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Easterday T, Byerly S, Magnotti L, Fischer P, Shah K, Croce M, Kerwin A, Howley I. Performance Improvement Program Review of Institutional Massive Transfusion Protocol Adherence: An Opportunity for Improvement. Am Surg 2024; 90:1082-1088. [PMID: 38297889 DOI: 10.1177/00031348221114036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Given the acuity of patients who receive MTPs and the resources they require, MTPs are a compelling target for performance improvement. This study evaluated adherence with our MTP's plasma:red blood cell ratio (FFPR) of 1:2 and platelet:red blood cell ratio (PLTR) of 1:12, to test the hypothesis that ratio adherence is associated with lower inpatient mortality. MATERIALS AND METHODS The registry of an urban level I trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 hours of presentation. Patients were excluded for interfacility transfer, cardiac arrest during the prehospital phase or within one hour of arrival, or for head AIS ≥5. Univariate analysis and multiple logistic regressions were performed to identify variables associated with early transfusion protocol noncompliance and the effect on inpatient mortality. RESULTS Three hundred and eighty-three patients were included, with mean ISS of 25.9 ± 13.3 and inpatient mortality of 28.5%. Increasing age, ISS, INR, and total units of blood product transfused were associated with increased odds of mortality, while an increase in revised trauma score was associated with a decreased odds ratio of mortality. Achieving our goal ratios were protective against mortality, with OR of .451 (P = .013) and .402 (P=.003), respectively. DISCUSSION Large proportions of critically injured patients were transfused fewer units of plasma and platelets than our MTP dictated; failure to achieve intended ratios at 4 hours was strongly associated with inpatient mortality. MTP processes and outcomes should be critically assessed on a regular basis as part of a mature performance improvement program to ensure protocol adherence and optimal patient outcome.
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Affiliation(s)
- Thomas Easterday
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya Byerly
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Louis Magnotti
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter Fischer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kinjal Shah
- Department of Pathology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Martin Croce
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew Kerwin
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac Howley
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
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Gendler S, Gelikas S, Talmy T, Nadler R, Tsur AM, Radomislensky I, Bodas M, Glassberg E, Almog O, Benov A, Chen J. Predictors of Short-Term Trauma Laparotomy Outcomes in an Integrated Military-Civilian Health System: A 23-Year Retrospective Cohort Study. J Clin Med 2024; 13:1830. [PMID: 38610595 PMCID: PMC11012665 DOI: 10.3390/jcm13071830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/03/2024] [Accepted: 03/14/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Trauma laparotomy (TL) remains a cornerstone of trauma care. We aimed to investigate prehospital measures associated with in-hospital mortality among casualties subsequently undergoing TLs in civilian hospitals. Methods: This retrospective cohort study cross-referenced the prehospital and hospitalization data of casualties treated by Israel Defense Forces-Medical Corps teams who later underwent TLs in civilian hospitals between 1997 and 2020. Results: Overall, we identified 217 casualties treated by IDF-MC teams that subsequently underwent a TL, with a mortality rate of 15.2% (33/217). The main mechanism of injury was documented as penetrating for 121/217 (55.8%). The median heart rate and blood pressure were within the normal limit for the entire cohort, with a low blood pressure predicting mortality (65 vs. 127, p < 0.001). In a multivariate analysis, prehospital endotracheal intubation (ETI), emergency department Glasgow coma scores of 3-8, and the need for a thoracotomy or bowel-related procedures were significantly associated with mortality (OR 6.8, p < 0.001, OR = 48.5, p < 0.001, and OR = 4.61, p = 0.002, respectively). Conclusions: Prehospital interventions introduced throughout the study period did not lead to an improvement in survival. Survival was negatively influenced by prehospital ETI, reinforcing previous observations of the potential deleterious effects of definitive airways on hemorrhaging trauma casualties. While a low blood pressure was a predictor of mortality, the median systolic blood pressure for even the sickest patients (ISS > 16) was within normal limits, highlighting the challenges in triage and risk stratification for trauma casualties.
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Affiliation(s)
- Sami Gendler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Shaul Gelikas
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Medicine, Sheba Medical Center, Tel-Hashomer 5262504, Israel
| | - Tomer Talmy
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Roy Nadler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Avishai M. Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Medicine, Sheba Medical Center, Tel-Hashomer 5262504, Israel
| | - Irina Radomislensky
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 5262100, Israel
| | - Moran Bodas
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 5262100, Israel
- Department of Emergency & Disaster Management, School of Public Health, Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo 6139001, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
- The Uniformed Services, University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ofer Almog
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
| | - Jacob Chen
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Meir Medical Center, Kfar Saba 4428164, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel
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Chang RK, Boyle BP, Udoh MO, Maestas JM, Gehrz JA, Ruano E, Banker L, Cap AP, Bitterman JW, Deaton TG, Auten JD. Prescreened Whole O Blood Group Walking Blood Bank Capabilities for Nontraditional Maritime Medical Receiving Platforms: A Case Series. J Spec Oper Med 2024:PC7T-LML9. [PMID: 38408045 DOI: 10.55460/pc7t-lml9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Tactical Combat Casualty Care (TCCC) guidelines recognize low-titer group O whole blood (LTOWB) as the resuscitative fluid of choice for combat wounded. Utilization of prescreened LTOWB in a walking blood bank (WBB) format has been well described by the Ranger O low-titer blood (ROLO) and the United States Marine Corps Valkyrie programs, but it has not been applied to the maritime setting. METHODS We describe three WBB experiences of an expeditionary resuscitative surgical system (ERSS) team, attached to three nontraditional maritime medical receiving platforms, over 6 months. RESULTS Significant variations were identified in the number of screened eligible donors, the number of LTOWB donors, and the timely arrival at WBB activation sites between the platforms. Overall, 95% and 84% of the screened eligible group O blood donors on the Arleigh Burke Class Destroyer (DDG) and Nimitz Class Aircraft Carrier (CVN), respectively, were determined to be LTOWB. However, only 37% of the eligible screened group O blood donors aboard the Harper's Ferry Class Dock Landing Ship (LSD) were found to be LTOWB. Of the eligible donors, 66% did not complete screening, with 52% citing a correctable reason for nonparticipation. CONCLUSION LTOWB attained through WBBs may be the only practical resuscitative fluid on maritime platforms without inherent blood product storage capabilities to perform remote damage control resuscitation. Future efforts should focus on optimizing WBBs through capability development, education, and training efforts.
