concentrates. Trauma centers of higher level of care are more likely to implement treatment protocols.

CONCLUSION

This survey confirms still existing differences in infrastructure, logistics and clinical practice management for the detection of acute trauma hemorrhage and coagulopathy amongst DGU^®-certified supraregional, regional and local trauma centers. Further work is recommended to locally implement diagnostics, therapies and treatment algorithms compliant to current guidelines to ensure the best possible outcomes in bleeding trauma patients.

Quality of Reporting on Guideline, Protocol, or Algorithm Implementation in Adult Trauma Centers: A Systematic Review

OBJECTIVE

To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0).

BACKGROUND

At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines.

METHODS

A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0.

RESULTS

Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report.

CONCLUSIONS

Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes.

A Decade of Damage Control Resuscitation: New Transfusion Practice, New Survivors, New Directions

OBJECTIVE

The aim of this study was to identify the effects of recent innovations in trauma major hemorrhage management on outcome and transfusion practice, and to determine the contemporary timings and patterns of death.

BACKGROUND

The last 10 years have seen a research-led change in hemorrhage management to damage control resuscitation (DCR), focused on the prevention and treatment of trauma-induced coagulopathy.

METHODS

A 10-year retrospective analysis of prospectively collected data of trauma patients who activated the Major Trauma Centre's major hemorrhage protocol (MHP) and received at least 1 unit of red blood cell transfusions (RBC).

RESULTS

A total of 1169 trauma patients activated the MHP and received at least 1 unit of RBC, with similar injury and admission physiology characteristics over the decade. Overall mortality declined from 45% in 2008 to 27% in 2017, whereas median RBC transfusion rates dropped from 12 to 4 units (massive transfusion rates from 68% to 24%). The proportion of deaths within 24 hours halved (33%-16%), principally with a fall in mortality between 3 and 24 hours (30%-6%). Survivors are now more likely to be discharged to their own home (57%-73%). Exsanguination is still the principal cause of early deaths, and the mortality associated with massive transfusion remains high (48%). Late deaths are now split between those due to traumatic brain injury (52%) and multiple organ dysfunction (45%).

CONCLUSIONS

There have been remarkable reductions in mortality after major trauma hemorrhage in recent years. Mortality rates continue to be high and there remain important opportunities for further improvements in these patients.

Assessing predictors of futility in patients receiving massive transfusions

BACKGROUND

Massive transfusions are associated with a high mortality rate, but there is little evidence indicating when such efforts are futile. The purpose of this study was to identify clinical variables that could be used as futility indicators in massively transfused patients.

METHODS

We retrospectively analyzed 138 adult surgical patients at our institution receiving a massive transfusion (2016-2019). Peak lactate and nadir pH within 24 h of massive transfusion initiation, along with other clinical variables, were assessed as predictors of the primary outcome, in-hospital mortality.

RESULTS

The overall rate of in-hospital mortality among our patient population was 52.9% (n = 73). Increasing lactate and decreasing pH were associated with greater mortality among massively transfused patients. Mortality rates were ~2-fold higher for patients in the highest lactate category (≥10.0 mmol/L: 25 of 37; 67.6%) compared to the lowest category (0.0-4.9 mmol/L: 17 of 48; 35.4%) (p = .005), and ~2.5-fold higher for patients in the lowest pH category (<7.00: 8 of 9; 88.9%) compared to the highest category (≥7.40: 8 of 23; 34.7%) (p = .016). Increasing age was also associated with higher mortality (≥65 years: 24 of 33; 72.7%) when compared to younger patients (18-64 years: 49 of 105; 46.7%) (p = .010).

CONCLUSIONS

Peak lactate ≥10.0 mmol/L, nadir pH <7.00, and age ≥65 years were significantly associated with higher rates of in-hospital mortality among massively transfused patients. Incorporating these clinical parameters into a futility index for massive transfusions will be useful in situations where blood products are scarce and/or mortality may be unavoidable.

