Civilian Trauma Centers Research Articles

Pharmacokinetics of Tranexamic Acid (TXA) Delivered by Expeditious Routes in a Swine Model of Polytrauma and Hemorrhagic Shock

Objective Hemorrhage is the leading cause of preventable death in civilian trauma centers and on the battlefield. One of the emerging treatment options for hemorrhage in austere environments is tranexamic acid (TXA). However, the landscape is not amenable to the current delivery standard. This study compared the pharmacokinetics of TXA via a standard 10-minute intravenous infusion (IV infusion), intravenous rapid push over 10 s (IV push), and intramuscular injection (IM) in a swine polytrauma and hemorrhagic shock model (trauma group) compared to uninjured controls (control group). Methods Thirty swine were randomized to the trauma or control group. Following anesthesia, the trauma group experienced a simulated blast injury and 40% controlled hemorrhage. Subjects in both groups were then randomized to receive 1 g/10 mL TXA via IV infusion, IV push, or IM. Animals were monitored for four hours with serial blood sampling. Serum TXA concentrations were measured by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and analyzed. Results The time to maximum TXA concentration (Tmax) was not affected by trauma in IV infusion or IV push, but was affected in the IM administration with Tmax significantly slower than the control group (p = 0.016). The minimum effective serum concentration of TXA (Ceff, 10 µg/mL) was reached in less than one minute with IV infusion and instantaneously with IV push. Despite lower bioavailability, the time to reach Ceff (Teff) was achieved via IM administration in less than 10 min for both groups (6.4 min trauma vs. 2.1 min control). Conclusions In austere prehospital environments, an alternative to intravenous infusion of a life-saving medication is desired. Administration of TXA via all three methods reached the level needed to cause substantial inhibition of fibrinolysis within 10 min. The IV push method showed similar pharmacokinetics to IV infusion of TXA but can be delivered quickly without sacrificing an access site for 10 min.

A survey of low titer O whole blood use within the trauma quality improvement program registry.

The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB. We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period. A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively. There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.

Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients

Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome. To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023. Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival. Primary outcomes were survival at 24 hours and 30 days. A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001). In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.

The State of the Union: Trauma System Development in the United States.

Injury is both a national and international epidemic that affects people of all age, race, religion, and socioeconomic class. Injury was the fourth leading cause of death in the United States (U.S.) in 2021 and results in an incalculable emotional and financial burden on our society. Despite this, when prevention fails, trauma centers allow communities to prepare to care for the traumatically injured patient. Using lessons learned from the military, trauma care has grown more sophisticated in the last 50 years. In 1966, the first civilian trauma center was established, bringing management of injury into the new age. Now, the American College of Surgeons recognizes 4 levels of trauma centers (I-IV), with select states recognizing Level V trauma centers. The introduction of trauma centers in the U.S. has been proven to reduce morbidity and mortality for the injured patient. However, despite the proven benefits of trauma centers, the U.S. lacks a single, unified, trauma system and instead operates within a "system of systems" creating vast disparities in the level of care that can be received, especially in rural and economically disadvantaged areas. In this review we present the history of trauma system development in the U.S, define the different levels of trauma centers, present evidence that trauma systems and trauma centers improve outcomes, outline the current state of trauma system development in the U.S, and briefly mention some of the current challenges and opportunities in trauma system development in the U.S. today.

Exploratory laparotomy during the battle of Mosul, 2016–2017: results from a tertiary civilian hospital in Erbil, Iraqi Kurdistan