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Harada K, Kojima D, Yamana I, Seike H, Fujikawa T. Damage Control Surgery for Duodenal Ulcer Bleeding With Massive Hematoma and Perforation Due to Over-the-Scope Clip (OTSC). Cureus 2024; 16:e56359. [PMID: 38633969 PMCID: PMC11022004 DOI: 10.7759/cureus.56359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Due to the advances in endoscopic technology, surgery for duodenal ulcer (DU) bleeding has decreased, although surgery is still necessary for more complicated cases. The concept of damage control surgery (DCS) has been established in the field of trauma, and a simple surgical approach may be preferable in serious cases such as uncontrolled DU bleeding. We present a successful case of bleeding with massive hematoma and perforation of the duodenum due to an over-the-scope clip that was treated by a less invasive surgical approach with consideration of the DCS.
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Affiliation(s)
- Kei Harada
- Surgery, Kokura Memorial Hospital, Kitakyushu, JPN
| | - Daibo Kojima
- Surgery, Kokura Memorial Hospital, Kitakyushu, JPN
- Gastroenterological Surgery, Fukuoka University, Faculty of Medicine, Fukuoka, JPN
| | - Ippei Yamana
- Surgery, Kokura Memorial Hospital, Kitakyushu, JPN
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Simovic MO, Bynum J, Liu B, Dalle Lucca JJ, Li Y. Impact of Immunopathy and Coagulopathy on Multi-Organ Failure and Mortality in a Lethal Porcine Model of Controlled and Uncontrolled Hemorrhage. Int J Mol Sci 2024; 25:2500. [PMID: 38473750 DOI: 10.3390/ijms25052500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Uncontrolled hemorrhage is a major preventable cause of death in patients with trauma. However, the majority of large animal models of hemorrhage have utilized controlled hemorrhage rather than uncontrolled hemorrhage to investigate the impact of immunopathy and coagulopathy on multi-organ failure (MOF) and mortality. This study evaluates these alterations in a severe porcine controlled and uncontrolled hemorrhagic shock (HS) model. Anesthetized female swine underwent controlled hemorrhage and uncontrolled hemorrhage by partial splenic resection followed with or without lactated Ringer solution (LR) or Voluven® resuscitation. Swine were surveyed 6 h after completion of splenic hemorrhage or until death. Blood chemistry, physiologic variables, systemic and tissue levels of complement proteins and cytokines, coagulation parameters, organ function, and damage were recorded and assessed. HS resulted in systemic and local complement activation, cytokine release, hypocoagulopathy, metabolic acidosis, MOF, and no animal survival. Resuscitation with LR and Voluven® after HS improved hemodynamic parameters (MAP and SI), metabolic acidosis, hyperkalemia, and survival but resulted in increased complement activation and worse coagulopathy. Compared with the LR group, the animals with hemorrhagic shock treated with Voluven® had worse dilutional anemia, coagulopathy, renal and hepatic dysfunction, increased myocardial complement activation and renal damage, and decreased survival rate. Hemorrhagic shock triggers early immunopathy and coagulopathy and appears associated with MOF and death. This study indicates that immunopathy and coagulopathy are therapeutic targets that may be addressed with a high-impact adjunctive treatment to conventional resuscitation.
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Affiliation(s)
- Milomir O Simovic
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - James Bynum
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Bin Liu
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | | | - Yansong Li
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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Talmy T, Malkin M, Esterson A, Yazer MH, Sebbag A, Shina A, Shinar E, Glassberg E, Gendler S, Almog O. Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience. Transfus Med 2023; 33:440-452. [PMID: 37668175 DOI: 10.1111/tme.12995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/24/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges. METHODS In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB. RESULTS Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge. CONCLUSIONS The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting.
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Affiliation(s)
- Tomer Talmy
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Michael Malkin
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anat Sebbag
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Avi Shina
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Eilat Shinar
- Magen David Adom, National Blood Services, Ramat Gan, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sami Gendler
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Ofer Almog
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Smedley WA, Mabry CD, Collins T, Tabor J, Bowman S, Porter A, Young S, Klutts G, Deloach J, Bhavaraju A, Maxson T, Robertson RD, Holcomb JB, Kalkwarf KJ. Access to Immediately Available Balanced Blood Products in a Rural State's Trauma System. Am Surg 2023:31348231160836. [PMID: 36877979 DOI: 10.1177/00031348231160836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
INTRODUCTION The Arkansas Trauma System was established by law more than a dozen years ago, and all participating trauma centers are required to maintain red blood cells. Since then, there has been a paradigm shift in resuscitating exsanguinating trauma patients. Damage Control Resuscitation with balanced blood products (or whole blood) and minimal crystalloid is now the standard of care. This project aimed to determine access to balanced blood products in our state's Trauma System (TS). METHODS A survey of all trauma centers in the Arkansas TS was conducted, and geospatial analysis was performed. Immediately Available Balanced Blood (IABB) was defined as at least 2 units (U) of thawed plasma (TP) or never frozen plasma (NFP), 4 units of red blood cells (RBCs), 2 units of fresh frozen plasma (FFP), and 1 unit of platelets or 2 units of whole blood (WB). RESULTS All 64 trauma centers in the state TS completed the survey. All level I, II, and III Trauma Centers (TCs) maintain RBC, plasma, and platelets, but only half of the level II and 16% of the level III TCs have thawed or never frozen plasma. A third of level IV TCs maintain only RBCs, while only 1 had platelets, and none had thawed plasma. 85% of people in our state are within 30 min of RBCs, almost two-thirds are within 30 min of plasma (TP, NFP, or FFP) and platelets, while only a third are within 30 min of IABB. More than 90% are within an hour of plasma and platelets, while only 60% are within that time from an IABB. The median drive times for Arkansas from RBC, plasma (TP, NFP, or FFP), platelets, and an immediately available and balanced blood bank are 19, 21, 32, and 59 minutes, respectively. A lack of thawed or non-frozen plasma and platelets are the most common limitations of IABB. One level III TC in the state maintains WB, which would alleviate the limited access to IABB. CONCLUSION Only 16% of the trauma centers in Arkansas can provide IABB, and only 61% of the population can reach IABB within 60 minutes. Opportunities exist to reduce the time to balanced blood products by selectively distributing WB, TP, or NFP to hospitals in our state trauma system.
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Affiliation(s)
- W Andrew Smedley
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Terry Collins
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeff Tabor
- Arkansas Trauma Communications Center, Little Rock, AR, USA
| | - Stephen Bowman
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Austin Porter
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sean Young
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Garret Klutts
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joseph Deloach
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Avi Bhavaraju
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Todd Maxson
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald D Robertson
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John B Holcomb
- Center for Injury Sciences, Division of Acute Care Surgery, 9967University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kyle J Kalkwarf
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Berková J, Kočí J. Massive transfusion protocol. Rozhl Chir 2023; 102:189-193. [PMID: 37527944 DOI: 10.33699/pis.2023.102.5.189-193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
The management of severe traumatic bleeding includes damage control resuscitation procedures including, in addition to surgical bleeding control, the application of the massive transfusion protocol. The aim of this paper is to present the massive transfusion protocol and selected scoring systems for an early detection of patients with severe post-traumatic bleeding. The use of a standardized protocol to activate the massive transfusion protocol reduces lethality due to severe traumatic bleeding and the consumption of blood products in trauma centers.