The European Perspective on the Management of Acute Major Hemorrhage and Coagulopathy after Trauma: Summary of the 2019 Updated European Guideline

Non-controlled hemorrhage with accompanying trauma-induced coagulopathy (TIC) remains the most common cause of preventable death after multiple injury. Rapid identification followed by aggressive treatment is the key for improved outcomes. Treatment of trauma hemorrhage begins at the scene, with manual compression, the use of tourniquets and (non) commercial pelvic slings, and rapid transfer to an adequate trauma center. Upon hospital admission, coagulation monitoring and support are to be initiated immediately. Bleeding is controlled surgically following damage control principles. Modern coagulation management includes goal-oriented, individualized therapies, guided by point-of-care viscoelastic assays. Idarucizumab can be used as an antidote to the thrombin inhibitor dabigatran, andexanet alpha as an antidote to factor Xa inhibitors. This review summarizes the key recommendations of the 2019 updated European guideline on the management of major bleeding and coagulopathy following trauma. These evidence-based recommendations may form the backbone of algorithms adapted to local logistics and infrastructure.

The Diagnosis and Treatment of Acute Traumatic Bleeding and Coagulopathy

BACKGROUND

Uncontrolled bleeding with trauma-induced coagulopathy (TIC) is still the most common avoidable cause of death in multiple trauma. The aging of the population has led to an increasing number of bleeding trauma patients with pre-existing anticoagulation. Such patients are not treated uniformly, even in major trauma centers.

METHODS

This review is based on a selective search of the literature (Medline/PubMed, Cochrane Reviews) and summarizes current treatment recommendations, including those of the newly revised European trauma guidelines.

RESULTS

The treatment of traumatic hemorrhage begins at the site of the accident, with compression, tourniquets, pelvic binders, and rapid transport to a certified trauma center. The early use of tourniquets was shown to lessen the trans- fusion requirement (packed red blood cells: 2.0 ± 0.1 vs. 9.3 ± 0.6; p < 0.001; fresh frozen plasma concentrates: 1.4 ± 0.08 vs. 6.2 ± 0.4; p < 0.001), while external pelvic stabilization was shown to reduce mortality (19.1% vs. 33.3%). Upon the patient's arrival in the hospital, steps are taken to measure, monitor, and support clotting function. Bleeding is controlled surgically according to the principles of damage control. Modern clotting management consists of goal-oriented, individualized therapy, including the use of point-of-care viscoelastic test procedures. Idarucizumab can be used as an antidote to the thrombin inhibitor dabigatran, andexanet alpha as an antidote to factor Xa inhibitors.

CONCLUSION

The evidence-based treatment of patients with hemorrhage from severe trauma, in accordance with the existing guidelines, can improve the clinical outcome. Corresponding algorithms, adapted to local logistics and infrastructure, must be developed and implemented.

Fresh Frozen Plasma-to-Packed Red Blood Cell Ratio and Mortality in Traumatic Hemorrhage: Nationwide Analysis of 4,427 Patients

BACKGROUND

Despite the presence of highly reliable data, studies on packed red blood cells (pRBC):fresh frozen plasma (FFP) ratio suffer from limited sample size and the presence of survivor bias. We sought to study the association between FFP:pRBC and early mortality in the hemorrhaging trauma patient.

STUDY DESIGN

This was a retrospective nationwide cohort that included all TQIP participating hospitals (2013 to 2016). We included all trauma patients who were transfused ≥10 pRBCs and ≥1 FFP within 24 hours. We excluded transferred patients and those who died in the emergency department or had missing/inaccurate transfusion data. Patients were assigned to 7 FFP:pRBC cohorts (range 1:1 to 1:6, and 1:6+) only if the ratio was similar at 4 and 24 hours and, to avoid survival bias, were excluded otherwise. Multivariable analyses correcting for all available confounders (age, demographics, comorbidities, vital signs, Injury Severity Score [ISS] and mechanism, procedures performed) were derived to study the independent relationship between FFP:pRBC and 24-hour mortality.

