Damage Control Resuscitation In Patients Research Articles

Injuries associated with hypotension after trauma: Is it always haemorrhage?

Introduction Restricted fluid replacement strategy is one part of damage control resuscitation for patients with trauma haemorrhage. However, not all patients presenting with physiological symptoms suggestive of haemorrhage are bleeding. This descriptive study aims to compare demographics and injuries in adult and older trauma patients presenting to the Emergency Department with hypotension versus normotension. Methods This was a retrospective, descriptive data analysis from a UK trauma registry. The records from one major trauma centre were analysed between 2014–2019, and every hypotensive (systolic blood pressure <90 mmHg) trauma patient investigated for injuries associated with hypotension. The hypotensive threshold for older patients was also adjusted to 110 mmHg for sub-cohort analysis. Results 6245 trauma patients were included, of which 255 (4.1%) arrived hypotensive at the Emergency Department. Significant blood loss was identified in 32.2% of those cases. In 27.1%, multiple potential associations obscured the underlying mechanism for the hypotension but were more commonly associated with hypotension than with normotension. Over a third (37.5%) were ≥65 years old. Neurological injuries occurred more frequently in both older hypotensive groups than younger patients. Conclusions This study sought to compare injuries of adult and older trauma patients to aid trauma teams with decision making. In severely injured hypotensive patients, significant blood loss was the principal association with hypotension. However, several factors can mimic bleeding in the hypotensive trauma patient, which should be carefully considered. A prospective study is needed to clarify the characteristics and causes of bleeding mimics.

Endovascular balloon occlusion of the aorta in the complex of damage control resuscitation in patients with acute massive blood loss: a retrospective propensity score matched analysis

INTRODUCTION. An increase of quality improvement program for severe polytrauma hypotensive patients is associated with new techniques of “endovascular resuscitation” of which resuscitative endovascular balloon occlusion of the aorta (REBOA) to be the most widespread and effective. OBJECTIVE. Treatment outcomes after damage control resuscitation and endovascular resuscitation strategies were evaluated in comparison between Russian and “foreign” cohorts. MATERIALS AND METHODS. A retrospective and propensity score matched analysis was performed to compare Russian (n = 24) and foreign (n = 241) cohorts of extremely severely injured trauma patients (in extremis) admitted to trauma centers during the period of 2013–2020. All hemodynamically unstable trauma patients admitted in shock, with signs of systemic hypoperfusion and non-compressible torso hemorrhage, were enrolled into the study. RESULTS. In average, REBOA was performed 22 minutes after admission in both groups. In most cases (65–75 %), occlusion of the thoracic aorta was performed, what resulted in a significant increase of blood pressure by 40–50 mm Hg from baseline and allowed temporary hemodynamic stabilization to initiate surgery and blood replacement therapy. Early fluid and blood replacement therapy was significantly different between groups. Total volume of fluid and blood replacement therapy was significantly higher in the foreign group (p = 0.001), mostly due to blood components: red packed blood cells and platelets (p < 0.05 before and after REBOA). No colloids were infused in the foreign group at all (p < 0.001). Early blood transfusion was found to improve survival until 50 % (95% CI, 43–56 %) (р = 0.002). CONCLUSIONS. REBOA seems to be an effective adjunct for temporary hemodynamic stabilization of extremely severe injured patients, but its effectiveness is likely to be defined by quality and quantity of infusion and transfusion strategy as well as by intensive care in whole.

Damage control resuscitation in patients with major trauma: prospects and challenges

: Trauma is the leading cause of death for younger ages across the world, with acute traumatic hemorrhage one of the main reasons of trauma mortality. In the last decade trauma resuscitation has significantly evolved away from the era of massive crystalloid transfusion where the endpoint was to keep a normal perfusing volume. A better understanding of homeostatic mechanisms of hemostasis, and of the systemic inflammatory and counter-inflammatory response syndromes gave birth to damage control and hemostatic resuscitation. Modern trauma resuscitation aims to control the lethal triad of coagulopathy, hypothermia and acidosis with the understanding that any deregulation from the steady state will lead to a cascade of adverse events. This review paper analyzes the latest evidence-based concepts of trauma resuscitation. These new strategies are the early transfusion of blood products in a ratio of ≤2:1:1 [packed red blood cells (PRBCs): fresh frozen plasma (FFP): platelets], the warming of the patient and of the administered fluids, the intravenous administration of 1 g of tranexamic acid (TXA) within 3 h of injury and then infusion of another 1 g for 8 hours, the use of viscoelastic hemostatic assays (VHAs) for optimization of the transfusion strategy, the minimization of active bleeding through permissive hypotension, and the early bleeding control with mechanical, interventional and surgical methods. Emphasis is placed in the evidence supporting each one of these interventions, and their application during the different stages of trauma care, from the prehospital to the hospital setting.