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9
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Ward HL, Downing N, Goller S, Stremick J. The Challenges of Treating Complex Medical Patients in the Role 2 Environment: A Case Series. J Spec Oper Med 2022; 22:93-96. [PMID: 36525020 DOI: 10.55460/8mrx-gxr1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 06/17/2023]
Abstract
The Role 2 environment presents several challenges in diagnosing and treating complex medical and life-threatening conditions. They are primarily designed to perform damage control resuscitation and surgery in the setting of trauma with less emphasis on complex medical care and limited ability to hold patients for more than 72 hours. Providing care to Soldiers and civilians in the deployed setting is made more difficult by the limited number of personnel, lack of advanced diagnostic equipment such as CT scanners, harsh working conditions, and austere resources. Despite these challenges, deployed physicians have continued to provide high levels of care to injured Soldiers and civilians by using clinical judgment, validated clinical decision-making tools, and adjunct diagnostic tools, such as ultrasound. In this case series we will present three complex medical cases involving pulmonary embolism (PE), ventricular tachycardia (VT), and aortic dissection that were seen in a deployed Role 2 setting. This article will highlight and discuss the challenges faced by deployed providers and ways to mitigate these challenges.
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Muacevic A, Adler JR. Navigated Percutaneous Sacroiliac Screw Fixation in Unstable Pelvic Ring Fracture. Cureus 2022; 14:e29897. [PMID: 36348881 PMCID: PMC9631861 DOI: 10.7759/cureus.29897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 01/24/2023] Open
Abstract
Since the late 1990s, navigation systems have been widely used in a variety of orthopaedic surgical procedures, with the majority of these procedures being complex arthroplasty surgeries and the correction of spinal abnormalities. Navigation systems are, however, infrequently used in trauma cases, especially in unstable pelvic ring fractures. The conventional method of percutaneous sacroiliac screw fixation typically used fluoroscopic image intensifiers to fix unstable pelvic ring fractures. We will examine how navigation systems can be used in trauma situations, particularly those involving unstable posterior pelvic ring fractures and focus on the advantages and disadvantages that we experienced during management.
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11
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Addams J, Arbabi S, Bulger EM, Stansbury LG, Tuott EE, Hess JR. How we built a hospital-based community whole blood program. Transfusion 2022; 62:1699-1705. [PMID: 35815552 DOI: 10.1111/trf.17018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whole blood (WB) is an attractive product for prehospital treatment of hemorrhagic shock and for initial in-hospital resuscitation of patients likely to require massive transfusion. Neither our regional blood provider nor our hospital blood bank had recent experience collecting or using WB, so we developed a stepwise process to gather experience with WB in clinical practice. METHODS When our Transfusion Committee suggested a WB program, we worked with our regional blood provider to collect cold-stored, leukoreduced, low-titer anti-A, and anti-B group O RhD positive WB (low-titer group O WB [LTOWB]) and worked with our city Fire Department to integrate it into prehospital care. This work required planning, development of protocols, writing software for blood bank and electronic medical records, changes in paramedic scope of practice, public information, training of clinicians, and close clinical follow-up. RESULTS Between June 2019 and December 2021, we received 2269 units of LTOWB and transfused 2220 units; 24 (1%) were wasted, two were withdrawn, and 23 were in stock at the end of that time. Most (89%) were transfused to trauma patients. Usage has grown from 48 to 120 units/month, covers all 5 Fire Districts in the county, and represents about ¼ of all hospital trauma blood product use. CONCLUSIONS Developing a WB program is complex but can be started slowly, including both pre-hospital and hospital elements, and expanded as resources and training progress. The investments of time, effort, and funding involved can potentially improve care, save blood bank and nursing effort, and reduce patient charges.
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Affiliation(s)
- Joel Addams
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Saman Arbabi
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lynn G Stansbury
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA.,Department of Anesthesia and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Erin E Tuott
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA.,Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA
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12
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Ali M, Liu Z, Taylor M, Orcutt T, Bledsoe A, Phuong J, Stansbury LG, Arbabi S, Robinson BRH, Bulger E, Vavilala MS, Hess JR. Blood product availability in the Washington state trauma system. Transfusion 2022; 62:1218-1229. [PMID: 35470898 DOI: 10.1111/trf.16888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/06/2022] [Accepted: 03/17/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Early transfusion can prolong life in injured patients awaiting definitive hemorrhage control. We conducted a community resources assessment of blood product availability at hospitals within the Washington State (WA) Regional Trauma System, with the expectation that a minority of Level IV and V centers would have blood products routinely available for use in resuscitation. METHODS We designed a questionnaire soliciting information on routinely available unit quantities of red blood cells (RBC), plasma, platelets, cryoprecipitate, and/or whole blood and submitted this questionnaire electronically to the 82 WA designated trauma centers (Levels I-V). Non-responders were contacted directly by telephone. The study was conducted in September and October 2021. US 2020 census data were used to correlate results with local population densities. RESULTS First-round contact netted responses from 57 (70%) centers; the remaining centers provided information via telephone, for a 100% final response. Packed RBC were available in 79 of the 82 centers (96%; range 6-220 units); plasma, 62 centers (76%, range 1-100 units); platelets, 40 centers (49%, range 1-8 units); cryoprecipitate, 45 centers (55%, range 1-20 units). Whole blood was only available at the Level I center. Three Level V centers, located in 2 of the 8 WA state trauma regions, reported no routine blood availability. The two trauma regions affected represent 12% of the state's population and more than a third of its geographic area. CONCLUSIONS Within the WA regional trauma system, blood products are wide, if unevenly, available. Large urban/rural disparities in availability exist that should be explored.