RESULTS

Of 1,002,595 patients, 4,427 patients were included. Mean age was 41 years, 79% were males, 61% had blunt trauma, and median ISS was 29. Most patients were transfused in a 1:1, 1:2, or 1:3 ratio (31%, 41%, and 11%, respectively); mortality ranged between 28% for 1:1 and 62% for 1:4. In multivariable analyses, the odds of mortality independently and incrementally increased to 1.23 (95% CI 1.02 to 1.48) for a 1:2 ratio, 2.11 (95% CI 1.42 to 3.13) for 1:4, and as high as 4.11 (95% CI 2.31 to 7.31) for 1:5 (all p < 0.05).

CONCLUSIONS

A 1:1 FFP:pRBC ratio is associated with the lowest mortality in the hemorrhaging trauma patient, and mortality increases with decreasing ratios.

Implementation of Trauma Center and Massive Transfusion Protocol Improves Outcomes for Major Trauma Patients: A Study at a Single Institution in Korea

BACKGROUND

This study evaluated the effectiveness and clinical outcomes of the implementation of a trauma center and massive transfusion protocol (TCMTP) in a developing country without a well-established trauma system.

METHODS

We included patients (1) aged >15 years, (2) with an Injury Severity Score >15, (3) who received ≥10 units of packed red blood cells (PRBCs) within 24 h, (4) who directly visited our institution from 2010 to 2016, and (5) who survived for ≥24 h. Patients treated during the post-TCMTP period (2015-2016) were compared with historical groups treated pre-TCMTP (2010-2012) and interim-TCMTP (2013-2014). Demographics, transfusion and fluid therapy performance, and clinical outcomes were compared between the three groups.

RESULTS

Overall, 190 patients were included: 64, 64, and 62 patients in the pre-TCMTP, interim-TCMTP, and post-TCMTP groups, respectively. Comparison between the three groups revealed significant differences in the fresh-frozen plasma/PRBC ratio (p = 0.001) and crystalloid infusion (p = 0.007); these variables gradually increased from pre- to post-TCMTP. Conversely, colloid infusion showed a reduction post-TCMTP (p < 0.001). Kaplan-Meier curves revealed that the 90-day survival rate was significantly higher in the post-TCMTP group (pre-TCMTP: 45.3 vs. 75.8%, p = 0.001; interim-TCMTP: 56.3 vs. 75.8%, p = 0.027). In Cox regression hierarchical survival analysis, TCMTP showed a hazard ratio for mortality of 0.380 after adjusting for all potentially confounding factors.

CONCLUSIONS

Our results suggest that building trauma centers and establishing a massive transfusion protocol according to the specific situations of a country will help improve outcomes for major trauma patients, even in developing countries without a well-established trauma system.

Implementation of a Massive Transfusion Protocol: Evaluation of Its Use and Efficacy

Massive transfusion protocols (MTPs) allow practitioners to follow a prescribed algorithm for the rapid replacement of blood products during a massive hemorrhage. They function as an established protocol to provide consistent treatment. Once implemented, the MTP must be evaluated to ensure best practice. The purpose of this clinical improvement project was to formally evaluate the use and efficacy of an MTP during its first year of implementation. The specific aims were to (1) determine whether MTP activations were missed; (2) compare outcomes between those patients managed by the MTP and those who were not; and (3) provide recommendations to the institution's stakeholders. A retrospective medical record review was conducted with 101 electronic medical records of adult trauma patients treated over 1 year. Patients were identified to have experienced massive bleeding if their medical record contained 1 of 4 indicators: (1) transfusion of uncrossmatched blood; (2) tranexamic acid administration; (3) transfusion of 4 or more units of packed red blood cells (PRBCs) in 1 hr; and/or (4) transfusion of 10 or more units of PRBCs in 24 hr. While 58 patients experienced massive bleeding, only 16 (28%) were managed using the MTP. Although the non-MTP group received fewer transfused blood products due to higher initial and 24-hr hemoglobin levels, more deaths occurred in this group than in the MTP group. The recommendations were to (1) establish well-defined criteria for MTP activation based on the 4 indicators of massive bleeding and (2) regularly evaluate the use and efficacy of the MTP to ensure positive patient outcomes.

A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children

BACKGROUND

Massive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear.

MATERIAL AND METHODS

A retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios.

RESULTS

There were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups.

CONCLUSIONS

A high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.