BackgroundThe Battle of Mosul (2016–2017) was an urban conflict resulting in over 9000 civilian deaths. Emergency Management Centre (EMC), located 90 km from Mosul, was designated as a civilian-run trauma centre as part of the novel Mosul Trauma Pathway. Patients necessitating exploratory laparotomy (ex-lap) provide a unique window into the system of care delivery in conflicts, given the importance of timely, resource-intensive care. However, there is insufficient knowledge regarding the presentation and outcomes for conflict-related ex-lap in civilian institutions.MethodsThis is a descriptive study retrospectively analyzing routinely collected data for all patients who underwent ex-lap at EMC for injuries sustained during the battle of Mosul. Differences in demographics, pre-hospital/hospital course, and New Injury Severity Scores (NISS) were analysed using student t-test, Hotelling T-squared, and linear regression.ResultsDuring the battle, 1832 patients with conflict-related injuries were admitted to EMC. Some 73/1832 (4.0%) underwent ex-lap, of whom 22/73 (30.1%) were children and 40/73 (54.8%) were non-combatant adults. Men constituted 51/73 (69%) patients. Gunshot wounds caused 19/73 (26.0%) injuries, while ordnances caused 52/73 (71.2%). Information regarding hospital course was available for 47/73 (64.4%) patients. Children had prolonged time from injury to first laparotomy compared to adults (600 vs 208 min, p < 0.05). Median LOS was 6 days (IQR 4–9.5); however, 11/47 (23%) patients left against medical advice. Post-operative complications occurred in 11/47 (23.4%) patients; 6/11 (54.5%) were surgical site infections. There were 12 (25.5%) patients who underwent relaparotomies after index surgery elsewhere; 10/12 (83.3%) were for failed repairs or missed injuries. Median NISS was 18 (IQR 12–27). NISS were significantly higher for women (vs men; 28.5 vs 19.8), children (vs adults; 28.8 vs 20), and relaparotomy patients (vs primary laparotomy patients; 32.0 vs 19.0). Some 3 patients died, 2 of whom were relaparotomies.ConclusionAt this civilian tertiary trauma centre, conflict-related exploratory laparotomies were associated with low morbidity and mortality. Long transport times, high rates of repeat laparotomies, and high numbers of patients leaving against medical advice raise questions regarding continuity of care along the Mosul Trauma Pathway.Trial registrationThe study protocol was registered at Clinicaltrails.gov, ID NCT03490305, prior to collection of data.

Injury Patterns and Treatment Strategies in Civilian and Military Isolated Abdominal Gunshot Wounds.

Combat-related gunshot wounds (GSW) may differ from those found in civilian trauma centers. Missile velocity, resources, logistics, and body armor may affect injury patterns and management strategies. This study compares injury patterns, management, and outcomes in isolated abdominal GSW between military (MIL) and civilian (CIV) populations. The Department of Defense Trauma Registry (DoDTR) and TQIP databases were queried for patients with isolated abdominal GSW from 2013 to 2016. MIL patients were propensity score matched 1:3 based on age, sex, and extraabdominal AIS. Injury patterns and in-hospital outcomes were compared. Initial operative management strategies, including selective nonoperative management (SNOM) for isolated solid organ injuries, were also compared. Of the 6435 patients with isolated abdominal GSW, 183 (3%) MIL were identified and matched with 549 CIV patients. The MIL group had more hollow viscus injuries (84% vs. 66%) while the CIV group had more vascular injuries (10% vs. 21%) (p < .05 for both). Operative strategy differed, with more MIL patients undergoing exploratory laparotomy (95% vs. 82%) and colectomy (72% vs. 52%) (p < .05 for both). However, no difference in ostomy creation was appreciated. More SNOM for isolated solid organ injuries was performed in the CIV group (34.1% vs. 12.5%; p < 0.05). In-hospital outcomes, including mortality, were similar between groups. MIL abdominal GSW lead to higher rates of hollow viscus injuries compared to CIV GSW. MIL GSW are more frequently treated with resection but with similar ostomy creation compared to civilian GSW. SNOM of solid organ injuries is infrequently performed following MIL GSW.

Operative management and outcomes of colorectal injuries after gunshot wounds in the deployed military setting versus civilian trauma centers.