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Affiliation(s)
- Mohamed Ali
- Department of Laboratory Medicine and Pathology, UW School of Medicine (SOM), Seattle, WA, USA
| | - Zhinan Liu
- Harborview Injury Prevention and Research Center (HIPRC), UW SOM, Seattle, WA, USA
| | - Mark Taylor
- Harborview Trauma Program, Harborview Medical Center (HMC), Seattle, WA, USA.,Office of Community Health, Emergency Care Systems, Washington State Department of Health, Olympia, WA, USA
| | - Tim Orcutt
- Office of Community Health, Emergency Care Systems, Washington State Department of Health, Olympia, WA, USA
| | - Anthony Bledsoe
- Office of Community Health, Emergency Care Systems, Washington State Department of Health, Olympia, WA, USA
| | - Jimmy Phuong
- Harborview Injury Prevention and Research Center (HIPRC), UW SOM, Seattle, WA, USA
| | - Lynn G Stansbury
- Harborview Injury Prevention and Research Center (HIPRC), UW SOM, Seattle, WA, USA.,Department of Anesthesiology and Pain Medicine, UW SOM, Seattle, Washington, USA
| | - Saman Arbabi
- Harborview Injury Prevention and Research Center (HIPRC), UW SOM, Seattle, WA, USA.,Department of Surgery, UW SOM, Seattle, Washington, USA
| | - Bryce R H Robinson
- Office of Community Health, Emergency Care Systems, Washington State Department of Health, Olympia, WA, USA.,Department of Surgery, UW SOM, Seattle, Washington, USA
| | - Eileen Bulger
- Department of Surgery, UW SOM, Seattle, Washington, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center (HIPRC), UW SOM, Seattle, WA, USA.,Department of Anesthesiology and Pain Medicine, UW SOM, Seattle, Washington, USA.,Department of Pediatrics, UW SOM, Seattle, Washington, USA
| | - John R Hess
- Department of Laboratory Medicine and Pathology, UW School of Medicine (SOM), Seattle, WA, USA.,Harborview Injury Prevention and Research Center (HIPRC), UW SOM, Seattle, WA, USA.,Transfusion Services, Harborview Medical Center (HMC), Seattle, Washington, USA
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13
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St. John AE, Wang X, Ringgold K, Lim EB, Chien D, Statz ML, Stern SA, White NJ. A Multifunctional, Low-Volume Resuscitation Cocktail Improves Vital Organ Blood Flow and Hemostasis in a Pig Model of Polytrauma with Traumatic Brain Injury. J Clin Med 2021; 10:jcm10235484. [PMID: 34884185 PMCID: PMC8658540 DOI: 10.3390/jcm10235484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 12/19/2022] Open
Abstract
The resuscitation of polytrauma with hemorrhagic shock and traumatic brain injury (TBI) is a balance between permissive hypotension and maintaining vital organ perfusion. There is no current optimal solution. This study tested whether a multifunctional resuscitation cocktail supporting hemostasis and perfusion could mitigate blood loss while improving vital organ blood flow during prolonged limited resuscitation. Anesthetized Yorkshire swine were subjected to fluid percussion TBI, femur fracture, catheter hemorrhage, and aortic tear. Fluid resuscitation was started when lactate concentration reached 3–4 mmol/L. Animals were randomized to one of five groups. All groups received hydroxyethyl starch solution and vasopressin. Low- and high-dose fibrinogen (FBG) groups additionally received 100 and 200 mg/kg FBG, respectively. A third group received TXA and low-dose FBG. Two control groups received albumin, with one also including TXA. Animals were monitored for up to 6 h. Blood loss was decreased and vital organ blood flow was improved with low- and high-dose fibrinogen compared to albumin controls, but survival was not improved. There was no additional benefit of high- vs. low-dose FBG on blood loss or survival. TXA alone decreased blood loss but had no effect on survival, and combining TXA with FBG provided no additional benefit. Pooled analysis of all groups containing fibrinogen vs. albumin controls found improved survival, decreased blood loss, and improved vital organ blood flow with fibrinogen delivery. In conclusion, a low-volume resuscitation cocktail consisting of hydroxyethyl starch, vasopressin, and fibrinogen concentrate improved outcomes compare to controls during limited resuscitation of polytrauma.
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14
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Sayre MR, Yang BY, Murphy DL, Counts CR, Dang M, Ubaldi P, Tuott EE, Hess JR. Providing whole blood for an urban paramedical ambulance system. Transfusion 2021; 62:82-86. [PMID: 34787330 DOI: 10.1111/trf.16749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/29/2021] [Accepted: 10/31/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hemorrhage is the second leading cause of death among urban trauma patients, and the provision of prehospital blood-based resuscitation can be lifesaving. We developed an efficient system to support blood-based resuscitation by an urban advanced life support ambulance system. METHODS We worked with our state health department for permission for fire department paramedics to initiate blood transfusion and built protocols for field whole blood resuscitation. Our regional trauma center transfusion service provided 2 units of O positive, low-titer, leukoreduced whole blood in an internally monitored and sealed ice box weighing 10 pounds to the fire department paramedic supervisor. When notified, the supervisor transported the blood to the sites of anticipated need. Total blood use and wastage were recorded. RESULTS Following two public hearings, we obtained state-wide approval for the initiation of emergency uncrossmatched blood transfusion by paramedics. Over a 1-year period beginning August 27, 2019, 160 units of whole blood were made available for use, and 51 units were transfused to 39 patients, 30 of whom were trauma patients. Other recipients include patients in shock from massive gastrointestinal, peripartum, or other suspected bleeding. Unused units were returned to the providing transfusion service after 1 week and used for hospital patient care without loss. The estimated cost of providing blood per mission was $0.28 and per patient transfused was $1138. CONCLUSIONS With appropriate attention to detail, it is possible to provide whole blood to an urban paramedical ambulance system with efficient blood component usage, minimal blood wastage, and low cost.
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Affiliation(s)
- Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.,Seattle Fire Department, Seattle, WA, USA
| | - Betty Y Yang
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - David L Murphy
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Catherine R Counts
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Maika Dang
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Erin E Tuott
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
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15
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Asif M, Hasan RA, Liu Z, Stansbury LG, Hess JR. Cold-stored whole blood and platelet counts in severe acute injury: A comparison of four retrospective cohorts. Transfusion 2021; 61:3321-3327. [PMID: 34633665 DOI: 10.1111/trf.16699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low-titer group O whole blood (LTOWB) is attractive for acute trauma care as it delivers concentrated and balanced hemostatic resuscitation in single large bags. Whether cold-stored LTOWB can sustain platelet counts is unclear. STUDY DESIGN AND METHODS Four cohorts of trauma patients-three historic, one retrospective-were identified by their urgency of blood use. Admission and all subsequent platelet counts over the first 24 h of care were compared with t-tests. The cohorts were as follows: 1292 patients at Maryland Shock Trauma as described by Stansbury and colleagues in 2013; 35 patients enrolled locally in the 1:1:2 arm of the pragmatic randomized optimal plasma and platelet ratios (PROPPR) trial; 34 patients enrolled locally in the 1:1:1 arm of PROPPR; and 59 patients receiving more than 3 units of LTOWB enroute to or at our Level 1 trauma center, 2019-2020. RESULTS Mean age of LTOWB units transfused was 9 ± 5 days and mean dose was 5 ± 2 units. All four cohorts were profoundly injured (mean Injury Severity Score ≥ 31), with mean first platelet counts 204-228 K/μ and subsequent counts approximately 100 k/μl lower. Through the first 24 h of care, mean platelet counts decreased least, 79 and 83 103 /μl, in the 1:1:1 PROPPR and LTOWB cohorts. Mean platelet counts in patients transfused with LTOWB remained stable after the third hour of care. DISCUSSION LTOWB transfusion was associated with lesser mean decrease in platelet counts during the first 24 h after injury, similar to those observed among patients receiving components 1:1:1 component in the PROPPR study.