Who Would Have Benefited from the Prehospital Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)? An Autopsy Study

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been increasingly used as part of damage control resuscitation for patients with non-compressible truncal hemorrhage. We hypothesized that there might be a select group of patients that could have benefited from prehospital placement of the REBOA. This was a retrospective cohort study including patients who presented to a Level I trauma center with cardiac arrest between January 2014 and March 2018. The findings of a full autopsy were reviewed for the details of internal injuries. A patient was determined to be a REBOA candidate if the patient sustained abdominal organ injuries or pelvic fractures and no associated severe head injuries. The candidate group was compared with the non-candidate group based on prehospital vital signs and other patient characteristics. A multiple logistic regression analysis was performed to identify certain prehospital factors associated with candidacy for prehospital REBOA. A total of 198 patients met our inclusion criteria. Of those, 27 (13.6%) patients were deemed REBOA candidates. Median Injury Severity Score was 22 (interquartile range 17 to 29). Patients in the candidate group were more likely to have a Glasgow Coma Scale score ≥9 (48% vs 15%; p= 0.012), oxygen saturation >90% (56% vs 35%; p= 0.03), and systolic blood pressure <90 mmHg (48% vs 26%; p= 0.04) in the field. Logistic regression showed that these 3 clinical parameters of prehospital vital signs were significantly associated with REBOA candidacy. Our data suggest that >10% of trauma patients who presented with cardiac arrest could have benefited from prehospital REBOA. Additional prospective studies are warranted to validate the use of field vital signs in selecting candidates.

Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma.

The resuscitation of severely injured bleeding patients has evolved into a multi-modal strategy termed damage control resuscitation (DCR). This guideline evaluates several aspects of DCR including the role of massive transfusion (MT) protocols, the optimal target ratio of plasma (PLAS) and platelets (PLT) to red blood cells (RBC) during DCR, and the role of recombinant activated factor VII (rVIIa) and tranexamic acid (TXA). Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines (PMG) Section of EAST conducted a systematic review using MEDLINE and EMBASE. Articles in English from1985 through 2015 were considered in evaluating four PICO questions relevant to DCR. A total of 37 studies were identified for analysis, of which 31 met criteria for quantitative meta-analysis. In these studies, mortality decreased with use of an MT/DCR protocol vs. no protocol (OR 0.61, 95% CI 0.43-0.87, p = 0.006) and with a high ratio of PLAS:RBC and PLT:RBC (relatively more PLAS and PLT) vs. a low ratio (OR 0.60, 95% CI 0.46-0.77, p < 0.0001; OR 0.44, 95% CI 0.28-0.71, p = 0.0003). Mortality and blood product use were no different with either rVIIa vs. no rVIIa or with TXA vs. no TXA. DCR can significantly improve outcomes in severely injured bleeding patients. After a review of the best available evidence, we recommend the use of a MT/DCR protocol in hospitals that manage such patients and recommend that the protocol target a high ratio of PLAS and PLT to RBC. This is best achieved by transfusing equal amounts of RBC, PLAS, and PLT during the early, empiric phase of resuscitation. We cannot recommend for or against the use of rVIIa based on the available evidence. Finally, we conditionally recommend the in-hospital use of TXA early in the management of severely injured bleeding patients.

Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: Analysis of 1,030 consecutive trauma laparotomies.

The aim of this study was to evaluate the related change in outcomes (mortality, complications) in patients undergoing trauma laparotomy (TL) with the implementation of damage control resuscitation (DCR). We hypothesized that the implementation of DCR in patients undergoing TL is associated with better outcomes. We analyzed 1,030 consecutive patients with TL. Patients were stratified into three phases: pre-DCR (2006-2007), transient (2008-2009), and post-DCR (2010-2013). Resuscitation fluids (crystalloids and blood products), injury severity score (ISS), vital signs, and laboratory (hemoglobin, international normalized ratio, lactate) parameters were recorded. Regression analysis was performed after adjusting for age, ISS, laboratory and vital parameters, comorbidities, and resuscitation fluids to identify independent predictors for outcomes in each phase. Patient demographics and ISS remained the same throughout the three phases. There was a significant reduction in the volume of crystalloid (p = 0.001) and a concomitant increase in the blood product resuscitation (p = 0.04) in the post-DCR phase compared to the pre-DCR and transient DCR phases. Volume of crystalloid resuscitation was an independent predictor of mortality in the pre-DCR (OR [95% CI]: 1.071 [1.03-1.1], p = 0.01) and transient (OR [95% CI]: 1.05 [1.01-1.14], p = 0.01) phases; however, it was not associated with mortality in the post-DCR phase (OR [95% CI]:1.01 [0.96-1.09], p = 0.1). Coagulopathy (p = 0.01) and acidosis (p = 0.02) were independently associated with mortality in all three phases. The implementation of DCR was associated with improved outcome in patients undergoing TL. There was a decrease in the use of damage control laparotomy, with a decrease in the use of crystalloid and an increase in the use of blood products. Prognostic study, level III.

Damage Control Resuscitation in Combination With Damage Control Laparotomy: A Survival Advantage

Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.