Colon and rectal injuries have been diverted at higher rates in military trauma compared with civilian injuries. However, in the last few years, there has been a shift to more liberal primary anastomosis in wartime injuries. The purpose of this study was to compare the management and outcomes in colorectal gunshot wounds (GSWs) between military and civilian settings. The study included Department of Defense Trauma Registry and Trauma Quality Improvement Program database patients who sustained colorectal GSWs, during the period 2013 to 2016. Department of Defense Trauma Registry patients were propensity score matched 1:3 based on age, sex, grade of colorectal injury, and extra-abdominal Abbreviated Injury Scale. Patients without signs of life, transfers from an outside hospital, and nonspecific colorectal Organ Injury Scale were excluded. Operative management and outcomes were compared between the two groups. Subanalysis was performed on the military cohort to identify any differences in the use primary repair, colectomy, or fecal diversion based upon military affiliation or North Atlantic Treaty Organization status. Overall, there were 2,693 patients with colorectal GSWs; 60 patients in the military group were propensity score matched with 180 patients in the civilian group. Overall, colectomy was the most common procedure performed (72.1%) and was used more frequently in the military group (83.3% vs. 68.3%; p < 0.05). However, the rate of fecal diversion was similar in the two groups (23.3% vs. 27.8%; p = 0.500). Among those in the military group, no difference was seen in primary repair, colectomy, or fecal diversion based upon military affiliation or North Atlantic Treaty Organization status. The rates of in-hospital compilations and mortality were similar between the military and civilian groups. The severity of GSW colorectal injuries in military and civilian trauma was comparable. There was no significant difference in terms of fecal diversion, mortality, and complications between groups. Military personnel are treated similarly regardless of affiliation. Therapeutic/Care Management; Level III.

Use of Whole Blood in Civilian Trauma Resuscitation: Is It Better Than Component Therapy?

Use of Whole Blood in Civilian Trauma Resuscitation: Is It Better Than Component Therapy?

Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers

Whole-blood (WB) resuscitation has gained renewed interest among civilian trauma centers. However, there remains insufficient evidence that WB as an adjunct to component therapy-based massive transfusion protocol (WB-MTP) is associated with a survival advantage over MTP alone in adult civilian trauma patients presenting with severe hemorrhage. To assess whether WB-MTP compared with MTP alone is associated with improved survival at 24 hours and 30 days among adult trauma patients presenting with severe hemorrhage. This retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2017, and December 31, 2018, included adult trauma patients with a systolic blood pressure less than 90 mm Hg and a shock index greater than 1 who received at least 4 units of red blood cells within the first hour of emergency department (ED) arrival at level I and level II US and Canadian adult civilian trauma centers. Patients with burns, death within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from February 2022 to September 2022. Resuscitation with WB-MTP compared with MTP alone within 24 hours of ED presentation. Primary outcomes were survival at 24 hours and 30 days. Secondary outcomes selected a priori included major complications, hospital length of stay, and intensive care unit length of stay. A total of 2785 patients met inclusion criteria: 432 (15.5%) in the WB-MTP group (335 male [78%]; median age, 38 years [IQR, 27-57 years]) and 2353 (84.5%) in the MTP-only group (1822 male [77%]; median age, 38 years [IQR, 27-56 years]). Both groups included severely injured patients (median injury severity score, 28 [IQR, 17-34]; median difference, 1.29 [95% CI, -0.05 to 2.64]). A survival curve demonstrated separation within 5 hours of ED presentation. WB-MTP was associated with improved survival at 24 hours, demonstrating a 37% lower risk of mortality (hazard ratio, 0.63; 95% CI, 0.41-0.96; P = .03). Similarly, the survival benefit associated with WB-MTP remained consistent at 30 days (HR, 0.53; 95% CI, 0.31-0.93; P = .02). In this cohort study, receipt of WB-MTP was associated with improved survival in trauma patients presenting with severe hemorrhage, with a survival benefit found early after transfusion. The findings from this study are clinically important as this is an essential first step in prioritizing the selection of WB-MTP for trauma patients presenting with severe hemorrhage.