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Affiliation(s)
- Maryam Asif
- Transfusion Medicine Fellowship, Bloodworks Northwest, Seattle, Washington, USA
| | - Rida A Hasan
- Transfusion Medicine Fellowship, Bloodworks Northwest, Seattle, Washington, USA
| | - Zhinan Liu
- Trauma Transfusion Research, Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Lynn G Stansbury
- Trauma Transfusion Research, Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA.,Department of Anesthesia and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
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16
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Rosenberger M, Lo J, Hinika G, Shenouda M, Salibian M. A Case of Aggressive Resuscitation and Timely Surgical Intervention to Reverse Severe Acidosis After Multiple Gunshot Wounds to the Chest, Abdomen, and Left Shoulder With a Bullet Fragment Retained in the Heart. Cureus 2021; 13:e16362. [PMID: 34395139 PMCID: PMC8360325 DOI: 10.7759/cureus.16362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/09/2022] Open
Abstract
The lethal triad of coagulopathy, hypothermia, and acidosis is a well-known cause of severe deterioration and poor prognosis in trauma patients. The presence of this triad complicates the surgical management of a patient suffering from penetrating injury and hemorrhage. Here, we report the case and management of a 44-year-old man with multiple high-caliber gunshot wound (GSW) injuries who became severely acidotic (pH <6.8) with hemorrhagic shock in the setting of massive hemorrhage due to penetrating chest and abdominal trauma. The patient sustained one high-caliber GSW to the left upper quadrant of the abdomen, one high-caliber GSW to the left periumbilical region of the abdomen, one high caliber GSW to the fourth intercostal space of the left chest just medial to the midclavicular line with an expanding hematoma, and one high-caliber GSW to the left shoulder with a floating left shoulder. He arrived at the Emergency Department conscious with a stable pulse but quickly became hemodynamically unstable. He required a thoracotomy and exploratory laparotomy in addition to a massive transfusion protocol. This case demonstrates the reversal of a severely acidotic patient due to massive hemorrhage to a blood pH within normal limits using damage control resuscitation surgery and massive transfusion protocols. The patient has since been discharged home in a stable condition with minimal long-term sequelae.
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Affiliation(s)
| | - Jonathan Lo
- Medical Education, Ross University School of Medicine, Miramar, USA
| | - Gudata Hinika
- Department of Surgery, California Hospital Medical Center, Los Angeles, USA
| | - Monika Shenouda
- Department of Surgery, California Hospital Medical Center, Los Angeles, USA
| | - Moses Salibian
- Department of Surgery, California Hospital Medical Center, Los Angeles, USA
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17
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Bridwell RE, Schaffrinna AM, Long B, Graybill JC, Mehta SG. Damage Control Resuscitation: A Narrative Review of Goals, Techniques, and Components. Med J (Ft Sam Houst Tex) 2021:20-31. [PMID: 34251661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Damage control resuscitation (DCR) simultaneously tackles hemorrhage control and balanced resuscitation in complex multisystem trauma patients. This technique can improve patient outcomes. This review outlines the importance of DCR with hemorrhage control and administration of fresh whole blood or component therapy if not available and avoiding crystalloid administration. Additionally, administration of tranexamic acid and calcium prove beneficial in critically ill trauma patients. Avoidance of acidosis, hypothermia, and coagulopathy remains a key but challenging goal of DCR.
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Affiliation(s)
| | | | - Brit Long
- Department of Emergency Medicine, SAUSHEC, Ft. Sam Houston, TX
| | | | - Sumeru G Mehta
- Greater San Antonio Emergency Physicians, San Antonio, TX
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18
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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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19
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Abstract
Introduction: Recognising acute traumatic coagulopathy (ATC) poses a significant challenge to improving survival in emergency care. Paramedics are in a prime position to identify ATC in pre-hospital major trauma and initiate appropriate coagulopathy management. Method: A database literature review was conducted using Scopus, CINAHL and MEDLINE. Results: Two themes were identified from four studies: prediction tools, and point-of-care testing. Prediction tools identified key common ATC markers in the pre-hospital setting, including: systolic blood pressure, reduced Glasgow Coma Score and trauma to the chest, abdomen and pelvis. Point-of-care testing was found to have limited value. Conclusion: Future research needs to explore paramedics using prediction tools in identifying ATC, which could alert hospitals to prepare for blood products for damage control resuscitation.
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20
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 1: A scoping review of current practice and transfusion triggers. Transfus Med 2020; 30:86-105. [PMID: 32080942 PMCID: PMC7317877 DOI: 10.1111/tme.12667] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/18/2019] [Accepted: 01/16/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The primary aim of this scoping review is to describe the current use of pre-hospital transfusion of red blood cells (PHTRBC) and to evaluate criteria used to initiate PHTRBC. The effects on patients' outcomes will be reviewed in Part 2. BACKGROUND Haemorrhage is a preventable cause of death in trauma patients, and transfusion of red blood cells is increasingly used by Emergency Medical Services (EMS) for damage control resuscitation. However, there are no guidelines and little consensus on when to initiate PHTRBC. METHODS PubMed and Web of Science were searched through January 2019; 71 articles were included. RESULTS Transfusion triggers vary widely and involve vital signs, clinical signs of poor tissue perfusion, point of care measurements and pre-hospital ultrasound imaging. In particular, hypotension (most often defined as systolic blood pressure ≤ 90 mmHg), tachycardia (most often defined as heart rate ≥ 120/min), clinical signs of poor perfusion (eg, prolonged capillary refill time or changes in mental status) and injury type (ie, penetrating wounds) are common pre-hospital transfusion triggers. CONCLUSIONS PHTRBC is increasingly used by Emergency Medical Services, but guidelines on when to initiate transfusion are lacking. We identified the most commonly used transfusion criteria, and these findings may provide the basis for consensus-based pre-hospital transfusion protocols.
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma SurgeryAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
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21
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 2: A systematic review of treatment effects on outcomes. Transfus Med 2020; 30:106-133. [PMID: 31903684 PMCID: PMC7317762 DOI: 10.1111/tme.12659] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/06/2019] [Indexed: 12/11/2022]
Abstract
The primary aim of this systematic review is to describe the effects of prehospital transfusion of red blood cells (PHTRBC) on patient outcomes. Damage control resuscitation attempts to prevent death through haemorrhage in trauma patients. In this context, transfusion of red blood cells is increasingly used by emergency medical services (EMS). However, evidence on the effects on outcomes is scarce. PubMed and Web of Science were searched through January 2019; 55 articles were included. No randomised controlled studies were identified. While several observational studies suggest an increased survival after PHTRBC, consistent evidence for beneficial effects of PHTRBC on survival was not found. PHTRBC appears to improve haemodynamic parameters, but there is no evidence that shock on arrival to hospital is averted, nor of an association with trauma induced coagulopathy or with length of stay in hospitals or intensive care units. In conclusion, PHTRBC is increasingly used by EMS, but there is no strong evidence for effects of PHTRBC on mortality. Further research with study designs that allow causal inferences is required for more conclusive evidence. The combination of PHTRBC with plasma, as well as the use of individualised transfusion criteria, may potentially show more benefits and should be thoroughly investigated in the future. The review was registered at Prospero (CRD42018084658).
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma Surgery, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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22
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Berková J. Prehospital blood and blood products administration. ACTA ACUST UNITED AC 2020; 98:481-487. [PMID: 31958961 DOI: 10.33699/pis.2019.98.12.481-487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The history of blood administration in injured patients in the prehospital care started early after the discovery of blood groups in the first decade of the 20th century. The first practical experiences were gained by army during World War I. During the 20th century blood products were not admini-stered in the civilian prehospital care due to the risk of infectious disease transmission, transfusion reactions and donor deficiency. A rebirth of this method was seen at the beginning of the 21st century when the concept of remote damage control resuscitation was defined and blood became a part of hemostatic resuscitation. Different countries may use different blood products (whole blood, erythrocytes, plasma, fibrinogen, etc.) in prehospital treatment of a severely bleeding patient. Prehospital blood administration is feasible and safe. However, what is the most beneficial blood product for a patient with severe hemorrhagic-traumatic shock during the prehospital phase? This question is now explored in ongoing studies. This paper provides an overview of current policies for pre-hospital blood products administration.
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23
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Heiss C, Foernges L, Minzola D. Damage Control Resuscitation of a Patient With Traumatic Aortic Rupture: A Case Report. AANA J 2020; 88:49-58. [PMID: 32008618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Traumatic aortic rupture (TAR) is a highly fatal injury mechanism resulting from blunt deceleration forces against the descending aorta. The mechanism of TAR is directly attributed to the aorta suffering damage by indirect shearing forces. The descending aorta remains fixed to the posterior chest wall, while the heart and ascending aorta are exerted forward, thus causing the intimal tear. A characteristic triad presents as increased blood pressure in the upper extremities, decreased blood pressure in the lower extremities, and a widened mediastinum on radiography. Early recognition of signs and symptoms of the mechanism of injury is key to initiating early damage control surgery and ultimately decreasing morbidity and mortality. This case report describes the intraoperative management of an elderly female patient with TAR following a motor vehicle collision in a remote location in rural Pennsylvania.
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Affiliation(s)
- Christopher Heiss
- is a staff CRNA at Geisinger Medical Center in Danville, Pennsylvania and has functioned throughout the continuum of prehospital, emergency, and surgical critical care. He has special interests in cardiovascular and trauma anesthesia
| | - Luiz Foernges
- is an associate trauma and acute care surgeon at Geisinger Medical Center, Danville, Pennsylvania and assistant professor of surgery at Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Debra Minzola
- is the program director of the Geisinger Health System/Bloomsburg University of Pennsylvania Nurse Anesthesia Program, an assistant professor of the Bloomsburg University of Pennsylvania, and a staff CRNA at Geisinger Medical Center
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24
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Abstract
OBJECTIVES: Recent advances in damage control resuscitation have advocated a push for early transfusion to maintain circulating volume and minimization of crystalloid use. While measures such as using rapid-matched group specific blood or uncrossmatched blood have been implemented to shorten this wait, delivery times can still be improved. We explored reducing delivery times by use of a pneumatic tube delivery system already built in our hospital. Few studies have evaluated this using fresh blood samples for one-way transport. We modified and evaluated our pneumatic tube delivery system for delivery timings and quality parameters; designing a robust protocol that also tested aged blood for simulated returns unlike other previous studies. METHODS: Delivery timings of emergency blood products by our present portering system were collected and compared against that of products sent through the pneumatic tube system (PTS). The samples sent through the PTS were also tested and analyzed for temperature, quality, and hemolysis in accordance with established blood banking quality guidelines. RESULTS: Blood products delivered by our PTS showed satisfactory conformance with all parameters of temperature, timing, and hemolysis. We showed a significant reduction in transport delivery times from mean of 8 min 43 s to 2 min 23 s. CONCLUSIONS: Delivery of blood products by our modified PTS is safe and significantly reduces delivery time. This time savings could be clinically significant in resuscitation. Usage of the PTS could also cut down on workforce utilization of porters, freeing them up for other tasks in the hospital.
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Affiliation(s)
- Jian Hao Jaryl Kok
- Department of Laboratory Medicine, Ng Teng Fong General Hospital, Singapore
| | | | - Mee Yin Joanne Lee
- Department of Laboratory Medicine, Ng Teng Fong General Hospital, Singapore
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25
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Robinson BRH, Cohen MJ, Holcomb JB, Pritts TA, Gomaa D, Fox EE, Branson RD, Callcut RA, Cotton BA, Schreiber MA, Brasel KJ, Pittet JF, Inaba K, Kerby JD, Scalea TM, Wade CE, Bulger EM. Risk Factors for the Development of Acute Respiratory Distress Syndrome Following Hemorrhage. Shock 2018; 50:258-264. [PMID: 29194339 PMCID: PMC5976504 DOI: 10.1097/shk.0000000000001073] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) study evaluated the effects of plasma and platelets on hemostasis and mortality after hemorrhage. The pulmonary consequences of resuscitation strategies that mimic whole blood, remain unknown. METHODS A secondary analysis of the PROPPR study was performed. Injured patients predicted to receive a massive transfusion were randomized to 1:1:1 versus 1:1:2 plasma-platelet-red blood cell ratios at 12 Level I North American trauma centers. Patients with survival >24 h, an intensive care unit (ICU) stay, and a recorded PaO2/FiO2 (P/F) ratio were included. Acute respiratory distress syndrome (ARDS) was defined as a P/F ratio < 200, with bilateral pulmonary infiltrates, and adjudicated by investigators. RESULTS Four hundred fifty-four patients were reviewed (230 received 1:1:1, 224 1:1:2). Age, sex, injury mechanism, and regional abbreviated injury scale (AIS) scores did not differ between cohorts. Tidal volume, positive end-expiratory pressure, and lowest P/F ratio did not differ. No significant differences in ARDS rates (14.8% vs. 18.4%), ventilator-free (24 vs. 24) or ICU-free days (17.5 vs. 18), hospital length of stay (22 days vs. 18 days), or 30-day mortality were found (28% vs. 28%). ARDS was associated with blunt injury (OR 3.61 [1.53-8.81] P < 0.01) and increasing chest AIS (OR 1.40 [1.15-1.71] P < 0.01). Each 500 mL of crystalloid infused during hours 0 to 6 was associated with a 9% increase in the rate of ARDS (OR 1.09 [1.04-1.14] P < 0.01). Blood given at 0 to 6 or 7 to 24 h were not risk factors for lung injury. CONCLUSION Acute crystalloid exposure, but not blood products, is a potentially modifiable risk factor for the prevention of ARDS following hemorrhage.