Early results of low-velocity ballistic femoral shaft fractures

IntroductionBallistic femur fractures are a common injury treated at United States civilian trauma centers. This study investigates the outcomes of these injuries by comparing the rates of infection, nonunion, secondary operations, and associated injuries from low-velocity gunshot (GSW) injuries with fractures sustained by blunt trauma. MethodsA retrospective cohort comparative study was performed at a Level 1 trauma center. 345 patients with closed blunt or GSW femoral shaft fractures over 10 years were included. All were treated with intramedullary nail fixation. Superficial and deep infection, vascular injury, compartment syndrome, nonunion, and secondary operations were identified. Results148 patients in the GSW group and 197 patients in the blunt trauma group had overall mean age 33.5 years and 80% were male. Deep infection rates were similar There were no nonunions in the GSW group, contrasted with 8 (4.4%) nonunions in the blunt trauma group (p = 0.02). The rate of compartment syndrome was higher in the GSW group (6.1% vs 0, p < 0.001). Arterial injury occurred in 9% following GSW (vs 0, p < 0.001). Overall, secondary unplanned procedure rates were the same: 8.1% for both groups. DiscussionBallistic femoral shaft fractures are often equated with open injuries; however, rates of infection and secondary operations closely mirror that of closed injuries resulting from blunt force trauma. Nonunions may be more common after blunt injury, and compartment syndrome and arterial injury are substantially more common following GSW, warranting careful clinical assessment. Level of evidencePrognostic, level III.

Outcomes of Cold-Stored, Low-Titer Group O Whole Blood Transfusions in Nontrauma Massive Transfusion Protocol Activations.

The use of low-titer group O whole blood (LTOWB) in military and civilian trauma centers shows no significant difference in outcomes compared with component therapy. To compare the use of LTOWB with standard component therapy in nontrauma patients requiring massive transfusion at a major academic medical center. This is a retrospective cohort study comparing nontrauma patients who received at least 1 unit of cold-stored LTOWB during a massive transfusion with those who received only blood component therapy during a massive transfusion. Primary outcomes are mortality at 24 hours and 30 days. Secondary outcomes are degree of hemolysis, length of inpatient hospital stay, and time to delivery of blood products. One hundred twenty massive transfusion activations using 1570 blood products from 103 admissions were identified during the study period. Fifty-five admissions were included in the component cohort and 48 in the LTOWB cohort. There were no significant differences in primary outcomes: 24-hour mortality odds ratio, 2.12 (P = .14); 30-day mortality odds ratio, 1.10 (P = .83). Length of stay was found to be statistically significantly different and was 1.58 days shorter in the LTOWB cohort compared with the component cohort (95% CI, 1.44-1.73; P < .001). There were no significant differences in the remaining secondary outcomes. LTOWB therapy appears no worse than using standard component therapy in nontrauma patients requiring a massive transfusion activation, suggesting that LTOWB is a reasonable alternative to component therapy in nontrauma, civilian hospital patients, even when blood type is known.

Improving Care During Peacetime, War, and Disasters: A Call for Agile Military Civilian Strategic Alliances.

Improving Care During Peacetime, War, and Disasters: A Call for Agile Military Civilian Strategic Alliances.

Data-driven readiness: A preliminary report on cataloging best practices in military civilian partnerships.