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Affiliation(s)
- Bryce RH Robinson
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle, WA
| | - Mitchell J Cohen
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO
| | - John B Holcomb
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Timothy A Pritts
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Dina Gomaa
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Erin E Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Richard D Branson
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Rachael A Callcut
- Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Bryan A Cotton
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Karen J Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Jean-Francois Pittet
- Division of Critical Care and Perioperative Medicine, Department of Anesthesiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kenji Inaba
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA
| | - Jeffery D Kerby
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | - Charlie E Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Eileen M Bulger
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle, WA
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26
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Abstract
The US Department of Defense recently made the decision to open direct ground combat roles to women. Blood product transfusion is an essential component of the US Military guidelines for tactical combat casualty care and damage control resuscitation, but blood transfusion carries with it the specific side effect of alloimmunization-a uniquely significant side effect for young women who may desire subsequent pregnancies. Presently to be considered are the changes that may need to be made to blood transfusion in the setting of battlefield medicine to optimally care for combat-injured women, as a majority of the existing data regarding the risks of transfusion in the trauma setting involve predominantly men. This article delves into the possibility of a new cohort of women at risk for hemolytic disease of the fetus and newborn, the need for women's health professionals to appropriately counsel women considering serving in direct ground combat roles about this specific risk, and the appropriate steps that should be considered to provide these women optimal medical care.
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Affiliation(s)
- Brendan C Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
| | - Lindsey J Graham
- Division of Hematology/Oncology, William Beaumont Army Medical Center, El Paso, TX
| | - Carl H Rose
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Jeffrey L Winters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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27
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Abstract
Damage control surgery (DCS) began as an adjunct approach to hemorrhage control, seeking to facilitate the body's innate clotting ability when direct repair or ligation was impossible, but it has since become a valuable instrument for a broader collection of critically ill surgical patients in whom metabolic dysfunction is the more immediate threat to life than imminent exsanguination. Modern damage control is a strategy that combines the principles of DCS with those of damage control resuscitation. When used correctly, damage control may improve survival in previously unsalvageable patients; when used incorrectly, it can subject patients to imprudent risk and contribute to morbidity. This review discusses the evolution of damage control in both concept and practice, summarizing available literature and experience to guide patient selection, medical decision-making, and strategy implementation throughout the preoperative, intraoperative, and early postoperative periods.
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Affiliation(s)
- Brian C Beldowicz
- Division of Military, Department of Emergency Medicine, Uniformed Services University of the Health Sciences, Sacramento, California
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28
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Horst J, Leonard JC, Vogel A, Jacobs R, Spinella PC. A survey of US and Canadian hospitals' paediatric massive transfusion protocol policies. Transfus Med 2016; 26:49-56. [PMID: 26833998 DOI: 10.1111/tme.12277] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 11/25/2015] [Accepted: 07/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Trauma is the leading cause of death in children >1 year of age, with haemorrhage as the most common cause of medically preventable deaths. While massive transfusion protocols (MTPs) have been investigated and used in adults to reduce death from haemorrhage, there are a paucity of published data on MTP practices and outcomes in children. This study aimed to survey current MTP policies and the frequency of activation at paediatric care centres. STUDY DESIGN AND METHODS We conducted a survey of MTPs at hospitals in the United States and Canada, including children's general hospitals, children's specialty hospitals and children's units in general hospitals. We collected information on how the MTP is activated, what therapeutics are given, frequency of its use, and how it is audited for compliance. RESULTS Forty-six survey responses were analysed. Physician discretion was the most common activation criteria (89%). A majority of sites (78%) targeted a 'high' (≥1 : 2) ratio of plasma to red blood cells (RBC). Fifteen percent of sites use antifibrinolytics in their MTPs. Eighty nine percent of sites have type-O RBC units and 48% of sites had thawed plasma units stored in an immediately available location. CONCLUSION There is a wide variation in MTPs among paediatric hospitals with regard to both activation criteria and products administered. This underscores the need for future prospective studies to determine the most effective resuscitation methods for paediatric populations to improve outcomes and therapeutic safety for massive bleeding.
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Affiliation(s)
- J Horst
- Division of Emergency Medicine, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - J C Leonard
- Section of Emergency Medicine, Department of Paediatrics, Nationwide Children's Hospital and the Ohio State University, Columbus, Ohio, USA
| | - A Vogel
- Division of Paediatric Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - R Jacobs
- Division of Critical Care, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - P C Spinella
- Division of Critical Care, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
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29
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Abstract
Damage control resuscitation (DCR) has become a more widely adopted acute management strategy over the past decade. A cornerstone of this strategy is the performance of an initial limited surgical intervention for the control of active bleeding and contamination. This technique is indicated where significant physiological compromise exists and immediate surgical intervention is required. This damage control surgery itself is completed judiciously to allow a period of resuscitative stabilisation before later definitive surgical solutions. This discussion describes the three further principles of DCR and then explores the rationale and drivers behind the development of this approach.