Between conflicts, many of the combat casualty care lessons learned are lost as the nation shifts priorities and providers leave the military. Solutions are needed to bridge the knowledge gap created by interwar periods. One of the foremost solutions is partnerships between civilian trauma centers and the military health system. Over the past two decades, a myriad of military-civilian partnerships (MCPs), which vary in their composition, duration, and focus, was created. The objective of this report is to describe the initial attempt of the Department of Defense to catalog existing MCPs to inform both civilian and military stakeholders. This initial catalog is intended as a reference to aid in future MCP development and facilitate the synchronization of efforts to improve trauma care delivery and readiness. Using methodology from the Institute of Defense Analysis, the total number of eligible trauma centers in the United States was determined. The Institute of Defense Analysis determined eligibility-based American College of Surgeons Trauma Center verification or state trauma center designation. Each military service provided their list of MCPs, which were categorized. Military-civilian partnerships were cataloged by various characteristics and program components. Key variables include number and type of personnel trained, duration of training, and focus, for example, team versus individual focused and training versus maintaining proficiency focused. A total of 1,139 hospitals in the United States are potentially eligible for MCPs. There are at least 87 unique partnerships; the majority are part-time sustainment MCPs. The Air Force has the largest number of providers in MCPs. There are many challenges to maintain accurate and up to date data on MCPs. With the collated information, the Defense Health Agency, military services, special operations community, and civilian partners will be better empowered to optimize the readiness value of their programs and better prepare our military medical providers for the nation's and military's future needs.

Building a sustainable Mil-Civ partnership to ensure a ready medical force: A single partnership site's experience.

One of the challenges in military medicine is ensuring that the medical force deployed to the theater of combat operations is prepared to perform life, limb, and eyesight saving care at a level of care comparable to our top civilian Level I trauma centers. There is increasingly more evidence demonstrating that the majority of military physicians are not exposed to trauma or combat casualty care-relevant surgical cases on a consistent basis in their daily practice at their garrison military treatment facility (MTF). To prevent this widening skills and experience gap from become more of a reality, the 2017 National Defense Authorization Act called for the expansion of military and civilian (Mil-Civ) medical partnerships, working toward embedding military medical providers and surgical teams in busy civilian trauma centers. Vanderbilt University Medical Center is one of the busiest trauma centers in the country and being in close proximity to the local MTF at Fort Campbell, KY, it is primed to become one of the premier Mil-Civ partnerships. Creating a strategy that builds the partnership in a calculated and stepwise fashion through multiple avenues with centralized leadership has resulted in the early success of the program. However, Vanderbilt University Medical Center is not immune to challenges similar to those at other Mil-Civ partnerships, but only by sharing best practices can we continue to make progress.

Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy.

Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis's relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.

Prospective Observational Study of an Integrated Therapeutic Initiative for Extremities (POSITIVE): Implementation of an Integrated Orthotic and Rehabilitation Program in the Civilian Setting

Category:Trauma; OtherIntroduction/Purpose:The Return to Run (RTR) pathway currently utilized in the military have been demonstrated to facilitate return to duty, recreation and physical activity and decrease pain in high functioning patients who have sustained high energy lower extremity trauma. A recent study also demonstrated that the processes and outcomes are translatable across military settings, however, to date there is no evidence on implementation of this pathway in the civilian setting. We sought to evaluate the feasibility of implementation of a similar, Return to Performance (RTP), pathway at a high volume, level I civilian trauma center. RTP combines a custom Variable Cadence Ankle-Foot Orthosis (VCAFO) with an 8-week exercise program designed to improve performance and reduce pain.Methods:A prospective observational study was conducted to enroll all patients eligible for the VCAFO. Patients were followed from initial referral through one year. A large, national prosthetic and orthotic company was utilized for brace manufacture and fitting. Physical therapy services were provided in the outpatient setting.Results:The RTP pathway has been fully operational for five years. There was an initial two year run in period for initial training of therapists and prosthetists and logistic implementation at our institution. 58 patients participated in the full RTP pathway, and 21 received RTP via remote rehabilitation delivered through a manual. An additional 6 patients met with the lead PT for at least 1 visit. All expenses for prostheses as well as therapy sessions have been covered by insurance. 32 prosthetists have been trained locally in the fabrication of the brace with an additional 70 trained at the brace manufacturers most recent national meeting. 13 physical therapists have been trained to perform functional rehabilitation through the RTP pathway.Conclusion:Implementation of the Return to Performance pathway can be translated and scaled to the civilian setting. The study has successfully replicated the brace fabrication necessary for optimal outcome in the RTR pathway, although there are remaining questions about scaling of physical therapy. This provides evidence that the process can be de-centralized and the benefits of dynamic bracing in high functioning patients following lower extremity trauma can be translated to the civilian population.

Systematic review of temporary intravascular shunt use in military and civilian extremity trauma.

The use of temporary intravascular shunts (TIVS) in the setting of military and civilian trauma has grown in recent years, predominantly because of the mounting evidence of improved limb outcomes. We sought to characterize the use and outcomes of TIVS in trauma through a systematic review of military and civilian literature. The MEDLINE, EBSCO, EMBASE, and Cochrane databases were searched for studies on TIVS use in military and civilian trauma settings published between January 2000 and March 2021. Reports lacking systematic data collection along with those with insufficient TIVS descriptive and outcome data were excluded. Data regarding the characteristics and outcomes of TIVS were assessed and collective syntheses of military and civilian data performed. Twenty-one reports were included, 14 from civilian trauma centers or databases and 7 from military field data or databases (total of 1,380 shunts in 1,280 patients). Sixteen were retrospective cohort studies, and four were prospective. Five studies had an unshunted comparison group. Shunts were predominantly used in the lower extremity and most commonly for damage control indications. Dwell times were infrequently reported and were not consistently linked to shunt thrombosis or other complications. Anticoagulation during shunting was sparsely reported and inconsistently applied. Shunted limbs had higher injury severity than unshunted limbs but similar salvage rates. Temporary intravascular shunts are effective for expeditious restoration of perfusion in severely injured limbs and likely contribute to limb salvage. There is a paucity of comparative TIVS data in the literature and no consistently applied reporting standards, so controversies regarding TIVS use remain. Systematic Review, level IV.

Safety and efficacy of low-titer O whole blood resuscitation in a civilian level I trauma center.

Military experience has shown low-titer O whole blood (LTOWB) to be safe and beneficial in the resuscitation of hemorrhaging trauma patients. However, few civilian centers use LTOWB for trauma resuscitation. We evaluated the early experience and safety of a LTOWB program at a level 1 civilian trauma center. We retrospectively reviewed our trauma registry from January 2018 to June 2020 for patients admitted in shock (defined as ≥1 of the following: heart rate, >120 beats per minute; systolic blood pressure, <90 mm Hg; or shock index, >0.9) who received blood products within 24 hours. Patients were grouped by resuscitation provided: LTOWB (group 1), component therapy (CT; group 2), and LTOWB-CT (group 3). Safety, outcomes, and variables associated with LTOWB transfusion and mortality were analyzed. 216 patients were included: 34 in Group 1, 95 in Group 2, and 87 in Group 3. Patientsreceiving LTOWB were more commonly male (p<0.001) and had a penetrating injury (p=0.005). Groups 1 and 3 had higher median ISS scores compared to Group 2 (19 and 20 vs 17; p=0.01). Group 3 received more median units of blood product in the first 4h (p<0.001) and in the first 24h (p<0.001). There was no difference between groups in 24h mortality or transfusion-related complications (all p>0.05). Arrival ED SBP was associated with LTOWB transfusion (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.95-1.00, p=0.03). ED lactate was independently associated with 24h mortality. (OR 1.27, CI 1.02-1.58, p=0.03). LTOWB transfusion was not associated with mortality (p=0.49). Abstract. Severely injured patients received LTOWB-CT and more overall product units but had similar 24 h mortality when compared with the LTOWB or CT groups. No increase in transfusion-related complications was seen after LTOWB transfusion. Low-titer O whole blood should be strongly considered in the resuscitation of trauma patients at civilian centers. Retrospective, therapeutic, level IV.

Nanoscale Chitosan-Based Hemostasis Membrane

Excessive bleeding or hemorrhage in traumatic injuries is the leading preventable cause of death in the combat and civilian trauma centers. Nearly 50% of military deaths, 90% of military battlefield casualties, and 33-56% mortalities in civilian’s surgical bleeding are associated with severe bleeding and can be prevented

Whole blood for blood loss: hemostatic resuscitation in damage control.

Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.