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Affiliation(s)
- David Quinn
- Emergency Department, Gosford District Hospital, Gosford, New South Wales, Australia
| | - Daniel Frith
- Trauma Sciences, Queen Mary University of London, London, UK
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30
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Abstract
Resuscitation of a severely traumatised patient with the administration of crystalloids, or colloids along with blood products is a common transfusion practice in trauma patients. The determination of this review article is to update on current transfusion practices in trauma. A search of PubMed, Google Scholar, and bibliographies of published studies were conducted using a combination of key-words. Recent articles addressing the transfusion practises in trauma from 2000 to 2014 were identified and reviewed. Trauma induced consumption and dilution of clotting factors, acidosis and hypothermia in a severely injured patient commonly causes trauma-induced coagulopathy. Early infusion of blood products and early control of bleeding decreases trauma-induced coagulopathy. Hypothermia and dilutional coagulopathy are associated with infusion of large volumes of crystalloids. Hence, the predominant focus is on damage control resuscitation, which is a combination of permissive hypotension, haemorrhage control and haemostatic resuscitation. Massive transfusion protocols improve survival in severely injured patients. Early recognition that the patient will need massive blood transfusion will limit the use of crystalloids. Initially during resuscitation, fresh frozen plasma, packed red blood cells (PRBCs) and platelets should be transfused in the ratio of 1:1:1 in severely injured patients. Fresh whole blood can be an alternative in patients who need a transfusion of 1:1:1 thawed plasma, PRBCs and platelets. Close monitoring of bleeding and point of care coagulation tests are employed, to allow goal-directed plasma, PRBCs and platelets transfusions, in order to decrease the risk of transfusion-related acute lung injury.
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Affiliation(s)
- V Trichur Ramakrishnan
- Department of Emergency Medicine, Sri Ramachandra Medical College Research Institute, Porur, Chennai, Tamil Nadu, India
| | - Srihari Cattamanchi
- Masters in Public Health (MPH) Candidate – May 2015, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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31
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Abstract
Hemorrhage remains one of the leading causes of trauma-related deaths. Uncontrolled diffuse microvascular bleeding in the course of initial care is common, potentially resulting in exsanguination. Early and aggressive hemostatic intervention increases survival and reduces the incidence of massive transfusion. Thus, timely diagnosis of the underlying coagulation disorders is mandatory. It has been shown that standard coagulation tests do not sufficiently characterize trauma-induced coagulopathy (TIC). This has led to increasing interest in alternatives, such as the viscoelastic test, to diagnose TIC and to provide the basis for a goal-directed hemostatic therapy. The concept of damage control resuscitation (DCR) has been introduced widely in trauma patients with severe bleeding. This strategy addresses important confounders of the coagulation process such as hemodilution, hypothermia, and acidosis; DCR is based on a damage control surgical approach, permissive hypotension, and improvement of hemostatic competence. Many studies have shown benefit in mortality when using high ratios of fresh frozen plasma (FFP) to red blood cells (RBC) as early treatment. However, there is increased awareness that coagulation factor concentrate could be beneficial in the treatment of trauma-induced coagulopathy.
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Affiliation(s)
- Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre, Salzburg, Austria.
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32
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Affiliation(s)
- Albert Pierce
- Department of Anesthesiology, University of Alabama at Birmingham
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33
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Johansson PI, Oliveri RS, Ostrowski SR. Hemostatic resuscitation with plasma and platelets in trauma. J Emerg Trauma Shock 2013; 5:120-5. [PMID: 22787340 PMCID: PMC3391834 DOI: 10.4103/0974-2700.96479] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Accepted: 06/28/2011] [Indexed: 12/28/2022] Open
Abstract
Background: Continued hemorrhage remains a major contributor of mortality in massively transfused patients and controversy regarding the optimal management exists although recently, the concept of hemostatic resuscitation, i.e., providing large amount of blood products to critically injured patients in an immediate and sustained manner as part of an early massive transfusion protocol has been introduced. The aim of the present review was to investigate the potential effect on survival of proactive administration of plasma and/or platelets (PLT) in trauma patients with massive bleeding. Materials and Methods: English databases were searched for reports of trauma patients receiving massive transfusion (10 or more red blood cell (RBC) within 24 hours or less from admission) that tested the effects of administration of plasma and/or PLT in relation to RBC concentrates on survival from January 2005 to November 2010. Comparison between highest vs lowest blood product ratios and 30-day mortality was performed. Results: Sixteen studies encompassing 3,663 patients receiving high vs low ratios were included. This meta-analysis of the pooled results revealed a substantial statistical heterogeneity (I2 = 58%) and that the highest ratio of plasma and/or PLT or to RBC was associated with a significantly decreased mortality (OR: 0.49; 95% confidence interval: 0.43-0.57; P<0.0001) when compared with lowest ratio. Conclusion: Meta-analysis of 16 retrospective studies concerning massively transfused trauma patients confirms a significantly lower mortality in patients treated with the highest fresh frozen plasma (FFP) and/or PLT ratio when compared with the lowest FFP and/or PLT ratio. However, optimal ranges of FFP: RBC and PLT : RBC should be established in randomized controlled trials.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Department of Clinical Immunology, Rigshospitalet, University of Copenhagen, Denmark
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34
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Chak Wah K, Wai Man C, Janet Yuen Ha W, Lai V, Kit Shing John W. Evolving frontiers in severe polytrauma management - refining the essential principles. Malays J Med Sci 2013; 20:1-12. [PMID: 23785252 PMCID: PMC3685221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Accepted: 09/11/2012] [Indexed: 06/02/2023] Open
Abstract
This editorial aims to refine the severe polytrauma management principles. While keeping ABCDE priorities, the termination of futile resuscitation and the early use of tourniquet to stop exsanguinating limb bleeding are crucial. Difficult-airway-management (DAM) is by a structured 5-level approach. The computerised tomography (CT) scanner is the tunnel to death for hemodynamically unstable patients. Focused Abdominal Sonography for Trauma-Ultrasonography (FAST USG) has replaced diagnostic peritoneal lavage (DPL) and is expanding to USG life support. Direct whole-body multidetector-row computed tomography (MDCT) expedites diagnosis & treatment. Non-operative management is a viable option in rapid responders in shock. Damage control resuscitation comprising of permissive hypotension, hemostatic resuscitation & damage control surgery (DCS) help prevent the lethal triad of trauma. Massive transfusion protocol reduces mortality and decreases the blood requirement. DCS attains rapid correction of the deranged physiology. Mortality reduction in major pelvic disruption requires a multi-disciplinary protocol, the novel pre-peritoneal pelvic packing and the angio-embolization. When operation is the definitive treatment for injury, prevention is best therapy.
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Affiliation(s)
- Kam Chak Wah
- Department of Accident & Emergency, Tuen Mun Hospital, Hong Kong
| | - Choi Wai Man
- Department of Social Work & Public Admin, The University of Hong Kong, Hong Kong
| | - Wong Janet Yuen Ha
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Vincent Lai
- Department of Diagnostic Radiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
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35
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Abstract
Interventions on the trauma patient are an essential component of the complete scope of care that is provided to the multiply injured patient today. The active participation by the interventional radiologist along the entire spectrum of clinical care is very important to optimize patient outcomes. Suggestions on how to establish a clinical presence are presented. A few of the newer concepts and terminology applicable to trauma care are reviewed. Tips useful in the trauma room, in the interventional radiology suite, and during the postprocedural period are discussed.
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Affiliation(s)
- Anthony D Goei
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
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